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Introduction

In shoulder surgery scoring instruments are well-established to evaluate functional outcome and patient satisfaction. A distinction is made between self-assessment questionnaires allowing for long-term follow-up examination of large patient collectives despite of long distances to the clinic without requiring face-to-face contact and physician-based scoring systems mostly used in the clinical setting. In general Patient-Reported Outcome (PRO) questionnaires showed to be more suitable for outcome research due to their superior validity in comparison to clinician assessed parameters [1]. Furthermore self-assessment eliminates selection or examiner observation bias of physicians rating the patients they treated before much better than other physicians or patients themselves [2]. Since subjective patient-satisfaction is not necessarily directly linked to physician-based objective examination [3], numerous scoring tools have been developed in the recent years. As most studies use different scoring systems, comparison of treatment results with literature, with the aim to improve therapeutic strategies, is limited. Consequently, the risk of maintaining inadequate treatment concepts is increased leading to reduced treatment quality and decreased patient satisfaction. Recently a new PRO shoulder questionnaire, the Munich Shoulder Questionnaire, was developed to calculate already well-established shoulder scores out of one single questionnaire [4] to compare the results of different therapeutic approaches with the objective on selecting the most effective treatment strategies and quitting obsolete therapy regimes.

The Munich Shoulder Questionnaire (MSQ) [4]

The MSQ is a universally applicable patient reported outcome (PRO) questionnaire which has been developed for an effective follow-up of shoulder patients. Analysing the items of already existing and well established shoulder scores (Shoulder Pain and Disability Index (SPADI), Disability of the Arm, Shoulder and Hand (DASH) and the Constant Score) for congruency in measurement and subsequent condensing of numerous items into one single question led to a 30 items containing tool. Typical shoulder movements are depicted as photographs to assess the range of motion. The MSQ has been demonstrated as a valid questionnaire allowing for reliable calculation of the SPADI, the DASH and the Constant Score and is currently in use in outcome research [5]. The Munich Shoulder Questionnaire is available at http://www.chirurgische-klinik.de/download/inhalt/fachgebiete/unfallchirurgie/MSQENG.pdf

The Shoulder Pain and Disability Index (SPADI) [6]

Roach et al. [6] developed a self-administered questionnaire consisting of 13 equally weighted items divided in two subscales to measure pain (see Table 21.1) and disability (Table 21.2) in shoulder diseases. The 5 items for pain and the 8 items for disability are visualized as visual analog scales ranging from 0 to 10 (0 = no pain/no difficulty; 10 = worst pain imaginable/so difficult required help).

Table 21.1 Pain subscale of the SPADI
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Table 21.2 Disability subscale of the SPADI
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The Disability of the Arm, Shoulder and Hand (DASH) [7]

The DASH is a 30-item self-administrated measurement tool to assess physical function and symptoms in patients with musculoskeletal disorders of the upper extremity. It was developed by the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS) and the Institute for Work and Health (Toronto, Ontario) to be used by physicians in daily practice and as a research tool. Two optional modules for work and sports or performing arts provide an amendment to measure symptoms and function in athletes, artists and other workers whose jobs require a high degree of physical performance. The DASH has been translated in numerous languages and is available under http://dash.iwh.on.ca free of charge.

The Constant Score [8]

The Constant Score was developed as a physician-based measurement tool to provide an overall clinical functional assessment [8]. It is a 100 point scaling system divided into four subscales: pain (15 points; Table 21.3), activities of daily living (20 points; Table 21.4), strength measurement (25 points) and range of motion (40 points; Table 21.5a, b). Shoulder strength is measured as abduction power at 90° with the wrist as point of loading [9].

Table 21.3 Pain subscale of the Constant Score
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Table 21.4 Activities of daily living subscale of the Constant Score
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Table 21.5 Range of motion subscale of the Constant Score
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The Relative Constant Score (Age- and Sex-Related) according to Gerber et al. [10]

The strength subscale of the Constant Score constitutes a potential source of error due to gender-related differences in absolute lean body mass resulting in an average lower muscular force in women compared to men [11]. Brinker et al. [12] reported a relevant bias of both age and gender on the total Constant Score in favour of young men. Therefore Yian et al. [10] developed normative age- and sex-specific Constant Scores and strength values in a large population sample (Table 21.6).

Table 21.6 Normative age- and sex-specific Constant Score
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The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [13]

This shoulder score was developed by the Research Committee of the American Shoulder and Elbow Surgeons (ASES) as a standardized method of assessing musculoskeletal function to facilitate the communication between investigators [13]. It constitutes a baseline measurement tool applicable to all shoulder patients regardless of diagnosis. The form consists of demographic information (Fig. 21.1), a patient self-evaluation section and a physician assessment section. The patient self-evaluation form is divided into three subscales (Fig. 21.2a–c): pain, instability and activities of daily living. The physician assessment portion of the form consists of a range of motion (Fig. 21.3a), a clinical signs (Fig. 21.3b), a strength (Fig. 21.3c) and an instability section (Fig. 21.3d).

Fig. 21.1
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Demographic information of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13])

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Fig. 21.2
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(a) Self-evaluation: pain section of the ASES standardized shoulder assessment form (Reprinted with permission from [13]). (b) Self-evaluation: Instability section of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13]). (c) Self-evaluation: Activities of daily living section of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13])

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Fig. 21.3
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(a) Physician assessment: range of motion section of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13]). (b) Physician assessment: Clinical signs section of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13]). (c) Physician assessment: Strength section of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13]). (d) Physician assessment: Instability section of the ASES standardized shoulder assessment form (Reprinted with permission from Richards et al. [13])

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Summary

In general scoring instruments are widely used to assess the preoperative and postoperative status of patients with shoulder diseases. Besides already existing physician-based scores numerous self-evaluation questionnaires have been developed to eliminate observer bias of physicians rating the patients they treated before. The Munich Shoulder Questionnaire, a patient-reported measurement tool, was especially developed for an effective self-evaluation of shoulder patients and allows for a quantitative assessment of the Constant, Shoulder Pain and Disability Index (SPADI) and Disabilities of the Arm, Shoulder and Hand (DASH) score. It presents a universally applicable baseline measurement tool to select the most effective treatment strategy and to facilitate communication of investigators.