Development of a Patient-Reported Measure of Function of the Knee*

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Abstract

The purpose of the present study was to demonstrate the reliability, validity, and responsiveness of the Activities of Daily Living Scale of the Knee Outcome Survey, a patient-reported measure of functional limitations imposed by pathological disorders and impairments of the knee during activities of daily living. The study comprised 397 patients; 213 were male, 156 were female, and the gender was not recorded for the remaining twenty-eight. The mean age of the patients was 33.3 years (range, twelve to seventy-six years). The patients were referred to physical therapy because of a wide variety of disorders of the knee, including ligamentous and meniscal injuries, patellofemoral pain, and osteoarthrosis.The Activities of Daily Living Scale was administered four times during an eight-week period: at the time of the initial evaluation and after one, four, and eight weeks of therapy. Concurrent measures of function included the Lysholm Knee Scale and several global measures of function. The subjects also provided an assessment of the change in function, with responses ranging from greatly worse to greatly better, at one, four, and eight weeks. The Activities of Daily Living Scale was administered to an additional sample of fifty-two patients (thirty-two male and twenty female patients with a mean age of 31.6 years [range, fourteen to sixty-six years]) before and after treatment within a single day to establish test-retest reliability.Factor analysis revealed two dominant factors: one that reflected a combination of symptoms and functional limitations and the other, only symptoms. The internal consistency of the Activities of Daily Living Scale was substantially higher than that of the Lysholm Knee Scale (coefficient alpha, 0.92 to 0.93 compared with 0.60 to 0.73), resulting in a smaller standard error of measurement for the former scale. Validity was demonstrated by moderately strong correlations with concurrent measures of function, including the Lysholm Knee Scale (r = 0.78 to 0.86) and the global assessment of function as measured on a scale ranging from 0 to 100 points (r = 0.66 to 0.75). Analysis of variance with repeated measures revealed significant improvements in the score on the Activities of Daily Living Scale during the eight weeks of physical therapy (F2,236 = 108.13; p < 0.0001); post hoc testing indicated that the change in the score at eight weeks was significantly greater than the change at four weeks and that the change at four weeks was significantly greater than that at one week (p < 0.0001 for both). As had been hypothesized, the patients in whom the knee had somewhat improved had a significantly smaller change in the score, both at four weeks (F1,189 = 33.50; p < 0.001) and at eight weeks (F1,156 = 22.48; p < 0.001), compared with those in whom the knee had greatly improved. The test-retest reliability coefficient (intraclass correlation coefficient[2,1]) was 0.97.These results suggest that the Activities of Daily Living Scale is a reliable, valid, and responsive instrument for the assessment of functional limitations that result from a wide variety of pathological disorders and impairments of the knee.

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