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      Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders II: interclinician and intraclinician reliability and validity of the newly established standard rating scales and Japanese Orthopaedic Association rating scale

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          This study evaluated the validity and inter- and intraclinician reliability of (1) the Japanese Society of Surgery of the Foot (JSSF) standard rating system for four sites [ankle-hindfoot (AH), midfoot (MF), hallux (HL), and lesser toe (LT)] and the rheumatoid arthritis (RA) foot and ankle scale and (2) the Japanese Orthopaedic Association’s foot rating scale (JOA scale).


          Clinicians from the same institute independently evaluated participating patients from their institute by two evaluations at a 1- to 4-week interval. Statistical evaluation was as follows. (1) The intraclass correlation coefficient (ICC) was calculated from data collected from at least two examinations of each patient by at least two evaluating clinicians (Data A). (2) Total scores for the two evaluations were determined from the distribution of differences in data between the two evaluations (Data B); each item was evaluated by determining Cohen’s coefficient of agreement. (3) The relation between patient satisfaction and total score was investigated only for patients who underwent surgery (Data C). Spearman’s rank correlation coefficient was obtained.


          Participants were 65 clinicians and 610 patients, including those with disorders of the AH (313), MF (47), HL (153), and LT (50) and those with RA (47). From Data A, the ICC was high for AH and HL by JSSF scales and for AH, MF, and LT by the JOA scale. From Data B, the coefficient showed high validity for both scales for AH, with almost no difference between the two scales; the validity for HL was higher with the JOA scale than with the JSSF scale. From Data C, correlations were significant between patient satisfaction and outcome for AH and HL by the JSSF scales and for AH, HL, and LT by the JOA scale.


          The validity of both scales was high. Clinical evaluation of the therapeutic results using these scales would be highly reliable.

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          Most cited references 22

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          Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes.

          Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.
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            Development of a patient-reported measure of function of the knee.

            The purpose of the present study was to demonstrate the reliability, validity, and responsiveness of the Activities of Daily Living Scale of the Knee Outcome Survey, a patient-reported measure of functional limitations imposed by pathological disorders and impairments of the knee during activities of daily living. The study comprised 397 patients; 213 were male, 156 were female, and the gender was not recorded for the remaining twenty-eight. The mean age of the patients was 33.3 years (range, twelve to seventy-six years). The patients were referred to physical therapy because of a wide variety of disorders of the knee, including ligamentous and meniscal injuries, patellofemoral pain, and osteoarthrosis. The Activities of Daily Living Scale was administered four times during an eight-week period: at the time of the initial evaluation and after one, four, and eight weeks of therapy. Concurrent measures of function included the Lysholm Knee Scale and several global measures of function. The subjects also provided an assessment of the change in function, with responses ranging from greatly worse to greatly better, at one, four, and eight weeks. The Activities of Daily Living Scale was administered to an additional sample of fifty-two patients (thirty-two male and twenty female patients with a mean age of 31.6 years [range, fourteen to sixty-six years]) before and after treatment within a single day to establish test-retest reliability. Factor analysis revealed two dominant factors: one that reflected a combination of symptoms and functional limitations and the other, only symptoms. The internal consistency of the Activities of Daily Living Scale was substantially higher than that of the Lysholm Knee Scale (coefficient alpha, 0.92 to 0.93 compared with 0.60 to 0.73), resulting in a smaller standard error of measurement for the former scale. Validity was demonstrated by moderately strong correlations with concurrent measures of function, including the Lysholm Knee Scale (r = 0.78 to 0.86) and the global assessment of function as measured on a scale ranging from 0 to 100 points (r = 0.66 to 0.75). Analysis of variance with repeated measures revealed significant improvements in the score on the Activities of Daily Living Scale during the eight weeks of physical therapy (F2,236 = 108.13; p < 0.0001); post hoc testing indicated that the change in the score at eight weeks was significantly greater than the change at four weeks and that the change at four weeks was significantly greater than that at one week (p < 0.0001 for both). As had been hypothesized, the patients in whom the knee had somewhat improved had a significantly smaller change in the score, both at four weeks (F1,189 = 33.50; p < 0.001) and at eight weeks (F1,156 = 22.48; p < 0.001), compared with those in whom the knee had greatly improved. The test-retest reliability coefficient (intraclass correlation coefficient[2,1]) was 0.97. These results suggest that the Activities of Daily Living Scale is a reliable, valid, and responsive instrument for the assessment of functional limitations that result from a wide variety of pathological disorders and impairments of the knee.
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              The American academy of orthopaedic surgeons outcomes instruments: normative values from the general population.

              The collection of population-based normative data is a necessary step in the process of standardization of eleven American Academy of Orthopaedic Surgeons (AAOS) musculoskeletal outcomes measures. These data serve as comparative normative scores with which to assess the effectiveness of treatment regimens in clinical practice settings and to study the clinical outcomes of treatment in musculoskeletal research. With use of a panel mail methodology, self-reported data on the eleven AAOS musculoskeletal outcomes measures were collected from the general population of the United States. The overall response rate of 67.4% for the various surveys met study expectations. For the eleven measures, the range of the confidence intervals for the surveys was +/-1.6% to +/-2.3%, exceeding the +/-3% set a priori. With use of the Multitrait/Multi-Item Analysis Program, all of the scales within each of eleven measures exhibited high internal reliability as well as discriminant and convergent validity. Items within each of the scales contributed roughly equal proportions of information to the total scale scores. All eleven instruments met study expectations for providing reliable and valid normative data for use in clinical and research settings.

                Author and article information

                J Orthop Sci
                Journal of Orthopaedic Science
                Springer-Verlag (Tokyo )
                September 2005
                : 10
                : 5
                : 466-474
                [ ]Department of Orthopaedic Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kanagawa, 216-8511 Japan
                [ ]Department of Orthopaedic Surgery, Keio University, Tokyo, Japan
                [ ]Department of Orthopaedic Surgery, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan
                [ ]Department of Orthopaedic Surgery, Osaka Medical College, Osaka, Japan
                [ ]Department of Orthopaedic Surgery, Sapporo Medical University, Hokkaido, Japan
                [ ]Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
                [ ]Department of Orthopaedic Surgery, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
                [ ]Nomura Seikeigeka Ganka Clinic, Yamaguchi, Japan
                [ ]Department of Orthopaedic Surgery, Tohoku University, Miyagi, Japan
                [ ]Unit of Medical Statistics, Faculty of Education and Culture, St. Marianna University School of Medicine, Kanagawa, Japan
                © The Japanese Orthopaedic Association 2005
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                © The Japanese Orthopaedic Association 2005



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