Patient-Report of Results Just As Important As Clinician Measures in Knee InjuriesThe winds of change have affected medicine -- how it's practiced and how results are measured. In this report, Dr. R. W. Wright, Associate Professor and Director of the Orthopedic Residency Program from Washington University in St. Louis focuses on how this has affected the treatment of knee injuries.
The first shift has come with a change from clinician-based measures of results more to a patient-reported outcomes base. This has meant a change in the tools doctors and other clinicians treating knee injuries use to measure change. Dr. Wright presents nine different outcomes measures for assessing patients with knee injury. Some are joint-specific, some address general health, and others are disease-specific. Disease-specific refers to a focus on one type of injury, such as an anterior cruciate ligament (ACL) injury.
With the rising cost of health care, using some type of measure to assess the effect of treatment is essential. Health care professionals are being asked to explain and justify health care dollars being spent on patients. Tools to measure patient outcomes must be geared toward patients and their specific diagnosis in order to guide future management programs.
Some of the instruments used today with knee injuries include the Short-Form-36 (SF-36), a measure of general health, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), specific to osteoarthritis of the lower extremity, and the Knee Injury and Osteoarthritis Outcome Score (KOOS), geared toward sports injuries.
Other knee specific (mostly focused on ligaments) include the International Knee Documentation Committee Subjective Form (IKDC), Lysholm Knee Scale, Cincinnati Knee Rating Scale, and the Anterior Cruciate Ligament Quality of Life (ACL QOL) score.
Each of these scales measure various aspects of physical functioning, emotional well-being, pain (and other symptoms), limp, work-related concerns, and sports participation. Sometimes specific activities such as running, cutting, decelerating, and pivoting are assessed. Just as important are measures for social functioning, emotional vitality, and quality of life.
Greater recognition is given these days to the importance of patient satisfaction. Patient-reported outcomes are certainly subjective (based on the patient's assessment). This is a shift from the measurements clinicians have always relied upon (e.g., range of motion, strength, motor control).
This is a reflection of the fact that sometimes objective measures of strength show improvement, but the patient's function doesn't improve or the patient isn't happy with the results. If a patient improves enough to return to school or work but not enough to return to sports or recreational activities, is that good enough? And by whose standards? In other words, who sets the bar for acceptable results -- the surgeon, the patient, or the health insurers?
The author suggests that separate measures are needed for separate areas. That's why knowing about multiple tools to assess outcomes is necessary and important. At the very least, the clinician should use a general health survey and a second scale to measure specific results of the disease, injury, or condition.
When choosing the right assessment tool, the surgeon or other health care clinician must keep in mind several factors. Is it relevant to the patient? Is it reliable and valid? Is it easy to administer, score, and interpret? Is it responsive? In other words, can it detect a change (improvement, decline) when it occurs?
With dozens and dozens of tests available, it may be best to stick with the more commonly used, researched, and recognized scales presented in this review article. Advantages and disadvantages of each scale are presented, along with suggestions for scale selection.
For example, it may be helpful to match the patient's goals with scales that provide a way to tell whether or not the goal(s) have been met. A different tool may be used with athletes who have higher expectations than an older adult who just wants to be able to walk again.
The concern over late complications such as osteoarthritis suggests the need to conduct a baseline exam and repeat measures during follow-up. The author suggests that all patients with ACL injuries should complete some type of joint specific and activity rating scale. The Tegner Activity Level Scale and the Marx Activity Level Scale may work best for this. The Marx Activity Level Scale is also useful for nonathletes as it measures function rather than sports activity.
The changes that are occurring in measuring the results of treatment for knee injuries are placing more of an emphasis on global (overall) assessment. Scales used can assess both recovery from the knee injury and effect of specific treatments applied. Including patient quality of life and satisfaction in the evaluation process rounds out the results. All of these measures should be used to justify treatment selected or to modify treatment when expected results are not forthcoming.
Rick W. Wright, MD. Knee Injury Outcomes Measures. In Journal of the American Academy of Orthopaedic Surgeons. January 2009. Vol. 17. No. 1. Pp. 31-39.
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