Shoulder-related dysfunction is a common health problem, for. Reliability of Function-Related Tests in Patients With Shoulder Pathologies

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1 Reliability of Function-Related Tests in Patients With Shoulder Pathologies Jing-lan Yang, PT, MS 1 Jiu-jenq Lin, PT, PhD 2 Study Design: Nonexperimental. Objective: To investigate the intertester and intratester reliability of a battery of function-related tests in patients with shoulder pathologies and associated reduced range of motion. Background: A battery of function-related tests has the potential to complement assessment of functional limitation in patients who have shoulder Methods and Measures: Three function-related tests (hand to neck, hand to scapula, and hand to opposite scapula) were conducted on 46 patients with shoulder pathologies, and 46 age- and gender-matched control subjects. The tests were performed by 2 independent physiotherapists to test intertester reliability. Intratester reliability was examined by investigating the reproducibility of the tests performed twice, with 3 to 5 days between tests, by the same physiotherapist. Comparison of the scores on the function-related tests between patients and controls was evaluated. A correlation matrix was calculated to test the level of association among the tests. Results: Intratester and intertester reliability on the 3 tests (weighted ) varied from 0.83 to The patient s test performances were decreased in comparison to the control group. The correlation matrix demonstrated a level of associations among the 3 tests varying from r = 0.64 to r = Conclusion: The results of this study indicate that function-related tests are reliable and could be used in clinical practice to document reduced function of the shoulder. The level of association among the tests indicates that each test measured different aspects of shoulder function. J Orthop Sports Phys Ther 2006;36(8): doi: /jospt Key Words: adhesive capsulitis, glenohumeral joint, outcome measure Shoulder-related dysfunction is a common health problem, for which adequate outcome measures to document functional deficits and monitor outcomes are still lacking. 2,8,11,15,16,17,18,20,22 Traditional impairment measures have been reported to have insufficient reliability 4,7,9 and validity. 7,18 Inconsistent relationships are also found among measurements of range of motion (ROM), strength, and function. 2,4,7,9,18 Given the inadequate reliability and validity of impairment measures, functional outcome measures are often used as the primary mean of evaluating effectiveness of intervention in patients with various shoulder 8,17,20,21 Although patients self-reports of functional status are generally reliable and valid outcome measures, 8,17,20,21 they may have specific limited applications. Based on the review of 11 self-report scales for the 1 Physical Therapist, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan. 2 Lecturer, School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan. The study protocol was approved by National Taiwan University Hospital. Address correspondence to Dr Jiu-jenq Lin, School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Room 327, No 17, Xuzhon Rd, Zhongzheng District, Taipei City, 100, Taiwan. assessment of functional status of the shoulder, Michener and Leggin 14 indicated that each selfreport measure has unique characteristics and that investigators must ensure appropriate use of the scale for the sample/ population of interest in the study being conducted. 14 Cook et al 3 investigated the reliability of 4 selfreports of shoulder function and suggested that the University of California at Los Angeles (UCLA) Shoulder Scale is inappropriate for use in individuals who did not have surgery because of low reliability. 3 Additionally, self-report measures may also be subject to perceptual differences because function is influenced by psychological, social, environmental, and physical factors. 6,19 Accordingly, a battery of function-related tests has the potential to complement functional outcome assessment in patients with various shoulder Functional measures appear to be helpful for their objectivity in measuring shoulder dysfunction. Mannerkorpi et al 13 used hand-toneck as well as hand-to-scapula tests to assess the status of shoulder dysfunction in patients with fibromyalgia and demonstrated significantly decreased performance in comparison with healthy subjects. However, reliability and validity of the tests have not been established for patients with other shoulder 572 Journal of Orthopaedic & Sports Physical Therapy

2 TABLE 1. Description of the 3 function-related tests. neck (shoulder flexion and external rotation)* 0 The fingers reach the posterior median line of the neck with the shoulder in full abduction and external rotation without wrist extension 1 The fingers reach the median line of the neck but do not have full abduction and/or external rotation 2 The fingers reach the median line of the neck, but with compensation by adduction in the horizontal plane or by shoulder elevation 3 The fingers touch the neck 4 The fingers do not reach the neck scapula (shoulder extension and internal rotation) 0 The hand reaches behind the trunk to the opposite scapula or 5 cm beneath it in full internal rotation. The wrist is not laterally deviated 1 The hand almost reaches the opposite scapula, 6-15 cm beneath it 2 The hand reaches the opposite iliac crest 3 The hand reaches the buttock 4 Subject cannot move the hand behind the trunk opposite scapula (shoulder horizontal adduction) 0 The hand reaches to the spine of opposite scapula in full adduction without wrist flexion 1 The hand reaches to the spine of the opposite scapula in full adduction 2 The hand passes the midline of the trunk 3 The hand cannot pass the midline of the trunk * This test measures an action essential for daily activities, such as using the arm to reach, pull, or hang an object overhead or using the arm to pick up and drink a cup of water. This test measures an action essential for daily activities, such as using the arm to pull an object out of a back pocket or tasks related to personal care. This test measures an action important for daily activities, such as using the arm to reach across the body to get a car s seat belt or using the arm to turn a steering wheel. Function-related tests of shoulder dysfunction reflect individual capabilities and serve as a complement to self-report of function. However, lack of information on their reliability and validity necessitates the investigation of their measurement properties. The primary objective of this study was to evaluate the intratester and intertester reliability of 3 tests: hand to neck, hand to scapula, and hand to opposite scapula (Table 1). We believe that the components of the tests are fundamental to activities of daily living. The second objective was to compare the performance of a group of patients with shoulder pathologies and a group of age- and gender-matched control subjects on those 3 tests. We hypothesized that the control group would perform better than the group with shoulder pathologies, establishing the ability of the tests to measure functional deficits. The third objective was to explore the level of association among the 3 tests. We hypothesized that the level of association among tests would be low, based on the assumption that each test measures a different aspect of shoulder function. METHODS Subjects A sample of convenience consisting of 46 patients with various shoulder pathologies was recruited from an outpatient clinic at a university hospital. Criteria for participation in the study included (1) being at least 18 years of age, (2) limited ROM in 1 shoulder, and (3) pain in the shoulder region. The specific exclusion criteria were (1) a history of pain in the elbow, wrist, or hand within the preceding 2 months, (2) receiving a cortisone injection in the affected shoulder the day of the appointment, or (3) changes in activities in the period of time between tests. For comparison of functional limitations between the patients and control subjects, 46 age- and gendermatched control subjects were also tested (Table 2). The control group was a convenience sample that was primarily comprised of healthcare workers and subjects without shoulder pathologies from an outpatient clinic. All subjects reviewed and signed an institutionally approved informed consent document before participating. The protocol for this study was approved by the Research Ethics Committee of the National Taiwan University Hospital. Study Design This was a nonexperimental research design. The intertester and intratester reliability of 3 functionrelated tests were investigated. During the first visit, each subject was evaluated by 2 physiotherapists to TABLE 2. Subject characteristics. Data are means ± SD. There were 22 males and 24 females in each group. Characteristics Patients (n = 46)* Controls (n = 46) Age (y) 54.9 ± ± 8.7 Body mass (kg) 65.2 ± ± 5.7 Height (cm) ± ± 7.5 Shoulder range of motion ( ) Flexion 114 ± ± 7 Abduction 92 ± ± 4 Medial rotation 29 ± ± 5 Lateral rotation 30 ± ± 9 Pain intensity (range, 0-10) 3.4±3.2 - Duration of symptoms (mo) 6.7 ± * Patients were diagnosed with adhesive capsulitis (n = 16), rotator cuff injury (n = 12), impingement (n = 10), or fracture (n = 8). Diagnoses were made by physicians based on history, physical examinations, special tests, and radiographs. Range of motion was measured by a physical therapist at the beginning of the session using standard guidelines for range-ofmotion measurement by using a hand-held standard universal goniometer (Ever Prosperous Instruments, Inc, Taipei, Taiwan). Pain was measured at the beginning of the session during the end range of movement. RESEARCH REPORT J Orthop Sports Phys Ther Volume 36 Number 8 August

3 A Three tests (Table 1 and Figure 1) were selected for evaluation because of their relation to the performance of daily living. For the tests, patients stood and moved their hands to the target positions (the posterior aspect of the neck, the posterior aspect of the back, and the opposite scapula). Data Analysis B C FIGURE 1. Photograph illustrating results of the function-related tests from 1 patient with a right frozen shoulder. (A) Hand-to-neck test: score, 3. (B) Hand-to-scapula test: score, 3. (C) Hand-toopposite-scapula test: score, 1. determine interrater reliability. To avoid carryover of symptoms, a 20-minute rest was allowed between tests. The physiotherapists were blinded to each other s results. The physiotherapists had a minimum of 5 years of clinical experience. To establish intratester reliability, all subjects were re-evaluated 3 to 5 days later by the same therapist. All subjects (patients and control group) underwent the same process. The order of the tests and order of testing for the therapists were randomly assigned. Function-Related Tests For the intratester and intertester reliability, weighted kappa statistics were calculated. 1,5,10,12 Intertester reliability was calculated using the measurements made by both therapists on the first visit. Intratester reliability was calculated using the measurements made on 2 different days by the same therapist. Landis and Koch 10 criteria were used to interpret the coefficient values. Strength of agreement was interpreted as follows: 0.00, poor; , slight; , fair; , moderate; , substantial; , almost perfect. We did not calculate reliability statistics on the control group because they all achieved the highest possible score. The correlation matrix was created to determine the level of association among the 3 function-related tests in the patients with shoulder The score obtained by tester 1 on the first testing occasion were used for group comparisons and correlation matrix. RESULTS All subjects completed all components of the tests. Characteristics of the study subjects and descriptive statistics of the patients function are presented in Table 2. The duration of symptoms (ranging from 2 to 28 months) and pain intensity (ranging from 1 to 8 out of 10) demonstrates the subacute clinical condition of the patients. A summary of the reliability results is presented in Table 3, agreement (weighted Kappa statistics) ranged from 0.83 to Figure 2 presents the histogram of the 3 function-related test scores for the patients with shoulder All individuals in the control group were able to meet the highest level of function for all 3 tests. The correlation matrix (Table 4) demonstrates the correlations among the function-related tests. Correlation coefficients between hand in neck, hand to scapula, and hand to opposite scapula were between r = 0.64 and r = DISCUSSION Function-related tests have the potential to contribute to clinical examination of patients with shoulder Because function-related tests depend in large measure on patient cooperation and motivation, evaluation of the reliability and validity is needed. Thus we examined the reliability of a battery of 3 function-related tests in patients with various shoulder 574 J Orthop Sports Phys Ther Volume 36 Number 8 August 2006

4 TABLE 3. Intratester and intertester reliability (kappa statistics) of the 3 function-related tests in patients with various shoulder Function-Related Tests Weighted 95% Confidence Interval for Intratester neck 0.80 (0.63, 0.93) scapula 0.90 (0.72, 0.92) opposite scapula 0.86 (0.65, 0.90) Intertester neck 0.90 (0.69, 0.96) scapula 0.90 (0.69, 0.94) opposite scapula 0.83 (0.75, 0.96) TABLE 4. Correlations (Spearman rho correlation) among the 3 function-related tests in patients with shoulder All values are significant (P.05). Neck Scapula Opposite Scapula neck scapula opposite scapula Mannerkorpi et al 13 evaluated the reliability of hand-to-neck and hand-to-scapula tests in patients with fibromyalgia and found good reliability for the hand-to-scapula test. Similar to their findings, the test battery in our study had high intratester and intertester reliability in assessing functional limitations in patients with various shoulder However, for their low reliability (kappa = 0.40) of the hand-to-neck test, they suggested that further standardization of the test is needed for use in patients with fibromyalgia. It seems likely that the different results are due to pain, which may have more impact on the test performance in patients with fibromyalgia (mean perceived pain was 4.5) than in our subjects (mean, 3.4). Thus, our results indicated that our measures can be used reliably and incorporated into standard clinical practice in patients with various shoulder Moderate correlations among hand-to-neck, handto-scapula, and hand-to-opposite-scapula test results indicate that the measures do not assess exactly the same aspects of shoulder function in patients. Magermans et al 12 described the required shoulder ROM to perform upper extremity activities of daily living. Similar to their tested activity (combing hair), the hand-in-neck movement in our study is more reflective of a combination of shoulder flexion, abduction, and external rotation. Comparable to their tested activity (perineal care), the hand-to-scapula movement in our study is more reflective of a combination of shoulder extension, adduction, and internal rotation. The hand-to-opposite-scapula movement, like washing the contralateral axilla activity, is more reflective of a combination of flexion and horizontal adduction. It is likely that patients were differentially challenged by the function-related tests used in this study. The limitations of the study should be noted. Although the test battery is believed to be comprised of movements fundamental to activities of daily living, the direct relationship between our test battery and activities of daily living cannot be assumed. Additionally, endurance, fatigue, and movement efficiency were not considered in the development of our test battery. Thus, the test battery cannot be used alone for assessment or outcome measures in patients with various shoulder We believe, however, that this test battery and self-report of function assess different components of the function construct. These methods are complementary and should be used together in clinical practice and research. The subacute clinical condition of our subjects also limits generalizability outside of this subacute condition. CONCLUSION The function-related tests in this study were easy to administer and interpret for the testers and straightforward to perform for the patients with various shoulder The tests were reliable and they can easily be incorporated individually or as a battery Number of subjects neck scapula opposite scapula Score FIGURE 2. Distribution of the scores for the group with shoulder pathologies (n = 46) for each of the 3 tests. All 46 individuals in the control group had a score of 0 for all 3 tests. Higher scores represent higher limitation of function. RESEARCH REPORT J Orthop Sports Phys Ther Volume 36 Number 8 August

5 during clinical practice. They are recommended as a supplement to patient self-report of function and clinicians judgments of function. REFERENCES 1. Altman DG. Practical Statistics for Medical Research. London, UK: Chapman & Hall; Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int. 2001;21: Cook KF, Roddey TS, Olson SL, Gartsman GM, Valenzuela FF, Hanten WP. Reliability by surgical status of self-reported outcomes in patients who have shoulder J Orthop Sports Phys Ther. 2002;32: Edwards TB, Bostick RD, Greene CC, Baratta RV, Drez D. Interobserver and intraobserver reliability of the measurement of shoulder internal rotation by vertebral level. J Shoulder Elbow Surg. 2002;11: Fleiss JL, Cohen J. The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educ Psychol Meas. 1973;33: Fordyce WE, Lansky D, Calsyn DA, Shelton JL, Stolov WC, Rock DL. Pain measurement and pain behavior. Pain. 1984;18: Gajdosik RL, Bohannon RW. Clinical measurement of range of motion. Review of goniometry emphasizing reliability and validity. Phys Ther. 1987;67: Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000;82- A: Hayes K, Walton JR, Szomor ZR, Murrell GA. Reliability of five methods for assessing shoulder range of motion. Aust J Physiother. 2001;47: Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33: Lin JJ, Hanten WP, Olson SL, et al. Functional activity characteristics of individuals with shoulder dysfunctions. J Electromyogr Kinesiol. 2005;15: Magermans DJ, Chadwick EK, Veeger HE, van der Helm FC. Requirements for upper extremity motions during activities of daily living. Clin Biomech (Bristol, Avon). 2005;20: Mannerkorpi K, Svantesson U, Carlsson J, Ekdahl C. Tests of functional limitations in fibromyalgia syndrome: a reliability study. Arthritis Care Res. 1999;12: Michener LA, Leggin BG. A review of self-report scales for the assessment of functional limitation and disability of the shoulder. J Hand Ther. 2001;14: Murnaghan JP. Frozen shoulder. In: Rockwood CA, Frederick A, Matsen I, eds. The Shoulder. Philadelphia, PA: WB Saunders Company; 1990: Neviaser TJ. Adhesive capsulitis. Orthop Clin North Am. 1987;18: Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S, Pagett BT. Long-term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop Relat Res. 1998; Reichmister JP, Friedman SL. Long-term functional results after manipulation of the frozen shoulder. Md Med J. 1999;48: Sager MA, Dunham NC, Schwantes A, Mecum L, Halverson K, Harlowe D. Measurement of activities of daily living in hospitalized elderly: a comparison of self-report and performance-based methods. J Am Geriatr Soc. 1992;40: van der Windt DA, Koes BW, Deville W, Boeke AJ, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998;317: Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing PM, van Den Ende CH. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Phys Ther. 2000;80: Wadsworth CT. Frozen shoulder. Phys Ther. 1986;66: White SA, van den Broek NR. Methods for assessing reliability and validity for a measurement tool: a case study and critique using the WHO haemoglobin colour scale. Stat Med. 2004;23: J Orthop Sports Phys Ther Volume 36 Number 8 August 2006

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