Data analysis resulted in the categorization of 6 themes that describe the issues that participants had when interpreting items. This is further described and illustrated by participants’ quotes, as demonstrated in Table 2.
Common issues that arose with the Short-WORC. (n = 26)
Calibration Across Items
Inadequate Response definition
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Overall, found to be relevant (73%)
Few participants felt it was only relevant if the injured arm was slept on.
2. Styling your hair
Gender issues arose (30%). E.x. men who were bald found this inapplicable
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Some participants calibrated this answer with the item of sleeping (19%)
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Overall, relevant to 79% of participants
3. Dressing or undressing
Some gender issues arose, i.e. men who did not rate this item as important (19%)
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Some participants calibrated this answer with the item of sleeping and styling hair
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Overall, relevant to 70% of participants
4. Daily activities about the house or yard
Some comprehension issues with defining daily activities and yard work
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Overall was relevant for 80% of participants
12% found work in the yard irrelevant to their Qol
5. Working above the shoulder
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Overall, 90% of participants found it was relevant to their QoL
6. Compensate with unaffected arm
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88% of participants found this relevant to their QoL.
12% found if the injury was on the non-dominant hand it was not relevant.
7. Lifting heavy objects at or below shoulder level
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92% of participants found this to be relevant to QoL
Overall findings demonstrate that individuals interpreted items based on their personal situation, personality traits, biology, work roles and/or environmental factors,19 which was represented through the theme of perspective modifiers.20 Certain items such as, styling your hair or dressing, were more influenced by gender. While the genders found this item relevant to QoL, males assigned less importance to this item when compared to items such as, working above shoulder level. Additionally, perspective modifiers also influenced the relevance of doing work outside the house for participants who specified living in an apartment or having designated help prior to the injury. Therefore, item relevancy to the construct is influenced by a person’s biological, environmental or social context.
Instructions on Short- WORC
The Short-WORC focuses on two different domains which have unique sets of instructions. When participants (n = 26) were asked to read the instructions out loud, some comprehension (C) issues arose. Specifically, there was misinterpretation around some of the important words in the instructions. For example, when asked to define the word “past week”, some participants confused this with “average week”.
“Okay so here I have to answer and think about my lifestyle and what I do on an average day in the week, and how much my shoulder has been kinda affecting or altering those activities.” – Measurement Researcher #1, female
Some participants also struggled with the interpretation of the word “lifestyle”. When asked to define, the majority of participants associated lifestyle with only activities of daily living.
“Lifestyle is my activities during the day. Would the term activities of daily living be better suited instead of lifestyle, is this what you are asking?” - Clinician #4, female
1. How much difficulty do you have sleeping because of your shoulder?
Overall, this item was well understood by most participants and did not demonstrate comprehension issues. When asked to define the term “sleeping”, frequent words such as: “at rest, relaxed at night and lying down” arose. The majority of participants (73%) considered this item to be relevant to their lifestyle, however, some suggested that it was only relevant if they slept on the injured shoulder.
“I always sleep on my left side so my right shoulder (injured) is fine at night.”- Patient #8, female
Additionally, some participants (19%) described compensator strategies that allowed them to sleep better at night. Participants discussed themes of intense shoulder pain, which translated to modifications of their sleeping position to comfortably rest.
“Since the surgery was on my left shoulder, my left shoulder was out, and so I mostly slept on my back.” – patient #4, male.
2. How much difficulty have you experienced with styling your hair because of your shoulder?
Comprehension of this item was generally clear to all participants. When asked to define the term “styling your hair”, phrases of “grooming, blow drying, combing, brushing and using styling products” arose. Findings demonstrate this item to be relevant to QoL with the majority of participants (79%), however, the theme of perspective modifiers heavily influenced the interpretation.
Relevance was a gendered issue with this item. Men more often found this item to be irrelevant to their QoL as they had short hair or were bald (30%).
“I’m bald, I don’t need to style my hair!” – Patient #5, male.
Furthermore, some participants (19%) used the item of sleeping, as a reference point to calibrate their response to the item of styling your hair. Additionally, some participants identified that styling their hair was critical to their QoL, and so needed to compensate with the uninjured arm, seek assistance or allot more time in their day for styling.
“If I were to injure my shoulder, I would still style my hair …I would get someone (roommate) to just help me out if I needed a specific style.”- Measurement Researcher #1, female.
3. How much difficulty do you have dressing or undressing?
In general, definitions of “dressing or undressing” were rephrased as “putting on clothes, removing clothes, and getting ready”, indicating no comprehension issues. Findings further indicated that participants (70%) strongly endorsed the relevance of this item to their QoL. Additionally, some participants (30%) calibrated their response to this item, based on their scores for the items of sleeping and styling their hair.
“I would say my answer would be the same as styling my hair…if I chose 5 or 6 in question 2, then I would choose the same answer for question 3.” – Measurement Researcher #2, male
Furthermore, participants identified the importance of completing this task and the need to compensate to complete it. Strategies for compensation included: requiring assistance from a device or family member, increasing the allotted time for changing of clothes, or changing the types of clothing worn in order to decrease shoulder movement.
“I can’t reach my back to put on my bra…that’s why my husband helps me out.” – Patient #6, female.
4. How much difficulty do you experience in daily activities about the house or yard?
Findings indicated some comprehension issues with this item, as participants would interchange the words “lifestyle” and “daily activities” often. When asked to define “daily activities”, terms such as: “chores, work, school, and living style” frequently arose.
“Yeah my daily activities are defined by my work and hobbies. My life is my job, family and other activities I do.” – Patient #5, female.
In contrast, definitions of “about the house or the yard” resulted in phrases of: “chores, eating, cleaning, cooking, gardening and yard /outdoors work”. Only one participant initially misinterpreted the meaning of about the house or yard, and defined it as occupational labour that involves working outdoors.
“This means work outside of the house like employment that you get paid for or yard work. This is both inside or outside the house and external jobs…that’s what I think”- Clinician #6, Female
Overall, participants (80%) identified this item to be relevant to their overall quality of life, but some (12%) were concerned with the phrasing of “work in the yard”. Due to participants’ living conditions, some did not require the need to do yard work, i.e. living in an apartment or having designated help prior to the injury.
“No, I do not do any yard work, my husband always does that.” – Patient #8, female.
Additionally, some compensatory strategies were mentioned such as: seeking assistance from someone else to do their daily activities or modifying the time period or frequency of activities they participated in.
5. How much difficulty do you experience with working above the shoulder?
Overall, this item received positive feedback from participants (90%), as many identified this item to be a critical component of recovery. Some participants (10%) identified that they did not need to do much overhead reaching and therefore, found this item less important to their quality of life.
“I have an office job, I don’t need to raise my arms much.” – Patient #8, female.
Definitions of “working above the shoulder” included phrases such as: “overhead reaching, lifting above my head and raising my arms”, indicating comprehension was generally good for this item. Participants frequently mentioned compensating strategies in order to continue to work above shoulder level, such as: modifying the placement of items for easier access or seeking assistance when needing to reach above shoulder level.
“I try to use my left hand a lot more to help out and then I keep things within reach. The shelves are much lower in my house and if something is too high for me I use a step ladder.” – Patient #10, female.
6. How much do you use your unaffected arm to compensate for the injured arm?
Definitions of “compensate” led to phrases such as: “using my not injured shoulder and using my healthy shoulder more”, indicating no comprehension issues amongst participants. Furthermore, this item was identified as a critical component for QoL by participants (88%).
“I use my left hand a lot, which is much harder since I am very right-hand dominant.” – patient #6, female.
In contrast, some participants (12%) indicated that compensating was less relevant, as their injury was on their non-dominant arm.
“I am right handed; my injury was on my left shoulder…do I compensate? Not frequently”.
7. How much difficulty do you experience lifting heavy objects at or below shoulder level? When asked to define “heavy objects”, participants stated words such as: “weight, large and using force”, indicating the item was well understood. Overall, this item resulted in a mix of responses depending on what stage of recovery the participant was in. Participants who were further along their recovery scored this item lower, while participants who were in the early stages of the injury scored it higher. Nevertheless, the majority of participants (92%) identified this item to be important to QoL. While evident that participants understood this item, some (12%) participate in a variety of tasks below shoulder level and therefore, were unsure which tasks to calibrate their score to.
“I do some yard work and cleaning that can be difficult to bend and pick up things from time to time...I think something in the middle?”- Patient, #3, female
Additionally, some participants discussed compensatory strategies such as re-allocating the task to someone else in order to feel less discomfort.
“Now with the snow coming, I will have to shovel myself since the weather is bad and I will have to find help.”- Patient #7, female.