among individuals who have intra-articular pathologies, such as knee OA. Documentation of the presence and amount of knee joint swelling can be subjective, but there are some standardized methods that can be used to evaluate joint effusion in a more objective manner. The therapist can measure the circumference of the knee at the midpatellar region. This can be compared between limbs, or it can be compared between treatment sessions to see if the effusion is getting worse. Additionally, effusion can be graded on an ordinal scale using a modified stroke test (Sturgill, Snyder-Mackler, Manal, & Axe, 2009). During this test, the therapist strokes the medial side of the Self-reported measures A variety of self-reported measures can be used to evaluate various domains of impairments, functional deficits, pain, psychological factors, self-efficacy, and participation limitations in patients with knee OA. Some of these outcome measures, such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), are condition-specific, meaning that they are suitable only for patients with knee OA. Other outcome measures are generic, such as the Short Form Health Survey (SF-36). Other measures are joint specific, but have been applied to other knee pathologies, such as the International Knee Documentation Committee’s knee scoring system (IKDC), also known as the IKDC subjective knee evaluation form. Some of the more common questionnaires used to evaluate patients with knee OA are discussed next. Lower extremity functional scales for patients with knee OA There are several questionnaires that may be applicable to evaluating a patient with knee OA, including the WOMAC, the Lower Extremity Functional Scale (LEFS), the Knee Outcome Survey (KOS), and the Knee injury and Osteoarthritis Outcome Score (KOOS). These questionnaires are considered questionnaires of functional outcomes because they include questions about how a patient’s knee or lower extremity injury interferes with their daily activities. The WOMAC is one of the most common questionnaires, and it is useful because it contains several subscales, including a pain, stiffness, and physical function subscale. The LEFS is not specific to the knee joint, but has been used extensively in clinical research studies for patients with lower extremity OA. It contains 20 questions about activities of daily living and can be completed in approximately 5 minutes. This makes it a suitable measure to add to evaluations of patients with knee OA. The KOS is a similar questionnaire that also has been shown to be reliable and valid for patients with knee OA. It contains two subscales, one for activities of daily living and one for sports participation. Therefore, this scale may be appropriate for patients whose primary complaint is inability to participate in sporting activities due to knee pain, instability, Performance-based measures Self-reported outcomes and functional questionnaires often are used in both clinical practice and research studies because they are low-cost, easy to administer, can be completed independently or outside of the clinic, and require no additional equipment or resources. However, patient-reported outcomes often are driven primarily by pain; when a patient’s pain decreases, the score on the questionnaire often improves, even if there has been no actual functional change (Mizner et al., 2011; Stevens-Lapsley, Schenkman, & Dayton, 2011). Therefore, objective performance-based measures of function also should be used when evaluating patients with knee OA. The Osteoarthritis Research Society International recommends several tests to evaluate functional performance (Dobson et al., 2013). These include the following: ● Minimum core set : ○ 30-second chair stand test. ○ 40-meter fast-paced walk test. ○ Stair climb test. ● Additional recommended items : ○ Timed up and go (TUG).
joint in an inferior to superior manner to remove the fluid from the joint space. Once the effusion has been removed from the joint space, the therapist strokes the lateral side of the knee in a superior to inferior manner (see Video 1). If no fluid returns, it is scored 0. It is called trace effusion if a small bulge of fluid returns on the lateral downstroke, or a 1+ if a large amount of fluid returns. If the fluid returns without needing to be stroked back into the joint space, it is graded a 2+, and if the effusion cannot be removed at all, it is graded a 3+. Grading effusion can help to determine if your intervention is causing additional joint inflammation when done in an objective and reliable manner. or weakness associated with knee OA. The KOOS is another common knee questionnaire that has been used extensively for patients with knee OA. This questionnaire consists of 42 questions that comprise five subscales, which are pain, symptoms, activities of daily living, sports and recreation, and quality of life. This questionnaire is similar to the WOMAC. It is a useful scale, particularly because (1) it has been translated and validated in over 40 languages; (2) normative values for older, athletic, healthy, and injured populations have been reported; and (3) it is available free through www.koos.nu. Some of the other questionnaires are considered proprietary and require fees to download, use, or score. Despite its benefits, one of the major drawbacks to the KOOS is the number of questions. Completing 42 questions can be burdensome to the patient, and it may take away from critical evaluation time that may be better spent doing a clinical examination or thorough history. Other scales appropriate for patients with knee OA While the WOMAC, LEFS, KOS, and KOOS are primarily focused on evaluating functional ability and symptom-related disability, there are a variety of other measures that may be appropriate for patients with knee OA. Physical activity, such as walking or endurance exercise, is beneficial to patients with knee OA (Hunter et al., 2015; White et al., 2014). Despite the benefits of physical activity, many patients fear that it will cause further pain or damage to the joint or are afraid of falling during physical activities (Gunn et al., 2017). For these patients, it may be appropriate to objectively evaluate kinesiophobia, or fear of movement. The Fear-Avoidance Beliefs Questionnaire (FABQ) and the Tampa Kinesiophobia scale are two common tools to measure fear of movement, although they were originally designed to evaluate patients with low back pain. Another questionnaire, the Brief Fear of Movement Scale for Osteoarthritis, was recently validated for use in patients with OA. This test was found to have sound psychometric properties and performed well across a heterogeneous group of people with OA (Shelby et al., 2012). ○ 6-minute walk. ○ The 30-second chair stand test counts the number of times a patient can rise out of a chair without using their arms. Because this is a timed test, a patient scores a “0” if they are unable to complete the test. A modified version of this test can be performed using the arms for assistance, but it should be clearly noted that the test was modified in the clinical assessment. The 40-meter fast-paced walk test is a measure of the amount of time it takes a patient to walk 40 meters as quickly but as safely as possible, without running. The course is comprised of a 10-meter linear walking path that the patient will turn and traverse four times for a total of 40 meters. This test is also called the 4×310-meter walking test because it is completed over a 10-meter span. The stair climb test evaluates how fast a patient can ascend and descend a flight of stairs. The number of stairs, the gait pattern (step-to vs. step-over), and whether or not the patient used a handrail should be recorded.
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