Department of Physical Therapy Student Theses, Dissertations and Capstones

Document Type


Degree Name

Doctor of Philosophy (PhD) in Physical Therapy

Copyright Statement

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College of Health Care Sciences - Physical Therapy Department

First Advisor

Alicia Fernandez-Fernandez

Publication Date / Copyright Date



Nova Southeastern University


Background: Physical therapists regularly make decisions regarding intervention intensity based upon pathoanatomy and symptom irritability, but the reliability and validity of classifying patients by symptom irritability are unknown. Purpose: Examine the reliability and construct validity of the shoulder symptom irritability classification (SSIC) system for the purposes of determining an appropriate treatment intensity. Design: Prospective repeated-measures cross-sectional single-blinded design. Methods: 101 consecutive subjects with primary complaints of shoulder pain were assessed by a pair of blinded raters. Raters recorded the SSIC level and selected the appropriate intervention intensities for the subjects. Data Analysis: Prevalence-adjusted, bias-adjusted Kappa for ordinal scales (PABAK-OS) and observed agreement were the primary measures of reliability. Analysis of variance (ANOVA) was used to compare functional disability across different levels of irritability. Receiver operating characteristic (ROC) curve analysis was utilized to derive cut-off scores for the patient-reported outcome (PRO) measures. Ordinal regression was utilized to compare the strength of patient-reported pain and disability in the determination of shoulder symptom irritability. Results: Inter-rater reliability (PABAK-OS) was 0.69 (95% Confidence Interval [CI] = 0.59, 0.78). ANOVA demonstrated significant differences in functional limitation between SSIC groups for all PRO measures. ROC curve analysis found significant cut-off scores for all PRO measures. Lastly, rater agreement between SSIC and treatment strategy was found to have PABAK-OS of 0.82 (95% CI 0.75, 0.88) with 80% agreement. Discussion: The inter-rater reliability of the SSIC system good and is not contingent upon experience or expertise. Despite lack of predominance of the function in the components of SSIC, functional limitation significantly influences SSIC along with aspects of pain that influence function. While the cut-off scores show promising results, further work is needed to validate the results. Ultimately, there appears to an excellent relationship between rater selected SSIC and treatment strategy demonstrating a foundation for construct validity of the SSIC. Therefore, the results of this study should serve as a foundation for future work for refinement of the SSIC as a component of the STAR-Shoulder diagnostic classification system. Clinical Significance: The shoulder symptom irritability classification scale is reliable and clinically useful for improvement of communication between medical providers.


Physical Therapy


Health and environmental sciences, Classification, Diagnosis, Intensity, Irritability, Reliability, Shoulder

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