ABSTRACT
In the past 20 years, there has been considerable growth in the number of knee instruments and rating scales designed to measure outcomes from the perspective of the patient. Only a few of these instruments have been evaluated for reliability, validity, and responsiveness. The purpose of this systematic review was to examine the psychometric evidence of patient-reported outcome measures for the knee and identify the best scores for specific knee conditions. A literature search was performed to retrieve references relating to the development and evaluation of knee-specific instruments. Twenty-four unique instruments were identified, and most have satisfactory evidence for internal (α ≥0.82) and test-retest reliability (intraclass correlation coefficient ≥0.80). Face/content validity was typically assessed during the item selection process, and construct validity was evaluated through strict hypothesis testing or correlations with other clinical measures. For many instruments, effect sizes and standardized response means measuring responsiveness were large (≥0.80) within disease-specific populations. Based on the psychometric data, recommendations include the Cincinnati Knee Rating System, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm Knee Score for anterior cruciate ligament (ACL) injuries, the Kujala Anterior Knee Pain Scale for anterior knee pain, the International Knee Documentation Committee (IKDC) Subjective Knee Form, KOOS, and Lysholm Knee Score for focal chondral defects, the Western Ontario Meniscal Evaluation Tool (WOMET) for meniscal injuries, and the KOOS for osteoarthritis (OA). Although the IKDC can be used as a general knee measure, no instrument is currently universally applicable across the spectrum of knee disorders and patient groups. Clinicians and researchers looking to use a patient-based score for measurement of outcomes must consider the specific patient population in which it has been evaluated. Using a diagnostic algorithm that measures the anatomic parts of the knee as separate constructs may solve this dilemma, allowing for measurement of treatment outcomes across patient groups and selection of the optimal clinical intervention.
KEYWORDS
Knee - instrument - outcome measure - scale - reliability - validity - responsiveness
REFERENCES
-
1
Neeb T B, Aufdemkampe G, Wagener J H, Mastenbroek L.
Assessing anterior cruciate ligament injuries: the association and differential value of questionnaires, clinical tests, and functional tests.
J Orthop Sports Phys Ther.
1997;
26
(6)
324-331
-
2
Sernert N, Kartus J, Köhler K et al..
Analysis of subjective, objective and functional examination tests after anterior cruciate ligament reconstruction. A follow-up of 527 patients.
Knee Surg Sports Traumatol Arthrosc.
1999;
7
(3)
160-165
-
3 Kane R L. Understanding Health Care Outcomes Research. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2006
-
4
Bollen S, Seedhom B B.
A comparison of the Lysholm and Cincinnati knee scoring questionnaires.
Am J Sports Med.
1991;
19
(2)
189-190
-
5
Risberg M A, Holm I, Steen H, Beynnon B D.
Sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score. A prospective study of 120 ACL reconstructed patients with a 2-year follow-up.
Knee Surg Sports Traumatol Arthrosc.
1999;
7
(3)
152-159
-
6
Marx R G, Jones E C, Allen A A et al..
Reliability, validity, and responsiveness of four knee outcome scales for athletic patients.
J Bone Joint Surg Am.
2001;
83-A
(10)
1459-1469
-
7
Sgaglione N A, Del Pizzo W, Fox J M, Friedman M J.
Critical analysis of knee ligament rating systems.
Am J Sports Med.
1995;
23
(6)
660-667
-
8
Roos E M, Lohmander L S.
The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis.
Health Qual Life Outcomes.
2003;
1
64
-
9 Streiner D L, Norman G R. Health Measurement Scales—A Practical Guide to Their Development and Use. 4th ed. New York, NY: Oxford University Press; 2008
-
10
Ponterotto J G, Ruckdeschel D E.
An overview of coefficient alpha and a reliability matrix for estimating adequacy of internal consistency coefficients with psychological research measures.
Percept Mot Skills.
2007;
105
(3 Pt 1)
997-1014
-
11 Rosner B. Fundamentals of Biostatistics. 6th ed. Belmont, CA: Thomson Brooks/Cole; 2006
-
12
McHorney C A, Tarlov A R.
Individual-patient monitoring in clinical practice: are available health status surveys adequate?.
Qual Life Res.
1995;
4
(4)
293-307
-
13
Lysholm J, Gillquist J.
Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.
Am J Sports Med.
1982;
10
(3)
150-154
-
14
Garratt A M, Brealey S, Robling M DAMASK Trial Team et al.
Development of the knee quality of life (KQoL-26) 26-item questionnaire: data quality, reliability, validity and responsiveness.
Health Qual Life Outcomes.
2008;
6
48
-
15
Kujala U M, Jaakkola L H, Koskinen S K, Taimela S, Hurme M, Nelimarkka O.
Scoring of patellofemoral disorders.
Arthroscopy.
1993;
9
(2)
159-163
-
16
Laprade J A, Culham E G.
A self-administered pain severity scale for patellofemoral pain syndrome.
Clin Rehabil.
2002;
16
(7)
780-788
-
17
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
(3)
350-359
-
18
Clark J A, Spiro III A, Fincke G, Miller D R, Kazis L E.
Symptom severity of osteoarthritis of the knee: a patient-based measure developed in the veterans health study.
J Gerontol A Biol Sci Med Sci.
1998;
53
(5)
M351-M360
-
19
Kirkley A, Griffin S, Whelan D.
The development and validation of a quality of life-measurement tool for patients with meniscal pathology: the Western Ontario Meniscal Evaluation Tool.
WOMET
Clin J Sport Med.
2007;
17
(5)
349-356
-
20
Marx R G, Stump T J, Jones E C, Wickiewicz T L, Warren R F.
Development and evaluation of an activity rating scale for disorders of the knee.
Am J Sports Med.
2001;
29
(2)
213-218
-
21
Tegner Y, Lysholm J.
Rating systems in the evaluation of knee ligament injuries.
Clin Orthop Relat Res.
1985;
198
(198)
43-49
-
22
Saleh K J, Mulhall K J, Bershadsky B et al..
Development and validation of a lower-extremity activity scale. Use for patients treated with revision total knee arthroplasty.
J Bone Joint Surg Am.
2005;
87
(9)
1985-1994
-
23
Johanson N A, Liang M H, Daltroy L, Rudicel S, Richmond J.
American Academy of Orthopaedic Surgeons lower limb outcomes assessment instruments. Reliability, validity, and sensitivity to change.
J Bone Joint Surg Am.
2004;
86-A
(5)
902-909
-
24
Roos E M, Roos H P, Lohmander L S, Ekdahl C, Beynnon B D.
Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure.
J Orthop Sports Phys Ther.
1998;
28
(2)
88-96
-
25
Irrgang J J, Anderson A F, Boland A L et al..
Development and validation of the international knee documentation committee subjective knee form.
Am J Sports Med.
2001;
29
(5)
600-613
-
26
Finch E, Kennedy D.
The lower extremity activity profile: a health status instrument for measuring lower extremity disability.
Physiother Can.
1995;
47
(4)
239-246
-
27
Jinks C, Lewis M, Ong B N, Croft P.
A brief screening tool for knee pain in primary care. 1. Validity and reliability.
Rheumatology (Oxford).
2001;
40
(5)
528-536
-
28
Flandry F, Hunt J P, Terry G C, Hughston J C.
Analysis of subjective knee complaints using visual analog scales.
Am J Sports Med.
1991;
19
(2)
112-118
-
29
Briggs K K, Kocher M S, Rodkey W G, Steadman J R.
Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the knee.
J Bone Joint Surg Am.
2006;
88
(4)
698-705
-
30
Briggs K K, Lysholm J, Tegner Y, Rodkey W G, Kocher M S, Steadman J R.
The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later.
Am J Sports Med.
2009;
37
(5)
890-897
-
31
Irrgang J J, Snyder-Mackler L, Wainner R S, Fu F H, Harner C D.
Development of a patient-reported measure of function of the knee.
J Bone Joint Surg Am.
1998;
80
(8)
1132-1145
-
32
Kocher M S, Steadman J R, Briggs K K, Sterett W I, Hawkins R J.
Reliability, validity, and responsiveness of the Lysholm knee scale for various chondral disorders of the knee.
J Bone Joint Surg Am.
2004;
86-A
(6)
1139-1145
-
33
Paxton E W, Fithian D C, Stone M L, Silva P.
The reliability and validity of knee-specific and general health instruments in assessing acute patellar dislocation outcomes.
Am J Sports Med.
2003;
31
(4)
487-492
-
34
Chesworth B M, Culham E, Tata G E, Peat M.
Validation of outcome measures in patients with patellofemoral syndrome.
J Orthop Sports Phys Ther.
1989;
10
(8)
302-308
-
35
Crossley K M, Bennell K L, Cowan S M, Green S.
Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?.
Arch Phys Med Rehabil.
2004;
85
(5)
815-822
-
36
Bennell K, Bartam S, Crossley K, Green S.
Outcome measures in patellofemoral pain syndrome: test retest reliability and inter-relationships.
Phys Ther Sport.
2000;
1
(2)
32-41
-
37
Harrison E, Quinney H, Magee D, Sheppard M S, McQuarrie A.
Analysis of outcome measures used in the study of patellofemoral pain syndrome.
Physiother Can.
1995;
47
(4)
264-272
-
38
MacIntyre D L, Hopkins P M, Harris S R.
Evaluation of pain and functional activity in patellofemoral pain syndrome: reliability and validity of two assessment tools.
Physiother Can.
1995;
47
(3)
164-172
-
39
Naal F D, Impellizzeri F M, Leunig M.
Which is the best activity rating scale for patients undergoing total joint arthroplasty?.
Clin Orthop Relat Res.
2009;
467
(4)
958-965
-
40
Barber-Westin S D, Noyes F R, McCloskey J W.
Rigorous statistical reliability, validity, and responsiveness testing of the Cincinnati knee rating system in 350 subjects with uninjured, injured, or anterior cruciate ligament-reconstructed knees.
Am J Sports Med.
1999;
27
(4)
402-416
-
41
Smith H J, Richardson J B, Tennant A.
Modification and validation of the Lysholm Knee Scale to assess articular cartilage damage.
Osteoarthritis Cartilage.
2009;
17
(1)
53-58
-
42
Conaghan P G, Emerton M, Tennant A.
Internal construct validity of the Oxford Knee Scale: evidence from Rasch measurement.
Arthritis Rheum.
2007;
57
(8)
1363-1367
-
43
Myers N D, Wolfe E W, Feltz D L, Penfield R D.
Identifying differential item functioning of rating scale items with the Rasch model: An introduction and an application.
Meas Phys Educ Exerc Sci.
2006;
10
(4)
215-240
-
44 Rasch G. Probabilistic Models for Some Intelligence and Attainment Tests. Chicago, IL: University of Chicago Press; 1960
-
45
Roos E M, Roos H P, Lohmander L S, Ekdahl C, Beynnon B D.
Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure.
J Orthop Sports Phys Ther.
1998;
28
(2)
88-96
-
46
Marx R G.
Knee rating scales.
Arthroscopy.
2003;
19
(10)
1103-1108
-
47
Tanner S M, Dainty K N, Marx R G, Kirkley A.
Knee-specific quality-of-life instruments: which ones measure symptoms and disabilities most important to patients?.
Am J Sports Med.
2007;
35
(9)
1450-1458
-
48
Bekkers J E, de Windt T S, Raijmakers N J, Dhert W J, Saris D B.
Validation of the Knee Injury and Osteoarthritis Outcome Score (KOOS) for the treatment of focal cartilage lesions.
Osteoarthritis Cartilage.
2009;
17
(11)
1434-1439
-
49
Gonçalves R S, Cabri J, Pinheiro J P, Ferreira P L.
Cross-cultural adaptation and validation of the Portuguese version of the Knee injury and Osteoarthritis Outcome Score.
KOOS
Osteoarthritis Cartilage.
2009;
17
(9)
1156-1162
-
50
Salavati M, Mazaheri M, Negahban H et al..
Validation of a Persian-version of Knee injury and Osteoarthritis Outcome Score (KOOS) in Iranians with knee injuries.
Osteoarthritis Cartilage.
2008;
16
(10)
1178-1182
-
51
de Groot I B, Favejee M M, Reijman M, Verhaar J A, Terwee C B.
The Dutch version of the Knee Injury and Osteoarthritis Outcome Score: a validation study.
Health Qual Life Outcomes.
2008;
6
16
-
52
Ornetti P, Parratte S, Gossec L et al..
Cross-cultural adaptation and validation of the French version of the Knee injury and Osteoarthritis Outcome Score (KOOS) in knee osteoarthritis patients.
Osteoarthritis Cartilage.
2008;
16
(4)
423-428
-
53
Xie F, Li S C, Roos E M et al..
Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) in Asians with knee osteoarthritis in Singapore.
Osteoarthritis Cartilage.
2006;
14
(11)
1098-1103
-
54
Roos E M, Toksvig-Larsen S.
Knee injury and Osteoarthritis Outcome Score (KOOS) - validation and comparison to the WOMAC in total knee replacement.
Health Qual Life Outcomes.
2003;
1
17
-
55
Roos E M, Roos H P, Ekdahl C, Lohmander L S.
Knee injury and Osteoarthritis Outcome Score (KOOS)—validation of a Swedish version.
Scand J Med Sci Sports.
1998;
8
(6)
439-448
-
56
Wright R W.
Knee injury outcomes measures.
J Am Acad Orthop Surg.
2009;
17
(1)
31-39
-
57
Jinks C, Jordan K, Ong B N, Croft P.
A brief screening tool for knee pain in primary care (KNEST). 2. Results from a survey in the general population aged 50 and over.
Rheumatology (Oxford).
2004;
43
(1)
55-61
-
58
LaValley M, McAlindon T E, Evans S, Chaisson C E, Felson D T.
Problems in the development and validation of questionnaire-based screening instruments for ascertaining cases with symptomatic knee osteoarthritis: the Framingham Study.
Arthritis Rheum.
2001;
44
(5)
1105-1113
-
59
March L M, Schwarz J M, Carfrae B H, Bagge E.
Clinical validation of self-reported osteoarthritis.
Osteoarthritis Cartilage.
1998;
6
(2)
87-93
-
60
Noyes F R, Mooar L A, Barber S D.
The assessment of work-related activities and limitations in knee disorders.
Am J Sports Med.
1991;
19
(2)
178-188
-
61
Leigh Brown A P, Kennedy A DM, Grant A M, Campbell J, Macnicol M F, Torgerson D J.
The development and validation of the Edinburgh Knee Function Scale: a simple tool for outcome measurement in non-surgical patients.
Knee.
1999;
6
(2)
115-123
-
62
Irrgang J J, Anderson A F, Boland A L et al..
Development and validation of the international knee documentation committee subjective knee form.
Am J Sports Med.
2001;
29
(5)
600-613
-
63
Rejeski W J, Ettinger Jr W H, Shumaker S et al..
The evaluation of pain in patients with knee osteoarthritis: the knee pain scale.
J Rheumatol.
1995;
22
(6)
1124-1129
-
64
Thomeé P, Währborg P, Börjesson M, Thomeé R, Eriksson B I, Karlsson J.
A new instrument for measuring self-efficacy in patients with an anterior cruciate ligament injury.
Scand J Med Sci Sports.
2006;
16
(3)
181-187
-
65
Dawson J, Fitzpatrick R, Murray D, Carr A.
Questionnaire on the perceptions of patients about total knee replacement.
J Bone Joint Surg Br.
1998;
80
(1)
63-69
-
66
Regensteiner J G, Steiner J F, Panzer R J, Hiatt W R.
Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease.
J Vasc Med Biol.
1990;
2
142-152
-
67
Greco N J, Anderson A F, Mann B J et al..
Responsiveness of the International Knee Documentation Committee Subjective Knee Form in comparison to the Western Ontario and McMaster Universities Osteoarthritis Index, modified Cincinnati Knee Rating System, and Short Form 36 in patients with focal articular cartilage defects.
Am J Sports Med.
2010;
38
(5)
891-902
-
68
Hopper D M, Goh S C, Wentworth L A et al..
Test-retest reliability of knee rating scales and functional hop tests one year following anterior cruciate ligament reconstruction.
Phys Ther Sport.
2002;
3
(1)
10-18
-
69
Higgins L D, Taylor M K, Park D International Knee Documentation Committee et al.
Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form.
Joint Bone Spine.
2007;
74
(6)
594-599
-
70
Watson C J, Propps M, Ratner J, Zeigler D L, Horton P, Smith S S.
Reliability and responsiveness of the lower extremity functional scale and the anterior knee pain scale in patients with anterior knee pain.
J Orthop Sports Phys Ther.
2005;
35
(3)
136-146
-
71
Collins E, O'Connell S, Jelinek C, Miskevics S, Budiman-Mak E.
Evaluation of psychometric properties of Walking Impairment Questionnaire in overweight patients with osteoarthritis of knee.
J Rehabil Res Dev.
2008;
45
(4)
559-566
-
72
Anderson A F, Irrgang J J, Kocher M S, Mann B J, Harrast J J. International Knee Documentation Committee .
The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data.
Am J Sports Med.
2006;
34
(1)
128-135
Dean WangB.S.E.
Cleveland Clinic Foundation–Cleveland Clinic Lerner College of Medicine
9500 Euclid Avenue, NA21, Cleveland, OH 44195
eMail: wangd@ccf.org
