The Relationship Between Patient Reported Outcomes Measurement Information System and Timed Up and Go Test in Patients Awaiting Total Knee Arthroplasty
Kaitlyn Elaine Sly, SPT, LAT-ATC
Overview
Physical therapists commonly evaluate and treat people with knee osteoarthritis (OA). In fact, OA is the leading cause of knee pain for adults over 50 years old and may lead to functional limitations, decreased mobility, and reduced quality of life.1 Therefore, physical therapists have the potential to help this patient population. It is critical for clinicians to accurately track patient-reported and functional outcomes for people with severe knee OA, especially if total knee arthroplasty (TKA) surgery is an option. By utilizing outcome measures, physical therapists may objectively report patient status, establish patient prognosis, and recognize those at risk for poor outcomes.
The Timed Up and Go (TUG) test is a commonly used measure in physical therapy practice and has been reported to be valid and reliable.2-5 However, completion of the TUG test might be limited due to lack of space, pain, or inability of the patient to follow multi-step commands. Patient Reported Outcomes Measurement Information System (PROMIS) has the potential to address concerns typically associated with functional outcome measures. PROMIS was established in 2004 by the US National Institutes of Health and may be administered though computerized adaptive testing (CAT).6 It utilizes psychometric techniques to collect information with relative brevity from subjective responses.7,8 PROMIS CAT has the potential to measure a domain, such as physical function, in 4 to 6 questions.9 Unfortunately, there is a lack of available evidence comparing the PROMIS CAT to functional outcome measures. Therefore, the purpose of my capstone project was to determine the strength of the relationship between the PROMIS CAT physical function domain and the TUG test in patients who are candidates for TKA surgery.
Statement of Need
My capstone project aimed to determine the convergent validity of the PROMIS CAT physical function domain compared to the TUG test in a patient population with severe knee OA who have been offered a TKA by an orthopedic surgeon. To my knowledge, research describing the relationship between the PROMIS CAT and TUG test has not been previously reported. Ultimately, it is critical for physical therapists and other health care providers to utilize appropriate, valid, and reliable outcome measures to adequately assess patients.
Products
The products that emerged from my capstone project include an abstract to be submitted to Combined Sections Meeting (CSM) and/or the North Carolina State Chapter Meeting. Additionally, I completed a manuscript draft with the intention to eventually submit to a peer reviewed journal. Please click the links to review my research project and results. My products are intended for an audience of physical therapists and other health care professionals who are interested in research or who treat people with severe knee OA.
Self-Assessment
To evaluate my products, I appraised the necessary requirements for abstract submission to CSM, as well as the requirements for submission to Archives of Physical Medicine and Rehabilitation. Additional evaluation of my manuscript was completed using the Downs and Black checklist for methodological quality.
Overall, my capstone project allowed me to glimpse into the life of a researcher. I am better aware of the time, effort, and coordination that must occur for a research project to be successful. I was fortunate enough to be a part of data collection and analysis. Additionally, I gained a better insight into scholarly writing. I hope to continue to refine my products and submit to a professional conference and/or peer-reviewed journal in the future.
Additional Works
Substantial preparation for this capstone project has occurred through previous class work, including:
- PHYT 752-Evidence Based Practice II: My clinically appraised topic reviewed and appraised research pertaining to the TUG test and the PROMIS in patients with knee OA.
- PHYT 754-Research Experience: This elective class allowed me to review available literature pertaining to my topic, as well as create a narrative literature review.
- PHYT 875-Advanced Orthopedic Assessment: I composed a paper exploring the development of knee OA and the plethora of treatment options for articular cartilage damage.
Additional Sources Read and Reviewed
If wanting to learn more about the topic presented in my capstone, please review these published sources.
Acknowledgements
I thank my capstone project advisor, Dr. Debby Givens, PT, PhD, DPT, for her guidance throughout this process. I greatly appreciate the help of research methodologist, Dr. Richard Faldowski, PhD, for explaining data analysis software and strategy. I appreciate the input on my products from my committee members, Dr. Carla Hill, DPT, MPT, OCS and Dr. Scott Eskildsen, MD. I also thank Dr. Dan Del Gaizo, MD and Kaitlin Healy, MPH from UNC Orthopedics for allowing me to be a part of the research process. Finally, I thank the Division of Physical Therapy faculty members for their dedication to my education, as well as the Class of 2016. I have truly enjoyed my time at the University of North Carolina, and I wish everyone the best of luck on all their future endeavors.
References
- Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT. Increasing prevalence of knee pain and symptomatic knee osteoarthritis: Survey and cohort data. Ann Intern Med. 2011;155(11):725-732.
- Bade MJ, Kittelson JM, Kohrt WM, Stevens-Lapsley JE. Predicting functional performance and range of motion outcomes after total knee arthroplasty. Am J Phys Med Rehabil. 2014;93(7):579-585.
- Podsiadlo D, Richardson S. The timed “up & go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-148.
- Kennedy DM, Stratford PW, Wessel J, Gollish JD, Penney D. Assessing stability and change of four performance measures: A longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskelet Disord. 2005;6:3.
- Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly people: Six-minute walk test, berg balance scale, timed up & go test, and gait speeds. Phys Ther. 2002;82(2):128-137.
- The Patient Reported Outcomes Measurement Information System (PROMIS): A Walk Through the First Four Years. http://www.nihpromis.org/Documents/PROMIS_The_First_Four_Years.pdf. Updated 2009. Accessed April 9, 2016.
- Broderick JE, Schneider S, Junghaenel DU, Schwartz JE, Stone AA. Validity and reliability of patient-reported outcomes measurement information system instruments in osteoarthritis. Arthritis Care Res. 2013;65(10):1625-1633.
- Fries JF, Cella D, Rose M, Krishnan E, Bruce B. Progress in assessing physical function in arthritis: PROMIS short forms and computerized adaptive testing. J Rheumatol. 2009;36(9):2061-2066.
- Hanmer J, Feeny D, Fischhoff B, et al. The PROMIS of QALYs. Health Qual Life Outcomes. 2015;13:122.
Picture available at: http://img.medscape.com/news/2014/ts_141117_knee_pain_800x600.jpg
6 Responses to “The Relationship Between Patient Reported Outcomes Measurement Information System and Timed Up and Go Test in Patients Awaiting Total Knee Arthroplasty”
Katie Sly
Hi Debby,
Thank you for your questions. There are several unexpected aspects of research that I learned throughout this process. First, I was unaware of the great deal of time that goes into data collection. I touched on this with Emily’s question but collecting 59 subjects over a 7-month period seemed slow moving at times. The process also involves multiple people over several disciplines so communicating effectively is very important. Finally, I was made more aware of the intricacies of study design and found that it is easy for bias or confounding to occur. For example, the application of outcome measures in this study was not randomized which may cause order bias. I did not consider this until I was writing the manuscript. On the other hand, sometimes there are changes that one might want to make but cannot. For example, the primary study involved randomization to a PT or No-PT group; unfortunately, the PT could not be paid for so it was difficult to standardize treatment. Overall, there are a lot of considerations when attempting to create a study of high methodological quality.
Though the process was challenging and/or confusing at times, I would be interested in conducting research in the future. I think it is critical to contribute to a body of research that is clinically applicable. Ultimately, I believe my capstone project better prepared me for any research that I might be a part of in the future.
Again, thank you for your questions, and I greatly appreciate your help and guidance throughout the past year!
Katie Sly
Debby Givens
Katie:
This project represents the tremendous amount of work and dedication that you showed to its success. I know you learned many things about the research process that will make you a better consumer and doer of research. It takes a dedicated team, integrity, patience, persistence, and a willingness to learn and to humble yourself at the mercy of others! I am excited to help you with the next steps to submit this as an abstract to CSM and to work towards publication of your manuscript. That’s when you really become hooked – when you are able to stand proudly by your work and see it in a final form. My questions to you are:
1) what was the most unexpected thing that you learned about conducting a pragmatic clinical study?
2) are you more or less likely to pursue a study like this in the future, given what you now know?
Debby
Katie Sly
Hi Emily,
Thank you for your comments and questions. I was fortunate enough to have the help of a biostatistician to complete my analysis. He was able to advise me on the statistical analyses I would need to run (i.e. determine linearity of data, Person’s R correlation vs Spearman’s correlation). This was extremely helpful, because I have to admit, my statistics are fairly rusty. He also was able to advise me on the use of JMP software, which is available through the UNC software acquisition website. Once I had an analysis strategy, utilizing the software was fairly simple. REDCap software was used to collect data. I was able to run a simple analysis of participant characteristics using this software. If you would like the software product information, please see the “Statistical Analysis” section of my manuscript.
In addition to analysis, the data collection process was also challenging. From August 2015 to March 2016, I went to the Ambulatory Care Clinic on a weekly basis to collect data for the primary study Dr. Givens is performing. This data was used in my secondary analysis. In that time, only 59 subjects consented to participate. So, data collection can move slowly, which I found to be a challenging aspect of the research process.
Again thank you for your questions!
Katie Sly
Emily Paul
Hi Katie,
As Jeremy said, your products clearly show the hard work and significant amount of time you invested into this project and specifically, your manuscript.
As you pointed out, it can be difficult for some patients to complete the TUG test because of pain or inability to follow command (especially if they have Dementia). There have been several times that this has posed a difficulty for me in the clinic. Because of this, it would be beneficial for more clinicians to be of the PROMIS. But as you concluded in your paper, a variety of tests are still needed in order to assess patients with knee OA prior to surgery.
In your paper it was clear that you had to complete some statistical analysis. Was this a challenge for you at all? Also, what software did you use. If this wasn’t a challenge for you (it certainly would be for me), what other parts of “the life of a researcher” did you find challenging.
Emily
Katie Sly
Hi Jeremy,
Thanks for your kind words. I am glad we got experience with the research process over the past year, and I think what we have learned will be very useful in the future!
Katie Sly
Jeremy Evans
Katie,
You did a great job putting this together and creating your abstract and manuscript! It’s pretty crazy how long we’ve been working on this research project when you think about our start way back in August. I really appreciate your efforts of reporting the results of the PROMIS, as well as providing all of the other work you’ve done in relation to knee OA, the TUG, and interventions for articular cartilage conditions. As you discussed in your overview, knee OA is such a prevalent condition that it’s really important for us as clinicians to understand how to treat it as well as what tests and measures can be used to measure function and progress. Great job on this project, it is clear that you put a lot of work into it!