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Properties of the Patient Administered Questionnaires
The Journal of Arthroplasty Vol. 27 No. 4 2012
Properties of the Patient Administered Questionnaires New Scales Measuring Physical and Psychological Symptoms of Hip and Knee Disorders Carol A. Mancuso, MD,* Amar S. Ranawat, MD,y Morteza Meftah, MD,y Trevor W. Koob, BA,y and Chitranjan S. Ranawat, MDy
Abstract: The Patient Administered Questionnaires (PAQ) incorporate physical and psychological symptoms into one scale and permit more comprehensive self-reports for hip and knee disorders. We tested the psychometric properties of the PAQ-Hip and PAQ-Knee. Correlations between baseline PAQ-Hip and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were .39 to .72 (n = 102), .39 to .69 for score change (n = 68 post-total hip arthroplasty), and most κ values N .60 (n = 50). Correlations between baseline PAQ-Knee and WOMAC were .35 to .64 (n = 100), .62 to .79 for score change (n = 43 post–total knee arthroplasty), and most κ values N.60 (n = 51). For both scales, effect sizes were higher than for the WOMAC, and there was modest correlation between physical and psychological questions, indicating these concepts are not completely interchangeable. Thus, the PAQ scales have strong psychometric properties and are unique compared with existing scales by including physical and psychological symptoms. Keywords: questionnaire, scale, psychological, hip, knee. © 2012 Elsevier Inc. All rights reserved.
Patients' perspectives are major considerations in choosing elective treatments for hip and knee disorders [1]. These perspectives can be efficiently and systematically obtained through self-report questionnaires or scales that have response options that can be quantified to generate scores [2-10]. Scores reflect current condition when used cross-sectionally and change in condition when used longitudinally [2,4,5,8]. These scales often are completed preoperatively and postoperatively and changes in scores are considered important patientcentered outcomes [2,8]. During the past several decades, multiple scales have been developed for hip and knee injuries and arthritis [3-11]. Most of the earlier scales included patients' assessments of pain and function as well as orthopedic surgeons' assessments of range of motion, deformity, and From the *Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; and yHospital for Special Surgery, New York, New York. Supplementary material available at www.arthroplastyjournal.org. Submitted March 4, 2011; accepted July 30, 2011. The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.07.014. Reprint requests: Carol A. Mancuso, MD, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. © 2012 Elsevier Inc. All rights reserved. 0883-5403/2704-0014$36.00/0 doi:10.1016/j.arth.2011.07.014
muscle strength and power [12-17]. More recent scales focus exclusively on patients' reports of physical symptoms and function. Although improving physical health is the major goal in treating hip and knee disorders, improving psychological well-being and maximizing satisfaction also are salient issues for patients [1-3,18-20]. To date, however, these issues have not been included with physical symptoms and function in self-report scales for hip and knee disorders. Including all these items in a single scale would acknowledge the unique contributions of each item and would allow patients to provide a more comprehensive picture of their overall condition. The goals of this study were to test the psychometric properties of 2 new self-report scales for hip and knee conditions that include physical symptoms, function, psychological symptoms, and satisfaction with clinical status.
Materials and Methods This study was approved by the Institutional Review Boards at Hospital for Special Surgery and Lenox Hill Hospital in New York City, and all patients provided written informed consent. There was no external funding source for this study. Separate scales were developed for hip and knee conditions—the Patient Administered Questionnaire (PAQ)-Hip and the PAQ-
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576 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 Knee—and each was tested in 3 phases for validity, reliability, and responsiveness. PAQ-Hip Development of the PAQ-Hip Questions for the PAQ-Hip were composed based on well-known clinical features of hip disorders described in scholarly reviews and used to varying degrees in other scales (Fig. 1; available online at www. arthroplastyjournal.org) [21,22]. To balance comprehensiveness and brevity, we focused on 2 domains, pain and function, and included some functions that indirectly address stiffness. For each hip, patients are asked about pain severity, with 5 response options ranging from none to excruciating; duration of pain, with 5 options ranging from never to always; and location of pain, such as the buttocks, groin, or thigh. Patients are asked how far they can walk (5 options, unlimited to housebound) and how much they limp (5 options, never to always). Assessment of function includes rating how much difficulty they have putting on shoes and socks, maintaining personal care, doing household activities, getting in and out of a car, going upstairs and downstairs, and how often they are limited in social and recreational or sports activities, which they are asked to describe. Responses for each function question range from no difficulty or never limited to unable to do or always limited on 5-point scales. Patients are asked 2 questions about their psychological state, specifically how often does hip pain influence their sense of well-being, with 5 response options ranging from never to always, and how satisfied are they with their ability to use their hip on a 10-point scale ranging from unsatisfied to fully satisfied. The PAQHip has 26 questions (Table 1), of which 17 are weighed and summed to generate an overall score that ranges from 0 (best condition) to 100 (worst condition) (Fig. 2; available online at www.arthroplastyjournal.org). The unscored questions address patient-specific recreational
Table 1. Number of Questions and Allotted Points for the PAQ-Hip and the PAQ-Knee PAQ-Hip
Items Pain Walk/limp * Function Psychological well-being Satisfaction with current condition Total
PAQ-Knee
Maximum Maximum Number of Possible Number of Possible Questions Points Questions Points 6 2 7 1
34 12 36 8
6 1 9 1
34 8 40 8
1
10
1
10
17
100
18
100
* Question about limp is not scored in PAQ-Knee, but 2 additional questions about function related to kneeling and squatting are scored.
or sports activities and are not included in the scoring because they are not uniformly applicable to all patients. They are included in the questionnaire, however, because they are useful during clinical discussions with patients. Phase 1: Validity Testing Validity is the ability of a scale to measures what it is suppose to and is ascertained by comparing it to a criterion standard [4]. The validity of the PAQ-Hip was measured by comparing it with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a well-established scale with 24 questions in 3 subscales measuring pain, stiffness, and function of the hip and knee [23]. A single overall score is usually not reported for the WOMAC; instead for each subscale, a score is generated ranging from 0 (best condition) to 100 (worst condition). For this study, 102 patients presenting to the practices of 3 orthopedic surgeons completed the PAQHip and the WOMAC at their first office visit. Consecutive patients were enrolled until PAQ-Hip scores were obtained that spanned the possible range of scores represented by the PAQ-Hip. The PAQ-Hip and the WOMAC were both self-administered. Phase 2: Reliability Testing Test-retest reliability, or repeatability, is the ability of a scale to obtain the same responses when administered twice over a brief interval of time during which there has been no change in clinical condition [4,8]. The reliability of the PAQ-Hip was tested in another consecutive sample of 50 patients with hip symptoms from the same orthopedic practices. This is a standard sample size for retest assessments and corresponds to projected reliability coefficient of .9, α of .05, β of .2, and 2 measurements per subject [24]. Patients completed the PAQ-Hip on 2 occasions. First, patients completed the scale during an in-person interview during their first office visit. Then several days later, patients were given the scale again during a telephone interview. This time interval was short enough so that there were no interim changes in clinical condition and long enough to minimize recollection of responses from the first administration [8]. Participants selected for this phase were a convenience sample of patients scheduled to undergo arthroplasty and no treatment or intervention was instituted between interviews. Phase 3: Responsiveness Testing Responsiveness is the ability of a scale to reflect direction and magnitude of change when the clinical condition has changed due to treatment or natural course [2,4,8]. For this study, responsiveness was ascertained with a subsample of 68 patients from phase 1. These patients were selected because they subsequently had arthroplasty and completed the PAQ-Hip
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Table 2. Baseline, Postoperative, and Changes in Scores for PAQ and WOMAC Scales Hip
PAQ Mean score ± SD * Score range * Cronbach α † WOMAC Pain Mean score ± SD * Score range * Stiffness Mean score ± SD * Score range * Function Mean score ± SD * Score range *
Knee
Baseline (n = 102)
Postoperative (n = 68)
Baseline to Postoperative Change (n = 68)
Baseline (n = 100)
Postoperative (n = 43)
Baseline to Postoperative Change (n = 43)
54 ± 14 15 to 80 .80
19 ± 14 0 to 58 .87
38 ± 15 ‡ 10 to 65 –
53 ± 16 15 to 91 .85
30 ± 16 3 to 64 .87
29 ± 18 ‡ −13 to 65 –
49 ± 17 10 to 100
11 ± 16 0 to 100
37 ± 18 ‡ −35 to 75
46 ± 19 0 to 95
19 ± 14 0 to 50
28 ± 18 ‡ −10 to 70
51 ± 24 0 to 100
24 ± 22 0 to 100
31 ± 30 ‡ −50 to 100
52 ± 23 0 to 100
33 ± 20 0 to 63
20 ± 25 ‡ −38 to 75
50 ± 18 10 to 100
14 ± 14 0 to 75
37 ± 20 ‡ −13 to 85
46 ± 20 6 to 100
20 ± 15 0 to 56
28 ± 19 ‡ −13 to 84
* Possible range 0 to 100; higher value indicates worse status. Possible range 0 to 1; higher value indicates better correlation. ‡ Paired t test, P b .0001. †
and the WOMAC during a postoperative visit that occurred at least 6 months later. PAQ-Knee Development of the PAQ-Knee The PAQ-Knee also was developed based on wellknown clinical features and tested in a similar fashion to the PAQ-Hip (Fig. 3; available online at www. arthroplastyjournal.org) [25,26]. For each knee, patients are asked to rate the severity, duration, and location of pain, such as the front or back, or the inner or outer parts of the knee. Walking is assessed by asking patients how far they can walk. Function is assessed for going upstairs and downstairs, putting on shoes and socks, maintaining personal care, doing household activities, getting in and out of a car, kneeling, squatting, and participating in social and recreational or sports activities. Psychological well-being and satisfaction are assessed with similar questions as the PAQHip. The PAQ-Knee has 29 questions (Table 1), of which 18 are weighed and summed to generate an overall score that ranges from 0 (best condition) to 100 (worst condition) (Fig. 4; available online at www. arthroplastyjournal.org). Unscored questions address patient-specific recreational or sports activities, difficulty sitting cross-legged, and whether there are clicking or snapping sounds from the knee. The point assignment for the PAQ-Knee (Table 1) is slightly different compared with the PAQ-Hip because 2 additional function items are scored for the knee. Phase 1: Validity Testing The validity of the PAQ-Knee was ascertained by comparing it with the WOMAC. For this study, 100 consecutive patients with a spectrum of knee symptoms
and functional limitations presenting to the practices of 3 orthopedic surgeons completed the PAQ-Knee and WOMAC during their first office visit. Both questionnaires were self-administered. Phase 2: Reliability Testing Test-retest reliability was assessed with another sample of 51 consecutive patients who completed the PAQ-Knee on 2 occasions, specifically, during an in-person interview during their first office visit and then again during a telephone interview several days later. Participants selected for this phase were a convenience sample of patients scheduled to undergo arthroplasty and no treatment or intervention was instituted between interviews. Phase 3: Responsiveness Testing Responsiveness was ascertained with a subsample of 43 patients from phase 1. These patients were selected because they subsequently had arthroplasty and completed the PAQ-Knee and the WOMAC during a postoperative visit that occurred at least 6 months later. Statistical Methods Similar analyses were carried out for the PAQ-Hip and PAQ-Knee. To ascertain validity, a total score for each PAQ scale was calculated and compared with each WOMAC subscale score with Pearson correlation coefficients. For each PAQ scale, a subscore also was calculated from the physical condition questions, and this was compared with responses from the well-being question and the satisfaction question in separate analyses. As a measure of internal validity, the Cronbach α coefficient was calculated, which summarizes correlations of all questions within a scale [4,8]. The higher the coefficient (possible range 0-1) the more likely the scale addresses characteristics of a specific condition [4,8].
578 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 Test-retest reliability was ascertained by measuring agreement or concordance of responses. Agreement was measured with the κ statistic for categorical data (ie, questions about location of pain) and with the weighted κ statistic for Likert data (ie, questions about walking, function, and severity and frequency of pain) [27]. κ and weighted κ values can range from 1 (perfect agreement), to 0 (agreement no better than chance), to −1 (perfect disagreement). By convention, a κ or weighted κ value of 0 to .3 is slight to fair agreement, .4 to .6 is moderate agreement, and .7 to .9 is substantial agreement [27]. For continuous data (ie, the satisfaction question and the PAQ total score), agreement was measured with the intraclass correlation coefficient, which similarly can range from −1 to 1 [28]. Within-patient changes in baseline to postoperative PAQ and WOMAC scores were calculated and compared with paired t tests. Comparisons between scales were made with Pearson correlation coefficients to ascertain responsiveness. Effect sizes, defined as the difference in baseline and postoperative scores divided by the SD of the baseline score, also were calculated [4,29]. Effect sizes represent magnitude of change expressed as a standardized value and can be compared between different scales. The scale with the higher effect size captures a greater magnitude of change and is considered more responsive [29]. All analyses were carried out in SAS (SAS, Cary, NC) [30].
Results PAQ-Hip Phase 1: Validity Testing The 102 patients who participated in the validity testing phase had a mean age of 62 ± 12 years, 58% were men, all had a diagnosis of osteoarthritis, and 79% went on to total hip arthroplasty. The PAQ-Hip required less than 5 minutes to complete, and all patients answered all questions. The PAQ-Hip mean total score was 54 ± 14, with a wide range of 15 to 80 (Table 2). This mean score was in the middle of possible scores, and there were no floor or ceiling effects, meaning no patients had the minimum or maximum possible scores at presentation. Thus, there was ample room for patients to improve (ie, have a subsequent lower score) or to get worse (ie, have a subsequent higher score). The PAQHip was internally consistent with a Cronbach α value
of .80. Seventy percent of patients rated that their hip influenced their sense of well-being frequently or always, and the mean satisfaction rating was 8.7 (10 = unsatisfied). The correlation coefficient between the subscore of the physical condition questions and the well-being question was .32, and the correlation coefficient between the subscore of the physical condition questions and the satisfaction question was .43. The WOMAC mean scores also were in the middle range, but there were ceiling effects (worst condition) for all subscales (Table 2). The correlation coefficients between the PAQ-Hip and WOMAC scores ranged from .39 for stiffness to .72 for function (Table 3) (Fig. 5). This is consistent with the fact that the majority of PAQ-Hip questions relate to function and indirectly address stiffness. PAQ-Hip Phase 2: Reliability Testing The 50 patients who participated in the reliability testing phase had a mean age of 61 ± 14 years, 12 (24%) were men, 39 (78%) had a diagnosis of osteoarthritis, 5 (10%) had avascular necrosis, and 6 (12%) had other diagnoses, primarily labral and inflammatory conditions. The mean number of days between the first and second administrations of the PAQ-Hip was 4 days, range 3 to 5 days, and all patients completed all questions both times. κ and weighted κ values ranged from .51 to .92, with most values greater than .60 (Table 4). The intraclass correlation coefficient for the satisfaction question was .94. PAQ-Hip total scores for the first and second administrations were both 51 ± 17 and the intraclass correlation coefficient was .95. PAQ-Hip Phase 3: Responsiveness Testing Sixty-eight patients from phase 1 completed the PAQHip and the WOMAC postoperatively at a mean of 15 ± 6 months. These patients had a postoperative PAQ-Hip mean score of 19 ± 14 and a mean baseline to postoperative change in score of 38 ± 15 (Table 2). Thus, change in score was marked and in the direction expected (ie, improvement). Similar baseline to postoperative changes in scores were noted for the WOMAC subscales (Table 2). Correlation coefficients for changes in scores between PAQ-Hip and WOMAC subscales ranged from .27 for stiffness to .69 for function (Table 3). Effect sizes were 2.7 for the PAQ-Hip and 2.2 for the pain, 1.3 for the stiffness, and 2.1 for the function subscales of the WOMAC.
Table 3. Correlation coefficients between PAQ and WOMAC scales for baseline, postoperative, and changes in scores * PAQ-Hip
PAQ-Knee
WOMAC
Baseline (n = 102)
Postoperative (n = 68)
Baseline to Postoperative Change (n = 68)
Baseline (n = 100)
Postoperative (n = 43)
Baseline to Postoperative Change (n = 43)
Pain Stiffness Function
.51 .39 .72
.65 .51 .69
.39 .27 .69
.50 .35 .64
.61 .50 .71
.66 .62 .79
* Possible range 0 to 1; higher value indicates better correlation.
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the well-being and satisfaction questions were .67 and .43, respectively. PAQ-Knee Phase 1: Validity Testing The 100 patients who participated in the validity testing phase had a mean age of 67 ± 11 years, 56% were men, all had a diagnosis of osteoarthritis, and 48% went on to total knee arthroplasty. The PAQ-Knee required less than 5 minutes to complete and all patients answered all questions. The PAQ-Knee mean total score was 53 ± 16, with a wide range of 15 to 91 (Table 2). This mean score was in the middle of possible scores and there were no floor or ceiling effects. The PAQ-Knee was internally consistent with a Cronbach α coefficient of .85. Fifty-eight percent of patients rated that their knee influenced their sense of well-being frequently or always, and the mean satisfaction rating was 8.0 (10 = unsatisfied). The correlation coefficient between the subscore of the physical condition questions and the well-being question was .50, and the correlation coefficient between the subscore of the physical condition questions and the satisfaction question was .56. The WOMAC mean scores also were in the middle range (Table 2). The correlation coefficients between the PAQ-Knee and WOMAC scores ranged from .35 to .64 at baseline (Fig. 6) and from .50 to .71 postoperatively, with higher correlations for the function subscale (Table 3). PAQ-Knee Phase 2: Reliability Testing The 51 patients who participated in the reliability testing phase had a mean age of 66 ± 9 years, 20 (39%) Table 4. Weighted κ Values for Administrations of the PAQ Scales Scale Item
Fig. 5. (A-C) Baseline PAQ-Hip and WOMAC scores.
When the psychological questions were considered individually, each showed marked improvement. Before surgery, 72% of patients reported their hip influenced their well-being frequently or always, and this decreased to 7% after surgery (P = .02). Before surgery, the mean value for satisfaction was 9.1 (10 = unsatisfied), and this improved to 1.5 (0 = fully satisfied) after surgery (P b .0001). Correlation coefficients between the PAQ-Hip postoperative physical condition subscore questions and
Right-side pain severity Right-side pain frequency Right-side pain location † Left-side pain severity Left-side pain frequency Left-side pain location † Limp Put on shoes/socks Personal care Household activities Get in and out of car Kneel Squat Go upstairs and downstairs Distance can walk Performance of activities Social activities Sense of well-being Satisfaction with use of hip (knee) ‡ Total score ‡
First
and
Second
PAQ-Hip *
PAQ-Knee *
.84 .53 .87 .51 .72 .84 .79 .58 .63 .67 .71 – – .80 .92 .69 .77 .75 .94 .95
.80 .64 .64 .67 .59 .73 – .64 .54 .67 .81 .64 .77 .85 .85 .76 .76 .75 .84 .98
* Range −1 perfect disagreement, 1 perfect agreement. † κ value. ‡ Intraclass correlation coefficient.
580 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 administrations, respectively, and the intraclass correlation coefficient was .98. PAQ-Knee Phase 3: Responsiveness Testing Forty-three patients from phase 1 completed the PAQ-Knee and the WOMAC postoperatively at a mean of 13 ± 4 months. These patients had a postoperative PAQ-Knee mean score of 30 ± 16 and a mean baseline to postoperative change in score of 29 ± 18 (Table 2). Thus, change was marked and in the direction expected. Correlation coefficients for changes in scores between the PAQ-Knee and WOMAC subscales ranged from .62 for stiffness to .79 for function (Table 3). Effect sizes were 1.8 for the PAQ-Knee and 1.5 for the pain, 0.9 for the stiffness, and 1.4 for the function subscales of the WOMAC. When the psychological questions were considered individually, each showed marked improvement. Before surgery, 63% of patients reported their knee influenced their well-being frequently or always, and this decreased to 19% after surgery, although this was not significant (P N .05). Before surgery, the mean value for satisfaction was 9.0 (10 = unsatisfied), and this improved to 2.5 (0 = fully satisfied) after surgery (P b .0001). Correlation coefficients between the PAQ-Knee postoperative physical condition subscale questions and the well-being and satisfaction questions were .58 and .60, respectively.
Discussion
Fig. 6. (A-C): Baseline PAQ-Knee and WOMAC scores.
were men, and 50 had a diagnosis of osteoarthritis and 1 had avascular necrosis. The mean number of days between the first and second administrations of the PAQ-Knee was 4 days, range 4 to 5 days, and all patients completed all questions both times. κ and weighted κ values ranged from .54 to .85, with most values greater than .60 (Table 4). The intraclass correlation coefficient for the satisfaction question was .84. PAQ-Knee total scores were 47 ± 18 and 47 ± 20 for the first and second
The PAQ-Hip and PAQ-Knee scales have test-retest reliability and are valid and responsive compared with the WOMAC subscales. The observed differences between the PAQ and the WOMAC scales most likely are due to unique variables in the PAQ that are not addressed by the WOMAC, such as psychological wellbeing, satisfaction, location of pain, and separate assessments for left and right-sided pain. Thus, the PAQ scales measure some similar variables and at the same time capture new variables that are not addressed by the WOMAC. These variables also are not included in other widely used hip and knee scales [4-9]. In addition, the PAQ scales have excellent effect sizes compared with the WOMAC and to other scales reported in the literature and therefore would be useful in research studies aimed at assessing treatment effectiveness [2]. Finally, the PAQ scales are brief, easy to administer, and well-received by patients in both selfadministered and interview formats. Traditionally, scales that record clinical status include both patient and physician assessments [12-17]. These scales are comprehensive in their ability to provide patients' reports of symptoms and function as well as physicians' measurements of physical condition. However, these scales are limited because interrater reliability among physicians needs to be established and
Properties of PAQ Mancuso et al
physical examinations are required. Thus, patients' and physicians' assessments are now usually measured separately, and scales that capture patients' assessments have become cornerstones of clinical evaluations. A unique feature of the PAQ scales is the inclusion of psychological well-being. In our analysis, there was an association between the well-being question and the physical condition questions; however, the correlation was modest. This indicates that these concepts are not interchangeable and that patients' perspectives extend beyond pain and physical function to include a psychological component [1,31]. Some psychological considerations that may be salient include feelings of dependence, disability, and regret at the loss of valued activities [1,18-20]. Because these feelings may not be in proportion to physical symptoms, recovery in one aspect may not necessarily result in recovery in the other [1]. Thus, physical symptoms are not proxies for psychological well-being, and these concepts should be measured independently. Another unique feature of the PAQ scales is the inclusion of a question about satisfaction with the ability to use the hip or knee. Similar to the analysis with wellbeing, satisfaction was only modestly correlated with physical condition, and thus also represents an aspect of patients' perspectives that extends beyond physical symptoms. Potential contributors to ratings of satisfaction include personal and process variables such as patients' personalities, expectations, and perceived quality of medical care received [32-34]. Another subtle feature of the PAQ satisfaction question is that it focuses on current clinical condition, as opposed to satisfaction with the outcome of treatment. This latter topic is a popular patient-centered variable in orthopedics and is most often reported as an overall stand-alone variable [32,35,36]. The satisfaction addressed in the PAQ scales, however, more closely reflects patients' willingness to accept their current condition, which probably integrates both physical and psychological considerations. Including this type of satisfaction makes the PAQ scales better able to capture how patients' view the overall effects of their hip or knee on their current life. Of course, when followed longitudinally, change in pretreatment to posttreatment PAQ satisfaction can be considered a measure of effectiveness or outcome from the patient's point of view. The PAQ scales also provide more comprehensive assessments of joint pain compared with other frequently used scales. Specifically, the PAQ scales incorporate severity, frequency, and location of pain in the total score, whereas most other scales do not. The PAQ scales also ask about bilateral pain and thus offer the opportunity to distinguish between marked pain in one joint and less notable, but still present, pain in the other joint. This is relevant for patients undergoing unilateral surgery because postoperatively pain most
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likely will be greatly improved in the operated joint but will not be diminished in the contralateral nonoperated joint. Bilateral symptoms are addressed seamlessly in the PAQ scales without unduly increasing the length of the questionnaires. Previous studies showed the effectiveness of measuring patient-specific variables in the assessment of hip and knee conditions. These variables are obtained by asking patients what aspects of their condition are particularly bothersome and what restrictions are most important to them [6,37-39]. When followed longitudinally, these variables are often the most strongly associated with ratings of treatment success. To include these types of variables in the PAQ, patients are encouraged to volunteer activities they are restricted in because of hip and knee symptoms. Although a single question about performance of these activities is included in the scoring of the PAQ, a patient-specific list can be generated and used to discuss current restrictions and possible future improvements. This study has several limitations. First, it was conducted in tertiary care orthopedic referral centers and may not be generalizable to patients in other settings. However, the concepts measured by the PAQ scales have been shown in diverse studies to apply to most patients with hip and knee osteoarthritis presenting to orthopedic surgeons. Second, the majority of patients underwent arthroplasty. Thus, the PAQ scales were not adequately tested in patients with other diagnoses and those treated nonsurgically. Third, although the majority of patients were enrolled consecutively, convenience samples were used in all 3 phases. In summary, the PAQ-Hip and the PAQ-Knee are valid, reliable, and responsive and are well-received by patients. The PAQ scales have several advantages over existing scales, specifically the inclusion of psychological well-being, satisfaction with clinical condition, and assessments of bilateral pain. Along with functional limitations, all these items are incorporated into a single overall score. Thus, the PAQ scales provide a comprehensive picture of current condition from the patient's perspective and, when used longitudinally, provide an effective measure of change in condition. These properties make the PAQ scales useful for research and clinical practice.
References 1. Salmon P, Hall GM, Peerbhoy D, et al. Recovery from hip and knee arthroplasty: patients' perspective on pain, function, quality of life, and well-being up to 6 months postoperatively. Arch Phys Med Rehabil 2001;82:360. 2. Wright JG, Young NL. A comparison of different indices of responsiveness. J Clin Epidemiol 1997;50:239. 3. Beaule PE, Dorey FJ, Hoke R, et al. The value of patient activity level in the outcome of total hip arthroplasty. J Arthroplasty 2006;21:547.
582 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 4. Dawson J, Fitzpatrick R, Carr A, et al. Questionnaire of the perceptions of patients about total hip replacement. J Bone Joint Surg 1996;78-B:185. 5. Johanson NA, Chalrson ME, Szatrowski TP, et al. A selfadministered hip-rating questionnaire for the assessment of outcome after total hip replacement. J Bone Joint Surg Am 1992;74-A:587. 6. Wright JG, Young NL, Waddell JP. The reliability and validity of the self-reported patient-specific index for total hip arthroplasty. J Bone Joint Surg 2000;82-A:829. 7. Noyes FR, McGinniss GH. Controversy about treatment of the knee and anterior cruciate laxity. Clin Ortho Relat Res 1985;198:61. 8. Irrgang JJ, Anderson AF. Development and validation of health-related quality of life measures for the knee. Clin Ortho Relat Res 2002;402:95. 9. Snyder-Mackler L, Wainner RS, Fu FH, et al. Development of a patient-reported measure of function of the knee. J Bone Joint Surg 1998;80-A:1132. 10. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Ortho Relat Res 1985;198:43. 11. Brinker MR, Garcia R, Barrack RL, et al. An analysis of sports knee evaluation instruments. Am J Knee Surg 1999; 12:15. 12. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. J Bone Joint Surg 1969;51-A:737. 13. Lazansky MG. A method for grading hips. J Bone Joint Surg 1967;49-B:644. 14. D'Aubigne M, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg 1954;36-A:451. 15. Salvati EA, Wilson P. Long-term results of femoral-head replacement. J Bone Joint Surg 1973;55-A:516. 16. Kettelkamp DB, Thompson C. Development of a knee scoring scale. Clin Orthop Relat Res 1975;107:93. 17. Marshall JL, Fetto JF, Botero PM. Knee ligament injuries: a standardized evaluation method. Clin Orthop Relat Res 1977;123:115. 18. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients' expectations of knee surgery. J Bone Joint Surg 2001;83A:1005. 19. Mancuso CA, Sculco TP, Salvati EA. Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty 2003;18:872. 20. Mancuso CA, Altchek DW, Craig EV, et al. Patients' expectations of shoulder surgery. J Shoulder Elbow Surg 2002;11:541. 21. Harris WH, Sledge CB. Total hip and total knee replacement (first of two parts). N Engl J Med 1990;323:725.
22. Total hip replacement. NIH Consensus Development Panel on Total Hip Replacement. JAMA 1995;273:1950. 23. Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis. J Orthop Rheum 1988;1:95. 24. Donner A, Eliasziw M. Sample size requirements for reliability studies. Statistics in Medicine 1987;6:441. 25. Harris WH, Sledge CB. Total hip and total knee replacement (second of two parts). N Engl J Med 1990;323:802. 26. Leopold SS. Minimally invasive total knee arthroplasty for osteoarthritis. N Engl J Med 2009;360:1749. 27. Kramer MS, Feinstein AR. Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 1981;29: 111. 28. Shrout PF, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bulletin 1979;86:420. 29. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Medical Care 1989; 27:S178. 30. SAS user's guide: statistics. Version 5 ed. Cary, NC: SAS Institute; 1985. 31. Johnston M. Dimensions of recovery from surgery. Int Rev Appl Psychol 1984;33:505. 32. Bourne RB, Chesworth BM, Davis AM, et al. Patient satisfaction after total knee arthroplasty. Clin Orthop Relat Res 2010;468:57. 33. Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Science Med 2001;52:609. 34. Mancuso CA, Jout J, Salvati EA, et al. Fulfillment of patients' expectations of total hip arthroplasty. J Bone Joint Surg 2009;91-A:2073. 35. Mancuso CA, Salvati EA, Johanson NA, et al. Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty 1997;12:387. 36. Solomon DH, Bates DW, Horsky J, et al. Development and validation of a patient satisfaction scale for musculoskeletal care. Arthritis Care Res 1999;12:96. 37. Wright JG, Rudicel S, Feinstein AR. Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg 1994;76-B:229. 38. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med 1998;26:350. 39. Tugwell P, Bombardier C, Buchanan WW, et al. The MACTAR patient preference disability questionnaire—an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. J Rheumatol 1987;14:446.
Properties of PAQ Mancuso et al
Ranawat Orthopaedic Center PATIENT ADMINISTERED QUESTIONNAIRE - HIP Name: ___________________________
(Please circle your responses)
Fig. 1. PAQ-Hip.
Date: _________________
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Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - HIP Scoring Instructions Assign points as follows: Maximum Possible points
Question
Question-1: …..……………………………………………….……………………………...………..34 No pain = 0. Left hip pain: Location: Severity: Frequency:
only one location = 0; more than one location = 1. mild = 3; moderate = 6; severe = 9; excruciating = 12. rarely = 1; occasionally = 2; frequently = 3; always = 4.
Right hip pain: Location: Severity: Frequency:
only one location = 0; more than one location = 1. mild = 3; moderate = 6; severe = 9; excruciating = 12. rarely = 1; occasionally = 2; frequently = 3; always = 4.
Question-2:.…………………………………………………………………….……….………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4.
Question-3:…..………….…..……………….……………………………...…………….…...………16 Socks/shoes Personal care Household activities In/out of car
none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4.
Question-4:……………….…………………………………….………………….………..…………..8 none = 0; cane/crutch/banister = 2; two crutches = 4; walker/someone’s assistance = 6; unable = 8.
Question-5: ...………………………………………………………..……………….…………………8 unlimited = 0; more than 10 blocks = 2; 4-10 blocks = 4; 1-3 blocks = 6; housebound = 8.
Question-6 is not scored.
Question-7:……………………………………………...………………………………………………8 never = 0; rarely = 2; occasionally = 4; frequently = 6; always = 8.
Fig. 2. Scoring instructions for the PAQ-Hip.
Properties of PAQ Mancuso et al
Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - HIP Scoring Instructions: continued Assign points as follows: Maximum Possible points
Question
Question-8:………………………………………….….…………………………….…………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4. Question-9:……………………………………………………….……………………………………..8 never = 0; rarely = 2; occasionally = 4; frequently = 6; always = 8. Question-10:…………………………………………………………………………..………...……..10 Score in reverse order: if 0 circled, assign 10 points; if 1 circled, assign 9 points; if 2 circled, assign 8 points; if 3 circled, assign 7 points; if 4 circled, assign 6 points; if 5 circled, assign 5 points; if 6 circled, assign 4 points; if 7 circled, assign 3 points; if 8 circled, assign 2 points; if 9 circled, assign 1 point; if 10 circled, assign 0 points.
Sum all points to generate the total score. The score range is 0 to 100, lower score indicates better status. © 2010 Ranawat Orthopaedic PAQ-Hip-SI. All rights reserved.
Fig. 2. (continued )
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Fig. 3. PAQ-Knee.
Properties of PAQ Mancuso et al
Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - KNEE Scoring Instructions Assign points as follows: Maximum Possible points
Question
Question-1: …..……………………………………………….……………………………...………..34 No pain = 0. Left knee pain: Location: Severity: Frequency:
only one location = 0; more than one location = 1. mild = 3; moderate = 6; severe = 9; excruciating = 12. rarely = 1; occasionally = 2; frequently = 3; always = 4.
Right knee pain: Location: only one location = 0; more than one location = 1. Severity: mild = 3; moderate = 6; severe = 9; excruciating = 12. Frequency: rarely = 1; occasionally = 2; frequently = 3; always = 4.
Question-2 is not scored.
Question-3:…..………….…..……………….……………………………...…………….…...………24 Socks/shoes Personal care Household activities In/out of car Kneeling Squatting Sitting cross-legged
none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. is not scored.
Question-4:……………….…………………………………….………………….………..…………..8 none = 0; cane/crutch/banister = 2; two crutches = 4; walker/someone’s assistance = 6; unable = 8.
Question-5: ...………………………………………………………..……………….…………………8 unlimited = 0; more than 10 blocks = 2; 4-10 blocks = 4; 1-3 blocks = 6; housebound = 8.
Question-6 is not scored.
Question-7:……………………………………………...………………………………………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4.
Fig. 4. Scoring instructions for the PAQ-Knee.
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Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - KNEE Scoring Instructions: continued Assign points as follows: Maximum Possible points
Question
Question-8:………………………………………….….…………………………….…………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4. Question-9:……………………………………………………….……………………………………..8 never = 0; rarely = 2; occasionally = 4; frequently = 6; always = 8. Question-10:…………………………………………………………………………..………...……..10 Score in reverse order: if 0 circled, assign 10 points; if 1 circled, assign 9 points; if 2 circled, assign 8 points; if 3 circled, assign 7 points; if 4 circled, assign 6 points; if 5 circled, assign 5 points; if 6 circled, assign 4 points; if 7 circled, assign 3 points; if 8 circled, assign 2 points; if 9 circled, assign 1 point; if 10 circled, assign 0 points.
Sum all points to generate the total score. The score range is 0 to 100, lower score indicates better status.
© 2010 Ranawat Orthopaedic PAQ-Knee-SI. All rights reserved.
Fig. 4. (continued )
Properties of the Patient Administered Questionnaires New Scales Measuring Physical and Psychological Symptoms of Hip and Knee Disorders Carol A. Mancuso, MD,* Amar S. Ranawat, MD,y Morteza Meftah, MD,y Trevor W. Koob, BA,y and Chitranjan S. Ranawat, MDy
Abstract: The Patient Administered Questionnaires (PAQ) incorporate physical and psychological symptoms into one scale and permit more comprehensive self-reports for hip and knee disorders. We tested the psychometric properties of the PAQ-Hip and PAQ-Knee. Correlations between baseline PAQ-Hip and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were .39 to .72 (n = 102), .39 to .69 for score change (n = 68 post-total hip arthroplasty), and most κ values N .60 (n = 50). Correlations between baseline PAQ-Knee and WOMAC were .35 to .64 (n = 100), .62 to .79 for score change (n = 43 post–total knee arthroplasty), and most κ values N.60 (n = 51). For both scales, effect sizes were higher than for the WOMAC, and there was modest correlation between physical and psychological questions, indicating these concepts are not completely interchangeable. Thus, the PAQ scales have strong psychometric properties and are unique compared with existing scales by including physical and psychological symptoms. Keywords: questionnaire, scale, psychological, hip, knee. © 2012 Elsevier Inc. All rights reserved.
Patients' perspectives are major considerations in choosing elective treatments for hip and knee disorders [1]. These perspectives can be efficiently and systematically obtained through self-report questionnaires or scales that have response options that can be quantified to generate scores [2-10]. Scores reflect current condition when used cross-sectionally and change in condition when used longitudinally [2,4,5,8]. These scales often are completed preoperatively and postoperatively and changes in scores are considered important patientcentered outcomes [2,8]. During the past several decades, multiple scales have been developed for hip and knee injuries and arthritis [3-11]. Most of the earlier scales included patients' assessments of pain and function as well as orthopedic surgeons' assessments of range of motion, deformity, and From the *Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; and yHospital for Special Surgery, New York, New York. Supplementary material available at www.arthroplastyjournal.org. Submitted March 4, 2011; accepted July 30, 2011. The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.07.014. Reprint requests: Carol A. Mancuso, MD, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. © 2012 Elsevier Inc. All rights reserved. 0883-5403/2704-0014$36.00/0 doi:10.1016/j.arth.2011.07.014
muscle strength and power [12-17]. More recent scales focus exclusively on patients' reports of physical symptoms and function. Although improving physical health is the major goal in treating hip and knee disorders, improving psychological well-being and maximizing satisfaction also are salient issues for patients [1-3,18-20]. To date, however, these issues have not been included with physical symptoms and function in self-report scales for hip and knee disorders. Including all these items in a single scale would acknowledge the unique contributions of each item and would allow patients to provide a more comprehensive picture of their overall condition. The goals of this study were to test the psychometric properties of 2 new self-report scales for hip and knee conditions that include physical symptoms, function, psychological symptoms, and satisfaction with clinical status.
Materials and Methods This study was approved by the Institutional Review Boards at Hospital for Special Surgery and Lenox Hill Hospital in New York City, and all patients provided written informed consent. There was no external funding source for this study. Separate scales were developed for hip and knee conditions—the Patient Administered Questionnaire (PAQ)-Hip and the PAQ-
575
576 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 Knee—and each was tested in 3 phases for validity, reliability, and responsiveness. PAQ-Hip Development of the PAQ-Hip Questions for the PAQ-Hip were composed based on well-known clinical features of hip disorders described in scholarly reviews and used to varying degrees in other scales (Fig. 1; available online at www. arthroplastyjournal.org) [21,22]. To balance comprehensiveness and brevity, we focused on 2 domains, pain and function, and included some functions that indirectly address stiffness. For each hip, patients are asked about pain severity, with 5 response options ranging from none to excruciating; duration of pain, with 5 options ranging from never to always; and location of pain, such as the buttocks, groin, or thigh. Patients are asked how far they can walk (5 options, unlimited to housebound) and how much they limp (5 options, never to always). Assessment of function includes rating how much difficulty they have putting on shoes and socks, maintaining personal care, doing household activities, getting in and out of a car, going upstairs and downstairs, and how often they are limited in social and recreational or sports activities, which they are asked to describe. Responses for each function question range from no difficulty or never limited to unable to do or always limited on 5-point scales. Patients are asked 2 questions about their psychological state, specifically how often does hip pain influence their sense of well-being, with 5 response options ranging from never to always, and how satisfied are they with their ability to use their hip on a 10-point scale ranging from unsatisfied to fully satisfied. The PAQHip has 26 questions (Table 1), of which 17 are weighed and summed to generate an overall score that ranges from 0 (best condition) to 100 (worst condition) (Fig. 2; available online at www.arthroplastyjournal.org). The unscored questions address patient-specific recreational
Table 1. Number of Questions and Allotted Points for the PAQ-Hip and the PAQ-Knee PAQ-Hip
Items Pain Walk/limp * Function Psychological well-being Satisfaction with current condition Total
PAQ-Knee
Maximum Maximum Number of Possible Number of Possible Questions Points Questions Points 6 2 7 1
34 12 36 8
6 1 9 1
34 8 40 8
1
10
1
10
17
100
18
100
* Question about limp is not scored in PAQ-Knee, but 2 additional questions about function related to kneeling and squatting are scored.
or sports activities and are not included in the scoring because they are not uniformly applicable to all patients. They are included in the questionnaire, however, because they are useful during clinical discussions with patients. Phase 1: Validity Testing Validity is the ability of a scale to measures what it is suppose to and is ascertained by comparing it to a criterion standard [4]. The validity of the PAQ-Hip was measured by comparing it with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a well-established scale with 24 questions in 3 subscales measuring pain, stiffness, and function of the hip and knee [23]. A single overall score is usually not reported for the WOMAC; instead for each subscale, a score is generated ranging from 0 (best condition) to 100 (worst condition). For this study, 102 patients presenting to the practices of 3 orthopedic surgeons completed the PAQHip and the WOMAC at their first office visit. Consecutive patients were enrolled until PAQ-Hip scores were obtained that spanned the possible range of scores represented by the PAQ-Hip. The PAQ-Hip and the WOMAC were both self-administered. Phase 2: Reliability Testing Test-retest reliability, or repeatability, is the ability of a scale to obtain the same responses when administered twice over a brief interval of time during which there has been no change in clinical condition [4,8]. The reliability of the PAQ-Hip was tested in another consecutive sample of 50 patients with hip symptoms from the same orthopedic practices. This is a standard sample size for retest assessments and corresponds to projected reliability coefficient of .9, α of .05, β of .2, and 2 measurements per subject [24]. Patients completed the PAQ-Hip on 2 occasions. First, patients completed the scale during an in-person interview during their first office visit. Then several days later, patients were given the scale again during a telephone interview. This time interval was short enough so that there were no interim changes in clinical condition and long enough to minimize recollection of responses from the first administration [8]. Participants selected for this phase were a convenience sample of patients scheduled to undergo arthroplasty and no treatment or intervention was instituted between interviews. Phase 3: Responsiveness Testing Responsiveness is the ability of a scale to reflect direction and magnitude of change when the clinical condition has changed due to treatment or natural course [2,4,8]. For this study, responsiveness was ascertained with a subsample of 68 patients from phase 1. These patients were selected because they subsequently had arthroplasty and completed the PAQ-Hip
Properties of PAQ Mancuso et al
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Table 2. Baseline, Postoperative, and Changes in Scores for PAQ and WOMAC Scales Hip
PAQ Mean score ± SD * Score range * Cronbach α † WOMAC Pain Mean score ± SD * Score range * Stiffness Mean score ± SD * Score range * Function Mean score ± SD * Score range *
Knee
Baseline (n = 102)
Postoperative (n = 68)
Baseline to Postoperative Change (n = 68)
Baseline (n = 100)
Postoperative (n = 43)
Baseline to Postoperative Change (n = 43)
54 ± 14 15 to 80 .80
19 ± 14 0 to 58 .87
38 ± 15 ‡ 10 to 65 –
53 ± 16 15 to 91 .85
30 ± 16 3 to 64 .87
29 ± 18 ‡ −13 to 65 –
49 ± 17 10 to 100
11 ± 16 0 to 100
37 ± 18 ‡ −35 to 75
46 ± 19 0 to 95
19 ± 14 0 to 50
28 ± 18 ‡ −10 to 70
51 ± 24 0 to 100
24 ± 22 0 to 100
31 ± 30 ‡ −50 to 100
52 ± 23 0 to 100
33 ± 20 0 to 63
20 ± 25 ‡ −38 to 75
50 ± 18 10 to 100
14 ± 14 0 to 75
37 ± 20 ‡ −13 to 85
46 ± 20 6 to 100
20 ± 15 0 to 56
28 ± 19 ‡ −13 to 84
* Possible range 0 to 100; higher value indicates worse status. Possible range 0 to 1; higher value indicates better correlation. ‡ Paired t test, P b .0001. †
and the WOMAC during a postoperative visit that occurred at least 6 months later. PAQ-Knee Development of the PAQ-Knee The PAQ-Knee also was developed based on wellknown clinical features and tested in a similar fashion to the PAQ-Hip (Fig. 3; available online at www. arthroplastyjournal.org) [25,26]. For each knee, patients are asked to rate the severity, duration, and location of pain, such as the front or back, or the inner or outer parts of the knee. Walking is assessed by asking patients how far they can walk. Function is assessed for going upstairs and downstairs, putting on shoes and socks, maintaining personal care, doing household activities, getting in and out of a car, kneeling, squatting, and participating in social and recreational or sports activities. Psychological well-being and satisfaction are assessed with similar questions as the PAQHip. The PAQ-Knee has 29 questions (Table 1), of which 18 are weighed and summed to generate an overall score that ranges from 0 (best condition) to 100 (worst condition) (Fig. 4; available online at www. arthroplastyjournal.org). Unscored questions address patient-specific recreational or sports activities, difficulty sitting cross-legged, and whether there are clicking or snapping sounds from the knee. The point assignment for the PAQ-Knee (Table 1) is slightly different compared with the PAQ-Hip because 2 additional function items are scored for the knee. Phase 1: Validity Testing The validity of the PAQ-Knee was ascertained by comparing it with the WOMAC. For this study, 100 consecutive patients with a spectrum of knee symptoms
and functional limitations presenting to the practices of 3 orthopedic surgeons completed the PAQ-Knee and WOMAC during their first office visit. Both questionnaires were self-administered. Phase 2: Reliability Testing Test-retest reliability was assessed with another sample of 51 consecutive patients who completed the PAQ-Knee on 2 occasions, specifically, during an in-person interview during their first office visit and then again during a telephone interview several days later. Participants selected for this phase were a convenience sample of patients scheduled to undergo arthroplasty and no treatment or intervention was instituted between interviews. Phase 3: Responsiveness Testing Responsiveness was ascertained with a subsample of 43 patients from phase 1. These patients were selected because they subsequently had arthroplasty and completed the PAQ-Knee and the WOMAC during a postoperative visit that occurred at least 6 months later. Statistical Methods Similar analyses were carried out for the PAQ-Hip and PAQ-Knee. To ascertain validity, a total score for each PAQ scale was calculated and compared with each WOMAC subscale score with Pearson correlation coefficients. For each PAQ scale, a subscore also was calculated from the physical condition questions, and this was compared with responses from the well-being question and the satisfaction question in separate analyses. As a measure of internal validity, the Cronbach α coefficient was calculated, which summarizes correlations of all questions within a scale [4,8]. The higher the coefficient (possible range 0-1) the more likely the scale addresses characteristics of a specific condition [4,8].
578 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 Test-retest reliability was ascertained by measuring agreement or concordance of responses. Agreement was measured with the κ statistic for categorical data (ie, questions about location of pain) and with the weighted κ statistic for Likert data (ie, questions about walking, function, and severity and frequency of pain) [27]. κ and weighted κ values can range from 1 (perfect agreement), to 0 (agreement no better than chance), to −1 (perfect disagreement). By convention, a κ or weighted κ value of 0 to .3 is slight to fair agreement, .4 to .6 is moderate agreement, and .7 to .9 is substantial agreement [27]. For continuous data (ie, the satisfaction question and the PAQ total score), agreement was measured with the intraclass correlation coefficient, which similarly can range from −1 to 1 [28]. Within-patient changes in baseline to postoperative PAQ and WOMAC scores were calculated and compared with paired t tests. Comparisons between scales were made with Pearson correlation coefficients to ascertain responsiveness. Effect sizes, defined as the difference in baseline and postoperative scores divided by the SD of the baseline score, also were calculated [4,29]. Effect sizes represent magnitude of change expressed as a standardized value and can be compared between different scales. The scale with the higher effect size captures a greater magnitude of change and is considered more responsive [29]. All analyses were carried out in SAS (SAS, Cary, NC) [30].
Results PAQ-Hip Phase 1: Validity Testing The 102 patients who participated in the validity testing phase had a mean age of 62 ± 12 years, 58% were men, all had a diagnosis of osteoarthritis, and 79% went on to total hip arthroplasty. The PAQ-Hip required less than 5 minutes to complete, and all patients answered all questions. The PAQ-Hip mean total score was 54 ± 14, with a wide range of 15 to 80 (Table 2). This mean score was in the middle of possible scores, and there were no floor or ceiling effects, meaning no patients had the minimum or maximum possible scores at presentation. Thus, there was ample room for patients to improve (ie, have a subsequent lower score) or to get worse (ie, have a subsequent higher score). The PAQHip was internally consistent with a Cronbach α value
of .80. Seventy percent of patients rated that their hip influenced their sense of well-being frequently or always, and the mean satisfaction rating was 8.7 (10 = unsatisfied). The correlation coefficient between the subscore of the physical condition questions and the well-being question was .32, and the correlation coefficient between the subscore of the physical condition questions and the satisfaction question was .43. The WOMAC mean scores also were in the middle range, but there were ceiling effects (worst condition) for all subscales (Table 2). The correlation coefficients between the PAQ-Hip and WOMAC scores ranged from .39 for stiffness to .72 for function (Table 3) (Fig. 5). This is consistent with the fact that the majority of PAQ-Hip questions relate to function and indirectly address stiffness. PAQ-Hip Phase 2: Reliability Testing The 50 patients who participated in the reliability testing phase had a mean age of 61 ± 14 years, 12 (24%) were men, 39 (78%) had a diagnosis of osteoarthritis, 5 (10%) had avascular necrosis, and 6 (12%) had other diagnoses, primarily labral and inflammatory conditions. The mean number of days between the first and second administrations of the PAQ-Hip was 4 days, range 3 to 5 days, and all patients completed all questions both times. κ and weighted κ values ranged from .51 to .92, with most values greater than .60 (Table 4). The intraclass correlation coefficient for the satisfaction question was .94. PAQ-Hip total scores for the first and second administrations were both 51 ± 17 and the intraclass correlation coefficient was .95. PAQ-Hip Phase 3: Responsiveness Testing Sixty-eight patients from phase 1 completed the PAQHip and the WOMAC postoperatively at a mean of 15 ± 6 months. These patients had a postoperative PAQ-Hip mean score of 19 ± 14 and a mean baseline to postoperative change in score of 38 ± 15 (Table 2). Thus, change in score was marked and in the direction expected (ie, improvement). Similar baseline to postoperative changes in scores were noted for the WOMAC subscales (Table 2). Correlation coefficients for changes in scores between PAQ-Hip and WOMAC subscales ranged from .27 for stiffness to .69 for function (Table 3). Effect sizes were 2.7 for the PAQ-Hip and 2.2 for the pain, 1.3 for the stiffness, and 2.1 for the function subscales of the WOMAC.
Table 3. Correlation coefficients between PAQ and WOMAC scales for baseline, postoperative, and changes in scores * PAQ-Hip
PAQ-Knee
WOMAC
Baseline (n = 102)
Postoperative (n = 68)
Baseline to Postoperative Change (n = 68)
Baseline (n = 100)
Postoperative (n = 43)
Baseline to Postoperative Change (n = 43)
Pain Stiffness Function
.51 .39 .72
.65 .51 .69
.39 .27 .69
.50 .35 .64
.61 .50 .71
.66 .62 .79
* Possible range 0 to 1; higher value indicates better correlation.
Properties of PAQ Mancuso et al
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the well-being and satisfaction questions were .67 and .43, respectively. PAQ-Knee Phase 1: Validity Testing The 100 patients who participated in the validity testing phase had a mean age of 67 ± 11 years, 56% were men, all had a diagnosis of osteoarthritis, and 48% went on to total knee arthroplasty. The PAQ-Knee required less than 5 minutes to complete and all patients answered all questions. The PAQ-Knee mean total score was 53 ± 16, with a wide range of 15 to 91 (Table 2). This mean score was in the middle of possible scores and there were no floor or ceiling effects. The PAQ-Knee was internally consistent with a Cronbach α coefficient of .85. Fifty-eight percent of patients rated that their knee influenced their sense of well-being frequently or always, and the mean satisfaction rating was 8.0 (10 = unsatisfied). The correlation coefficient between the subscore of the physical condition questions and the well-being question was .50, and the correlation coefficient between the subscore of the physical condition questions and the satisfaction question was .56. The WOMAC mean scores also were in the middle range (Table 2). The correlation coefficients between the PAQ-Knee and WOMAC scores ranged from .35 to .64 at baseline (Fig. 6) and from .50 to .71 postoperatively, with higher correlations for the function subscale (Table 3). PAQ-Knee Phase 2: Reliability Testing The 51 patients who participated in the reliability testing phase had a mean age of 66 ± 9 years, 20 (39%) Table 4. Weighted κ Values for Administrations of the PAQ Scales Scale Item
Fig. 5. (A-C) Baseline PAQ-Hip and WOMAC scores.
When the psychological questions were considered individually, each showed marked improvement. Before surgery, 72% of patients reported their hip influenced their well-being frequently or always, and this decreased to 7% after surgery (P = .02). Before surgery, the mean value for satisfaction was 9.1 (10 = unsatisfied), and this improved to 1.5 (0 = fully satisfied) after surgery (P b .0001). Correlation coefficients between the PAQ-Hip postoperative physical condition subscore questions and
Right-side pain severity Right-side pain frequency Right-side pain location † Left-side pain severity Left-side pain frequency Left-side pain location † Limp Put on shoes/socks Personal care Household activities Get in and out of car Kneel Squat Go upstairs and downstairs Distance can walk Performance of activities Social activities Sense of well-being Satisfaction with use of hip (knee) ‡ Total score ‡
First
and
Second
PAQ-Hip *
PAQ-Knee *
.84 .53 .87 .51 .72 .84 .79 .58 .63 .67 .71 – – .80 .92 .69 .77 .75 .94 .95
.80 .64 .64 .67 .59 .73 – .64 .54 .67 .81 .64 .77 .85 .85 .76 .76 .75 .84 .98
* Range −1 perfect disagreement, 1 perfect agreement. † κ value. ‡ Intraclass correlation coefficient.
580 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 administrations, respectively, and the intraclass correlation coefficient was .98. PAQ-Knee Phase 3: Responsiveness Testing Forty-three patients from phase 1 completed the PAQ-Knee and the WOMAC postoperatively at a mean of 13 ± 4 months. These patients had a postoperative PAQ-Knee mean score of 30 ± 16 and a mean baseline to postoperative change in score of 29 ± 18 (Table 2). Thus, change was marked and in the direction expected. Correlation coefficients for changes in scores between the PAQ-Knee and WOMAC subscales ranged from .62 for stiffness to .79 for function (Table 3). Effect sizes were 1.8 for the PAQ-Knee and 1.5 for the pain, 0.9 for the stiffness, and 1.4 for the function subscales of the WOMAC. When the psychological questions were considered individually, each showed marked improvement. Before surgery, 63% of patients reported their knee influenced their well-being frequently or always, and this decreased to 19% after surgery, although this was not significant (P N .05). Before surgery, the mean value for satisfaction was 9.0 (10 = unsatisfied), and this improved to 2.5 (0 = fully satisfied) after surgery (P b .0001). Correlation coefficients between the PAQ-Knee postoperative physical condition subscale questions and the well-being and satisfaction questions were .58 and .60, respectively.
Discussion
Fig. 6. (A-C): Baseline PAQ-Knee and WOMAC scores.
were men, and 50 had a diagnosis of osteoarthritis and 1 had avascular necrosis. The mean number of days between the first and second administrations of the PAQ-Knee was 4 days, range 4 to 5 days, and all patients completed all questions both times. κ and weighted κ values ranged from .54 to .85, with most values greater than .60 (Table 4). The intraclass correlation coefficient for the satisfaction question was .84. PAQ-Knee total scores were 47 ± 18 and 47 ± 20 for the first and second
The PAQ-Hip and PAQ-Knee scales have test-retest reliability and are valid and responsive compared with the WOMAC subscales. The observed differences between the PAQ and the WOMAC scales most likely are due to unique variables in the PAQ that are not addressed by the WOMAC, such as psychological wellbeing, satisfaction, location of pain, and separate assessments for left and right-sided pain. Thus, the PAQ scales measure some similar variables and at the same time capture new variables that are not addressed by the WOMAC. These variables also are not included in other widely used hip and knee scales [4-9]. In addition, the PAQ scales have excellent effect sizes compared with the WOMAC and to other scales reported in the literature and therefore would be useful in research studies aimed at assessing treatment effectiveness [2]. Finally, the PAQ scales are brief, easy to administer, and well-received by patients in both selfadministered and interview formats. Traditionally, scales that record clinical status include both patient and physician assessments [12-17]. These scales are comprehensive in their ability to provide patients' reports of symptoms and function as well as physicians' measurements of physical condition. However, these scales are limited because interrater reliability among physicians needs to be established and
Properties of PAQ Mancuso et al
physical examinations are required. Thus, patients' and physicians' assessments are now usually measured separately, and scales that capture patients' assessments have become cornerstones of clinical evaluations. A unique feature of the PAQ scales is the inclusion of psychological well-being. In our analysis, there was an association between the well-being question and the physical condition questions; however, the correlation was modest. This indicates that these concepts are not interchangeable and that patients' perspectives extend beyond pain and physical function to include a psychological component [1,31]. Some psychological considerations that may be salient include feelings of dependence, disability, and regret at the loss of valued activities [1,18-20]. Because these feelings may not be in proportion to physical symptoms, recovery in one aspect may not necessarily result in recovery in the other [1]. Thus, physical symptoms are not proxies for psychological well-being, and these concepts should be measured independently. Another unique feature of the PAQ scales is the inclusion of a question about satisfaction with the ability to use the hip or knee. Similar to the analysis with wellbeing, satisfaction was only modestly correlated with physical condition, and thus also represents an aspect of patients' perspectives that extends beyond physical symptoms. Potential contributors to ratings of satisfaction include personal and process variables such as patients' personalities, expectations, and perceived quality of medical care received [32-34]. Another subtle feature of the PAQ satisfaction question is that it focuses on current clinical condition, as opposed to satisfaction with the outcome of treatment. This latter topic is a popular patient-centered variable in orthopedics and is most often reported as an overall stand-alone variable [32,35,36]. The satisfaction addressed in the PAQ scales, however, more closely reflects patients' willingness to accept their current condition, which probably integrates both physical and psychological considerations. Including this type of satisfaction makes the PAQ scales better able to capture how patients' view the overall effects of their hip or knee on their current life. Of course, when followed longitudinally, change in pretreatment to posttreatment PAQ satisfaction can be considered a measure of effectiveness or outcome from the patient's point of view. The PAQ scales also provide more comprehensive assessments of joint pain compared with other frequently used scales. Specifically, the PAQ scales incorporate severity, frequency, and location of pain in the total score, whereas most other scales do not. The PAQ scales also ask about bilateral pain and thus offer the opportunity to distinguish between marked pain in one joint and less notable, but still present, pain in the other joint. This is relevant for patients undergoing unilateral surgery because postoperatively pain most
581
likely will be greatly improved in the operated joint but will not be diminished in the contralateral nonoperated joint. Bilateral symptoms are addressed seamlessly in the PAQ scales without unduly increasing the length of the questionnaires. Previous studies showed the effectiveness of measuring patient-specific variables in the assessment of hip and knee conditions. These variables are obtained by asking patients what aspects of their condition are particularly bothersome and what restrictions are most important to them [6,37-39]. When followed longitudinally, these variables are often the most strongly associated with ratings of treatment success. To include these types of variables in the PAQ, patients are encouraged to volunteer activities they are restricted in because of hip and knee symptoms. Although a single question about performance of these activities is included in the scoring of the PAQ, a patient-specific list can be generated and used to discuss current restrictions and possible future improvements. This study has several limitations. First, it was conducted in tertiary care orthopedic referral centers and may not be generalizable to patients in other settings. However, the concepts measured by the PAQ scales have been shown in diverse studies to apply to most patients with hip and knee osteoarthritis presenting to orthopedic surgeons. Second, the majority of patients underwent arthroplasty. Thus, the PAQ scales were not adequately tested in patients with other diagnoses and those treated nonsurgically. Third, although the majority of patients were enrolled consecutively, convenience samples were used in all 3 phases. In summary, the PAQ-Hip and the PAQ-Knee are valid, reliable, and responsive and are well-received by patients. The PAQ scales have several advantages over existing scales, specifically the inclusion of psychological well-being, satisfaction with clinical condition, and assessments of bilateral pain. Along with functional limitations, all these items are incorporated into a single overall score. Thus, the PAQ scales provide a comprehensive picture of current condition from the patient's perspective and, when used longitudinally, provide an effective measure of change in condition. These properties make the PAQ scales useful for research and clinical practice.
References 1. Salmon P, Hall GM, Peerbhoy D, et al. Recovery from hip and knee arthroplasty: patients' perspective on pain, function, quality of life, and well-being up to 6 months postoperatively. Arch Phys Med Rehabil 2001;82:360. 2. Wright JG, Young NL. A comparison of different indices of responsiveness. J Clin Epidemiol 1997;50:239. 3. Beaule PE, Dorey FJ, Hoke R, et al. The value of patient activity level in the outcome of total hip arthroplasty. J Arthroplasty 2006;21:547.
582 The Journal of Arthroplasty Vol. 27 No. 4 April 2012 4. Dawson J, Fitzpatrick R, Carr A, et al. Questionnaire of the perceptions of patients about total hip replacement. J Bone Joint Surg 1996;78-B:185. 5. Johanson NA, Chalrson ME, Szatrowski TP, et al. A selfadministered hip-rating questionnaire for the assessment of outcome after total hip replacement. J Bone Joint Surg Am 1992;74-A:587. 6. Wright JG, Young NL, Waddell JP. The reliability and validity of the self-reported patient-specific index for total hip arthroplasty. J Bone Joint Surg 2000;82-A:829. 7. Noyes FR, McGinniss GH. Controversy about treatment of the knee and anterior cruciate laxity. Clin Ortho Relat Res 1985;198:61. 8. Irrgang JJ, Anderson AF. Development and validation of health-related quality of life measures for the knee. Clin Ortho Relat Res 2002;402:95. 9. Snyder-Mackler L, Wainner RS, Fu FH, et al. Development of a patient-reported measure of function of the knee. J Bone Joint Surg 1998;80-A:1132. 10. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Ortho Relat Res 1985;198:43. 11. Brinker MR, Garcia R, Barrack RL, et al. An analysis of sports knee evaluation instruments. Am J Knee Surg 1999; 12:15. 12. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. J Bone Joint Surg 1969;51-A:737. 13. Lazansky MG. A method for grading hips. J Bone Joint Surg 1967;49-B:644. 14. D'Aubigne M, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg 1954;36-A:451. 15. Salvati EA, Wilson P. Long-term results of femoral-head replacement. J Bone Joint Surg 1973;55-A:516. 16. Kettelkamp DB, Thompson C. Development of a knee scoring scale. Clin Orthop Relat Res 1975;107:93. 17. Marshall JL, Fetto JF, Botero PM. Knee ligament injuries: a standardized evaluation method. Clin Orthop Relat Res 1977;123:115. 18. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients' expectations of knee surgery. J Bone Joint Surg 2001;83A:1005. 19. Mancuso CA, Sculco TP, Salvati EA. Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty 2003;18:872. 20. Mancuso CA, Altchek DW, Craig EV, et al. Patients' expectations of shoulder surgery. J Shoulder Elbow Surg 2002;11:541. 21. Harris WH, Sledge CB. Total hip and total knee replacement (first of two parts). N Engl J Med 1990;323:725.
22. Total hip replacement. NIH Consensus Development Panel on Total Hip Replacement. JAMA 1995;273:1950. 23. Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis. J Orthop Rheum 1988;1:95. 24. Donner A, Eliasziw M. Sample size requirements for reliability studies. Statistics in Medicine 1987;6:441. 25. Harris WH, Sledge CB. Total hip and total knee replacement (second of two parts). N Engl J Med 1990;323:802. 26. Leopold SS. Minimally invasive total knee arthroplasty for osteoarthritis. N Engl J Med 2009;360:1749. 27. Kramer MS, Feinstein AR. Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 1981;29: 111. 28. Shrout PF, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bulletin 1979;86:420. 29. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Medical Care 1989; 27:S178. 30. SAS user's guide: statistics. Version 5 ed. Cary, NC: SAS Institute; 1985. 31. Johnston M. Dimensions of recovery from surgery. Int Rev Appl Psychol 1984;33:505. 32. Bourne RB, Chesworth BM, Davis AM, et al. Patient satisfaction after total knee arthroplasty. Clin Orthop Relat Res 2010;468:57. 33. Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Science Med 2001;52:609. 34. Mancuso CA, Jout J, Salvati EA, et al. Fulfillment of patients' expectations of total hip arthroplasty. J Bone Joint Surg 2009;91-A:2073. 35. Mancuso CA, Salvati EA, Johanson NA, et al. Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty 1997;12:387. 36. Solomon DH, Bates DW, Horsky J, et al. Development and validation of a patient satisfaction scale for musculoskeletal care. Arthritis Care Res 1999;12:96. 37. Wright JG, Rudicel S, Feinstein AR. Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg 1994;76-B:229. 38. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med 1998;26:350. 39. Tugwell P, Bombardier C, Buchanan WW, et al. The MACTAR patient preference disability questionnaire—an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. J Rheumatol 1987;14:446.
Properties of PAQ Mancuso et al
Ranawat Orthopaedic Center PATIENT ADMINISTERED QUESTIONNAIRE - HIP Name: ___________________________
(Please circle your responses)
Fig. 1. PAQ-Hip.
Date: _________________
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Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - HIP Scoring Instructions Assign points as follows: Maximum Possible points
Question
Question-1: …..……………………………………………….……………………………...………..34 No pain = 0. Left hip pain: Location: Severity: Frequency:
only one location = 0; more than one location = 1. mild = 3; moderate = 6; severe = 9; excruciating = 12. rarely = 1; occasionally = 2; frequently = 3; always = 4.
Right hip pain: Location: Severity: Frequency:
only one location = 0; more than one location = 1. mild = 3; moderate = 6; severe = 9; excruciating = 12. rarely = 1; occasionally = 2; frequently = 3; always = 4.
Question-2:.…………………………………………………………………….……….………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4.
Question-3:…..………….…..……………….……………………………...…………….…...………16 Socks/shoes Personal care Household activities In/out of car
none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4.
Question-4:……………….…………………………………….………………….………..…………..8 none = 0; cane/crutch/banister = 2; two crutches = 4; walker/someone’s assistance = 6; unable = 8.
Question-5: ...………………………………………………………..……………….…………………8 unlimited = 0; more than 10 blocks = 2; 4-10 blocks = 4; 1-3 blocks = 6; housebound = 8.
Question-6 is not scored.
Question-7:……………………………………………...………………………………………………8 never = 0; rarely = 2; occasionally = 4; frequently = 6; always = 8.
Fig. 2. Scoring instructions for the PAQ-Hip.
Properties of PAQ Mancuso et al
Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - HIP Scoring Instructions: continued Assign points as follows: Maximum Possible points
Question
Question-8:………………………………………….….…………………………….…………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4. Question-9:……………………………………………………….……………………………………..8 never = 0; rarely = 2; occasionally = 4; frequently = 6; always = 8. Question-10:…………………………………………………………………………..………...……..10 Score in reverse order: if 0 circled, assign 10 points; if 1 circled, assign 9 points; if 2 circled, assign 8 points; if 3 circled, assign 7 points; if 4 circled, assign 6 points; if 5 circled, assign 5 points; if 6 circled, assign 4 points; if 7 circled, assign 3 points; if 8 circled, assign 2 points; if 9 circled, assign 1 point; if 10 circled, assign 0 points.
Sum all points to generate the total score. The score range is 0 to 100, lower score indicates better status. © 2010 Ranawat Orthopaedic PAQ-Hip-SI. All rights reserved.
Fig. 2. (continued )
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Fig. 3. PAQ-Knee.
Properties of PAQ Mancuso et al
Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - KNEE Scoring Instructions Assign points as follows: Maximum Possible points
Question
Question-1: …..……………………………………………….……………………………...………..34 No pain = 0. Left knee pain: Location: Severity: Frequency:
only one location = 0; more than one location = 1. mild = 3; moderate = 6; severe = 9; excruciating = 12. rarely = 1; occasionally = 2; frequently = 3; always = 4.
Right knee pain: Location: only one location = 0; more than one location = 1. Severity: mild = 3; moderate = 6; severe = 9; excruciating = 12. Frequency: rarely = 1; occasionally = 2; frequently = 3; always = 4.
Question-2 is not scored.
Question-3:…..………….…..……………….……………………………...…………….…...………24 Socks/shoes Personal care Household activities In/out of car Kneeling Squatting Sitting cross-legged
none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. none = 0; slight = 1; moderate = 2; great = 3; unable = 4. is not scored.
Question-4:……………….…………………………………….………………….………..…………..8 none = 0; cane/crutch/banister = 2; two crutches = 4; walker/someone’s assistance = 6; unable = 8.
Question-5: ...………………………………………………………..……………….…………………8 unlimited = 0; more than 10 blocks = 2; 4-10 blocks = 4; 1-3 blocks = 6; housebound = 8.
Question-6 is not scored.
Question-7:……………………………………………...………………………………………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4.
Fig. 4. Scoring instructions for the PAQ-Knee.
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Ranawat Orthopaedic Center © PATIENT ADMINISTERED QUESTIONNAIRE - KNEE Scoring Instructions: continued Assign points as follows: Maximum Possible points
Question
Question-8:………………………………………….….…………………………….…………………4 never = 0; rarely = 1; occasionally = 2; frequently = 3; always = 4. Question-9:……………………………………………………….……………………………………..8 never = 0; rarely = 2; occasionally = 4; frequently = 6; always = 8. Question-10:…………………………………………………………………………..………...……..10 Score in reverse order: if 0 circled, assign 10 points; if 1 circled, assign 9 points; if 2 circled, assign 8 points; if 3 circled, assign 7 points; if 4 circled, assign 6 points; if 5 circled, assign 5 points; if 6 circled, assign 4 points; if 7 circled, assign 3 points; if 8 circled, assign 2 points; if 9 circled, assign 1 point; if 10 circled, assign 0 points.
Sum all points to generate the total score. The score range is 0 to 100, lower score indicates better status.
© 2010 Ranawat Orthopaedic PAQ-Knee-SI. All rights reserved.
Fig. 4. (continued )