Du Hwan Kim

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Outcome Measurement in Shoulder Diseases: Focus on Shoulder Pain and Disability Index (SPADI)  Du Hwan Kim, MD, PhD  Department of Physical Medicine and Rehabilitation, Chung-Ang University College of Medicine, Seoul, Korea  Editorial: Outcome Measures in Rehabilitation MedicineAnn Rehabil Med 2023;47(5):315-317eISSN: 2234-0653https://doi.org/10.5535/arm.23130Received: September 11, 2023 Revised: September 14, 2023 Accepted: September 18, 2023 Correspondence: Du Hwan KimDepartment of Physical Medicine and Rehabilitation, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea.Tel: +82-2-6299-1884Fax: +82-2-6299-1886E-mail: ri-pheonix@hanmail.netCopyright © 2023 by Korean Academy of Rehabilitation Medicine   This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Physiatrists deal with the evaluation, diagnosis and nonsurgical management of neuromuscu-loskeletal conditions, of which shoulder pain (such as rotator cuff spectrum diseases, frozen shoulder, degenerative arthritis, instability, and rheumatic diseases) is one of the common man-ifestations. Outcome measures for shoulder care included pain severity, range of motion, and patient-reported outcome measures (PROMs). In this editorial, I would like to comment on some issues regarding PROMs applied to shoulder diseases and recommend options for appro-priate PROMs in Korean clinical settings. There are numerous PROMs with more than 30 different tools for measuring the symptoms and functional states of patients with shoulder diseases [1-4]. Validated legacy PROMs com-monly refer to Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its Short Version (QuickDASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society Standardized Shoulder Assessment Form, Constant (Mur-ley) Score (CS), Simple Shoulder Test, Oxford Shoulder Score, and Western Ontario Rotator Cuff index (WORC) [5]. Previous articles summarized the psychometric properties of legacy PROMs for shoulder diseases [1,2,6]. While these instruments have an overall high quality of psychometric properties, respondent and administrative burdens and ceiling/floor effects have been reported in some PROMs such as ASES and DASH [6]. Most PROMs were developed in English. The preferred PROMs tend to differ depending on the continent because of the historical requirements and availability of the translated version [7]. A recent survey reported that ASES was most commonly used in articles originating from North America and Asia, while it was CS from Europe [7]. Although there are few reports on the transcultural adaptation validation of the ASES in Asia, the fact that many studies using the ASES have been published indicates that it involves a transcultural adaptation issue [8-10]. As far as my knowledge, validity studies on the Korean versions of the SPADI and DASH have been conducted, but there is no validation of the Korean versions of other commonly used eval-uation tools, such as the ASES, CS, and WORC [11]. A transcultural adaptation procedure from the English version to the Korean version for major PROMs and a comparative analysis of the psychometric properties of the Korean and original versions are needed. Currently, there is no consensus regarding the recommended PROMs for specific shoulder diseases. A recent study revealed that ASES was most commonly used for rotator cuff and sub-acromial pathology, followed by DASH and SPADI, while the use of SPADI is overwhelming for 316 www.e-arm.orgDu Hwan Kim Outcome Measures for Monitoring Shoulder Diseaseshoulder stiffness, calcific tendinitis, and nonspecific shoulder pain [12]. Moreover, a recent study demonstrated that the SPA-DI can be used as a shoulder-specific PROMs in patients with rotator cuff tears because of its strong reliability and excellent discriminatory properties [13]. Considering the presence of the Korean version and good evidence in support of its high-quality psychometric properties, the SPADI can be recommended for monitoring common shoulder diseases such as rotator cuff pa-thology and shoulder stiffness in Korean clinical practice. The SPADI was designed to evaluate the degree of shoulder pain and discomfort in performing activities of daily living by the patients themselves, without clinician components. The original version was developed by a panel of rheumatologists and physical therapists and was published in 1991 [14]. Be-cause of this background, SPADI still tends to be preferred in the field of rheumatology and rehabilitation medicine. It has 13 items, with 5 items for pain and 8 items for disability. In the original version, items were rated using a visual analog scale; however, in the more recent version, each item used an 11-point numerical rating scale (0–10) (Table 1) [14,15]. SPADI takes 2–3 minutes to complete. The SPADI total score is the mean of the pain and disability sub-scores. SPADI has been shown to have excellent internal reliability/consistency (Cronbach’s alpha=0.86–0.96) and test-retest reliability (intra-class correla-tion coefficient=0.84–0.95) [2,6]. SPADI total score correlated well with the ASES score, although there was a low correlation between the SPADI total score and the Short Form 36. Howev-er, some disability items (items 4, 7, and 8) showed unsuitable criterion validity [6]. Disability items included only one item to assess overhead words or heavy use. Therefore, the SPADI could have a ceiling effect because it is difficult to accurately evaluate activities that require high shoulder function. A pre-vious study reported that the minimum clinically important difference (MCID) of 13.2 was smaller than the minimally de-tectable change (MDC) of 18.1%; thus, a change in the MDC is necessary to be confident in the MCID (Table 1) [16]. In conclusion, I recommend the SPADI as a shoulder-specific PROM in patients with shoulder stiffness, rotator cuff spectrum disease, and nonspecific shoulder pain, given the overall psy-chometric properties and availability of the Korean-language Table 1. SPADI items, practical application and psychometric information 1. SPADI itemsPain scale (5 items) (0=no pain, 10=the worst pain imagnable) Disability scale (8 items) (0=no disability, 10=unable to perform) (1) At its worst?  (1) Washing your hair? (2) When lying on the involvled side?  (2) Washing your back? (3) Reaching for something on a high shelf?  (3) Putting on an undershirt or jumper? (4) Touching the back of your neck?  (4) Putting on a shirt that buttons down the front? (5) Pushing with the involved arm?  (5) Putting on your pants? Total pain score: ______/50×100=%  (6) Placing an object on a high shelf? (7) Carrying a heavy object of 10 pounds (8) Removing something from your back pocket? Total disability score: ______/80×100=%Total SPADI score: ______/130×100=%2. Practical application and psychometric propertiesTime to complete 2–3 minutes to completeTranslation Spanish, Chinese, Arabic, Danish, Norwegian, Dutch, Indian, Hindi, Greek, Turkish, Brazilian Portuguese, Persian, Thai, Nepali, Italian, German, and KoreanReliability Internal consistency (Cronbach’s alpha=0.86–0.96)Test-retest reliability (intra-class correlation coefficient=0.84–0.95)Validity American Shoulder and Elbow Surgeon Score: r=0.77 in patients referred to an upper extremity clinic for shoulder problemsShort Form 36 physical component scale: r=-0.46 in patients with  shouder painAbility to detect change Estimated minimal detectable change 18.1 for musculoskeletal upper extremity problemsEstimated minimal clinically important difference 13.2 for  musculoskeletal upper extremity problemsSPADI, Shoulder Pain and Disability Index.Ann Rehabil Med 2023;47(5):315-317317www.e-arm.orgversion. Considering its frequency of use and psychometric properties, the ASES can also be an excellent option; however, the issue of transcultural adaptation remains. CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was re-ported. FUNDING INFORMATION None. ORCID Du Hwan Kim, https://orcid.org/0000-0002-9980-8549REFERENCES 1. Aldon-Villegas R, Ridao-Fernández C, Torres-Enamorado D, Chamorro-Moriana G. How to assess shoulder functionality: a sys-tematic review of existing validated outcome measures. Diagnostics (Basel) 2021;11:845. 2. Buchbinder R, Ramiro S, Huang H, Gagnier JJ, Jia Y, Whittle SL. Measures of adult shoulder function. Arthritis Care Res (Hoboken) 2020;72 Suppl 10:250-93. 3. Furtado R, Bobos P, Ziebart C, Vincent J, MacDermid J. Patient-re-ported outcome measures used for shoulder disorders: an overview of systematic reviews. J Hand Ther 2022;35:174-85. 4. Huang H, Grant JA, Miller BS, Mirza FM, Gagnier JJ. 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Choosing patient-re-ported outcome measures for shoulder pathology. EFORT Open Rev 2021;6:779-87. 13. Dabija DI, Pennings JS, Archer KR, Ayers GD, Higgins LD, Kuhn JE, et al. Which is the best outcome measure for rotator cuff tears? Clin Orthop Relat Res 2019;477:1869-78. 14. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Devel-opment of a Shoulder Pain and Disability Index. Arthritis Care Res 1991;4:143-9. 15. Williams JW Jr, Holleman DR Jr, Simel DL. Measuring shoulder function with the Shoulder Pain and Disability Index. J Rheumatol 1995;22:727-32. 16. Schmitt JS, Di Fabio RP. Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. J Clin Epidemiol 2004;57:1008-18. 

Outcome Measurement in Shoulder Diseases: Focus on Shoulder Pain and Disability Index (SPADI)

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Outcome Measurement in Shoulder Diseases: Focus on Shoulder Pain and Disability Index (SPADI)

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