Constant-Murley Shoulder Outcome Score

Definition/ Description


The Constant-Murley score (CMS) is a 100-points scale composed of a number of individual parameters. These parameters define the level of pain and the ability to carry out the normal daily activities of the patient.[1] The Constant-Murley score was introduced to determine the functionality after the treatment of a shoulder injury. The test is divided into four subscales: pain (15 points), activities of daily living (20 points), strength (25 points) and range of motion: forward elevation, external rotation, abduction and internal rotation of the shoulder (40 points). The higher the score, the higher the quality of the function.[2]

Subjective findings (severity of pain, activities of daily living and working in different positions) of the participants are responsible for 35 points and objective measurements (AROM without pain, measurements exo -and endorotation via reference points and measuring muscle strength) are responsible for the remaining 65 points.[3] The Constant-Murley score is used in almost every language without official translations. In French a validated translation has been published. Time needed to complete the Constant-Murley test is between 5 to 7 minutes. [4]

Response options/scale.


Pain item:               4 Likert levels or visual analog scale
                              0 = maximal pain, 15 = no pain


ADL:                       Likert scales
                              0 = worst and 5 = best


Mobility:                 Active, pain-free range of elevation: 2 points per 30°
                             0 = worst, 10 = best

                             Position of hand:0 = worst, 10 = best


Strength:               Measured at 90° lateral abduction
                            1 point per 0.5 kg, maximum 25 points

Use of the instrument


The European Society of shoulder and elbow surgery (ESSE) promotes the Constant-Murley score for a comprehensive and comparable assessment of shoulder function. The score is widely used and accepted throughout the European community as a shoulder golden standard for the assessment of shoulder function. [5]  The Constant-Murley score records individual parameters and provides a generally clinical functional assessment. Therefore it’s applicable irrespective of details of the diagnostic or radiological abnormalities. [4]

Scores and strength of the Constant-Murley test are age related, both will decrease as the patient is older. There are also gender-related differences in score and strength. When one uses the original values to calculate the relative Constant score, one may overestimate the shoulder function in women older than 40 years and men over 60 years. If relative Constant scores (scores based on an age-and sex-matched normal population of Constant original research) are used, the absolute scores must be given simultaneously to create comparison with different populations. [6]

Reference values for the relative Constant scores original research

Reference values for the relative Constant scores original research
Age (y)/sex               Strength             Constant scores
21–30/M                          24                        98 ± 4.2
31–40/M                            22                         93 ± 3.4
41–50/M                            19                         92 ± 3.6
51–60/M                            15                         90 ± 3.1
61–70/M                            12                         83 ± 4.2
71–80/M                            11                         75 ± 3.6
81–90/M                             /                           66 ± 3.1
91–100/M                           /                           56 ± 4.3
21–30/F                             23                         97 ± 4.7
31–40/F                             20                         90 ± 4.1
41–50/F                             14                         80 ± 3.8
51–60/F                             10                         73 ± 2.8
61–70/F                              9                          70 ± 4.0
71–80/F                              6                          69 ± 3.9
81–90/F                              /                           64 ± 2.9
91–100/F                            /                           52 ± 5.1         [6][7]


Purpose


The aim of this instrument is evaluative and intends to create a balance. [5] It suggests a scoring system directed toward a numerical rating of the quality of function of the shoulder. It uses objective and subjective measures to determine whether a certain functional movement is possible (e.g., forward elevation, external rotation, abduction and internal rotation of the shoulder). The Constant-Murley score is applicable regardless of the diagnosis and is one of the most frequently used scoring systems in the follow-up of shoulder injuries. (Grade of recommendation: B) [8]


Technique


The material needed for this test is the Constant-Murley scale, a goniometer and a spring balance test. The subjective part of the test can be completed by the patient himself, the objective section must be carried out by the assessor.[9] In proposing the score scale, power was measured with a spring balance that was mounted around the forearm of the patient. A different method to measure the force has also been published. This method makes use of weights that have to be carried with the arm in a maximum of 90 ° abduction and in the plane of the scapula. For every pound that can be carried 1 point is assigned, with a maximum of 25 points.[10]

 

The specific method to measures strength using a spring balance:
• A spring balance is attached distal on the forearm.
• Strength is measured with the arm in 90 degrees abduction, full extension of the elbow and the palm of the hand in pronation.
• The patient is asked to maintain this position for 5 seconds.
• Then repeated 3 times, immediately after another.
• The average in pound (lb) is noted.


The measurement should be pain free. If pain is involved the patient gets 0 points. Same for if the patient is unable to achieve 90 degrees of elevation.


Evidence

 Diagnostic Accuracy

Accuracy of Constant-Murley scale for Predicting Patient Satisfaction (Neer)  [11]

 

%Satisfied Patients  % Unsatisfied Patients %Patients Classified %Patients Classified   
  Correctly Classified      Correctly Classified       as Satisfied              as Unsatisfied
    as Satisfied                     as Satisfied             Actually Satisfied       Actually Unsatisfied

      96                            76                                93                          87
               

Results show that the use of the Constant-Murley score yields more accurate results, if the results of the affected side are compared with the performance of the unaffected side instead of a comparison against parameters of age and sex-matched groups. Even in larger groups of patients makes this method a better comparison of the functional results than the Constant-Murley score (reference parameters out of healthy age and gender related control groups). When the other shoulder has a positive history of a condition to the shoulder or is injured at the same moment, there is some weakness in this method. (Grade of recommendation: B) [12]

The Constant-Murley shoulder test is a valid instrument for health status and is useful for patients with various upper extremity symptoms; it is sensitive enough to notice small changes. (Grade of recommendation: B) [13]


 

 Psychometric properties  

  • Reliability
ICC                  0, 80 – 0, 96
ICC (95% CI)        0.80 (0.63 -0.90) (operation group)
                         0.87 (0.73- 0.94) (group without surgery)


  • Construct Validity
Correlation of the Constant-Murley score to other instruments
DASH:                             r= 0, 82; 0,76 and 0,50
ASES:                             r= 0,72 – 0,87
OSS:                               r= 0,65 – 0,87
SPADI:                           r= 0,53 and 0,82
SST:                               r= 0,49
Rating of change:    r= 0,32 – 0,70


A correlation of 0,49 complies with a significant but moderate correlation between the simple shoulder test and the Constant-Murley Shoulder Score. The significant correlation implicates a similar performance of the simple shoulder test, compared to the Constant-Murley Shoulder Score. The Constant-Murley Shoulder Test can only be used or in combination with the simple shoulder test. [14]


  • Sensitivity/ responsiveness
Standardized response mean Effect size 
6 weeks 0, 62 0, 56
3 months  1, 12 1, 23
6 months 2, 09 1, 92
*( NOTE: Sensitivity measures: greater magnitude indicates greater sensitivity, magnitude >1.0 reflects large change equivalent to one standard deviation in the sample. An effect size of 1.0 is equivalent to a change of one standard deviation in the sample and is considered to be very large.)


It has been shown that the Constant-Murley score is a reliable (ICC=0, 80-0, 87) and responsive (effect size= 0, 59) instrument in the assessment of the impact of the shoulder interventions. This test has been shown to be responsive to detecting improvement after shoulder intervention in a variety of shoulder pathologies. This responsiveness, or ability to assess change over time, has been found to be adequate. (Grade of recommendation: B) [15] [16] Several studies confirmed a good reproducibility, responsiveness and construct validity of the scores. (Grade of recommendation: B) [17] The Constant-Murley score correlates strongly with shoulder specific questionnaires. (Grade of recommendation: A) [18]

The intraobserver reliability of the Constant-Murley test is higher than the intraobserver reliability for the total score and for the single items. (Grade of recommendation: B) [5]  The high percentage of objective data for the Constant-Murley scale increases the possibility of a significant interobserver reliability. (Grade of recommendation: B) [11] Studies showed that standardization of the items significantly improve the interobserver reliability and the intraobserver reliability of the Constant-Murley shoulder test. (Grade of recommendation: B) [19]

Validity of the constant-Murley test has been questioned based on three concerns (Grade of recommendation: B):
(a) A single pain scale is considered inadequate to gain a true picture of the patient’s pain.
(b) The report of function is left to interpretation by the patient because it isn’t specific enough to any particular activity.
(c) The method of measuring strength has not been standardized. [16]

Criteria validity: There is no gold standard for self- and examiner-assessed shoulder function. (Grade of recommendation: B) [4] The internal consistency of the Constant-Murley score ranges from 0, 60 to 0, 75 (evaluated with the Cronbach α), suggesting that it measures different aspects of function. [18]


Dysfunction 


The Constant-Murley shoulder evaluation is not appropriate to measure outcomes for patients with shoulder instability, because it contains no elements that relate directly to the instability. (Grade of recommendation: c) [14]

The validity, the interobserver reliability and consistency of the strength of the tests are negatively affected by the lack of consensus on a reproducible measurement of force. There is need for further improvement in the way this score is used, reported and interpreted. [11] [20]


References


  1. V. B. Conboy, R.W. Morris et al.; “ An evaluation of the constant-Murley shoulder assessment”; J Bone Joint Surg 1996;78-B:229-32 (Level of evidence: 2B)
  2. M.T. Hirschmann, B. Wind et al.; “Reliability of Shoulder Abduction Strength Measure for the Constant-Murley Score”; Clin Orthop Relat Res 2010; 468; 1565–1571 (Level of evidence: 2B)
  3. A. A. Romeo, A. Mazzocca et al.;” Shoulder Scoring Scales for the Evaluation of Rotator Cuff Repair”; clinical orthopaedics and related research 2004; 427; 107-114 (Level of evidence: 2B)
  4. 4.0 4.1 4.2 F. ANGST, H.-K. SCHWYZER et al.; Measures of adult shoulder function.” ; Arthritis Care & Research November 2011; 63 (S11); 174-188 (level of evidence 2A)
  5. 5.0 5.1 5.2 M. H. H. Rocourt, L. Radlinger et al.; Evaluation of intratester and intertester reliability of the Constant-Murley shoulder assessment; Journal of Shoulder and Elbow Surgery Board of Trustees 2008 (Level of evidence: 1B)
  6. 6.0 6.1 E.H. Yian, A.J. Ramappa et al.; “The Constant score in normal shoulders”; J Shoulder Elbow Surg 2005; 14; 128-133 (Level of evidence: 3B)
  7. C. Fialka, G. Oberleitner et al.; “Modification of the Constant—Murley shoulder score—introduction of the individual relative Constant score Individual shoulder assessment”; Injury, Int. J. Care Injured 2005; 36; 1159—1165. (Level of evidence: 3B)
  8. L. I. Katolik, A. A. Romeo et al.; “Normalization of the Constant score”; J Shoulder Elbow Surg 2005 ;14; 279-285. (Level of evidence: 2B)
  9. K. A. R. Kemp, D.M. Sheps; “An Evaluation of the Responsiveness and Discriminant Validity of Shoulder Questionnaires among Patients Receiving Surgical Correction of Shoulder Instability”; The ScientificWorld Journal; Volume 2012; Article ID 410125 (Level of evidence: 2B)
  10. A. A. Romeo, A. Mazzocca et al.;” Shoulder Scoring Scales for the Evaluation of Rotator Cuff Repair”; clinical orthopaedics and related research 2004; 427; 107-114 (Level of evidence: 2B)
  11. 11.0 11.1 11.2 A. A. Romeo, A. Mazzocca et al.;” Shoulder Scoring Scales for the Evaluation of Rotator Cuff Repair”; clinical orthopaedics and related research 2004; 427; 107-114 (Level of evidence: 2B)
  12. C. Fialka, G. Oberleitner et al.; “Modification of the Constant—Murley shoulder score—introduction of the individual relative Constant score Individual shoulder assessment”; Injury, Int. J. Care Injured 2005; 36; 1159—1165. (Level of evidence: 3B)
  13. R Magetsari et al.; “Sensitiveness of the Constant-Murley’s Shoulder and Quick DASH as an Outcome Measure for Midshaft Clavicle Fracture”; Malaysian Orthopaedic Journal 2010; Vol 4; No 1 (Level of evidence: 2B)
  14. 14.0 14.1 M. Skutek, R. W. Fremerey et al.; “Outcome analysis following open rotator cuff repair.Early effectiveness validated using four different shoulder assessment scales”; Arch Orthop Trauma Surg 2000; 120; 432–436 (level of evidence: 2B)
  15. K. A. R. Kemp, D.M. Sheps; “An Evaluation of the Responsiveness and Discriminant Validity of Shoulder Questionnaires among Patients Receiving Surgical Correction of Shoulder Instability”; The ScientificWorld Journal; Volume 2012; Article ID 410125 (Level of evidence: 2B)
  16. 16.0 16.1 J. Stiller, Timothy L et al.; “Outcomes measurement of upper extremity function”; 2005 Human Kinetics-ATT 2005; 10(3); . 24-25 (level of evidence:2A)
  17. M.T. Hirschmann, B. Wind et al.; “Reliability of Shoulder Abduction Strength Measure for the Constant-Murley Score”; Clin Orthop Relat Res 2010; 468; 1565–1571 (Level of evidence: 2B)
  18. 18.0 18.1 J.-Se´bastien Roy, J. C. MacDermid et al.; “A systematic review of the psychometric properties of the Constant-Murley score” ; J Shoulder Elbow Surg 2010; 19; 157-164 (Level of evidence: 1A)
  19. D. Blonna, M. Scelsi et al.; “Can we improve the reliability of the Constant-Murley score?” Journal of Shoulder and Elbow Surgery Board of Trustees 2012; 21; 4-12. (Level of evidence: 2B )
  20. L. I. Katolik, A. A. Romeo et al.; “Normalization of the Constant score”; J Shoulder Elbow Surg 2005 ;14; 279-285. (Level of evidence: 2B)