ISAKOS Scientific Committee Report

Scoring Systems for the Functional Assessment of the Shoulder

Alexandra Kirkley,† M.D., M.Sc., F.R.C.S.C., Sharon Griffin, C.S.S., and

Katie Dainty, M.Sc., C.R.P.C.

Abstract: A number of instruments have been developed to measure the quality of life in patients
with various conditions of the shoulder. Older instruments appear to have been developed at a time
when little information was available on the appropriate methodology for instrument development.
Much progress has been made in this area, and currently an appropriate instrument exists for each of
the main conditions of the shoulder. Investigators planning clinical trials should select modern
instruments that have been developed with appropriate patient input for item generation and
reduction, and established validity and reliability. Among the other factors discussed in this review,
responsiveness of an instrument is an important consideration as it can serve to minimize the sample
size for a proposed study. The shoulder instruments reviewed include the Rating Sheet for Bankart
Repair (Rowe), ASES Shoulder Evaluation Form, UCLA Shoulder Score, The Constant Score,
Disabilities of the Arm, Shoulder and Hand (DASH), the Shoulder Rating Questionnaire, the Simple
Shoulder Test (SST), the Western Ontario Osteoarthritis of the Shoulder Index (WOOS), the Western
Ontario Rotator Cuff Index (WORC), the Western Ontario Shoulder Instability Index (WOSI),
Rotator Cuff Quality of Life (RC-QOL), and the Oxford Shoulder Scores (OSS). Key Words:
Quality of life—Shoulder outcomes—Outcome development.

I n a previous article in this series, the methodology

for the development and evaluation of a disease-
specific quality of life instrument was described. We
will now discuss each of the most commonly used
shoulder scoring systems, commenting on their
strengths and weaknesses. The shoulder instruments
reviewed in this article include the Rating Sheet for
Bankart Repair (Rowe), UCLA Shoulder Score, The
Shoulder Pain and Disability Index (SPADI), ASES
Shoulder Evaluation Form, The Constant Score, Dis-
abilities of the Arm, Shoulder and Hand (DASH), the
From the Fowler Kennedy Sport Medicine Clinic, London, On-
tario, Canada.
†Deceased.
Address correspondence and reprint requests to Katie Dainty,
M.Sc., C.R.P.C., Fowler Kennedy Sport Medicine Clinic, 3M Cen-
tre, University of Western Ontario, London, Ontario N6A 3K7,
Canada. E-mail: kdainty@uwo.ca
© 2003 by the Arthroscopy Association of North America
0749-8063/03/1910-3893$30.00/0
doi:10.1016/j.arthro.2003.10.030
Shoulder Rating Questionnaire, the Western Ontario
Osteoarthritis of the Shoulder Index (WOOS), the
Western Ontario Rotator Cuff Index (WORC), the
Western Ontario Shoulder Instability Index (WOSI),
Rotator Cuff Quality of Life (RC-QOL), and the Ox-
ford Shoulder Scores (OSS).
THE RATING SHEET FOR BANKART
REPAIR
In 1978, Carter Rowe published a classic article
evaluating the long-term results of the Bankart repair.1
It was in this article that he introduced a new rating
system for the postoperative assessment of patients
undergoing anterior stabilization. This system scores
patients based on 3 separate areas—stability, motion,
and function—with 1 item for each of these areas. The
weighting is such that stability accounts for 50 points,
motion for 20 points and function for 30 points, giving
a total possible score of 100 points.
Unfortunately, there are no published reports on the

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 10 (December), 2003: pp 1109-1120 1109
1110 A. KIRKLEY ET AL.
development or testing of this instrument. It is likely
that the items used in the questionnaire were selected
without direct patient input. There are a number of
problems that can be identified with this instrument.
Each of the 3 domains in this instrument contains
“double-barreled” questions, i.e., the subject is asked
to consider more than 1 question at the same time,
each of which may be answered differently. For ex-
ample, in responding to the stability domain, the sub-
ject must choose the best response considering dislo-
cations, subluxations, and apprehension. The motion
domain includes 3 different motions (external rota-
tion, forward elevation, and internal rotation) and the
function domain includes both functional limitation
and pain. Some subjects may choose the response
option only if all conditions are met while others may
choose based on the 1 condition they think is the most
important.
It is unknown why the developers of this instrument
assigned the various weights to the 3 items (stability
accounts for 50%, motion 20%, function 30%). While
not necessarily incorrect, it is unsupported. Similarly,
it is unknown why the items have been assigned what
appear to be random scores. For instance, a total of 30
points are assigned to the function domain. The dif-
ference in score from no limitation to mild limitation
is 5 points, whereas the difference from mild to mod-
erate limitation is 15 points. Although this is not
necessarily incorrect, it is unconventional and is fun-
damentally arbitrary.
It is not clear whether apprehension is to be mea-
sured by asking the patient whether they have appre-
hension or by examining the patient and doing an
apprehension test (putting the arm in a position of
extreme abduction and external rotation and monitor-
ing the sensation of instability). This is important to
define because many patients will deny apprehension
for day-to-day activities but if put in a provocative
position will feel apprehensive.
The evaluation of motion is not defined as active or
passive nor does the instrument describe whether the
scapulothoracic joint is to be stabilized. Further, since
for this instrument, motion is based on a percentage of
the normal shoulder, it is not clear how one would
score a patient who does not have a contralateral
normal shoulder.
This instrument combines 2 items of subjective
evaluation with 1 item of physical examination. As
these items are measuring fundamentally different at-
tributes it is probably not meaningful to combine them
for a total score as is meant to be done in this instru-
ment.
THE UCLA SHOULDER SCORE
The University of California at Los Angeles Shoul-
der Rating scale was first published in 1981 in a paper
by H. C. Amstutz et al.2 The instrument was intended
to be used in studies of patients undergoing total
shoulder arthroplasty for arthritis of the shoulder.
Since then, however, it has been used for patients with
other shoulder conditions including rotator cuff dis-
ease3 and shoulder instability.4
This instrument assigns a score to patients based on
5 separate domains: pain, function, active forward
flexion, strength of forward flexion, and overall satis-
faction. There is 1 item for each of these areas. The
weighting is such that pain accounts for 10 points,
function for 10 points, forward flexion for 5 points,
strength for 5 points, and overall satisfaction for 5
points, giving a total of 35 points.
There are no publications available on the develop-
ment or testing of this instrument. It is likely that the
items on this instrument were also selected by the
authors without direct patient input, similar to the
Rowe instrument. Several problems can be identified
with this tool.
The items in the pain and function domains are
“double-barreled.” As an example, when measuring
pain, the patient is asked to comment on frequency,
severity, and the type and amount of medication that is
required to relieve the pain. This certainly presents
difficulties in choosing an appropriate response when
the patients will be unlikely to find a perfect match
from the response options available.
Again similar to the Rowe, it is unknown why the
developers of this instrument assigned the various
weights to the 5 domains (Pain 28.6%, Function
28.6%, Range of Motion 14.3%, Strength 14.3%, Sat-
isfaction 14.3%). While not necessarily incorrect, it is
unsupported.
The overall satisfaction item only allows for the
instrument to be used after an intervention and not
before and after as would be ideal in most clinical
trials. In addition, it is not clear how a subject would
respond if his or her condition were unchanged.
This instrument also combines 2 items of subjective
evaluation of function with 1 item of physical exam-
ination. As these are measuring fundamentally differ-
ent attributes it is probably not meaningful to combine
them for a total score.
Clearly both of these first 2 instruments were de-
veloped before the advent of modern measurement
development methodology. The problems identified
with these instruments may lead to poor reliability,
 REVIEW OF SHOULDER OUTCOME TOOLS
validity, and responsiveness, and therefore they may
or may not be ideal choices for evaluating patients in
the research or clinical environment.
THE SHOULDER PAIN AND DISABILITY
INDEX (SPADI)
In 1991, Roach et al. published the development
and evaluation of the SPADI.5 The authors state that
“the SPADI was developed to provide a self-admin-
istered instrument that would reflect the disability and
pain associated with the clinical syndrome of painful
shoulder.” It was designed as both a discriminative
and evaluative instrument. The majority of the item
generation and reduction was carried out by a panel of
3 rheumatologists and a physical therapist without
direct patient input. Further items were eliminated
based on poor test-retest reliability or a low correla-
tion with shoulder range of motion (ROM) on the
involved side. Eliminating items based on poor reli-
ability is logical for a discriminative instrument but
not necessarily ideal for an evaluative instrument, as
an item can have poor reliability but be important to
patients and therefore be highly responsive. Eliminat-
ing items based on poor correlation with range of
motion may have a negative impact on the final tool
make-up, as range of motion has been found to rarely
correlate more than modestly with patients’ estimation
of their subjective functioning. There is no report of
formal pretesting.
The instrument has 13 items divided into 2 sub-
scales: pain (5 items) and disability (8 items). The
response format selected for the instrument was the
10-cm VAS anchored verbally at each end. However,
in distinction to the usual method of scoring a VAS in
which the slash on the line is measured from the left
anchor in millimeters, the authors describe dividing
the horizontal line into 12 segments of equal length. A
number ranging from 1 to 11 is attached to the seg-
ment to produce a score for each item.
The scores for the individual items are given equal
weight within their domain and the domain scores are
reported by converting to a score out of 100, with a
score of 0 being perfect and a score of 100 being the
worst score possible. The total score for the instru-
ment is determined by averaging the scores for the two
domains of pain and disability.
The reliability of the instrument has been evaluated
by measuring test-retest reliability over several days in
23 subjects who represented a subset of 37 male
patients presenting to an ambulatory care clinic with a
complaint of shoulder pain and who were subse-
1111
quently enrolled in a randomized clinical trial. The
ages of the subjects ranged from 23 to 76 years, with
a mean age of 58 years. Of the patients included, 27
had shoulder pain of musculoskeletal origin. The ma-
jority of the remaining subjects had shoulder pain of
neurogenic or undetermined origin. The intraclass cor-
relation coefficient (ICC) for the SPADI total score
(.65) and for the pain and disability subscales (.64 and
.64) may be falsely elevated by the short time interval
of several days, which may not be long enough for
subjects to have forgotten their original score. The
diverse population on which it was tested may also
have an effect on the overall outcome. Despite this,
the scores of reliability are only modest. The authors
explain that the subjects may have actually improved
over the short time frame as most were started on an
analgesic at the original visit. As a global rating of
change score was not administered concurrently, it is
unknown if this is the case or not. The authors also
report on the internal consistency of the instrument
using Cronbach’s alpha (total score .95, pain subscale
.86, disability subscale .93). Further, factor analysis
found that most of the items loaded onto 1 factor
supporting the conclusion that the SPADI measures 1
construct. Varimax rotation provided limited support
for 2 subscales.
Limited validation testing has been described. Con-
struct validation consisted of testing the hypotheses
that the SPADI would correlate with baseline shoulder
active ROM (flexion, abduction, extension, external
rotation) measurements as an indicator of discrimina-
tive function and over time using change scores after
an intervention (as a measure of evaluative function).
The tool was administered to all 37 of the previously
described subjects. Correlations with baseline range of
motion ranged from .55 to .80. Correlations with
range of motion change scores ranged from .50 to .70.
The responsiveness has not been formally tested. No
report of the minimally important difference has been
provided.
THE AMERICAN SHOULDER AND ELBOW
SURGEONS EVALUATION FORM (ASES)
In 1993, the Society of the American Shoulder and
Elbow Surgeons developed a standardized form for
the assessment of shoulder function.6 The purpose was
to facilitate communication between investigators and
to permit and encourage multicenter trials. The mem-
bers felt that the required attributes of any new tool
were ease of use, a method of assessing activities of
daily living and inclusion of a patient self-evaluation
1112 A. KIRKLEY ET AL.
section. The research committee of the ASES re-
viewed all published forms available at the time and
based on those and their own ideas developed a pro-
totype instrument. It is not stated how the committee
selected the items for this instrument. The prototype
instrument was distributed to the members, who were
encouraged to use the instrument and then offer con-
structive criticism. More than 70 suggestions to im-
prove the instrument were made after distribution of
the prototype. Following review by the research com-
mittee a second prototype was distributed in the sum-
mer of 1992. A further 15 suggestions were made and
further revisions resulted in the final instrument. The
instrument consists of a physician assessment section
and a patient self-evaluation section.
The physician assessment section includes physical
examination and documentation of range of motion,
strength, and instability, and demonstration of specific
physical signs. No score is derived for this section of
the instrument. The patient self-evaluation section has
11 items that can be used to generate a score. These
are divided into 2 areas: pain (1 item) and function (10
items). The response to the single pain question is
marked on a 10-cm visual analog scale (VAS), which
is divided into 1-cm increments and anchored with
verbal descriptors at 0 and 10 cm.
The 10 items in the function area of the ASES
include activities of daily living such as managing
toileting, putting on a coat, etc. There are more de-
manding activities such as lifting 10 pounds above
shoulder height and throwing a ball overhand. Finally,
there are 2 general items: doing usual work and doing
usual sport. There are 4 categories for response op-
tions from 0 (unable to do) to 3 (not difficult). Because
of this, the responsiveness of the individual items is
likely poor, especially in higher functioning patients.
As an example, if a patient found an activity some-
what difficult prior to treatment he or she would have
to have no difficulty whatsoever after treatment to
improve by 1 category.
The final score is tabulated by multiplying the pain
score (maximum 10) by 5 (therefore total possible 50)
and the cumulative activity score (maximum 30) by
5/3 (therefore, a total possible 50) for a total of 100.
No rationale has been presented for the weighting
scheme of this instrument. While not necessarily in-
correct, it is unsupported. No published data is avail-
able on the testing of this instrument.
Three of these instruments, the Rowe, UCLA score,
and ASES score have been compared in a group of 52
patients with shoulder instability undergoing surgical
stabilization.4 The 3 scales provided remarkably dif-
ferent categorization of patients and correlated poorly
with each other. The authors of this study concluded,
“the most commonly used scoring systems for shoul-
der conditions yield varying results when used to
evaluate shoulder instability outcomes in our patient
population. We urgently need a well-accepted shoul-
der system based on the patient’s functional status to
critically assess our management of various shoulder
conditions.”4
THE CONSTANT SCORE
The Constant Score7 has become the most widely
used shoulder evaluation instrument in Europe. This
scoring system combines physical examination tests
with subjective evaluations by the patients. The sub-
jective assessment consists of 35 points and the re-
maining 65 points are assigned for the physical exam-
ination assessment.
The subjective assessment includes a single item for
pain (15 points) and 4 items for activities of daily
living (work 4, sport 4, sleep 2, and positioning the
hand in space 10 points).
The objective assessment includes: range of motion
(forward elevation, 10 points; lateral elevation, 10
points; internal rotation, 10 points; external rotation,
10 points) and power (scoring based on the number of
pounds of pull the patient can resist in abduction to a
maximum of 25 points). The total possible score is
therefore 100 points.
The publication by Constant7 in which he describes
the instrument does not include methodology for how
it was developed and more specifically, the rationale
for item selection and relative weighting of the items.
The strength of this instrument is that the method
for administering the tool is quite clearly described
which is an improvement on pre-existing tools.
It is unknown why the developers of this instrument
assigned various weights to the items (pain 15%,
function 20%, range of motion 40%, strength 15%).
While not necessarily incorrect, it is unsupported.
This instrument combines 4 items of function with
5 items of physical examination. As these are measur-
ing fundamentally different attributes, they should be
measured separately as opposed to being combined for
a total score.
This instrument is weighted heavily on range of
motion (40%) and strength (25%). Although this may
be useful for discriminating between patients with
significant rotator cuff disease or osteoarthritis, it is
not useful for patients with instability. In fact, in one
study all the patients with instability of the shoulder
 REVIEW OF SHOULDER OUTCOME TOOLS
scored nearly perfectly (95-100) despite having prob-
lems of sufficient magnitude to request surgical inter-
vention. The reliability of this measurement tool has
been evaluated on a limited basis.8 Although the meth-
odology is not described in detail, Constant7 states that
when the instrument was used to assess 100 abnormal
shoulders by 3 different observers, the interobserver
error was an average of 3% ranging from 0% to 8%.
Conboy et al.8 measured the reliability on 25 patients
with varying diagnoses of shoulder syndromes. They
demonstrated that the 95% confidence limit between
observers was 27.7 points and within observers was
16 points. No data on the formal testing of validity nor
the responsiveness of this instrument has been pub-
lished.
THE DISABILITIES OF THE ARM,
SHOULDER AND HAND (DASH)
Recently, the American Academy of Orthopaedics
Surgeons (AAOS) along with the Institute for Work &
Health (Toronto, Ontario, Canada) developed an out-
come tool to be used for patients with any condition of
any joint of the upper extremity. This instrument
called the Disabilities of the Arm, Shoulder and Hand
Measurement tool or DASH is made available by the
AAOS. A brief description of the methodology for the
item generation and the initial item reduction phases
has been published.9 In 1999, the AAOS and Institute
for Work & Health developed and published a User’s
Manual for the DASH outcome measure.10 The com-
plete development and testing of the instrument is
detailed in this manual.
The DASH is a 30-item questionnaire designed to
evaluate “upper extremity-related symptoms and mea-
sure functional status at the level of disability.” Dis-
ability is defined as “difficulty doing activities in any
domain of life (the domains typical for one’s age/sex
group) due to a health or physical problem.”11 Con-
cepts covered by the DASH include symptoms (pain,
weakness, stiffness, and tingling/numbness), physical
function (daily activities, house/yard chores, shop-
ping, errands, recreational activities, self-care, dress-
ing, eating, sexual activities, sleep, and sport/perform-
ing art), social function (family care occupation,
socializing with friends/family) and psychological
function (self-image).
Item generation was carried out by first reviewing
the literature. Thirteen scales were combined to pro-
duce an initial pool of 821 items. Item reduction was
carried out in 2 steps. Three members of the collabo-
rative development group reviewed the original items.
1113
The items were stripped of scaling and attribution to a
specific disorder. Items that were repetitive or obvi-
ously unrelated to the upper extremity were elimi-
nated. The reduced list was then sent to clinician
“content experts” for their input as to content/face
validity and the importance of the items (5 point scale:
2 ⫽ definitely yes, to ⫺2 ⫽ definitely no). This
allowed for reduction of 821 potential items to a 67
item questionnaire.
The 67 items were reformatted into a questionnaire
suitable for field testing. This questionnaire was pre-
tested on 20 patients with upper limb problems to
ensure readability, absence of ambiguity, and under-
standing of scaling and content, as well as to confirm
that an adequate number/type of response items were
available. In this publication the authors state,
“. . . further item reduction will be carried out after
field testing of the questionnaire on 420 patients in
Canada, Australia, and the United States. Frequency
of endorsement and internal consistency will be as-
sessed using the data generated by the field testing.
Items with a very high or low endorsement rate or
excessively high correlations with other items in the
same scale will be eliminated. Factor analysis will
also be used to empirically validate the aggregation of
items into subscales.” This testing was actually com-
pleted by Marx et al. in 1996.
The major criticism of this tool is that the item-
generation phase did not include interviews with pa-
tients with the conditions of interest. It has been well
documented that physicians are poor judges of patient
status12,13 and likely are poor judges of what is im-
portant to patients. The initial item reduction was done
by clinicians, although it has been reported that item
impact, as determined from patient input, was used for
the remainder of the item reduction.
There are several examples in the DASH where one
item is a more specific version of another item. For
example, item 324 “pain in the arm, shoulder, or hand
when performing any specific activity” is a more
specific version of item 323, which asks about arm,
shoulder, or hand pain in general. It is unclear why
they would choose 2 items where the more specific
one would make up part or all of the response to the
more general one. Similarly, the 4 questions relating
to sports or playing an instrument would appear to
have considerable overlap. Item 332, “difficulty play-
ing your musical instrument or sport as well as you
would like” would have a large contribution from item
331 “difficulty playing your musical instrument or
sport because of pain.” Although it is not technically
incorrect, it builds in considerable redundancy into the
1114 A. KIRKLEY ET AL.
tool, which has the effect of attributing more weight or
value to these items.
This instrument is intended for patients with any
condition of any joint of the upper extremity. This
makes it attractive for use in the clinical setting where
patients present in an undifferentiated fashion. The
patients can complete the questionnaire before a diag-
nosis is established. There is also much more infor-
mation currently available on scoring of the DASH
now that the DASH User’s Manual is available. This
is a very useful resource for clinicians interested in
properly implementing the DASH as an outcome tool
in their practice.
Unfortunately the broader scope of this instrument
makes it less attractive for use in a clinical trial. Many
of the items may seem irrelevant to patients with
specific conditions. In addition, this instrument has
been shown to be less responsive than other shoulder
specific and shoulder condition specific instruments
making it less efficient as a research tool.14-16
THE SHOULDER RATING
QUESTIONNAIRE
In 1997, L’Insalata et al. published the Shoulder
Rating Questionnaire “a self-administered question-
naire for the assessment of symptoms and function of
the shoulder.”18 It is unknown how the items on the
instrument were generated or selected. It is simply
stated that “A preliminary questionnaire was devel-
oped.” The preliminary questionnaire was adminis-
tered to 30 patients and a subset of those patients were
interviewed to identify clinical relevance, relative im-
portance, and ease of completion and grading. This
allowed for modifications to be made to produce a
revised questionnaire. An “assessment” of the ques-
tionnaire was said to have been completed, after
which “questions that had poor reliability, substan-
tially reduced the total or subset internal consistency,
or contributed little to the clinical sensitivity of the
over-all instrument were eliminated to produce the
final questionnaire.”
The final instrument includes 6 separately scored
domains: global assessment, pain, daily activities, rec-
reational and athletic activities, work, and satisfaction.
A final, nongraded domain allows the patient to select
2 areas in which he or she believes improvement is
most important. The global assessment domain con-
sists of a single VAS. Each of the other scored do-
mains consists of a series of multiple-choice questions
with 5 response categories from 1 (poorest) to 5 (best).
Each domain is scored separately by averaging the
scores of the completed questions and multiplying by
two. Thus, the possible score for each domain ranges
from 2 (poorest) to 10 (best). Further, the investigators
suggest a weighting scheme based on “consultation
with several shoulder surgeons and patients regarding
the relative importance of each of the domains.” The
weighting is as follows: global assessment 15%, pain
40%, daily activities 20%, recreational and athletic
activities 15%, work 10%. Therefore, the total possi-
ble score ranges from 17 to 100.
Testing of this instrument has been described by the
developers. Test-retest reliability was evaluated in 40
patients with a wide variation of characteristics (age,
gender, shoulder disease, and severity) at variable
time intervals within 1 week of initial administration
(mean of 3 days, range 1 to 7 days). They reported the
Spearman Rank Correlation Coefficient for the overall
instrument (.96) and each of the domains (range .81-
.96). A criticism of this approach is that the values
may have been falsely elevated for 2 reasons. First, 3
days is unlikely to be long enough for patients to
forget their previous responses, making it more likely
that they could reproduce their original score. Second,
because reliability is a measure of the between-person
variance to the total variance, testing reliability in
such a diverse population increases the numerator,
giving a higher reliability than one might get in a
population more representative of a typical study pop-
ulation where all the patients have only 1 condition.
To date, the responsiveness for this tool has not been
compared with any other existing shoulder instru-
ments.
The investigators indicate that a difference of 12
points for the total score and 2 points for each domain
score compared with pretreatment scores is clinically
important although the rationale for the selection of
these values is not described.
The validation described consisted of correlating
scores on the Shoulder Rating Questionnaire with
comparable domains of the Arthritis Impact Measure-
ment Scales 2. No a priori predictions were made and
no interpretation of the observed correlations (ranging
from .56 to .89) is described. A second construct was
tested: that patients who selected a particular domain
as an important area for improvement would score
lower on that domain than patients who did not select
it as an important area. A significant difference was
found for each of the 4 domains tested (pain, daily
activities, recreation/athletic activities, and work).
Construct validation through correlations between this
instrument and other measures of shoulder function
have not been determined.
 REVIEW OF SHOULDER OUTCOME TOOLS
THE SIMPLE SHOULDER TEST (SST)
In 1992 Lippitt, Harryman, and Matsen reported on
the development and testing of the Simple Shoulder
Test (SST).19 The purpose of the instrument is stated
to be a means of documenting the functional improve-
ment resulting from a specified procedure performed
by a specific surgeon in response to a given diagnosis
and to characterize the severity of the condition.
The SST consists of 12 questions with “yes or no”
response options. The instrument combines subjective
items and items that actually require the patient to
perform a physical function. For example, the patient
is asked “Does your shoulder allow you to sleep
comfortably?” which is subjective and “Can you lift 8
pounds to the level of your shoulder without bending
your elbow?” which requires the patient to perform
the maneuver.
Item generation and reduction was based on Neer’s
evaluation,20 the ASES evaluation,21 and observation
of complaints of patients by the instrument develop-
ers. It is not clear how the final 12 items were actually
selected. The tool was administered to 49 subjects
between the ages of 60 and 70 with (1) no history of
shoulder disease, injury, or surgery, (2) no shoulder
symptoms, and (3) a normal shoulder ultrasound to
rule out silent rotator cuff tears. Essentially, all pa-
tients obtained a perfect score (3% unable to place 8 lb
at head level, 2% unable to carry 20 lb at the side, 5%
incapable of throwing 20 yards). The tool has been
administered to 250 patients with different diagnoses
(osteoarthritis, rheumatoid arthritis, avascular necro-
sis, subacromial impingement, rotator cuff tears, fro-
zen shoulder, traumatic anterior instability, and mul-
tidirectional instability). The instrument is able to
distinguish between patients with these conditions and
normal shoulder function. The authors noted distinct
patterns between groups of patients with the different
conditions, indicating that the instrument might be
helpful in establishing a diagnosis. Some data on the
SST following patients after rotator cuff repair indi-
cates that the instrument can be used to determine
what functional improvement the average patient ob-
tains post treatment. The authors provide no report of
formal testing of reliability of this instrument. The
responsiveness has not been evaluated nor compared
with other measures of shoulder function. The SST is
unlikely to be sensitive to small but clinically impor-
tant changes in patient function because of the dichot-
omous response options (yes or no). For the same
reason, the instrument is likely have poor discrimina-
1115
tive function to differentiate between patients with
varying severity of the same condition.
THE WESTERN ONTARIO SHOULDER
TOOLS
In 1998, Kirkley et al. published the first in a series
of disease-specific quality of life measure tools for the
shoulder, The Western Ontario Shoulder Instability
Index (WOSI).14 This instrument was developed and
evaluated using the methodology as described by
Kirschner and Guyatt.22 The stated purpose of the
instrument was for use as the primary outcome mea-
sure in clinical trials evaluating treatments for patients
with shoulder instability.
In 2001, the second in the series of disease-specific
quality of life instruments for the shoulder, The West-
ern Ontario Osteoarthritis of the Shoulder Index
(WOOS), was published.23 The authors state that the
instrument was developed and evaluated using similar
methodology as was used in the development of the
WOSI.14 The WOOS is meant for use as the primary
outcome measure in clinical trials evaluating patients
with symptomatic primary osteoarthritis of the shoul-
der.
Most recently, in 2003, the third instrument in the
series, the Western Ontario Rotator Cuff Index
(WORC) was accepted for publication as a primary
outcome measure in clinical trials evaluating treat-
ments for patients with degeneration of the rotator
cuff.15 The WORC was also developed and evaluated
using the methodology as described by Kirschner and
Guyatt.22
Item generation was carried out in 3 steps for all 3
of the tools, which included a review of the literature
and existing instruments, interviews with clinician
experts, and interviews with 33 patients (sampled to
redundancy), representing the full spectrum of patient
characteristics. Item reduction was carried out using
the frequency importance product (impact) from a
survey of 100 patients representing the full spectrum
of patient characteristics and a correlation matrix to
eliminate redundant items. The response format se-
lected for the instrument was the 10-cm VAS an-
chored verbally at each end. The prototype instrument
was pretested on 2 consecutive groups of 10 patients.
The items were assigned equal weight based on the
uniformly high impact scores.
A database of patients meeting the inclusion/exclu-
sion criteria for symptomatic shoulder instability from
all the clinically relevant categories with the exception
of fixed dislocations was established. A database of
1116 A. KIRKLEY ET AL.

TABLE 1. The Western Ontario Instruments

WOSI (21 items) WORC (21 items) WOOS (19 items)

Physical Symptoms (10 items)
Sport/Recreation/Work Function (4 items)
Lifestyle Function (4 items)
Emotional Function (3 items)
Physical Symptoms (6 items)
Sport/Recreation (4 items)
Work Function (4 items)
Lifestyle Function (4 items)
Emotional Function (3 items)
Physical Symptoms (6 items)
Sport/Recreation/Work Function (5 items)
Lifestyle Function (5 items)
Emotional Function (3 items)

patients meeting the inclusion/exclusion criteria for
symptomatic rotator cuff disease including rotator cuff
tendinitis, rotator cuff tendinosis with no tear, partial-
thickness rotator cuff tears, full-thickness rotator cuff
tears (small to massive) and rotator cuff arthropathy
was established. Similarly, a database of patients of all
ages with a diagnosis of primary osteoarthritis of the
shoulder was defined and established.
The Western Ontario instruments are constructed as
shown in Table 1. Each instrument includes instruc-
tions to the patients, a supplement with an explanation
of each item, and detailed instructions for the clinician
on scoring. The authors recommend using the total
score for the primary outcome in clinical trials but also
recommend reporting individual domain scores. The
scores can be presented in their raw form or converted
to a percent score. The best possible total score is
100% (raw score ⫽ 0) and signifies that the patient has
no decrease in shoulder-related quality of life. The
worst possible score is 0% (raw score ⫽ 2,100 in the
WOSI and the WORC and 1,900 in the WOOS) and
signifies that the patient has an extreme decrease in
shoulder-related quality of life.
Validity has been assessed through construct vali-
dation by making a priori predictions of how the
instrument would correlate with other measures of
health status at 1 time point, as an indicator of dis-
criminative function, and over time using change
scores after an intervention of known effectiveness, as
a measure of evaluative function (Table 2).
THE WESTERN ONTARIO SHOULDER
INSTABILITY INDEX (WOSI)
The reliability of the WOSI has been evaluated in
51 stable patients at 2 weeks and 3 months in con-
junction with a global rating of change score. The
patient population tested was only briefly described as
patients with shoulder instability who were stable and
it is not clear how diverse a population this was. The
ICCs at 2 weeks and 3 months for the total score (.95
and .91) and individual domain scores (range .72 to
.94) are reported.
The instrument was administered to 47 patients
undergoing surgical repair for anterior instability. All
correlations were within .2 of the predicted values. As
predicted, the WOSI correlated best with the DASH as
both a discriminative and evaluative instrument (r ⫽
.77, r ⫽ .76) and showed poor correlations with the
SF-12 mental score (r ⫽ .115 discriminative; r ⫽ .12
evaluative).
The responsiveness has been evaluated using the
Standardized Response Mean and compared with the
other measures of shoulder function in the same 47
patients used for the validation testing. The WOSI was
more responsive than the others tested (in order of
responsiveness: WOSI, Rowe, DASH, Constant
Score, ASES, Range of Motion, UCLA, SF-12 phys-
ical, and SF-12 mental).
The minimally important difference was estimated
in the same group of 47 patients.25 The patients were
administered the WOSI concurrently with a 5-point
global rating of change score. Patients were asked
whether, after treatment, they were better, worse, or
the same. If they indicated that they were better or
TABLE 2. The Western Ontario Indexes
Western Ontario
Index Correlated Measures
WOSI ASES, UCLA, Constant, DASH, Rowe, SF-12
(Physical & Mental domains), and range of
motion
WORC ASES, UCLA, Constant, DASH, Global
Rating of Change, Sickness Impact Profile
Total Scale, SF-36 (Bodily Pain/Physical,
Social Function/Lifestyle, Physical Role
Limitation/Work and Mental Health
domains), and range of motion
WOOS ASES, UCLA, Constant, Global Rating of
Change, McGill Pain Questionnaire, McGill
VAS, SF-12 (Physical & Mental domains),
and range of motion
 REVIEW OF SHOULDER OUTCOME TOOLS
worse, they were asked to quantify their change on a
5-point scale (1 to 5, very little different to a great deal
different). Patients with 1 or 2 points change were
considered minimally different, 3 or 4 points change
moderately different, and those with 5 points change a
great deal different. The estimates were as follows:
MID change in total score of 220 (10.4%), moderate
difference change in total score of 469 (22.3%), and
large difference change in total score of 527.46 (25%).
The confidence intervals around these estimates were
large because of the small number of patients involved
in the determination. Further testing is needed to make
more accurate estimates.
The WOSI is more responsive than other tools for
shoulder instability. Richards et al.16 reported on the
results of treatment of posterior shoulder instability
and determined that the WOSI was more responsive
than the SPADI, DASH, Constant, and ASES. The
results of a randomized clinical trial evaluating the
treatment of patients with a first anterior dislocation of
the shoulder showed that the WOSI was more respon-
sive than other instruments tested.26 (In order of re-
sponsiveness: WOSI, Rating Sheet for Bankart Re-
pair, DASH, Constant, ASES, ROM, UCLA, SF-12
physical score, and SF-12 mental score).
THE WESTERN ONTARIO
OSTEOARTHRITIS OF THE SHOULDER
INDEX (WOOS)
The reliability of the WOOS instrument has been
evaluated in 58 stable patients at 3 months in conjunc-
tion with a global rating of change score. The patient
population tested was described as meeting the inclu-
sion criteria of primary osteoarthritis of the shoulder.
The ICC was calculated based on the 22 subjects who
remained stable over the 3 months. The ICC for the
total score was .96 and for each of the domains ranged
from .87 to .95. This number may be falsely decreased
by the long test-retest interval of 3 months.
The instrument was administered to 41 patients
selected from the database undergoing treatment for
osteoarthritis of the shoulder. All correlations were
within .2 of the predicted values. As predicted, the
WOOS correlated best with the Constant Score as
both a discriminative and evaluative instrument (r ⫽
.69, r ⫽ .73).
The responsiveness was evaluated using the Stan-
dardized Response Mean and compared with the other
measures of shoulder function in 41 patients involved
in a randomized clinical trial of hemiarthroplasty ver-
sus total shoulder arthroplasty.15 The WOOS was
1117
more responsive than the others tested (in order of
responsiveness WOOS, McGill VAS, UCLA, ASES,
McGill Pain, Constant Score, SF-12 physical, ROM,
and SF-12 mental).
No estimate of the minimally important difference
or the responsiveness data has been reported for the
WOOS. This instrument has been translated and val-
idated in French, Spanish, and German.
THE WESTERN ONTARIO ROTATOR CUFF
INDEX (WORC)
The reliability and validity of the WORC was as-
sessed in patients who were being treated for rotator
cuff tendinosis with no or a small full-thickness cuff
tear. Patients completed the WORC and other mea-
sures of health as well as a global rating of change
score. Those that indicated they had not changed at 2
weeks were used for the analysis of reliability. The
ICC was calculated based on the 50 subjects who
remained stable over the 2 weeks. The ICC for the
total score was .96 and for each of the domains ranged
from .63 for the emotional well being domain to .91
for the physical symptoms domain.
The instrument was administered to 110 patients
with rotator cuff tendinopathy or small full-thickness
cuff tears who were undergoing active treatment (in-
jections, physiotherapy, or arthroscopy and subacro-
mial decompression) All correlations were within .2
of the predicted values. The WORC correlated best
with the ASES and DASH as a discriminative instru-
ment (r ⫽ .73, r ⫽ .69) and with the ASES and UCLA
as an evaluative instrument (r ⫽ .75, r ⫽ .65). Data on
the responsiveness of the WORC tool has not been
reported.
The minimally important difference was calculated
using 44 patients meeting specific inclusion/exclusion
criteria for chronic cuff tendinosis without tear under-
going treatment with subacromial injection. They
were prospectively evaluated at baseline and 3 months
after injection using a global rating of change and the
WORC Index. Patients were asked whether, after
treatment, they were better, worse, or the same. If they
indicated that they were better or worse, they were
asked to quantify their change on a 5-point scale (1 to
5, very little different to a great deal different). Pa-
tients with 1 or 2 points change were considered
minimally different, 3 or 4 points change moderately
different, and those with 5 points change a great deal
different. The estimates were as follows: MID change
in total score of 245.26 (11.7%), moderate difference
change in total score of 371.3 (17.68%), and large
1118 A. KIRKLEY ET AL.
difference change in total score of 773.4 (36.82%).
The confidence intervals around these estimates were
large because of the small number of patients involved
in the determination. Further testing is needed to make
more accurate estimates. This instrument has also
been translated into French and German.
THE ROTATOR CUFF QUALITY-OF-LIFE
MEASURE (RC-QOL)
In October 2000, Hollinshead et al. published a
paper reporting on the 6-year follow-up of large and
massive rotator cuff tears.27 In the article, they intro-
duced a new disease-specific quality of life instrument
for patients with rotator cuff disease. The instrument
was developed and tested using similar methodology
to that described by Guyatt et al.28 This instrument is
indicated for use as an outcome tool in patients with
the “full spectrum of rotator cuff disease.”
Item generation was carried out in 3 steps, including
a review of the literature and existing outcome tools,
discussions with clinician experts, and “direct input
from a set of patients with a full spectrum of rotator
cuff disease ranging from primary impingement ten-
dinopathy to massive rotator cuff defects.” It is not
stated how many patients were interviewed nor how
many items were generated at this phase. A prelimi-
nary questionnaire was formulated using 10-cm VAS
response format. The preliminary questionnaire was
pretested on 20 patients with documented rotator cuff
disease. Patients underwent a structured interview
consisting of 5 questions pertaining to whether the
items were semantically appropriate, whether the pa-
tient considered the items important to his or her
quality of life, whether the patient could comprehend
the question, and whether the patient would suggest
any modifications to the questionnaire.” A revised
55-item questionnaire was then developed. The au-
thors describe further item reduction, from 55 to 34
items, but do not provide details on the methodology.
They state “On the basis of qualitative and quantita-
tive criteria, reduction of this 55-item instrument to a
smaller, more manageable questionnaire was consid-
ered.” The qualitative criteria included the importance
of each item in demonstrating a quality-of life issue,
the importance of each item to patients and the elim-
ination of redundancy or ambiguity. The quantitative
criterion was based on reliability testing. Items that
had an average difference score of 15% or greater
were eliminated from the tool. Although eliminating
items based on poor reliability is logical for a discrim-
inative instrument it is not necessarily ideal for an
evaluative instrument as an item can have poor reli-
ability but be important to patients (high impact) and
be highly responsive.
The instrument has 34 items with 5 domains: Symp-
toms and Physical Complaints (16 items), Sport/Rec-
reation (4 items), Work-Related Concerns (4 items),
Lifestyle Issues (5 items), and Social and Emotional
issues (5). The instrument does provide instructions to
the patients. It asks the patients to consider the last 3
months when answering questions which may be too
long for most patients’ recall. Some of the items are
double barreled as they ask the subject to consider
pain and difficulty at the same time. The response
options are written such that the best score is 100 mm
and the worst score is 0 mm. However, because the
items are asking about symptoms, this requires the
patient to consider the amount of the symptom from
right to left as opposed to the traditional left to right.
It is unknown if this presents any difficulty to patients.
The reliability of the instrument was evaluated in 30
consecutive patients with an interval of 2 weeks. The
patient population tested was not described other than
they had documented rotator cuff disease. The authors
report “average difference in score” as a measure of
reliability. The average difference for the total score
was 5.05%. The reliability of each of the domains is
not reported. The ICC values are not reported.
Some validation of the discriminative function of
the RC-QOL has been performed. The RC-QOL has
been correlated with other measures of shoulder func-
tion and measures of health status (Functional Shoul-
der Elevation Test, ASES, and SF-36) at final fol-
low-up (average, 42 months; range, 25 to 71 months)
in 70 patients undergoing surgical treatment for large
and massive rotator cuff tears. The authors do not
comment on the surprisingly high correlations be-
tween it and the generic health profile, the global
shoulder tool and the functional test. The RC-QOL
correlated very highly with the SF-36 (.78) the ASES
(.84), and the FSET (.84). In addition, the hypothesis
that the RC-QOL should be able to distinguish be-
tween patients with large and massive rotator cuff
tears as further indication of its discriminative func-
tion is described. The RC-QOL, ASES, and the FSET
were all able to distinguish between patients with
large and massive cuff tears in this sample of 73
shoulders (17 large and 56 massive cuff tears) at final
follow-up. No validation of the instrument’s evalua-
tive function has been reported. The responsiveness
and determination of the minimally important differ-
ence have also not been reported.
 REVIEW OF SHOULDER OUTCOME TOOLS
For example:
Question: With any prolonged activity how much
pain or discomfort do you experience in your shoul-
der?
0 100
Severe Pain No pain at all
The authors recommend converting the raw scores
(0 to 3,400; 0 ⫽ worst score, 3,400 ⫽ best score) to a
percentage score, i.e., presenting scores out of 100.
OXFORD SHOULDER SCORES (OSS)
Similar to Kirkley et al., Dawson, Fitzpatrick and
Carr29 have published 2 questionnaires that deal with
the perceptions of patients about shoulder surgery.
The first, the Oxford Shoulder Score (OSS) was pub-
lished in 1996 and is for patients having shoulder
operations other than stabilization. The second ques-
tionnaire was published in 1999 and is meant for the
group of patients who had been excluded from the
original questionnaire, those presenting with shoulder
instability.30 Both are 12-item questionnaires with
each item scored from 1 to 5, from least to most
difficulty or severity, combined to produce a single
score ranging from 12 (best score) to 60 (worst score).
The Oxford Shoulder Instability Questionnaire was
developed by interviewing 20 patients referred to an
outpatient clinic with shoulder instability. It is un-
known whether these patients represented all types of
shoulder instability categories, age, gender, and treat-
ment experiences. Based on the interviews, an 18-item
instrument was drafted and then pared down to 12
questions following pretesting on a further 2 groups of
20 patients. It is not stated by what method the items
were selected or discarded. The instrument has been
tested for test-retest reliability in 34 patients at 24-
hour recall period. The ICC was not calculated; how-
ever, it is likely that the Pearson Correlation Coeffi-
cient closely approximates it. The r value was
reported as .97. The recall period was very short for
this type of assessment raising the possibility that
patients were able to remember their previous scores
and artificially increasing the r value. Construct va-
lidity has been determined through prospective studies
in which both instruments have been compared to
other outcome tools as discriminative instruments (1
point in time both before treatment and at 6 months
after treatment). Although predictions as to how the
instruments should correlate were not made, the re-
sults, which show modest correlation with the other
1119
shoulder instruments and the appropriate domains of
the global tools, seem appropriate. Finally, respon-
siveness or sensitivity to change was measured by
comparing the effect sizes of the new questionnaires
and the SF-36 scores, as well as the HAQ, Constant,
and Rowe scores in patients undergoing surgical sta-
bilization. The results show that the instruments were
more sensitive than the generic instruments. In addi-
tion, the new questionnaire was compared with the
other instruments for the ability to distinguish between
patients who reported the most positive change in their
shoulder from all other patients on 3 separate ques-
tions of patient perception of overall success of treat-
ment, room for improvement, and perception of im-
provement in shoulder problems following treatment.
Medium-term results have also been reported for
the OSS.31 Once again comparisons were made with
the SF-36 and the Constant Shoulder score. In addi-
tion to these measures, patients were also asked to
assess the success of their surgery and to judge the
degree of change in the symptoms arising from their
shoulder. Ninety-three patients were assessed preop-
eratively, and at 6 months and 4 years postoperatively.
The correlation coefficients between the absolute
scores of the OSS, the Constant assessment and the
relevant dimensions of the SF-36 were generally high
(r ⬎ .5) and highly significant. Comparisons between
mean change scores, grouped responses, and the pa-
tient satisfaction question further strengthened support
for the OSS questionnaire. Patients reported consider-
able differences in mean change scores 6 months
postoperatively on the Constant, OSS, and relevant
domains of the SF-36. Similar results at the 4-year
assessment were shown for the OSS and the pain
dimension of the SF-36. Interestingly, differences at
this stage for the Constant barely approached signifi-
cance, mean differences being significantly reduced
between the 6-month and 4-year assessment points.
This suggests that the reliability and sensitivity of the
Constant Score relative to the OSS were significantly
reduced over the long term. However, in reporting all
of these medium-term results, the authors acknowl-
edge that only 66% of the original sample underwent
a clinical assessment at the 4-year mark and that this
variation in the period of follow-up may have affected
the clinical validity of the investigation.
It would seem from the publications that these ques-
tionnaires have been tested and should provide reli-
able, valid, and responsive information. The authors
of the present article have no experience with these
particular tools and perhaps in the future, more infor-
mation regarding their effectiveness will be available.
1120 A. KIRKLEY ET AL.
CONCLUSION
In summary, older instruments designed for evaluating
shoulder conditions were developed at a time when little
information was available or little attention was paid to
the appropriate methodology for such endeavors. How-
ever, there now exist a number of instruments that are
excellent for specific conditions of the shoulder. Much
work remains to be done to evaluate these instruments in
specific patient populations, to determine values for the
minimally clinically important difference for each of
these tools, and to develop valid translations such that
they can be used internationally. It is clear that much
progress has already been made in this area of orthopae-
dic surgery and that currently there exists an appropriate
instrument for each of the main conditions of the shoul-
der. Investigators planning clinical trials should select a
modern instrument developed with appropriate patient
input for item generation and reduction, established va-
lidity, and reliability. All things being equal, the most
responsive instrument available should be used in order
to minimize the sample size for the proposed study.
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