The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 80, Issue 1

Articles | January 01, 1998

The Relationship between Motion of the Shoulder and the Stated Ability to Perform Activities of Daily Living*

PAUL D. TRIFFITT, M.A., M.D., F.R.C.S.†, LEICESTER, UNITED KINGDOM

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Investigation performed at the Department of Orthopaedic Surgery, The Glenfield Hospital, Leicester

J Bone Joint Surg Am, 1998 Jan 01;80(1):41-6

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Abstract

One hundred and twenty-five patients who were seen because of symptoms related to the shoulder completed a questionnaire regarding their ability to perform activities of daily living. The ability was graded, and the grades were related to the range of motion of the shoulder with use of correlation analysis and simple and multiple linear regression analyses. All but two activities of daily living were found to correlate significantly (p < 0.001) with at least one range of motion of the shoulder. The strongest correlations (r > 0.5, Spearman rank correlation) were found for activities that are performed regularly by most patients, such as using a comb or washing the back. Less of a correlation (r = 0.5) was found for activities in which pain might constitute a large element or that are less specific, such as sleeping on the affected shoulder or performing work-related activities.The stated ability to perform various activities of daily living is part of a number of scoring systems for shoulder function. This implies that the ability to perform these activities reflects, among other factors, the range of motion of the shoulder. The relationships found in the present report validate various activities of daily living as measures of shoulder function and may help in the design of follow-up questionnaires.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

A number of scoring systems for the shoulder include the patient's assessment of his or her ability to perform various activities of daily living^{7,9,12-14,16,19-21}. This approach offers the potential for obtaining a good deal of information with a simple method that does not require a clinical examination. The patient's ability to use the upper extremity depends on the strength and range of motion of the shoulder, as modified by pain. Thus, if the stated ability to perform activities of daily living is to be a useful indicator of shoulder function, it would be expected to reflect, among other factors, changes in the range of motion of the affected shoulder. I examined the relationship between a number of important activities of daily living and motion of the shoulder.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, University of Leicester, School of Medicine, The Glenfield Hospital, Groby Road, Leicester LE3 9QP, United Kingdom.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, University of Leicester, School of Medicine, The Glenfield Hospital, Groby Road, Leicester LE3 9QP, United Kingdom.

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TABLE I REGRESSION OF RANGE OF MOTION ON ACTIVITIES OF DAILY LIVING

*The value is significant (p < 0.001). †Does not include patients who had symptoms in the contralateral shoulder.

Activity of Daily Living	Range of Motion	No. of Patients	Slope	Intercept	Pearson Correlation Coefficient	Spearman Rank Correlation Coefficient
Combing hair
	Elevation	112	37.2	44.9	0.72	0.72*
	Abduction	112	39.6	31.5	0.69	0.68*
	Internal rotation	112	3.7	2.6	0.56	0.58*
	External rotation	111	11.7	22.5	0.35	0.33*
Putting on coat
	Elevation	113	29.9	58.8	0.51	0.51*
	Abduction	113	31.8	46.6	0.49	0.48*
	Internal rotation	113	3.4	3.2	0.46	0.49*
	External rotation	112	12.3	21.4	0.33	0.33*
Washing back
	Elevation	114	25.6	87.5	0.60	0.62*
	Abduction	114	26.1	77.9	0.55	0.56*
	Internal rotation	114	3.2	5.9	0.61	0.65*
	External rotation	113	10.5	33.2	0.38	0.40*
Washing contralateral armpit
	Elevation	114	25.5	61.6	0.53	0.50*
	Abduction	114	25.1	52.9	0.47	0.45*
	Internal rotation	114	3.1	2.8	0.51	0.50*
	External rotation	113	6.9	29.8	0.22	0.19
Using toilet
	Elevation	114	26.6	45.3	0.43	0.42*
	Abduction	114	27.8	33.5	0.41	0.40*
	Internal rotation	114	2.9	2.0	0.38	0.38*
	External rotation	113	10.6	17.0	0.27	0.23
Sleeping on affected side
	Elevation	114	17.1	94.1	0.40	0.42*
	Abduction	114	18.4	83.1	0.39	0.38*
	Internal rotation	114	2.1	6.9	0.38	0.38*
	External rotation	113	5.3	37.8	0.19	0.18
Sleeping on unaffected side†
	Elevation	71	2.4	112.0	0.03	0.09
	Abduction	71	10.6	82.2	0.13	0.17
	Internal rotation	71	1.6	5.1	0.18	0.19
	External rotation	70	2.7	36.0	0.06	0.05
Reaching high shelf
	Elevation	115	24.6	88.5	0.56	0.58*
	Abduction	115	27.2	77.3	0.55	0.55*
	Internal rotation	115	3.1	6.2	0.56	0.57*
	External rotation	114	6.9	36.8	0.24	0.23
Lifting above shoulder level
	Elevation	116	27.4	86.4	0.57	0.57*
	Abduction	116	27.2	77.4	0.51	0.50*
	Internal rotation	116	3.1	6.3	0.51	0.53*
	External rotation	115	7.2	37.5	0.23	0.22
Pulling
	Elevation	113	21.7	84.8	0.51	0.50*
	Abduction	113	20.3	78.4	0.43	0.42*
	Internal rotation	113	2.5	5.9	0.47	0.47*
	External rotation	112	6.3	35.4	0.23	0.22
Performing work-related activities
	Elevation	59	15.7	104.6	0.43	0.43*
	Abduction	59	14.5	98.6	0.32	0.33
	Internal rotation	59	2.1	7.1	0.41	0.42*
	External rotation	59	3.9	40.6	0.14	0.13
Throwing overhand
	Elevation	46	15.3	118.6	0.42	0.39
	Abduction	46	18.0	109.8	0.43	0.42
	Internal rotation	46	1.8	9.7	0.39	0.46
	External rotation	46	6.5	41.8	0.26	0.26
Using racquet
	Elevation	44	18.9	108.3	0.56	0.51*
	Abduction	44	22.7	97.7	0.58	0.53*
	Internal rotation	44	2.3	8.3	0.55	0.55*
	External rotation	44	6.4	38.6	0.27	0.29
Performing other types of sports activities
	Elevation	44	17.2	108.3	0.43	0.38
	Abduction	44	20.5	96.9	0.44	0.38
	Internal rotation	44	3.2	7.1	0.59	0.58*
	External rotation	44	8.0	37.8	0.28	0.29

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TABLE I REGRESSION OF RANGE OF MOTION ON ACTIVITIES OF DAILY LIVING

*The value is significant (p < 0.001). †Does not include patients who had symptoms in the contralateral shoulder.

Activity of Daily Living	Range of Motion	No. of Patients	Slope	Intercept	Pearson Correlation Coefficient	Spearman Rank Correlation Coefficient
Combing hair
	Elevation	112	37.2	44.9	0.72	0.72*
	Abduction	112	39.6	31.5	0.69	0.68*
	Internal rotation	112	3.7	2.6	0.56	0.58*
	External rotation	111	11.7	22.5	0.35	0.33*
Putting on coat
	Elevation	113	29.9	58.8	0.51	0.51*
	Abduction	113	31.8	46.6	0.49	0.48*
	Internal rotation	113	3.4	3.2	0.46	0.49*
	External rotation	112	12.3	21.4	0.33	0.33*
Washing back
	Elevation	114	25.6	87.5	0.60	0.62*
	Abduction	114	26.1	77.9	0.55	0.56*
	Internal rotation	114	3.2	5.9	0.61	0.65*
	External rotation	113	10.5	33.2	0.38	0.40*
Washing contralateral armpit
	Elevation	114	25.5	61.6	0.53	0.50*
	Abduction	114	25.1	52.9	0.47	0.45*
	Internal rotation	114	3.1	2.8	0.51	0.50*
	External rotation	113	6.9	29.8	0.22	0.19
Using toilet
	Elevation	114	26.6	45.3	0.43	0.42*
	Abduction	114	27.8	33.5	0.41	0.40*
	Internal rotation	114	2.9	2.0	0.38	0.38*
	External rotation	113	10.6	17.0	0.27	0.23
Sleeping on affected side
	Elevation	114	17.1	94.1	0.40	0.42*
	Abduction	114	18.4	83.1	0.39	0.38*
	Internal rotation	114	2.1	6.9	0.38	0.38*
	External rotation	113	5.3	37.8	0.19	0.18
Sleeping on unaffected side†
	Elevation	71	2.4	112.0	0.03	0.09
	Abduction	71	10.6	82.2	0.13	0.17
	Internal rotation	71	1.6	5.1	0.18	0.19
	External rotation	70	2.7	36.0	0.06	0.05
Reaching high shelf
	Elevation	115	24.6	88.5	0.56	0.58*
	Abduction	115	27.2	77.3	0.55	0.55*
	Internal rotation	115	3.1	6.2	0.56	0.57*
	External rotation	114	6.9	36.8	0.24	0.23
Lifting above shoulder level
	Elevation	116	27.4	86.4	0.57	0.57*
	Abduction	116	27.2	77.4	0.51	0.50*
	Internal rotation	116	3.1	6.3	0.51	0.53*
	External rotation	115	7.2	37.5	0.23	0.22
Pulling
	Elevation	113	21.7	84.8	0.51	0.50*
	Abduction	113	20.3	78.4	0.43	0.42*
	Internal rotation	113	2.5	5.9	0.47	0.47*
	External rotation	112	6.3	35.4	0.23	0.22
Performing work-related activities
	Elevation	59	15.7	104.6	0.43	0.43*
	Abduction	59	14.5	98.6	0.32	0.33
	Internal rotation	59	2.1	7.1	0.41	0.42*
	External rotation	59	3.9	40.6	0.14	0.13
Throwing overhand
	Elevation	46	15.3	118.6	0.42	0.39
	Abduction	46	18.0	109.8	0.43	0.42
	Internal rotation	46	1.8	9.7	0.39	0.46
	External rotation	46	6.5	41.8	0.26	0.26
Using racquet
	Elevation	44	18.9	108.3	0.56	0.51*
	Abduction	44	22.7	97.7	0.58	0.53*
	Internal rotation	44	2.3	8.3	0.55	0.55*
	External rotation	44	6.4	38.6	0.27	0.29
Performing other types of sports activities
	Elevation	44	17.2	108.3	0.43	0.38
	Abduction	44	20.5	96.9	0.44	0.38
	Internal rotation	44	3.2	7.1	0.59	0.58*
	External rotation	44	8.0	37.8	0.28	0.29

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Figs. 1-A through 1-D: Graphs of the mean ranges of motion (and 95 per cent confidence intervals) versus the degree of difficulty in performing the most closely correlated activities of daily living. 0 = it is impossible for the patient to perform the activity, 1 = it is very difficult, 2 = it is somewhat difficult, and 3 = it is not difficult at all. Fig. 1-A: Elevation versus combing the hair.

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Fig. 1-B Abduction versus combing the hair.

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Fig. 1-C Internal rotation versus washing the back. The numbers on the y axis indicate the anatomical level that the patient could reach with the thumb: 1 = the greater trochanter, 2 = the buttock, 3 = the sacrum, 4 = the fifth lumbar vertebra, and so on up the vertebral column.

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Fig. 1-D External rotation versus washing the back.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Clinical Assessment

One hundred and twenty-five consecutive patients who were seen at a shoulder clinic were asked to fill out a questionnaire that included assessment of the ability to perform certain activities of daily living involving use of the affected shoulder. These activities included combing the hair, putting on a coat, washing the back, washing the contralateral armpit, using the toilet, sleeping on the affected side, sleeping on the unaffected side, reaching a high shelf, lifting above shoulder level, pulling, performing work-related activities, throwing overhand, using a racquet, and performing other types of sports activities. A patient was asked to assess the ability to perform sports activities only if he or she participated in such activities. Similarly, the ability to perform work-related activities was analyzed only if the patient was employed. The patient was asked to grade each activity as not difficult (3 points), somewhat difficult (2 points), very difficult (1 point), or impossible (0 points) by checking one of four boxes "to show how well you can do the different activities with your affected arm."

Active total elevation (maximum elevation of the shoulder in the most comfortable plane, which is usually several degrees lateral to the sagittal plane¹¹), active abduction in the scapular plane^8,18(approximately 30 degrees anterior to the coronal plane), active internal rotation in adduction, and passive external rotation in adduction were recorded as part of the clinical assessment. Elevation and abduction were measured with an inclinometer (Plurimeter-V; La Conversion, Champs des Pierretes, Switzerland). Internal rotation was recorded as the most cephalad anatomical level reached by the thumb, starting at the greater trochanter (graded as 1 point) and proceeding to the buttock (2 points), the sacrum (3 points), the fifth lumbar vertebra (4 points), and so on up the vertebral column. External rotation is difficult to measure accurately because of the absence of a clear neutral plane and its variation with the position of the shoulder; a visual estimation was routinely recorded. The ranges other than internal rotation were recorded in degrees to the nearest multiple of ten. All measurements were performed, with the patient upright, by the same examiner, who had seen the questionnaire as part of the clinical assessment.

Statistical Analysis

The relationships between the scores for the activities of daily living and the range of motion of the shoulder were assessed with linear regression analysis. The non-parametric Spearman correlation coefficient was also calculated, with correction for tied ranks. In view of the multiple comparisons, the level of significance was set at p < 0.001.

The data were then subjected to multiple linear regression analysis with use of a forward stepwise method. Variables were added to the models for each of the four types of motion if their contribution both was significant (r < 0.05) (partial F statistic) and resulted in an increase in adjusted r², a measure of the amount of variation explained by the model¹.

Results

Introduction | Materials and Methods | Results | Discussion | References

The mean age of the patients was 47.9 years (median, forty-nine years; range, thirteen to eighty-seven years). Sixty-two patients were male and sixty-three were female. Sixty (48 per cent) had a problem related to the rotator cuff, twelve (10 per cent) had instability, twelve (10 per cent) had capsulitis, five (4 per cent) had glenohumeral arthropathy, and the remaining thirty-six (29 per cent) had another condition. The diagnosis was made by the examiner after clinical and radiographic assessments had been performed. Each non-sports-related activity of daily living was rated by 90 to 95 per cent of the patients; 77 per cent of the patients rated all of the non-sports-related activities. Each of the sports-related activities was rated by 67 to 70 per cent of the patients who participated in sports activities. The mean active elevation was 115 degrees (range, 20 to 180 degrees), the mean active abduction was 106 degrees (range, 20 to 180 degrees), the mean active internal rotation was to the twelfth thoracic vertebra (range, the greater trochanter to the second thoracic vertebra), and the mean passive external rotation was 45 degrees (range, -10 to 90 degrees).

The parametric and non-parametric regression coefficients were closely parallel (Table I). Most of the regression analyses showed a significant correlation. The notable exception was sleeping on the unaffected side, as might be expected. Elevation and abduction correlated best with combing the hair, and internal and external rotation correlated best with washing the back (Figs. 1-A, 1-B, 1-C and 1-D). In general, the correlation coefficients for external rotation were lower than those for the other types of motion.

Multiple regression analysis gave the following models. For elevation, (26.7 x combing the hair) + (12.1 x lifting above shoulder level) + (7.4 x washing contralateral armpit) + 37.4 (adjusted r² = 0.61, r = 0.79, F = 57.06, p < 0.0001 with 108 degrees of freedom). For abduction, (40.0 x combing the hair) + (12.9 x reaching high shelf) + 35.0 (adjusted r² = 0.51, r = 0.72, F = 58.40, p < 0.0001 with 109 degrees of freedom). For internal rotation, (2.0 x washing back) + (1.6 x reaching high shelf) + (1.1 x washing contralateral armpit) + 3.3 (adjusted r² = 0.47, r = 0.70, F = 33.72, p < 0.0001 with 110 degrees of freedom). For external rotation, (10.5 x washing back) + 33.2 (adjusted r² = 0.14, r = 0.38, F = 18.92, p < 0.0001 with 112 degrees of freedom).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

In general, the correlations between activities of daily living and range of motion of the shoulder followed expected patterns, with the more specific activities that are performed regularly by most patients correlating better than activities that covered a wider spectrum. Thus, the highest correlations were for combing the hair and washing the back, whereas the correlations were lower for work-related activities and other types of sports activities. The ability to sleep on the affected side, which principally depends on whether or not the activity causes pain, had a low correlation with the range of motion of the shoulder, whereas the ability to sleep on the unaffected side did not correlate with motion at all. External rotation correlated poorly, probably because of the difficulty in measuring it and because it is a passive rather than an active motion. External rotation in abduction may be a more functional measure than external rotation in adduction.

Multiple regression analyses gave satisfactory models for elevation and abduction, but the models were less satisfactory for rotation, especially external rotation. This was also noted with simple regression analysis. Of interest is the fact that washing the contralateral armpit was in the model for elevation. Washing the armpit is a universal activity regularly performed with both the dominant and the non-dominant upper extremity; thus, it may be a more consistent indicator of overall function of the shoulder than other activities that involve greater actual elevation.

The correlations for elevation and abduction in general were similar. The former is considered to be the more functional motion¹⁷, and therefore it correlated somewhat better than the latter. Elevation represents motion in the changing plane of the scapula as the scapula protracts around the chest wall, whereas the older definition of motion in this plane (abduction in the scapular plane) refers to a less functional motion of the upper extremity in the plane adopted by the scapula only in adduction. It appears that measurement of both motions is not necessary to assess function of the shoulder, and that measurement of elevation is the more satisfactory of the two. However, I find the assessment of abduction to be useful diagnostically³.

Meaningful clinical measurement of the range of motion of a joint can be difficult because of problems with reproducible positioning of the patient and with avoidance of motion in related joints. While interobserver variation was not a factor in this study, the examiner did see the questionnaires before performing the measurements. Although this is a potential source of detection bias, I do not believe that a brief look at as many as fourteen checked-off boxes substantially affected the measurements.

Few common activities of daily living require an angle between the humerus and the long axis of the thorax of more than 90 degrees¹⁵. The exceptions include use of a comb, which correlated well with the range of motion of the shoulder, and sports activities such as those involving use of a racquet or throwing overhand. The sports activities correlated less well than use of a comb did, possibly because they involve considerable stress to the shoulder with consequent exacerbation of symptoms. The correlations that were found for most of the activities of daily living are evidence that they are useful measures of shoulder function. The activities that did not correlate with motion may nevertheless be useful in assessing the impact of the problem related to the shoulder on the quality of life because the range of motion of the shoulder is only one factor that affects the ability to perform activities of daily living.

The use of regression analysis to predict the range of motion of the shoulder in another group of patients could be helpful in the follow-up of patients with the use of a questionnaire. Use of a questionnaire is an alternative to the assessment of activities of daily living by a therapist, which may not always be possible¹⁰. Such questionnaires would provide more reliable information if the activities of daily living assessed were shown to relate to a measure of function (range of motion) in a population different from that in which the relation was initially calculated. Such an approach could be used to predict with accuracy only the mean ranges of motion of the shoulder in a population and not the actual range of motion for an individual. However, in general, the ability of the patient to use the shoulder for activities is more important than the actual range of motion. For example, asymptomatic older people regard the function of the shoulder as normal even though the range of motion decreases with age^4,5. I confirmed that the range of motion of the symptomatic shoulder was significantly negatively correlated with the age of the patient.

Three studies of patient-completed questionnaires assessed the relationship of motion of the shoulder to the overall shoulder scores. The originators of the Shoulder Pain and Disability Index²⁰ found that it correlated significantly with flexion, abduction, extension, and external rotation; this was also true for the combined score of the activities of daily living used in that system. However, in a review that included that questionnaire as well as four others², only one (the American Shoulder and Elbow Surgeons Shoulder Index¹⁹) correlated overall with elevation of the shoulder. Finally, the overall score of another disability questionnaire was found on trend analysis to relate to abduction and internal rotation but not to external rotation⁶.

In conclusion, I found that patients' assessments of the inability to carry out activities of daily living, particularly those that are performed regularly by most patients (such as combing the hair and washing the back), correlate significantly with the range of motion of the shoulder. Thus, they appear suitable for inclusion in patient questionnaires designed to assess the function of the shoulder at the time of presentation.

NOTE: The author gratefully acknowledges the assistance of Dr. Jane P. Reeves in the preparation of the figures.

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

activities of daily living ; range of motion ; shoulder region ; abduction

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PAUL D. TRIFFITT; The Relationship between Motion of the Shoulder and the Stated Ability to Perform Activities of Daily Living*. The Journal of Bone & Joint Surgery. 1998 Jan;80(1):41-6.

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