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American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form

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Purpose

The ASES is a condition-specific scale that is intended to measure functional limitations and pain of the shoulder.

Link to Instrument

Instrument Details

Acronym ASES

Area of Assessment

Activities of Daily Living
Functional Mobility
Pain
Upper Extremity Function

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Pain Management
  • Sports & Musculoskeletal Injuries

Populations

Mixed Populations
Joint Pain and Fractures

Key Descriptions

  • The ASES is a 100-point scale that consists of two dimensions: pain and activities of daily living. There is one pain scale worth 50 points and ten activities of daily living worth 50 points. Patients can complete the questionnaire in less than five minutes (Leggin, 2006).
  • The patient self-assessment (pASES) includes 6 pain items and 10 functional items that are shoulder specific (Angst, 2008).
  • The pASES form has 3 sections: pain, instability, ADLs (Goldhahn, 2008).
    1) Pain section: 4 questions with yes/no responses, 1 question covering number of pain tablets per day, and a VAS scale from 0 (no pain) to 10 (worst pain).
    2) Instability section: 2 questions (1. Response yes/no about feelings of instability, 2. Quantify instability from 0 (stable) to 10 (very unstable).
    3) ADLs: Each shoulder is included (affected/non affected), 10 items, with a 4 point ordinal scale, range: 0 (unable to perform activity) to 3 (no difficulty in doing activity) (Goldhahn 2008).
  • ASES-s contains 2 parts: patient self evaluation and physician assessment. Self evaluation: visual analog scales for assessment of pain/instability, ADL: utilizes 4 point scale, 3 min to fill out (Dowrick, 2004).
  • Modified ASES eliminates “sleep on painful side” and “throw ball overhead”, and adds “open a jar of food”, “cut with a knife”, “use a phone”, “do up buttons”, and “carry shopping bag” (Beaton, 1998).
  • Originally made as: “baseline measure of shoulder function, applicable to all patients regardless of diagnosis.” Was designed with aspiration to be utilized widely (Goldhahn, 2008).
  • When it was created (ASES-s) it was supposed to be a “state-of-the-art questionnaire” with three main components: 1) Ease of use, 2) Method of assessing ADLs, and 3) Inclusion of a patient self-evaluation section (Goldhahn, 2008).

Equipment Required

  • Patient Report Form
  • Writing Utensil

Time to Administer

5 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Katie Sly SPT, LAT-ATC; Kelly Walsh SPT; Ellese Nickles, SPT; Andrew Foster, SPT; Alexis Williams, SPT, LAT-ATC; Mary Anne Rutz, SPT; Christopher Ritter, SPT; Karl Lutschewitz, SPT; Jonathan Outlaw, SPT, NCMBT, LMBT; Holli McClendon, SPT.

Body Part

Upper Extremity

ICF Domain

Body Function
Activity
Participation

Measurement Domain

Motor
Activities of Daily Living
Sensory

Professional Association Recommendation

Reliability by Surgical Status of Self-Reported Outcomes in Patients Who Have Shoulder Pathologies: (Cook, 2002)

  • Recommendations: for use based on acuity level of the patient, based on level of care in which the assessment is taken, based on SCI AIS Classification, based on EDSS Classification, for entry-level physical therapy education and use in research

Considerations

Shoulder Dysfuntion: (Cook, 2002)

  • Lack of a gold standard for comparing estimates of shoulder outcome variables.
  • Self-reported function, disability, and satisfaction may be compared across measure and across time, but there is no external referent by which the scales’ external validity can be established.
  • The small sample size also limited the current study.
  • A larger pool of participants would have narrowed the confidence intervals around the calculated ICC values and may have broadened the conclusions that could be drawn from the results.
  • No control over when patients actually completed the second questionnaire.
  • After completing the first questionnaire, participants were given a blank second copy and asked to return this copy 1 week later. It is possible that some patients completed the second questionnaire after less than the requested amount of time had elapsed.

Shoulder instability, Rotator cuff disease, Glenohumeral arthritis: (Kocher, 2005) Study limitations include the use of a large, prospectively maintained computerized database, heterogeneity among the patients, and variation in the specific surgical techniques used. All psychometric properties of the ASES were acceptable, however the reliability may not be precise enough to use on an individual basis. Other shoulder-specific instruments need psychometric testing to compare to the ASES and aid in the formal development of a widely accepted shoulder-specific outcome measure.

Patients without shoulder problems: (Sallay, 2003) Study limitations include the use of patients from an outpatient subspecialty practice in the Midwest because it may not be representative of a larger population. The ASES was found to be highly reliable, but age and demographics including attitude, activity level, and general well-being of the patients should be taken into consideration when evaluating posttreatment scores because these things may be related to shoulder function.

Shoulder Arthroplasty: (Goldhahn, 2008) ASES shoulder form did not disclose any key differences in cross-cultural adaptation process from English to German.  Total score of German ASES demonstrated good reliability/validity that could be utilized following a joint replacement. The instability portion of the measure does not give useful clinical information.

Patients without shoulder problems: (Sallay, 2003) Study limitations include the use of patients from an outpatient subspecialty practice in the Midwest because it may not be representative of a larger population. The ASES was found to be highly reliable, but age and demographics including attitude, activity level, and general well-being of the patients should be taken into consideration when evaluating posttreatment scores because these things may be related to shoulder function.  

Shoulder Arthroplasty:(Goldhahn, 2008) ASES shoulder form did not disclose any key differences in cross-cultural adaptation process from English to German. Total score of German ASES demonstrated good reliability/validity that could be utilized following a joint replacement. The instability portion of the measure does not give useful clinical information.

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Mixed Populations

back to Populations

Standard Error of Measurement (SEM)

Shoulder Dysfunction: (Michener, 2002) 

  • Pain: SEM= 5.1 +/- 8.4
  • Function: SEM= 4.1 +/- 6.7
  • Total: SEM= 6.7 +/- 11.0

Minimal Detectable Change (MDC)

Shoulder Dysfunction: (Michener, 2002)

  • Pain: MDC= 7.2
  • Function: MDC= 5.8
  • Total: MDC= 9.4

 

Total Shoulder Arthroplasty: (Angst, 2008)

  • Total: MDC= 10.5 (90% CI)

 

Shoulder Trauma: (Slobogean, 2011)

  • MDC= 16 (90% CI)

Minimally Clinically Important Difference (MCID)

Shoulder Dysfunction: (Michener, 2002)

  • MCID= 6.4 points

 

Shoulder Trauma: (Slobogean, 2011)

  • MCID= 6.4 points

Test/Retest Reliability

Shoulder Dysfunction: (Michener, 2002)

  • Excellent: ICC= 0.84

 

Shoulder Arthroplasty: (Angst, 2008) 

  • Pain: Excellent (ICC=0.84)
  • Function: Excellent (ICC=0.92)
  • Total: Excellent (ICC=0.93).
  • Instability: Adequate (ICC=0.54).

 

Shoulder Arthroplasty: (Goldhahn, 2008)

pASES

  • “Does your shoulder feel unstable?”: Poor (ICC=0.37)
  • “Lift 5 kg above shoulder”: Excellent (ICC=0.88),
  • 21/28 items: Adequate to Excellent ICC> 0.70
  • Instability (2 questions) were least reliable:
    • Item 07: Poor (ICC=0.37)
    • Item 08: Adequate ICC=0.54.  

 

Shoulder pain: (Beaton, 1998)  

  • ICC: Excellent= 0.96

 

Shoulder dysfunction [instability, dislocation, humeral fracture]:

(Dowrick, 2004)

  • Pain: Excellent (ICC=0.79)
  • Function: Excellent (ICC=0.82)
  • Total: Excellent (ICC=0.84)

 

Shoulder instability, Rotator cuff disease, Glenohumeral arthritis: (Kocher, 2005)

  • Total: Excellent (ICC = 0.94)
  • Pain: Excellent (ICC = 0.83)
  • Excellent ICC (≥0.75) for all domains of function except sleep on affected side (ICC = 0.71).

 

Patients without shoulder problems: (Sallay, 2003)

  • ICC: Excellent= 0.96

Internal Consistency

Shoulder Dysfunction: (Michener, 2002)

  • Excellent: (Chronbach alpha= 0.86)

 

Shoulder dysfunction [instability,dislocation, humeral fracture]: (Dowrick, 2004)

  • Excellent: (Cronbach's Alpha= 0.86)

 

Shoulder Trauma: (Slobogean, 2011):

  • Adequate to Excellent: (Chronbach's Alpha= 0.61-0.86)

 

Rotator Cuff, SLAP, and Instability Surgeries: (Oh, 2009)

  • ADL: Excellent (Cronbach's Alpha = 0.850)
  • Strength: Excellent (Cronbach's Alpha = 0.830)
  • Instability: Excellent (Cronbach's Alpha = 0.970)
  • Pain: Adequate (Cronbach's Alpha = 0.711)
  • ROM: Adequate (Cronbach's Alpha = 0.770)
  • Signs: Adequate (Cronbach's Alpha = 0.700)

 

Shoulder instability, Rotator cuff disease, Glenohumeral arthritis: (Kocher, 2005)

  • Patients w/ shoulder instability: Poor (Cronbach's Alpha = 0.61)
  • Patients w/ rotator cuff disease: Poor (Cronbach alpha = 0.64)
  • Patients w/ glenohumeral arthritis: Poor (Cronbach alpha = 0.62).

 

Shoulder Arthroplasty: (Goldhahn, 2008)

  • Pain: Excellent (Cronbach's Alpha= 0.91)
  • Instability: Adequate (Cronbach's Alpha= 0.70)
  • Function: Excellent (Cronbach's Alpha= 0.96)
  • Function (control side): Excellent (Cronbach's Alpha= 0.93)
  • Total ASES: Excellent (Cronbach's Alpha= 0.96)

Criterion Validity (Predictive/Concurrent)

Rotator Cuff, SLAP, and Instability Surgeries: (Oh, 2009)

  • SF-36 Physical Function: Poor (Pearson r = 0.266)
  • SF-36 Role Physics: Poor (Pearson r = 0.208)
  • SF-36 Bodily Pain: Poor (Pearson r = 0.048)
  • SF-36 General Health: Poor (Pearson r = 0.026)
  • SF-36 Vitality: Poor (Pearson r = 0.102)
  • SF-36 Social Function: Poor (Pearson r = 0.179)
  • SF-36 Role Emotion: Poor (Pearson r = 0.106)
  • SF-36 Mental Health: Poor (Pearson r = 0.053)
  • SF-36 Physical Component Score: Poor (Pearson r = 0.199)
  • SF-36 Mental Component Score: Poor (Pearson r = 0.058)

 

Shoulder Arthroplasty: (Goldhahn, 2008)

  • pASES demonstrated Adequate to Excellent correlations (r= 0.57-0.66) with many scales of SF-36.
  • Joint Specific Questionnaire SPADI (shoulder) had highest correlation Excellent: (r= 0.92). 
  • Strong correlation between pASES and joint specific measures. Weakest correlations: between SPADI and pASES.

 

Shoulder instability, Rotator cuff disease, Glenohumeral arthritis: (Kocher, 2005)

Significant correlations (p < 0.05) between the ASES shoulder scale and the physical functioning Adequate: (r= 0.57),

role-physical Poor: (r = 0.32), and bodily pain Adequate: (r= 0.58) domains of the SF-12 scale.

Construct Validity

Shoulder Dysfunction: (Michener, 2002)  The correlations (95% CI) for the assessment of convergent validity were significant between the patient self-report sections of the ASES and the Penn Score (r=0.78; P<.01; CI, 0.86-0.66), SF-36 physical function score (r-0.41; P=0.001; CI, 0.18-0.69(, SF-36 role physical score (r=0.33; P=0.008; CI, 0.09-0.53), and SF-36 physical component summary score (r=0.40; P=0.001; CI, 0.17-0.59). The correlations for the assessment of divergent validity were not significant between the ASES and the SF-36 role emotional score (r=0.24; P=.21; CI, 0.01-0.46), SF-36 mental health score (r=0.05; P=.70; CI, 0.20 to 0.29), or SF-36 mental component summary score (r=0.15; P+.25: CI 0.10-0.38)

 

Rotator Cuff, SLAP, and Instability Surgeries: (Oh, 2009)

Adequate correlation of ASES with (SST) Simple Shoulder Test (Pearson r = 0.350) and (Constant) Constant score (Pearson r = 0.356) and (UCLA) University of California, Los Angeles shoulder score (Pearson r = 0.373). Poor correlation of ASES with (WOSI) Western Ontario Shoulder Instability Index (Pearson r = 0.144) and Rowe (Pearson r = -.146).

 

Shoulder Arthroplasty: (Angst, 2008) Excellent correlation between the ASES and SPADI (r=0.79), excellent correlation between the ASES  and DASH (r=0.63), adequate correlation between the pASES and SF-36 PCS (r=0.41), poor correlation between the ASES and SF-36 MCS (r=0.05).

 

Variety of Shoulder Disorders : (Leggin, 2006) Excellent correlation between the ASES and Penn Shoulder Score (r=0.87).

 

Full Spectrum RC pathology: (Kirkley, 2003) Construct validation demonstrated that this instrument correlated predictably with other measurement tools (Disabilities of the Arm, Shoulder, and Hand outcome measure; University of California Los Angeles Shoulder Rating Scale; Constant Score; Rowe; Sickness Impact Profile; Short Form 36; and range of motion); 21 of 21 correlations within 0.19.

Face Validity

Shoulder Dysfunction: (Michener, 2002)

  • The patient self-report section of the ASES evaluates aspects of activities of daily living as well as work and recreational activities, which provides evidence for the face validity of this scale. However, no further data is provided.

Floor/Ceiling Effects

Shoulder Arthroplasty: (Goldhahn, 2008)

Average scores (65/81 out of 100), upper ⅓ scale.

  • “Do you take narcotic pain medication?”: Poor (92% did not take pain medication)
  • “Does your shoulder feel unstable?”: Poor (86% put stable)
  • “Manage Toileting”: Poor 88%, “Comb hair”: Poor 77%.
  • pASES: Did not show floor/low ceiling effects.
  • Researchers had expectations of an increased floor effect Items 07/08, the results did not meet their expectations (item 07: floor effect 86%, item 08: 45%).

 

Shoulder instability, Rotator cuff disease, Glenohumeral arthritis: (Kocher, 2005)

  • Adequate to Excellent: (<15%) floor and ceiling effects

    • Ceiling effect for shoulder instability = 1.3%, all other floor and ceiling effects = 0%). 

Responsiveness

Shoulder Dysfunction: (Michener, 2002)

  • Large (ES= 1.4)
  • Large (SRM=1.54)

 

Rotator Cuff, SLAP, and Instability Surgeries: (Oh, 2009)

  • Large: (ES = 0.617, SRM = 0.771).

 

Shoulder dysfunction [instability,dislocation, humeral fracture]: (Dowrick, 2004)

  • Pain: Large (SRM=1.08)
  • Function: Large (SRM= 1.34)
  • Total Score: Large (SRM= 1.54)

 

Shoulder Trauma: (Slobogean, 2011)

  • Large effect size of 1.3 and average standard response mean of 1.1

 

Shoulder Arthroplasty: (Angst, 2008)

  • pASES Pain: Large (SRM=1.35)
  • Function: Large (SRM=1.73)
  • Total: Large (SRM=1.81).
  • pASES Instability: Moderate (SRM=0.29)

 

Osteoarthritis: (Angst, 2011)

  • Total or hemi shoulder arthroplasy: Large (ES=3.53).

 

Rheumatoid, osteoarthritis: total shoulder arthroplasty:(Angst, 2011)

  • Large (ES= 2.13, SRM 1.81).

 

Calcific tendinitis: (Angst, 2011)

  • Subacromial steroid: Large (ES= 1.65-1.84)

 

Various, mainly impingement: (Angst, 2011)

  • Large (ES= 1.39, SRM= 1.54)

 

Rotator cuff disease: (Angst, 2011)

  • Large (SRM= 1.42)

 

Rotator cuff, instability, arthritis, surgery: (Angst, 2011)

  • Large (ES= 0.93-1.16).

 

Shoulder instability, Rotator cuff disease, Glenohumeral arthritis: (Kocher, 2005)

  • Shoulder Instability: Large (ES= 0.86, SRM= 0.93)
  • Rotator Cuff Disease: Large (ES= 1.33, SRM= 1.16)
  • Glenohumeral Arthritis: Large (ES= 1.74, SRM= 1.11).

Bibliography

Angst, F. et. al. (2008). Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism: Arthritis Care & Research, 59(3), 391-398.

Angst, F. et. al. (2011) Measures of Adult Shoulder Function. Arthritis Care & Research. American College of Rheumatology.  63(S11), S174-188

Beaton, D. (1998). Assessing the reliability and responsiveness of 5 shoulder questionnaires. Journal of shoulder and elbow surgery, 7(6), 565-572.

Bot, S. (2004). Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Annals of the rheumatic diseases, 63(4), 335-341.

Cook, K. (2002). Reliability by surgical status of self-reported outcomes in patients who have shoulder pathologies. The journal of orthopaedic and sports physical therapy, 32(7), 336-346.doi:10.2519/jospt.2002.32.7.336

Dowrick, A. (2005) Outcome instruments for the assessment of the upper extremity following trauma: a review. International Journal of the Care of the Injured. (4):468-76.

Ge, Y. et al. (2013). “The Development and Evaluation of a New Shoulder Scoring System Based on the View of Patients and Physicians:   The Fudan University Shoulder Score.” Journal of Anthroscopy and Related Surgery. 29(4): 613-622.

Goldhahn, J. et al. (2008). Lessons learned during the cross-cultural adaptation of the American Shoulder and Elbow Surgeons shoulder form into German. Journal of Shoulder and Elbow Surgery. Mar-Apr; 17 (2): 248-254. doi:10.1016/j.jse.2007.06.027. Epub 2008 Jan 22

Kirkley A, et. al (2003) “The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: The Western Ontario Rotator Cuff Index.” Clin J Sport Med. (2):84-92. PubMed PMID: 12629425.

Kocher M. S. et. al. (2005) Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons Subjective Shoulder Scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. J. Bone Joint Surg. Am. (87-A):2006-2011. doi:10.2106/JBJS.C.01624                              

Leggin, B. et al. (2006). The Penn Shoulder Score: reliability and validity. Journal Of Orthopaedic & Sports Physical Therapy, 36(3), 138-151.

Michener, L. et al. (2011) American Shoulder and Elbow Surgeons Standardized Shoulder  Assessment Form, patient self-report section: reliability, validity, and responsiveness. Journal of shoulder and elbow surgery. 11:587-594.

Oh J. H. et al. (2009). “Comparative Evaluation of the Measurement Properties of Various Shoulder Outcome Instruments.” The American Journal of Sports Medicine 37(6): 1161-1167.

Richards R. R. et. al (1994)  A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. (6):347-52. doi: 10.1016/S1058-2746(09)80019-0. Epub 2009 Feb 13. PubMed PMID: 22958838.

Sallay P. et. al. (2003) The measurement of normative American Shoulder and Elbow Surgeons scores. J. Shoulder Elbow Surg. 12(6):622-627. doi:10.1016/S1058-2746(03)00209-X.

Saboe, L. A. et. al. (1997). "Early predictors of functional independence 2 years after spinal cord injury." Arch Phys Med Rehabil 78(6): 644-650.

Shoulder Trauma (Slobogean, 2011): Slobogean G.P., Slobogean B.L. Measuring Shoulder Injury Function: Common Scales and Checklists. Injury, Int. J. Care Injured 42 (2011) 248-252

 

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