Current Concepts
Analysis of Evidence-Based Medicine for Shoulder Instability

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Abstract

Clinical research has become a major influencing factor in the determination of treatment choice in our society. Outcome data have been requested by third-party payers, patients, and administrators alike. Currently, there are over 10 different scoring systems that have been used to evaluate the efficacy of treatment for shoulder instability. Some of these scoring systems are based on the specific condition of shoulder instability; however, other systems are broadly based to incorporate a spectrum of shoulder conditions. This review summarizes the process of proper development and testing of the scoring systems, discusses their role in clinical research with respect to shoulder instability, and explains the dichotomy of postoperative recurrence of instability and high shoulder scores. The Shoulder Rating Questionnaire (SRQ), Melbourne Instability Shoulder Score (MISS), Western Ontario Shoulder Instability Index (WOSI), Oxford Instability Score (OIS), and Simple Shoulder Test were shown to be reliable for patients with instability. The SRQ, MISS, WOSI, OIS, and American Shoulder and Elbow Surgeons score have all been shown to be largely responsive. There are 2 shoulder scoring systems, the WOSI and the MISS, that we recommend be used to evaluate shoulder instability. The SRQ and OIS were found to be less responsive for patients with instability compared with patients with other shoulder dysfunctions. Other scoring systems lack inter-rater reliability, validity, and/or responsiveness for patients in the instability population. The optimal scoring system for patients with upper extremity problems other than those with shoulder instability has yet to be determined; however, the American Shoulder and Elbow Surgeons score may be considered, because this instrument has been proven to be valid, reliable, and responsive.

Section snippets

Instrument Development and Testing

A proper quality-of-life tool requires a formal development process and extensive instrument testing. The approach to this methodology is described by Guyatt and colleagues10 and is divided into 2 phases with a total of 9 steps. The first phase, the development process, involves 4 steps. The first step specifies measurement goals. The next step is item generation. This is both expert and patient based. The third step involves item reduction. The fourth step is questionnaire formatting. This

Scoring Systems

When creating a shoulder scoring system, patient input and feedback should be emphasized. The population for whom the tool is being designed should be adequately defined. The purpose of the instrument should be discriminative, evaluative, or predictive. Discriminative systems will differentiate between patients with different levels of a condition, whereas evaluative systems will determine the effectiveness of the treatment. Predictive systems will classify individuals against an external

Discussion

Overall, there were a total of 11 scoring systems that were thoroughly evaluated. Systems were evaluated for proper development, reliability, validity, and responsiveness for a homogeneous subset of patients with known instability (Table 2). Only 3 of the 11 scoring systems, the MISS, the DASH, and the WOSI, appear to have used an adequately described development process. Most of the other systems either did not provide a description of item generation and/or reduction or provided a limited

Conclusions

It is imperative to develop common guidelines and criteria for treatment, which will facilitate identification of effective outcomes for similar conditions. Comparative prospective studies should be encouraged. There is a need for a standardized measuring system that incorporates the following: (1) it must satisfy the needs of those using it, (2) it must satisfy development testing criteria, (3) it must be strongly weighted toward functional outcome, (4) it must be simple and effective, and (5)

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    The authors report no conflict of interest.

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