Pain, physical functioning and quality of life of individuals awaiting total joint replacement: a longitudinal study

Objectives To investigate if pain, physical function and the quality of life changed among adults with osteoarthritis while on the waiting list for hip or knee joint replacement. Methods A longitudinal study of patients listed for primary hip or knee joint replacement. Participants were interviewed at baseline (n = 105) and followed up at 3 (n = 84), 6 (n = 47) and 9 months (n = 24), or until their joint replacement. Measurement tools used were a visual analogue scale (VAS), Western Ontario and McMaster’s Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study Short Form Health Survey (SF‐36). Results Baseline data indicated high levels of pain as measured by VAS [mean 7.0 (SD 2.2)] and WOMAC pain [mean 11.2 (SD 3.5)]. At baseline, the mean physical function measured by WOMAC was 40.3 (SD 12.1). At the 3‐month follow‐up, there was significant deterioration in VAS pain scores (0.6; 95% CI mean difference 0.3, 1.0); WOMAC pain scores (1.2; 95% CI mean difference 0.7, 1.8) and WOMAC physical function scores (4.8; 95% CI mean difference 2.8, 6.7) compared with baseline. Conclusion The often long wait for joint replacement surgery and deterioration in pain and physical function has highlighted the need for active management by health professionals while patients are on the waiting list.     

Determinants of pain, functional limitations and health-related quality of life six months after total knee arthroplasty: results from a prospective cohort study

Background

Total knee arthroplasty (TKA) is an effective procedure. However, for some patients, the outcomes are not satisfactory. Identification of TKA determinants could help manage these patients more efficiently. The purpose of this study was to identify pre- and perioperative determinants of pain, functional limitations and health-related quality of life (HRQoL) 6 months after TKA.

Methods

138 participants were recruited from 3 hospitals in Quebec City, Canada and followed up until 6 months after surgery. Data were collected through review of the subjects’ medical files and structured telephone interviews before and 6 months after TKA. Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Independent variables included demographic, socioeconomic, psychosocial, clinical and surgical characteristics of participants as well as data on health services utilization. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.

Results

Higher preoperative pain, cruciate retaining implants and the number of complications were significantly associated with worse pain 6 months after TKA (p < 0.05) and explained 11% of the variance of the WOMAC pain score. Higher preoperative functional limitations, being single, separated, divorced or widowed, being unemployed or retired and the number of complications were significantly associated (p < 0.05) with worse functional limitations 6 months after TKA and explained 16% of the variance of the WOMAC function score. Lower preoperative HRQoL, contralateral knee pain, higher psychological distress and comorbidities were significantly associated (p < 0.05) with worse HRQoL 6 months after TKA and explained 23% of the variance of the SF-36 physical functioning score.

Conclusions

Several variables were found to be significantly associated with worse outcomes 6 months after TKA and may help identify patients at risk of poorer outcome. The identification of these determinants could help manage patients more efficiently and may help target patients who may benefit from extensive rehabilitation.     

Patients waiting for a hip or knee joint replacement: is there any prioritization for surgery?

Objective To investigate whether patients are prioritized for joint replacement surgery on the basis of severity of osteoarthritis, pain and physical functioning. Method A total of 105 patients on the waiting list for primary total knee or hip replacement from a UK regional orthopaedic centre were interviewed at baseline and followed up at 3, 6 and 9 months or until joint replacement. Measurement tools were the visual analogue scale (VAS), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index and the Oxford hip or knee score. Results Most participants (81, 77%) were categorized on the waiting list as ‘routine’, despite having high levels of pain according to the measurement scales. There was no significant correlation between the waiting list categorization and the actual waiting time for a hip or knee joint replacement operation (Kendall’s tau = 0.17; P = 0.062) and the waiting list categorization did not appear to ensure that patients were operated upon earlier. There were also no significant differences in measures (VAS pain, WOMAC and Oxford hip or knee scores) between those individuals who had their operations earlier (before 6 months) compared with those participants who had their operations later (6 months or greater) or even not at all. Of the 105 patients who were listed for joint replacement, 24 (25%) patients did not have their operation due to: a medical delay (14); self‐delay/cancellation (7); arthroscopy instead (2); and death (1). Conclusion With the expected increase in demand for joint replacement, there needs to be a re‐examination of assessment procedures of patients listed for joint replacement. The use of measurement tools to assess symptoms such as pain and physical function would be one way forward.     

Evaluating waiting time effect on health outcomes at admission: a prospective randomized study on patients with osteoarthritis of the knee joint

AIMS: To evaluate the effect of waiting on health-related quality of life (HRQoL), pain and physical function in patients awaiting primary total knee replacement (TKR) due to osteoarthritis. METHODS: Some 438 patients awaiting TKR were randomized to a short waiting time (WT) group (< or =3 months) or a non-fixed WT group. In the final assessment, 310 patients (213 women) with a mean age of 68 years were included. HRQoL was measured on being placed on the waiting list and again at hospital admission using the generic 15D. Patients' self-report pain and physical function were evaluated using a scale modified from the Knee Society Clinical Rating System. RESULTS: The median WTs for patients with short and non-fixed WT were 73 days (range 8-600 days) and 266 days (range 28-818 days), respectively. At admission, as assessed by the intention-to-treat analysis, there were no statistically significant differences between the groups in the 15D total score and disease-specific pain and function. CONCLUSIONS: Our study showed that longer WT did not result in worse pre-operative HRQoL.     

Patients on the waiting list for total hip replacement: a 1‐year follow‐up study

Untreated osteoarthritis (OA) in the hip causes pain and reduced physical and social functioning. The aim of this study was to evaluate the effect of waiting time on health‐related quality of life (HRQOL), functional condition and dependence on help at the time of surgery and during follow‐up 1 year after surgery. A further aim was to elucidate possible differences between men and women. Two hundred and twenty‐nine consecutively included patients with OA in the hip were interviewed when assigned to the waiting list, again 1 week prior to surgery with unilateral total hip replacement (THR), and 1 year after surgery. Health‐related quality of life and function were measured using the Nottingham Health Profile, EuroQoL and the Western Ontario and McMaster Universities Osteoarthritis Index. The result showed that the average waiting time was 239 days, that 15% of the patients were operated on within 3 months, and that 21% had to wait more than 6 months. At the time of surgery, HRQOL had deteriorated significantly (p < 0.05) and the number of patients receiving support from relatives had increased from 31% to 58% during the wait. At the 1‐year follow‐up, both HRQOL and functional condition had improved significantly despite the wait, and the need for support from relatives had decreased to 11% (p < 0.001). In conclusion, long waiting time for THR is detrimental to patients’ HRQOL causing reduced functional condition, pain and increased need for support from relatives, which limit the independence in daily life.     

Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial

AIMS AND OBJECTIVES: To assess the effectiveness of pre- and post-operative physiotherapy at home for unilateral total knee replacement (TKR). METHODS: In this pragmatic randomized controlled trial set in participants' homes (four primary care trust areas) and physiotherapy outpatients in a South Yorkshire teaching hospital trust, 160 osteoarthritis patients waiting for unilateral TKR were randomly allocated to intervention (home) group (n=80) or control (hospital outpatient) group (n=80). The intervention group had pre- and post-operative home visits for assessment and treatment by a community physiotherapist. Outcome measures were health-related quality of life (HRQoL), measured by the Western Ontario McMaster Osteoarthritis index (WOMAC) and the Short Form 36 health survey (SF-36) pre-operatively and at 12 weeks post-TKR operation; patient satisfaction; and NHS resource use. RESULTS: No significant differences were observed between the two treatment groups in the primary outcome measure, the WOMAC pain score, or any other HRQoL score. The home group had a significantly greater mean number of physiotherapy sessions than the hospital group [mean difference 5.2 sessions, 95% confidence interval (CI)=-6.3 to -4.1; P=0.001]. There was no significant difference in the total NHS costs per patient between groups. However, home physiotherapy for TKR was significantly more expensive (mean difference-pound136.5, 95% CI=- pound160 to-pound113; P=0.001). Patients were equally satisfied with physiotherapy at home or in hospital; however, more of the home group would choose their location for physiotherapy again. CONCLUSIONS: Although home physiotherapy was as effective and as acceptable to patients as hospital outpatient physiotherapy for unilateral TKR, it was more expensive. Additional pre-operative home physiotherapy did not improve patient-perceived health outcomes.     

Electronic medical records for appropriate timing of arthroplasty

Objective The objective of this study was to analyse whether electronic medical records (EMRs) of total hip and knee arthroplasty can be used to manage the optimal time of surgery. Design Retrospective registry study. Setting Data on waiting time for operation, age, gender, body mass index (BMI), operable condition pre‐operatively and the functional scores at 3 and 12 months after arthroplasty were obtained from EMRs and from an electronic implant database. Participants The participants of the study were 162 arthroplasty patients. Results An increase in waiting time of hip patients decreased significantly the change in functional scores at 3 months (P = 0.006, n = 56). The score reductions of older patients were more marked than of younger patients and of patients of normal weight compared with overweight patients. In patients undergoing knee arthroplasty, the association between a longer waiting time and profound change in functional score was statistically significant after 1 year (P = 0.03, n = 75). After adjustment of the results for pre‐operative scores, age group, BMI class, American Society of Anesthesiologists class and gender, the waiting time turned out to affect only the scores of patients undergoing hip arthroplasty at 3 months post‐operatively. Conclusions Data from electronic patient entries complemented with data of the operable condition can be used for defining the optimal operation time with regard to the pre‐operative condition of the patients. The implication of prolonged waiting times was not very profound, but elderly patients benefit from a short waiting time.     

The burden of waiting for hip and knee replacements in Ontario*

The objectives of this study were to assess the impact of major joint replacements in reducing pain and disability and to describe the burden of pain and disability that could be avoided by ordering the queues with respect to severity of disease. A secondary goal was to compare the uses of a general health status measure, the Short Form Health Survey (SF-36), and a disease-specific measure, the Western Ontario McMaster Osteoarthritis Index (WOMAC), for accomplishing the objectives. The results are based on interviews with 209 patients before and after they had surgery. Only 15.9% of the patients had surgery within 3 months' waiting time, 19.2% waited 4–6 months, 30.7% waited 7–9 months, and the remaining 34.1 % waited a year or more. The waiting times were unrelated to the seventy of pain or disability reported in the initial interview. Following surgery, there were large reductions in the WOMAC scores for pain, stiffness and difficulty in functioning. The SF-36 showed substantial improvements in relief from pain and in physical functioning, and reductions in role limitation due to physical problems, but not for scores related to mental health. The WOMAC scores were more responsive to the benefits of surgery than the SF-36 scores. Queuing systems keyed on burden of symptoms could reduce the burden of pain and disability suffered by patients awaiting surgery. The improvements from hip and knee replacements suggest that equitable access for these procedures should be a priority in Ontario.     

Chronic disease management programme in people with severe knee osteoarthritis: efficacy and moderators of response.

AIMS: To establish (1) the efficacy of a six-week chronic disease management programme for knee osteoarthritis and (2) whether previous physiotherapy or being wait listed for surgery moderated the outcome of the programme.DESIGN: A pretest, posttest design with multivariate statistical modelling.PARTICIPANTS: One hundred and twenty-one people with severe osteoarthritis who were waiting, or being considered, for surgery.METHODS AND MEASURES: Western Ontario Osteoarthritis Index (WOMAC) scores, arthritis self-efficacy, distress and a patient-rated global indicator of response were collected at baseline, 6 and 12 weeks. History of previous physiotherapy, waiting list status, symptom duration, New Zealand disease severity score, radiographic changes and self-perceived need for surgery were recorded at baseline.RESULTS: There were moderate improvements in most outcomes; WOMAC function decreased by 0.29, WOMAC pain by 0.27, pain self-efficacy by 4.4, function self-efficacy by 5.6 and visual analogue scale (VAS) distress by 0.2 (effect sizes ranging from 0.3 to 0.5 at 12 weeks). Waiting list status was a significant modifier for function, pain, distress and self-related outcomes. Participants on the waiting list for surgery experienced lesser improvements. Previous physiotherapy was associated with greater improvements in WOMAC scores at six weeks, but not at 12 weeks.CONCLUSION: The chronic disease management programme could be considered for people with severe knee osteoarthritis, but should be given prior to referral and placement on the waiting list for surgery. Previous physiotherapy should not preclude people from participating in a chronic disease management programme.     

Predictors of functional ambulation and patient perception following total knee replacement and short-term rehabilitation

Purpose.?To investigate whether measured and patient-perceived function 6 months after total knee replacement (TKR) can be predicted from factors measured during post-operative rehabilitation.

Method.?Retrospective analysis of data from a randomised clinical trial involving 100 patients after TKR. High- and low-performing subjects for pain, WOMAC score and 6-min walk test (6MWT) at 2, 8 and 26 weeks post-TKR were partitioned and analysed. Multiple stepwise regression analysis was applied to the contributing factors to determine associations with outcome.

Results.?Prediction of outcome was unconvincing based upon variables recorded at 2 weeks; however, status at 8 weeks was a better indicator of functional performance and perception at 26 weeks. 6MWT at 26 weeks could be predicted from VAS pain scores and 6MWT at 8 weeks (r?=?0.789; p?<?0.001). Prediction of pain and patient perceived function at 26 weeks was also dependent on performance in 6MWT at 8 weeks (r = 0.51; p?<?0.05). Males and those with lower body mass index values demonstrated better functional outcomes.

Conclusion.?Functional status at 2 weeks post-surgery gives few indicators of ultimate status, possibly because of pain, joint swelling and other immediate post-operative factors. However, measurements taken at 8 weeks, following an outpatient-based exercise programme, provides a reasonable estimate of performance and response 26 weeks after surgery. Patient and clinician expectations for longer-term recovery could be informed by these findings.     

Analgesia and Improved Performance in a Patient Treated by Cooled Radiofrequency for Pain and Dysfunction Postbilateral Total Knee Replacement

Total knee replacement (TKR) is a terminal therapy for osteoarthritis (OA) of the knee. While TKR results are generally satisfactory, a significant proportion of patients experience persistent pain lasting > 3 months following surgery, even after a technically acceptable operation. Knee pain of any kind post‐TKR has been reported in up to 53% of patients, while 15% of patients have reported severe pain. Pain post‐TKR is worse than preoperative pain in 7%, often resulting in surgical revision. The clinical experience of a patient that originally presented to an orthopedic surgeon with OA of both knees demonstrates an alternative relatively noninvasive pain management strategy: cooled radiofrequency (CRF) ablation of sensory nerves.     

Waiting list management: priority criteria or first‐in first‐out? A case for total joint replacement

Background Total joint replacements are interventions with large waiting times from indication to the surgery management. These patients can be managed in two ways; first‐in first‐out or through a priority tool. The aim of this study was to compare real time on waiting list (TWL) with a priority criteria score, developed by our team, in patients awaiting joint replacement due to osteoarthritis. Methods Consecutive patients placed on waiting list were eligible. Patients fulfilled a questionnaire which included items of our priority tool and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) specific questionnaire. Other priority items were extracted from the clinical history. The priority tool gives a score from 0 to 100 points, and three categories (urgent, preferent and ordinary). We studied the differences among categories and TWL by means of one‐way analysis of variance. Correlational analysis was used to evaluate association among priority score and TWL and WOMAC baseline and gains at 6 months with priority score and TWL. Results We have studied 684 patients. Women represented 62% of sample. The mean age was 70 years. There were not association between the categories of priority score and TWL (P = 0.12). The rho correlation coefficient between TWL and priority score was ?0.11. Among baseline WOMAC scores and priority score, the rho coefficients were 0.79, 0.7 and 0.52 with function, pain and stiffness dimensions, respectively. There were differences in the mean scores of WOMAC dimensions according to the three priority categories (P < 0.001) but no with TWL categories. Data of gains in both health‐related quality of life dimensions at 6 months were similar, with differences according to priority categories but no regarding TWL. Conclusions The results of the study support the necessity of implementing a prioritization system instead of the actual system if we want to manage the waiting list for joint replacement with clinical equity.     

滑膜切除对全膝关节置换术术后失血及功能恢复的影响

目的 探讨全膝关节置换术（TKR）时同时行滑膜切除术对术后失血及膝关节功能恢复的影响.方法 对我院2010年9月至2011年9月因骨性关节炎（OA）入院并拟行单侧TKR的患者187例,随机分为两组,试验组（男30例,女66例）为TKR术中切除滑膜,对照组（男18例,女73例）为TKR术中保留滑膜.通过Gross方程计算出两组术后隐性失血量,比较两组术后输血率、引流量、隐性失血量、住院时间、手术时间、术后24 h、3d及4周平均疼痛视觉模拟评分（VAS）、术后4周及12个月时膝关节协会临床评分和功能评分（KSS）、术后12个月浮髌试验阳性率等指标.结果 两组隐性失血量差异有统计学意义（P=0.042）,两组引流量差异有统计学意义（P=0.03）,两组手术时间差异有统计学意义（P=0.006）,两组术后输血率、术后平均住院天数、术后3d膝关节活动度差异无统计学意义.两组术后24 h、3d及4周后平均VAS疼痛评分差异无统计学意义.两组术后4周平均KSS临床评分及功能评分差异无统计学意义.两组术后12个月平均KSS临床评分及功能评分差异无统计学意义.两组术后12个月浮髌试验阳性率差异无统计学意义.结论 在行TKR治疗OA时,术中行滑膜切除与保留滑膜相比,在患肢功能恢复及疼痛缓解方面无任何优势,只增加了术后出血及延长了手术时间.     

Effects of Inpatient Rehabilitation in Hip and Knee Osteoarthritis: A Naturalistic Prospective Cohort Study With Intraindividual Control of Effects

Objectives

To quantify pain, function, and health-related quality of life in comparison with normative data, and to quantify intervention effects.

Design

Naturalistic cohort study without a control group. Correction of the effects observed during the intervention by those observed during waiting time prior to the intervention.

Setting

Inpatient rehabilitation clinic.

Participants

Patients with hip (n=88) and knee (n=164) osteoarthritis.

Intervention

Comprehensive, multidisciplinary inpatient rehabilitation lasting 3 weeks.

Main Outcome Measures

Medical Outcomes Study 36-Item Short-Form Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results

Four or more comorbid conditions had 45.3% of the hip and 51.8% of the knee patients on entry to and discharge from the clinic. On entry, physical health and some dimensions of psychosocial health were significantly diminished compared with population norms. At discharge, hip osteoarthritis had improved by a corrected effect size of .20 to .47 in pain, .04 to .39 in function, and −.04 to .32 in psychosocial health. Knee osteoarthritis showed a corrected effect size of .43 to .62 in pain, .19 to .51 in function, and .19 to .30 in psychosocial health. All but 1 effect in WOMAC pain and WOMAC function were higher than the minimal clinically important differences.

Conclusions

Hip and knee osteoarthritis patients admitted to the inpatient intervention were affected by a substantial burden of disease and comorbidities. Inpatient rehabilitation resulted in small to moderate, statistically significant, and clinically important improvements in pain, function, and psychosocial health.     

Weight-bearing asymmetry during sit-stand transitions related to impairment and functional mobility after total knee arthroplasty

Christiansen CL, Bade MJ, Judd DL, Stevens-Lapsley JE. Weight-bearing asymmetry during sit-stand transitions related to impairment and functional mobility after total knee arthroplasty.

Objectives

To examine changes in weight-bearing (WB) asymmetry during sit-stand transitions for individuals during the first 6 months after unilateral total knee arthroplasty (TKA). Relationships between WB asymmetry, clinical measures of knee impairment, and functional mobility also were evaluated.

Design

Prospective repeated-measures design.

Setting

Clinical research laboratory.

Participants

People (N=36) with knee osteoarthritis (OA) scheduled to undergo unilateral TKA and a control (CTL) group (N=17 healthy people) were enrolled.

Intervention

The TKA group participated in acute, home, and outpatient phases of exercise-based rehabilitation.

Main Outcome Measures

WB asymmetry measured during a 5-Times Sit-to-Stand Test (FTSST) based on average vertical ground reaction force under each foot, self-reported knee pain using a numerical pain rating scale, knee active range of motion symmetry, knee extensor strength symmetry, FTSST time, 6-minute walk test distance, and Stair Climbing Test time.

Results

Compared with preoperative values, the TKA group showed greater WB asymmetry at 1 month after surgery (P<.001). By 6 months, the TKA group had less WB asymmetry than preoperative values (P<.001), which was not different from the CTL group. Symmetry in WB correlated with functional outcomes and symmetry of quadriceps strength for the TKA group 6 months postoperatively.

Conclusions

Patients with unilateral knee OA showed WB asymmetry during sit-stand transitions early after unilateral TKA that improved by 6 months after surgery and was no different from that for healthy people of similar age. For people in the first 6 months after TKA, greater symmetry was related to better function and strength symmetry.     

In the queue for total joint replacement: patients' perspectives on waiting times

We assessed patients on the waiting lists of a purposive sample of orthopaedic surgeons in Ontario, Canada, to determine patients' attitudes towards time waiting for hip or knee replacement. We focused on 148 patients who did not have a definite operative date, obtaining complete information on 124 (84%). Symptom severity was assessed with the Western Ontario/McMaster Osteoarthritis Index and a disease-specific standard gamble was used to elicit patients' overall utility for their arthritic state. Next, in a trade-off task, patients considered a hypothetical choice between a 1-month wait for a surgeon who could provide a 2% risk of post-operative mortality, or a 6-month wait for joint replacement with a 1% risk of post-operative mortality. Waiting times were then shifted systematically until the patient abandoned his/her initial choice, generating a conditional maximal acceptable wait time.
Patients were divided in their attitudes, with 57% initially choosing a 6-month wait with a 1% mortality risk. The overall distribution of conditional maximum acceptable wait time scores ranged from 1 to 26 months, with a median of 7 months. Utility values were independently but weakly associated with patients' tolerance of waiting times (adjusted R -square = 0.059, P = 0.004). After splitting the sample along the median into subgroups with a relatively 'low' and 'high' tolerance for waiting, the subgroup with the apparently lower tolerance for waiting reported lower utility scores ( z = 2.951; P = 0.004) and shorter times since their surgeon first advised them of the need for surgery ( z = 3.014; P = 0.003).
These results suggest that, in the establishment and monitoring of a queue management system for quality-of-life-enhancing surgery, patients' own perceptions of their overall symptomatic burden and ability to tolerate delayed relief should be considered along with information derived from clinical judgements and pre-weighted health status instruments.     

Is discharge knee range of motion a useful and relevant clinical indicator after total knee replacement? Part 2

Objective Knee range of motion (ROM) at discharge from acute care is used as a clinical indicator following total knee replacement (TKR) surgery. This study aimed to assess the clinical relevance of this indicator by determining whether discharge knee ROM predicts longer‐term knee ROM and patient‐reported knee pain and function. Methods A total of 176 TKR recipients were prospectively followed after discharge from acute care. Outcomes assessed included knee ROM and Oxford knee score post rehabilitation and 1 year post surgery. Discharge ROM and other patient factors were identified a priori as potential predictors in multiple linear regression modelling. Results A total of 133 (76%) and 141 (80%) patients were available for follow‐up post rehabilitation [mean postoperative week 8.1 (SD 2.7)] and at 1 year [mean postoperative month 12.1 (SD 1.4)], respectively. Greater discharge knee flexion was a significant (P < 0.001) predictor of greater post‐rehabilitation flexion but not 1‐year knee flexion (P < 0.083). Better discharge knee extension was a significant predictor of better post‐rehabilitation (P = 0.001) and 1‐year knee extension (P = 0.013). Preoperative Oxford score and post‐rehabilitation knee flexion independently predicted post‐rehabilitation Oxford score, and gender predicted 1‐year Oxford score. Discharge ROM did not significantly predict Oxford score in either model. Conclusion The finding that early knee range predicts longer‐term range provides clinical evidence favouring the relevance of discharge knee ROM as a clinical indicator. Although longer‐term patient‐reported knee pain and function were not directly associated with discharge knee ROM, they were associated with ROM when measured concurrently in the sub‐acute phase. No causal effect has been demonstrated, but the findings suggest it may be important for physiotherapists to maximize range in the early and sub‐acute periods.     

Validation of a prioritization tool for patients on the waiting list for total hip and knee replacements

Rationale and aims Total hip and knee replacements, usually, have long waiting lists. There are several prioritization tools for these kind of patients. A new tool should undergo a standardized validation process. The aim of the present study was to validate a new prioritization tool for primary hip and knee replacements. Methods We carried out a prospective study. Consecutive patients placed on the waiting list were eligible for the study. Patients included were mailed a questionnaire which included, among other questions, the seven items of the priority tool and the Western Ontario and McMasters Universities Arthritis Index (WOMAC) specific questionnaire. The priority tool gives a score from 0 to 100 points, and three categories (urgent, preferent and ordinary). We studied the content and construct validity. We used Student's t‐test or one‐way analysis of variance. Correlational analysis was used to evaluate convergent and discriminate validity. Results The sample consisted of 838 patients (62.3% were female), with mean age of 70.2 years (SD 8.4). A total of 55.5% patients underwent knee replacement. Given that the tool was elaborated by patients and orthopaedic surgeons, it shows a good content validity. The priority score was statistically different (P < 0.001) among the three urgency categories created. The scores of the three WOMAC dimensions showed differences (P < 0.001) by the three urgency categories created. The correlations between the priority score and WOMAC dimensions were 0.79 (function), 0.69 (pain) and 0.51 (stiffness). The correlations between WOMAC items and items from priority tool were greater (0.47–0.69) between items measuring similar constructs than those measuring different constructs (0.27–0.49). These data are similar in both joints. Conclusions Results support the validity of the prioritization tool to be used with patients waiting for hip or knee replacement.     

Health-related quality of life, disability and severity of disease in patients with migraine attending to a specialty headache center

(Headache 2010;50:1576‐1586) Background.— The impact of migraine on patients’ daily life has been evaluated in several studies. The relationship between disability and health‐related quality of life (HRQoL) in patients with migraine, however, has not been systematically evaluated. Objective.— To assess the impact of migraine on patients’ HRQoL and disability patterns and to describe the relationship between disability and HRQoL in patients with migraine attending a specialty Italian headache center according to the biopsychosocial model of disability endorsed by the International Classification of Functioning, Disability and Health. Methods.— In this observational study, adult patients with migraine were consecutively recruited. Disability was measured with the MIDAS (Migraine Disability Assessment) and the WHO‐DAS II (World Health Organization Disability Assessment Schedule), HRQoL with the SF‐36 (Medical Outcome Survey 36‐item Short‐Form Health Survey). Spearman's rank correlation between MIDAS score, SF‐36 and WHO‐DAS II scales was performed to evaluate the relationships between quality of life and disability. The impact of migraine on disability and HRQoL was assessed by comparing WHO‐DAS II and SF‐36 scores against Italian normative values, and by evaluating the different disability and HRQoL profiles in patients with different severity of migraine, defined according to migraine frequency and pain intensity. Results.— A total of 102 patients with migraine (87 females) were enrolled. Mild to moderate correlations were reported between WHO‐DAS II and SF‐36's PCS (r = ?0.67, P < .01) and MCS (r = ?0.36, P < .05) scales; MIDAS score correlations to SF‐36's PCS (r = ?0.44, P < .01) and MCS (not significant) were lower than WHO‐DAS II summary score. The correlation between MIDAS score and the WHO‐DAS II summary score was mild (r = ?0.36, P < .05). The majority of HRQoL and disability scales (with the exception of SF‐36's Physical Functioning, and WHO‐DAS II Getting along with people scales) scored significantly lower than normative values. A trend towards worsening of both HRQoL and disability, consistent with increasing migraine severity, was reported (Mann‐Whitney's U = 119.5 for MIDAS; U = 113.0 for WHO‐DAS II summary score, both with P < .01; U = 152.9 for PCS; U = 171.0 for MCS, both with P < .05) Conclusions.— In migraineurs attending an Italian specialty headache clinic, disability scores were worse and HRQoL scores lower than those of the general population, and worsened consistently with increased migraine severity. Measures of HRQoL and disability evaluate different psychosocial aspects of migraine and researchers should continue to employ them in public health and clinical research on migraine. They provide information on a poorly recognized part of migraine's burden, where economic impact is minimal but there are important effects on patients’ daily lives in terms of interpersonal relationships, perceived quality of life and emotional status.     

Chronic pain and depression in the quality of life of women with migraine--a controlled study

Background.— Migraine is comorbid to depression and widespread chronic pain (WCP), but the influence of these conditions on the health‐related quality of life (HRQoL) of individuals with episodic (EM) and chronic migraine (CM) is poorly understood. Objective.— To assess the prevalence of depressive symptoms and WCP in individuals with EM and CM, as well as to estimate the joint impact of these conditions on the HRQoL of these individuals. Methods.— All women aged 18 to 65 years with a first diagnosis of EM or CM from September of 2006 to September of 2008 seen in an outpatient headache service were invited to participate. They were asked to attend a separate appointment in the service, and to bring another woman of similar age that also agreed to participate. Depressive symptoms were assessed using the Beck Depression Inventory. Questions about WCP followed the protocol of the American College of Rheumatology. HRQoL was assessed using the Short‐Form 36 (SF‐36). Multivariate analysis modeled HRQoL as a function of headache status, depressive symptoms, and pain, using quantile regression. Results.— Sample consisted of 179 women, 53 in the EM group, 37 in the CM group and 89 in control group. Groups did not differ by demographics. Mean scores of SF‐36 were 53.6 (standard deviation [SD] = 23.5) for EM, 44.2 (SD = 18.5) for CM and 61.8 (SD = 21.5) for controls. In multivariate analysis, SF‐36 scores were predicted by a CM status (P = .02; ?10.05 [95% CI ?18.52; ?1.58]) and by a Beck Depression Inventory score (P < .01; ?1.27 [95% CI ?1.55; ?0.99]). The influence of WCP in the SF‐36 scores approached significance (P = .08; ?0.78 [95% CI ?1.64; 0.88]). Age did not contribute to the model. Conclusion.— Women with migraine are at an increased chance of WCP, and the chance increases as a function of headache frequency. Both depressive symptoms and CM independently predict HRQoL status. (Headache 2012;52:400‐408)