Summary

Among 15 expert shoulder surgeons, there was lack of consensus on the definition of pseudoparalysis and minimal agreement on the diagnosis of pseudoparalysis based on clinical scenarios; additionally, about half believed pseudoparalysis and pseudoparesis are identical, while the other half believed they represent two separate clinical entities.

Abstract

There is a lack of consensus regarding the definition and diagnosis of pseudoparalysis. This makes it difficult for surgeons to effectively communicate and disseminate knowledge regarding the management of this condition. To better understand the current expert consensus on pseudoparalysis, this study was designed to determine clinical agreement of pseudoparalysis by surveying 15 expert shoulder surgeons.

This IRB approved (17121001-IRB01) prospectively enrolling single center study included 18 patients. Included patients had a massive rotator cuff tear diagnosed by MRI, restricted active range of motion, full passive range of motion, and were between the ages of 18 and 80 years old. Patients were excluded if they had significant advanced rotator cuff arthropathy (Hamada grade >3), previous rotator cuff surgery, previous shoulder arthroplasty, or a diagnosis of adhesive capsulitis. The survey included 18 patient vignettes with key clinical details relevant to the patient’s case and medical history. This was followed by a de-identified video demonstrating the physical exam of the patient. The video included a frontal view of active forward elevation, active external rotation at the side, and passive abduction in the scapular plane with an isometric hold at 90°. Active forward elevation was also recorded in the lateral view. For certain patients, the video-taped physical exam was repeated after a subacromial injection of lidocaine with triamcinolone, if clinically indicated under the normal standard of care. For all patients, surgeons were instructed to assume the patient has a full passive ROM. An AP radiograph was also provided followed by T2 sequences of the patient’s coronal, axial, and sagittal MRI. After each case, the surgeons were asked: (1) does the patient have pseudoparalysis, and (2) if so, how severe is it. At the end of the patient vignettes, surgeons were asked to define pseudoparalysis using a check list with the options: active glenohumeral elevation less than 90°, any attempted elevation causing anterosuperior escape, maintained full passive elevation, absence of pain, and other. Surgeons were also asked if there was a difference between the term pseudoparalysis and pseudoparesis. Finally, they were asked about their number of years in practice, their fellowship training, and their practice setting. Fifteen expert shoulder surgeons were surveyed using RedCap, and Fleiss’ kappa correlation coefficient was utilized to determine inter-rater agreement amongst the surgeons for the diagnosis of pseudoparalysis, the determination of pseudoparalysis severity, and the definition of pseudoparalysis. The guidelines for interpreting Fleiss’ kappa correlation coefficient are as follows: <0.20 is no agreement, 0.21-0.40 is minimal agreement, 0.41-0.60 is weak agreement, 0.61 to 0.80 is moderate agreement, 0.81 to 0.90 is strong agreement, and 0.91 to 1.00 is perfect agreement.

Of the surgeons included in this study, 8 were fellowship trained in shoulder and elbow, while 7 were fellowship trained in sports medicine. Eight surgeons practiced in an academic setting, 1 practiced in a private setting, and 6 practiced in a hybrid private-academic setting. There was minimal interrater agreement on the diagnosis of pseudoparalysis for the 18 patient vignettes (kappa = 0.360 [95% CI: 0.322-0.397]. There was no agreement on describing the severity of pseudoparalysis (kappa = -0.057 [95% CI: -0.142-0.027]. When defining the criteria for pseudoparalysis, 80% included active glenohumeral elevation less than 90°, 67% included maintained full passive elevation, 33% included the absence of pain, 67% included elevation causing anterosuperior escape, and 27% included an additional unlisted factor. There was no agreement among the 15 surgeons on the diagnostic criteria of pseudoparalysis (kappa = 0.116 [95% CI: 0.031-0.202]. Finally, 7 surgeons stated that pseudoparalysis and pseudoparesis are identical, while 8 surgeons stated that they are two different clinical diagnoses. Therefore, a standardized definition of pseudoparalysis would be of value to facilitate communication and research efforts.