IJCRR - Vol 08 Issue 05, March, 2016
Date of Publication: 13-Mar-2016
Download XML Download PDF
IPSYCHOMETRIC EVALUATION OF KNEEPAIN: ABAB DESIGN A Single Subject Randomized Control Trial
Author: Mahamed Ateef
Abstract:Aim: The purpose of this study was to evaluate the efficacy of psychometrictools andphysiotherapeutic interventions on pain perception in knee osteoarthritis patient. Case Study: A 58-year-old male patient with bilateral grade-2 primary knee was referred to a physiotherapist with a complaint of bilateral knee pain. He experienced pain severity of nine on visual analog scale, difficulty climbing stairs and while walking. Pain was also assessed using self-rated psychometric tool such as Knee pain and osteoarthritis outcome score(KOOS). The pain subscale was 12% means severe painprior to the intervention using KOOS questionnaire. The patient was given bilateral multiple angled resisted exercises twice daily for 3 weeks. At the end of 6th week pain was nearly normal twoon visual analog scale andKnee pain and osteoarthritis outcome scorepain subscalewas 90% means substantial pain relief and good improvementin gait. Discussion: Psychometric tools are the most reliable and validated tools in the evaluation pain perception in bilateral knee osteoarthritis as the pain perception differs during various activities of daily life. Conclusion: This case concludes that resisted exercises were effective and these scales are diagnostic as well prognostic in use for longitudinal prospective interventional studies due to their validity and reliability.
Keywords: Resisted exercises, Knee pain, Visual analog scale, Pain subscale of KOOS
Pain is the most excruciating and occurring symptom in people with knee osteoarthritis leading to worsening of the activities of daily living. Many patients with bilateral or unilateral knee pain may appreciate various degree of pain perception during their physical activities of daily living. Among available interventions,resisted exercises were also beneficial in the management of Osteoarthritis knee. Visual analog scale which is most reliable subjective method used to provide pain perception at rest in knee osteoarthritis patients1 and patients may not be able to differentiate pain threshold at various physical activities but the recent development of psychometric tools are most useful tools which assesses the pain levels during activities of daily living2 . Hence, this single subject control trial3 was done to evaluate the effects of resisted exercises and efficacy of psychometric tool as subjective and specific assessment tools.
A SINGLE SUBJECT RANDOMIZED CONTROL TRIAL
Patient history The patient, a 58-year-old male complained of bilateral knee pain for 5 months that had started gradually. There was no history of trauma, congenital or acquired knee deformities, ankylosing spondylitis. The cardinal symptoms were knee pain, with restricted knee painful movements. He had no history of a similar problem in the past. The symptoms worsened as the day progressed and relieved with rest. Physical examination On examination, it was found that the patient had decreased knee movements,inability to flex full range of flexion. Restriction of active extension and flexion were measured using a universal goniometer, where flexion was more restricted than extension , measuring 110° flexion, left and right knee exion was110° each side, He rated his pain threshold level as 9 on a 0-10 linear visual analog scale (VAS). There are 9 psychometric questions of pain domain of KOOS scale2 .
Treatment methods: The patient was informed about the study and his consent was taken. The patient’s pain severity was measured before the intervention as base line value usingvisual analog scale.. Many authors have emphasized the importance of self- rated/subjective scales to evaluate the pain threshold by visual analog scale in musculoskeletal injuries1 .Terweealso reported that physical functioning was very much influenced by knee pain4 . In the present study, active movements were measured by universal goniometer method in knee pain. The patient was then educated about his condition and the possible treatment to be given.
EXERCISE THERAPEUTICS Strengthening Strengthening exercises for extensors and flexors of the knee were administered to maintain the muscle strength. The patient was givenresisted exercise in sitting position twice a day for three alternative weeks along with initial isometrics to overcome muscle soreness and to facilitate resisted exercises. Resisted exercise was carried out using a minimalweights after determining the repetition maximum[1RM]. In the second week, therewas no exercise given . In the third and fifth weeks, the weight was progressed as the patient was more comfortable to the resisted exercise twice a day, like wise on the second,fourth and sixth weeks, he was discontinued from the resisted exercise to see the efficacy of the resisted exercise on pain variable as under ABAB [A-intervention, B-no intervention, A- intervention- no intervention design3 . The first, third and fifth were treatment given weeks, likewise the second, fourth and sixth weeks were control weeks.
clinical outcomes: At the end of the first week of intervention with consolidated weight, the patient was reassessed; his pain had decreased from 9/10 to 7/10, pain subscale of KOOS was 30% from 12% and ROMs of flexion had improved from 110° to 115°. At the end of the second week, without intervention the patient was reassessed; his pain status was the same like at the end of first week, 7/10 on VAS, KOOS was 30% respectively. At the end of the third week of intervention with progressed weight, the patient was reassessed; his pain had decreased from 7/10 to 4/10, KOOS was 60% from 30% and ROMs of flexion had improved from 115° to 120° and respectively. At the end of the fifth week of intervention with progressed weight, the patient was reassessed; his pain had decreased from 4/10 to 2/10, KOOS was 90% from 60% and ROMs of flexion had improved from 120° to 135° and respectively. At the end of the sixth week without intervention, the patient was reassessed, his pain status was same like at the end of the fifth week. This case study with single subject randomized control trial design clearly shows the efficacy of resisted exerciseand psychometric tools in assessing pain and improving the ROM of flexion and extension.
There are many linear psychometric scales available but VAS is more reliable in terms of quantification of pain as a subjective measure of specification of pain intensity and it is unidirectional measure of pain intensity. The sensitivity and reproducibility are very much acceptable5 . But more reliable in literate people than illiterate people5 and also VAS scale has limitation in measuring pain among older adults due to decline in cognitive ability6 and older adults with knee OA may not be able to differentiate the quantity of pain as this OA pain is mostly perceptual during physical activities. The pain subscale of KOOS scale has nine items which is constructed based on the symptoms of rheumatic diseases2 . This scale is highly comprehensive and multidimensional in terms of physical functioning6,7. Due to its comprehensiveness it evaluates the pain threshold during different physical activities6-8 as it helps the clinician to understand and plan the rehabilitation program8,9,10.
In this single subject randomized control trial, resisted exercises shown to be effective and pain subscale of KOOS scale has better multidimensional pain evaluation capability than unidirectional VAS scale compared to control weeks.
Clinical implications: Clinicians must select proper questionnaire that is most appropriate for their specificpurpose and betterment of the patient prognosis.
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed Conflict of interest: None Source of funding: None Abbreviations: KOOS - Knee pain and osteoarthritis outcome score, VAS:visual analog scale, ABAB :A-intervention, B-no intervention ,OA: Osteoarthritis, ROM : Range of motion, 1RM : repetition maximum
1. Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH.Reliability of pain scales in the assessment obliterate and illiterate patients with rheumatoid arthritis. J Rheumatol.1990;17:1022-4.
2. Roos EM, Lohmander LS. Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes.2003;1:64.
3. Backman CL1, Harris SR.Mar-Apr Case studies, single-subject research, and N of 1 randomized trials: comparisons and contrasts. Am J Phys Med Rehabil.1999;78(2):170-6.
4. Terwee CB, van der Slikke RMA, van Lummel RC, Benink RJ, Meijers WGH, de Vet HCW.Self-reported physical functioning was more influenced by pain than performance-based physical functioning in knee-osteoarthritis patients. Journal of Clinical Epidemiology.2006;59(7):724-731.
5. Grant S, Aitchison T, Henderson E, Christie J, Zare S, McMurray J and Dargie J. A comparison of the reproducibility and the sensitivity to change of visual analogue scales, Borg scales, and Likert scales in normal subjects during submaximal exercise. Chest.1999,116(5):1208-17.
6. Collins NJ, Misra D, Felson DT, Crossley KM., Roos EM.Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis care and research. 2011;63(11):208-28.
7. Nebel MB, Sims EL, Keefe FJ, et al.The relationship of self-reported pain and functional impairment to gait mechanics in overweight and obese persons with knee osteoarthritis. Archives of Physical Medicine and Rehabilitation.2009; 90(11):1874-1879.
8. AteefMd, Shaziya T, Kulandaivelan S. Influence of age on self-reported and actual physical performance measures in primary knee osteoarthritis. Indian Journal of Health and Wellbeing. 2012;3(4):1087-1089.
9. Kulandaivelan S, MahamedAteef, andShaziyaTahseen.Correlation of Self-Reported Questionnaire (KOOS) withSome Objective Measures in Primary OA Knee Patients.ISRN Rheumatology. 2014; Volume 2014 pp:5
10. MahamedAteef.Resisted exercise and outcomes using diseasespecific Urdu version of osteoarthritis outcome score questionnaire in knee osteoarthritis. Saudi Journal of Sports Medicine. 2015; volume 15(1) : 103-5.