title: Are current foot- and ankle outcome measures appropriate for the evaluation of treatment for osteoarthritis of the ankle?: Evaluation of ceiling effects in foot- and ankle outcome measures. Responsiveness of Self‐Reported and Objective Measures of Disease Severity in Carpal Tunnel Syndrome Comparative responsiveness of generic versus disease-specific and weighted versus unweighted health status measures in carpal tunnel syndrome. Clinical Interpretation of a Lower-Extremity Functional Scale–Derived Computerized Adaptive Test Preoperative PROMIS Scores Predict Postoperative Success in Foot and Ankle Patients Evaluation of the PROMIS physical function item bank in orthopaedic patients. An Evaluation of the Use of Retrospectively Acquired Preoperative AOFAS Clinical Rating Scores to Assess Surgical Outcome after Elective Foot and Ankle Surgery Measurement of pain. The Foot Function Index: a measure of foot pain and disability. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. Clinical interpretation of computerized adaptive test outcome measures in patients with foot/ankle impairments.
abstract: BACKGROUND Many PROMs used for evaluation of ankle  osteoarthritis  are not vali date d for this purpose . We hypothesize that frequently used PROMs have an early ceiling or floor effect . METHODS We prospect ively collected data from patients with ankle osteoarthritis between 2011 and 2013 . At baseline visit patients completed the Foot and Ankle Outcome Score , the Ankle Osteoarthritis Score , the American Orthopaedic Foot and Ankle Society scale , a visual analogue scale for pain and quality of life . Outcomes were analyzed for floor or ceiling effects . RESULTS 197 patients were included in the study . A floor effect was present for the AOFAS and VAS for pain in all groups . Floor and ceiling effect are absent for the FAOS outcome measure for all groups . CONCLUSIONS Physicians should be aware of floor or ceiling effects when evaluating treatment using patient reported outcome measures . The FAOS outcome measure lacks early ceiling or floor effects Responsiveness , the ability to detect meaningful clinical change , is a critical attribute of instruments used to evaluate outcomes of treatments . The authors hypothesized that self-administered symptom severity and functional status question naires are more responsive to clinical improvement after carpal tunnel release than traditional physical examination measures of strength and sensibility . Data were obtained from a r and omized clinical trial of  endoscopic versus open carpal tunnel release  conducted in four university medical centers . Patients were evaluated before surgery and 3 months after surgery . Seventy-four patients indicating that they were more than 80 % satisfied with the results of surgery were assumed to have clinical ly meaningful improvement and were the focus of the analysis . Evaluations included question naires assessing symptom severity , functional status , and activities of daily living as well as measurement of grip , pinch , and abductor pollicus brevis strength , and 2-point discrimination and Semmes-Weinstein pressure sensibility . Responsiveness was calculated with the st and ardized response mean ( mean change/st and ard deviation of change ) as well as the effect size ( mean change/st and ard deviation of baseline values ) . The symptom severity scale was four times as responsive , and the functional status and activities of daily living scales were twice as responsive , as the measures of strength and sensibility . Self-administered symptom severity and functional status scales are much more responsive to clinical improvement than measures of neuromuscular impairment and should serve as primary outcomes in clinical studies of therapy for carpal tunnel syndrome OBJECTIVES The authors evaluated the relative responsiveness to change of generic versus disease-specific and unweighted versus weighted health status measures in carpal tunnel syndrome ( CTS ) . METHODS Data were obtained from 196 subjects followed in a prospect i ve community-based cohort study in Maine who underwent carpal tunnel release ( The Maine Carpal Tunnel Syndrome Study ) . Patients were evaluated before and 6 months after surgery . The disease-specific , unweighted severity score was derived from the vali date d Carpal Tunnel Syndrome Assessment Question naire . Patients were asked to rate the importance of each symptom included in the severity score . Each severity question was weighted by its importance , creating a disease-specific weighted score . Generic instruments were the SF-36 , SF-12 , and a  Quality of Life Rating Scale .  Sensitivity to change was calculated with the st and ardized response mean ( SRM , mean change/st and ard deviation of change ) as well as the effect size ( ES , mean change/st and ard deviation of baseline values ) . The ability of the instruments to distinguish clinical ly important differences was assessed by correlating the changes in scores with global ratings on satisfaction and perceived improvement as external criteria . RESULTS The disease-specific weighted score ( SRM : 1.56 , ES : 1.99 ) was more responsive than the unweighted score ( SRM : 1.36 , ES : 1.57 ) . The Quality of Life Rating Scale , SF-36 , and SF-12 subscales were less sensitive to change , with st and ardized response means and effect sizes that ranged from -0.23 to 0.88 . The ability to distinguish clinical ly important differences was higher for the two disease-specific scales . The coefficients of correlation with the external criteria ranged from 0.50 to 0.56 for the unweighted score and 0.56 to 0.62 for the weighted score and were significantly stronger than the correlations between external measures and the most responsive subscale of the SF-36 ( Bodily Pain subscale , r = 0.36 ) . The SF-12 health survey performed as well as the SF-36 in term of responsiveness and ability to distinguish clinical ly important change . CONCLUSIONS Disease-specific measures were superior to generic measures in capturing clinical change after carpal tunnel release , and a weighted score was slightly more responsive than the unweighted score . The SF-12 showed comparable psychometric properties compared with the longer 36-item Short-Form Survey Background : The increasing use of computerized adaptive tests ( CATs ) to generate outcome measures during rehabilitation has prompted questions concerning score interpretation . Objective : The purpose of this study was to describe meaningful interpretations of functional status ( FS ) outcome measures estimated with a body part – specific CAT developed from the Lower-Extremity Functional Scale ( LEFS ) . Design : This investigation was a prospect i ve cohort study of 8,714 people who had hip impairments and were receiving physical therapy in 257 outpatient clinics in 31 states ( United States ) between January 2005 and June 2007 . Methods : Four approaches were used to clinical ly interpret outcome data . First , the st and ard error of the estimate was used to construct the 90 % confidence interval for each CAT-generated score estimate . Second , percentile ranks were applied to FS scores . Third , 2 threshold approaches were used to define individual subject – level change : statistically reliable change and clinical ly important change . The fourth approach was a functional staging method . Results : The precision of a single score was estimated from the FS score ±4 . On the basis of the score distribution , 25th , 50th , and 75th percentile ranks corresponded to intake FS scores of 40 , 48 , and 59 and discharge FS scores of 50 , 61 , and 75 , respectively . The reliable change index supported the conclusion that changes in FS scores of 7 or more units represented statistically reliable change , and receiver operating characteristic analyses supported the conclusion that changes in FS scores of 6 or more units represented minimal clinical ly important improvement . Participants were classified into 5 hierarchical levels of FS using a functional staging method . Limitations : Because this study was a secondary analysis of prospect ively collected data via a proprietary data base management company , generalizability of results may be limited to participating clinics . Conclusions : The results demonstrated how outcome measures generated from the hip LEFS CAT can be interpreted to improve clinical meaning . This finding might facilitate the use of patient-reported outcomes by clinicians during rehabilitation services Background : The use of patient-reported outcomes continues to exp and beyond the scope of clinical research to involve st and ard of care assessment s across orthopedic practice s. It is currently unclear how to interpret and apply this information in the daily care of patients in a foot and ankle clinic . We prospect ively examined the relationship between preoperative patient-reported outcomes ( PROMIS Physical Function , Pain Interference and Depression scores ) , determined minimal clinical important differences for these values , and assessed if these preoperative values were predictors of improvement after operative intervention . Methods : Prospect i ve collection of all consecutive patient visits to a multisurgeon tertiary foot and ankle clinic was obtained between February 2015 and April 2016 . This consisted of 16 023 unique visits across 7996 patients , with 3611 new patients . Patients undergoing elective operative intervention were identified by ICD-9 and CPT code .  PROMIS physical function , pain interference , and depression scores were assessed at initial and follow-up visits . Minimum clinical ly important differences ( MCIDs ) were calculated using a distribution-based method . Receiver operating characteristic ( ROC ) curves were calculated to determine whether preoperative PROMIS scores were predictive of achieving MCID . Cutoff values for PROMIS scores that would predict achieving MCID and not achieving MCID with 95 % specificity were determined . Prognostic pre- and posttest probabilities based off these cutoffs were calculated . Patients with a minimum of 7-month follow-up ( mean 9.9 ) who completed all PROMIS domains were included , result ing in 61 patients . Results : ROC curves demonstrated that preoperative physical function scores were predictive of postoperative improvement in physical function ( area under the curve [ AUC ] 0.83 ) . Similarly , preoperative pain interference scores were predictive of postoperative pain improvement ( AUC 0.73 ) and preoperative depression scores were also predictive of postoperative depression improvement ( AUC 0.74 ) . Patients with preoperative physical function T score below 29.7 had an 83 % probability of achieving a clinical ly meaningful improvement in function as defined by MCID . Patients with preoperative physical function T score above 42 had a 94 % probability of failing to achieve MCID . Patients with preoperative pain above 67.2 had a 66 % probability of achieving MCID , whereas patients with preoperative pain below 55 had a 95 % probability of failing to achieve MCID . Patients with preoperative depression below 41.5 had a 90 % probability of failing to achieve MCID . Conclusion : Patient-reported outcomes ( PROMIS ) scores obtained preoperatively predicted improvement in foot and ankle surgery . Threshold levels in physical function , pain interference , and depression can be shared with patients as they decide whether surgery is a good option and helps place a numerical value on patient expectations . Physical function scores below 29.7 were likely to improve with surgery , whereas those patients with scores above 42 were unlikely to make gains in function . Patients with pain scores less than 55 were similarly unlikely to improve , whereas those with scores above 67 had clinical ly significant pain reduction postoperatively . Reported prognostic cutoff values help to provide guidance to both the surgeon and the patient and can aid in shared decision making for treatment . Level of Evidence : Level II , prognostic study The patient-reported outcomes measurement information system ( PROMIS ) physical function item bank v1 ( PPFIB ) contains 124 item response theory ( IRT ) calibrated items ( Rose et al. 2008 . J Clin Epidemiol 61:17–33).We report the psychometric properties of these items within an outpatient , orthopaedic patient population . In particular , we investigated whether a single unidimensional IRT scale can adequately define physical function of patients presenting with primarily upper or lower extremity orthopaedic complaints . We conducted a prospect i ve study at an orthopaedic outpatient clinic to collect data from 865 adult patients with all 124 PROMIS physical function items and seven demographic items . Items were evaluated by a Rasch model . Total variance ( 60.6 % ) across the 124 items was explained by a single Rasch dimension . The variance explained by the second dimension was 7.7 % , reflecting differential item functioning in the upper and lower extremity patients . The upper extremity physical function items had a pronounced ceiling effect . A single physical function dimension accounts for most of the item variance in the PPFIB , suggesting that the items are measuring predominantly one single construct . Separate subscales for lower versus upper extremities , especially with additional items at the upper trait level of the upper extremity subscale , may further enhance evaluation of physical function in orthopaedic patients The use of retrospectively acquired preoperative AOFAS rating scores in clinical research to assess the outcomes of elective foot and ankle surgery has not been vali date d. The data obtained utilizing this methodology may misrepresent the results and lead to spurious conclusions . This investigation compared preoperative AOFAS Ankle-Hindfoot scores obtained before and after surgery from patients who had undergone elective surgery to determine if retrospectively acquired scores match those collected prospect ively . Only two out of 47 patients ( 4 % ) recalled identical AOFAS scores . The mean difference between the preoperative scores ( preoperative score obtained after surgery minus preoperative score obtained before surgery ) was −5.3 points . Fifteen patients ( 32 % ) had preoperative scores that differed by 20 points or more . Kappa statistics found little agreement among the five elements that comprised the two preoperative scores when responses obtained before and after surgery were compared to one another . The results suggest that  preoperative clinical rating scores  obtained after elective surgery are a poor predictor of the patient 's preoperative condition and that studies which employ retrospectively acquired preoperative AOFAS clinical rating scores may overestimate the benefit of surgery Abstract Of the various methods for measuring pain the  visual analogue scale seems to be the most sensitive . For assessing response to treatment a pain-relief scale has advantages over a pain scale . Pain can not be said to have been relieved unless pain or pain relief has been directly measured A Foot Function Index ( FFI ) was developed to measure the impact of foot pathology on function in terms of pain , disability and activity restriction . The FFI is a self-administered index consisting of 23 items divided into 3 sub-scales . Both total and sub-scale scores are produced . The FFI was examined for test-retest reliability , internal consistency , and construct and criterion validity . A total of 87 patients with rheumatoid arthritis were used in the study .  Test-retest reliability of the FFI total and sub-scale scores ranged from 0.87 to 0.69 . Internal consistency ranged from 0.96 to 0.73 . With the exception of two items , factor analysis supported the construct validity of the total index and the sub-scales . Strong correlation between the FFI total and sub-scale scores and clinical measures of foot pathology supported the criterion validity of the index . The FFI should prove useful for both clinical and research purpose The assessment of a measure of chronic pain , should be reliable , valid and sensitive to change . Our study evaluated the reliability of 3 pain scales , visual analogue scale ( VAS ) , numerical rating scale ( NRS ) and verbal rating scale ( VRS )  in literate and illiterate patients with rheumatoid arthritis ( RA ) . Patients with RA attending an outpatient rheumatology clinic were interviewed and asked to score their pain levels on the 3 pain scales . The scales were presented in r and om order , twice , before and just after a regular medical consultation . Ninety-one patients were studied ( 25 illiterate and 66 literate ) . The Pearson product moment correlation between first and second assessment was 0.937 for VAS , 0.963 for NRS and 0.901 for VRS in the literate patient group and 0.712 for VAS , 0.947 for NRS and 0.820 for VRS in the illiterate patient group . These results indicate that the NRS has the higher reliability in both groups of patients STUDY DESIGN Prospect i ve cohort study of 10 287 patients with foot/ankle impairments receiving outpatient physical therapy .  OBJECTIVES To describe meaningful interpretations of functional status ( FS ) outcomes measures , estimated using a body-part-specific computerized adaptive test ( CAT ) . BACKGROUND Increased use of CATs to generate outcome measures in rehabilitation has stimulated questions concerning score interpretation . Identifying meaningful intra-individual change and reporting clinical interpretation of those generated outcomes are essential to advance the quality of rehabilitation practice . METHODS We performed 4 approaches to clinical ly interpret outcomes data . First , we used the st and ard error of the estimate to construct a 90 % confidence interval for each CAT estimated score . Second , we presented the percentile rank of FS scores . Third , we used 2 threshold approaches to define individual-patient-level change : statistically reliable change and clinical ly important change . Last , we illustrated a functional staging method . RESULTS Precision of a single score was estimated by an FS score of + /-4 . Based on score distribution , percentile ranks at 25th , 50th , and 75th percentiles corresponded to intake FS scores of 38 , 47 , and 57 , and discharge FS scores of 52 , 64 , and 77 , respectively . Minimal detectable change supported 7 or more FS change units out of 100 represented statistically reliable change , and ROC analyses supported 8 or more FS change units represented minimal clinical ly important improvement . Using a functional staging system , we established 5 hierarchical functional status levels . CONCLUSION CAT-generated outcome measures can be interpreted to improve clinical interpretation and to assist clinicians in using patient-reported outcomes during therapy practice
target: While there are many different scoring systems available for foot and ankle specialists to use to assess or demonstrate the effectiveness of treatments , the AOFAS , while it is an unvali date d scoring system , is the most commonly used scoring system in this review .
  This review presents data about commonly used patient reported outcomes systems in foot and ankle surgery .
background: The goal of this systematic review is to determine the most commonly used outcome measurement tools used by foot and ankle specialists and determine their limitations , such as whether they are vali date d , have floor/ceiling effects , and so on .