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Association of psychological status and patient-reported physical outcome measures in joint arthroplasty: A lack of divergent validity


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Background Patient-reported outcome measures have become a well-recognised part of outcome assessment in orthopaedic surgery. These questionnaires claim to measure joint-specific dimensions like pain, function in activities of daily living, joint awareness or stiffness. Interference of the patient’s psychological status with these orthopaedic questionnaires however may make accurate interpretation difficult. Methods We recruited 356 patients after unilateral, primary THA or TKA and performed a postal survey including the Brief Symptom Inventory (psychological distress measure), the Catastrophising Scale (from the Coping Strategies Questionnaire), the WOMAC score (Western Ontario and McMaster Universities Osteoarthritis Index) and the Forgotten Joint Score – 12 (FJS-12). Associations between the different questionnaires were determined calculating Pearson correlation coefficients. Two multiple linear regression models were used to investigate the impact of socio-demographic variables, clinical variables and of the psychological scales (BSI and Catastrophising Scale) separately for the WOMAC score and the FJS-12. Results WOMAC-Total score showed strong correlation to Catastrophising (r = 0.79), BSI-Somatisation (r = 0.63) and BSI-GSI (r = 0.54). The FJS-12 demonstrated modest to strong correlation with Catastrophising (r = −0.60), BSI-Somatisation (r = −0.49) and the BSI-GSI (Global Severity Index) (r = −0.44). BSI-GSI and Catastrophising explained 54.3% of variance in a multivariate regression model for the WOMAC score. The same two scales explained 30.0% of variance for the FJS-12. Conclusions There is a strong relationship between psychological status and orthopaedic outcome. The scale names of orthopaedic outcome measures suggest to measure specific dimensions like pain, stiffness, function or joint awareness. In fact they largely include patient’s psychological status indicating poor divergent validity.
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R E S E A R C H Open Access
Association of psychological status and
patient-reported physical outcome measures in
joint arthroplasty: a lack of divergent validity
Johannes M Giesinger
, Markus S Kuster
, Henrik Behrend
and Karlmeinrad Giesinger
Background: Patient-reported outcome measures have become a well-recognised part of outcome assessment in
orthopaedic surgery. These questionnaires claim to measure joint-specific dimensions like pain, function in activities
of daily living, joint awareness or stiffness. Interference of the patients psychological status with these orthopaedic
questionnaires however may make accurate interpretation difficult.
Methods: We recruited 356 patients after unilateral, primary THA or TKA and performed a postal survey including
the Brief Symptom Inventory (psychological distress measure), the Catastrophising Scale (from the Coping Strategies
Questionnaire), the WOMAC score (Western Ontario and McMaster Universities Osteoarthritis Index) and the
Forgotten Joint Score 12 (FJS-12). Associations between the different questionnaires were determined calculating
Pearson correlation coefficients. Two multiple linear regression models were used to investigate the impact of
socio-demographic variables, clinical variables and of the psychological scales (BSI and Catastrophising Scale)
separately for the WOMAC score and the FJS-12.
Results: WOMAC-Total score showed strong correlation to Catastrophising (r = 0.79), BSI-Somatisation (r = 0.63) and
BSI-GSI (r = 0.54). The FJS-12 demonstrated modest to strong correlation with Catastrophising (r = 0.60),
BSI-Somatisation (r = 0.49) and the BSI-GSI (Global Severity Index) (r = 0.44). BSI-GSI and Catastrophising explained
54.3% of variance in a multivariate regression model for the WOMAC score. The same two scales explained 30.0% of
variance for the FJS-12.
Conclusions: There is a strong relationship between psychological status and orthopaedic outcome. The scale
names of orthopaedic outcome measures suggest to measure specific dimensions like pain, stiffness, function or
joint awareness. In fact they largely include patients psychological status indicating poor divergent validity.
There is widespread recognition that assessment of pa-
tient outcome following total hip and total knee
arthroplasty (THA and TKA respectively) should employ
patient-reported outcome (PRO) measures. These tools
allow a more patient-centred view in treatment evalu-
ation [1-3] and advocates suggest that they provide a
remarkably sophisticated evaluation of whether a treat-
ment has worked in the (important) sense of whether or
not the patient feels better, and how much better [4].
Consequently a number of disease and joint-specific
PRO assessment instruments have been developed for
use with orthopaedic conditions [5-8]. These outcome
questionnaires focus mainly on the patients function in
typical activities of daily living (ADLs), pain intensity or
joint stiffness. They are often employed in tandem with
more generic health outcome instruments such as the
SF-36 which in addition to assessing physical health in-
corporates questions on psycho-social aspects of general
health. Some generic tools such as the SF-12 have
separate summary scores for physical and mental health.
Tools such as this have been shown to display good di-
vergent validity [9] in that there is very little interaction
between physical and mental component questions and
thus overall scores. Interestingly in disease-specific scores
that do not have specific mental health components,
* Correspondence:
Department of Orthopaedic Surgery, Kantonsspital St. Gallen,
Rorschacherstrasse 95, CH- 9000 St., Gallen, Switzerland
Full list of author information is available at the end of the article
© 2013 Giesinger et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Giesinger et al. Health and Quality of Life Outcomes 2013, 11:64
significant correlation of psychological variables and dis-
ease specific variables has been demonstrated [10-12].
This interaction is somewhat expected as poor physical
outcome and pain after THA/TKA can cause psycho-
logical distress and reduce quality of life, or alternatively,
poor psychological status can result in worse physical out-
come by interfering with the patientscompliance to treat-
ment [13] and affect pain coping strategies [14]. Such
causal dependency is probably bidirectional with the di-
rections difficult to separate. An alternative explanation
though to the overlap in mental and physical health pa-
rameters in these assessment tools is a failure of the
patient-reported outcome measure to discriminate the
overlapping constructs, and thus poor divergent validity
[15,16]. A lack of divergent validity means that inter-
pretability of such scales is limited since the resulting
scores blend different constructs. Poor outcome scores
can then reflect poor physical outcome, poor psycho-
logical status, or both. It is clearly desirable to use a
diagnostic tool that separates physical from psycho-
logical variables as well as possible if one wishes to as-
sess physical function in isolation.
Thresholds for correlations as indicators of divergent val-
idity are rarely explicitly stated in the literature. However,
some studies suggest that correlations below 0.30 indicate
divergent validity [17,18], whereas correlations above 0.40
are considered as indicating convergent validity [19].
The aim of this study was to evaluate the divergent
validity of the WOMAC score and the Forgotten Joint
Score, and to investigate correlations with psychological
variables after joint arthroplasty.
Patients and methods
All patients that underwent THA or TKA at our institu-
tion within the last five years were considered for enrol-
ment in this study and approached for study participation
at their follow-up visits in 2008.
Inclusion criteria were: unilateral THA (cemented
Stuemer-Weber hip stem, uncemented Fitmore cup,
Zimmer) or unilateral TKA (cemented LCS complete,
DePuy), primary arthroplasty surgery, no previous THA
or TKA surgery.
Sociodemographic and clinical data including sex, age,
education, type and location of implant and time since
surgery were collected. Patients were sent the question-
naires and an informed consent form via mail. A reminder
call was made to those patients who did not send back the
questionnaires within eight weeks. If there was no re-
sponse for another four weeks they were excluded. Rea-
sons for not participating in the study were recorded.
Ethical approval for this study was obtained from
the ethics committee of the canton of St Gallen,
Assessment instruments
Forgotten joint score-12
The Forgotten Joint Score-12 (FJS-12) is a recently
published PRO measure to assess joint awareness in
hips and knees during various activities of daily living
[6]. It consists of 12 questions and is scored using a 5-
transformed onto a 0100 point scale. High scores indi-
cate good outcome. The FJS has been shown to have a
low ceiling effect and discriminates well between good,
very good and excellent outcome after THA and TKA.
It has shown high internal consistency (Cronbachs
Alpha 0.95) and discriminates well in known group
comparisons [6].
Western Ontario and McMaster Universities Osteoarthritis
The Western Ontario and McMaster Universities
(WOMAC) Osteoarthritis Index is a widely used out-
come measure in patients with lower limb osteoarthritis
(OA) [5]. It consists of 24 questions covering three di-
mensions: pain (five questions), stiffness (two questions)
and function (17 questions). Scale scores are derived
from adding up the item scores. High scores indicate
poor outcome. The WOMAC OA index has been exten-
sively tested for validity, reliability, feasibility and re-
sponsiveness for measuring changes after different OA
interventions [5,20-22].
Brief symptom inventory
The Brief Symptom Inventory (BSI) [23] is a psychological
self-report symptom scale developed as a short-form ver-
sion of the SCL-90-R [24]. It is widely used in various
medical fields to assess current psychological status and
Table 1 Descriptive statistics for clinical and socio-
demographic variables (n = 243)
Gender Male 123/243 (50.6%)
Female 120/243 (49.4%)
Age Mean (SD) 70.6 (11.3)
Range 32-91
Education Compulsory school 54/243 (22.2%)
Apprenticeship 104/243 (42.8%)
A-level/professional school 39/243 (16.0%)
University 13/243 (5.3%)
Missing 33/243 (13.5%)
Location THA 157/243 (64.6%)
TKA 86/243 (35.4%)
Side Left 116/243 (47.7%)
Right 127/243 (52.3%)
Time since surgery
Mean (SD) 31.1 (12.3)
Range 15-42
Giesinger et al. Health and Quality of Life Outcomes 2013, 11:64 Page 2 of 6
distress. The 53 items are grouped in nine symptom scales
(somatisation, obsessive-compulsive behaviour, interper-
sonal sensitivity, depression, anxiety, hostility, phobic anx-
iety, paranoid ideation, and psychoticism) and three global
indices, Global Severity Index (GSI) as a global distress
measure, Positive Symptom Distress Index (PSDI), and
Positive Symptom Total (PST). Scale scores are derived
from mean item scores. High scores indicate high psycho-
logical symptom burden.
Catastrophising scale
The catastrophising scale is part of the Coping Strategies
Questionnaire developed by Rosenstiel and Keefe [25]. It
comprises six items assessing catastrophising as a pain-
related coping strategy characterised by a feeling of
being overstrained and a pessimistic future perspective.
The scale scores are derived from adding up the items.
A high score indicates poor coping.
Statistical analysis
Sample characteristics are presented as percentages or
as means with standard deviations and ranges. For de-
termining associations between the administered scales
(WOMAC score, FJS-12, BSI, Catastrophising scale)
Pearson-correlation coefficients were calculated. Two
multiple linear regression models were used to investigate
the impact of sociodemographic and clinical variables and
of the psychological scales (BSI and Catastrophising scale)
separately for the WOMAC and for the FJS-12 score. In
these models adjusted R-Squared (R
) indicates the pro-
portion of variance explained by the independent variables
(predictors) in the model. Variables having a significant as-
sociation with the WOMAC or the FJS-12 in univariate
analyis were considered for inclusion into the multivariate
regression model if p < 0.05. In a first block of predictors,
the patient characteristics sex, education, and location
were included. In a second block of predictors the
Table 2 Correlations between WOMAC, FJS-12, Catastrophising and BSI
FJS-12 WOMAC Total WOMAC Pain WOMAC Stiffness WOMAC Function
Catastrophising 0.60 0.79 0.78 0.60 0.77
BSI Somatisation 0.49 0.63 0.60 0.53 0.64
BSI Obsessive-compulsive 0.33 0.39 0.36 0.36 0.39
BSI Interpersonal sensitivity 0.34 0.39 0.38 0.30 0.39
BSI Depression 0.28 0.39 0.37 0.28 0.39
BSI Anxiety 0.38 0.49 0.47 0.40 0.50
BSI Hostility 0.33 0.38 0.37 0.26 0.38
BSI Phobic anxiety 0.39 0.46 0.44 0.42 0.45
BSI Paranoid ideation 0.32 0.41 0.41 0.25 0.40
BSI Psychoticism 0.30 0.35 0.34 0.28 0.35
BSI GSI 0.44 0.54 0.52 0.43 0.54
All correlations are significant at the 0.01 level (two-tailed). Negative correlations reflect the direction of the scoring used for the FJS-12.
Table 3 Multiple linear regression model for FJS-12 and WOMAC-Total
FJS-12 WOMAC-Total
Predictors Adjusted R
Change adjusted R
F p Adjusted R
Change adjusted R
Gender 0.018 0.018 4.75 0.030 0.019 0.019 4.84 0.029
+ Education 0.036 0.018 2.88 0.024 0.043 0.024 2.18 0.014
+ Location 0.063 0.027 3.67 0.003 0.093 0.050 3.24 <0.001
+ BSI-GSI 0.237 0.174 11.34 <0.001 0.353 0.260 8.71 <0.001
+ Catastrophising 0.363 0.126 17.29 <0.001 0.636 0.283 13.00 <0.001
+ BSI-Somatisation 0.379 0.016 16.27 <0.001 0.683 0.047 12.20 <0.001
Equations for the final regression models (unstandardised):
WOMAC Total = 5.176 + 0.986*sex - 1.614*education _d1 -
3.503*education_d2 -3.939*education_d3 + 2.058*location + 0.311*BSI-GSI + 7.984*Catastrophising + 13.292*BSI-Somatisation.
FJS-12 = 84.521 - 2.258*sex + 0.540*education_d1 + 3.125*education_d2 + 13.073*education_d3 - 4.178*location - 7.105*BSI-GSI - 8.675*Catastrophising
- 13.102*BSI-Somatisation.
Coding of predictors:
Sex: Male = 0, Female = 1.
Education (dummy-coded):
Apprenticeship: d1 = 1.
A-level/professional school: d2 = 1.
University: d3 = 1.
Else: d1. d2. d3 = 0.
Location: 1 = THA, 2 = TKA.
Giesinger et al. Health and Quality of Life Outcomes 2013, 11:64 Page 3 of 6
psychological scales (BSI scales and the Catastrophising
scale) were included using a forward selection procedure.
Sample characteristics
A total number of 356 patients were contacted in a mail
survey in August 2008. 243 (68.3%) patients returned
the questionnaires along with written informed consent.
Reasons for not participating in the study (phone call)
were: refusal of participation (42 patients; 11.8%), wrong
address (29 patients; 8.1%), death (22 patients; 6.2%),
cognitive impairment (3 patients; 0.8%), moving abroad
(1 patient; 0.3%) and unknown reasons (16 patients;
4.5%). Mean patient age was 70.6 (SD 11.3) and 120
patients (49.4%) were female. 157 (64.6%) patients had
THA surgery and 86 (35.4%) had TKA surgery. For fur-
ther details see Table 1.
Correlations between FJS-12, WOMAC, BSI and the
Correlation coefficients for the relationship between
WOMAC, FJS-12, BSI scales and catastrophising scale
are presented in Table 2. Highest correlations for the
FJS-12 were found for Catastrophising (r = 0.60), BSI-
Somatisation (r = 0.49) and the BSI-GSI (r = 0.44).
WOMAC-Total also showed the strongest relation to
Catastrophising (r = 0.79), BSI-Somatisation (r = 0.63)
and BSI-GSI (r = 0.54). For comparison, correlations be-
tween the WOMAC subscales (pain, stiffness, and func-
tion) were between r = 0.80 and r = 0.91.
Multivariate analysis of the FJS-12 and the WOMAC score
Sex, education and location of implant (hip or knee) have
previously been shown to impact on the FJS-12 and
WOMAC-Total score [6]. These variables were included
as predictors in two separate linear regression models,
with the WOMAC total score and FJS-12 as the depend-
ant variables. The global distress scale of the BSI (BSI-
GSI) as well as BSI-Somatisation and the Catastrophising
scale were included as predictors in both models.
Overall the demographic and psychological variables
explained 38% of the variance in the FJS-12 and 68% of
the variance in the WOMAC score. Gender, education,
and implant location (hip or knee replacement) explained
similar small proportions of each score (gender explained
1.8% of the variance in FJS-12 and 1.9% of WOMAC-
Total score; Education 1.8% of FJS-12 and 2.4% of
WOMAC-Total score; and implant location, 2.7% of the
FJS-12 and 5.0% of the WOMAC-Total score). Larger dis-
crepancies were seen between WOMAC and FJS-12 in
terms of the amount of variance explained by BSI-GSI
scale (17.4% of FJS-12, and 26.0% of WOMAC-Total
score), Catastrophising scale (12.6% of FJS-12, and 28.3%
of WOMAC-Total score), and the BSI-Somatisation
scale (1.6% of FJS-12, and 4.7% of WOMAC-Total
score) (Table 3 and Figure 1).
This study investigated the associations between psycho-
logical parameters and physical outcome assessed by two
PRO instruments, the WOMAC score and the FJS-12.
We found high correlations between disease-specific
outcome measures and several of the assessed psycho-
logical domains. Multivariate regression showed that
catastrophising, psychological distress and somatisation
explained almost 60% variance of the WOMAC score
beyond the known covariates of sex, implant location
and education. We found the same predictor set for the
FJS-12, however, psychological parameters accounted
only for half the variance seen in the WOMAC score.
Our findings indicate a significant lack of divergent
validity of the WOMAC score and, to a lesser extent, of
the FJS-12. The variance proportions estimated with
help of the regression model suggest a substantial over-
lap between the orthopaedic and psychological scales.
The lack of divergent validity becomes even more evi-
dent when opposing the high correlations between the
1.9% 2.4%
Unexplained variance
1.8% 1.8%2.7%
Unexplained variance
Figure 1 Explained and unexplained variance for the WOMAC
(1a) and FJS-12 scores (1b).
Giesinger et al. Health and Quality of Life Outcomes 2013, 11:64 Page 4 of 6
WOMAC subscales themselves (above 0.80) and the cor-
relations of the WOMAC total score with the psycho-
logical scores (up to 0.79).
This significant overlap with psychological status is
not reflected in the WOMAC scalesnames (pain, stiff-
ness, function) which somewhat misleadingly suggest to
just measure physical, joint-related characteristics. This
is also true for the FJS-12 which refers to joint aware-
ness. However, the term joint awareness seems more
closely related to psychological aspects.
We also found that location of joint arthroplasty (hip
or knee) explained less than 5% of variance of both FJS-
12 and the WOMAC score. This is interesting as it is
well accepted that outcome differs between total hip and
total knee arthroplasty populations [26,27]. In contrast,
the psychological scales exceeded these proportions by a
factor of 10 (for both FJS-12 and WOMAC). Thus, our
data indicate a stronger association between psycho-
logical factors and joint-related outcomes than that be-
tween outcome and the type of joint replaced.
Our findings compare well to other results from litera-
ture. Escobar et al. [15] investigated the association be-
tween WOMAC scores and the different subscales of
the SF-36. They showed that both psycho-social and
physical SF-36 scales correlated to the WOMAC score
in a similar way. The WOMAC function subscale dem-
onstrated the same correlation with both SF-36 social
and physical function scores. WOMAC stiffness was
equally correlated with SF-36 role-physical function
score and mental health score. Similarly Wolfe [16]
highlighted that divergent validity of the WOMAC may
be compromised by factors such as fatigue, symptom
counts, depression, and low back pain.
The strong correlation between physical and psycho-
logical scales found here and in other studies [28-30]
may partially be explained by causal interdepencies that
have been suggested by several longitudinal studies.
Sharma et al. [31] demonstrated that mental health
measured with the SF-36 predicted subsequent improve-
ment in physical function in TKA, results in line with
Brander et al. [32], who showed that preoperative de-
pression substantially influences Knee Society Rating
Scale function scores five years post-operatively. In con-
trast, Lingard et al. [33] found (in a large prospective ob-
servational study) that although psychological distress
decreased post-operatively, pre-operative levels of dis-
tress were not related to post-operative improvement
(change in pain and function).
Lopez-Olivo et al. [12] found a strong correlation
between pre-operative psychological status and post-
operative physical function at 6 months. Education, cop-
ing style and locus of control over health at baseline
explained 22% of variance in WOMAC pain at follow-up.
A similar predictor-set explained 19% of the WOMAC
function scale and 36% of the total score of the Knee Soci-
ety Rating Scale.
Our study was based on a cross-sectional design which
is reasonable for the investigation of divergent validity.
However, it does not allow for causal interpretation of
the associations between orthopaedic outcomes and psy-
chological variables. A limitation is the limited number
of predictors in our model that left a large proportion of
unexplained variance. Further interesting predictors that
may be of future research interest include patient activ-
ity level, social support, cognitive function, range of mo-
tion and joint stability.
A particular strength of this study is the use of a com-
prehensive and detailed assessment of psychological sta-
tus (BSI and the Catastrophising Scale from the Coping
Strategies Questionnaire). These scales are more differ-
entiated and comprehensive than other tools such as the
SF-36 which has previously been employed to assess
psychosocial characteristics of arthroplasty populations.
We found a substantial overlap between physical and psy-
chological patient-reported symptoms in an arthroplasty
population, i.e. orthopaedic PRO measures were strongly
associated with psychological PRO measures indicating
poor divergent validity.Whereas this may also reflect
existing causal dependencies, it impairs valid measure-
ment of orthopaedic outcome. Divergent validity is an im-
portant psychometric characteristic of PRO instruments
that is required to guarantee accurate assessment of spe-
cific orthopaedic outcomes.
Problematically, the category names of the orthopaedic
outcome scales suggest measurement of specific con-
structs such as pain, stiffness, function or joint awareness
but they appear to be strongly associated with patients
psychological status. Our findings suggest that the names
of certain orthopaedic scales do not adequately reflect the
constructs assessed with these scales.
Competing interests
The authors declare that they have no competing interests.
KG, MSK and JMG conceived the study objective. All authors participated in
the study design. KG and HB coordinated data collection. JMG and KG
performed the statistical analysis, interpreted the results and drafted the
manuscript. All authors read and approved the final manuscript.
The work of Johannes M. Giesinger was funded by a grant from the Austrian
Science Fund (FWF L502).
Author details
Department of Psychiatry and Psychotherapy, Innsbruck Medical University,
Anichstr, 35, A-6020, Innsbruck, Austria.
Department of Orthopaedic Surgery,
Royal Perth Hospital, University of Western Australia, Wellington Street, Perth,
WA 6000, Australia.
Department of Orthopaedic Surgery, Kantonsspital St.
Gallen, Rorschacherstrasse 95, CH- 9000 St., Gallen, Switzerland.
Giesinger et al. Health and Quality of Life Outcomes 2013, 11:64 Page 5 of 6
Received: 30 November 2012 Accepted: 16 April 2013
Published: 19 April 2013
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Cite this article as: Giesinger et al.:Association of psychological status
and patient-reported physical outcome measures in joint arthroplasty: a
lack of divergent validity. Health and Quality of Life Outcomes 2013 11:64.
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Giesinger et al. Health and Quality of Life Outcomes 2013, 11:64 Page 6 of 6
... 11,16,26,36 It is important to understand which patient-specific factors (including mental health) and intra-articular factors (assessed during arthroscopic surgery) in patients undergoing MPFL reconstruction contribute to knee pain and function. Although similar studies have investigated these findings in shoulder, 37 knee, 6,8,11,16,18,25 and hip arthroscopy, 36 no study inclusive of patient-specific factors and intraarticular findings has been performed to assess baseline predictors of knee pain and function among patients undergoing MPFL reconstruction for lateral patellar instability. ...
... Previous orthopaedic literature has reported that mental health is closely associated with patient symptoms as well as patient outcomes in knee arthroplasty, knee arthroscopy, and spine surgery. 11,17,18 In our study, VR-12 MCS was associated with all 3 PROMs. This suggests an association among mental health, pain, function, and quality of life in patients undergoing MPFL reconstruction. ...
... Although one cannot deny the stress that patients experience before the surgery, this method has been used and validated for a long time and our prior reports confirm this. 6,8,11,16,18,25,36,37 This analysis was performed only on patients who had consented to undergo open MPFL reconstruction. No asymptomatic control group was included, and these results may not be applicable to patients with lateral patellar instability who did not undergo surgical reconstruction. ...
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Background Medial patellofemoral ligament (MPFL) reconstruction is performed to treat recurrent patellar instability. Measurement of joint pain and function at the time of surgery has been demonstrated to be a predictor of the final outcomes in many surgical procedures. Purpose/Hypothesis The purpose of this study was to evaluate the relationship between baseline patient characteristics, mental health, and intraoperative findings and patient-reported knee pain and function at the time of MPFL reconstruction. We hypothesized that patient characteristics and associated pathology would be associated with the degree of pain and dysfunction. Study Design Cross-sectional study; Level of evidence, 3. Methods Included were skeletally mature patients who underwent unilateral open MPFL reconstruction between 2015 and 2020 at a single institution. Baseline descriptive information was collected, and the following outcome measures were administered preoperatively: the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS) and the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Short Form (PS), and Quality of Life (QoL) subscales. Intraoperative findings were collected in a standardized format. Patient characteristics, preoperative variables, intraoperative findings, and VR-12 MCS were used as risk factors, and multivariate analysis was conducted to assess for relationships with the KOOS subscale scores. Results In total, 201 patients with patella dislocations were included in this analysis. Intraoperatively, 122 patients (60.7%) had either normal cartilage or grade 1 or 2 cartilage injury, 79 patients (39.3%) had grade 3 or 4 cartilage injury, 35 patients (17.4%) had a loose body, and 3 patients (1.49%) had evidence of synovitis. Younger age ( P = .012), male sex ( P < .001), never having smoked ( P = .029), and lower baseline VR-MCS ( P < .001) were significantly associated with higher baseline KOOS Pain scores. Older age ( P = .035), female sex ( P = .003), higher body mass index ( P = .005), and lower baseline VR-12 MCS ( P < .001) were significantly associated with higher baseline KOOS PS scores. Younger age ( P = .003), male sex ( P < .001), lower baseline VR-12 MCS ( P < .001), and no dysplasia ( P = .023) were significantly associated with higher baseline KOOS QoL scores. Conclusion Patient age, sex, and baseline VR-12 MCS were associated with all 3 baseline KOOS subscale scores, whereas intraoperative findings outside of trochlear dysplasia were not associated with any of the KOOS subscale scores.
... One such risk factor that has been studied extensively in primary TJA is psychological distress and depressive symptoms, which have been associated with increased complications, health-care utilization, readmission rates, and cost [5][6][7][8][9][10][11][12][13][14][15]. These patients typically report higher levels of postoperative pain and consume larger amounts of opioids [16][17][18][19][20][21][22]. ...
... Compared to aseptic revision matched controls, the prevalence of depressive symptoms identified by MCS < 42 was significantly higher in the 2-stage exchange arthroplasty group preoperatively (40.54% [15] vs 10.8% [4], P < .01), but not postoperatively (21.6% [8] vs 10.8% [4], P ¼ .20) ...
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Background Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. Patients undergoing revision for PJI may experience psychological distress and symptoms of depression, both of which are linked to poor postoperative outcomes. We, therefore, aim to identify the prevalence of depression and depressive symptoms in patients before treatment for PJI and their link to functional outcomes. Methods Patients undergoing either debridement with implant retention (DAIR) or 2-stage exchange for PJI with minimum 1-year follow-up were retrospectively reviewed. The 2-stage (n = 37) and single-stage (n = 39) patients that met inclusion criteria were matched based off age (±5 years), gender, and body mass index (±5) to patients undergoing aseptic revisions. Outcomes evaluated included a preoperative diagnosis of clinical depression and preoperative and postoperative Veterans RAND 12 Item Health Survey mental component score and physical component score. Results Compared to matched controls, the prevalence of depressive symptoms was significantly greater in patients undergoing 2-stage exchange preoperatively (40.5% vs 10.8%, P < .01) but not postoperatively (21.6% vs 10.8%, P = .20). Patients undergoing DAIR with either preoperative depressive symptoms (31.3 vs 40.9, P = .05) or a preoperative diagnosis of depression (27.7 vs 43.1, P < .01) had significantly lower physical component scores postoperatively. Conclusions Patients undergoing 2-stage exchange for PJI have a four times higher prevalence of preoperative depressive symptoms than patients undergoing aseptic revision. Patients undergoing DAIR with depression or preoperative depressive symptoms have lower functional scores postoperatively. Orthopedic surgeon screening of PJI patients with referral for treatment of depression may help improve outcomes postoperatively.
... We tested the divergent validity of BSES-SF using Pearson's correlation among BSES-SF scores and the scores of EPDS and HADS. The Pearson's correlation coefficient of <.30 indicated a good divergent validity (Giesinger et al., 2013). The EPDS and HADS were adopted in this study because of the lack of validated instruments to measure general self-efficacy in Indonesia. ...
This study aimed to evaluate the psychometric properties of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) in Indonesian postpartum women. We conducted a cross-sectional study including 237 postpartum women in Yogyakarta City, Indonesia. Participants completed the BSES-SF, Edinburgh Postnatal Depression Scale (EPDS), and Hospital Anxiety and Depression Scale (HADS). Construct validity, internal reliability, and divergent validity were examined using confirmatory factor analysis, Cronbach’s alpha, and Pearson’s correlations. We identified a unidimensional structure through confirmatory factor analysis with an excellent internal consistency by Cronbach’s alpha of .90. Divergent validity was evidenced by low correlation of the BSES-SF with the depressive symptoms (EPDS, r = −.21; HADS-D, r = −.17, p < .05) and anxiety symptoms (HADS-A, r = −.15, p = .02). It is concluded that the Indonesian version of BSES-SF is a valid and reliable measurement tool to assess breastfeeding self-efficacy among postpartum women.
... Specifically, there was a high proportion of missing data for the psychological variables, which have only been collected since September 2017. We have chosen to still include these because previous studies have shown that these are associated with treatment outcomes of thumb base osteoarthritis [18,52]. Additionally, we compared patient characteristics and preoperative symptom severity to assess whether nonresponders differed from responders and found only small differences with negligible effect sizes. ...
Background: Surgery for thumb carpometacarpal osteoarthritis is offered to patients who do not benefit from nonoperative treatment. Although surgery is generally successful in reducing symptoms, not all patients benefit. Predicting clinical improvement after surgery could provide decision support and enhance preoperative patient selection. Questions/purposes: This study aimed to develop and validate prediction models for clinically important improvement in (1) pain and (2) hand function 12 months after surgery for thumb carpometacarpal osteoarthritis. Methods: Between November 2011 and June 2020, 2653 patients were surgically treated for thumb carpometacarpal osteoarthritis. Patient-reported outcome measures were used to preoperatively assess pain, hand function, and satisfaction with hand function, as well as the general mental health of patients and mindset toward their condition. Patient characteristics, medical history, patient-reported symptom severity, and patient-reported mindset were considered as possible predictors. Patients who had incomplete Michigan Hand outcomes Questionnaires at baseline or 12 months postsurgery were excluded, as these scores were used to determine clinical improvement. The Michigan Hand outcomes Questionnaire provides subscores for pain and hand function. Scores range from 0 to 100, with higher scores indicating less pain and better hand function. An improvement of at least the minimum clinically important difference (MCID) of 14.4 for the pain score and 11.7 for the function score were considered "clinically relevant." These values were derived from previous reports that provided triangulated estimates of two anchor-based and one distribution-based MCID. Data collection resulted in a dataset of 1489 patients for the pain model and 1469 patients for the hand function model. The data were split into training (60%), validation (20%), and test (20%) dataset. The training dataset was used to select the predictive variables and to train our models. The performance of all models was evaluated in the validation dataset, after which one model was selected for further evaluation. Performance of this final model was evaluated on the test dataset. We trained the models using logistic regression, random forest, and gradient boosting machines and compared their performance. We chose these algorithms because of their relative simplicity, which makes them easier to implement and interpret. Model performance was assessed using discriminative ability and qualitative visual inspection of calibration curves. Discrimination was measured using area under the curve (AUC) and is a measure of how well the model can differentiate between the outcomes (improvement or no improvement), with an AUC of 0.5 being equal to chance. Calibration is a measure of the agreement between the predicted probabilities and the observed frequencies and was assessed by visual inspection of calibration curves. We selected the model with the most promising performance for clinical implementation (that is, good model performance and a low number of predictors) for further evaluation in the test dataset. Results: For pain, the random forest model showed the most promising results based on discrimination, calibration, and number of predictors in the validation dataset. In the test dataset, this pain model had a poor AUC (0.59) and poor calibration. For function, the gradient boosting machine showed the most promising results in the validation dataset. This model had a good AUC (0.74) and good calibration in the test dataset. The baseline Michigan Hand outcomes Questionnaire hand function score was the only predictor in the model. For the hand function model, we made a web application that can be accessed via Conclusion: We developed a promising model that may allow clinicians to predict the chance of functional improvement in an individual patient undergoing surgery for thumb carpometacarpal osteoarthritis, which would thereby help in the decision-making process. However, caution is warranted because our model has not been externally validated. Unfortunately, the performance of the prediction model for pain is insufficient for application in clinical practice. Level of evidence: Level III, therapeutic study.
... Patient-reported outcome measures (PROMs) are important in the evaluation of patient outcome and quality of life following total hip arthroplasty (THA) [1,2]. Hipspecific PROMs primarily focus on patients' level of pain and joint stiffness and functioning in typical daily activities [3,4]. Patients should be included in the development of PROMs to ensure content validity and, thereby, reliability, thus reducing the ceiling effect [5,6]. ...
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Background The Oxford Hip Score is used to evaluate the outcome after total hip arthroplasty. The Oxford Hip Score was developed more than 20 years ago with only some degree of patient involvement. We question if the Oxford Hip Score is still relevant for the present-day total hip artrhoplasty patients. We aimed to determine whether the Oxford Hip Score contains items that are relevant for present-day patients with osteoarthritis undergoing total hip arthroplasty, thus investigating the content validity. Methods Patients aged 60–75 years, undergoing total hip arthroplasty for primary osteoarthritis were recruited to participate in focus group interviews preoperatively and at 3 and 12 months after primary total hip arthroplasty. We conducted 6 focus group interviews in which 30 patients participated. The interviews were audio-recorded and transcribed verbatim. Using Interpretative Phenomenological Analysis, we inductively organised the interview transcripts into particular items/themes which we then compared to items in the Oxford Hip Score. Results We identified 6 general items with 41 sub-items. The 6 general items were pain, walking, physical activities, functional abilities, quality of life and psychological health. We found that items in the Oxford Hip Score were all in some way relevant to the patients but that the Oxford Hip Score lacks several important items relevant for present-day total hip artrhoplasty patients, including several physical activities, functional abilities and certain aspects of quality of life and psychological health. Conclusion We found that the Oxford Hip Score lacks important items for present-day patients in our population. Due to findings regarding several additional items that are not present in the Oxford Hip Score, particularly concerning physical activities and quality of life, we question the content validity of the Oxford Hip Score for a present-day population. Our findings indicate a need for a revision of the Oxford Hip Score.
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Objectives: The aim of this study was to investigate the preoperative factors affecting health-related quality of life (HRQOL) at 3 and 12 months after total knee arthroplasty (TKA). Methods: In total, 156 patients who underwent unilateral TKA for knee osteoarthritis were included in the study. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used as a measure of HRQOL before surgery and 3 and 12 months post-TKA. The Modified Gait Efficacy Scale (mGES) score, tibiofemoral angle, rest pain, walking pain, knee joint range of motion, knee joint extensor strength, and walking speed were recorded preoperatively. Pearson’s correlation coefficient and the correlation ratio were used to calculate the correlation between KOOS and preoperative factors at 3 and 12 months post-TKA. Multiple regression analysis was performed using the stepwise method with the five postoperative KOOS subscales as dependent variables and the other preoperative factors as independent variables. Results: Preoperative mGES scores were significantly correlated with KOOS Activities of Daily Living, Sport/Rec, and QOL subscores at 3 months post-TKA and with all five KOOS subscales at 12 months post-TKA. Multiple regression analysis identified mGES as an influencing factor for all KOOS subscales except Pain at 3 months post-TKA and all KOOS subscales except Symptoms at 12 months post-TKA. Conclusions: Preoperative walking self-efficacy influenced HRQOL at 3 and 12 months post-TKA. Psychological factors such as self-efficacy should be considered when predicting postoperative outcomes.
Resilience is a dynamic construct defined as the ability to recover from stress. There is no literature examining the impact of resilience on outcomes following foot and ankle surgery. Retrospective analysis of patients who underwent first MTP arthrodesis from September 2011 to May 2020 were reviewed for patient characteristics and union status. PROMIS Physical Function (PF), Pain Interference (PI), Depression (D), and Foot Function Index (FFI) were collected. Resilience was measured using the Brief Resilience Scale. A multivariable linear regression analysis examining the impact of resilience on patient reported was conducted. At an average of 3.4 years postoperatively, resilience was found to independently affect patient reported outcomes across all instruments, except the FFI pain subscale. In the first study examining the impact of resilience following foot and ankle surgery, we found that resilience has an independent positive effect on overall physical function, disability, pain, and mental health following MTP arthrodesis. Preoperative resilience scores could be used to predict postoperative functional outcomes following MTP arthrodesis and guide postoperative rehabilitation. These findings help establish the role of early positive psychosocial characteristics within orthopaedic foot and ankle population.
Introduction Patients who undergo total hip arthroplasty (THA) require resilience to recover and resume daily functions. Increased resilience may be an important factor for achieving improved outcomes. The purpose of this study was to examine the impact of resilience on time to discharge and on early patient reported outcomes following primary THA. Methods A retrospective review of patients who underwent primary THAs and completed the Brief Resilience Scale (BRS) was conducted from 2020-2021 at an urban, academic hospital. Patients were separated into three cohorts based on BRS score: low (1-2.99), normal (3-4.30), and high (4.31-5) resilience. Demographics, participation in same day discharge (SDD) program, length of stay (LOS), and preoperative and 3-month postoperative scores on the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) were assessed. SDD patients were excluded from LOS analysis. Results A total of 393 patients were included. Compared to low resilience patients, odds of being enrolled in SDD program were 1.49 and 3.01 times higher (p=0.01) and 3-month HOOS, JR scores improved by 4.7% and 11.7% (p=0.03) for normal and high resilience patients, respectively. As resilience increased from low to normal to high in non-SDD patients, LOS significantly decreased (53.27 ± 51.92 vs. 38.70 ± 28.03 vs.25.64 ± 14.48 hours, respectively; p=0.001). Conclusion Increased resilience is positively associated with likelihood of SDD participation or decreased LOS. Increased resilience was associated with increased HOOS, JR scores at 3 months, though this did not reach the minimal clinically important difference (MCID). The BRS may be a useful tool for predicting patients who can successfully participate in SDD or predicting LOS after primary THA.
Introduction: Patient-reported outcomes (PROs) provide data on the effect of conditions and treatments on patients' lives without third party interpretation. Mounting evidence suggests that PROs may be useful in elective procedure decision making, but its utility in trauma remains unclear. Longitudinally collected PROs may prove effective in identifying patients recovering below the norm. We sought to document recovery trajectory in patients with and without complication and to evaluate the sources of variability in functional recovery after injury. Methods: This retrospective study included 831 patients with trauma, identified via Current Procedural Terminology (CPT) codes for surgical extremity and/or pelvic/acetabular fracture management between 2014 and 2018. Global Physical Health (GPH) scores collected via the PROMIS Global Health in a 14-month window after injury were analyzed using mixed-effects modeling. Results: A curvilinear GPH recovery trajectory was observed where patients demonstrated an initial positive recovery trajectory (B = 1.28, P < 0.001) gradually decelerating over time (B = -0.07, P < 0.001). Patients who experienced complications requiring revision surgery demonstrated markedly lower GPH scores. Several notable predictors of postoperative physical health recovery were identified, including both between-person (B = 0.52, 95% CI, 0.48 to 0.56) and within-person (B = 0.41, 95% CI, 0.36 to 0.46) Global Mental Health (GMH) score, Body Mass Index (BMI) (B = -0.07, 95% CI, -0.12 to -0.02), two or more psychiatric diagnoses (B = -0.97, 95% CI, -1.84 to 0.09), Injury Severity Score 10 to 15 and 16+ (B = -2.62, 95% CI, -4.81 to 0.42 and B = -2.17, 95% CI, -3.60 to 0.74, respectively), readmission for complication (B = -2.64, 95% CI, -3.60 to 1.68), and lower extremity or multiextremity fracture (relative to upper extremity) (B = -3.61, 95% CI, 4.45 to 2.78, B = -4.11, 95% CI, -5.77 to 2.44, respectively). Additional analysis suggests that GMH scores are related to the presence of psychiatric diagnoses. Discussion: This study establishes a normal course of recovery as reflected by PROMIS GPH score to serve as an index for monitoring individual postoperative course. Patients who experienced a complication demonstrated markedly lower GPH across all time points, potentially allowing earlier identification of at-risk patients. Furthermore, GMH may represent a modifiable risk factor that could profoundly affect physical recovery. Level of evidence: Level III (Prognostic Study = Retrospective Cohort).
Objective: The aim of this study was to systematically review whether the altered central pain modulation has a significant influence on post-surgical outcomes in patients undergoing shoulder surgery due to musculoskeletal disorders. Methods: A systematic search of MEDLINE, PEDro, and EMBASE was conducted without time restriction, including observational prognostic studies. Quality in Prognostic Studies Tool was adopted for critical appraisal, and a qualitative synthesis was undertaken. Two authors independently performed study selection, data extraction, and risk of bias assessment; any disagreement was resolved by a third author. A review protocol is published in the PROSPERO registry (CRD42019122303). The data regarding the potential predictors and outcome measures were obtained from the studies. Results: 11 prospective cohort studies were appraised. Overall, 952 patients were included with a sample size that ranged from 20 to 314. Studies included both arthroscopy and open surgery and presented low to moderate ROB. The prognostic factors investigated were depression, psychological distress, anxiety, catastrophizing, fear avoidance beliefs, self-efficacy and quantitative sensory testing. Only avoidance behaviors and self-efficacy were significantly related to post-surgical pain and function at 12 months after surgery. Conclusion: Fear avoidance beliefs and inadequate coping strategies seem to be the most correlated factors with the worst pain and function scores. Surgeons and physical therapists should look for patients with signs of altered central pain modulation before surgery as they might be at risk of unfavorable outcome. Level of evidence: Level II, Therapeutic Study.
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The comparative outcome of primary hip and knee arthroplasty is not well understood. This study aimed to investigate the outcome and satisfaction of these procedures and determine predictive models for 1 year patient outcome with a view to informing surgical management and patient expectations. Prospective cohort study of all primary hip and knee arthroplasty procedures performed at the Royal Infirmary of Edinburgh between January 2006 and November 2008. General health (SF-12) and joint specific function (Oxford Score) was assessed pre-operatively and at 6 and 12 months post-operatively. Patient satisfaction was assessed at 12 months. 1410 total hip arthroplasty (THA) and 1244 total knee arthroplasty (TKA) procedures were assessed. Oxford Score improved by 4.9 points more in THA patients than in TKA patients. SF-12 physical scores were on average 2.7 points greater in the THA patients at one year. Satisfaction was also greater (91%) following THA compared with TKA (81%). Regression modelling was not able to predict individual patient outcome; however, mean pre-operative Oxford Scores were found to be strong predictors of mean post-operative Oxford Scores for each procedure. Age, gender and pre-operative general health scores did not influence these models. Both THA and TKA confer substantial improvement in patient outcome; however, greater joint specific, general health and satisfaction scores are reported following THA. This difference is physical in nature. Regression models are presented that can be applied to predict mean hip/knee arthroplasty outcome based on preoperative values.
Quality of life studies form an essential part of the evaluation of any treatment. Written by two authors who are well respected within this field, Quality of Life: The Assessment, Analysis and Interpretation of Patient-reported Outcomes, Second Edition lays down guidelines on assessing, analysing and interpreting quality of life data. The new edition of this standard book has been completely revised, updated and expanded to reflect many methodological developments emerged since the publication of the first edition. Covers the design of instruments, the practical aspects of implementing assessment, the analyses of the data, and the interpretation of the results Presents all essential information on Quality of Life Research in one comprehensive volume Explains the use of qualitative and quantitative methods, including the application of basic statistical methods Includes copious practical examples Fills a need in a rapidly growing area of interest New edition accommodates significant methodological developments, and includes chapters on computer adaptive testing and item banking, choosing an instrument, systematic reviews and meta analysis This book is of interest for everyone involved in quality of life research, and it is applicable to medical and non-medical, statistical and non-statistical readers. It is of particular relevance for clinical and biomedical researchers within both the pharmaceutical industry and practitioners in the fields of cancer and other chronic diseases. Reviews of the First Edition - Winner of the first prize in the Basis of Medicine Category of the BMA Medical Book Competition 2001: "This book is highly recommended to clinicians who are actively involved in the planning, analysis and publication of QoL research." CLINICAL ONCOLOGY "This book is highly recommended reading." QUALITY OF LIFE RESEARCH.
We previously reported preoperative depression, anxiety, and pain were associated with greater pain, more utilization of healthcare resources, and worse outcome 1 year after total knee arthroplasty. We asked whether these outcomes persisted over time and whether patients with unexplained heightened pain early after surgery were ultimately satisfied. We prospectively followed and evaluated 83 patients (109 TKAs) 5 years postoperative. The mean age was 66 years; 55% were women. Preoperative pain and depression predicted lower Knee Society score mostly related to lower function subscores. Although anxiety was associated with greater pain, worse function, and more use of resources in the first year after surgery, anxiety did not affect ultimate outcome. Most patients required a full year to recover from surgery but with negligible improvements in most parameters afterward. However, patients with heightened, unexplained pain at 1 year had progressive improvement in pain over several years. By 5 years, nearly all of these patients were satisfied. Therefore, assuming good range of motion and well-aligned implants, most patients with pain 1 year after surgery can be reassured pain ultimately improves. Depression drives long-term outcomes; the Knee Society score is influenced by psychologic variables and does not solely reflect issues related to the knee. Expansion of this tool to include measures sensitive to psychologic and other health factors should be considered.
The principle methods for developing and validating new questionnaires are introduced, and the different approaches are described. These range from simple global questions to detailed psychometric and clinimetric methods. We review traditional psychometric techniques including summated scales and factor analysis models, as well as psychometric methods that place emphasis upon probabilistic item response models. Whereas psychometric methods lead to scales for QoL that are based upon items reflecting patients' level of QoL, the clinimetric approach makes use of composite scales that may include symptoms and side-effects of treatment.
Cognitive and behavioral pain coping strategies were assessed by means of questionnaire in a sample of 61 chronic low back pain patients. Data analysis indicated that the questionnaire was internally reliable. While patients reported using a variety of coping strategies, certain strategies were used frequently whereas others were rarely used. Three factors: (a) Cognitive Coping and Suppression, (b) Helplessness and (c) Diverting Attention or Praying, accounted for a large proportion of variance in questionnaire responses. These 3 factors were found to be predictive of measures of behavioral and emotional adjustment to chronic pain above and beyond what may be predicted on the basis of patient history variables (length of continuous pain, disability status and number of pain surgeries) and the tendency of patients to somaticize. Each of the 3 coping factors was related to specific measures of adjustment to chronic pain.
A consecutive series of 640 total joint arthroplasty patients was interviewed before surgery and at a minimum of 2 years following surgery. Statistical analyses were conducted to examine the effect of psychological distress and other patient characteristics on outcomes (Western Ontario and McMaster Universities Osteoarthritis Index, Short Form 36, and Quality of Well-Being index). Before and after surgery, distressed subjects had significantly lower scores than nondistressed subjects for most dependent measures (P range, .05 ≤ .001). All mean outcomes improved by follow-up in both groups (P ≤ .001) except mental health scores of nondistressed subjects. Stepwise regression analysis found that low baseline mental health score, non-Hispanic ethnicity, and fewer years since procedure were the strongest predictors of worse Western Ontario and McMaster Universities Osteoarthritis Index scores at follow-up. Although the magnitude of improvement is similar to nondistressed subjects, distressed patients do not achieve comparable functional and psychosocial outcomes.