Rajiv Gandhi University of Health Sciences



INTER- RATER RELIABILITY OF ICF IN KNEE REPLACEMENT ARTROPLASTY DURING FIRST POST-OPERATIVE WEEK.

A

Protocol submitted to

HOSMAT HOSPITAL EDUCATIONAL INSTITUTE

Bangalore

DISSERTATION RESEARCH PROJECT

By

Micheal varghese

M.P.T. 1st year

M.P.T (Musculoskeletal and sports)

Guide: Dr. R. Dev Anand (PT)

INTER- RATER RELIABILITY OF ICF IN KNEE REPLACEMENT ARTROPLASTY DURING FIRST POST-OPERATIVE WEEK.

RESEARCH APPROVAL

Research proposal approved by Institutional ethics Committee

On

13/12/2011

INSTITUTIONAL ETHICS COMMITTEE

HOSMAT HOSPITAL EDUCATIONAL INSTITUTE

BANGALORE -25.

CONTENTS

Page No.

1 INTRODUCTION 04

1.1 Background of the study 04

1.2 Statement of the problem 04

1.3 Objective of the study 04

1.5 clinical significance 05

2 REVIEW OF LITERATURE 06

3 METHODOLOGY 10

3.1 Study Design 10

3.2 Study Setting 10

3.3 Inclusion Criteria 10

3.4 Exclusion Criteria 10

3.5 Materials 10

3.6 Sampling 10

3.7 Sample size 10

3.8 Procedure 11

3.9 Outcome measures 11

3.10 Data analysis 11

4 REFERENCES 12

5 APPENDIX

Appendix I 15

Appendix II 16

Appendix III 21

INTRODUCTION

1. Background of the study

Knee replacement arthroplasty KRA is a common procedure that despite low level of mortality and complication. Major joint arthroplasty is normally performed to improve patient’s quality of life. Patient’s perspective is vital in assessing the effect of the procedure. Functional status of subject can be quantified before and after procedure 1 .

Common Patient concerns after knee replacement arthroplasty include, decrease in pain, reduction of swelling, avoiding of infections, better sleep at night, increase ROM at knee, increase strength in legs, getting in and out of bed, getting in and out of bath, self-dressing, walking on flat surface, walking on uneven surface, descending stairs, ascending stairs, doing own house work2.the most common anticipated impairments and functional limitation after KRA are Pain, immobilized postoperatively in bed,edema,limited strength, limited bed mobility and transfer, limited gait3.

Impairment and functional limitations have to be quantified to guide interventional program and measure the improvements. Impairments and functional limitation have been measured by various outcome measures. In recent years the International Classification of Functioning, Disability and Health (ICF) has been widely adopted as a conceptual model for describing outcome measures. Briefly, the ICF is a bio psychosocial model of health that focuses on the consequences of disease and includes two parts, with each part containing separate components. The first part covers functioning and disability and includes the components of Body Structure and Function, Activities, and Participation. The second part covers contextual factors and includes the components of Environmental Factors and Personal Factors. The ICF provides a unified framework for evaluating health and health related states of populations in both clinical practice and research.4..ICF has been shown to link disciplines by providing common language for measurement of function.5

 

2. Statement of problem:

➢ Inter rater reliability of ICF in knee replacement arthroplasty in first post-operative week

3. Objective of the study

➢ The purpose of this study is to use ICF core set as a outcome tool after knee replacement arthroplasty.

➢ Check the inter rater reliability

4. Clinical significance

➢ ICF core sets can be used as outcome tool after KRA for education, goal setting and managing expectations about return to participation roles.

➢ ICF applicability in clinical practise.

2 . Review of Literatures

Arthroplasty is a surgical procedure for construction of a new movable joint6.Knee replacement arthroplasty is a common procedures that is despite low level of mortality and complications1.Arthritis of a joint is a major cause for arthroplasty 78 .Knee replacement arthroplasty is the second most popular orthopaedic surgeries9.total joint arthroplasty for management of end stage arthritis has been shown to be effective in improving physical functioning and reducing pain in over 90% of patients 10.

Common indications for knee replacement arthroplasty are osteoarthritis, ankylosis, joint stiffness, rheumatoid arthritis, traumatized and misaligned joint4611.Goals of rehabilitation after knee replacement arthroplasty are, prevention of hazards of bed rest, guard against dislocation of implant, strengthen hip and knee musculature, gain functional strength, assist with adequate and functional range of motion ROM,assist patient in achieving functional independent activities of daily living, independent ambulation with an assistive device12.

Examination and evaluation procedures require assessment of quantifiable outcome measures. These measures identify the level of impairments. Common impairments after KRA and their quantification are, Pain (visual analogue scale13,Western Ontario and McMaster Universities WOMAC14 , Knee injury and Osteoarthritis Outcome Score KOOS15, The Pain Disability Index (PDI)16,The McGill Pain Questionnaire17), Strength (muscle strength scale18,isometric dynamometer19, isokinetic dynamometer20,manual muscle testing MMT21).Stiffness(WOMAC14).Activities of daily living (ADL)(The Lower Extremity Functional Scale (LEFS)22, BARTHEL INDEX23, KOOS15, WOMAC14). Quality of life( QOL), SF-36(tm) Health Survey24.

ICF provides common language and frame work for describing health and health-related states.ICF is used to describe how functional problems can result in difficulties carrying out tasks and how these problems are manifested in a person’s environment, rather than focussing on the consequences of disease.ICF frame work is based on a bio psychosocial model of functioning and disability, functional status information (FSI) relates to an individual’s capacity to carry out a set of task or actions, and to changes in body structure and functions arising from a health condition25.

FLOW CHART DEPICTING ICF FRAME-WORK:

[pic]

ICF core sets used in arthroplasty 26

|Body Function |Body Structure |

| | | | |

|b 130 |Energy and drive fn |s 750 |Structure of lower ext |

|b 134 |Sleep function |S 770 |Addtn MS str related to movement |

|b 152 |Emotional function |s 799 |Str related to movement unspecified |

|b 280 |Sensation of pain | |

|b 710 |Mobility of joint fn |Activity & Participation |

|b 715 |Stability of joint fn |d 410 |Change basic position |

|b 720 |Mobility of bone fn |d 415 |Maintaining a body position |

|b 730 |Muscle power fn |d 430 |Lifting and carrying objects |

|b 735 |Muscle tone function |d 450 |walking |

|b 740 |Muscle endurance fn |d 455 |Moving around |

|b 760 |Control of vol. movement fn |d 470 |Using transportation |

|b 770 |Gait pattern function |d 475 |driving |

|b 780 |Sensation rel. to muscle&mvt fn |d 510 |Washing oneself |

| | |d 530 |Toileting |

|Environmental |d 540 |Dressing |

|e 110 |Product for consumption |d 620 |Acquisition of good and services |

|e 115 |Product & technology for ADL |d 640 |Doing housework |

|e 120 |Products & technology for personal indoor and |d 660 |Assisting others |

| |outdoor mobility and transportation | | |

|e 135 |Product & technology for employment |d 770 |Intimate relationship |

|e 150 |Design , construction &building products & |d 850 |Remunerative employment |

| |technology of building for public use | | |

|e 155 |Design , construction and building products and |d 910 |Community life |

| |technology of building for private use | | |

|e 225 |Climate |d 920 |Recreation and leisure |

|e 310 |Immediate family | | |

|e 320 |Friends |Environmental (Contd) |

|e 340 |Personal care providers and personal assistance |e 460 |Societal attitudes |

|e 355 |Health professionals |e 540 |Transportation services system and policies |

|e 410 |Individual attitude of immediate family members |e 575 |General social support services, systems and policies |

|e 450 |Individual attitude of health professional s |e 580 |Health services, systems and policies |

Reliability and validity of ICF in orthopaedic conditions.

1) ICF core sets for osteoarthritis were shown to be valid and reliable through rasch analysis and classical psychometric methods r =0.79, 0.86, 0.8827 .

2) Reliability of ICF core set of rheumatoid arthritis was low to moderate. The metric of the qualifiers scale may be improved by reducing the number of qualifiers to three for all the component Weighted kappa statistics showed reliability of 0.4 or higher

in 82/95 ICF categories (86%) within raters, but only in 41/95 ICF categories (43%) between raters, 28.

3) ICF is valid and reliable in low back ach (LBA) patients for symptom and functional limitation of LBA patient highest Cronbach’s alpha (0.90–0.95) and all items had item–total,29.

4) The ICF has showed at least moderate inter-rater and excellent intra-rater reliability in patients with multiple injuries, Kappas above 0.8030.

3. METHODOLOGY

3.1 Study design

Observational study

3.2 Study setting

Department of physiotherapy, HOSMAT HOSPITAL, Bangalore

3.3 Sample size:

Minimum 30

3.4 sampling:

Subjects who are electively selected for arthroplasty between January 2012-december 2012.

3.5 Inclusion criteria

• Subjects with knee replacement arthroplasty.

• Independent mobility with assistive aid under supervision

• Age: 40-80 years.

• Gender :male & female.

3.6 Exclusion criteria

• Psychological disorder/unco-operative subjects.

• Severe systemic disease, cognitive impairment.

• Unstable vitals

• Infections post-operative

• Bed sores

• Auditory & visual deficits

3.7 Materials:

• VAS (Visual analogue scale)

• Goniometer

• ICF core sets

• Questionnaire

3.8 Procedure:

➢ Phase 1 :Two raters will be selected. One rater is the researcher and the other will be an intern or staff from physiotherapy department. They will be trained about ICF core set and methods of measuring. (Annexure II). The duration of training will be for one week. 10 knee arthroplasty subjects will be selected and the raters will familiarize in scoring the ICF core sets, in a supervised training program. The difficulties faced and discrepancies in scoring shall be discussed in academic postgraduate meeting and a consensus shall be reached.

➢ Phase 2 :Rating of subjects will be done by two raters R1 and R2,subjects will be chosen from post-operative day by screening with inclusion and exclusion criteria’s, these subjects will be explained the procedure and asked about their willingness to participate in the study. Subjects will be taken in to study after signing a written consent.

Knee arthroplasty subjects commonly stay as in-patients for 4-8 days after surgery. The subjects shall be rated when they are independently mobile under supervision

Subjects shall be rated by two raters on subsequent days ,coin toss method will be used in the selection of order of rater assessment, if the coin shows heads R1 will assess the patient on first day and R2 on second day. If the coin shows tails R2 will assess the patient on first day and R1 on second day .The rater documents will be blinded from each other till the end of the study.

Measures of impairment like pain, range of motion (ROM) ,stiffness,activitys of daily living (ADL),quality of life (QOL),will be taken during the assessment period for 1-8 days and measured by using measurement scales. (Annexure II)

ICF categories like body function, activity and participation, environment will be quantified by rater at the end of the day, once the rater procedure comes to an end R1-R2 observation will be analysed for inter-rater reliability of ICF .

3.9 outcome measure:

• ICF Core set

3.10 Data analysis:

Reliability coefficient: Cronbach’s alphas coefficient

REFERENCES

1. Peter Salmon, DPhil, FBPsS, George M. Hall, PhD, FRCA, Denise Peerbhoy, BSc, Alan Shenkin, PhD, FRCP, FRCPath, Christopher Parker, MD, FRCA, 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 Vol 82, March 2001.

2. Ravi Rastogi*1, Bert M Chesworth2 and Aileen M Davis3, Change in patient concerns following total knee arthroplasty described with the International Classification of Functioning, Disability and Health: a repeated measures design, Health and Quality of Life Outcomes 2008, 6:112.

3. Lisa maxey,jim Magnusson, text book of rehabilitation of post surgical orthopaedics page no 180 and 274 , A Harcourt Health Sciences Company.

4. Ravi Rastogi1, Aileen M Davis2 and Bert M Chesworth. A cross-sectional look at patient concerns in the first six weeks following primary total knee arthroplasty. Health and Quality of Life Outcomes 2007, 5:48 .

5. International classification of functioning, disability and health, world health organisation, Geneva.

6.J maheshwari, Text book of essential orthopaedics ,3rd edition page no 68-69.

7. Chung-Wei Christine Lin, MaximLyn March2, Jack Crosbie3, Ross Crawford4,Stephen Graves5, Justine Naylor6, Alison Harmer3, Stephen Jan1,Kim Bennell7, Ian Harris8, David Parker9, Helene Moffet10 and Marlene Fransen*1,11um recovery after knee replacement – the MARKER study rationale and protocol, BMC Musculoskeletal Disorders 2009, 10:69.

8. Canadian Institute for Health Information: Canadian Joint Replacement Registry (CJRR) 2007 annual report – hip and knee replacements in CanadaOttawa: CIHI; 2008.

9. François Desmeules*1,2, Clermont E Dionne†1,3, Étienne Belzile†4,Renée Bourbonnais†3,5 and Pierre Frémont, Waiting for total knee replacement surgery: factors associated with pain, stiffness, function and quality of life, BMC Musculoskeletal Disorders 2009, 10:52.

10. Robert B. Bourne MD, Patient Satisfaction after Total Knee Arthroplasty Published online: 21 October 2009 The Association of Bone and Joint Surgeons1 2009.

11. Elaine Trudelle-Jackson, PT, PhD1 Outcomes of Total Hip Arthroplasty: A Study of Patients One Year Post surgery, Orthop Sports Phys Ther 2002;32:260–267.

12.S.brent brotzman,clinical orthopaedic rehabilitation, chapter seven, page no 284-302

13. Shaun O` Leary, Deborah Falla, Paul W. Hodge, Gwendolyn Jull, Bill Vicenzino. A specific therapeutic exercise of the neck induces immediate local hypoalgesias. The journal of pain.2007; 8(11):832-39.

14. Bellamy N Buchanan WW . Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to ant rheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988; 15: 1833-1840.

15. E Roos, S Toksvig-Larsen: Knee injury and Osteoarthritis Outcome Score (KOOS) -validation and comparison to the WOMAC in total knee replacement. Health and Quality of Life Outcomes 2003, 1.

16. Chibnall JT Tait RC. The Pain Disability Index: Factor Structure and Normative Data. Arch Phys Med Rehabil. 1994; 75: 1082-1086.

17. Melzack R. The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1975; 1: 277-299.

18. Miller DW Hahn JF. Chapter 1: General methods of clinical examination. pags 31-32. IN: Youmans JR. Neurological Surgery 4 edition. W.B. Saunders Company. 1996

19. CAROLYN KISNER, PT, MS. Therapeutic Exercise Foundations and Techniques , 5th edition.

20. John W. Chow, ISOKINETIC EXERCISES AND KNEE JOINT FORCES DURING ISOKINETIC KNEE EXTENSIONS, Department of Exercise and Sport Sciences, University of Florida, Gainesville, FL 32611

21.Florence kendall,muscle testing and function,4th edition.

22.Binkley JM Stratford PW. The Lower Extremity Functional Scale (LEFS): Scale development measurement properties and clinical application. Physical Therapy. 1999; 79: 371-383 (Appendix page 383)..

23. Mahoney FI, Barthel D. “Functional evaluation: The Barthel Index.” Maryland State Medical Journal 1965;14:56-61.

24. SF-36(tm) Health Survey.

25. RITA KUKAFKA DRPH, MA, MICHAEL E. BALES, MPH, ANN BURKHARDT, OTD, OTR/L, BCN,CAROL FRIEDMAN, PHD, Human and Automated Coding of Rehabilitation Discharge Summaries According to the International Classification of Functioning, Disability, and Health, Journal of the American Medical Informatics Association Volume 13 Number 5 Sep / Oct 2006.

26.C.pison,A giaridini,g.ma jani,m.maini,international classification of functioning, disability and health core sets for osteoarthritis, a useful tool in the follow-up of patients after arthroplasty,European journal of physical and rehabilitation medicine vol.44-no.4

27. Yeşim Kurtaiş, Reliability, construct validity and measurement potential of the ICFcomprehensive core set for osteoarthritis. Kurtaiş et al. BMC Musculoskeletal Disorders 2011, 12:255.

28. Till Uhlig, RSolva° r Lillemo, Rikke Helene Moe, Tanja Stamm, Alarcos Cieza, Annelies Boonen, Petter Mowinckel, Tore Kristian Kvien, Gerold Stuckieliability of the ICF Core Set for rheumatoid arthritis, Ann Rheum Dis 2007;66:1078–1084. doi: 10.1136/ard.2006.058693.

29. Martin Bjo¨rklund Æ Jern Hamberg Æ Marina Heiden Æ,Margareta Barnekow-Bergkvist, The assessment of symptoms and functional limitations in low back pain patients: validity and reliability of a new questionnaire, Eur Spine J (2007) 16:1799–1811.

30. Soberg HL, Sandvik L, Ostensjo S, Reliability and applicability of the ICF in coding problems, resources and goals of persons with multiple injuries. Department of Physical Medicine and Rehabilitation, Oslo University College, Oslo, Norway.

31. Hauser SL, Dawson DM, Lehrich JR, Beal MF, Kevy SV, Propper RD, Mills JA,Weiner HL. Intensive immunosuppression in progressive multiple sclerosis. A randomized, three arm study of high-dose intravenous cyclophosphamide, plasma exchange, andACTH.N Engl J Med. 1983 Jan 27;308(4):173-80.

32.Cynthia norkins,Pamela K. Levangie,,Joint structure and function,forth edition.

33.Valeria.m.pomeeroy,David Dean,Laura sykes,E.brah=n faragher,martin yates,pippa j tyrrell,Sylvia moss,Raymond tallis,The unreliability of clinicle measures of muscle tone implication for stroke patient,Age and ageing 2000;29:229-333.

34. Jann M. Fielden, RCpN, MA,P. H. Gander, PhD, J. G. Horne, MBChB, FRACS,B. M. F. Lewer, MBChB, FANZCA,R. M. Green, BSc,and P. A. Devane, MBChB, MSc, FRACS. An Assessment of Sleep Disturbance in Patients Before and After Total Hip Arthroplasty. The Journal of Arthroplasty Vol. 18 No. 3 2003.

APPENDIX – I

HOSMAT College of Physiotherapy

Rajiv Gandhi University

Consent Form

I ________________________________ agree to take part in the research study conducted , by Micheal Varghese Postgraduate student (M.P.T. Musculoskeletal & Sports), HOSMAT College of Physiotherapy, Rajiv Gandhi University, entitled Inter- rater reliability of ICF in Knee replacement arthroplasty during 1st week post-operatively

I acknowledge that the research study has been explained to me and I understand that agreeing to participate in the research means that I am willing to

• Provide information about my health status to the researcher

• Allow the researcher to have access to my medical records, pertaining to purpose of the study

• Participate in evaluator program

• Make myself available for further follow up

I have been informed about the purpose; procedures, measurements and risks involved in the research and my queries towards the research have been clarified.

I provide consent to the researcher to use the information, video or audio recordings, for research and educational purpose only.

I understand that my participation is voluntary and can withdraw at any stage of the research project.

I understand that no monitory benefit will be given for participation in this research study.

Name of the applicant –

Signature Date

Signature of the researcher:

APPENDIX II

Data collection Form:

Name: age/ sex:

Occupation: patient number:

Hospital number:

Research study number:

Date of surgery :

Date of assessment:

Date of discharge:

Type of surgery: KNEE__________

Contact no :

QUESTIONER

ICF core sets used for data collection

|b 130 |Energy and drive function |

|b 134 |Sleep function |

|b 152 |Emotional function |

|b 280 |Sensation of pain |

|b 710 |Mobility of joint function |

|b 730 |Muscle power function |

|b 735 |Muscle tone function |

|b 740 |Muscle endurance function |

|b 770 |Gait pattern function |

|s 750 |Structure of lower extremity |

|d 410 |Changing basic position |

|d 415 |Maintaining a body function |

|d 450 |Walking |

|d 455 |Moving around |

|d 510 |Washing one self |

|d 530 |Toileting |

|d 540 |Dressing |

|e 115 |Product and technology for personal use in daily living |

|e 340 |Personal care provider & personal assistance |

|e 355 |Health professional |

Questionnaire

1. b 130 Energy and drive function (sf36,Q9)

| |All of time |Most of time |A good bit of time |Some of time |A little of time |

|1.Anxiety | | | | | |

|2.Irritability | | | | | |

|3.Frustration | | | | | |

|4.Depression | | | | | |

|5.Relaxation | | | | | |

|6.Insomnia | | | | | |

|7.Boredom | | | | | |

|8.Loneliness | | | | | |

|9.Stress | | | | | |

|10.Well-being | | | | | |

2. b 280 sensation of pain (koos)

| |NONE |MILD |MODERATE |SEVERE |EXTREME |

|1.Straightening knee | | | | | |

|fully | | | | | |

|2.Bending knee fully | | | | | |

|3.Walking on flat | | | | | |

|surface | | | | | |

|4.At night while in bed | | | | | |

|5.sitting or lying | | | | | |

|6.standing upright | | | | | |

3. b 710 Mobility of joint function –Goniometer, it is performed during the assessment32.

4. b 730 Muscle power function –(Isometric muscle grading) performed for quadriceps and hamstrings.

i. 0-none

ii. 1-trace

iii. 2-poor

iv. 3-fair

v. 4-good

vi. 5-normal

7. b 735 Muscle tone function VAS33.

0HYPOTONIC________________________10HYPERTONIC

8. b 770 Gait pattern function

A. Asymmetrical

B. Symmetrical

C. Limping

D. Antalgic

9. s 750 structure of lower extremity

a) s 75002 muscles of thigh-assessed by using a inch tape to check atrophy

s 7501 structure of lower leg

b) s 75011 knee joint-assessed by using a inch tape to assess for swelling at the knee.

c) s 75012 muscles of lower leg-assessed by using inch tape to check atrophy

10. d 410 changing basic position (LEFS,WOMAC)

Today do you have any difficulty at these activity

| |NONE |SLIGHT |MODERATE |SEVERE |EXTREME |

|1.Rolling over in | | | | | |

|bed | | | | | |

|2.Rising from bed | | | | | |

|3.Rising from | | | | | |

|sitting | | | | | |

|4.Bending to floor | | | | | |

11. d 415 maintaining a body function

a. d 4150 maintaining a lying position

b. d 4151 maintaining a squatting position

c. d 4153 maintaining a sitting position

d. d 4154 maintaining a standing position.

| |Extreme |Quite a |Moderate |Little difficulty|No difficulty |

| |difficulty |difficulty |difficulty | | |

|1.Lying in bed | | | | | |

|2.squatting | | | | | |

|3.sitting for one hour | | | | | |

|4.standing for one hour | | | | | |

12. d 450 walking –assessed by Hauser Ambulation Index31

13.d 510 washing one self

a. d 5100 washing body parts

EASY__________________________________________NOT POSSIBLE

14. d 530 toileting (Barthel Index23)

1) getting on and off of toilet –scoring till ten

15.d 540 dressing (Barthel Index23)

1) dressing/undressing-scoring ten to zero

10_____________5______________0

• Ten – able to dress

• Five –able to dress with assistance

• Zero- unable

16. e 115 product and technology for personal use in daily living.

1)use of a crutch or a walker

17. e 335 health professional (Score on 0 to 5, with 0 referring the worst & 5 referring the best)

• How do you rate the role of doctor in alleviation of your knee complaint

• How do you rate the role of nurse in alleviation of your knee complaint

• How do you rate the role of physiotherapist in alleviation of your knee complaint & rehabilitation scoring

Appendix III

SCALES USED FOR STUDY

Hauser Ambulation Index

❏ 0 = Asymptomatic; fully active.

❏ 1 = Walks normally, but reports fatigue that interferes with athletic or other demanding activities.

❏ 2 = Abnormal gait or episodic imbalance; gait disorder is noticed by family and friends; able to walk 25 feet (8 meters) in 10 seconds or less.

❏ 3 = Walks independently; able to walk 25 feet in 20 seconds or less.

❏ 4 = Requires unilateral support (cane or single crutch) to walk; walks 25 feet in 20 seconds or less.

❏ 5 = Requires bilateral support (canes, crutches, or walker) and walks 25 feet in 25 seconds or less; or requires unilateral support but needs more than 20 seconds to walk 25 feet.

❏ 6 = Requires bilateral support and more than 20 seconds to walk 25 feet; may use wheelchair* on occasion.

❏ 7 = Walking limited to several steps with bilateral support; unable to walk 25 feet; may use wheelchair* for most activities.

❏ 8 = Restricted to wheelchair; able to transfer self independently.

❏ 9 = Restricted to wheelchair; unable to transfer self independently.

*The use of a wheelchair may be determined by lifestyle and motivation. It is expected that patients in Grade 7 will use a wheelchair more frequently then those in Grades 5 or 6. Assignment of a grade in the range of 5 to 7, however, is determined by the patient’s ability to walk a given distance, and not by the extent to which the patient uses a wheelchair.

WOMAC (Western Ontario and McMaster Universities) Index of Osteoarthritis

Overview:

The WOMAC (Westren Ontario and McMaster Universities) index is used to assess patients with osteoarthritis of the hip or knee using 24 parameters. It can be used to monitor the course of the disease or to determine the effectiveness of anti-rheumatic medications.

|Pain: |Social function: |

|(1) walking |(1) leisure activities |

|(2) stair climbing |(2) community events |

|(3) nocturnal |(3) church attendance |

|(4) rest |(4) with spouse |

|(5) weight bearing |(5) with family |

|Stiffness: |(6) with friends |

|(1) morning stiffness |(7) with others |

|(2) stiffness occurring later in the day |Emotional function: |

|Physical function: |(1) anxiety |

|(1) descending stairs |(2) irritability |

|(2) ascending stairs |(3) frustration |

|(3) rising from sitting |(4) depression |

|(4) standing |(5) relaxation |

|(5) bending to floor |(6) insomnia |

|(6) walking on flat |(7) boredom |

|(7) getting in or out of car |(8) loneliness |

|(8) going shopping |(9) stress |

|(9) putting on socks |(10) well-being |

|(10) rising from bed | |

|(11) taking off socks | |

|(12) lying in bed | |

|(13) sitting | |

|(14) sitting | |

|(15) getting on or off toilet | |

|(16) heavy domestic duties | |

|(17) light domestic duties | |

| |SCORING |

| |RESPONSE |POINTS |

| |None |0 |

| |Slight |1 |

| |Moderate |2 |

| |Severe |3 |

| |Extreme |4 |

Alternatively a visual analogue scale (VAS) may be used ranging from 0 to 10.

Score = SUM(points for relevant items) and Average score = (total score) / (number of items)

BARTHEL INDEX

| | |With Help |Independent |

|1 |Feeding (if food needs to be cut up = help) |5 |10 |

|2 |Moving from wheelchair to bed and return |5 - 10 |15 |

| |(includes sitting up in bed) | | |

|3 |Personal toilet (wash face, comb hair, shave, |0 |5 |

| |clean teeth) | | |

|4 |Getting on and off toilet (handling clothes, |5 |10 |

| |wipe, flush) | | |

|5 |Bathing self |0 |5 |

|6 |Walking on level surface (or if unable to |0* |5* |

| |walk, propel wheelchair) *score only if unable to walk | | |

|7 |Ascend and descend stairs |5 |10 |

|8 |Dressing (includes tying shoes, fastening fasteners) |5 |10 |

|9 |Controlling bowels |5 |10 |

|10 |Controlling bladder |5 |10 |

A patient scoring 100 BI is continent, feeds himself, dresses himself, gets up out of bed and chairs, bathes himself, walks at least a block, and can ascend and descend stairs. This does not mean that he is able to live alone: he may not be able to cook, keep house, and meet the public, but he is able to get along without attendant care.

DEFINITION AND DISCUSSION OF SCORING

1. Feeding

10 = Independent. The patient can feed himself a meal from a tray or table when someone puts the food within his reach. He must put on an assistive device if this is needed, cut up the food, use salt and pepper, spread butter, etc. He must accomplish this in a reasonable time.

5 = Some help is necessary (with cutting up food, etc., as listed above).

2. Moving from wheelchair to bed and return

15 = Independent in all phases of this activity. Patient can safely approach the bed in his wheelchair, lock brakes, lift footrests, move safely to bed, lie down, come to a sitting position on the side of the bed, change the position of the wheelchair, if necessary, to transfer back into it safely, and return to the wheelchair.

10 = Either some minimal help is needed in some step of this activity or the patient needs to be reminded or supervised for safety of one or more parts of this activity.

5 = Patient can come to a sitting position without the help of a second person but needs to be lifted out of bed, or if he transfers with a great deal of help.

3. Doing personal toilet

5 = Patient can wash hands and face, comb hair, clean teeth, and shave. He may use any kind of razor but must put in blade or plug in razor without help as well as get it from drawer or cabinet. Female patients must put on own makeup, if used, but need not braid or style hair.

4. Getting on and off toilet

10 = Patient is able to get on and off toilet, fasten and unfasten clothes, prevent soiling of clothes, and use toilet paper without help. He may use a wall bar or other stable object for support if needed. If it is necessary to use a bed pan instead of a toilet, he must be able to place it on a chair, empty it, and clean it. Patient needs help because of imbalance or in handling clothes or in using toilet paper.

5. Bathing self

5 = Patient may use a bath tub, a shower, or take a complete sponge bath. He must be able to do all the steps involved in whichever method is employed without another person being present.

6. Walking on a level surface

15 = Patient can walk at least 50 yards without help or supervision. He may wear braces or prostheses and use crutches, canes, or a walkerette but not a rolling walker. He must be able to lock and unlock braces if used, assume the standing position and sit down, get the necessary mechanical aides into position for use, and dispose of them when he sits. (Putting on and taking off braces is scored under dressing.)

10 = Patient needs help or supervision in any of the above but can walk at least 50 yards with a little help.

6a. Propelling a wheelchair

5 = If a patient cannot ambulate but can propel a wheelchair independently. He must be able to go around corners, turn around, maneuver the chair to a table, bed, toilet, etc. He must be able to push a chair at least 50 yards. Do not score this item if the patient gets score for walking.

7. Ascending and descending stairs

10 = Patient is able to go up and down a flight of stairs safely without help or supervision. He may and should use handrails, canes, or crutches when needed. He must be able to carry canes or crutches as he ascends or descends stairs.

5 = Patient needs help with or supervision of any one of the above items.

8. Dressing and undressing

10 = Patient is able to put on and remove and fasten all clothing, and tie shoe laces (unless it is necessary to use adaptations for this). The activity includes putting on and removing and fastening corset or braces when these are prescribed. Such special clothing as suspenders, loafer shoes, dresses that open down the front may be used when necessary.

5 = Patient needs help in putting on and removing or fastening any clothing. He must do at least half the work himself. He must accomplish this in a reasonable time. Women need not be scored on use of a brassiere or girdle unless these are prescribed garments.

9. Continence of bowels

10 = Patient is able to control his bowels and have no accidents. He can use a suppository or take an enema when necessary (as for spinal cord injury patients who have had bowel training).

5 = Patient needs help in using a suppository or taking an enema or has occasional accidents.

10. Controlling bladder

10 = Patient is able to control his bladder day and night. Spinal cord injury patients who wear an external device and leg bag must put them on independently, clean and empty bag, and stay dry day and night.

5 = Patient has occasional accidents or can not wait for the bed pan or get to the toilet in time or needs help with an external device.

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VISUAL ANALOGUE SCALE

How severe is your pain today? Place a vertical mark on the line below to indicate how bad you feel your pain is today

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