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The Shoulder Symptom Modification Procedure (SSMP): A Reliability Study

Hilla Sarig Bahat and Orna Kerner

Study design: Cross section reliability study. The study assessed inter-tester (n=90) and intra-tester reliability (n=25) of the Shoulder Symptom Modification Procedure (SSMP) in adults with localized shoulder pain. Objective: To evaluate the inter- and intra-tester reliability of the SSMP for shoulder assessment in patients with shoulder pain. Background: Diagnosing the underlying structures responsible for shoulder symptoms is difficult and commonly does not advance treatment. Current orthopedic assessment techniques are mostly provocative, and do not necessarily direct towards an effective strategy. The SSMP was developed to provide a treatment-oriented assessment. Methods: Patients underwent an initial functional test used as a reference for their shoulder symptoms. The SSMP aimed to find a technique that eases these symptoms. It comprised four modification categories: Thoracic kyphosis, scapular position, humeral head position, and neuro-modulation. Each modification resulted as positive if symptoms improved more than 30%. Inter-tester reliability was assessed by comparing findings by 2 physiotherapists (arranged in 3 pairs of 3 blinded testers). Intra-tester reliability evaluation included repeated testing by one physiotherapist. A washout period of 20-40 minutes was allowed in between repeated tests, during which intra-tester assessed/treated others and patients rested. Cohen’s kappa was used for statistical analysis. Results: Inter-tester reliability showed moderate to almost perfect agreement in the thoracic kyphosis and humeral head position categories (Ð�=0.77, 0.86 and Ð�=0.78, Ð�=0.74 respectively). Intra-tester reliability showed moderate agreement in the humeral head category (Ð�=0.66). Other categories showed poor to moderate agreement. Conclusion: Findings showed overall moderate reliability, with good reliability achieved for thoracic and humeral head modifications alone. Reliability was possibly limited due to the changeable nature of the variable being assessed. Symptom intensity may have changed due to modifications, altering the response to the provocation in the second test. Further research should investigate whether higher reliability can be achieved with procedures addressing the limitations identified.