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Patients Reporting Outcomes: Are We Getting It Right?

Commentary on an article by Frederick A. Matsen III, MD, et al.: “Relationship Between Patient-Reported Assessment of Shoulder Function and Objective Range-of-Motion Measurements”

Abrams, Jeffrey S. MD*

doi: 10.2106/JBJS.16.01453
Commentary and Perspective
Related Article

University Medical Center at Princeton, Princeton, New Jersey

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As physicians and surgeons, we continue to measure the value of interventions to our patients. Matsen et al. compared subjective data acquired with the Simple Shoulder Test (SST), a validated questionnaire, with objective measurements of patients with osteoarthritis of the glenohumeral joint. The pendulum has shifted from physician-measured deficits to qualifying patients’ level of satisfaction with their comfort and ability to return to an active lifestyle. The authors showed that both subjective and objective assessments are important in determining the potential and acquired benefits of surgical or medical intervention but either assessment used independently may lead to the wrong impression. Also, combining these measurements into a single score may be misleading because of the potential arbitrary weighting of the importance of one over the other.

It is important to be able to measure patients’ baseline status and clinical changes in order to assess the benefits of intervention and compare them with the natural history of the diseased state. Quantifying deficits and symptoms is key to properly monitoring patients prior to surgical intervention and providing advice on management options. Patients often base their decision regarding treatment on their subjective impressions of their disability combined with the treating physician’s and therapist’s assessment of changes that may or may not occur with physical therapy and self-directed exercises. Combined decision-making provides the best scenario for achieving patient satisfaction1. In addition, preoperative expectations can be best managed by sharing subjective and objective information with the patient. During the course of treatment, physicians rely on subjective and objective measurement tools to measure changes in the patient’s status and use these changes to assess the value of the treatment to that patient. Assessment of the impact of surgical and nonsurgical interventions, in general, relies on these subjective and objective measurement tools.

Osteoarthritis is unique in the shoulder setting because of its gradual onset and, in most cases, the ability of the shoulder to compensate for movement limitations. Different disease processes necessitate separate measurement tools and potentially different patient-completed assessments. Younger patients with objective loss of abduction may qualify their limitations differently than a person in their eighth decade of life. Interestingly, Matsen et al. found a more consistent relationship between measured abduction and the SST score when assessing the contralateral shoulder. Since osteoarthritis of the shoulder is often a bilateral disease state, as indicated by imaging studies, the contralateral shoulder does not truly reflect a baseline status. Also, applying the SST to a nondominant shoulder may be affected by the fact that, for some individuals, using the nondominant shoulder to perform activities— e.g., throwing a ball—may handicap their performance. Nevertheless, the SST has become a validated study questionnaire for obtaining patients’ subjective measurement of their activity level.

The most common task for a physician dealing with a patient with degenerative shoulder disease is qualifying and quantifying pain2,3. This aspect of a patient’s disability level is reflected in some of the SST questions, but additional investigation is needed to determine whether the SST accurately demonstrates the benefit of the intervention in terms of relieving pain and improving function. Fortunately, treatment of osteoarthritis is often successful in terms of reducing pain and improving function. Although not a focus of this study, loss of glenohumeral rotation can also be a disabling feature of this disease.

Patients, physicians, developers of research instruments, payers, and the government are interested in assessing the value of interventions. Separating a patient’s subjective assessment from the objective data obtained by the physician with a physical examination and imaging is the best method to evaluate the enlarging populations undergoing treatment. Using one type of assessment more than the other can lead to false impressions, as can creating scales that combine objective and subjective measurements because of potential arbitrary weighting of the importance of one or the other. Different disease processes need separate measurement tools and potentially different patient-completed assessments.

*On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, the author checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (

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1. Henn RF 3rd, Ghomrawi H, Rutledge JR, Mazumdar M, Mancuso CA, Marx RG. Preoperative patient expectations of total shoulder arthroplasty. J Bone Joint Surg Am. 2011 Nov 16;93(22):2110-5. Epub 2012 Jan 21.
2. Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012 Sep 05;94(17):e127.
3. Castricini R, Gasparini G, Di Luggo F, De Benedetto M, De Gori M, Galasso O. Health-related quality of life and functionality after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2013 Dec;22(12):1639-49. Epub 2013 Mar 19.

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