ORIGINAL ARTICLES
Development of a Shoulder Pain and
Disability Index
Kathryn E. Rouch, Elly Budiman-Muk, Norwarat Songsiridej, and Yongsuk Lertratanakul
A shoulder pain and disability index (SPADI) was
developed to measure the pain and disability associ-
cited with shoulder pathology. The SPADI is a self-
administered index consisting of 13 items divided
into two subscales: pain and disability. Thirty-seven
male patients with shoulder pain were used in a
study to examine the measurement characteristics of
the SPADI. Test-retest reliability of the SPADI total
cind subscale scores ranged from 0.6377 to 0.6552.
Jnternal consistency ranged from 0.8604 to 0.9507.
SPADI total and subscale scores were highly nega-
tively correlated with shoulder range of motion
(ROhl)supporting the criterion validity of the index.
Principal components factor analysis with and with-
out varimax rotation supported the construct valid-
j ty of the total SPADI and its subscales. High negative
correlations between changes in SPADI scores and
changes in shoulder ROM indicated the SPADI de-
lected changes in clinical status over short time inter-
vals. The SPADI should prove useful for both clinical
(2nd research purposes.
'The shoulder girdle is composed of the sternoclavicu-
jar, acromioclavicular, and glenohumeral joints as
Kathryn E. Roach, hIHS/PT, is Assistant Professor, University of
Miami School of Medicine, Division of Physical Therapy, Coral
Gables, Florida. At the time of this study, she was Project Director.
Health Services Research and Development Field Program, VA
Hines Hospital, Hines; and a doctoral candidate in Epidemiology,
University of Illinois Chicago, School of Public Health, Chicago,
Illinois. Elly Budiman-Mak, MD, MPH, is Assistant Chief, General
M e d i d Section, Ambulatory Care Service, VA Hines Hospital,
Hines; and Assistant Professor, Loyola University, Stritch School
iof Medicine, Maywood, Illinois. Norwarat Songsiridej, MD, is Clin-
ical Assistant Professor, University of North Dakota, and Attending
Physician, St. Olenis Medical, Bismark, North Dakota. Yongsuk
Lertratanakul, MD, is Chief, Rheumatology Section, VA Hines Hos-
pital, Hines; and Clinical Associate Professor of Medicine, Stritch
School of Medicine, Maywood, Illinois.
0893-7524/91/$3.50
well as the scapulothoracic articulation [l].Shoulder
girdle pain refers to pain occurring in or around any
of these structures. It is one of the most common
presenting complaints in the outpatient setting, espe-
cially among older patients [2-51.
Although painful shoulder is not a life-threatening
disorder, it can produce substantial disability. A
study of 79-year-old men and women conducted in
Sweden found that impaired shoulder function was
associated with difficulty performing a number of
self-care activities and in using public transportation
161.
The primary complaints associated with shoulder
problems are largely subjective in nature. Manual
muscle testing and goniometry are used as objective
measures of shoulder strength and range of motion
(ROM) [l]. However, both patients and health-care
providers judge the severity of the problem and the
response to treatment based on the pain and difficulty
experienced by the patient. Even though such subjec-
tive complaints are difficult to quantify, pain and
disability may be the most valid outcome measures
in the treatment of shoulder problems.
A large number of instruments currently exist to
measure the pain and disability associated with joint
disease [ 7-1 11. Unfortunately, all of these instru-
ments are global rather than joint specific. Because
global instruments include items that involve the
function of many different joints, the use of a global
instrument to measure the pain and disability associ-
ated with a disease process involving only one joint
Address correspondence to Kathryn E. Roach, MHSIPT, Univer-
sity of Miami School of Medicine, Division of Physical Therapy,
5915 Ponce de Leon Boulevard, 5th Floor, Coral Gables, FL 33146,
USA.
Received for publication September 4, 1990; accepted August
19, 1991.
0 1991 by the Arthritis Health Professions Association.
143
144 Roach et aJ.
could result in a lack of precision. The impact of a
specific joint problem on the disability score would
be diminished by the irrelevant items. For the same
reason, a global instrument may be unable to demon-
strate the effect of a treatment directed at only one
joint.
A few joint-specific instruments are available, but
none of them were fully satisfactory for our purposes.
'The American Shoulder and Elbow Surgeons Shoul-
der Evaluation Form includes 1 4 function items and
one pain item. This instrument was designed for ad-
ministration by a clinician and includes an extensive
clinical evaluation, but does nat produce a numerical
!;core and no information on reliability or validity has
been reported [ 121.
Viikari-Juntura et al. [13] conducted a study that
employed a '13-item index of shoulder and neck pain
and disability. They did not report information on
the reliability or validity of this index, but stated that
it was adapted from a back pain and disability index
developed by Million et al. [14] that had been tested
for inter- and intrarater reliability.
Because no reliable, valid, shoulder-joint-specific
instruments were available, the shoulder pain and
disability index (SPADI) was developed to provide a
self-administered instrument that would reflect the
disability and pain associated with the clinical syn-
drome of painful shoulder. The SPADI was designed
to measure current status and change over time. Since
it is critical that the reliability and validity of any
new functional status instrument be determined [ 151,
we conducted a study to determine the SPADI's inter-
nal consistency, test-retest reliability, criterion and
construct validity and ability to detect change.
METHOD
Subjects
The subjects for this study consisted of 37 male pa-
tients who came to the ambulatory care clinic with a
complaint of shoulder pain and were subsequently
enrolled in a randomized clinical trial. Patients who
had fractures, joint infections, hemiplegia, or spinal
cord injury, and those who were unable to follow
directions or who were already under treatment for
painful shoulder at the time of enrollment were ex-
cluded. The ages of the subjects ranged from 23 to 76
years with a mean age of 58 years. Twenty-seven had
shoulder pain of musculoskeletal origin. The major-
ity of the remaining subjects had shoulder pain of
neurogenic or undetermined origin.
Vol. 4,No. 4, December 1991
TABLE: 1
Shoulder Pain and Disability Index: Items Listed
by Scale
-7
Pain scide
How severe is your pain
1. At it:; worst?
2. When lying on the involved side?
3 . Reaching for something on a high shelf?
4. Touching the back of your neck?
5. Pushing with the involved arm?
Disability scale
How much difficulty do you have
1. Washing your hair?
2. Washing your back?
3. Putting on an undershirt or pullover sweater?
4. Putting on a shirt that buttons down the front?
5. Putting on your pants?
6. Placiing an object on a high shelf?
7. Carrying a heavy object of 10 pounds?
8. Removing something from your back pocket?
Description of the Index
The SF'ADI was developed for use in an outpatient
setting It was designed to measure the impact of
shoulder pathology in terms of pain and disability,
for both current status and change in status over time.
The initial version of the SPADI consisted of 20
items grouped into pain and disability subscales.
Items were selected and placed in either the pain or
disability subscale by a panel that included three
rheumatologists and a physical therapist. The face
validity of each subscale was addressed by selecting
items that the panel felt reflected pain and disability
associated with shoulder problems.
In an effort to improve reliability and validity and
to decrease the time required to complete the index,
some items were eliminated from each subscale.
Items were excluded from the final form of the SPADI
if test-retest reliability was low or if correlation with
shoulder ROM on the involved side was low. The pain
subscale was reduced from nine to five items and the
disability subscale was reduced from 11to eight items
(Table 3 ). The SPADI was self-administered and, in its
final form, required 5-10 minutes to complete.
Scoring System. All items were rated using a visual
analogue scale. Visual analogue scales seem to reflect
more closely what the subject actually experiences
[16] and are the most widely employed type of scale
in the measurement of the pain associated with rheu-
matic d.isorders [ l l ] .The visual analogue scales used
Arthritis Care and Research
Pain Scale
How severe is your pain?
When lying on
the involved side. ......No pain
Disability Scale
How much difficulty did you have?
Washing your back ...No Difficulty
Figure 1. Shoulder pain and disability index: sample items.
in the SPADI consisted of horizontal lines to which
were attached neither numbers nor divisions. Verbal
anchors, representing opposite extremes of the di-
mension being measured, were placed at either end
of the line. The patient was instructed to place a mark
on the line in the position that best represented his
experience during the past week attributable to the
shoulder problem (Figure 1).
The SPADI’s scoring system was based on the as-
sumption that the severity of pain or disability re-
sulting from shoulder pathology was a function of
the number of situations in which pain or disability
was experienced as well as the intensity of that expe-
rience in each situation. A numeric score was calcu-
lated for each item by arbitrarily dividing the hori-
zontal line into 12 segments of equal length. A
number ranging from 0 to 11 was attached to this
segment to produce a score for each item. The sub-
scale scores were calculated by adding the item
scores for that subscale and dividing this number by
the maximum score possible for the items that were
deemed applicable by the subject. This number was
ihen multiplied by 100.Any item marked by the pa-
tient as not applicable was not included in the maxi-
inum possible score. If a subject marked more than
two items not applicable, no score was calculated.
Therefore, scores could theoretically range from 0 to
‘100 with higher scores indicating greater impair-
ment. The total SPADI score was calculated by aver-
aging the pain and disability subscale scores. Thus,
the total SPADI score could also range from 0 to 100.
Shoulder Pain and Disability Index 145
Score
Worst pain
Imaginable
Score
So difficult
required help
Data Collection
During the initial visit, demographic and clinical in-
formation was collected on all subjects. Active shoul-
der ROM measurements were taken during the initial
visit and repeated at the 30-day follow-up visit. Sub-
jects were asked to complete the SPADI at the initial
visit, at home 24-48 hours later, and at the 30-day
follow.-up visit.
Analysis
Reliability. The test-retest reliability of the SPADI
was examined to determine whether the scores de-
rived were relatively stable over periods of time
which were short enough that little real clinical
change could be expected. Intraclass correlation coef-
ficients and their 95% confidence intervals were cal-
culated to test the level of agreement between the
initial and 24-hour follow-up scores 117, 181. Data
from the 23 subjects who completed the SPADI for
the second time within days of the initial visit were
used to analyze test-retest reliability.
The internal consistency of the SPADI and the two
subscales was examined by calculating a Cronbach’s
a using data from the initial visit for the entire group
of 37 subjects.
Criterion Validity. The criterion validity of the
SPADI was examined using active shoulder ROM [l,
3, 191 as the gold standard. Criterion validity was
tested by examining the correlation between the
SPADI total and subscale scores and active shoulder
146 Roach et al. Vol. 4, No. 4, December 1991

TABLE 2 bility of the total SPADI and pain and disability sub-
Shoulder Pain and Disability Index: Reliability
scale scores was examined using intraclass correla-
tion coefficients. The highest level of test-retest
Intraclass
agreement was found for the SPADI total score,
correlation ICC = 0.6552 (Table 2). Agreement between scores
coefficient Cronbach's (Y at time 1 and time 2 was slightly lower for the pain
~~

and disability subscales: ICC = 0.6377 and ICC =

Pain scale 0.6377 0.8604
0.6441, respectively.
0.3994-0.7953a
23b 33b The internal consistency of the total index as well
as that of the pain and disability subscales was high.
Klisability scale 0.6441 0.9321
0.4118-0.7991
The Cronbach's CY was 0.9507 for the total index,
23 33 0.8604 for the pain scale, and 0.9321 for the disability
index (Table 2). In no instance did dropping one of
Total SPADI 0.6552 0.9507
0.4236-0.8058 the items from a subscale appreciably improve the
23 33 Cronbach's a.
~~~

a Confidence interval Criterion Validity

Number of subjects.
The level of correlation between the initial total
SPADI score and baseline active shoulder ROM mea-
E.OM based on the assumption that if the SPADI surements was moderate to high and in the predicted
scores actually reflected the severity of shoulder pain negative direction. Correlations ranged from
and disability, they should be a highly negatively -0.5455 to -0.8036 (Table 3). Both the pain and
correlated with active shoulder ROM. This relation- disability scale scores were also highly negatively
ship was examined using a Pearson product-moment correlal ed with initial active shoulder ROM.
correlation coefficient. Data from the initial visit for
all 37 subjects were used in this analysis. Construct Validity
Principal components factor analysis without rota-
Construct Validity. The construct validity of the tion produced one factor, and all items from both
SPADI was examined by performing a principal com- subscales loaded strongly on this factor (Table 4).
ponents factor analysis with and without varimax Principal components factor analysis with varimax
rotatjon. If the SPADI is a valid measure of shoulder
impairment, then all items from both subscales
should load most strongly on one factor. Varimax TABLE :3
rotation should produce two factors with the majority Criterion Validity: Correlation Between Shoulder Pain
of items from each subscale primarily loading on and Disability Index Scores and Shoulder Range
different factors. Data from the initial visit for all 37 of Motion
subjects were used in this analysis.
SPADI Pain Disability
Change in Status. The ability of the SPADI to detect score score score
change over time was tested by examining the corre-
Shoulder flexion -0.5693d -0.5868 - 0.5226
lation between changes in total SPADI and pain and
0.0003b 0.0002 0.0011
disability subscale scores and changes in active 36' 36 36
shoulder ROM that occurred between the initial and
Shoulder abduction -0.5455 -0.5412 - 0.5202
30-day follow-up visits. Data from the 30 subjects 0.0006 0.0002 0.0011
who completed the SPADI at the time of the 30-day 36 36 36
follow-up visit were used in this analysis.
Shoulder extension - 0.8036 - 0.7950 - 0.7686
0.0001 0.0001 0.0001
36 36 36
RESULTS Shoulder external -0.5625 -0.5571 --0.5374
rotation 0.0004 0.0004 0.0007
Reliability 36 36 36
Twenty-three of the subjects completed the SPADI
* Pearson correlation coefficient.
correctly within several days of the initial visit and " p value.
returned it to the investigators. The test-retest relia- ' Number of subjects
Arthritis Care and Kesearch Shoulder Pain and Disability Index 147

TABLE 4 TABLE 5
Construct Validity: Principal Components Factor Construct Validity: Principal Components Factor
Analysis Without Rotation Analysis with Varimax Rotation

All items are listed under the factor for which they have the
strongest loading. The original subscale to which the item was
assigned is designated as follows:
(P) Pain subscale
(D) Disability subscale
All items are listed under the factor for which they have the
strongest loading. The original subscale to which the item was
assigned is designated as follows:
(P) Pain subscale
(D) Disability subscale

Factor Factor 1 Factor 2

Factor 1 loading loading loading

Pain severity reaching 0.7853 Factor 1

Pain severity at worst 0.6824 (P) Pain severity pushing 0.7061 0.3346
Pain severity lying on side 0.7496 (P) Pain severity touching back of 0.7382 0.4649
Pain severity pushing 0.7507 neck
Pain severity touching back of neck 0.8610 (D) Difficulty washing back 0.8328 0.3377
Ilifficulty washing back 0.8473 (D) Difficulty carrying heavy object 0.8941 0.1639
Difficulty with buttoned shirt 0.9017 (D) Difficulty placing on a high shelf 0.7428 0.3490
Difficulty carrying heavy object 0.7784 (D) Difficulty putting on pants 0.6308 0.4028
Difficulty placing on a high shelf 0.7877 (D) Difficulty washing hair 0.6ia8 0.5543
Difficulty putting on pants 0.7394
Factor 2
Difficulty putting hand in back pocket 0.7074
[P) Pain severity reaching 0.4999 0.6203
Difficulty with pullover shirt 0.8806
(P) Pain severity at worst 0.1314 0.8817
1)ifficulty washing hair 0.8307
(P) Pain severity lying on side 0.3261 0.7629
(D) Difficulty with buttoned shirt 0.6208 0.6591
N = 37
(D) Difficulty putting hand in back 0.3893 0.6276
pocket
(D) Difficulty with pullover shirt 0.5263 0.7342
rotation produced two factors. The majority of items ~~

from the disability subscale most strongly loaded on N = 35‘

the first factor, whereas the majority of items from the

pain subscale strongly loaded on the second factor.
However, there were a number of items that did not would be expected in this population even over a 48-
follow this pattern (Table 5). hour period. Almost all of these patients (91%) were
placed on analgesic medication and 50% of them
Change in Status received a periarticular corticosteroid injection to de-
On average, the subjects showed improvement in crease pain and inflammation at the time of the initial
shoulder function at the time of the 30-day follow-up visit. Changes in SPADI and in pain and disability
visit. Although there was a wide range in individual scale scores between the initial and 48-hour follow-
response, the group demonstrated a mean increase in up periods, in part, may represent real change.
shoulder ROM and a mean decrease in SPADI total
and subscale scores (Table 6). High negative correla-
tions were produced between the changes in SPADI TABLE 6
total score and changes in active shoulder ROM.
‘These correlations ranged from - 0.5203 to - 0.7010 Change in Shoulder Pain, Disability, and Range of
and were all statistically significant (Table 7). Motion Between the Initial and Final Visits
Changes in pain and disability subscale scores were
idso highly negatively associated with changes in ac- Mean change Lowest Highest
tive shoulder ROM. SPADI score - 25.6 - 94.3 26.5
Pain score - 25.8 - 100.00 29.1
Disability score - 25.3 - 90.9 26.1
DISCUSSION Flexion 23.7 - 45 100
Abduction 16.2 - 40 90
Extension 10.2 - 20 45
‘The total SPADI as well as pain and disability sub- External rotation 11.0 - 40 55
scale scores demonstrated acceptable levels of
test-retest reliability, given that some real change N = 30.
‘148 Roach et oJ. Vol. 4 , No. 4, December 1991

‘TABLE 7 is supported by the finding that at baseline the

Ability to Detect Change in Status: Correlation Between
correlation between the pain and disability sub-
Change in Shoulder Pain and Disability Index Scores scales is 0.8673 ( p = 0.0001).
and Change in Shoulder Range of Motion The ability of the SPADI to detect change in status
was demonstrated by the highly negative correlation
Change in Change in Change in between the changes in active shoulder ROM and
SPADI pain disability the changes in total SPADI and pain and disability
score score score subscale scores. The changes experienced by the sub-
--
Change in shoulder - 0.7010a -0.7031 - 0.6630
jects in this study ranged from marked improvement
flexion 0.0001h 0.0001 0.0001 to deterioration. Therefore the SPADI’s ability to de-
30‘ 30 30 tect change was tested over a wide range of possible
Change in shoulder - 0.6045 -0.5875 - 0.5905
situations. The fact that changes in ROM were
abduction 0.0004 0.0006 0.0006 strangly reflected in changes in SPADI scoTes implies
30 30 30 that the SPADI could function well as a measure of
Change in shoulder - 0.5203 -0.5178 - 0.4961
response to treatment.
extension 0.0032 0.0034 0.0053
30 30 30

Change in shoulder - 0.6248 -0.6176 -0.5995 CONCLUSION

external rotation 0.0003 0.0004
30 30
Pearson correlation coefficient.
p value.
Number of subiects.
The total SPADI and both the pain and disability
scales demonstrated high levels of internal consis-
tency. This indicates that all of the items contained
in the SPADI contribute to the measurement of the
phenomenon of interest.
The highly negative correlation between total
SPADI and pain and disability scale scores and mea-
sures of active shoulder ROM indicated that the
SPADI achieved acceptable criterion validity. Ten
percent of the patients in this study had shoulder
pain of radicular origin that may not be associated
with decreased shoulder ROM. The association be-
tween active shoulder ROM and SPADI scores may
have been decreased somewhat by their inclusion of
subjects with radicular pain in the analysis.
Factor analysis without rotation produced strong
loading of all SPADI items an one factor. This
supports the conclusion that the SPADI measures
one construct, namely, shoulder impairment. Vari-
max rotation produced two factors. Although,
grouping the items according to the strongest factor
loading did not perfectly reproduce the two sub-
scales, the majority of the items were correctly
grouped by this process. A number of the disability
items loaded strongly onto both factors. The results
of the varimax rotation provided limited support
for maintaining two separate subscales. It appears
likely that, at least in this population, shoulder pain
and shoulder disability are highly associated. This
0.0006
30
The SPADI appears to have functioned well in a pa-
tient population that consisted primarily of alder
men. The degree to which these results can be gener-
alized to women and younger individuals with shoul-
der problems remains to be fully demonstrated,
The !<PAD1is an easily self-administered clinical
index. Unlike goniometry, it need not be adminis-
tered by a trained clinician. Patients must be in-
structed in the proper use of the SPADI. After the
initial training session, however, most patients can
complete the SPADI without further assistance.
Therefore, the SPADI could be administered by mail
and used to monitor a patient’s progress at home.
The SPADI demonstrates good internal consis-
tency, test-retest reliability, and criterion and con-
struct validity. It also appears able to detect change in
patient status over time. The SPADI should therefore
prove to be a useful instrument both in clinical prac-
tice and in clinical research.
This research was supported by a grant from the Department of
Veterans Affairs, Health Services Research and Development, LOC
88-019. The authors are grateful to Mira Iskadar, Larry Brand, and
Angela Lear for their contributions to this project.
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