Convergent Validity of the Patient-Reported Outcomes Measurement Information System's Physical Function Computerized Adaptive Test for the Knee and Shoulder Injury Sports Medicine Patient Population

Patient reported outcome scores following traumatic hip dislocations

OBJECTIVE

Traumatic native hip dislocations require immediate orthopaedic attention and have been associated with significant long-term morbidity. Previous studies have reported radiographic outcomes and clinical complication rates, however; evidence evaluating the effect of these injuries on patient-reported outcomes (PROs) is limited. The purpose of our study was to evaluate PRO scores among patients with native hip dislocations.

METHODS

Adult patients with native hip dislocations between 2005 and 2020 at a single academic Level 1 trauma center were retrospectively reviewed. Radiographs and medical records were reviewed for patient demographics and comorbidities, injury characteristics, details of treatment including time to reduction, and complications. Patients were given the PROMIS Physical Function (PROMIS PF) and Short Form-36 (SF-36) via HIPAA compliant electronic data capture. Outcomes were analyzed using Student t-tests and Mann-Whitney U comparisons of means/medians. Floor and ceiling effects were also characterized for the various outcomes scores.

RESULTS

A total of 168 patients with native hip dislocation were identified, 78 (46.4 %) of whom completed all PROs measures. Among responders, mean age was 36.2 years (SD 14.5), mean BMI was 29.2 (SD 6.7), and mean dislocation duration was 8.9 h (SD 5.1). On univariable regression, older age was associated with worse SF-36 Physical scores (p = 0.007). PROMIS PF showed an estimated 2.18 decrease for every one grade increase in Kellgren-Lawrence score (p = 0.01). There were no ceiling or floor effects seen with PROMIS PF, SF-36 Physical Summary, or SF-36 Mental Summary Scores.

CONCLUSIONS

Patients of older age and higher Kellgren-Lawrence score exhibited worse SF-36 Physical Function and PROMIS PF scores, respectively, highlighting the functional impact that native hip dislocations may have. PROMIS PF, SF-36 Physical and Mental Summary Scores were without floor or ceiling effects, rendering this an important tool in the evaluation of patients with traumatic native hip dislocation.

The Oxford Elbow Score demonstrated good measurement properties when used with a shortened 7-day recall period

Background

The Oxford Elbow Score (OES) is a well-validated, elbow-specific, patient-reported outcome measure (PROM), originally assigned a 4-week recall period. For PROMs, short recall periods could have some advantages, such as optimizing validity by minimizing the negative effects of inaccurate recollection and temporal trends (increase or decrease) in symptoms over the course of the recall period. Temporal trends in elbow function can, for example, be expected to occur over 4 weeks in patients recovering from an injury or surgery. The purpose of this study was to evaluate the measurement properties of the OES using a shortened, 7-day, recall period (OES-7d).

Methods

The inclusion criteria were fracture, tendon rupture or dislocation affecting the elbow, and age ≥18 years. Patients with Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores of ≥10 points preinjury (pre-existing upper extremity condition) or concurrent upper extremity injuries were excluded. Patients completed the OES-7d, QuickDASH, and Single Assessment Numeric Evaluation-Function for the last 7 days preinjury (T1), the first 7 days postinjury (T2) and a 7-day period 3-5 months postinjury (T3). Correlations were assessed with Spearman's rho. Analyses of construct validity (correlation between scores) and internal consistency (Cronbach's alpha) were based on T3 data. Responsiveness was assessed by correlating changes in scores (change scores) between time points. Intra-rater reliability was assessed by calculating intraclass correlation coefficients based on 2 administrations (1- to 3-week interval) of PROMs in a separate group of patients who had sustained an elbow injury 1-2 years previously.

Results

Seventy-five patients (45 women) were included between May 2020 and July 2021. Their mean age was 51.7 years. At T3, Spearman's rho was -0.91 for the correlation between OES total and QuickDASH scores and 0.76 for the correlation between OES total scores and Single Assessment Numeric Evaluation-Function values (construct validity). Spearman's rho for correlation between OES total and QuickDASH change scores from T2 to T3 (T3 minus T2) was -0.85 (responsiveness for improvement) and -0.88 for change scores from T1 to T2 (T2 minus T1, responsiveness for deterioration). For the OES domains, Cronbach's alpha was 0.83 for elbow function, 0.91 for pain and 0.90 for social-psychological domains. The intraclass correlation coefficient for the OES total score was 0.96.

Conclusion

The OES demonstrated good measurement properties when used with a 7-day recall period (OES-7d). These results further establish the OES as a well-validated, elbow-specific PROM and support using a 7-day recall period.

An Exploratory Factor Analysis of the National Institutes of Health Patient-Reported Outcomes Measurement Information System and the Single Assessment Numeric Evaluation in Knee Surgery Patients

INTRODUCTION

Patient-Reported Outcomes (PROs) have been suggested for use in measuring treatment effectiveness. To minimize patient burden, two approaches have been proposed: An orthopedic-specific Single Assessment Numeric Evaluation (SANE) or computer adaptive testing methods such as the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS). The goal of this work was to examine the constructs measured by the SANE and PROMIS system in a military orthopedic population undergoing knee surgery.

MATERIALS AND METHODS

In 732 patients and 2,166 complete observations, the SANE-Knee PRO and PROMIS surveys for Depression, Anxiety, Pain Interference, Sleep Disturbance, and Physical Function were obtained. A correlation matrix between the PROs was calculated, the number of latent factors to extract was determined via parallel plot, and the final principal axis exploratory factor analysis was performed.

RESULTS

The parallel plot analysis indicated that two latent factors existed. One latent factor corresponded to measures of psychological distress (PROMIS Sleep Disturbance, Depression, and Anxiety) and the second latent factor corresponded to physical capability (SANE, PROMIS Physical Function, Pain Interference, and Sleep Disturbance). Both PROMIS Physical Function (0.83) and Pain Interference (-0.80) more strongly weigh on the physical capability latent factor than SANE (0.69).

CONCLUSIONS

In a knee surgical population, the SANE, PROMIS Physical Function, and PROMIS Pain Interference measure the same human dimension of physical capability; however, PROMIS Physical Function and Pain Interference may measure this construct more effectively in isolation. The SANE may be a more viable option to gauge physical capability when computer adaptive testing is not possible.

Can the Single Assessment Numeric Evaluation be used as a stand-alone subjective outcome instrument in patients undergoing rotator cuff repair?

BACKGROUND/HYPOTHESIS

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. The Single Assessment Numeric (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis was that SANE will correlate with and be comparable in responsiveness to other subjective outcome measures that have been used in a stand-alone fashion in patients undergoing rotator cuff repair (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Western Ontario Rotator Cuff Index [WORC], and the Simple Shoulder Test [SST]). In addition, the SANE will be more relevant to each patient compared to the ASES, further supporting its use as a stand-alone shoulder-specific outcomes measure.

METHODS

A retrospective review of a database of patients undergoing rotator cuff repair was reviewed where the SANE was recorded with the ASES, WORC, and/or SST. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean (SRM) and the effect size (ES) of all scores. Relevance and precision of the SANE and ASES were examined using 150 consecutive patients to determine the number of questions in each score that were not answered.

RESULTS

Correlation was excellent for the SANE and the ASES (n = 1838, r = 0.81, P < .0001), the WORC (n = 1793, r = 0.82, P < .0001), and the SST (n = 1836, r = 0.76, P < .0001). Correlation of preoperative scores was moderate and postoperative scores were excellent when comparing the SANE with all 3 scores. All scores were highly responsive, with the SRM of the SANE = 2.1, ASES = 2.2, WORC = 2.4, and the SST = 1.8. The ES of the SANE = 2.4, ASES = 2.7, WORC = 3.0, and the SST = 2.1. One hundred percent of the SANE scores were answered completely compared with 57% (P < .0001) of the ASES, with significant variability found in the answers to the "work" and "score" questions.

CONCLUSION

In patients undergoing rotator cuff repair, the SANE highly correlated and has equivalent responsiveness with the WORC, ASES, and SST, which have been used as stand-alone shoulder-specific outcomes measures. The SANE may provide the same information as the WORC, ASES, and SST regarding outcome with significant reduction in responder burden. This study supports that the SANE can be used as a subjective, stand-alone instrument for patients undergoing rotator cuff repair.

Preoperative Opioid Use Is Associated With Inferior Patient-Reported Outcomes Measurement Information System Scores Following Rotator Cuff Repair

PURPOSE

To determine the influence of preoperative opioid use on Patient-Reported Outcomes Measurement Information System (PROMIS) scores pre- and postoperatively in patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective review of all RCR patients aged >18 years old was performed. PROMIS pain interference ("PROMIS PI"), upper extremity function ("PROMIS UE"), and depression ("PROMIS D") scores, were reviewed. These measures were collected at preoperative, 6-month, and 1-year postoperative time points. A prescription drug-monitoring program was queried to track opioid prescriptions. Patients were categorized as chronic users, acute users, and nonusers based on prescriptions filled. Comparison of means were carried out using analysis of variance and least squares means. Effect sizes and 95% confidence intervals were calculated.

RESULTS

In total, 184 patients who underwent RCR were included. Preoperatively, nonusers (n = 92) had superior PROMIS UE (30.6 vs 28.9 vs 26.1; P < .05) and PI scores (61.5 vs 64.9 vs 65.3; P < .001) compared with acute users (n = 65) and chronic users (n = 27), respectively. At 6 months postoperatively; nonusers demonstrated significantly greater PROMIS UE (41.7 vs 35.6 vs. 33.5; P < .001), lower PROMIS D (41.6 vs 45.8 vs 51.1; P < .001), and lower PROMIS PI scores (50.7 vs 56.3 vs 58.1; P < .01) when compared with acute and chronic users, respectively. Nonusers had lower PROMIS PI (47.9 vs 54.3 vs 57.4; P < .0001) and PROMIS D (41.6 vs 48.3 vs 49.2; P = .0002) scores compared with acute and chronic users at 1-year postoperatively. Nonusers experienced a significantly greater magnitude of improvement in PROMIS D 6 months postoperatively compared with chronic opioid users (-5.9 vs 0.0; P < .01).

CONCLUSIONS

Patients undergoing RCR demonstrated superior PROMIS scores pre- and postoperatively if they did not use opioids within 3 months before surgery.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

Can the Single Assessment Numeric Evaluation (SANE) be used as a stand-alone outcome instrument in patients undergoing total shoulder arthroplasty?

BACKGROUND AND HYPOTHESIS

There is no consensus as to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes for either clinical or research purposes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. To date, the Single Assessment Numeric Evaluation (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis of this study was that the SANE would correlate with and be equal or superior in responsiveness to other outcome measures that have been used in a stand-alone fashion in patients undergoing total shoulder arthroplasty (American Shoulder and Elbow Surgeons [ASES], Western Ontario Osteoarthritis of the Shoulder [WOOS], and Simple Shoulder Test [SST] scores). In addition, it was hypothesized that the SANE would be more relevant to each patient than the ASES assessment, further supporting the use of the SANE as a stand-alone shoulder-specific outcome measure.

METHODS

A retrospective review of a database of patients undergoing total shoulder arthroplasty was performed, in which the SANE score was recorded simultaneously with the ASES, WOOS, and/or SST score. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine whether correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of all scores. The relevance of the SANE and ASES assessments was examined using the scores of 150 consecutive patients to determine the number of questions on each assessment that were not answered.

RESULTS

Correlation was excellent for the SANE score and the ASES score (n = 1447, r = 0.82, P < .0001), WOOS score (n = 1514, r = 0.83, P < .0001), and SST score (n = 1095, r = 0.81, P < .0001). The correlation of preoperative scores was moderate and that of postoperative scores was strong-moderate when the SANE score was compared with all 3 other scores. All scores were highly responsive, with standardized response mean values of 2.2 for the SANE score, 2.3 for the ASES score, 1.4 for the WOOS score, and 1.6 for the SST score. The effect size of the SANE score was 2.9; ASES score, 2.9; WOOS score, 2.9; and SST score, 2.3. One hundred percent of the SANE questions were answered completely compared with 61% of the ASES questions (P < .0001).

CONCLUSION

In patients undergoing total shoulder arthroplasty, the SANE score highly correlated with the WOOS, ASES, and SST scores, which have been used as stand-alone shoulder-specific outcome measures. The SANE score may provide the same information as the WOOS, ASES, and SST score regarding outcomes with a significant reduction in responder burden. It is logical that the SANE can be used as a stand-alone instrument for patients undergoing total shoulder arthroplasty.

Predictors of PROMIS Physical Function at 2 Years following Knee Surgery

The purpose of this study was to evaluate Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) 2 years following knee surgery, and identify preoperative factors associated with postoperative PROMIS PF. Three hundred and sixty-five patients, age 17 years and older, undergoing knee surgery at one institution were studied. Patients completed multiple questionnaires prior to surgery and again 2 years postoperatively including PROMIS PF, International Knee Documentation Committee (IKDC), joint and body numeric pain scales (NPS), Tegner's activity scale (TAS), and Marx's activity rating scale (MARS). Mean PROMIS PF improved from 41.4 to 50.9 at 2 years postoperatively (p < 0.001) and was strongly correlated with 2-year IKDC scores. Older age, female gender, non-Hispanic ethnicity, unemployment, lower income, government insurance, smoking, preoperative opioid use, having a legal claim, comorbidities, previous surgeries, higher body mass index (BMI), and knee arthroplasty were associated with worse 2-year PROMIS PF. Multivariable analysis confirmed that lower BMI, less NPS body pain, and higher MARS were independent predictors of greater 2-year PROMIS PF and better improvement in PROMIS PF. In this large, broad cohort of knee surgery patients, multiple preoperative factors were associated with PROMIS PF 2 years postoperatively. PROMIS PF scores improved significantly, but worse 2 year PROMIS PF scores and less improvement from baseline were independently predicted by higher BMI, greater NPS body pain, and lower MARS activity level. PROMIS PF can be implemented as an efficient means to assess outcomes after knee surgery.

Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Instruments Compare Favorably With Legacy Patient-Reported Outcome Measures in Upper- and Lower-Extremity Orthopaedic Patients: A Systematic Review of the Literature

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with traditional ("legacy") patient-reported outcome measures (PROMs) in regard to correlations, ease of use, and quality criteria for upper (UE) and lower extremity (LE) orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 857 studies, 85 of which were selected for independent review by 2 authors. Of these, 54 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 6,074 UE and 9,366 LE patients. Overall, PROMIS PF measures demonstrated strong correlations with legacy PROMs among UE (weighted Pearson correlation, 0.624, standard error [SE] = 0.042; weighted Spearman correlation, 0.566, SE = 0.042) and LE patients (weighted Pearson correlation, 0.645, SE = 0.062; weighted Spearman correlation, 0.631, SE = 0.041). PROMIS PF questionnaires completed by UE patients had fewer questions than legacy PROMs (5.9 vs 17.7, P = .0093) and were completed in less time (90.5 vs 223.8 seconds, P = .084). PROMIS PF questionnaires completed by LE patients had fewer questions than legacy PROMs (4.81 vs 15.33, P < .001) and were completed in less time (63.6 vs 203.2 seconds, P = .0063). The differences for the reliability measures were not significant.

CONCLUSIONS

PROMIS PF scores correlate strongly with commonly used legacy PROMs in orthopaedics, particularly in UE and LE patients. PROMIS PF forms can be administered efficiently and to a broad patient population while remaining highly reliable. Therefore, they can be justified for standardized use among orthopaedic patients with UE and LE conditions, improving the ability to aggregate and compare outcomes in orthopaedic research.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

The American Shoulder and Elbow Score Is Highly Correlated With the Western Ontario Rotator Cuff Index and Has Less Responder and Administrator Burden

Purpose

To compare the correlation, responsiveness, and responder and administrator burdens of the American Shoulder and Elbow Score (ASES) with the Western Ontario Rotator Cuff Index (WORC) for patients undergoing arthroscopic rotator cuff repair to determine whether one score is superior to the other to limit the use of multiple scoring measures when tracking patient outcomes.

Methods

A retrospective review of a database of patients undergoing arthroscopic rotator cuff repair was reviewed where the ASES was simultaneously recorded with the WORC. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of both scores. Responder and administrator burden was examined using 50 consecutively scored WORC and ASES scores by determining the number of questions accurately answered and the length of time taken to score each questionnaire.

Results

Correlation was excellent for the ASES and WORC (r = 0.90). The correlation of preoperative scores was strong-moderate (r = 0.69), and the correlation of postoperative scores was excellent (r = 0.86). The standardized response mean WORC = 2.3; ASES = 2.2) and the effect size (WORC = 2.9; ASES = 2.8) demonstrated comparable responsiveness. In total, 71.5% of the WORC questions were able to be scored compared with 93.3% for the ASES (P < .0001). The mean time to score the WORC was significantly greater than the ASES (154 vs 23 seconds; P < .0001).

Conclusions

There is excellent correlation and comparable responsiveness between the ASES and WORC. Since there is greater responder and administrative burden for the WORC score, the authors recommend using the ASES over the WORC in patients undergoing rotator cuff repair.

Level of Evidence

Level IV, diagnostic series.

PROMIS Versus Legacy Patient-Reported Outcome Measures for Sports Medicine Patients Undergoing Arthroscopic Knee, Shoulder, and Hip Interventions: A Systematic Review

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) was designed to monitor the global wellbeing of patients, with the Physical Function Computer-Adaptive Test (PF-CAT) component focused specifically on functional outcome. PROMIS aims for increased item-bank accuracy, lower administrative burden, and decreased floor and ceiling effects compared to legacy patient-reported outcome measures (PROMs). Our primary research outcomes focused on sports medicine surgical populations, which may skew younger or have wide-ranging functional statuses. Specifically, for this population, we questioned if PROMIS PF-CAT was equal to legacy PROMs in (1) construct validity and (2) convergent/divergent validities; and superior to legacy PROMs with respect to (3) survey burden and (4) floor and ceiling effects.

METHODS

Searches were performed in April 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing PubMed, Cochrane Central, and Embase databases for Level I-III evidence. This resulted in 541 records, yielding 12 studies for inclusion. PROM data was available for patients undergoing arthroscopic orthopaedic procedures of the knee, shoulder, and hip. Measures of construct validity, convergent/divergent validity, survey burden, and floor/ceiling effects were evaluated for PROMIS PF-CAT versus legacy PROMs.

RESULTS

PROMIS PF-CAT demonstrated excellent or excellent-good correlation with legacy PROMS for physical function and quality of life for patients undergoing arthroscopic interventions of the knee, shoulder, and hip. Compared to legacy PROM instruments, PROMIS PF-CAT demonstrated the lowest overall survey burden and had the lowest overall number of floor or ceiling effects across participants.

CONCLUSION

PROMIS PF-CAT is an accurate, efficient evaluation tool for sports medicine surgical patients. PROMIS PF-CAT strongly correlates with legacy physical function PROMs while having a lower test burden and less incidence of floor and ceiling effects. PROMIS PF-CAT may be an optimal alternative for traditional physical function PROMs in sports medicine patients undergoing arthroscopic procedures. Further studies are required to extend the generalizability of these findings to patients during postoperative timepoints after shoulder and hip interventionsLevel of Evidence: III.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population

BACKGROUND

Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages.

PURPOSE

To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis.

RESULTS

A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R² = 0.71-0.74; root mean square error = 9.3-10.0).

CONCLUSION

The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

The American Shoulder and Elbow Surgeons score has excellent correlation with the Western Ontario Osteoarthritis score

BACKGROUND/HYPOTHESIS

The purpose of this study was to compare the correlation, responsiveness, and responder and administrator burden of the American Shoulder and Elbow Surgeons (ASES) score with the Western Ontario Osteoarthritis of the Shoulder (WOOS) score for patients undergoing total shoulder arthroplasty. The goal was to determine whether one score was superior to the other to limit the use of multiple scoring measures when tracking patient outcomes. The hypothesis of this study was that for patients undergoing total shoulder arthroplasty, the WOOS score would have (1) a high level of correlation with the ASES score, (2) comparable responsiveness to the ASES score, and (3) a higher responder and administrator burden than the ASES score.

METHODS

We performed a retrospective review of a database of patients undergoing total shoulder arthroplasty in which the ASES score was recorded with the WOOS score. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine whether correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations and by type of arthroplasty (anatomic vs. reverse). Responsiveness was determined by calculating the standardized response mean and the effect size of both scores. Responder and administrator burden was examined using 50 consecutive preoperative patients to determine the number of incorrectly completed WOOS and ASES scores.

RESULTS

The correlation of the ASES and WOOS scores for all patients was excellent (n = 1218, r = 0.88, P < .0001). The correlation of the ASES and WOOS scores was excellent for patients undergoing anatomic total shoulder arthroplasty (n = 695, r = 0.71, P < .0001) and reverse total shoulder arthroplasty (n = 523, r = 0.88, P < .0001). The correlation of preoperative scores was strong-moderate (n = 606, r = 0.62, P < .0001), and that of postoperative scores was strong-moderate (n = 612, r = 0.69, P < .0001). The standardized response mean (WOOS score, 2.1; ASES score, 2.1) and the effect size (WOOS score, 3.0; ASES score, 3.0) demonstrated comparable responsiveness. Twenty-six percent of the WOOS scores were completed incorrectly and were invalid compared with 0% of the ASES scores (P < .0001).

CONCLUSION

There is excellent correlation and comparable responsiveness between the ASES score and WOOS score. Including these scores simultaneously when tracking patient-determined outcomes appears to be redundant and therefore unnecessary. Because there is higher responder and administrative burden for the WOOS score, we recommend use of the ASES score over the WOOS score in patients undergoing total shoulder arthroplasty.

Development and validation of the disease - specific problems questionnaire for patients with multiple sclerosis

BACKGROUND

Patients with multiple sclerosis face numerous problems during their lifetime. A self-report measurement of disease - specific problems is required to be developed for patients with multiple sclerosis based on different cultural factors. Accordingly, this can advance our understanding on the disease-specific problems for care planning as well as improving coping ways and quality of life. This study aimed to develop and validate the scale of disease-specific problems of Multiple Sclerosis.

METHODS

This was an exploratory sequential mixed method study conducted in three phases. Correspondingly, in the first phase, the concept of disease-specific problems was defined using the content analysis approach in patients with MS. In the second phase, the item pool was generated from the findings of the first phase, and in the third phase, psychometric properties of the scale, including face, content, and construct validity and reliability, were evaluated.

RESULTS

After examining both validity and reliability, 28 items were developed in the final questionnaire. As well, by performing the factor analysis, five factors were revealed as follows: physical problems, psychological problems, emotional problems, family problems, and socio-economic problems. Internal consistency and stability of the questionnaire were calculated as 0.82 and 0.90, respectively, indicating an excellent reliability.

CONCLUSION

The 28-item questionnaire is valid and reliable for measurement of level of disease - specific problems in Iranian people with MS.

Persistent joint pain and arm function in former baseball players

Background

Baseball has specific sport and positional demands that may modify joint pain compared with other sports. Persistent joint pain reduces function and is an underlying reason for seeking medical care. The pain and functional status of players after they stop competitive play are unknown. Such knowledge can assist clinicians in creating personalized physical examinations and interventions for baseball players as they transition to retirement. The purpose of this study was to (1) evaluate persistent joint pain and arm function in former baseball players and (2) determine whether playing position is associated with increased odds of joint pain and reduced arm function in former baseball players.

Methods

A cross-sectional survey was performed. Eligibility criteria consisted of (1) played ≥1 collegiate baseball season, (2) aged ≥18 years, and (3) formerly played baseball (currently retired). Outcomes assessed included persistent joint pain and Single Assessment Numeric Evaluation (SANE). Explanatory variables included playing position (position, two-way, or pitcher). Multivariable logistic and linear regressions were performed. Models were adjusted for age, body mass index, arm dominance, playing standard, years played baseball, and injury and surgery history.

Results

A total of 117 former baseball players participated (age: 36.8 [13.7] years). The mean dominant SANE score was 70.2 (standard deviation 24.1), and the mean nondominant SANE score was 85.2 (standard deviation 19.4). There was no difference in dominant arm SANE scores when stratified by arm injury history (4.6 [95% confidence interval: −14.9, 5.8]) or arm surgery history (−3.8 [95% confidence interval: 13.4, 5.8]). The shoulders had the greatest persistent joint pain prevalence (28% of all participants) and elbows (21% of all participants). There was no relationship between dominant arm pain or function and playing position.

Conclusion

This is the first study to demonstrate an increase in dominant arm disability in former baseball players. The high prevalence of persistent arm pain and poor arm function among former baseball players is concerning considering participants were younger than 40 years of age. No differences were observed in arm function when stratifying by arm history, surgery, or position demonstrating the potential relationship between baseball participation and arm disability after cessation of play. Clinicians should consider working with baseball players to develop long-term strategies to maintain joint health, especially in the throwing arm, when baseball players are transitioning to retirement. Future research is needed to understand the long-term effectiveness of clinical treatments and the implications of specific arm injuries such as ulnar collateral ligament tears on persistent arm pain and function.

Normative PROMIS Scores in Healthy Collegiate Athletes: Establishing a Target for Return to Function in the Young Adult Athlete

Background

The Patient-Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) has been shown to be a valid and reliable means of assessing patient-reported outcomes. However, normal scores and distributions for a subset of a healthy young athletic population have not been established.

Purpose

To establish normative PROMIS scores for the domains of Physical Function (PF-CAT), Mobility (M-CAT), Upper Extremity Function (UE-CAT), and Pain Interference (PI-CAT) and determine the frequency of floor and ceiling effects in a population of healthy collegiate athletes.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Healthy collegiate athletes (18-23 years of age) were prospectively enrolled to complete the 4 PROMIS CAT domains. Additionally, the athletes provided information regarding their age, sex, and sport(s). Mean scores (±SD) and identification of ceiling or floor effects were calculated. Ceiling and floor effects were considered significant if >15% of the participants obtained the highest or lowest possible score on a domain.

Results

A total of 194 healthy athletes (mean age, 19.1 years) were included in the study: 118 (60.8%) men and 76 (39.2%) women. Mean scores were 62.9 ± 6.7 for PF-CAT, 58.2 ± 4.1 for M-CAT, 57.4 ± 5.8 for UE-CAT, and 43.2 ± 6.2 for PI-CAT. Distributions of scores for M-CAT and UE-CAT indicated strong ceiling effects by 77.3% and 66.0% of the participants, respectively. In healthy athletes, the PF-CAT differed most from the expected population-based mean score (50), with the mean being >1 SD above (62.9), without a ceiling effect observed. There were no significant sex- or age-based differences on any of the PROMIS domain scores.

Conclusion

Healthy collegiate athletes scored nearly 1 SD from population-based means for all of the domains tested. M-CAT and UE-CAT demonstrated ceiling effects in more than two-thirds of healthy athletes, which may limit their utility in this population. The PF-CAT did not demonstrate floor or ceiling effects and demonstrated differences in a young adult athletic population from the population mean. The mean PF-CAT score of 62.9 can represent a target for return of function in injured athletes.

Latent Factor Analysis of the PROMIS and Single Assessment Numeric Evaluation in Patients Undergoing Shoulder Surgery

INTRODUCTION

Patient-reported outcomes (PROs) are reporting tools that quantify patients' perceptions of their mental and physical health. Many PROs may inadvertently measure the same or overlapping theoretical constructs (e.g., pain, function, depression, etc.), which is both inefficient and a patient burden. The purpose of this study was to examine the functional relationship of the Single Assessment Numeric Evaluation (SANE) score and general constructs measured with the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) in young patients undergoing shoulder surgery.

MATERIAL AND METHODS

This study was an institutional review board approved retrospective case control of the Military Orthopaedics Tracking Injuries and Outcomes Network using 805 patients and 1,373 observations. All patients underwent shoulder surgery and had multiple observations ranging from 28 days pre-surgery to 428 days post-surgery. Correlation matrices and exploratory factor analysis were used to examine how each of the measured variables (PROMIS physical function, PROMIS pain interference, PROMIS sleep disturbance, PROMIS anxiety, PROMIS depression, and SANE surveys) contribute or "weigh" on latent factors, which are then mapped to a theoretical construct. This statistical method helps uncover structural relationships between measured variables.

RESULTS

The PROMIS and SANE surveys collectively weigh on two latent factors: psychological health (measured variables: PROMIS anxiety [0.95] and PROMIS depression [0.86]) and physical capabilities (measured variables: PROMIS physical function [0.81], PROMIS pain interference [-0.82], PROMIS sleep disturbance [-0.51], and SANE [0.68]). Although the physical capability construct is functionally related to psychological health (-0.45), there is no direct relation between SANE and measures of depression or anxiety.

CONCLUSIONS

This study supports the use of the SANE as a valid single question to assess physical function providing similar information to the PROMIS in regard to measuring physical capabilities. Its simplicity makes it easy to use and implement with minimal uplift or change in workflow.

The American Shoulder and Elbow Surgeons score highly correlates with the Simple Shoulder Test

BACKGROUND/HYPOTHESIS

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes for either clinical or research purposes. The use of multiple outcome scores may be redundant and cause increased responder burden. The hypothesis of this study is that the American Shoulder and Elbow Surgeons score (ASES) will highly correlate with the Simple Shoulder Test (SST) for rotator cuff repair and total shoulder arthroplasty and have comparable responsiveness. If determined to be highly correlated, the use of these scores simultaneously may be redundant and one score may be eliminated.

METHODS

A retrospective review of the senior author's database of patients undergoing rotator cuff repair and total shoulder arthroplasty was reviewed in which the ASES was recorded simultaneously with the SST. Correlations were determined using the Pearson correlation coefficient (r > 0.7 excellent; r = 0.61-0.7 strong-moderate; r = 0.31-0.6 moderate; r = 0.2-0.3 poor) for all interactions between the 2 scores. Subgroup analysis was performed to determine if correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of both scores.

RESULTS

There were a total of 1810 simultaneous measurements (both rotator cuff repair and total shoulder arthroplasty) of the ASES and SST. The correlation was excellent for the ASES and SST for all patients (n = 1810; r = 0.81; P < .0001). The correlation of preoperative scores was strong-moderate (n = 1191; r = 0.60; P < .0001), and the correlation of postoperative scores was excellent (n = 619; r = 0.78; P < .0001). Both scores were determined to be highly responsive, but both the standardized response mean (2.8 vs. 2.1) and the effect size (2.2 vs. 1.8) of the ASES were greater than those of the SST.

CONCLUSION

In general, there was an excellent correlation between the ASES and the SST for all patients undergoing arthroscopic rotator cuff repair and total shoulder arthroplasty. Because there is an excellent correlation between the 2 scores, including these 2 scores simultaneously in tracking patient-determined outcomes appears to be redundant and therefore unnecessary. Because there is superior responsiveness of the ASES score compared with the SST, the authors recommend utilization of the ASES over the SST in patients undergoing rotator cuff repair and total shoulder arthroplasty.

The PROMIS CAT Demonstrates Responsiveness in Patients After ACL Reconstruction Across Numerous Health Domains

Background:

The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a dynamic, efficient, and validated patient-reported outcome measure in the field of orthopaedics. However, the responsiveness, which is defined as the ability to detect changes in scores over time, of PROMIS computer adaptive tests (CATs) after anterior cruciate ligament reconstruction (ACLR) has not been well documented.

Purpose:

To investigate the responsiveness up to 1 year postoperatively of multiple PROMIS CAT domains in patients undergoing ACLR.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

All patients who underwent ACLR by 1 of 2 fellowship-trained sports medicine orthopaedic surgeons, with preoperative and at least 6 months postoperative visits, were included in this study. PROMIS CAT physical function (PF), pain interference (PI), and depression (D) scores from each visit were collected and analyzed. Preoperative patient-centric factors, including demographic factors and meniscal pathology, were analyzed for associations with improvements in PROMIS scores.

Results:

A total of 100 patients (62 male patients and 38 female patients; mean age, 27.6 ± 11.8 years) with an average follow-up of 338.5 ± 137.5 days were included in this study. Preoperative PF, PI, and D scores improved significantly from 38.5 ± 7.3, 60.3 ± 7.0, and 47.9 ± 9.1, respectively, to 53.6 ± 10.3, 48.1 ± 8.5, and 41.0 ± 9.9, respectively (P < .001 for each domain). Lower preoperative PF scores, PI scores, and a lower body mass index (BMI) were predictive for greater improvements in PF. Higher preoperative PI scores and a lower BMI were predictors for greater improvements in PI. Meniscal pathology was not predictive of improvement in PROMIS scores.

Conclusion:

PROMIS CAT assessments of PF, PI, and D demonstrated responsiveness in patients undergoing ACLR up to 1 year. Worse preoperative PROMIS scores and a lower BMI were predictive of greater improvements in PROMIS scores.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System

Introduction

Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense’s Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care.

Materials and Methods

MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management.

Results

This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report.

Conclusions

MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency’s Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Performance of PROMIS Physical Function, Pain Interference, and Depression Computer Adaptive Tests Instruments in Patients Undergoing Meniscal Surgery

Purpose

To compare the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PIF), and depression computer adaptive tests (CAT) relative to legacy instruments in patients undergoing meniscal surgery.

Methods

Patients scheduled to undergo meniscal surgery completed legacy knee function PROMs (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] subscores), Marx Activity Rating Scale (MARS), Veterans-Rand 12 (VR12), Short Form 12 (SF12), and the Brief Resilience Scale (BRS) alongside PROMIS PF, PIF, and Depression preoperatively. Spearman rank correlations were calculated, and score distributions were examined for floor and ceiling effects.

Results

152 patients (46.6 ± 14.9 years, 67.1% male) completed PROMs for appropriate inclusion. PROMIS PF yielded high-moderate to high correlations with the IKDC and KOOS subscales (r = 0.61 to 0.73), demonstrating similar performance to the IKDC. PROMIS PIF demonstrated moderately high-moderate to high correlations with the IKDC, KOOS subscales, VR-12 Physical Component Score (PCS), and SF12 PCS (r = 0.62 to 0.71), performing comparably to KOOS Pain (r = 0.55 to 0.92). PROMIS Depression demonstrated moderate to high-moderate correlations with the mental health legacies (r = 0.46 to 0.66). Significant ceiling effects were observed for MARS (n = 29, 18.8%), and significant floor effects were exhibited by PROMIS Depression (n = 38, 25%) and MARS (n = 27, 17.6%).

Conclusion

The PROMIS PF, PIF CAT, and Depression instruments exhibit comparable performance profiles relative to legacy knee PROMs. PROMIS PF and PIF demonstrated no floor and ceiling effects, whereas PROMIS Depression exhibited a significant relative floor effect. PROMIS PF and PIF may be appropriately used to establish functional baselines preoperatively.

Level of Evidence

IV, diagnostic case series.

Psychometric properties of the Single Assessment Numeric Evaluation (SANE) in patients with shoulder conditions. A systematic review

BACKGROUND

Musculoskeletal injuries (i.e. shoulder pain) is the third most commonly reported symptom. The development of the Single Assessment Numeric Evaluation (SANE) scale has presented clinicians and researchers with a more efficient approach in measuring function. Therefore, it is important to establish the reliability, validity and responsiveness properties of this scale, prior to its application in research and clinic.

OBJECTIVES

To identify, critically appraise and synthesize the reported psychometric properties of the SANE scale in patients with shoulder related pathologies.

DATA SOURCES

Medline, Embase, Scopus and CINAHL databases from inception till February 2019 were searched. Two independent reviewers carried out the systematic electronic searches in each database and screened the retrieved studies and assessed their eligibility.

STUDY SELECTION OR ELIGIBILITY CRITERIA

Randomized/prospective studies, that included patients with shoulder joint related pathologies, that reported on the psychometric properties (reliability, validity, responsiveness) of SANE scale.

STUDY APPRAISAL AND SYNTHESIS METHODS

The "Quality Appraisal for Clinical Measurement Research Reports Evaluation Form" - a 12-item structured clinical measurement specific appraisal tool was used to assess studies. A qualitative synthesis was performed, and main results summarized based on the shoulder conditions, reported properties and study quality.

RESULTS

Nine studies were included. The quality ranged from 82% to 95% - very good to excellent quality. SANE scale reliability measures indicated excellent reliability properties. The Intra-class Correlation Coefficient (ICC) was ≥0.80 and Standard Error of Measurement (SEM) ranged from 4.23 to 7.82 points. Validity measures displayed correlations of 0.50-0.88 (moderate to very strong correlations) between the SANE scale and other patient reported outcomes (American Shoulder and Elbow Surgeons, Rowe score, Simple Shoulder Test, Physical Function Computerized Adaptive Test). Four studies assessed SANE scale responsiveness measures. Effect sizes of 1.5 and 0.83; and minimal clinically important differences that ranged from 27.25 to 37.05 (anchor-based approach) and 11.80 to 18.1 (distribution-based approach) were reported.

LIMITATIONS

Caution must be used when interpreting our ICCs values.

CONCLUSION IMPLICATIONS OF KEY FINDINGS

Very good to excellent quality evidence indicated that the SANE scale demonstrates evidence of a reliable, valid and responsive tool in patients with shoulder related pathologies.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018117874.

Mental health and tobacco use are correlated with PROMIS upper extremity and pain interference scores in patients with shoulder pathology

PURPOSE

To determine whether patient demographics have predictive influence on patient-reported outcomes measurement information system (PROMIS) domains of pain interference (PROMIS-PI), depression (PROMIS-D), and upper extremity (PROMIS-UE) for patients with shoulder pathology treated nonoperatively.

METHODS

Patients with partial rotator cuff tears, impingement, scapular dyskinesia, osteoarthritis, muscle strains, biceps tendonitis, instability, and acromioclavicular arthritis were retrospectively identified. Patients who underwent surgery were excluded. Demographic characteristics were documented, and PROMIS scores before and after nonoperative intervention were analyzed for correlations between each domain.

RESULTS

A total of 638 questionnaires (PROMIS-UE, PROMIS-PI, and PROMIS-D) were analyzed. PROMIS-UE had a strong negative correlation with PROMIS-PI (R = - 0.73, P < .001). PROMIS-PI and PROMIS-D demonstrated a positive correlation of moderate strength (R = 0.54, P < .001). Patients who never used tobacco, compared to current or former users, had significantly higher PROMIS-UE scores (34.5 vs. 30.6 and 31.9; P < .001), lower PROMIS-PI (59.7 vs. 63.1 and 60.9; P < .001), and lower PROMIS-D scores (47.3 vs. 52.1 and 49.3; P < .001). Patients with body mass index < 24.8 had significantly higher PROMIS-UE scores than those with > 24.8 (P < .05).

CONCLUSION

There is an inverse relationship between upper extremity physical function and pain and depression, as measured by PROMIS scores. Smoking and increased BMI are significant contributors to worse outcomes in patients with shoulder pathology, even in nonoperative populations. Counseling patients regarding prognosis and functional outcomes is important in managing their expectations in this patient population.

Accuracy and Validity of Computer Adaptive Testing for Outcome Assessment in Patients Undergoing Total Knee Arthroplasty

BACKGROUND

Computerized adaptive test (CAT) questionnaires may allow standardization of patient-reported outcome measures and reductions in questionnaire burden. We evaluated the validity, accuracy, and efficacy of a CAT system in patients with end-stage osteoarthritis undergoing total knee arthroplasty.

METHODS

CAT Knee Osteoarthritis Outcome Scores (KOOS) and CAT KOOS-JR questionnaires were applied to 1871 standard form KOOS and 1493 KOOS-JR patient responses, respectively. Mean, standard deviations, Pearson's correlation coefficients, interclass correlation coefficients (ICCs), frequency distribution plots, and Bland-Altman plots were used to compare the precision, validity, and accuracy between CAT scores and full-form scores.

RESULTS

There was a mean reduction of 14 questions (33%) in the CAT KOOS and 1.4 questions (20%) with the CAT KOOS-JR version, compared with the standard KOOS and KOOS-JR surveys, respectively. There were no significant differences between KOOS and CAT KOOS scores with respect to pain (P = .66), symptoms (P = .43), quality of life (P = .99), activities of daily living (P = .68), and sports (P = .84). Similarly, there were no significant differences between the standard form KOOS-JR and CAT KOOS-JR scores (P = .94). There were strong correlations with minimal variability between the CAT KOOS and standard KOOS questionnaires for pain (r = 0.98, ICC: 0.98), symptoms (r = 0.97, ICC: 0.97), quality of life scores (r = 0.99, ICC: 0.99), activities of daily living scores (r = 0.99, ICC: 0.99), and sports scores (r = 0.99, ICC: 0.99). Similarly, there were strong correlations between the KOOS-JR and the CAT KOOS-JR scores (r = 0.99, ICC: 0.99).

CONCLUSION

CAT KOOS and the CAT KOOS-JR versions are accurate and reduce questionnaire burden up to one-third compared with standard surveys. CAT versions may improve patient compliance and decrease fatigue.

What Are the Floor and Ceiling Effects of Patient-Reported Outcomes Measurement Information System Computer Adaptive Test Domains in Orthopaedic Patients? A Systematic Review

PURPOSE

To perform a systematic review to answer the following: (1) What are the floor and ceiling (F/C) effects of the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) domains of physical function (PF), upper extremity physical function (UE), pain interference (PI), and depression (D) in adult orthopaedic patients? (2) Do the PROMIS-PF and PROMIS-PI domains have differing F/C effects depending on use in upper extremity, lower extremity, spine, neck, and back, or trauma patients?.

METHODS

(Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed, the review was registered on PROSPERO, and the methodological index for non-randomized studies was used for this systematic review. Studies reporting the F/C effects of at least 1 of 4 PROMIS CAT domains in orthopaedic patient cohorts accessed through PubMed and Embase on October 30, 2018, were included. F/C effects for each study were reported within forest plots.

RESULTS

Forty-three studies were included. Generally, varying cohorts demonstrated no F/C effects for PROMIS-PF (0%-9.0%), variable ceiling effects for PROMIS-UE (lower in v2.0; 0%-28.2%), variable floor effects for PROMIS-PI (0%-19.0%), and significant floor effects for PROMIS-D (0.4%-23.4%).

CONCLUSIONS

The orthopaedic literature demonstrated generally favorable floor and ceiling effects for PROMIS CAT domains, with the exception of variable ceiling effects for PROMIS-UE (the newer version exhibits only minor effects), variable floor effects for PROMIS-PI, and significant floor effects for PROMIS-D. In addition, the F/C effects of PROMIS-PF did not vary based on patient population. Although the floor effects of PROMIS-PI did vary based on patient population, the variability does not appear to be based solely on anatomic location. The PROMIS-PF and PROMIS-UE v2.0 demonstrate consistently low floor and ceiling effects. However, the PROMIS-PI and PROMIS-D may need modification before widespread adoption for clinical and research purposes.

LEVEL OF EVIDENCE

III; systematic review of Level I-III studies.

Floor and Ceiling Effects, Time to Completion, and Question Burden of PROMIS CAT Domains Among Shoulder and Knee Patients Undergoing Nonoperative and Operative Treatment

The Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) have emerged as an efficient technique for measuring patient-reported outcomes among orthopaedic patients. The purpose of this study was to investigate the floor and ceiling (F/C) effects, time to completion (TTC), and question burden of PROMIS CATs administered to patients presenting to a shoulder and sports medicine orthopaedic clinic.

Mental Health and Tobacco Use Are Correlated With Physical Function Outcomes in Patients With Knee Pain and Injury

PURPOSE

To examine the relation between the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Pain Interference (PROMIS-PI), Depression (PROMIS-D), and Physical Function (PROMIS-PF) for nonoperative patients presenting to our ambulatory sports orthopaedic clinic with knee complaints and to determine whether patient demographic characteristics influence PROMIS scores, particularly tobacco use.

METHODS

All patients treated nonoperatively for a primary complaint of knee pain were recruited for participation. Patients were included if they completed all 3 PROMIS questionnaires prior to their clinical evaluation. Patients were excluded if their treatment plan determined that surgical intervention was warranted. Survey results were compiled, and statistical correlations were run between PROMIS domains and patient demographic characteristics.

RESULTS

A total of 527 PROMIS questionnaire sets were included. PROMIS-PF had a strong negative correlation with PROMIS-PI (R = -0.75, P < .001) and a nearly moderate negative correlation with PROMIS-D (R = -0.47, P < .001). When evaluating patient demographic characteristics, we found a significant decrease in physical function scores and increases in pain and depression scores in both current and former tobacco users compared with nonsmokers. Differences in all PROMIS domains between smokers and nonsmokers exceeded minimal clinically important differences.

CONCLUSIONS

Our study showed an inverse correlation between PROMIS-PI and PROMIS-PF, as well as between PROMIS-D and PROMIS-PI, in patients seen in the ambulatory setting for knee complaints treated nonoperatively. A positive correlation was found between PROMIS-PI and PROMIS-D. Tobacco use was a patient demographic factor found to significantly impact PROMIS scores leading to minimal clinically important differences across all 3 PROMIS domains. The findings of this study may be used to identify patients at high risk of poor outcomes.

LEVEL OF EVIDENCE

Level III, observational study.

A One-Question Patient-Reported Outcome Measure Is Comparable to Multiple-Question Measures in Total Knee Arthroplasty Patients

BACKGROUND

Patient-reported outcome measures (PROMs) are important for tracking outcomes following total knee arthroplasty (TKA) but can be limited by time constraints and patient compliance. We sought to evaluate the utility of the one-question, modified single assessment numerical evaluation (M-SANE) score in TKA patients compared to legacy PROMs.

METHODS

Patients undergoing TKA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Knee Disability and Osteoarthritis Outcomes Score Junior (KOOS Jr), and M-SANE (modified-SANE) assessments both preoperatively and postoperatively. The M-SANE score asked patients to rate their native or prosthetic knee on a scale from 0 to 10, with 10 being the best function. M-SANE validity was determined by the Spearman's correlation between the collected PROMs and the Bland-Altman plots. PROM responsiveness was assessed using the standardized response mean.

RESULTS

In total, 217 patients completed PROMs preoperatively and at 1 year postoperatively. Floor and ceiling effects of the M-SANE were higher than other PROMs but still relatively low (4%-11%). There was a moderate to strong correlation at nearly all time points between the M-SANE and KOOS Jr (ρ = 0.44-0.78, P < .001). There was a weak correlation between the M-SANE and PROMIS physical component summary at the preoperative evaluation (ρ = 0.28) but a strong correlation at 1-year follow up (0.65, P < .001). The long-term responsiveness of the M-SANE to TKA (standardized response mean [SRM] = 0.98, 95% confidence interval [CI] 0.80-1.17) was comparable to both the KOOS Jr (SRM = 1.19, 95% CI 1.00-1.38) and PROMIS physical component summary (SRM = 0.82, 95% CI 0.74-0.91). Bland-Altman plots demonstrated that the M-SANE and KOOS Jr capture combined knee pain and functionality differently.

CONCLUSION

The M-SANE score was comparable to validated multiple-question PROMs in TKA patients. The demonstrated validity of the M-SANE, as well as its comparable responsiveness to more lengthy PROMs, highlights its use as a one-question PROM for assessment of patient undergoing TKA.

Concurrent validity of the single assessment numerical evaluation and patient-reported functional measures in patients with musculoskeletal disorders: An observational study

INTRODUCTION

As patient-reported outcome measures (PROMs) continue to evolve as vital measures of patient status, it may be useful to identify efficiently, Single Assessment Numeric Evaluation (SANE) scores that are valid and related to the patient's specific functional needs.

OBJECTIVE

To evaluate the concurrent validity between SANE scores and commonly used body region-specific functional PROMs, functional percentage change scores, and total visits in patients with musculoskeletal (MSK) disorders.

METHODS

479 patients completed the SANE and one of the following PROMs at physical therapy discharge: Modified Low Back Pain Disability Questionnaire [MDQ], Neck Disability Index [NDI], Penn Shoulder Score [PSS], International Knee Documentation Committee [IKDC], Lower Extremity Functional Scale [LEFS]. Pearson correlation coefficients were used to assess the relationship between SANE and the aforementioned outcomes and total visits.

RESULTS

The SANE was moderately negatively correlated with the MDQ and NDI at discharge. There were high positive correlations between SANE and PSS and IKDC and moderate positive correlation between SANE and LEFS. The SANE and MDQ and IKDQ demonstrated low positive correlation for functional percentage change scores, and the SANE and NDI demonstrated moderate positive correlation for functional percentage change scores. For total visits outcome, there was a negligible negative correlation between SANE and MDQ and NDI at discharge.

CONCLUSION

The SANE exhibits acceptable concurrent validity across all investigated PROMs at physical therapy discharge. However, inconsistent relationships across body regions for functional percentage change and total visits suggest differences in these values as compared to raw discharge scores.

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background:

There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear.

Purpose/Hypothesis:

The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship–trained orthopaedic surgeons were included in the study. Preoperative PROMIS–Upper Extremity (PROMIS-UE), PROMIS–Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors.

Results:

Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = –0.61; P < .001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = –0.28; P < .001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = –0.77 vs –0.46, respectively; P < .001 for both), stronger in black patients compared with white patients (R = –0.72 vs –0.56, respectively; P < .001 for both), and highest in current tobacco users (R = –0.80; P < .001).

Conclusion:

Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups.

Relationship Between PROMIS Computer Adaptive Tests and Legacy Hip Measures Among Patients Presenting to a Tertiary Care Hip Preservation Center

BACKGROUND

Legacy hip outcome measures may be burdensome to patients and sometimes yield floor or ceiling effects. Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) allow for low-burden data capture and limited ceiling and floor effects.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine whether the PROMIS CAT domains demonstrate correlation against commonly used legacy patient-reported outcome measures in a population of patients presenting to a tertiary care hip preservation center. The authors hypothesized the following: (1) PROMIS CAT scores based on physical function (PF), pain interference (PIF), pain behavior, and pain intensity would show strong correlation with the following legacy scores: modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), Hip Outcome Score (HOS) Sports and Activities of Daily Living subscales, and Veterans RAND-6D (VR-6D) utility measure. (2) The mental and physical health portions of the VR-6D legacy measure would show weak correlation with mental- and psychosocial-specific PROMIS elements-depression, anxiety, fatigue, sleep, and ability to participate in social roles and activities. (3) All PROMIS measures would exhibit fewer floor and ceiling effects than legacy scores.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Prospective data were collected on 125 patients in the hip preservation clinics. Enrollees completed legacy scores (visual analog scale for pain, mHHS, iHOT-12, HOS, and VR-6D) and PROMIS CAT questionnaires (PF, PIF, pain behavior, anxiety, depression, sleep, social roles and activities, pain intensity, fatigue). Spearman rank correlations were calculated, with r_s values of 0 to 0.3 indicating negligible correlation; 0.3 to 0.5, weak correlation; 0.5 to 0.7, moderately strong correlation; and >0.7, strong correlation. Floor and ceiling effects were evaluated.

RESULTS

As anticipated, the PF-CAT yielded strong correlations with the iHOT-12, mHHS, HOS-Sports, HOS-Activities of Daily Living, and VR-6D, with r_s values of 0.76, 0.71, 0.81, 0.87, and 0.71, respectively. The PIF-CAT was the only pain score to show moderately strong to strong correlation with all 14 patient-reported outcome measures. A strong correlation was observed between the VR-6D and the social roles and activities CAT ( r_s = 0.73). The depression CAT had a significant floor effect at 19%. No additional floor or ceiling effect was present for any other legacy or PROMIS measure.

CONCLUSION

The PF-CAT shows strong correlation with legacy patient-reported outcome scores among patients presenting to a tertiary care hip preservation center. The PIF-CAT also correlates strongly with legacy and PROMIS measures evaluating physical and mental well-being. PROMIS measures are less burdensome and demonstrate no floor or ceiling effects, making them a potential alternative to legacy patient-reported outcome measures for the hip.

Correlation of Patient-Reported Outcome Measurement Information System Physical Function Upper Extremity Computer Adaptive Testing, With the American Shoulder and Elbow Surgeons Shoulder Assessment Form and Simple Shoulder Test in Patients With Shoulder Pain

PURPOSE

To evaluate the Patient-Reported Outcome Measurement Information System Physical Function Upper Extremity Computer Adaptive Testing (PROMIS PFUE CAT) measurement tool against the already validated American Shoulder and Elbow Surgeons Shoulder Assessment Form (ASES) and the Simple Shoulder Test (SST) in patients presenting with shoulder pain and determine the responder burden for each of the 3 surveys.

METHODS

Ninety patients presenting with shoulder pain were asked to fill out the ASES, SST, and PROMIS PFUE CAT. The time for completion of each survey was measured to determine responder burden, and the Pearson correlation between the 3 instruments was defined as excellent (r > 0.7), excellent-good (0.61 ≤ r ≤ 0.7), good (0.31 ≤ r ≤ 0.6), and poor (0.2 ≤ r ≤ 0.3).

RESULTS

The PROMIS PFUE CAT showed an excellent correlation with the SST (r = 0.82, P < .001) and ASES (r = 0.72, P < .001). The average time to complete SST, ASES, and PROMIS PFUE CAT was 92.8 ± 35.8, 142.3 ± 60.1, and 61.3 ± 28.8 seconds, respectively. The time to complete the PROMIS PFUE CAT was significantly less than both the SST (P < .001) and ASES (P < .001).

CONCLUSIONS

The PROMIS PFUE CAT showed an excellent correlation with the previously validated ASES and SST in patients with shoulder pain. The time saving of the PROMIS PFUE CAT was found to be smaller than that of the ASES and SST but shows that moving forward, using the PROMIS PFUE CAT would not place any additional burden on the patient filling out the survey. The lack of ceiling or floor effects with the PROMIS PFUE CAT indicates its ability to differentiate both high and low functioning patients. All of these findings indicate that the PROMIS PFUE CAT is an adequate tool for the evaluation of patients with shoulder pain and should be used in these patients going forward.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Patient-Reported Outcomes Measurement Information System Physical Function Item Bank, Version 1.0: Physical Function Assessment for Athletic Patient Populations

CONTEXT

The Patient-Reported Outcomes Measurement Information System (PROMIS) item banks have been validated for general populations, but their application to high-functioning patient populations remains speculative.

OBJECTIVE

To examine the measurement properties of the PROMIS physical function item bank, version 1.0, when applied to individuals representing high levels of physical ability.

DESIGN

Cross-sectional study.

SETTING

National Collegiate Athletic Association Division I and III collegiate athletic training rooms and intramural events.

PATIENTS OR OTHER PARTICIPANTS

A heterogeneous sample of 215 adults from Division I or Division III collegiate or recreational sports volunteered for this study. Participants were divided into 4 groups depending on sport activity and injury status: healthy collegiate (HC; 33 men, 37 women; age = 19.7 ± 1.1 years), injured and currently active in sport (IP; 21 men, 29 women; age = 19.9 ± 1.2 years), injured and currently not active in sport (INP; 12 men, 18 women; age = 19.7 ± 1.3 years), and healthy recreational (HR; 47 men, 18 women; age = 20.1 ± 1.4 years).

MAIN OUTCOME MEASURE(S)

Participants completed 2 assessments: (1) an injury-history questionnaire and (2) the PROMIS physical function item bank, version 1.0, in computer-adaptive form. Mean PROMIS physical function scores were determined for each group.

RESULTS

The PROMIS physical function score for the HC group (61.7 ± 6.0) was higher than for the IP (54.9 ± 7.5) and INP (44.1 ± 8.2) groups (P < .001). The IP group had a higher score than the INP group (P < .001). Mean PROMIS scores were not different between the HC and HR participants (mean difference = 1.9, P = .10).

CONCLUSIONS

The computer-adaptive PROMIS physical function item bank, version 1.0, accurately distinguished injury status in elite-level athletes on a physical function latent trait continuum. Although it was unable to distinguish HC athletes from HR athletes, exposing a possible ceiling effect, it offers potential for use as an outcome instrument for athletic trainers and other sports medicine clinicians.