1. For shoulder pathology excluding instability a combination of the OSS and VAS would provide a validated shoulder specific assessment of the patient.

2. An additional advantage of the OSS is that it has been validated into Afrikaans and less sensitive to geographic change. This may make it more relevant to our population.

3. The alternative would be to use the ASES system which combines both pain and ADL components into a single scoring system. This scoring system seems more complex to interpret and may have more error in cross cultural interpretation.

4. Most studies show no benefit of one scoring system over the other.
 

5. A specific shoulder instability score would be preferable to using a more general score in the shoulder instability patients.

6. The OSIS is simple and validated. The use of this together with the OSS and VAS for pain would provide a comprehensive assessment of shoulder function in instability patients.

7. Addition of a general quality-of-life score (e.g. SF-36) or DASH score (which has been shown to correlate well with general quality-of-life scores) would provide a more extensive information about global well-being of the patient which would be useful for longer term follow-up.

8. There is the risk however that this would negatively impact on the completion rates of the scoring system. The SF 12 has been validated for orthopaedic conditions and could be used instead to reduce the burden of too many scoring systems. While this may not be required in every patient, it could be included as a resource on the website.

2022: SASES Shoulder Scoring Systems Recommendations

Which Shoulder Scoring Systems to Use?

A: Patient centred vs Surgeon led – does the examination and objective assessment influence validity or strength of score?

There was no benefit found in including an objective assessment by the physician in a score⁴.

The OSS has been validated with the CS¹⁴.

Algorithms have been developed to predict shoulder scores from each other; OSS from ASES² and OSS from CS¹⁴.

B: Which scores are most valid and most commonly used?

The OSS⁷, ASES and SST have been shown to be most valid³.

The Constant, OSS and ASES are the most commonly used in the literature.

The OSS is used in the national joint registry in England and Wales⁵.

The most commonly used scoring systems in the UK are the OSS (69%), Constant (49%), OIS (38%) and DASH (25%) ⁵.

Between the shoulder scores multiple studies have shown their interchangeability^1,2.

C: Single score or combination of scores?

The combination of scores may provide better information on global health of the patients.

This has been shown to be the case in follow-up of patients after shoulder fractures.

More general quality-of-life scores were found to be more useful, especially when assessing limitations after longer follow-up⁶.

General quality of life scores were well predicted by the DASH score¹.

General quality of life scores were less well predicted by shoulder specific scores¹.

Other studies have also shown poor correlation with shoulder specific scores and general health related quality of life scores²⁰.

The ASES is bidimensional and includes both a pain scale and ADLs component.

The OSS is unidimensional³.

D: Which scores cover widest pathology?

ASES has also been validated for use in patients with osteoarthritis, shoulder instability, rotator cuff injuries and shoulder arthroplasty¹².

ASES has been validated for: RC disease, OA, glenohumeral instability, Impingement syndrome, instability/dislocation, adhesive capsulitis, humeral fractures and malunion, SLAP lesions, ACJ arthritis and biceps tendonopathy¹⁵.

OSS was designed to measure outcomes after shoulder surgery but does not specifically include instability¹³.

It is recommended that a general health assessment be combined with the OSS, such as the SF-36¹³.

Other studies have shown other usefulness of the OSS:

• The OSS at six months postop, has been shown to be predictive of early failure after arthroplasty in the New Zealand national joint registry⁸.
• The OSS has been used in a wide variety of conditions including: Impingement syndrome, RC tear, calcified deposits in the RC tendon, primary or secondary OA, inflammatory arthritis, adhesive capsulitis and proximal humerus fractures¹⁵.
• The OSS is not validated for shoulder instability.

E: Does the length of score impact patient responsiveness?

The DASH score is a long score to complete.

Some studies have shown that the length of the questionnaire impacts negatively on the completion rate.

No specific cut off in the length of the score was found¹⁰.

Another study reported minimal patient dropout rates for in completion of 30 minute oncology scoring system¹¹.

Studies concluded that patients are willing to commit a significant amount of time to completing a questionnaire for a condition that has affected their lives¹¹.

F: Which score is most appropriate for our patients?

Some scoring systems (ASES, SPADI and UCLA) have been shown to vary in their responsiveness depending on the geographical area in which they were used.

This was not found with the Constant or OSS scores⁴.

The OSS has been translated into Afrikaans and validated⁹.

The OSS has the highest degree of cross cultural relevance¹⁵.

G: Are some scores more complicated to use and interpret?

The interpretation of the OSS is fairly straightforward; 12 questions scored from 0 to 4 with four being the best outcome.

This gives the entire scoring system a maximum of 48 points (best result) and a minimum of zero points (worst result).

The scoring system was changed in 2009 to bring it in line with other international scoring systems where a higher points score was associated with a better outcome¹³.

Interpreting the ASES is a little more complex but not overly so. The use of a formula is required.

Transforming the pain and the ADLs domains into the final score relies on the following formulas:

• Pain = 5 x (10 – Score from question 7)
• ADL = 5 x ADL Raw Score / 3
• ASES Score = Pain + ADL

H: Is licencing required?

ASES – no licence required

OSS – Permission to use the Oxford Shoulder Score can be acquired from Isis Innovation Ltd (the technology transfer company of the University of Oxford) via their website or by e-mail healthoutcomes@isis.ox.ac.uk

OSIS – Permission can be acquired from the website – The Oxford Shoulder Instability Score (OSIS)

https://innovation.ox.ac.uk › outcome-measures › oxford-…

I: Instability specific scores:

While the ASES can be used for instability it is not specific to that condition.

The 3 most validated, self reported scores specific to instability – WOSI¹⁷, OSIS¹⁸ and Melbourne instability shoulder scale¹⁹,¹⁶.

Of these the OSIS was the shortest to complete and the easiest to interpret¹⁶.

The initial development of the OSIS¹⁸ had the same counterintuitive scoring as the OSS; the score getting higher the worse the patient was. This was revisited to bring the system in line with the OSS in 2009 and the score is now from 0-48 with 48 being the best result¹³.

The Rowe score is the most widely accepted questionnaire, but it has not been fully validated and includes an examiner-based physical examination assessment¹⁶.

J: Pain scores

The VAS (Visual analogue scale) and GRS (graphic rating scale) have been found to be sensitive to treatment effects, correlate positively with other self-reported outcome scores for pain and when measured at two time points, represent a real difference in the magnitude of pain²¹.

The VAS score has also been validated for digital use on a laptop or cellphone²².

K: Quality of life scores

The general quality-of-life scores such as the SF 36, provide much longer term follow-up than the shoulder specific scores and for that reason it may be a good idea to include one of these.

The SF 12 has been validated with the SF 36 and provides a shorter, more concise score. Although validated the standard errors seen are amplified in the shorter version²⁴.

The SF 12 has been validated in orthopaedic conditions such as chronic back pain²³.

References:

1. Correlation and responsiveness of global health, upper extremity-specific, andshoulder-specific functional outcome measures following reverse total shoulder
   arthroplasty for proximal humerus fracture. Barger et al. BMC Musculoskeletal Disorders (2021) 22:574 https://doi.org/10.1186/s12891-021-04450-y

2. A correlation study of the American Shoulder and Elbow Society Score and the Oxford Shoulder Score with the use of regression analysis to predict one score from the other in patients undergoing reverse shoulder joint arthroplasty for cuff tear arthropathy. Kamal S Hapuarachchi & Peter C Poon. Shoulder Elbow. 2014 Apr;6(2):81-9. doi: 10.1177/1758573213518499

3. Evaluation of shoulder-specific patient-reported outcome measures: a systematic and standardized comparison of available evidence. Stefanie Schmidt, Montse Ferrer, Marta Gonzalez,
   Nerea Gonzalez, Jose Maria Valderas, Jordi Alonso, Antonio Escobar, Kalliopi Vrotsou,J Shoulder Elbow Surg (2014) 23, 434-444. http://dx.doi.org/10.1016/j.jse.2013.09.029

4. An international, multicenter cohort study comparing 6 shoulder clinical scores in an asymptomatic population. James M. McLean, Daniel Awwad, Ryan Lisle, James Besanko, Donald Shivakkumar, Jordan Leith. J Shoulder Elbow Surg (2018) 27, 306–314
   https://doi.org/10.1016/j.jse.2017.08.016

5. The use of shoulder scoring systems and outcome measures in the UK. M Varghese, J Lamb, R Rambani, B Venkateswaran. Ann R Coll Surg Engl 2014; 96: 590–592. doi 10.1308/003588414X14055925058157

6. Construct Validity and Precision of Different Patient-reported Outcome Measures During Recovery After Upper Extremity Fractures. Prakash Jayakumar, Teun Teunis, Ana-Maria Vranceanu, Sarah Lamb, Mark Williams, David Ring, Stephen Gwilym. Clin Orthop Relat Res (2019) 477:2521-2530
   DOI 10.1097/CORR.0000000000000928

7. Outcome Measures to Evaluate Upper and Lower Extremity: Which Scores are Valid?
   Ali Darwich, Viola Schüttler, Udo Obertacke, Ahmed JawharZ Orthop Unfall. 2020 Feb;158(1):90-103. doi: 10.1055/a-0837-1085.

8. An analysis of the Oxford Shoulder Score and its relationship to early joint revision in the New
   Zealand Joint Registry. Vikesh Gupta, Ritwik Kejriwal, Chris Frampton. J Shoulder Elbow Surg (2021) 30, e282–e289. https://doi.org/10.1016/j.jse.2020.08.043

9. The Oxford Shoulder Score: Cross-cultural adaptation and translational validation into Afrikaans.
   Kruger N; Stander L; Maqungo S; Roche S; Held M. SA orthop. j. vol.17 n.1 Centurion Feb./Mar. 2018. http://dx.doi.org/10.17159/2309-8309/2018/v17n1a2

10. Response Burden and Questionnaire Length: Is Shorter Better? A Review and Meta-analysis. Rolstad S, Adler J, Rydén A. Value in Health. 2011;14(8):1101–8.

11. Perceptions of Response Burden Associated with Completion of Patient- Reported Outcome Assessments in Oncology. Atkinson TM, Schwartz CE, Goldstein L, Garcia I, Storfer DF, Li Y, et al. Value in Health. 2019;22(2): 225–30.

12. http://freecontent.lww.com/wp-content/uploads/2014/12/Ianotti-Ch36-Measurement-of-Shoulder-Outcomes.pdf

13. The Oxford shoulder score revisited. Jill Dawson, Katherine Rogers, Ray Fitzpatrick, Andrew Carr. Arch Orthop Trauma Surg .2009 Jan;129(1):119-23. doi: 10.1007/s00402-007-0549-7. Epub 2008 Jan 9.

14. A comparison of the Constant and Oxford shoulder scores in patients with conservatively treated proximal humeral fractures. Paul Baker, Rajesh Nanda, Lorna Goodchild, Paul Finn, Amar Rangan J. Shoulder Elbow Surg. Jan-Feb 2008;17(1):37-41. doi: 10.1016/j.jse.2007.04.019. Epub 2007 Nov 26.

15. How to Assess Shoulder Functionality: A Systematic Review of Existing Validated Outcome Measures. Aldon-Villegas R, Ridao-Fernández C, Torres-Enamorado D, Chamorro-Moriana G. 2021 May 8;11(5):845. doi: 10.3390/diagnostics11050845.

16. Systematic review of patient-administered shoulder functional scores on instability. Rouleau DM, Faber K, MacDermid JC. J Shoulder Elbow Surg. 2010 Dec;19(8):1121-8. doi:10.1016/j.jse.2010.07.003.

17. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Kirkley A, Griffin S, McLintock H, Ng L. Am J Sports Med 1998;26:764-72.

18. The assessment of shoulder instability. The development and validation of a questionnaire. Dawson J, Fitzpatrick R, Carr A. J Bone Joint Surg Br 1999;81:420-6.

19. A new clinical outcome measure of glenohumeral joint instability: the MISS questionnaire. Watson L, Story I, Dalziel R, Hoy G, Shimmin A, Woods D. J Shoulder Elbow Surg 2005;14:22-30. doi:10.1016/j.jse.2004.05.002

20. Comparative evaluation of the measurement properties of various shoulder outcome instruments. Oh JH, Jo KH, Kim WS, Gong HS, Han SG, Kim YH.Am J Sports Med. 2009 Jun;37(6):1161-8. doi: 10.1177/0363546508330135. Epub 2009 Apr 29.

21. Pain Assessment. Eur Spine J. 2006 Jan;15 Suppl 1(Suppl 1):S17-24. doi: 10.1007/s00586-005-1044-x. Epub 2005 Dec 1.

22. Validation of Digital Visual Analog Scale Pain Scoring With a Traditional Paper-based Visual Analog Scale in Adults J Am Acad Orthop Surg Glob Res Rev. 2018 Mar 23;2(3):e088. doi: 10.5435/JAAOSGlobal-D-17-00088.

23. Reliability, validity, and responsiveness of the short form 12-item survey (SF-12) in patients with back pain. Xuemei Luo, Mandy Lynn George, Ikey Kakouras, Christopher L Edwards, Ricardo Pietrobon, William Richardson, Lloyd Hey. Spine (Phila Pa 1976). 2003 Aug 1;28(15):1739-45. doi: 10.1097/01.BRS.0000083169.58671.96

24. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. J Ware Jr, M Kosinski, S D Keller Med Care. 1996 Mar;34(3):220-33. doi: 10.1097/00005650-199603000-00003.

2022: SASES Shoulder Scoring Systems Recommendations –Scoring systems explained

The Oxford Shoulder Score

From the website:

https://innovation.ox.ac.uk/outcome-measures/oxford-shoulder-score-oss/

Each question on the OSS should be scored 0 to 4, with 4 representing the best. When the 12 items are summed, this produces overall scores that run from 0 to 48 with 48 being the best outcome.

Each of the 12 questions on the Oxford shoulder score is scored in the same way with the score decreasing as the reported symptoms increase (i.e. become worse).

All questions are laid out similarly with response categories denoting least (or no) symptoms being to the left of the page (scoring 4) and those representing greatest severity lying on the right hand side (scoring 0).

For example question 1:

Score                     4                                   3                                         2                                   1                                         0

applied/

response category

The overall score is reached by simply summing the scores received for individual questions.

This results in a continuous score ranging from 0 (most severe symptoms) to 48 (least symptoms).

Missing values/notes for analysis.

We also propose that, if, after repeated attempts to obtain complete data from an individual, only one or two questions have been left unanswered, it is reasonable to enter the mean value representing all of their other responses, to fill the gaps.

If more than two questions are unanswered we recommend that an overall score should not be calculated. If patients indicate two answers for one question we recommend that the convention of using the worst (most severe) response is adopted.

Further reading:-

• Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder surgery. J Bone Joint Surg [Br] (1996) 78-B: 4 593-600
• Dawson J, Hill G, Fitzpatrick R, Carr A. The benefits of using patient-based methods of assessment. Medium term results of an observational study of shoulder surgery. J Bone Joint Surg. [Br] (2001) 83(6): 877-882
• Dawson J, Rogers K, Fitzpatrick R, Carr A. The Oxford Shoulder Score revisited. Arch Orthop Trauma Surg (2009) 129:119–123

Users familiar with the original scoring system (as described in the first paper referenced above: JBJS, 1996) should note the change to this new scoring system.

Further details on the reasoning and changes to the scoring system, adopted in the last few years, and how to convert between the old scoring system and this preferred new scoring system, can be found in the third paper (Arch Orthop Trauma Surg, 2009) referenced above.

ASES Shoulder Score

The American Shoulder and Elbow Surgeons Shoulder Score (ASES) is a mixed outcome reporting measure for use in a variety of shoulder pathology.

The ASES score can be viewed as a 100-point scale that evaluates two dimensions of shoulder function: pain and performance in activities of daily living. Each of the two domains make up for 50 of the 100 points.

The pain domain questions focus on the presence or absence of pain at night, use of OTC or prescription pain killers and a self-report of perceived intensity of pain.

The ADLs domain contains 10 functional items that are shoulder specific, as follows:

• Putting on a coat;
• Sleeping on the affected side;
• Washing your back/do up bra;
• Managing toileting;
• Combing hair;
• Reaching a high shelf;
• Lifting 10lbs. (4.5kg) above the shoulder;
• Throwing a ball overhand;
• Usual work;
• Usual sport/leisure activity.

Each of the above activities is scored on a scale from 0 to 3, depending on the difficulty encountered in performing the ADL:

• Unable to do (0);
• Very difficult to do (+1);
• Somewhat difficult (+2);
• Not difficult (+3).

Originally developed by Richards et al. in 1994, this composite instrument provides results in the 0 to 100 range, where 0 indicates a worse shoulder condition and 100 indicates best shoulder condition, so the greater the score, the lower the level of shoulder disability.

The score is easy to administer and the patient can complete it in up to 5 minutes.

Transforming the pain and the ADLs domains into the final score relies on the following formulas:

• Pain = 5 x (10 – Score from question 7)
• ADL = 5 x ADL Raw Score / 3
• ASES Score = Pain + ADL

Where ADL Raw score is sum of points from questions 8 to 17.

The ASES methodology has been found to be comparable in responsiveness with the Shoulder Pain and Disability Index (SPADI).

The score has been validated and showed reliability and responsiveness in conditions such as rotator cuff disease, glenohumeral arthritis, shoulder instability, and shoulder arthroplasty.

Original reference

Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994; (November/December):347–52.

ASES has also been validated for use in patients with osteoarthritis, shoulder instability, rotator cuff injuries and shoulder arthroplasty [5].

5. http://freecontent.lww.com/wp-content/uploads/2014/12/Ianotti-Ch36-Measurement-of-Shoulder-Outcomes.pdf

The Oxford Shoulder Instability score

From the website:

https://innovation.ox.ac.uk/outcome-measures/oxford-shoulder-instability-score-osis/

Each question on the OSIS should be scored 0 to 4, with 4 representing the best. When the 12 items are summed, this produces overall scores that run from 0 to 48 with 48 being the best outcome.

Each of the 12 questions on the Oxford Shoulder Instability Score is scored in the same way with the score decreasing as the reported symptoms increase (i.e. become worse). All questions are laid out similarly with response categories denoting least (or no) symptoms being to the left of the page (scoring 4) and those representing greatest severity lying on the right hand side (scoring 0). For example question 1:

Score                     4                                   3                                         2                                   1                                         0

applied/

response category

The overall score is reached by simply summing the scores received for individual questions. This results in a continuous score ranging from 0 (most severe symptoms) to 48 (least symptoms).

Missing values/notes for analysis.

We also propose that, if, after repeated attempts to obtain complete data from an individual, only one or two questions have been left unanswered, it is reasonable to enter the mean value representing all of their other responses, to fill the gaps.

If more than two questions are unanswered we recommend that an overall score should not be calculated. If patients indicate two answers for one question we recommend that the convention of using the worst (most severe) response is adopted.

Further reading:-

• Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder surgery. J Bone Joint Surg [Br] (1996) 78-B: 4 593-600
• Dawson J, Hill G, Fitzpatrick R, Carr A. The benefits of using patient-based methods of assessment. Medium term results of an observational study of shoulder surgery. J Bone Joint Surg. [Br] (2001) 83(6): 877-882
• Dawson J, Rogers K, Fitzpatrick R, Carr A. The Oxford Shoulder Score revisited. Arch Orthop Trauma Surg (2009) 129:119–123

Users familiar with the original scoring system (as described in the first paper referenced above: JBJS, 1996) should note the change to this new scoring system. Further details on the reasoning and changes to the scoring system, adopted in the last few years, and how to convert between the old scoring system and this preferred new scoring system, can be found in the third paper (Arch Orthop Trauma Surg, 2009) referenced above.