The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb

Objectives-Following a consensus statement from a multidisciplinary UK work shop, a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb. The aim of this study was to test the repeatability and the validity of the newly deve loped schedule in a hospital setting. Method-43 consecutive referrals to a soft tissue rheumatism clinic (group 1 )and 45 subjects with one of a list of specific upper limb disorders (inclu ding shoulder capsulitis, rotator cuff tendinitis, lateral epicondylitis an d tenosynovitis) (group 2), were recruited from hospital rheumatology and o rthopaedic outpatient clinics. All 88 subjects were examined by a research nurse (blinded to diagnosis), and everyone from group 1 was independently e xamined by a rheumatologist. Between observer agreement was assessed among subjects from group 1 by calculating Cohen's a for dichotomous physical sig ns, and mean differences with limits of agreement for measured ranges of jo int movement. To assess the validity of the examination, a pre-defined algo rithm was applied to the nurse's examination findings in patients from both groups, and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinic's independent diagnosis as the ref erence standard. Results-The between observer repeatability of physical signs varied from go od to excellent, with kappa coefficients of 0.66 to 1.00 for most categoric al observations, and mean absolute differences:of 1.4 degrees-11.9 degrees for measurements of shoulder movement. The sensitivity of the schedule in c omparison with the reference standard varied between diagnoses from 58%-100 %, while the specificities ranged from 84%-100%. The nurse and the clinic p hysician generally agreed in their diagnoses, but in the presence of should er capsulitis the nurse usually also diagnosed shoulder tendinitis, whereas the clinic physician did not. Conclusion-The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting. Examination can feasibly be dele gated to a trained nurse, and the protocol has the benefit of face and cons truct validity as well as consensus backing. Its performance in the communi ty, where disease is less clear cut, merits separate evaluation, and furthe r refinement is needed to discriminate between discrete pathologies at the shoulder.