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British Medical Bulletin Advance Access published online on June 6, 2008
British Medical Bulletin, doi:10.1093/bmb/ldn023
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© The Author 2008. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

Rating systems for evaluation of the elbow

Umile Giuseppe Longo{dagger}, Francesco Franceschi{dagger}, Mattia Loppini{dagger}, Nicola Maffulli*,{ddagger} and Vincenzo Denaro{dagger}

{dagger} Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Via Alvaro del Portillo, 200, 00128 Trigoria Rome, Italy
{ddagger} Department of Trauma and Orthopaedic Surgery, University Hospital of North Staffordshire, Keele University School of Medicine, Stoke-on-Trent ST4 7LN, UK

* Correspondence to: Nicola Maffulli, Department of Trauma and Orthopaedic Surgery, University Hospital of North Staffordshire, Keele University School of Medicine, Stoke-on-Trent ST4 7LN, UK. E-mail: osa14{at}keele.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Discussion
 References
 
Introduction: Many scoring systems have been used for elbow disorders. However, only few of these have been validated, and many assess only few aspects of elbow function.

Methods: A literature search was performed using the keyword ‘elbow’ in combination with ‘scoring system’, ‘outcome assessment’, ‘elbow disorder’ and ‘clinical evaluation’.

Results: Eighteen scoring systems are currently available for the evaluation of elbow disorders. Each of them evaluates the elbow performance using specific variables, including both objective and subjective criteria. All these scoring systems are presented.

Discussion: Although many scoring systems have been used to evaluate elbow function, we are still far from a single outcome evaluation system which is reliable, valid and sensitive to clinically relevant changes, takes into account both patients' and physicians' perspective and is short and practical to use.

Conclusion: Further studies are required to evaluate the reliability, validity and sensitivity of the elbow scoring systems used in the common clinical practice.

Keywords: elbow • scoring system • outcome assessment • clinical evaluation • arthroscopy


   Introduction
Top
 Abstract
 Introduction
Methods
 Discussion
 References
 
The measurement of patients' outcomes in modern orthopaedic practice includes the use of scoring systems to determine general health, regional, joint- and disease-specific results.1 Two types of questionnaires are available: physician-rated and patient-rated questionnaires. Physician-rated questionnaires use clinical and functional measurements. On the other hand, patient-rated questionnaires assess subjective component of a condition.2,3 Questionnaires must be properly validated in terms of consistency, sensitivity and reliability.4

The development of instruments to measure the outcome of management of musculoskeletal disorders of elbow has been the subject of increasing interest. Many scoring systems have been used for elbow disorders.5 However, only few of these have been validated, and many assess only some aspects of elbow function.4

Each score assesses elbow performance by specific criteria which are different among various scales.6 Their domains are often unrelated, with little uniformity in the distribution of categories, and different weights to the various aspects of elbow performance.7 Bias can be present both in objective criteria (derived from physical examination) and subjective criteria (determined by interview). This makes the interpretation of results and the valid comparison between studies very difficult.8

In this paper, we review the more common elbow score systems and their use in current orthopaedic practice.


   Methods
Top
 Abstract
 Introduction
 Methods
Discussion
 References
 
We performed a search using the keyword ‘elbow’ in combination with ‘scoring system’, ‘outcome assessment’, ‘elbow disorder’ and ‘clinical evaluation’, with no limit regarding the year of publication. The following databases were accessed on 15th April 2008: PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez/); Ovid (http://www.ovid.com); Cochrane Reviews (http://www.cochrane.org/reviews/). Given the linguistic capabilities of the research team, we considered the publications in English, Spanish and Italian. Two authors (U.G.L. and M.L.) independently read the abstract of each publication identified (if an abstract was available). If no abstract was available, the publication was excluded. In addition, the References section of all the publications identified were studied to ascertain whether other relevant material could be found. The personal collection of scientific material of the three senior authors (F.F., N.M. and V.D.) was consulted for the same purpose. If deemed relevant, all relevant publications were retrieved. The most relevant material was drawn between the years 1990 and 2007. A large number of publications focusing on surgical techniques of the elbow, not including outcome scores, were not included. The publications thus selected were examined by all authors. After this further selection, 61 publications relevant to the topic at hand were included (Fig. 1).


Figure 1
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  		Fig. 1 Details of the investigations excluded and included in the study.

 
Analytical description of elbow scoring systems

American Shoulder and Elbow Surgeons-Elbow
 The American Shoulder and Elbow Surgeons-Elbow (ASES-E) is a standardized elbow evaluation developed by the Research Committee of the American Shoulder and Elbow Surgeons1 (ASES) (Table 1). This score allows the evaluation of elbow function independently from the underlying diagnosis. It consists of two parts: a patient questionnaire and a form for the physician to record elbow impairment.


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  		Table 1. ASES-E scoring system.

 
The patient self-evaluation form is divided into three sections: pain, function and satisfaction. The first section contains visual analogical scales (from 0 = no pain to 10 = worst pain ever) for pain evaluation. The second section contains questions relating to the function of right and left arms. The responses are scored on a four-point ordinal scale: 0 = unable to do; 1 = very difficult to do; 2 = somewhat difficult; 3 = no difficult. The third section assesses the success of surgery on a scale from 0 to 10.

The section on physician assessment consists of four parts: motion, stability, strength and physical findings. Regarding motion, the physician records active flexion, extension, pronation and supination for both elbows. Active range of motion is measured with a standard goniometer. Concerning stability, the involved elbow is evaluated for valgus, varus and posterolateral rotatory instability. Each of them is graded on a four-point scale: 0 = no instability; 1 = mild laxity with good endpoint; 2 = moderate laxity with no endpoint; 3 = gross instability. Strength is rated in flexion, in extension, in pronation and in supination with a six-point scale: 0 = no contraction; 1 = flicker; 2 = movement with gravity eliminated; 3 = movement against gravity; 4 = movement with some resistance; 5 = normal power. Grip strength is also recorded. A series of possible physical findings are listed so that the examiner can record abnormalities. The physical findings enclose the evaluation of tenderness, graded on a four-point scale (0 = none; 1 = mild; 2 = moderate; 3 = severe), and other signs (such as pain, scars and atrophy) are reported described only as present or absent (Y/N).

Disability of Arm, Shoulder and Hand Questionnaire

The Disability of Arm, Shoulder and Hand (DASH) Questionnaire9 (Table 2) is a standardized questionnaire which evaluates impairments and activity limitations, as well as participation restrictions for both leisure activities and work.10 The DASH consists of three sections: the first module includes questions about symptoms and disabilities of upper limb (30 items); the second and the third sections are optional. The optional modules produce scores for participation with regard to sports/music (four items) and work activities (four items). All items of DASH are scored with a five-point scale: 1 = no difficulty; 2 = mild difficulty; 3 = moderate difficulty; 4 = severe difficulty; 5 = unable. For each module, the sum of the responses produces a score, which then is transformed to obtain the DASH scores. This score ranges between 0 (no disability) and 100 (severe disability) for each domain. Therefore, a high DASH score indicates severe disability.


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  		Table 2. DASH questionnaire

 
Quick DASH

The QuickDASH11 (Table 3) is a shortened version of the DASH scoring system. It consists of 11 items to measure physical function and symptoms in people with any or multiple musculoskeletal disorders of the upper limb. Similar to the DASH, each item has five response options (1 = no difficulty; 2 = mild difficulty; 3 = moderate difficulty; 4 = severe difficulty; 5 = unable). From the item scores, a summative score is calculated. The final score ranges between 0 (no disability) and 100 (the greatest possible disability). Only one missing item can be tolerated, and, if two or more items are missing, the score cannot be calculated.12


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  		Table 3. Quick DASH.

 
Musculoskeletal function assessment

The musculoskeletal function assessment (MFA) instrument13 comprises 100 items grouped into 10 categories: self-care; sleep/rest; hand/fine motor skills; mobility; housework; employment/work; leisure/recreational activities; family relationships; cognition/thinking; emotional adjustment, coping and adaptation (Table 4). Earlier versions of the questionnaire13 used in its developmental phase included 100 items, because there was one item less in the employment/work category. All categories and total score have been calculated and standardized on a scale of 0–100. Patients assess their function by answering ‘yes’ or ‘no’ to each item; each ‘yes’ response corresponds to 1 point, and each ‘no’ response or unanswered question corresponds to 0 points. The total score can range from 0 to 100 points, with 0 representing minimum dysfunction and 100 representing maximum dysfunction. It takes ~15 min to complete. Validity analyses require supplemental questions about sociodemographic characteristics such as race, education, income, marital status, health insurance, work status, co-morbid conditions, health habits and changes in life and health status.14


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  		Table 4. Musculoskeletal function assessment.

 
The MFA instrument shows good content validity and reliability.13 Its scoring scheme, with the highest scores assigned to the patients with the most disability, matches those used by other functional status instruments.15 A study has compared the MFA with three health status measures [Medical Outcomes Study Short Form-36 (SF-36), the WOMAC and the SIP] used to evaluate musculoskeletal disorders. The MFA must perform as good as or better than other questionnaires according to the criteria of reliability, validity and responsiveness.14

Short musculoskeletal functional assessment

The short musculoskeletal functional assessment16 (SMFA) is a short-form MFA (Table 5). It is a self-reported 46-item questionnaire consisting of two parts: a dysfunction index and a bother index. The dysfunction index consists of four categories (daily activities, emotional status, function of the arm and hand, mobility) and has 34 items: 25 items evaluate the amount of difficulty that patients have when performing certain functions; and nine items evaluate how often the patients have difficulty when performing certain functions. Each item is graded with a five-point scale ranging from ‘good function’ to ‘poor function’. The bother consists of 12 items and assesses how much the patient is bothered by problems associated with broad functional areas. The bother index is also graded with a five-point scale, ranging from 1 point (not at all bothered) to 5 points (extremely bothered). The scores are calculated by summing the responses to the items and then transforming the scores so that they range from 0 to 100. This transformation is made with use of the formula: [(actual raw score – lowest possible raw score)/possible range of raw score] x 100. The total score ranges from 0 to 100, with higher scores indicating a poorer level of function.17


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  		Table 5. Short musculoskeletal function assessment.

 
Patient-rated elbow evaluation

The patient-rated elbow evaluation18 (PREE) consists of two sections investigating pain and function (Table 6). All questions are scored on a 10-point scale. The pain section has four questions that rate pain from ‘no pain’ to ‘worst ever’. In addition, there is a question that rates how often the patient has pain (‘never’ to ‘always’). The scale for the function questions ranges from ‘no difficulty’ to ‘unable to do’. The function section has 11 questions regarding specific activities of daily living, and four questions regarding personal care, household work, occupational work and recreational activities. Higher scores represent worse functioning.17,19


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  		Table 6. Patient-rated elbow evaluation.

 
Liverpool elbow score

The Liverpool elbow score4 (LES) is an elbow-specific score. It consists of two main components (Table 7): a patient-rated questionnaire which assesses the elbow function, including a question about pain; and clinical data, which can be measured objectively, regarding the condition of the elbow. The patient-answered questionnaire contains nine items. Each of them is graded using a five-point scale, from 0 (worst/least function) to 4 (best/most function). Clinical assessment score component contains six items, and some of them are graded using a four-point scale (from 0 to 3), whereas others are graded using a three-point scale (from 0 to 2). For calculation of the final score, all responses are transformed to a scale of 0–10. Therefore, the final score ranges between 10 (best) and 0 (worst).


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  		Table 7. Liverpool elbow score.

 
Mayo elbow performance index

The Mayo elbow performance index20 (MEPI) is one of the most commonly used physician-based elbow rating systems. This index consists of four parts (Table 8): pain (with a maximum score of 45 points), ulnohumeral motion (20 points), stability (10 points) and the ability to perform five functional tasks (25 points). Pain is rated as none (45 points); mild (30 points) if there is no limitation of activity and occasional use of analgesics; moderate (15 points) if there is limitation of activity and regular use of analgesics; severe (0 points) if there is constant pain and regular use of analgesics. The joint's stability is graded as stable, mildly unstable or unstable. The functional score is determined on the basis of the patient's ability to perform normal activities of daily living. The total score ranges from 5 to 100 points, with higher scores indicating better function. If the total score is included between 90 and 100 points, it can be considered excellent; between 75 and 89 points, good; between 60 and 74 points, fair; less than 60 points, poor.21–24


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  		Table 8. Mayo elbow performance index.

 
Variants of MEPI
 The first variant of the modified version of the Mayo elbow score25 was used for a comparison of pre-operative and post-operative status, in a study which evaluated the Kudo elbow prosthesis in patients with rheumatoid arthritis.26 In this score (Table 9), total active range of motion, instability and pain are recorded. Patient satisfaction and pain are determined on a four-point scale. Results are classified according to total score, which ranges between 0 and 100. If the total score ranges between 75 and 100, the result is good (satisfactory); 50–74, fair, acceptable; <50, poor (or unsatisfactory).


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  		Table 9. Variant of MEPI.

 
The second variant of the modified version of the Mayo elbow score27 is a performance index which is based on pain and joint's function as follows: motion, 40 points; pain, 35 points; strength, 20 points; stability, 5 points. Pain is rated as none, mild or severe. Motion is recorded with goniometric measurements of flexion, extension, pronation and supination. Strength is evaluated with biomechanical assessments with a torque dynameter; the loss of strength can involve only flexion or extension or pronation or supination, but is also possible that there is a composite strength loss. Regarding stability, clinical examination assesses varus/valgus instability. This instability is graded as follows: none; mild, if a perception of instability is observed by the physician; moderate, if definite instability is observed; severe, if perceptible varus/valgus laxity is detected by the physician and perceived by the patient. A total score which is comprised between 95 and 100 points is considered excellent; 80–95, good; 60–80, fair; <60, poor.

The third variant of the modified version of the Mayo elbow score28 is an objective elbow performance index based on elbow's function and pain. It is a 100-point system and includes several domains: motion, 40 points; pain, 35 points; strength, 20 points; stability, 5 points. Pain is graded as none, mild, moderate or severe. The varus/valgus instability is evaluated according to a previously described technique,29 and it is scored as none, mild, moderate and severe. Motion is measured with a hand-held goniometer. The strength of flexion and extension is assessed according to a clinical rating scale, which assigns 20 points for normal strength; 14 points for mild loss of strength; 7 points for moderate loss of strength; 0 points for marked weakness. The results of elbow performance index can range between 0 and 100 and are rated as follows: an excellent result ranges from 91 to 100 points; good, 81 to 90 points; fair, 71 to 80 points; poor, ≤70 points.

Broberg and Morrey rating system

The rating system of Broberg and Morrey (Table 10) is a 100-point system, which summarizes data from the clinical record, personal interview and biomechanics laboratory examination.29 It consists of four sections: motion (40 points), strength (20 points), stability (5 points) and pain (35 points). Pain is rated as none (35 points); mild with activity but requiring no medication (28 points); moderate with or after activity (15 points); severe at rest, requiring constant medication, and disabling (0 points). The clinical and biomechanical assessments are obtained measuring motion with a hand goniometer and assessing flexion/extension of the elbow and pronation/supination of the forearm. The grip strength of the hand is measured with a specially designed torque dynamometer. Stability is graded by varus–valgus stress according to the technique described previously.30


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  		Table 10. Broberg and Morrey rating system.

 
In the categorical rating, 95–100 points indicates an excellent outcome; 80–94 points, a good outcome; 60–79 points, a fair outcome; ≤60 points, a poor outcome.21 The outcome can be considered satisfactory if the result is rated as good or excellent, and unsatisfactory if it is fair or poor.

The Hospital for Special Surgery scoring system

The Hospital for Special Surgery (HSS) scoring system31 consists of eight domains (Table 11): pain, function, sagittal range, muscle strength, flexion contracture, extension contracture, pronation and supination. Pain is evaluated in bending and at rest; its maximum score is 30, which reflects a condition of no pain at any time. In the function's evaluation, ability to perform bending activities and ability to perform a task are considered: patient score 8 points when able to perform bending activities for 30 min, and 0 points when they cannot use elbow. Regarding abilty to perform a task, patients score 12 points when there is an unlimited use of elbow, and 0 points when they are invalid. The maximum score for function is 20 (12 + 8). In the evaluation of the sagittal range, patients receive 1 point for each 7° of motion, to a maximum score of 20. Flexion and extension contractures have both a maximum score of 6. Pronation and supination have both a maximum score of 4. An excellent result is considered to be a score of 90–100 points; a good result, 80–89 points; a fair result, 70–79 points; a poor result, 60–69 points; a failed result, <60 points.32


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  		Table 11. The HSS scoring system.

 
Variants of the HSS scoring system
 A shortened version of the HSS Scoring System33 consists of four domains (Table 12): pain, function, activity and use. Pain ranges between not pain (50 points) and severe pain (0 points). Function ranges between no limitations (30 points) and unable to feed oneself (0 points). Activity ranges between capacity to perform activities for 30 min (8 points) and inability to use the elbow (0 points). Use ranged between unlimited use (12 points) and invalid (0 points). Activity domain and use domain can be added to produce a total activity score, which has a maximum of 20 points. As the function domain includes a total activity score, the HSS Scoring System gives the same weight to pain and function, because each of these domains has a 50-points score. Regarding outcome, a total score of 90–100 points indicates an excellent result; 80–89 points, a good result; 70–79 points, a fair result; <60 points, a failure.24


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  		Table 12. Variant of the HSS scoring system.

 
Ewald scoring system

Ewald scoring system is a 100-point rating system,34 which evaluates several aspects of elbow function (Table 13). Its domains are pain, 50 points; function, 30 points; motion, 10 points; flexion contracture, 5 points; cubitus valgus alignment, 5 points. The functional evaluation is limited to the involved elbow and includes six categories: no limitations, slight restriction of activities of daily living, unable to lift objects weighing more than 10 pounds (4.5 kg), moderate restriction of activities of daily living, unable to comb the hair or touch the head and unable to feed oneself. Pain evaluation includes five categories: none, slight, moderate, interferes with sleep at night, severe. Regarding motion, the physician measures degrees of flexion, extension, pronation and supination.35,36 Rating categories were grouped as follows: excellent, 90–100; good, 80–89; fair, 70–79; poor, ≤69 points.37


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  		Table 13. Ewald scoring system.

 
Khalfayan score

Khalfayan scoring system38 investigates: pain, elbow range of motion, strength (including both elbow and grip strength) and daily activity (Table 14). Each category has a maximum score of 25 points. Patients are interviewed regarding pain and level of function in specific activities of daily living. Clinical examination consists of elbow range of motion, elbow strength and grip strength measured with a hand-held dynamometer.


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  		Table 14. Khalfayan score.

 
Pain is rated as none (30 points), slight with continuous activity and no medication required (25 points), moderate with occasional activity and some medication required (15 points), moderately severe with much pain and frequent medication (10 points), severe with constant pain and markedly limited activity (5 points) and complete disability (0 points). The maximum points of pain are 30. The score is calculated by the formula: (points divided by 30) x 25. The maximum score is 25.

The evaluation of elbow's motion range consists in measuring degrees of extension (8 points maximum), flexion (17 points maximum), pronation (6 points maximum) and supination (6 points maximum). Degrees of extension are included between >70° (0 points) and <10° (8 points). Degrees of flexion are included between >120° (17 points) and <30° (0 points). Regarding pronation and supination, 0.1 points per each degree are assigned. The maximum points for range of motion are 37 (8 + 17 + 6 + 6). The score is calculated by the formula: (points divided by 37) x 25. The maximum obtainable score is 25.

Strength measurement includes both elbow and grip strength. Elbow strength (10 points maximum) is rated as normal, good, fair, poor, trace and paralysis. Strength in extension, flexion, pronation and supination is rated. To obtain elbow strength points, the sum of extension, flexion, pronation and supination indexes is computed. At the end, the total index is multiplied by 0.67. The evaluation of grip strength (8 points maximum) is expressed as a percentage of the uninjured extremity. The range is between ≥90% (8 points) and ≥50% (4 points). The maximum points for strength are 18 (10 + 8). The score is calculated by the formula: (points divided by 18) x 25. The maximum obtainable score is 25.

Elbow's function is rated as normal (1 point), mild compromise (0.75 points), difficulty (0.5 points), with aid (0.25) and unable (0 points). It is evaluated in 12 conditions: (i) use back pocket; (ii) rise from chair; (iii) perineal care; (iv) wash opposite axilla; (v) eat with utensil; (vi) comb hair; (vii) carry 10–15 lb with arm at side; (viii) dress; (ix) pulling; (x) throwing; (xi) do usual work and (xii) do usual sport. The maximum points for function are 12. The score is calculated by the formula: (points divided by 12) x 25. The maximum obtainable score is 25.

The final score is included between 0 and 100. A result between 90 and 100 is considered excellent; between 80 and 89, good; between 70 and 79, fair; poor if it is <70. An acceptable outcome is considered with excellent or good results (score 80–100), and an unacceptable outcome with fair or poor results (score <80).39

Flynn criteria

Flynn criteria40,41 are obtained measuring with goniometers the range of elbow movement and the carrying angle (Table 15). Both loss in carrying angle and loss in elbow motion are scored as follows: between 0 and 5°, excellent; 6–10°, good; 11–15°, fair; <15°, poor.


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  		Table 15. Flynn criteria.

 
Neviaser criteria

These criteria have been arbitrarily established by the authors to study long-term follow-up of elbow dislocation.42 The range of motion is scored as follows: excellent, when there is a ≤10° loss of full extension with full supination and pronation; good, when there is no greater than a 30° loss of extension and/or no more than a 10° loss of supination or pronation; fair, when there is no greater than a 45° loss of extension and/or no more than a 30° loss of either supination or pronation; poor, when there is a loss of more than a 45° loss of extension and/or more than a 30° loss of either supination or pronation.

Jupiter criteria

Jupiter criteria evaluate pain, disability and range of movement.43 Symptoms are recorded at clinical interview, and the patients are examined clinically and radiographically.44 Elbow and forearm movements are measured using a standard large goniometer, recording the extension of the elbow with the forearm in maximal supination. Double-exposure photographs show the range of elbow movement, and loss of flexion/extension is expressed by comparison with the normal arm. Ulnar nerve function is also assessed (Table 16).


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  		Table 16. Jupiter criteria.

 
Oxford elbow score

The Oxford elbow score is a 12-item questionnaire (Table 17).45 It comprises three unidimensional domains: elbow function, pain and social-psychological, with each domain comprising four items with good measurement properties.


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  		Table 17. Oxford elbow score.

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Discussion
References
 
Many elbow score rating systems have been described.5 Each of them evaluates the elbow performance using specific variables, including both objective and subjective criteria. Also, when the same parameters are evaluated, a different weight is attributed to the single domain. Interpreting these domains becomes difficult, because, even though they can be common to more than one scoring system, each stresses them in a different way.4,7

There is a strong influence of pain on elbow ratings and health status measures.46 However, the experience and expression of pain are strongly influenced by psychological and sociological factors.47,48 As a result of the influence of pain on both physician-rated and patient-rated quantitative measures of elbow function, objective improvements in elbow function achieved by operative procedures may be undervalued by these systems. Therefore, subjective factors such as pain should probably be evaluated separately from objective measures of elbow function in physician-based elbow ratings.21

The ASES-E1 is an organ-specific score which has been developed by the Research Committee of the ASES. This score consists of a patient self-evaluation, which allows the evaluation of pain and functional deficits, and a physician assessment section. This score contains objective criteria, represented by measurements of motion, stability and strength.

The PREE18 is another organ-specific score in which both pain and function are investigated. The evaluation of elbow function is performed by questions, whereas in the ASES-E, objective evaluation is made by measurements.17,19 The LES4 also evaluates elbow function by measurements. It assesses elbow's function and pain by questions, and the condition of the elbow by objectively measured clinical data. Reproducibility and internal consistency are good. Both pre-operative results and the effects of surgery correlate acceptably with the DASH score.

The DASH9 is available in several languages, and studies of its test–re-test reliability and construct validity have been published for the original English version,49–52 and for the Swedish,53 German,54 Spanish,55 Dutch,56 Italian,57 Chinese58 and Japanese59 versions. One of the optional DASH modules, the work module, has been studied only in the Italian,60 Chinese58 and Japanese59 versions. The DASH score has been used in patients with disorders of major areas of the extremity, such as shoulder, elbow, wrist and hand.59 The construct validity of DASH score has been evaluated by establishing its correlation to SF-36,51 which is used for measuring health outcomes in patients with musculoskeletal ailments. The DASH Questionnaire correlates moderately well to SF-36 and is a valid measure of health status in patients with a variety of upper extremity disorders.

The DASH score is strongly correlated with pain levels.9 It can detect and differentiate small and large changes in disability over time after surgery in patients with upper extremity musculoskeletal disorders. A 10-point difference in the mean DASH score might be considered as a minimally clinically relevant change.50 The DASH score can reliably capture the limitations of patients on an individual item basis. Thus, the DASH can provide diagnosis-specific limitation profiles identifying disease-specific problems which are not recognizable from the summary DASH score, but which may be relevant for rehabilitation. In fact, if the limitation profile of a disease is known, therapy regimes can be tailored to this to improve the process and the outcome.10

The main limitations of the use of the DASH score to evaluate elbow function are related to its non-organ-specific nature, and to the large number of questions. For this reason, researchers have proposed a shorter version of DASH, the QuickDASH.11 The QuickDASH has several advantages: can be compiled quickly, is easy to use and minimizes missing data. It shows reliability, validity and responsiveness when used for patients with either a proximal or a distal disorder of the upper extremity. The final version of the QuickDash consists of items selected from the key domains identified in the theoretical framework of the DASH with the so called ‘concept-retention approach’. Instead of 30 items, the QuickDASH uses 11 items to measure physical function and symptoms in people with any or multiple musculoskeletal disorders of the upper limb. Only one missing item can be tolerated, and, if two or more items are missing, the score cannot be calculated.12 The optional modules (sports/performing arts and work) are retained as optional and have not changed from the original DASH. The QuickDASH is comparable with the full DASH: although there is a little loss of reliability, validity or responsiveness, its construct validity and responsiveness suggest that this score should give views of disability and symptoms relatively similar to those provided by the full DASH.11 Another study12 has evaluated the performance of the QuickDash and its cross-sectional and longitudinal validity and reliability by comparing this test with the DASH in the whole population and in different diagnostic groups. In this way, the study has demonstrated that the QuickDASH can be used instead of the DASH to measure disability/symptom severity with similar precision in a variety of arm disorders.

Other scores used in disorders of the musculoskeletal system (for example in shoulder, elbow or hand disorders) are the MFA and its short form, the SMFA.

Khalfayan et al.38 have used this standardized elbow evaluation score in a study about treatment of Mason type II radial head fractures. This score has been also used by other authors.39

Most scores do not appear to have been constructed in a systematic fashion using recommended methodology. There is an increasing need for orthopaedic surgeons both to be familiar with and to routinely use objective measures of outcome for their procedures.61 There is a trend towards the increased use of validated patient-based scores, but many have not been properly tested for validity, repeatability and sensitivity to change. Scores are not valid when used in a modified form and their use should be discouraged.61 One of the further areas of study is to compare and contrast two or more scoring scales, to ascertain whether they address the same broad category of elbow function. To our knowledge, no such study has been performed in a systematic fashion. In a preliminary study, our group assessed the functional outcome of patients who had undergone elbow arthroscopy, evaluating the correlation between three elbow scoring systems and the patients' subjective perception of satisfaction as expressed by a simple satisfaction test and by a global visual analogue scale which investigate both pain and satisfaction. We have shown that there was no correlation between the results of the three scoring systems and patients' satisfaction: patients with the same level of satisfaction could perform differently at the scoring systems. However, the results of this study have not been published yet in a peer-reviewed journal.62

In conclusion, although many scoring systems have been used to evaluate elbow function, we are still far from a single outcome evaluation system which is reliable, valid and sensitive to changes of clinical importance, which takes into account both patients' and physicians' perspective and which is short and practical to use.

Accepted for publication May 13, 2008.


   References
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 Abstract
 Introduction
 Methods
 Discussion
 References
 

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