[

brief report

]

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ANDERS D. MOELLER, PT1 • RIKKE R. THORSEN, PT1 • TINA P. TORABI, PT1 • ANNE-SOFIE D. BJOERKMAN, PT1 ELSEBETH H. CHRISTENSEN, PT, MSC1 • THOMAS MARIBO, PT, MHSc, PhD2 • DAVID H. CHRISTIANSEN, PT, MHSc3

The Danish Version of the Modified Constant-Murley Shoulder Score: Reliability, Agreement, and Construct Validity

R

eliable and valid tools to assess shoulder function are important in research and clinical practice.10 A number of evaluation tools have been developed to assist pain and disability assessment in patients with shoulder conditions, one of which is the ConstantMurley score (CMS).7 The CMS evaluates pain and disability in terms of both subjective and objective parameters.6 The CMS has a maximum

of 100 points, of which 35 are allocated to subjective parameters and 65 to objective parameters. The subjective component is composed of 5 items that assess pain and TTSTUDY DESIGN: Test-retest study.

TTOBJECTIVES: To assess the reliability, agreement, and validity of the Danish version of the modified Constant-Murley score (CMS).

TTBACKGROUND: Modified CMS guidelines were

published in 2008. These modifications have recently been translated and cross-culturally adapted into a Danish version. However, the reliability and the validity of this version have yet to be established.

TTMETHODS: A total of 45 patients with shoulder

impingement syndrome were examined by 2 raters using the modified version of the CMS and a questionnaire that included the Oxford shoulder score. Both raters had a minimum of experience using the CMS. Intrarater and interrater agreement and reliability were examined and compared. Construct validity was assessed by the correlation

activities of daily living, and the objective component includes measurement of active range of motion (AROM) and strength. Pain-free AROM is measured in between the scores of the CMS and the Oxford shoulder score.

TTRESULTS: The minimal detectable change was

estimated to be 13 and 11 points for raters A and B, respectively. The intraclass correlation coefficient was 0.93 for rater A and 0.95 for rater B. Interrater comparison demonstrated a minimal detectable change of 12 points and an intraclass correlation coefficient of 0.94. The correlation coefficient between the CMS and the Oxford shoulder score was 0.76.

TTCONCLUSION: The intrarater and interrater reliability and agreement of the Danish version of the modified CMS were found to be acceptable, and construct validity was confirmed. J Orthop Sports Phys Ther 2014;44(5):336-340. Epub 27 March 2014. doi:10.2519/jospt.2014.5008

TTKEY WORDS: Constant score, function scale, outcome measure, questionnaire

forward and lateral elevation with a goniometer, internal and external rotation is measured by performing composite functional movements, and, finally, isometric strength is measured in abduction. It has been suggested that the CMS is the best instrument to examine shoulder function.6 Still, the test has met substantial criticism of its reliability and validity.15,16 The psychometric properties of the CMS were recently systematically reviewed.16 Although evidence was found to support the use of the CMS, several aspects of the methodological properties of the CMS have not been adequately evaluated. The CMS is a widely used outcome measure in research, but a standardized test protocol is lacking. Different test procedures have made it difficult to interpret findings and to compare the results of studies that have used the CMS as their outcome measure. In 2008, a new guideline was published to meet some of this criticism.6 The subjective measures of pain, occupational ability, and recreational activity were changed from categories to visual analog scales, and the objective measure of strength was further described. The modified CMS has recently been translated and cross-culturally adapted to the

Department of Physiotherapy, VIA University College, Holstebro, Denmark. 2Department of Physiotherapy and Occupational Therapy, University Hospital Aarhus, Aarhus, Denmark. 3Department of Occupational Medicine, Danish Ramazzini Centre, Regional Hospital Herning, Herning, Denmark. The Regional Research Ethics Committee determined that formal ethical approval was not required for this study. The study was approved by the Danish Data Protection Agency (number 2011-41-6713). The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to David H. Christiansen, Department of Occupational Medicine, Regional Hospital Herning, Gl Landevej 61, 7400 Herning, Denmark. E-mail: David. [email protected] t Copyright ©2014 Journal of Orthopaedic & Sports Physical Therapy® 1

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Danish population.1 However, the reliability and the validity of the modified version of the CMS have yet to be established. The objective of the present study was to evaluate the interrater and intrarater reliability, agreement, and construct validity of the modified Danish version of the CMS.

METHODS

A

test protocol (APPENDIX A, available online) was developed for the present study based on the guidelines from Constant et al.6 The protocol was further standardized with respect to the question regarding work in the activities-of-daily-living section, the verbal instructions, and the test procedures in the objective measures. The criterion of pain-free AROM was found difficult to apply, as some patients may feel pain in the resting position, even if they have full AROM. To accommodate this, patients without pain at rest were assessed as originally described, whereas patients with pain at rest were instructed to continue movement until pain worsened. Moreover, we allowed for the presence of pain during the strength measurement. Strength was measured at 90° of abduction in the scapular plane, with the wrist pronated,6 using IsoForceControl dynamometers (Medical Device Solutions AG, Oberburg, Switzerland). The patients performed 3 trials, each separated by 80 seconds of rest, and the best trial was used. The dynamometer provides both a maximum and an average value of each effort for a period of 5 seconds. Keeping with the recommendations from Constant et al,6 the latter value was chosen. Each rater used the same dynamometer throughout the course of the study. The 2 raters were physical therapy students with 6 months of clinical experience but no prior experience with the CMS. Prior to the start of the study, pilot testing of 20 patients with shoulder conditions was conducted to familiarize the 2 raters with the test protocol. After examinations, differences were discussed

and corrected. During the actual study period, the raters were blinded to the patient’s history and to CMS scores in the retest examination.

Patient Selection Patients were recruited from rehabilitation units, physical therapy clinics, and 1 hospital in the Central Denmark Region. Inclusion criteria were being older than 18 years of age and having shoulder impingement syndrome as diagnosed by a medical doctor or physical therapist. Exclusion criteria were other shoulder pathologies, surgical treatment of any condition in the affected shoulder in the previous 12 months, mental disorders, or not being able to communicate in the Danish language. Participation was based on the principles of informed consent, and all patients signed informed consent forms prior to participation. The study was approved by the Danish Data Protection Agency.

Procedures Data were collected from October 31, 2011 to December 15, 2011. The patients were examined twice, with 1 hour of rest between the examinations. To reduce any impact of same-day fatigue on interrater reliability, half of the patients were tested by rater A as the first tester and the other half by rater B as the first tester. Between the first and second examinations, the patients completed a short questionnaire that included the Oxford shoulder score (OSS).8 The OSS consists of 12 items about pain and disability, which are converted into a sum score from 0 (worst) to 48 (best). The OSS has been shown to be a reliable and valid outcome measure.11 The procedure was repeated within 2 to 4 days in the same clinical setting, with raters performing the tests in the same order.

Statistical Analysis The sample size was determined according to a general recommendation that at least 50 subjects should be included in a method-comparison study.12,18 Descriptive statistics were calculated for

all variables. Possible floor and ceiling effects were examined and considered to be present if more than 15% of the respondents achieved the highest or the lowest score.10 Systematic differences in intrarater and interrater agreement were assessed by paired t tests. These differences were plotted against the mean of the 2 measurements in Bland-Altman plots, with 95% confidence interval (CI) and 95% limits of agreement (LOA). Absolute measurement errors were estimated by calculating the standard error of the measurement (SEM) and converting the SEM into the minimal detectable change at the 95% confidence level (MDC95) (MDC = 1.96 × √2 × SEM).18 Standard deviations of the difference between the first and second examinations were compared between raters by the variance ratio test. The intraclass correlation coefficient (ICC) model 2,1, with corresponding 95% CI, was used to assess reliability. The Pearson correlation coefficient between the CMS for the patients’ first examination and the OSS at day 1 was calculated. Based on results from previous studies, we expected a positive correlation greater than 0.60 to confirm construct validity of the CMS.2,4,13,14 Statistical analysis was performed with Stata Version 11 software (StataCorp LP, College Station, TX).

RESULTS

A

total of 74 patients were assessed for eligibility. Of these, 6 patients were excluded, 3 did not show up, and 13 declined participation. Additionally, 7 patients completed only the first test session: 2 withdrew because of worsening of their shoulder pain, 2 patients became ill with the flu, and 3 patients had a steroid injection between the 2 test days. This left 45 patients for the study. The characteristics of the included patients are presented in TABLE 1. The mean  SD score of the CMS for the patients’ first examination was 59.0  17.7. No floor or ceiling effects in total scores and subscores were found.

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[ Agreement parameters for intrarater and interrater comparisons are presented in TABLE 2 and APPENDIX B (available online). No statistically significant mean differences in scores between the first and second examinations were found for rater A (0.8; 95% CI: –1.2, 2.9) and rater B (0.4; 95% CI: –1.3, 2.1). The upper and lower 95% LOA ranged from –12.3 to 14.0 for rater A and from –10.9 to 11.6 for rater B. The estimated SEM and MDC95 for the 2 raters are presented in TABLE 2. The estimated MDC95 was 13 points for rater A and 11 points for rater B. Comparison of the within-subject variation (standard deviation of the differences) for each tester by the variance ratio test displayed no significant differences between the raters (6.7 versus 5.7, P = .308). The ICC was 0.93 for rater A and 0.95 for rater B. Interrater comparison demonstrated comparable results, with no significant difference between the scores (mean difference, 0.9; 95% CI: –0.9, 2.7). The upper LOA was 12.5 and the lower LOA was –10.8. The estimated MDC95 was 12 points and the ICC was 0.94 (TABLE 2). On the first day of examination, the mean  SD score on the OSS was 32.1  8.2. The Pearson correlation coefficient between the OSS and CMS scores was 0.76.

DISCUSSION

I

ntrarater and interrater reliability of the Danish version of the modified CMS obtained by relatively inexperienced raters was found to be acceptable, and convergent construct validity was confirmed by high correlation with the OSS. In both subjective and objective measures, it is generally recommended that reliability coefficients, as a minimum, exceed 0.70 to discriminate between groups in clinical trials and exceed 0.90 to evaluate individual patients.10,12 According to these recommendations, the modified CMS is suited for both. The level of the estimated MDC95 implies that at least 13 points are needed to detect a “true” within-person change

brief report TABLE 1

]

Patient Characteristics (n = 45)*

Characteristic

Value

Gender (men)

27 (60.0)

Mean  SD age, y

48.1  15.0

Employment Currently employed

28 (62.2)

Unemployed

5 (11.1)

Student/training

3 (6.7)

Retired

9 (20.0)

On sick leave

8 (17.8)

Pain duration Less than 7 mo

11 (24.4)

7 to 12 mo

14 (31.1)

1 to 2 y

6 (13.3)

Greater than 2 y

14 (31.1)

Dominant shoulder affected

21 (46.6)

Mean  SD CMS score (0-100)†

59.0  17.7

Abbreviation: CMS, Constant-Murley score. *Values are n (%) unless otherwise indicated. † Score from the first examination at day 1.

TABLE 2

Intrarater and Interrater Agreement and Reliability of the Constant-Murley Score in 45 Patients With Shoulder Impingement Syndrome SEM*

MDC95

ICC2.1*

Rater A

4.7 (3.9, 6.0)

13.1

0.93 (0.88, 0.97)

Rater B

4.1 (3.4, 5.1)

11.2

0.95 (0.92, 0.98)

Interrater

4.2 (3.5, 5.3)

11.6

0.94 (0.91, 0.98)

Abbreviations: ICC, intraclass correlation coefficient; MDC, minimal detectable change; SEM, standard error of measurement. *Values in parentheses are 95% confidence interval.

in the total score. In TABLE 3, findings of the present study and previous studies are summarized. ICCs from 0.80 to 0.96 for intrarater comparison and 0.84 to 0.87 for interrater comparison have been reported for the original version of the CMS.3,19 The study by Blonna et al3 demonstrated that the reliability of the CMS could be significantly improved in the hands of a rater, both experienced and inexperienced, if a standardized test protocol was used. Comparable results were obtained in the present study. This underlines the importance of a stan-

dardized test protocol when using the CMS. In contrast to other publications, we addressed the concept of “pain-free movement.” A total of 9 patients (20%) reported shoulder pain at rest before AROM was measured. Our standardization and additions to AROM assessment seem to eliminate floor effects and could be a valuable contribution to the administration of the CMS in the future. The MDCs in the present study are as good as or better than those of other well-established shoulder outcome measures. Ekeberg et al9 investigated the MDC95

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Reliability and Agreement Compared to Other Studies

TABLE 3

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Present study

Study Population

CMS Version

Statistical Test

Intratester

Intertester

Impingement

Modified

ICC

0.93-0.95

0.94

LOA

12-14

13

SEM

4.1-4.7

4.2

MDC95 Blonna et al3

Shoulder dysfunction

11-13

12

Original

ICC

0.80-0.93

0.86

Modified

ICC

0.95-0.97

0.95

Original

LOA

16-22

24

Modified

LOA

9-13

12

Rocourt et al15

Shoulder dysfunction

Original

Spearman

0.94-0.96

0.90

van Den Ende et al19

Rheumatoid arthritis

Original

ICC

0.95-0.96

0.84-0.87

Conboy et al5

Shoulder pathology

Original

SD

...

8.86

95% CL

...

16-20

Abbreviations: CL, confidence limits of a single measurement from the true value; CMS, ConstantMurley score; ICC, intraclass correlation coefficient; LOA, 95% limits of agreement (upper); MDC, minimal detectable change; SEM, standard error of measurement.

of 3 self-reported shoulder assessment tools and found values varying from 16% to 20%, which indicates that fewer points are needed to demonstrate real change when using the modified CMS. Comparison of the CMS and the OSS has previously been reported, with correlations varying from 0.60 to 0.74.2,4,13,14 Our results exceed these previous results. The present study has some limitations. The time between test days was shorter than that proposed by some authors,3,17 though others have suggested time intervals similar to ours in studies of patients with shoulder conditions.2,13,14 The present time interval was chosen to minimize the change in shoulder condition that may occur over time, because all patients in the present study were attending physical therapy treatment. However, such a short interval may be a source of bias, because the patients and the raters may recall previous answers, which may affect the objectivity of the tests. Thus, as a precaution against such bias, raters and patients were blinded to previous results on the second test day. Interrater examination was performed on the same day, with a 1-hour interval to eliminate dayto-day variation. The interval was actually larger than a previous study in this

area,3 and other studies failed to report time intervals between examinations.5,15 Although the patients were instructed not to receive treatment, 3 patients received steroid injections. A total of 7 patients were excluded between the 2 test days, therefore our sample size did not fulfill the minimum requirement for method-comparison studies.12,18 Finally, these findings can only be generalized to patients with signs and symptoms of subacromial impingement syndrome. Future studies evaluating longitudinal validity are needed.

CONCLUSION

T

he intrarater and interrater reliability and agreement of the Danish version of the modified CMS were found to be acceptable, and construct validity was confirmed. The CMS provides a reliable and valid assessment tool for patients with shoulder impingement. The measurement error should be taken into account when evaluating change over time and planning future clinical studies. t

KEY POINTS FINDINGS: The Danish version of the mod-

ified CMS showed acceptable intrarater and interrater reliability in patients with shoulder impingement syndrome, and construct validity was confirmed. IMPLICATIONS: When using a standardized test protocol, the CMS provides a reliable and valid tool for evaluation of shoulder function. The level of the estimated MDC95 implies that at least 13 points are needed to observe a “true” within-person change above measurement error. CAUTION: A study population of 45 patients did not completely fulfill sample-size recommendations for a method-comparison study. Furthermore, the generalization of our findings may be limited, as only patients with subacromial impingement syndrome were studied.

REFERENCES 1. B  an I, Troelsen A, Christiansen DH, Svendsen SW, Kristensen MT. Standardised test protocol (Constant Score) for evaluation of functionality in patients with shoulder disorders. Dan Med J. 2013;60:A4608. 2. Berendes T, Pilot P, Willems J, Verburg H, te Slaa R. Validation of the Dutch version of the Oxford Shoulder Score. J Shoulder Elbow Surg. 2010;19:829-836. http://dx.doi.org/10.1016/j. jse.2010.01.017 3. Blonna D, Scelsi M, Marini E, et al. Can we improve the reliability of the Constant-Murley score? J Shoulder Elbow Surg. 2012;21:4-12. http://dx.doi.org/10.1016/j.jse.2011.07.014 4. Christie A, Hagen KB, Mowinckel P, Dagfinrud H. Methodological properties of six shoulder disability measures in patients with rheumatic diseases referred for shoulder surgery. J Shoulder Elbow Surg. 2009;18:89-95. http://dx.doi. org/10.1016/j.jse.2008.07.008 5. Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley shoulder assessment. J Bone Joint Surg Br. 1996;78:229-232. 6. Constant CR, Gerber C, Emery RJ, Søjbjerg JO, Gohlke F, Boileau P. A review of the Constant score: modifications and guidelines for its use. J Shoulder Elbow Surg. 2008;17:355-361. http:// dx.doi.org/10.1016/j.jse.2007.06.022 7. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987:160-164. 8. Dawson J, Rogers K, Fitzpatrick R, Carr A. The Oxford shoulder score revisited. Arch Orthop Trauma Surg. 2009;129:119-123. http://dx.doi. org/10.1007/s00402-007-0549-7

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[ 9. Ekeberg OM, Bautz-Holter E, Tveitå EK, Keller A, Juel NG, Brox JI. Agreement, reliability and validity in 3 shoulder questionnaires in patients with rotator cuff disease. BMC Musculoskelet Disord. 2008;9:68. http://dx.doi. org/10.1186/1471-2474-9-68 10. Fayers PM, Machin D. Scores and measurements: validity, reliability, sensitivity. In: Fayers PM, Machin D, eds. Quality of Life: Assessment, Analysis and Interpretation of Patient-Reported Outcomes. 2nd ed. Chichester, UK: Wiley; 2007:77-108. 11. Frich LH, Noergaard PM, Brorson S. Validation of the Danish version of Oxford Shoulder Score. Dan Med Bull. 2011;58:A4335. 12. Hopkins WG. Measures of reliability in sports medicine and science. Sports Med. 2000;30:1-15. 13. Huber W, Hofstaetter JG, Hanslik-Schnabel B,

brief report

]

Posch M, Wurnig C. The German version of the Oxford shoulder score—cross-cultural adaptation and validation. Arch Orthop Trauma Surg. 2004;124:531-536. http://dx.doi.org/10.1007/ s00402-004-0716-z 14. Murena L, Vulcano E, D’Angelo F, Monti M, Cherubino P. Italian cross-cultural adaptation and validation of the Oxford Shoulder Score. J Shoulder Elbow Surg. 2010;19:335-341. http:// dx.doi.org/10.1016/j.jse.2009.07.068 15. Rocourt MH, Radlinger L, Kalberer F, et al. Evaluation of intratester and intertester reliability of the Constant-Murley shoulder assessment. J Shoulder Elbow Surg. 2008;17:364-369. http:// dx.doi.org/10.1016/j.jse.2007.06.024 16. Roy JS, MacDermid JC, Woodhouse LJ. A systematic review of the psychometric properties of the Constant-Murley score. J Shoulder Elbow Surg. 2010;19:157-164. http://dx.doi.

org/10.1016/j.jse.2009.04.008 17. S  choltes VA, Terwee CB, Poolman RW. What makes a measurement instrument valid and reliable? Injury. 2011;42:236-240. http://dx.doi. org/10.1016/j.injury.2010.11.042 18. Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60:34-42. http://dx.doi. org/10.1016/j.jclinepi.2006.03.012 19. van Den Ende CH, Rozing PM, Dijkmans BA, Verhoef JA, Voogt-van der Harst EM, Hazes JM. Assessment of shoulder function in rheumatoid arthritis. J Rheumatol. 1996;23:2043-2048.

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APPENDIX A

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TEST PROTOCOL FOR CONSTANT-MURLEY SCORE A. Pain Points Instruction Note B. Daily activities (4 questions) B1. Undisturbed sleep Points Instruction B2. Work Points Instruction Note

B3. Recreation Points Instruction Note B4. Hand positioning Points Instruction Note C. Movement Overall

C1. Forward elevation Points

Description • The patient must indicate on a 150-mm line the most severe pain felt in the shoulder within the past 24 hours. Anchors are “no pain” on the left and “intolerable pain” on the right • 0 to 15 [(150 – x mm)/10 = score], rounding to closest integer • Indicate the most severe pain felt in your shoulder during ordinary activities within the past 24 hours • Pain must not be episodic and severe, as following a dislocation, for example • Make sure that the patient understands the anchors • The patient must indicate the level of disturbance caused by the shoulder when sleeping. Three possible answers are provided • 0 to 2 (undisturbed sleep, 2 points; occasional disturbance, 1 point; disturbance every night, 0 points) • Is your sleep disturbed by your shoulder? • The patient must indicate on a 150-mm line how much the shoulder allows him or her to perform normal work. Anchors are “all” on the left and “none” on the right • 0 to 4 (0-30 mm, 4 points; greater than 30 to 60 mm, 3 points; greater than 60 to 90 mm, 2 points; greater than 90 to 120 mm, 1 point; greater than 120 to 150 mm, 0 points) • How much of your normal work does your shoulder allow? • If unemployed, consider last place of employment • If studying, this is considered as normal work • If retired, consider activities of daily living as normal work • Make sure that the patient understands the anchors • The patient must indicate on a 150-mm line his or her ability to perform normal recreational activities. Anchors are “all” on the left and “none” on the right • 0 to 4 (0-30 mm, 4 points; greater than 30 to 60 mm, 3 points; greater than 60 to 90 mm, 2 points; greater than 90 to 120 mm, 1 point; greater than 120 to 150 mm, 0 points) • How much of your normal recreational activity does your shoulder allow you to do? • Make sure that the patient understands the anchors • The patient must indicate to which level he or she is able to use the hand without feeling pain or discomfort. Six possible answers are given • 0 to 10 (below the waist, 0 points; up to the waist, 2 points; up to xiphoid, 4 points; up to neck, 6 points; up to top of head, 8 points; above head, 10 points • To which level are you able to use your hand without pain or discomfort? • The position of the hand decides, not the arm • Prior to the examination, ask the patient if the affected shoulder is hurting – If no, continue all movements until pain occurs – If yes, continue all movements until pain worsens • All movements should be shown by the examiner during or after the instructions • Have the patient stand during all examinations with a shoulder-width distance between his or her feet • Allow a trial before measuring • 0 to 10 (0°-30°, 0 points; 31°-60°, 2 points; 61°-90°, 4 points; 91°-120°, 6 points; 121°-150°, 8 points; 151°-180°, 10 points)

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[

brief report

]

APPENDIX A

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Description C1. Forward elevation (continued) Instruction

Note

C2. Lateral elevation Points Instruction

• “Place yourself comfortably standing with your feet in shoulder-width distance. When I tell you to, elevate your arm in front of yourself with your elbow joint as stretched as possible and your thumb pointing upward. Continue the movement until pain occurs/worsens and remain in this position until I have performed my measurement. Keep your upper body steady and make sure that movement is limited to your shoulder”

• Use a long goniometer • The patient should not compensate with excessive movement in other parts of the body. If so, correct the patient’s position and allow a new attempt • Landmarks for goniometer are the axis of the upper arm and the midaxillary line • 0 to 10 (0°-30°, 0 points; 31°-60°, 2 points; 61°-90°, 4 points; 91°-120°, 6 points; 121°-150°, 8 points; 151°-180°, 10 points) • “Place yourself comfortably standing with your feet in shoulder-width distance. When I tell you to, elevate your arm laterally with your thumb pointing laterally and your elbow joint as stretched as possible. When your arm reaches a horizontal position, rotate your thumb backward. Continue the lateral elevation until pain occurs/worsens and remain in this position until I have performed my measurement. Keep your upper body steady and make sure that movement is limited to your shoulder”

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APPENDIX A

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Description C2. Lateral elevation (continued) Note

C3. External rotation Points

Instruction

Note

C4. Internal rotation

Points Instruction

• Use a long goniometer • The patient should not compensate with excessive movement in other parts of the body. If so, correct the patient’s position and allow a new attempt • Landmarks for goniometer are the axis of the upper arm and parallel to the spinous processes of the thoracic spine • The patient should perform the movements separately. Two points are awarded for each movement that is performed without pain occurring/worsening • 0 to 10 (hand behind neck and elbow pointing forward, 2 points; hand behind neck and elbow pointing lateral, 2 points; hand above head and elbow pointing forward, 2 points; hand above head and elbow pointing lateral, 2 points; full elevation, 2 points • “Place yourself comfortably standing with your feet in shoulder-width distance. When I tell you to, imitate me in a series of separate movements. After each movement, I will ask you if pain occurred.” Show movements while instructing and ask for pain occurrence after each movement

• Movements are performed separately • The patient should not compensate with excessive movement in other parts of the body. If so, correct the patient’s position and allow a new attempt • The attempt is not accepted if it cannot be performed without the hands touching the neck or head. Let the patient know • “Elbow pointing lateral” is accepted when the elbow is in line with or behind the ear. Let the patient know and stress the importance of looking straight forward • The patient is asked to place the dorsum of the hand on the back of the thigh with the thumb pointing upward and to move the hand upward along the spine until pain occurs/worsens. Notice how far the hand is moved upward with the thumb as a pointer • 0 to 10 (lateral thigh, 0 points; buttock, 2 points; sacroiliac joint, 4 points; waist, 6 points; the 12th thoracic vertebra, 8 points; interscapular area, 10 points • “Place yourself comfortably standing with your feet in shoulder-width distance. When I tell you to, place the back of your hand on the thigh with your thumb pointing upward. Move your hand upward along the spine until pain occurs/worsens and remain in this position until I have performed my measurement. Make sure that movement is limited to your shoulder”

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[

brief report

]

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Bibliotheque de l'Universite Laval on June 2, 2014. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Description C4. Internal rotation (continued) Note

D. Strength Points Instruction

• The patient should not compensate with excessive movement in other parts of the body. If so, correct the patient’s position and allow a new attempt • Movement must be performed active and in constant flow • Strength is measured isometrically in 90° of lateral elevation with a dynamometer • 0 to 25 (1 point for each pound [0.45 kg] applied) • “Place yourself comfortably standing with your feet in shoulder-width distance and your arm in this position [examiner ensures that the patient is in the correct position]. You now have a trial where you should not perform your maximum”

• “You now have 3 attempts. When I tell you to, pull the strap with maximum effort until the dynamometer beeps. During the pull, keep your elbow stretched, do not lean toward the opposite side, and limit movement to your shoulder. Ready: 3, 2, 1, pull, pull, pull”

Note

• Arm laterally elevated 90° in the plane of the scapula. If the patient is unable to reach the position, award 0 points. Pain is allowed • Elbow joint fully extended and hand in prone • Place the strap with the distal edge along the styloid process of the ulna. The edge with stitches is placed distally • The patient should not compensate with excessive movement in other parts of the body or lean toward the opposite side. If so, correct the patient’s position and allow a new attempt

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APPENDIX B

B

C 20

10

10

Difference

20

0 –10

10

Difference

A

Difference

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Bibliotheque de l'Universite Laval on June 2, 2014. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

BLAND-ALTMAN PLOTS FOR INTRARATER AND INTERRATER AGREEMENT

0 –10

–20 20

40

60

Average

80

100

–10

–20

–20 10

0

10

20

40

60

80

100

10

20

Average

40

60

80

100

Average

Differences in scores are plotted against mean (average) of the 2 measurements. (A) Rater A, (B) rater B, and (C) interrater.

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The Danish version of the modified Constant-Murley shoulder score: reliability, agreement, and construct validity.

Test-retest study. Objectives To assess the reliability, agreement, and validity of the Danish version of the modified Constant-Murley score (CMS)...
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