Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) in Asians with knee osteoarthritis in Singapore

Is Kinesiophobia Associated With Quality of Life, Level of Physical Activity, and Function in Older Adults With Knee Osteoarthritis?

BACKGROUND

Beyond knee pain itself, the fear of movement, also known as kinesiophobia, recently has been proposed as a potential factor contributing to disability and functional limitation in patients with knee osteoarthritis (OA). Nevertheless, the available evidence on the association of kinesiophobia with patient-reported outcome measures (PROMs) in knee OA remains limited.

QUESTIONS/PURPOSES

Among patients with nonoperatively treated knee OA, we asked: (1) Is kinesiophobia associated with decreased quality of life (QoL), functional outcomes, and physical activity? (2) What are the patient disease and psychosocial demographic factors associated with kinesiophobia?

METHODS

This was a multicenter, cross-sectional study of 406 general orthopaedic patients from two urban, referral-based tertiary hospitals in Singapore under a single healthcare group who received nonoperative treatment for knee OA. Between July 2020 and January 2022, a total of 1541 patients were treated for knee OA nonoperatively. Based on that, 60% (923) of patients were rejected due to refusal to participate in the study, 3% (52) of patients were enrolled but did not show up for their appointments for data collection, and a further 10% (160) had incomplete data sets, leaving 26% (406) for this study's analysis. The mean age of patients was 64 ± 8 years, 69% were women, and 81% were Chinese. The level of kinesiophobia in patients was measured using the Brief Fear of Movement scale, a validated 6-item questionnaire ranging from a score of 6 to 24 to measure kinesiophobia in OA, with higher scores representing higher levels of kinesiophobia. In terms of PROMs, the QoL and functional level of patients were measured using the QoL and activities of daily living (ADL) components of the widely validated 12-item Knee Injury and Osteoarthritis Outcome Score (KOOS-12). The KOOS-12 is a questionnaire consisting of 12 items encompassing three domains (QoL, ADL, and pain), with each item ranging from 0 to 4 and higher scores representing worse outcomes. The University of California, Los Angeles (UCLA) Activity Scale was used to measure the level of physical activity in patients. The UCLA score is a descriptive 10-level activity scale ranging from a score of 1 to 10, with higher scores representing greater physical activity levels. A directed acyclic graph, which is a relationship map used to depict and visualize the confounders between the studied variables, was used to identify the confounders between kinesiophobia and PROMs (QoL, function, and physical activity). An ordinal regression model was used to explore: (1) the association between kinesiophobia (as measured using the Brief Fear of Movement scale) and PROMs (as measured using KOOS QoL, KOOS ADL, and the UCLA Activity Scale), adjusting for key confounders such as age, gender, pain, side of arthritis, OA duration/severity, and psychosocial factors (for example, depression, anxiety, and education levels), and (2) the association between kinesiophobia (Brief Fear of Movement scale) and various patient disease and psychosocial demographic factors.

RESULTS

After accounting for confounders, greater kinesiophobia (higher Brief Fear of Movement scores) was associated with lower QoL (KOOS QoL score adjusted IQR OR 0.69 [95% confidence interval (CI) 0.53 to 0.90]; p = 0.007) and lower physical activity (UCLA score adjusted IQR OR 0.68 [95% CI 0.52 to 0.90]; p = 0.007); however, there was no association between kinesiophobia and function (KOOS ADL score adjusted IQR OR 0.90 [95% CI 0.70 to 1.17]; p = 0.45). After adjusting for age, gender, OA duration, pain, and BMI, higher levels of anxiety (Patient Health Questionnaire 2 [PHQ-2] anxiety score adjusted OR 2.49 [95% CI 1.36 to 4.58]; p = 0.003) and depression (PHQ-2 depression score adjusted OR 3.38 [95% CI 1.73 to 6.62]; p < 0.001) were associated with higher levels of kinesiophobia. Education level, OA disease severity, side of arthritis (unilateral versus bilateral), and history of previous injury or surgery on the knee were not associated with kinesiophobia.

CONCLUSION

Clinicians should assess for kinesiophobia and other psychological comorbidities such as depression and anxiety at the point of initial evaluation and subsequent follow-up of knee OA with simple validated tools like the Brief Fear of Movement scale (kinesiophobia) in the clinic. This allows for clinicians to identify high-risk individuals and offer evidence-based treatment such as cognitive behavioral therapies with a multidisciplinary team, including a physical therapist and psychologist, to manage these psychological comorbidities and improve outcomes in patients with knee OA. While kinesiophobia was found to be associated with poorer QoL and physical activity, future studies including larger observational cohort studies should be conducted to determine causal and prognostic relationships between kinesiophobia and outcomes in knee OA.

LEVEL OF EVIDENCE

Level III, prognostic study.

How Does Shame Relate to Clinical and Psychosocial Outcomes in Knee Osteoarthritis?

BACKGROUND

Knee osteoarthritis (OA) is a common and disabling condition that often carries severe psychosocial implications. Chronic illness-related shame has emerged as a substantial psychosocial factor affecting individuals with knee OA, but it is unclear how chronic illness-related shame is associated with the long-term clinical and psychosocial outcomes in individuals with knee OA.

QUESTIONS/PURPOSES

(1) Does a higher level of shame correlate with worse clinical and psychosocial outcomes at baseline among individuals with knee OA? (2) Is a higher level of shame at baseline associated with worse clinical and psychosocial outcomes at 4-month and 12-month follow-up among individuals with knee OA? (3) Are sociodemographic characteristics correlated with levels of shame among individuals with knee OA?

METHODS

Between June 2021 and February 2022, we screened 977 patients based on the inclusion criteria of (1) age 45 years or older, (2) independent in community mobility with or without walking aids, (3) proficient in English or Chinese language, and (4) met the clinical criteria for OA diagnosis outlined by the National Institute for Health and Care Excellence. Of these patients, 47% (460) were eligible and enrolled. A further 53% (517) were excluded for prespecified reasons. Of the 460 enrolled patients, 7% (30) dropped out before data collection began, and 46% (210) of patients did not complete the psychological questionnaires, leaving 48% (220) of patients for analysis. From this final sample, 25% (56) were lost to follow-up at 4 months, and an additional 7% (16) were lost by the 12-month follow-up, leaving 67% (148) of the original eligible group for analysis. All patients were recruited from the outpatient clinics of the orthopaedic and physiotherapy departments across two Singapore hospitals within the National Healthcare Group. The study population had a mean ± SD age of 64 ± 8 years, with 69% (152 of 220) women, and the mean ± SD duration of knee OA symptoms was 6 ± 6 years. Outcome measures used were the Chronic Illness-Related Shame Scale (CISS), the 12-item Knee Injury and Osteoarthritis Outcome Score (KOOS-12), Patient Health Questionnaire 4 (PHQ-4), the 8-item Arthritis Self-Efficacy Scale (ASES-8), and the Brief Fear of Movement Scale (BFOM). The CISS is a validated tool specifically designed to measure feelings of shame (internal and external shame) in individuals living with chronic illness. The scale has been validated for use among patients with knee OA in Singapore. The functional outcome measure used was the Modified Barthel Index. Data on demographic characteristics were collected. Data were collected at baseline, 4-month follow-up, and 12-month follow-up. Statistical analyses included the Spearman correlation, linear regression, and cluster analysis.

RESULTS

At baseline, there was a weak to moderate negative correlation between CISS scores and KOOS-12 and ASES-8 scores (Spearman correlation coefficients ranged from -0.46 to -0.36; all p values < 0.001), indicating that higher levels of shame were associated with slightly to moderately worse knee function and lower self-efficacy. There was a modest positive correlation between CISS scores and PHQ-4 and BFOM scores (the Spearman correlation coefficients ranged from 0.43 to 0.46; all p values < 0.001), indicating that higher levels of shame were linked to more psychological distress and greater fear of movement. At the 4-month follow-up, a higher CISS score at baseline was associated with a decrease in KOOS-12 (adjusted coefficient -0.86 [95% confidence interval (CI) -1.33 to -0.40]; p < 0.001) and ASES-8 (adjusted coefficient -0.12 [95% CI -0.19 to -0.06]; p < 0.001) scores, indicating worsened knee function and reduced self-efficacy over time. Higher CISS scores at baseline were also associated with an increase in PHQ-4 (adjusted coefficient 0.23 [95% CI 0.14 to 0.31]; p < 0.001) and BFOM (adjusted coefficient 0.22 [95% CI 0.08 to 0.36]; p = 0.002) scores at the 4-month follow-up, reflecting greater psychological distress and greater fear of movement. At the 12-month follow-up, a higher CISS score at baseline was associated with a decrease in KOOS-12 (adjusted coefficient -0.72 [95% CI -1.25 to -0.19]; p = 0.008) and ASES-8 (adjusted coefficient -0.12 [95% CI -0.20 to -0.04]; p = 0.002) scores, indicating that those with higher initial levels of shame continued to experience poorer knee function and lower self-efficacy. Higher CISS scores at baseline were also associated with an increase in PHQ-4 (adjusted coefficient 0.13 [95% CI 0.04 to 0.21]; p = 0.004) as well as BFOM (adjusted coefficient 0.20 [95% CI 0.06 to 0.34]; p = 0.007) scores at the 12-month follow-up, indicating ongoing psychological distress and fear of movement. Cluster analysis found that unemployed older patients with lower CISS scores and BMI, as well as having unilateral arthritis and shorter duration of OA, were observed to have better knee function at 4 months (mean difference 7 [95% CI 1 to 12]; p = 0.02) and 12 months (mean difference 7 [95% CI 1 to 13]; p = 0.02) compared with the opposite. After controlling for age, gender, ethnicity, and employment status, the regression analysis found that higher BMI was related to higher CISS scores (adjusted coefficient 0.21 [95% CI 0.07 to 0.34]; p = 0.003).

CONCLUSION

Chronic illness-related shame has a small to modest association with clinical and psychosocial outcomes for individuals with knee OA. Healthcare professionals should routinely incorporate psychosocial assessments to identify and manage shame early, potentially improving both clinical and psychosocial outcomes. Recognizing that higher BMI is linked to increased shame can specifically guide targeted emotional and psychosocial support. Additionally, integrating interventions such as acceptance and commitment therapy and peer support with traditional treatments could enhance adherence and overall patient outcomes, making comprehensive care more effective.

LEVEL OF EVIDENCE

Level II, prognostic study.

Development of the assessment for emotional and behavioral problems in school-aged children

BACKGROUND

Several assessments have been developed to assess school-aged children's emotional and behavioral problems (EBPs), but none based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision. This study aimed to develop the Assessment for Emotional and Behavioral Problems in School-aged children (AEBPS) fitting current knowledge of mental health disorders.

MATERIALS AND METHODS

This study included 2 phases. In Phase I, the assessment construct and its corresponding items were developed. In Phase II, the reliability and validity of the AEBPS were examined.

RESULTS

The AEBPS contains 120 items in five subscales. The psychometric results showed that the AEBPS subscales had high internal consistency (Cronbach's alpha = 0.83-0.97) and acceptable to good test-retest reliability (intra-class correlation coefficient = 0.65-0.93). The results of exploratory factor analysis showed that most items within each subscale of the AEBPS significantly contributed to their respective concepts. The AEBPS subscales had small to high correlations with the subscales of the Child Behavior Checklist (r = 0.37-0.87). The AEBPS had good discriminant validity to differentiate children with and without EBPs.

CONCLUSIONS

The newly-developed AEBPS fits the current knowledge of mental health diagnoses for assessing school-aged children's EBPs and has sound psychometric evidence. The AEBPS can be reliably and validly used in a variety of settings.

Systematic reviews and quality assessment of patient-reported outcome measures for physical function in comparative effectiveness studies regarding acute postoperative pain after total knee arthroplasty-Do we need to start all over again?

BACKGROUND AND OBJECTIVE

Recently, a consensus process specified a core outcome set (COS) of domains to be assessed in each comparative effectiveness research and clinical practice related to acute postoperative pain. Physical function (PF) was one of these domains. The aim of this review was to investigate which patient-reported outcome measures (PROMs) are used to assess PF after total knee arthroplasty (TKA) in clinical trials and if they fulfil basic requirements for a COS of PROMs based on their psychometric properties.

METHODS

A systematic review of randomized controlled trials and observational studies based on a search in MEDLINE, EMBASE and CENTRAL was undertaken. PROMs and performance measures were extracted and investigated, including evaluation of psychometric properties of PROMs based on COSMIN recommendations.

RESULTS

From initially 2896 identified records, 479 studies were included in the qualitative synthesis. Only 87 of these trials (18%) assessed PF using PROMs, whereas especially performance outcome measures were used in 470 studies (98%). Application of the 'COSMIN Risk-of-Bias-Box 1' to 13 of the 14 identified PROMs resulted in insufficient content validity of the included PROMs regarding the target population based on the inauguration or development articles.

CONCLUSION

Our data indicate that a patient-centred postoperative assessment of PF in pain-related clinical trials early after TKA is not common, even though patient-reported assessment is widely recommended. In addition, none of the applied PROMs shows content validity based on their inauguration or development articles for the assessment of postoperative pain-related PF after TKA.

SIGNIFICANCE

A systematic search for patient-reported outcome measures assessing postoperative, pain-related physical function after total knee arthroplasty in clinical trials and assessment of their content validity revealed none that fulfilled requirements based on COSMIN recommendations.

Patient Demographic Factors Impact KOOS JR Response Rates for Total Knee Arthroplasty Patients

The Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) is a validated patient-reported measure for assessing pain and function following total knee arthroplasty (TKA). This study investigates how patient demographic factors (i.e., age, sex, and race) correlate with KOOS JR response rates. This was a retrospective cohort study of adult, English-speaking patients who underwent primary TKA between 2017 and 2023 at an academic institution. KOOS JR completion status-complete or incomplete-was recorded within 90 days postoperatively. Standard statistical analyses were performed to assess KOOS JR completion against demographic factors. Among 2,883 total patients, 70.2% had complete and 29.8% had incomplete KOOS JR questionnaires. Complete status (all p < 0.01) was associated with patients aged 60 to 79 (71.8%), white race (77.6%), Medicare (81.7%), marriage (76.8%), and the highest income quartile (75.7%). Incomplete status (all p < 0.001) was associated with patients aged 18 to 59 (64.4%), Medicaid (82.4%), and lower income quartiles (41.6% first quartile, 36.8% third quartile). Multiple patient demographic factors may affect KOOS JR completion rates; patients who are older, white, and of higher socioeconomic status are more likely to participate. Addressing underrepresented groups is important to improve the utility and generalizability of the KOOS JR.

Cultural adaptation and validation of the knee injury and osteoarthritis outcome score into Sinhala language in patients with primary knee osteoarthritis: a cross-sectional study

BACKGROUND

Knee Injury and Osteoarthritis Outcome Score (KOOS) scale is a patient-reported outcome measurement tool. It evaluates both short- and long-term consequences of knee injury and primary osteoarthritis. This study aims to translate and validate the KOOS scale for a Sinhala-speaking Sri Lankan population.

METHODS

A cross sectional study was conducted in three hospitals. Four hundred and fifteen patients comprising 185 males and 227 females (3 subjects did not reveal their gender) with knee osteoarthritis (KOA) participated in the study. Seventy nine participants without KOA were recruited as controls. The functionality and quality of life level in patients and healthy participants were assessed using translated versions of the KOOS and Short Form-36 (SF-36) scales. Internal consistency of the instrument was assessed by Cronbach alpha. Construct validity and test-retest reliability were examined using the Intraclass Correlation Coefficient (ICC). Confirmatory Factor Analysis (CFA) was used to assess factorial validity.

RESULTS

The mean age (± sd) of the KOA subjects was 54.9 (± 9.2) years and for the control group was 49.2 (± 8.0) years. Majority of the respondents were female and Sinhalese in both groups. Internal consistency reliability was high (Cronbach's alpha values ≥ 0.70). The test-retest reliability was excellent with the intraclass correlation coefficient for all subscales being above 0.90. Construct validity was assessed by the magnitude of the correlation coefficient between KOOS and SF-36 subscale scores. KOOS Pain scale moderately correlated with SF-36 bodily pain (Pearson's r = 0.41). SF-36 physical function scores had a weak positive correlation with all KOOS subscales and SF-36 emotional wellbeing was not significantly correlated with KOOS Quality of Life (QoL) subscale. A five-factor Confirmatory Factor Analysis (CFA) model yielded a Comparative Fit Index (CFI) = 0.950, Tucker Lewis Index (TLI) = 0.946, Root Mean Square Error of Approximation (RMSEA) = 0.082 and Standardised Root Mean squared Residual (SRMR) = 0.072.

CONCLUSION

The Sinhala translation of the KOOS scale is a reliable and valid instrument to assess KOA in a Sinhala-speaking Sri Lankan population. Studies to assess its use as a scale to evaluate responsiveness are recommended.

Collaborative model of care between orthopaedics and allied healthcare professionals (CONNACT) in knee osteoarthritis: Effectiveness-implementation hybrid randomized controlled trial of a community-based, multidisciplinary, stratified intervention

OBJECTIVE

To compare the clinical and cost effectiveness of the Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT), a community-based, stratified, multidisciplinary intervention consisting of exercise, education, psychological and nutrition delivered through a chronic care model to usual hospital care in adults with knee osteoarthritis (OA).

METHODS

Pragmatic, parallel-arm, single-blinded superiority RCT trial. Community-dwelling, ambulant adults with knee OA (Kellgren-Lawrence grade > 1; Knee Injury and OA Outcome Score (KOOS4) ≤75) were enrolled. Primary outcome was KOOS4 at 12-months; secondary outcomes included: quality of life, physical performance measures, symptom satisfaction, psychological outcomes, dietary habits, and global perceived effect. Intention-to-treat analysis using generalized linear model (GLM) and regression modeling were conducted. Economic evaluation through a societal approach was embedded.

RESULTS

110 participants (55 control, 55 intervention) were randomized. No between-group difference found for the primary outcome (MD [95%CI]: -1.86 [-9.11. 5.38]), although both groups demonstrated within-group improvement over 12-months. Among the secondary outcomes, the CONNACT group demonstrated superior dietary change (12 months) and physical performance measures (3 months), and global perceived effect (6 months). While there was no between-group difference in total cost, significant productivity gains (reduced indirect cost) were seen in the CONNACT group.

CONCLUSION

CONNACT was not superior to usual care at 1 year. Further efforts are needed to understand the underlying contextual and implementation factors in order to further improve and refine such community-based, stratified care models moving forward.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT03809975. Registered January 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03809975.

Moderating effects of preoperative knee pain and pain catastrophizing on the relation between COMT rs4680 genotypes and chronic postsurgical pain in total knee arthroplasty patients

BACKGROUND

The Catechol-O-methyltransferase (COMT) gene, responsible for encoding an enzyme crucial in the metabolism of catecholamines, is known to play a significant role in pain perception. Polymorphisms within this gene, particularly the COMT rs4680 genotypes, have been linked to various acute pain phenotypes. This prospective cohort study examines interactions among the genetic polymorphism COMT rs4680 genotypes, preoperative knee pain, and pain catastrophizing in chronic postsurgical pain (CPSP) at 3, 6, and 12 months post-total knee arthroplasty (TKA).

STUDY DESIGN

A total of 280 patients undergoing primary unilateral TKA participated, sharing demographic details, preoperative knee pain levels, psychological variables (pain catastrophizing), and COMT rs4680 genotyping via venous blood samples. Telephone interviews at specified intervals enabled the application of binary logistic regressions and interaction models.

RESULTS

Significant influences of preoperative knee pain and pain catastrophizing on postsurgical outcomes were observed. Specifically, at the first time point (T1, 3 months post-TKA), a notable moderation effect was identified in preoperative knee pain (R2 change = 0.026, p = 0.026). The Johnson-Neyman regions of significance (RoS) indicated these moderation effects were significant above a threshold of 17.18 (p = 0.05), accounting for 26.4%. At the third time point (T3, 12 months post-TKA), a complex three-way interaction among genotypes (GG, GA, and AA carriers) was evident, resulting in an R2 change of 0.051 (p = 0.009). Here, the RoS for pain catastrophizing was above 32.74 for 30.5% of GG genotype carriers, above 22.38 for 50.8% of GA carriers, and below 11.94 for 63.2% of AA carriers.

CONCLUSION

This study illuminates the significant role of the COMT Val158Met rs4680 polymorphism in susceptibility to prolonged pain following TKA. It also elucidates how these genetic genotypes interplay with preoperative knee pain and pain catastrophizing. Such intricate genetic-psychological-pain relationships necessitate additional investigation to confirm these findings and potentially guide post-TKA pain management strategies.

Assessing the Structural Validity of the Knee Injury and Osteoarthritis Outcome Score Scale

BACKGROUND

The Knee Injury and Osteoarthritis Outcome Score (KOOS) scale is used to assess patient perspectives on knee health. However, the structural validity of the KOOS has not been sufficiently tested; therefore, our objective was to assess the KOOS in a large, multi-site database of patient responses who were receiving care for knee pathology.

METHODS

A cross-sectional study was conducted using the Surgical Outcome System (SOS) database. A confirmatory factor analysis (CFA) was conducted to assess the proposed five-factor KOOS using a priori cut-off values. Because model fit indices were not met, a subsequent exploratory factor analysis (EFA) was conducted to identify a parsimonious model. The resulting four-factor structure (i.e., KOOS SF-12) was then assessed using CFA and subjected to multigroup invariance testing.

RESULTS

The original KOOS model did not meet rigorous CFA fit recommendations. The KOOS SF-12 did meet model fit recommendations and passed all invariance testing between intervention procedure, sex, and age groups.

CONCLUSION

The KOOS failed to meet model fit recommendations. The KOOS SF-12 met model fit recommendations, maintained a multi-factorial structure, and was invariant across all tested groups. The KOOS did not demonstrate sound structural validity. A refined KOOS SF-12 model that met recommended model fit indices and invariance testing criteria was identified. Our findings provide initial support for a multidimensional KOOS structure (i.e., KOOS SF-12) that is a more psychometrically sound instrument for measuring patient-reported knee health.

A cross sectional study exploring the relationship of self-reported physical activity with function, kinesiophobia, self-efficacy and quality of life in an Asian population seeking care for knee osteoarthritis

BACKGROUND

Physical activity is a guideline-recommended first-line intervention for people with knee osteoarthritis. Physical activity levels, and its potential correlates, is underexplored in Asian populations with knee osteoarthritis.

METHODS

Participants enrolled in a longitudinal study in Singapore self-reported physical activity (UCLA activity score), function (Knee Osteoarthritis Outcome Score [KOOS-12]), kinesiophobia (Brief fear of movement [BFOM]), self-efficacy (ASES-8), and quality of life (EQ-5D-5 L). One-Way ANOVA was used to test the difference in outcomes between UCLA categories, while ordinal logistic regression was used to identify the associated factors to physical activity level.

RESULTS

Seventy-three percent of all enrolled participants (n = 311/425) reported either inactivity or low physical activity (median 4, IQR 3-5). Significant, weak, positive correlations were observed be-tween UCLA activity score and either KOOS-12 (Spearman's rho: 0.1961; p < 0.001), ASES-8 (0.1983; p = 0.004), or EQ-5D-5 L (0.2078; p < 0.001). A significant, weak, negative correlation was observed between physical activity and BFOM (-0.2183; p < 0.001). Significant differences in function between groups (moderate vs. inactive or low physical activity) were not clinically important. Participants with obesity, from the eldest age category (i.e. ≥75), or who identified as Malay or female, were less physically active than those with a healthy BMI, below the age of 54, or who identified as Chinese or male, respectively.

CONCLUSION

Healthcare professionals in Asia should be aware of the large proportion of people with knee osteoarthritis who are either inactive or have low physical activity levels. Screening for, and offering interventions to promote, physical activity and its correlates should be prioritised.

Study protocol for the validation of a new pictorial functional scale in patients with knee osteoarthritis: the functional activity scoring tool (FAST)

BACKGROUND

Patient-reported outcome measures (PROMs) are required for patient-centred care. There are limited PROMs with good psychometric properties, and limitations to any language-based scale are often constrained by the written words or numerals used. Therefore, we developed the Functional Activity Scoring Tool (FAST), a self-reporting pictorial scale. FAST measures the impact of knee osteoarthritis on essential activities of daily living (ADL) and the significant changes in the self-perceived functional status over time.

OBJECTIVES

This study aims to (1) develop FAST with adaptation from the Wong-Baker FACES pain rating scale, (2) validate FAST against the Patient-Specific Functional Scale (PSFS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) and (3) establish the reliability, validity and responsiveness of FAST in individuals with knee osteoarthritis.

METHODS AND ANALYSIS

The prospective study protocol investigates the validity, responsiveness and reliability of FAST. The PSFS and KOOS will be gold standard comparisons. Participant recruitment will occur at four public polyclinics that offer physiotherapy outpatient services in Singapore. Onsite physiotherapists familiar with the study eligibilities will refer potential participants to the investigators after the routine physiotherapy assessment. After providing written consent, eligible participants will complete outcome measurements with FAST, the PSFS and KOOS during baseline and follow-up assessments. The Global Rating of Change (GROC) scale will determine how the participant's knee status was changed compared with the beginning of the physiotherapy intervention.

ETHICS AND DISSEMINATION

SingHealth Centralised Institutional Review Board approved the study (CIRB reference number: 2022/2602). The final results will be published via scientific publication. FAST will benefit the evaluation and management of those who suffer knee osteoarthritis regardless of English proficiency or language barriers.

TRIAL REGISTRATION NUMBER

NCT05590663.

The simplified Chinese version of the Knee Injury and Osteoarthritis Outcomes Score (KOOS) in individuals with knee osteoarthritis for mainland China: the study of reliability and validity

BACKGROUND

The Knee Injury and Osteoarthritis Outcomes Score (KOOS) is a free clinical tool commonly used to evaluate the symptoms and functional status of patients with knee injury. For people who speak Chinese, the Hong Kong Chinese and Singapore Chinese versions are preferred. However, variations in the Chinese language and culture are influenced by the country's geography. KOOS for Mainland China has not been reported. Therefore, the current study was to cross-culturally translate the original English version into a simplified Chinese version and to investigate its psychometric properties.

METHODS

The simplified Chinese KOOS was obtained through forward-backward translation according to appropriate guidelines. A total of 158 individuals with knee osteoarthritis (KOA) were recruited from 13 hospitals in China to examine the psychometric properties. The test-retest questionnaire was performed at an interval of 5-7 days. Test-retest reliability and internal consistency were evaluated using the intraclass correlation coefficient (ICC) and Cronbach's alpha, respectively. The data of the first test were used to analyse the construct validity of the simplified Chinese KOOS and Chinese SF-36 through convergent and discriminant validity using Spearman's correlation coefficient.

RESULTS

Cross-cultural translation exhibited minor cultural differences, and the questionnaire was well understood by the patients. The data from 128 patients, used for the test-retest reliability study, showed good to excellent reliability, with an ICC of 0.808-0.976 for all KOOS subscales. The Cronbach's alpha for all subscales ranged from 0.757 to 0.970, indicating acceptable internal consistency. There was a low-to-high correlation between the five domains of the simplified Chinese version of the KOOS and all domains of the SF-36 in construct validity.

CONCLUSION

The simplified Chinese KOOS demonstrated acceptable reliability and validity. In clinical practice and research, this version can help provide valuable information on health-related quality of life for Chinese individuals with KOA in mainland China.

Low Correlation between Gait and Quality of Life in Advanced Knee Osteoarthritis

Advanced knee osteoarthritis patients' gait usually undergoes alterations leading to decreased mobility and lower functional performance, which can result in a worsening of their quality of life (QoL). While several authors have reported a moderate correlation between gait parameters and QoL assessed by generic questionnaires, the literature is scarce. This study aimed to explore the relationship between gait and QoL parameters assessed by a generic and a disease-specific questionnaire in patients with advanced knee osteoarthritis. In this single-centre, prospective, observational study, 129 patients with advanced knee osteoarthritis scheduled for elective total knee replacement were selected. The patients' gait was evaluated by means of a validated wireless device while they walked 30 m at a comfortable speed. Patient function was also analysed using the Knee Society Score (KSS). QoL was measured with the EQ-5D and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires. Patients showed a mean walking speed of 0.95 ± 0.19 m/s, a mean cadence of 105.6 ± 9.9 steps/min, and a mean stride length of 1.25 ± 0.17 m on both legs. They presented poor knee status (KSS < 60) and poor QoL, with an EQ-5D of 0.44 ± 0.24 and a total KOOS of 29.77 ± 13.99. Positive low correlations (r <0.5, p <0.5) were found only between the speed, propulsion and stride length of both legs, and the overall and ADLs subscale scores of the total KOOS questionnaire. In conclusion, several gait parameters have a significant low correlation with the QoL of patients with advanced knee osteoarthritis, as assessed by an osteoarthritis-specific questionnaire.

Cross-Culturally Adapted Versions of Patient Reported Outcome Measures for the Lower Extremity

Background

A large number of patient reported outcome measures (PROMs) have been developed in the English language for various lower extremity orthopaedic pathologies. Twenty different PROMs were recommended for 15 specific musculoskeletal lower extremity pathologies or surgeries. However, the availability of cross-culturally adapted versions of these recommended PROMs is unknown.

Purpose

The purpose of this study was to identify the cross-culturally adapted versions of recommended PROMs for individuals experiencing orthopedic lower extremity pathologies or undergoing surgeries, and to identify the psychometric evidence that supports their utilization.

Study design

Literature Review.

Methods

PubMed, Embase, Medline, Cochrane, CINAHL, SPORTDisucs and Scopus were searched for cross-culturally adapted translated studies through May 2022. The search strategy included the names of the 20 recommended PROMs from previous umbrella review along with the following terms: reliability, validity, responsiveness, psychometric properties and cross-cultural adaptation. Studies that presented a non-English language version of the PROM with evidence in at least one psychometric property to support its use were included. Two authors independently evaluated the studies for inclusion and independently extracted data.

Results

Nineteen PROMS had cross-culturally adapted and translated language versions. The KOOS, WOMAC, ACL-RSL, FAAM, ATRS, HOOS, OHS, MOXFQ and OKS were available in over 10 different language versions. Turkish, Dutch, German, Chinese and French were the most common languages, with each language having more than 10 PROMs with psychometric properties supporting their use. The WOMAC and KOOS were both available in 10 languages and had all three psychometric properties of reliability, validity, and responsiveness supporting their use.

Conclusion

Nineteen of the 20 recommended instruments were available in multiple languages. The PROM most frequently cross-culturally adapted and translated were the KOOS and WOMAC. PROMs were most frequently cross-culturally adapted and translated into Turkish. International researchers and clinicians may use this information to more consistently implement PROMs with the most appropriate psychometric evidence available to support their use.

Level of evidence

3a.

Isolated Arthroscopic Partial Meniscectomy Is More Effective at Improving Meniscal Symptoms in Comparison With Mechanical Symptoms in Patients With Concomitant Untreated Chondral Lesions

PURPOSE

To rank Knee Injury and Osteoarthritis Outcome Score (KOOS) questions from most to least improvement after arthroscopic partial meniscectomy (APM) and compare improvement of meniscal versus mechanical symptoms.

METHODS

A secondary analysis of the Chondral Lesions and Meniscus Procedures (ChAMP) Trial was performed. Inclusion criteria were age 30 years or older with degenerative meniscal tear failing nonoperative management, with or without associated unstable chondral lesions. No chondral debridement was performed. Responses to the 42 KOOS questions ranged from 0 (extreme problems) to 4 (no problems), and were answered preoperatively and at 1 year after isolated APM. The 1-year mean change, or delta (Δ), was calculated for each KOOS question and the Δ for meniscal and mechanical symptoms were statistically compared.

RESULTS

Greatest improvement in 135 eligible patients was observed for questions about (1) awareness of knee problems (Δ = 1.93, standard deviation [SD] = 1.38), (2) frequency of knee pain (Δ = 1.93, SD = 1.29), (3) degree of difficulty while twisting/pivoting on the injured knee (Δ = 1.88, SD = 1.13), (4) degree of difficulty while running (Δ = 1.67, SD = 1.30), and (5) being troubled by lack of confidence in the knee (Δ = 21.67, SD = 1.11). Least improvement was observed for questions about: (1) degree of difficulty while getting on/off the toilet (Δ = 0.94, SD = 0.96), (2) feel grinding or hear clicking when the knee moves (Δ= 0.90, SD = 1.25), 3) degree of difficulty while getting in/out of the bath (Δ= 0.88, SD = 1.00), (4) knee catches/hangs up during movement (Δ= 0.80, SD = 1.09), and (5) the ability to straighten the knee fully (Δ= 0.54, 1.44). There was greater improvement for the KOOS questions pertaining to meniscal versus mechanical symptoms (P < .00001).

CONCLUSIONS

KOOS symptoms as reported by subjects' responses to the questions pertaining to the frequency of knee pain, twisting/pivoting, running, squatting, and jumping showed the most improvement 1 year after isolated APM, whereas those relating to mechanical symptoms improved the least. Focusing on meniscal rather than mechanical symptoms may help surgeons better identify patients expected to benefit from APM.

LEVEL OF EVIDENCE

IV, retrospective analysis of prospectively collected data.

Ultrasound examination of tibiofibular widening of forceful knee flexion is recommended for patients with proximal tibiofibular joint instability

BACKGROUND

Proximal tibiofibular joint (PTFJ) instability is uncommon, resulting from violent twisting motions of the flexed knee during sport activities. No known image variables functionally relate the degrees of PTFJ instability.

OBJECTIVE

This study used ultrasound imaging to quantify the discrimination threshold for PTFJ instability and relevant functional significances.

METHODS

Twenty patients (mean age: 42.7 (21-59) years) with chronic PTFJ instability participated in this study. Along with the Knee Injury and Osteoarthritis Outcome Score (KOOS),the tibiofibular distances of the affected and unaffected knees were estimated with ultrasonography in the four standardized conditions at 90° of flexion of the hip and knee, including neutrally relaxed position, passive internal rotation, passive external rotation, and forceful flexion of the knee joint.

RESULTS

During forceful knee flexion, the absolute tibiofibular distance in the affected leg (28.1 ± 4.0 mm) was greater than the unaffected leg (25.1 ± 3.7 mm). Relative changes in tibiofibular distance (RTFD) were different for both legs (affected leg:3.9 ± 2.7 mm; unaffected leg:1.0 ± 1.4 mm) (P < 0.001). The area under the receiver operator characteristic curve for the RTFD was a potent predictor of PTFJ instability (84.5%) with specificity of 95% and sensitivity of 65%. Patients with RTFD greater than 2.95 mm exhibited higher scores on the KOOS subscales of pain (P = 0.043) and quality of life (P = 0.009).

CONCLUSION

Ultrasonic measurement of the tibiofibular distance under forceful knee flexion is clinically valuable for diagnosing PTFJ instability with functional significance.

Coping Patterns Among Primary Informal Dementia Caregivers in Singapore and Its Impact on Caregivers-Implications of a Latent Class Analysis

BACKGROUND AND OBJECTIVES

Existing studies typically explore the factor structure of coping strategies among dementia caregivers. However, this approach overlooks the fact that caregivers often use different coping strategies simultaneously. This study aims to explore the coping patterns of primary informal dementia caregivers in Singapore, examine their significant correlates, and investigate whether different patterns would affect the depressive symptoms of caregivers.

RESEARCH DESIGN AND METHODS

Two hundred eighty-one primary informal caregivers of persons with dementia (PWD) were assessed. Coping strategies were measured by the Brief Coping Orientation to Problem Experienced inventory. A latent class analysis was performed to explore caregivers' coping patterns, followed by logistic regressions to identify the significant correlates and the relationships between coping patterns and caregiver depression.

RESULTS

The latent class analysis suggested a three-class solution that was featured by the frequency and variety of coping strategies used by caregivers-high coping (36.3%), medium coping (37.7%), and low coping (26.0%). Factors influencing the coping patterns of our sample were mainly related to caregivers' individual resources such as personal characteristics and caregiving stressors like PWD's problematic behaviors and caregiving burden. Compared to caregivers in the low coping group, those in the medium coping group had significantly higher risks of potential depression.

DISCUSSION AND IMPLICATIONS

The current study confirmed that there are distinct coping patterns among primary informal dementia caregivers, and caregivers with the low coping pattern had fewer depressive symptoms. Future research is needed to explore if coping patterns from our sample are generalizable to dementia caregivers elsewhere.

Translation, cross-cultural adaptation and psychometric properties of the Urdu version of knee injury and osteoarthritis outcome score questionnaire for Pakistani population

Background

Knee injury and osteoarthritis outcome score questionnaire is a widely used tool for measuring short and long-term patient-relevant outcomes following knee injury. KOOS is neither translated nor examined for psychometric properties before. Therefore, the aim of this study was to translate, culturally adapt and check the psychometric properties of the KOOS in Urdu.

Methodology

The translation and cultural adaptation was performed according to pre-defined guidelines. A total of 117 participants (54 males and 63 females) were recruited. The study had two steps: 1) Translation and cultural adaptation 2) Reliability and validity testing. The reliability (test-retest and internal consistency at (95% confidence interval) as well as the validity (Convergent validity) of final Urdu version of KOOS was tested.

Results

For all five domains, the KOOS Urdu version (KOOS-U) has demonstrated high test-retest reliability ICC = 0.90–0.96(CI = 95%). For all domains, the internal consistency was determined to be excellent (α = 0.82–0.96). There were no floor or ceiling impacts noted. Convergent validity was found to be good, as measured by Pearson’s correlation coefficient. The findings revealed a strong negative association between the KOOS-U (QOL and pain) and the NPRS. And there was a low to high positive correlation between five KOOS-U domains and all SF-12 domains, i.e., there was a significant positive correlation between the pain domains of both KOOS and SF-12 with the r = 0.87(p < 0.05).

Conclusion

The Urdu version of KOOS is a valid, reliable, and responsive instrument to assess functional disability of patients with Knee Osteoarthritis with excellent psychometric properties.

Cross-cultural validation of Hindi version Knee Injury and Osteoarthritis Outcome Score (KOOS) in osteoarthritis knee

PURPOSE

To assess the reliability, validity and responsiveness of the Hindi version of the Knee Injury and Osteoarthritis Outcome Score (H-KOOS) in osteoarthritic knee.

METHODS

Two hundred and fourteen patients of osteoarthritis knee (OA) between 40 and 80 years of age were evaluated with H-KOOS, Short form health survey (SF12v2) and the WHOQOL-BREF questionnaire. The H-KOOS was re-evaluated after 48 h in 125 patients to assess the test-retest reliability. For responsiveness, 40 patients were treated with the intra-articular hyaluronic acid injection, and the effect was assessed after 6 weeks.

RESULTS

Most of the domains in H-KOOS did not show a ceiling effect. The floor values were observed in 3.75% of patients in sports/recreation function and 2.75% of patients in Quality of life (QoL). The test-retest reliability was excellent with the Intraclass-Correlation-Coefficient (ICC) ranging from 0.89 to 0.94. Internal consistency as assessed using Cronbach's alpha coefficient was acceptable for pain, activities of daily living (ADL) and sport/recreation function (range 0.86-0.93); however, symptoms and QoL had weak internal consistency. There were moderate to strong correlations (r = 0.35 to 0.6) between domains measuring similar constructs in H-KOOS, SF12v2 and WHOQOL-BREF indicating good convergent construct validity. The responsiveness as measured by the effect size (ES) and standardized response mean (SRM) was large for pain (ES 0.9, SRM 0.8), moderate for Sport/Rec (ES 0.66, SRM 0.2) and small for ADL, QoL and Symptoms subscales.

CONCLUSION

The Hindi version KOOS is a valid, reliable and responsive measure to evaluate osteoarthritis knee with minimal ceiling and floor effects.

LEVEL OF EVIDENCE

Prospective cohort study, level II.

Knee Injury and Osteoarthritis Outcome Score: Validity and Reliability of an Indonesian Version

Background: The Knee injury and Osteoarthritis Outcome Score (KOOS) is a useful diagnostic tool to assess knee ligament injury and osteoarthritis, but no validated Indonesian version of the KOOS was available.

Methods: We used the forward-backward translation protocol to develop the Indonesian version of the KOOS. The translated questionnaire was administered twice to 51 subjects diagnosed with a knee ligament injury and osteoarthritis. Validity of the questionnaire was assessed by analyzing the correlation between the score of each subscale and the overall score of the 36-Item Short Form Health Survey (SF-36) using the Pearson correlation coefficient. Reliability was measured by evaluating internal consistency (Cronbach α) and test-retest reliability (intraclass correlation coefficient).

Results: For construct validity, moderate Pearson correlation coefficients were found between the KOOS subscales and the SF-36. Cronbach α was 0.84 to 0.97 for all subscales, indicating adequate internal consistency. The test-retest reliability was excellent, with intraclass correlation coefficients ranging from 0.91 to 0.99 for all subscales. No significant differences were found in the KOOS subscale responses between the first administration of the questionnaire and the second administration within 21 days.

Conclusion: The Indonesian version of the KOOS was determined to be valid and reliable and is therefore an objective instrument for evaluating knee ligament injury and knee osteoarthritis in the Indonesian population.

Collaborative model of care between Orthopaedics and allied healthcare professionals in knee osteoarthritis (CONNACT): study protocol for an effectiveness-implementation hybrid randomized control trial

Background

Knee Osteoarthritis (OA) is a leading cause of global disability. The Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT) Model of Care (MoC) was developed by optimizing evidence-based non-surgical treatments to deliver value-based care for people with knee OA. The primary aim of this study is to determine the clinical effectiveness of the CONNACT MoC (3 months) compared to usual care. The secondary aims are: a) To determine the cost-effectiveness and b) To develop an evaluation and implementation framework to inform large scale implementation for this MoC.

Methodology

Type 1 Effectiveness-Implementation Hybrid Trial using an explanatory sequential mixed-method approach. The study consists of 3 components. The first component is the pragmatic, parallel-arm, single-blinded randomized control trial. Inclusion criteria are patients with knee OA based on the National Institute of Health and Care Excellence (NICE) criteria with radiographic severity of greater than Kellgren-Lawrence 1, and Knee Injury and OA Outcome Score (KOOS₄) of equal or less than 75. Exclusion criteria include other forms of arthritis, history of previous knee arthroplasty or wheelchair-bound patient. KOOS₄ is the primary outcome measure at 3 months, 6 months and 1 year. Secondary outcomes include KOOS individual subscales, quality of life scoring, functional performance, global, diet and psychological related outcomes. The second component is an economic evaluation of the cost-effectiveness of the CONNACT MoC using a societal perspective. The third component is an implementation and evaluation framework using process evaluation under the RE-AIM framework using a mixed-method approach. Sample size of 100 patients has been calculated.

Discussion

CONNACT MoC is a complex intervention. In line with the MRC guidance for developing and evaluating complex interventions, a pilot feasibility study was completed and a comprehensive approach including an RCT, economic evaluation and process evaluation is described in this study protocol. Results from this study will help clinicians, healthcare administrators and policymakers guide the sustainable and effective implementation of the CONNACT MoC for knee OA and serve as a basis for similar multidisciplinary MoC for chronic degenerative musculoskeletal conditions to be developed.

Trial registration

Clinicaltrials.gov Identifier: NCT03809975. Registered January 182,019.

Collaborative model of care between Orthopaedics and allied healthcare professionals trial (CONNACT) - a feasibility study in patients with knee osteoarthritis using a mixed method approach

Background

Osteoarthritis is a leading cause of global disability resulting in significant morbidity and cost to the healthcare system. Current guidelines recommend lifestyle changes such exercises and weight loss as first line treatment prior to surgical consideration. Our current model of care is inefficient with suboptimal allied health intervention for effective behaviour changes. A 12-week community based, individualized, multidisciplinary new model of care for knee osteoarthritis was developed in light of current deficiencies.

Methods

The primary aim of this study was to determine the feasibility of a full randomized controlled trial evaluating this new model of care using pre-defined progression criteria. The secondary aim was to optimize the intervention and study design through a process evaluation. A pilot exploratory, parallel arm, single blinded randomized trial design using a mixed method approach was utilized. Progression criteria for a full trial including key domains of patient recruitment and retention, outcome measure acceptability and improvement, adverse events were developed. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and 12-weeks. Secondary outcomes included quality of life, functional and psychological assessments. Semi-structured interviews were conducted with the patients at 12-weeks.

Results

20 patients (3 males, 17 females) were randomized (10 intervention, 10 control). Intervention arm patients reported better improvements in their knee function, quality of life, psychological outcome, dietary improvement and weight loss compared to the control arm at 12-weeks. Semi-structured interviews revealed several themes pertaining to feasibility and intervention optimization. 5 out of the 6 progression criteria’s domains were met (recruitment criteria not met).

Conclusion

This pilot has demonstrated the feasibility of a full randomized control trial investigating the potential effectiveness of the new proposed model of care for knee osteoarthritis using pre-defined progression criteria and process evaluation. Results from the qualitative study were used to modify and improve the intervention content, delivery model and study design for a large effectiveness-implementation hybrid randomized control trial that is currently underway.

Trial registration

Retrospectively registered on 18 January 2019 at http://clinicaltrial.gov ID: NCT03809975.

Combined effect of laser acupuncture and electroacupuncture in knee osteoarthritis patients: A protocol for a randomized controlled trial

BACKGROUND

Knee osteoarthritis (KOA) is a common degenerative joint disorder that affects 250 million people globally. KOA can lead to disability and is often associated with cardiovascular disease, poor quality of life, and mortality. The most common treatment for KOA is non-steroidal anti-inflammatory drug administration. However, the analgesic effect is limited and often accompanied by multiple side effects. Hence, many KOA patients opt for complementary and alternative medicine. Acupuncture is one of the most popular complementary treatments with great analgesic effect and minimal side effect. Electroacupuncture (EA) and laser acupuncture (LA) have been known to reduce pain in KOA patients. However, to date, no study has assessed the benefits of combining these two therapies.

METHODS

Fifty participants diagnosed with KOA, aged 50 years or older, and with consistent knee pain for more than 3 months were recruited and randomly assigned to the treatment group (EA plus LA) or control group (EA plus sham LA without laser output). All subjects in the treatment group will undergo a combined EA and LA treatment thrice a week for 4 weeks. The acupuncture will be performed on GB33, GB34, SP9, SP10, and ST36 sites. The treatment group will receive acupuncture with a transcutaneous electrical nerve stimulator at GB33, GB34, SP9, and SP10 sites and with LA at EX-LE5, ST35, and BL40 sites. The subjects in the control group will undergo the same treatment modality as the treatment group, except these subjects will not be exposed to laser output. Outcome measurements will include visual analog scale, Western Ontario McMaster Universities Osteoarthritis Index, Knee injury and osteoarthritis outcome, body composition analysis, knee range of motion, quadriceps muscle stiffness, one-leg standing with eyes open test, and the 30-s chair stand test before and after 4 weeks of intervention.

OBJECTIVES

This protocol aims to investigate the combined effect of EA and LA in KOA patients.

Staging dementia based on caregiver reported patient symptoms: Implications from a latent class analysis

Background

Tailoring interventions to the needs of caregivers is an important feature of successful caregiver support programs. To improve cost-effectiveness, group tailoring based on the stage of dementia could be a good alternative. However, existing staging strategies mostly depend on trained professionals.

Objective

This study aims to stage dementia based on caregiver reported symptoms of persons with dementia.

Methods

Latent class analysis was used. The classes derived were then mapped with disease duration to define the stages. Logistic regression with receiver operating characteristic curve was used to generate the optimal cut-offs.

Results

Latent class analysis suggested a 4-class solution, these four classes were named as early (25.9%), mild (25.2%), moderate (16.7%) and severe stage (32.3%). The stages based on the cut-offs generated achieved an overall accuracy of 90.8% compared to stages derived from latent class analysis.

Conclusion

The current study confirmed that caregiver reported patient symptoms could be used to classify persons with dementia into different stages. The new staging strategy is a good complement of existing dementia clinical assessment tools in terms of better supporting informal caregivers.

Developing item banks to measure three important domains of health-related quality of life (HRQOL) in Singapore

Objectives

To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans – physical functioning, social relationships, and positive mindset.

Methods

We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n = 134 participants) and item(n = 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were “binned” and “winnowed” by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews.

Results

Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset).

Conclusions

We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively.

Decreased perceived ankle and knee joint health in individuals with perceived chronic ankle instability

PURPOSE

Abnormal movement patterns and neuromuscular impairments at the ankle are thought to contribute to ankle joint degeneration in those with chronic ankle instability. However, these impairments are not confided to the ankle; rather, proximal neuromuscular deficiencies at the knee and aberrant movement patterns, thought to be responsible for reductions in knee joint health, have also been identified. While neuromuscular impairments and self-reported functional limitations have been examined in those with chronic ankle instability, patient-generated symptoms associated with joint health of the ankle and knee have not been investigated. Therefore, the purpose was to compare perceived ankle and knee joint health in individuals with and without chronic ankle instability.

METHODS

The Ankle Osteoarthritis Scale and the Knee Injury and Osteoarthritis Outcome Score assessed region-specific ankle and knee joint health.

RESULTS

Participants with chronic ankle instability reported more ankle pain (P < 0.001) and disability (P < 0.001) than the control group. Chronic ankle instability individuals also reported worse knee joint health (P < 0.05).

CONCLUSIONS

The increased symptomology associated with decreased ankle joint health further supports information demonstrating joint degeneration in young adults with chronic ankle instability. The decreased perceived knee joint health provides preliminary evidence of the negative impact proximal neuromuscular impairments associated with chronic ankle instability that may have on joints other than the ankle. Assessing subjective ankle and knee joint function can guide clinicians in developing individualized rehabilitation by providing them with an understanding if a patient presenting with chronic ankle instability suffers from symptoms arising from more than just the ankle.

LEVEL OF EVIDENCE

Case-control, Level III.

Validation of the Spanish Version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) for Elderly Patients With Total Knee Replacement

The purpose of this study was to validate the Knee Injury and Osteoarthritis Outcome Score (KOOS) for elderly patients who undergo total knee replacement (TKR). The validated Spanish versions of the KOOS and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaires were applied to 137 patients (mean age 72.3, SD 7.5 years). Test-retest data were collected with an intermediate period of 1-2 weeks. To evaluate the clinimetric properties of the KOOS, internal consistency (Cronbach's α), reproducibility (intraclass correlation coefficient [ICC]), construct validity (Spearman's correlation), responsiveness (effect sizes [ES], and standardized response mean [SRM]), and floor and ceiling effects (<15%) were assessed. As result, Cronbach's coefficients of the KOOS subscales ranged from 0.78 to 0.93, and ICC from 0.76 to 0.91. Construct validity was supported by the confirmation of the three predefined hypotheses involving expected correlations between KOOS subscale and SF-36 physical health subscales. Spearman's correlations were strong between KOOS Pain and SF-36 Bodily Pain (r = 0.81), KOOS Pain and SF-36 Physical Functioning (r = 0.67), KOOS activities of daily living (ADL) and SF-36 Bodily Pain (r = 0.69), KOOS ADL and SF-36 Physical Functioning (r = 0.74), and KOOS Sports/Recreation and SF-36 Physical Functioning (r = 0.76). Responsiveness at 1 year after TKR was large with the ES ranging from 0.81 to 2.12, and the SRM from 0.70 to 1.91. Floor and ceiling effects were low. In conclusion, the Spanish version of KOOS has successful psychometric characteristics and is a reliable and valid instrument for assessment of patient-relevant outcomes in elderly patients with advanced OA who undergo TKR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2157-2162, 2019.

Mapping EQ-5D-3L from the Knee Injury and Osteoarthritis Outcome Score (KOOS)

Purpose

To develop a mapping model to estimate EQ-5D-3L from the Knee Injury and Osteoarthritis Outcome Score (KOOS).

Methods

The responses to EQ-5D-3L and KOOS questionnaires (n = 40,459 observations) were obtained from the Swedish National anterior cruciate ligament (ACL) Register for patients ≥ 18 years with the knee ACL injury. We used linear regression (LR) and beta-mixture (BM) for direct mapping and the generalized ordered probit model for response mapping (RM). We compared the distribution of the original data to the distributions of the data generated using the estimated models.

Results

Models with individual KOOS subscales performed better than those with the average of KOOS subscale scores (KOOS₅, KOOS₄). LR had the poorest performance overall and across the range of disease severity particularly at the extremes of the distribution of severity. Compared with the RM, the BM performed better across the entire range of disease severity except the most severe range (KOOS₅ < 25). Moving from the most to the least disease severity was associated with 0.785 gain in the observed EQ-5D-3L. The corresponding value was 0.743, 0.772 and 0.782 for LR, BM and RM, respectively. LR generated simulated EQ-5D-3L values outside the feasible range. The distribution of simulated data generated from the BM model was almost identical to the original data.

Conclusions

We developed mapping models to estimate EQ-5D-3L from KOOS facilitating application of KOOS in cost-utility analyses. The BM showed superior performance for estimating EQ-5D-3L from KOOS. Further validation of the estimated models in different independent samples is warranted.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02303-9) contains supplementary material, which is available to authorized users.

Cross-Cultural Adaptation and Validation of the Hong Kong Version of the Knee Injury and Osteoarthritis Outcome Score (HK-KOOS) for Patients with Knee Osteoarthritis

Introduction

This study aimed to validate the Hong Kong version of the Knee Injury and Osteoarthritis Outcome Score (HK-KOOS) for patients with knee osteoarthritis.

Methods

Content validity was assessed using the Item and Scale Content Validity Index (I-CVI and S-CVI). Test-retest reliability and internal consistency were assessed by the Intraclass Correlation Coefficient (ICC) and Cronbach's alpha. Dimensionality was assessed by performing exploratory factor analysis (EFA). Convergent and Divergent Validity was performed by examining the correlation between the HK-KOOS and the Chinese version of the Short Form 12 (SF-12) Health Survey, the Chinese Modified Barthel Index (C-MBI), and the Visual Analogue Scale for Pain (VAS-Pain). Ceiling and floor effects were also examined.

Results

A total of 125 participants were recruited in this study. In general, all instructions, items, and response options were considered as understandable, indicating a satisfactory cross-cultural adaptation. The I-CVI and S-CVI scores were 0.80-1 and 0.90-1, respectively, indicating excellent content validity in terms of relevance, representativeness, and understandability. The test-retest reliability of all HK-KOOS subscales was satisfactory with ICC exceeding 0.70 for all domains. Cronbach's alpha exceeded 0.80 for all subscales, indicating satisfactory internal consistency. Medium to strong correlations were found between the HK-KOOS and the VAS-Pain, SF-12, and C-MBI. However, factor analysis indicated a seven-factor structure, rather than the original five-factor structure. Items on pain and activities of daily living were loaded in the same factors. A floor effect was present in the sports and recreation subscale.

Discussion and Conclusions

Future studies should further examine the dimensionality of the KOOS. The HK-KOOS is a culturally adapted, reliable, and valid outcome measure instrument to be used in Hong Kong patients with primary knee osteoarthritis.

The Association of Balance, Fear of Falling, and Daily Activities With Drug Phases and Severity of Disease in Patients With Parkinson

Introduction:

In the elderly, functional balance, fear of falling, and independence in daily living activities are interrelated; however, this relationship may change under the influence of drug phase and the severity of disease in individuals with idiopathic Parkinson disease. This study aimed to investigate the association of functional balance, fear of falling, and independence in the Activities of Daily Living (ADL) with the drug on- and drug off-phases.

Methods:

A total of 140 patients with Parkinson disease (age: Mean±SD; 60.51±12.32 y) were evaluated in terms of their functional balance, fear of falling, and independence in their daily activities by the Berg Balance Scale (BBS), Fall Efficacy Scale-International (FES-I), and Unified Parkinson Disease Rating Scale-ADL (UPDRS-ADL), respectively, in drug on- and drug off-phases. The Hoehn and Yahr scale recorded global disease rating. The Spearman coefficient, Kruskal-Wallis, and Mann-Whitney tests were used to find out whether the distribution of scale scores differs with regard to functional balance or disease severity.

Results:

A strong correlation was found between the functional balance, fear of falling, and independence in ADL with both drug phases. The results also showed the significant difference in the distribution of the FES-I and UPDRS-ADL scores with regard to functional balance (except independence in ADL in drug off-phase). Also, the distribution of the scores of BBS, FES-I, and UPDRS-ADL showed significant differences with regard to disease severity.

Conclusion:

The study showed a strong correlation between functional balance, fear of falling, and independence in ADL that can be affected by the drug phase and severity of the disease. However, more studies are needed to understand this relationship precisely.

Twenty-four-week hospital-based progressive resistance training on functional recovery in female patients post total knee arthroplasty

BACKGROUND

After total knee arthroplasty (TKA) surgery, a decline in muscle strength is associated with a decrease in function. The aim of this study was to demonstrate the effect of a further 24 weeks of hospital-based resistance training under supervision, and precise dose on knee functional recovery and daily activities for female TKA patients.

METHODS

Twenty-nine patients who underwent unilateral primary TKA were allocated into either resistance training (RT) (n = 14) or control (CON) (n = 15) groups. All patients were assessed, with an isokinetic dynamometer, for hip and knee flexor and extensor muscle strength, physical function test, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Resistance training was initiated three months after index surgery. The assessments were performed before exercise (Baseline), in the middle of the resistance training at 12 weeks (Mid-exercise), completion of the resistance training (Post-exercise), and 12 weeks after resistance training completion (Follow-up). A statistical test was performed by using generalized estimating equations.

RESULTS

Patients in RT had more of an increase in both knee extensor and flexor muscle strength than those in CON at the Post-exercise assessment. The six-minute walk test distance was more in RT compared with CON at the same Post-exercise assessment. Furthermore, the RT group had increases in Activities of daily living and Sports subscales compared to the CON group.

CONCLUSIONS

A further 24 weeks of hospital-based progressive resistance training facilitated improvement in knee muscle strength and functional outcome in TKA patients. Active hospital-based progressive resistance training is recommended for rehabilitation following TKA surgery.

Can muscle weakness and disability influence the relationship between pain catastrophizing and pain worsening in patients with knee osteoarthritis? A cross-sectional study

OBJECTIVE

To verify if the relationship between pain catastrophizing and pain worsening would be mediated by muscle weakness and disability in patients with symptomatic knee osteoarthritis.

METHODS

This was a cross-sectional study in a hospital out-patient setting. Convenience sampling was used with a total of 50 participants with symptomatic knee osteoarthritis. Pain and the activities of daily livings (ADL) were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale. Pain catastrophizing was assessed using the Coping Strategy Questionnaire (CSQ) subscale. Muscle strength of knee extension and 30-s chair stand test (30CST) were also assessed. Path analysis was performed to test the hypothetical model. Goodness of fit of models were assessed by using statistical parameters such as the chi-square value, goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA).

RESULTS

The chi-square values were not significant (chi-square=0.283, p=0.594), and the indices of goodness of fit were high, implying a valid model (GFI=1.000; AGFI=0.997; CFI=1.000; RMSEA=0.000). Pain was influenced significantly by muscle strength and ADL; muscle strength was influenced significantly by ADL via 30CST; ADL was influenced by pain catastrophizing.

CONCLUSION

The relationship between pain catastrophizing with pain worsening are mediated by muscle weakness and disability.

Construct validity and reliability of the Finnish version of the Knee Injury and Osteoarthritis Outcome Score

Background

The Knee Injury and Osteoarthritis Outcome Score (KOOS) is a commonly used knee assessment and outcome tool in both clinical work and research. However, it has not been formally translated and validated in Finnish. The purpose of this study was to translate and culturally adapt the KOOS questionnaire into Finnish and to determine its validity and reliability among Finnish middle-aged patients with knee injuries.

Methods

KOOS was translated and culturally adapted from English into Finnish. Subsequently, 59 patients with knee injuries completed the Finnish version of KOOS, Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short-Form 36 Health Survey (SF-36) and Numeric Pain Rating Scale (Pain-NRS). The same KOOS questionnaire was re-administered 2 weeks later. Psychometric assessment of the Finnish KOOS was performed by testing its construct validity and reliability by using internal consistency, test-retest reliability and measurement error. The floor and ceiling effects were also examined.

Results

The cross-cultural adaptation revealed only minor cultural differences and was well received by the patients. For construct validity, high to moderate Spearman’s Correlation Coefficients were found between the KOOS subscales and the WOMAC, SF-36, and Pain-NRS subscales. The Cronbach’s alpha was from 0.79 to 0.96 for all subscales indicating acceptable internal consistency. The test-retest reliability was good to excellent, with Intraclass Correlation Coefficients ranging from 0.73 to 0.86 for all KOOS subscales. The minimal detectable change ranged from 17 to 34 on an individual level and from 2 to 4 on a group level. No floor or ceiling effects were observed.

Conclusion

This study yielded an appropriately translated and culturally adapted Finnish version of KOOS which demonstrated good validity and reliability. Our data indicate that the Finnish version of KOOS is suitable for assessment of the knee status of Finnish patients with different knee complaints. Further studies are needed to evaluate the predictive ability of KOOS in the Finnish population.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2078-7) contains supplementary material, which is available to authorized users.

Comparing the Chinese versions of two knee-specific questionnaires (IKDC and KOOS): reliability, validity, and responsiveness

BACKGROUND

The International Knee Documentation Committee Subjective Knee Form (IKDC) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) are knee-specific questionnaires that have been widely used and translated into numerous languages. However, the differences in the psychometric properties between the Chinese IKDC and KOOS remain unclear. The purpose of this study was to conduct a cross-cultural adaptation of the Chinese IKDC and Chinese KOOS and to compare the psychometric properties of these two measures in patients with various knee injuries from the acute stage up to 12 weeks after receiving treatment.

METHODS

The original IKDC and KOOS were translated into Chinese based on the guidelines of cross-cultural adaptation and translation protocols. One hundred and seventy-three patients with various knee injuries were recruited in this study and completed both Chinese IKDC and Chinese KOOS as well as a generic health status questionnaire (Chinese Short Form-36 [SF-36]). The reliability, internal consistency, content validity, convergent and divergent validity and responsiveness of both IKDC and KOOS were assessed with appropriate indices.

RESULTS

The Chinese IKDC showed excellent reliability (ICC = 0.97) and strong internal consistency (Cronbach alpha = 0.87). The Chinese KOOS also presented good reliability with ICCs ranging from 0.89 to 0.95 and internal consistency (Cronbach alpha coefficients ranging from 0.76 to 0.97). The content validity of these two questionnaires were excellent, yielding no floor or ceiling effects. Both the Chinese IKDC and KOOS were highly associated with the physical component summary (PCS) score and weakly related to the mental component summary (MCS) score of the SF-36. Responsiveness to change was large (effect size =0.95) for the Chinese IKDC and moderate (effect sizes = 0.49~0.60) at 12-week after physical therapy.

CONCLUSION

Both the Chinese IKDC and KOOS demonstrated good psychometric properties. However, the Chinese IKDC was more sensitive to changes over a period of 2, 4, 8, 12 weeks of physical therapy than the Chinese KOOS. The ROC analyses revealed a value of area under the curve (0.83 for the Chinese IKDC and 0.67-0.79 for the subscales of Chinese KOOS). Minimal clinically important difference values were 9.8 for the Chinese IKDC and 0.79, 0.76, 0.76, 0.76, 0.67 for the Symptoms, Pain, Activities of Daily Living, Sport/Recreation, and Quality of Life subscales of Chinese KOOS, respectively. The current study provides information for clinicians and researchers to use these appraisal tools for Chinese-speaking patients with various knee disorders.

Cross-Cultural Validation of Urdu Version KOOS in Indian Population with Primary Knee Osteoarthritis

Purpose

The primary aim of this study was to translate a self-reported questionnaire (KOOS) from English to Urdu and then to see its internal consistency, agreement, test-retest reliability, and validity among primary OA knee patients.

Methodology

First, KOOS questionnaire was translated from English language to Urdu through standardized cross-cultural protocol. This translated version of KOOS was administered to 111 radiographically diagnosed primary OA knee patients at two times with 48-hour interval in-between. Cronbach's alpha, floor and ceiling effect, intraclass correlation coefficient (ICC), absolute agreement %, and Spearman correlation were used to fulfill our objectives.

Results

Average time to administer this questionnaire was 20 minutes. There was good internal consistency with Cronbach's alpha ranging from 0.7246 to 0.9139. The absolute agreement of each item between two tests ranged from 81.08% to 98.20%. Test-retest reliability was excellent (“r” ranged from 0.9673 to 0.9782). There was no ceiling effect; however less than 4% floor effect was seen in two subscales. There was significant difference that existed between different X-ray grades in all subscales meaning good content validity for disease prognosis.

Conclusion

The present results show that KOOS Urdu version is a reliable and valid measure for primary OA knee patients.

Circuit training enhances function in patients undergoing total knee arthroplasty: a retrospective cohort study

Background

The number of patients receiving total knee arthroplasty (TKA) has been rising every year due to the aging population and the obesity epidemic. Post-operative rehabilitation is important for the outcome of TKA.

Methods

A series of 34 patients who underwent primary unilateral TKA was retrospectively collected and divided into either exercise group (n = 16) and control group (n = 18). The exercise group underwent a 24-week course of circuit training beginning 3 months after total knee arthroplasty (TKA). The effect of circuit training on TKA patients in terms of motion analysis, muscle strength testing, Knee injury and Osteoarthritis Outcomes Score (KOOS) questionnaire and patient-reported outcome measurement Short-Form Health Survey (SF-36) at the pre-operation, pre-exercise, mid-exercise, and post-exercise.

Results

Motion analysis revealed the stride length, step velocity, and excursion of active knee range of motion significantly improved in the exercise group when compared to those in the control group. KOOS questionnaire showed a greater improvement in pain, ADL, and total scores in the exercise group. The SF-36 questionnaire revealed a significant improvement in general health, bodily pain, social function, and physical components score in the exercise group.

Conclusions

The post-operative circuit training intervention can facilitate recovery of knee function and decrease the degree of pain in the TKA and might be considered a useful adjunct rehabilitative modality. The ultimate influence of circuit training on TKA needs further a prospective randomized clinical trial study and long-term investigation.

Trial registration

NCT02928562

Long-Term Outcomes of Anterior Cruciate Ligament Reconstruction Using Either Synthetics With Remnant Preservation or Hamstring Autografts: A 10-Year Longitudinal Study

BACKGROUND

The optimal graft choice of anterior cruciate ligament (ACL) reconstruction remains controversial.

PURPOSE

To compare the outcomes, especially the long-term cumulative failure rate, of ACL reconstruction using either synthetics with remnant preservation or hamstring autografts (4-strand semitendinosus and gracilis tendons).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 133 patients who underwent ACL reconstruction (synthetics: n = 43; hamstring autografts: n = 90) between July 2004 and December 2007 were included. Questionnaires (Tegner activity scale, Lysholm knee scale, and International Knee Documentation Committee [IKDC] subjective form) were completed preoperatively and at 6 months, 1 year, 5 years, and 10 years postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was additionally applied at 10 years' follow-up. The physical examination was based on the 2000 IKDC form. The manual maximum side-to-side difference (KT-1000 arthrometer), single-hop test, thigh muscle atrophy, and joint degeneration (Kellgren and Lawrence classification) were evaluated. The Kaplan-Meier curve and log-rank test (Mantel-Cox, 95% CI) were used to compare graft survivorship.

RESULTS

Ten years postoperatively, 111 patients were available, with 38 (88.4%) patients (mean age, 27.6 ± 9.3 years; 28 men) with synthetics and 73 (81.1%) patients (mean age, 28.6 ± 8.8 years; 64 men) with hamstring autografts. Among them, 104 patients (synthetics: n = 35 [81.4%]; hamstring autografts: n = 69 [76.7%]) completed subjective evaluations, and 89 patients (synthetics: n = 30 [69.8%]; hamstring autografts: n = 59 [65.6%]) completed objective evaluations. For hamstring autografts and synthetics, the cumulative failure rates were 8.2% and 7.9%, respectively, and the log-rank test demonstrated no significant difference between the 2 Kaplan-Meier survival curves ( P = .910). At 6 months postoperatively, for hamstring autografts and synthetics, the mean Lysholm score was 83.0 ± 7.8 and 88.1 ± 7.5, respectively ( P < .001); the mean IKDC score was 83.8 ± 7.8 and 86.9 ± 4.5, respectively ( P = .036); and the mean Tegner score was 3.7 ± 1.1 and 5.0 ± 1.5, respectively ( P < .001). At 1 year postoperatively, the mean Tegner score was 5.5 ± 1.9 and 6.5 ± 2.0, respectively ( P = .011). No statistically significant difference was observed on other subjective evaluation findings, physical examination findings (overall IKDC grade A: 45.8% of hamstring autografts, 50.0% of synthetics), side-to-side difference (1.5 ± 1.5 mm for synthetics, 2.4 ± 2.1 mm for hamstring autografts), single-hop test findings (grade A: 84.7% of hamstring autografts, 93.3% of synthetics), grade A/B thigh muscle atrophy (88.1% of hamstring autografts, 93.3% of synthetics), ipsilateral radiographic osteoarthritis (55.9% of hamstring autografts, 50.0% of synthetics), and graft survivorship.

CONCLUSION

In this prospective cohort study, primary ACL reconstruction using either synthetics with remnant preservation or hamstring autografts showed satisfactory outcomes, especially the long-term cumulative failure rate, at 10 years postoperatively. Patient-reported outcomes suggested that symptom relief and restoration of function might occur earlier in those with synthetics.

Simplified Chinese Version of University of California at Los Angeles Activity Score for Arthroplasty and Arthroscopy: Cross-Cultural Adaptation and Validation

BACKGROUND

To translate and cross-culturally adapt the University of California at Los Angeles (UCLA) activity score into a simplified Chinese version (UCLA-C) and evaluate the reliability and validity of the UCLA-C for patients with both knee arthroscopy and total knee arthroplasty.

METHODS

Cross-cultural adaptation was performed according to the internationally recognized guidelines of the American Academy of Orthopaedic Surgeons Outcome Committee. A total of 200 participants (100 arthroscopy and 100 total knee arthroplasty) were recruited in this study. An intraclass correlation coefficient (ICC) was used to determine reliability. Construct validity was analyzed by evaluating the correlations between UCLA-C and the Tegner activity score, Knee Injury and Osteoarthritis Outcome Score, and the short-form (36) health survey.

RESULTS

The original version of the UCLA activity score was cross-culturally well adapted and translated into simplified Chinese. UCLA-C was found to have excellent reliability in both arthroscopy (ICC = 0.984, 95% confidence interval 0.976-0.989) and arthroplasty (ICC = 0.946, 95% confidence interval 0.920-0.964). Absolute reliability as evaluated by minimal detectable change was 0.789 and 0.837 for both arthroscopy and arthroplasty groups. Moderate to high correlations between UCLA-C and Tegner activity score (0.799, P < .001); Knee Injury and Osteoarthritis Outcome Score (0.449-0.715, P < .001); and Physical Functioning, Pain, General Health, and Social Functioning (0.549-0.746, P < .001) subdomains of short-form (36) health survey were observed.

CONCLUSION

UCLA-C was demonstrated to have excellent acceptability, reliability, and validity in both arthroscopy and arthroplasty, and could be recommended for patients in mainland China.

Translation, cultural adaptation and validation of simplified Chinese version of the anterior cruciate ligament return to sport after injury (ACL-RSI) scale

PURPOSE

To translate and cross-culturally adapt the anterior cruciate ligament-return to sport after injury (ACL-RSI) into simplified Chinese [ACL-RSI (Cn)].

METHOD

In this diagnostic study, the translation, cross-culturally adaptation, and validation of the ACL-RSI was performed according to international guidelines. A total of 112 patients with ACL reconstruction participated in this study. All were capable of competitive sports before the injury and completed the Knee Injury and Osteoarthritis Outcome (KOOS), the International Knee Documentation Committee (IKDC), the Tampa Scale of Kinesiophobia (TSK), and the Tegner activity score. Forty-eight patients completed the ACL-RSI (Cn) twice within two weeks. The validity was tested using seven premade hypotheses. Internal consistency, reliability, and measurement error was assessed.

RESULT

At meanly 15.6 months postoperative, 81 (72.3%) patients returned to sport, with 57 (50.9%) to competitive sport and 24 (21.4%) to recreational sport. Thirty-one (27.7%) patients didn't return to any sport, with 19 (17.0%) still had planned to return, and 12 (10.7%) gave up sport. The ACL-RSI (Cn) demonstrated excellent validity with all hypotheses confirmed. The outcome of ACL-RSI (Cn) was strongly correlated the KOOS subscale quality of life (r = 0.66, p<0.001), the TSK (r = -0.678, p<0.001), the Tegner score (r = 0.695, p<0.001). There was statistic difference between cases returned (68.6 ± 10.1) and didn't return to sport (41.3 ± 17.7), p<0.001; between cases returned to competitive (71.1 ± 8.9) and recreational sport (62.9 ± 10.5), (P = 0.002); between cases who planned to return (50.7 ± 14.1) and gave up sport (26.5 ± 11.7), (P<0.001). The internal consistency (Cronbach's α = 0.96) and test-retest reliability [intra-class correlation coefficient (ICC) = 0.90] was excellent. The measurement error, floor and ceiling effect was satisfactory. Administration time was 3.2 minutes, and no item was missed.

CONCLUSIONS

The ACL-RSI (Cn) scale was confirmed as a valid, reliable, and feasible tool for evaluating psychological factors influencing return to sport.

Psychometric Properties of the Malay Language Version of Knee Injury and Osteoarthritis Outcome Score (KOOS) Questionnaire among Knee Osteoarthritis Patients: A Confirmatory Factor Analysis

Introduction: This study aimed to cross-culturally adapt a Malay version of Knee Injury and Osteoarthritis Outcome Score (KOOS) and to evaluate its psychometric properties in patients with knee osteoarthritis (OA).

Materials and Methods: The English version KOOS was translated into a Malay version using forward and backward translation process, followed by face validity and content validity. Two hundred and twenty-six knee OA patients attending the Outpatient and Orthopaedic Clinics, Universiti Sains Malaysia Hospital, completed the Malay version KOOS. Construct validity using confirmatory factor analysis and internal reliability assessment were performed.

Results: The results showed that the original five-factor model with 42 items failed to achieve acceptable values of the goodness of fit indices, indicating poor model fit. A new five-factor model of 26 items demonstrated acceptable level of goodness of fit (comparative fit index= 0.929, incremental fit index= 0.930, Tucker Lewis fit index= 0.920, root mean square error of approximation= 0.073 and Chisquared/degree of freedom= 2.183) indices to signify a model fit. The Cronbach’s alpha value for the new model ranged from 0.776 to 0.946. The composite reliability values of each construct ranged between 0.819 and 0.921, indicating satisfactory to high level of convergent validity.

Conclusion: The five-factor model with 26 items in the Malay version of KOOS questionnaire demonstrated a good degree of goodness of fit and was found to be valid, reliable and simple as an assessment tool for symptoms, pain, activity of daily living, sports and recreational activity and quality of life for Malaysian adults suffering from knee osteoarthritis.

Chinese translation and validation of the Oxford Knee Scale for patients with knee osteoarthritis

Background:

Oxford Knee Scale (OKS) is a commonly used instrument to assess the symptoms and functional status in people with knee osteoarthritis. However, a Chinese version of this scale is not yet available.

Objective:

The objective of this study was to translate the OKS into Chinese and validate the Chinese version of OKS.

Methods:

The Chinese OKS was translated from the original English version following the recommendations of the International Society for Pharmacoeconomics and Outcomes Research. One hundred Chinese reading patients with knee osteoarthritis were recruited from local hospitals and physiotherapy clinics. Psychometric properties were evaluated in terms of test–retest reliability and internal consistency. Convergent validity was examined by Spearman rank correlation coefficient tests by comparing its score with the validated Chinese version of the Western Ontario and McMaster Universities Osteoarthritis Index and Health Outcome Survey Short Form-36.

Results:

Chinese OKS demonstrated excellent reliability (intraclass correlation coefficient = 0.88). Cronbach α of individual questions was > 0.7. Strong correlation was found between the Chinese OKS and the Western Ontario and McMaster Universities Osteoarthritis Index (ρ > 0.553, p < 0.001). Fairly strong negative correlation was also found between Chinese OKS and Health Outcome Survey Short Form-36 (ρ = −0.273 to −0.666, p < 0.05).

Conclusion:

The Chinese translated version of OKS is a reliable and valid instrument for clinical evaluation in Chinese reading patients with knee osteoarthritis.

Validity and Responsiveness of the Knee Injury and Osteoarthritis Outcome Score: A Comparative Study Among Total Knee Replacement Patients

OBJECTIVE

To evaluate validity and responsiveness of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in relation to other patient-reported outcome measures before and after total knee replacement (TKR).

METHODS

Pre-TKR and 6-month post-TKR data from 1,143 patients in a US joint replacement cohort were used to compare the KOOS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the SF-36 Health Survey (SF-36). Validity was evaluated with multiple methods, including correlations of pre-TKR scale scores and analysis of variance models that used pre-TKR data to compare the relative validity of scales in discriminating between groups differing in assistive walking device use and number of comorbid conditions. Validity was also evaluated by using post-TKR minus pre-TKR change scores to assess relative validity of scales in discriminating between groups rating themselves as better, same, or worse (BSW) in their capability to do activities at 6 months. Responsiveness also was described using effect sizes and standardized response means.

RESULTS

In support of convergent and discriminant validity, KOOS scale scores were worse for patients using an assistive device but only declined weakly with increasing comorbid conditions. While all knee-specific scales discriminated between BSW groups, the KOOS quality of life (QOL) scale was significantly better (P < 0.05) than all measures except the SF-36 physical component summary. KOOS QOL also had the highest effect size, while SF-36 measures had lower effect sizes and standardized response means. KOOS pain and symptoms scales discriminated better than WOMAC pain and stiffness scales among BSW groups.

CONCLUSION

KOOS scales were valid and responsive in this cohort of US TKR patients. KOOS QOL performed particularly well in capturing aggregate knee-specific outcomes.

Simplified Chinese version of the Forgotten Joint Score (FJS) for patients who underwent joint arthroplasty: cross-cultural adaptation and validation

BACKGROUND

The Forgotten Joint Score (FJS) is a newly developed health-related quality of life (HRQoL) questionnaire designed to evaluate the awareness after total knee arthroplasty (TKA). This study cross-culturally adapted and psychometrically validated a simplified Chinese version of the FJS (SC-FJS).

METHODS

Cross-cultural adaptation was performed according to the internationally recognized guidelines. One-hundred and fifty participants who underwent primary TKA were recruited in this study. Cronbach's α and intra-class correlations were used to determine reliability. Construct validity was analyzed by evaluating the correlations between SC-FJS and the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the short form (36) health survey (SF-36).

RESULTS

Each of the 12 items was properly responded and correlated with the total items. SC-FJS had excellent reliability [Cronbach's α = 0.907, intra-class correlation coefficient (ICC) = 0.970, 95% CI 0.959-0.978). Elimination of any one item in all did not result in a value of Cronbach's α of <0.80. SC-FJS had a high correlation with symptoms (0.67, p < 0.001) and pain (0.60, p < 0.001) domains of KOOS and social functioning (0.66, p < 0.001) domain of SF-36, and it also moderately correlated with function in daily living (0.53, p < 0.001) and function in sport and recreation (0.40, p < 0.001) domains of KOOS, and physical subscale of SF-36 (0.49-0.53, p < 0.001) but had a low (r = 0.20) or not significant (p > 0.05) correlation with mental subscale of SF-36.

CONCLUSIONS

SC-FJS demonstrated excellent acceptability, internal consistency, reliability, and construct validity, which can be recommended for patients who underwent joint arthroplasty in Mainland China.

Knee Injury and Osteoarthritis Outcome Score in patients with isolated meniscus injury; Validity and reliability

BACKGROUND

The aim of this study is evaluation of the validity and reliability of the Persian version of Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients with isolated meniscus injury.

MATERIALS AND METHODS

One hundred people with isolated meniscal injury (29 females and 71 males with a mean age ± standard deviation [SD] = 32.37 ± 9.97 years) and fifty normal people with no knee problems (34 females and 16 males with a mean age ± SD = 28.42 ± 8.84 years) participated in this study. In patients, the duration of meniscus injury ranged from 1 month to 4 years. For evaluation of discriminate validity, we compared scores of KOOS questionnaire between patients and healthy people, and for concurrent validity, in addition to filling KOOS questionnaire, patients completed Short Form (SF-36) questionnaire, test-retest reliability with intraclass correlation coefficient) ICC), and internal consistency with Cronbach's alpha was calculated.

RESULTS

Mean scores of patients (49.51 ± 17.13) and healthy people (86.01 ± 13.44) were different significantly (P < 0.001). The correlation between total score of SF-36 and KOOS was significant (r = 0.77, P < 0.001). ICC was 0.80 (ranged from 0.64-0.75) and Cronbach's alpha was 0.96 (ranged from 0.72 to 0.94).

CONCLUSION

The Iranian version of KOOS is a reliable and valid tool for patients with isolated meniscus injury, so the clinicians and investigators may use this questionnaire in clinical settings and their researches.

Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties

OBJECTIVE

To conduct a systematic review and meta-analysis to synthesize evidence regarding measurement properties of the Knee injury and Osteoarthritis Outcome Score (KOOS).

DESIGN

A comprehensive literature search identified 37 eligible papers evaluating KOOS measurement properties in participants with knee injuries and/or osteoarthritis (OA). Methodological quality was evaluated using the COSMIN checklist. Where possible, meta-analysis of extracted data was conducted for all studies and stratified by age and knee condition; otherwise narrative synthesis was performed.

RESULTS

KOOS has adequate internal consistency, test-retest reliability and construct validity in young and old adults with knee injuries and/or OA. The ADL subscale has better content validity for older patients and Sport/Rec for younger patients with knee injuries, while the Pain subscale is more relevant for painful knee conditions. The five-factor structure of the original KOOS is unclear. There is some evidence that the KOOS subscales demonstrate sufficient unidimensionality, but this requires confirmation. Although measurement error requires further evaluation, the minimal detectable change for KOOS subscales ranges from 14.3 to 19.6 for younger individuals, and ≥20 for older individuals. Evidence of responsiveness comes from larger effect sizes following surgical (especially total knee replacement) than non-surgical interventions.

CONCLUSIONS

KOOS demonstrates adequate content validity, internal consistency, test-retest reliability, construct validity and responsiveness for age- and condition-relevant subscales. Structural validity, cross-cultural validity and measurement error require further evaluation, as well as construct validity of KOOS Physical function Short form. Suggested order of subscales for different knee conditions can be applied in hierarchical testing of endpoints in clinical trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42011001603).