Anesth Analg 2008; 107:722-723
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e31817b65e2
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidmanm
Valid and Relevant Outcome Measures Are Critical for Objective Hypothesis-Testing
Klaus F. Hofmann-Kiefer, MD,
Tim Eiser, MD,
Daniel Chappell, MD,
Stephan Leuschner, MD,
Peter Conzen, MD, and
Dierk Schwender, MD
University of Munich; Munich, Germany; klaus.hofmann-kiefer{at}med.uni-muenchen.de
In Response:
Ilfeld et al.1 question the validity of the Constant-Murley assessment2 (CS) for the immediate postoperative period after open shoulder surgery and whether this scoring system is relevant for hospitalized patients. In our opinion, there are two requirements for validating a new measurement system: the results from a new test can be compared with those obtained from established and reliable predecessors, i.e., a "gold standard," or the test has to prove its reliability over an extended period of time and numerous applications in clinical trials and (with restrictions) by mathematical and/or statistical controls.
When Constant and Murley developed their score in 1987, standard tests to evaluate shoulder pathology did not exist. However, the CS is now the most frequently used method for assessing shoulder function in orthopedics and trauma surgery. The CS is the only measurement validated in the original paper3 and, more importantly, validated by comparison with other measurement systems, such as the "Neer-Score."4 In addition, the CS is explicitly recommended for use in the postoperative period by the European Society for Surgery of the Shoulder and Elbow5 (ESSSE). Thus, we believe the CS to be the gold standard for postoperative shoulder testing.
Although some use regional anesthesia for pain control at home,6 presently, most catheters are removed before the patient leaves the hospital. Therefore, it is important to assess the influence of regional anesthesia on the early postoperative period. Ilfeld et al. have done so themselves.7–9 We do not claim the CS to be an ideal measurement tool for this period, and explicitly referred to this limitation in our results and discussion section.10 However, regarding the remarks of Ilfeld and co-workers on the most important part of the CS testing-active motion may be inadequate as an instrument of early physiotherapy, but could be easily and safely practiced during the short CS testing periods. None of our patients suffered any harm during the study. On the contrary, the risk to damage of the supraspinatus and/or deltoid repairs may even be less than that during passive training, if the patient is in control of his/her movements. As stated—and criticized— by Ilfeld et al., one subsection of the CS is titled "Activity of Daily Life" (ADL). To be "active" as early as possible after surgery today is one of the basic principles of modern patient management. Hospitalized patients nowadays are "out of bed" on the first postoperative day and we see no reason to exclude this point from the Score.
REFERENCES
- Ilfeld BM, Wright TW, Sessler DI, Chmielewski TL. Valid and relevant outcome measures are critical for objective hypothesis-testing. Anesth Analg 2008;107:722[Free Full Text]
- Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; 160–4
- Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley shoulder assessment. J Bone Joint Surg Br 1996;78:229–32[Medline]
- Tingart M, Bathis H, Lefering R, Bouillon B, Tiling T. Constant Score and Neer Score. A comparison of score results and subjective patient satisfaction. Unfallchirurg 2001;104:1048–54[Web of Science][Medline]
- European Society for Surgery of the Shoulder and the Elbow. 2007 Ref Type: Internet Communication: http://www.shoulderdoc.co.uk/education/article.asp
- Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesthesiology 2002;96:1297–304[Web of Science][Medline]
- Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesth Analg 2003;96:1089–95[Abstract/Free Full Text]
- Ilfeld BM, Wright TW, Enneking FK, Morey TE. Joint range of motion after total shoulder arthroplasty with and without a continuous interscalene nerve block: a retrospective, case-control study. Reg Anesth Pain Med 2005;30:429–33[Web of Science][Medline]
- Ilfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology 2006;105:999–1007[Web of Science][Medline]
- Hofmann-Kiefer K, Eiser T, Chappell D, Leuschner S, Conzen P, Schwender D. Does patient-controlled continuous interscalene block improve early functional rehabilitation after open shoulder surgery? Anesth Analg 2008;106:991–6[Abstract/Free Full Text]
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