Gait Characteristics Based on Pain Detect Questionnaire and Pain Catastrophizing Scale in Patients with Knee Osteoarthritis

doi:10.21203/rs.3.rs-954180/v1

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Gait Characteristics Based on Pain Detect Questionnaire and Pain Catastrophizing Scale in Patients with Knee Osteoarthritis

https://doi.org/10.21203/rs.3.rs-954180/v1

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Background

Although patient-reported evaluation of knee osteoarthritis has been more common, little attention has been paid to the relationship between patient-reported questionnaire and gait analysis. The purpose was to investigate the relationship between patient-reported questionnaire and gait parameters.

Methods

A total of 31 knees in 31 patients (22 females and 9 males) who were diagnosed as end-stage medial compartmental knee osteoarthritis participated in the present study. All the patients were evaluated based on New Knee Society Score, pain detect questionnaire and pain catastrophizing scale. They were divided into two categories based on pain detect questionnaire scores: Group Low (12 ≥ score) and Group High (score > 12). Gait analysis was performed using three-dimensional motion analysis system. Statistical analysis was done using one-tailed Mann-Whitney U-test to compare age, body mass index, Knee Society Score, pain catastrophizing scale, and gait parameters between groups.

Results

Twenty-six patients were allocated to Group Low, and five patients were to Group High. Subjective pain during walking was significantly worse in Group Low (P = 0.037) and helplessness in pain catastrophizing scale was notably worse in Group High (P = 0.035). Peak vertical ground reaction force (P = 0.018) and knee adduction moment (P < 0.01) were significantly greater in Group Low. Moreover, flexion-extension excursion during mid-stance phase was significantly smaller in Group Low (P = 0.038).

Conclusions

Patients with likely neuropathic pain had atypical osteoarthritis-related pain as well as atypical gait pattern, compared to patients without neuropathic pain.

Sports Medicine and Kinesiology

Orthopedics

Rheumatology

knee osteoarthritis

gait analysis

pain detect

pain catastrophizing scale

End-stage knee osteoarthritis (OA) is one of major factors which negatively affect daily activities in the elderly people. Although main symptom in patients with knee OA is subjective pain, radiographic findings do not always match subjective pain level[1, 2]. Therefore, pain phenotype has been a common topic in knee OA[3]. Clinically, several knee scoring systems have been used to evaluate subjective pain in patients with knee OA. For instance, pain detect questionnaire (PD-Q) was a useful tool to evaluate a self-report measure with the purpose of classifying patients as having either unlikely, uncertain or likely neuropathic pain components[4, 5]. In addition, pain catastrophizing scale (PCS) was widely used to assess negative mental state that arises in the context of actual or anticipated pain, leading to a tendency to excessive worrying and the amplification of the sensation of pain[6]. Mental condition is known to be associated with postoperative clinical score including Knee Society Score or others[7–9].

Although patient-reported evaluation has been more common in the recent years, actual knee function is difficult to assess so far[10]. Therefore, gait analysis has been performed as clinical and functional assessment tool in patients with knee OA. As described in previous gait analysis studies, abnormal joint loading pattern should be observed in those patients[11, 12]. For example, the patients with medial knee OA have increased external knee adduction moment (KAM) during walking[12–16]. However, little attention has been paid to the relationship between patient-reported questionnaire and gait analysis.

The purpose of the present study was to investigate and clarify the relationship between patient-reported questionnaire and gait analysis. It was hypothesized that pain pattern would affect gait characteristics in patients with symptomatic end-stage knee OA.

Subjects

A total of 31 knees in 31 patients (22 females and 9 males with a mean age of 73.2 ± 7.2 years and a mean body mass index [BMI] of 24.4 ± 2.5 kg/m²), who were diagnosed as end-stage medial compartmental knee OA of at least grade 3 severities according to the Kellgren–Lawrence scale, participated in the present study. All the patients were scheduled to undergo knee replacement surgery based on surgeon’s judgement. None of the subjects had any history of major injuries to the trunk, and hip osteoarthritis. An informed consent form approved by Institutional Review Board of our university was obtained in each subject.

Clinical score and patient-reported assessment

All the patients were evaluated based on 2011 New Knee Scoring System (KSS), Pain detect questionnaire (PD-Q) and pain catastrophizing scale (PCS). The PD-Q is a validated scale to assess neuropathic pain (NP). Scores range from 0-35, with 12 ≥; no NP (Low score), > 12; indicating possible NP and ≥ 19; indicating likely NP (Intermediate and High score). Subjects were divided into two categories (Group L; Low, Group I & H; Intermediate and High) based on PD-Q. PCS was evaluated using total score and subcategories (rumination, helplessness, magnification).

Gait analysis

After a written informed consent was obtained, gait analysis was performed using three-dimensional motion analysis system which consisted of 8 cameras (120 frames/s; Oqus, Qualisys, Sweden) and 2 force plates (frequency 600 Hz; AM6110, Bertec, Columbus, OH, USA). A total of 46 retroreflective markers (14mm in diameter) were placed on standardized bony landmarks (Fig. 1). The force plate collected ground reaction force (GRF) data at 600Hz were synchronized to the camera sampling rate (120 Hz). The subjects performed level walking at a self-selected speed. The motion of markers was recorded by Qualisys Track Manager Software (version 2.7). To calculate knee kinematics and kinetics, Visual 3D (C-motion Company, Rockville, MD, USA) was used. Gait parameters, including gait speed (m/s), step length (m), single leg stance time (s) peak values of vertical GRF (kN/kg), flexion-extension knee excursion during midstance phase, peak values of net external knee flexion and adduction moment (Nm/kg), and the time from initial contact to first peak GRF (Second).

Statistical analysis

Statistical analysis was done using one-tailed Mann-Whitney U-test to compare age, BMI, KSS, PCS, and gait parameters between groups. Fisher exact test was used for categorical variables. P-values of < 0.05 were considered as significant. The sample size for the current investigation was determined to be 5 subjects in each group with 80 % power. This calculation was performed using knee adduction moment with defined significant differences of 0.26 Nm/kg between groups. All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., New York, USA).

Patient demographics, clinical score and patient-reported assessment in each group

Twenty-six patients were allocated to Group L, and five patients were to Group I & H. Age, BMI, knee range of motion, total activity score in KSS and total PCS were not significantly different between groups (Table 1 and 2). However, subjective pain during walking was significantly worse in Group L and helplessness in PCS was notably worse in Group I & H (Table 2), while other subcategories, including rumination and magnification were not significantly different.

Table 1

Patient demographics in each group (mean ± SD)
	Group L	Group I & H	P Value^a
Age (yrs)	74.2 ± 7.6	73.2 ± 7.1	0.10
BMI (kg/m²)	24.4 ± 2.0	24.4 ± 2.4	0.34
Gender (Female/male)	18 / 8	4 / 1	1.0
^a Values obtained using one-tailed Mann-Whitney U test or Fisher exact test.

Table 2

Clinical score and patient-reported assessment in each group (mean ± SD)
	Group L	Group I & H	P Value^a
Total PD-Q	4.7 ± 3.6	19.0 ± 2.2	<0.001
Total KSS	123.5 ± 32.4	128.6 ± 33.5	0.38
Range of motion (KSS)	21.3 ± 4.9	24.4 ± 4.3	0.12
Flexion contracture (KSS)	6.9 ± 4.8	4.0 ± 3.7	0.11
Pain during gait (VAS)	5.0 ± 2.7	2.4 ± 2.0	0.037
Activity Score (KSS)	55.1 ± 20.7	61.6 ± 21.3	0.26
Total PCS	24.0 ± 11.6	31.8 ± 11.9	0.09
Rumination (PCS)	12.8 ± 4.5	13.6 ± 5.6	0.39
Helplessness (PCS)	6.7 ± 5.1	12.0 ± 5.0	0.035
Magnification (PCS)	4.5 ± 3.2	6.2 ± 2.1	0.17
^a Values obtained using one-tailed Mann-Whitney U test

Gait parameters in each group

Peak vertical GRF and adduction moment were significantly greater in Group L (Table 3). In addition, flexion-extension excursion during mid-stance phase was significantly smaller in Group L. This phenomenon was known as stiffening strategy in anterior cruciate ligament (ACL) deficient knee. On the other hand, other parameters including gait speed, step length, and stance time were not significantly different between Groups.

Table 3

Gait parameters in each group (mean ± SD)
	Group L	Group I & H	P Value^a
Gait speed (m/s)	0.8 ± 0.2	0.7 ± 0.2	0.40
Step length (m)	0.5 ± 0.1	0.4 ± 0.1	0.39
Stance time (s)	0.7 ± 0.2	0.7 ± 0.1	0.43
Peak vGRF (kN/kg)	1.0 ± 0.1	0.8 ± 0.2	0.018
Flex-ext excursion during mid-stance (°)	5.2 ± 3.9	8.1 ± 3.7	0.038
Peak knee flexion moment (Nm/kg)	0.2 ± 0.2	0.2 ± 0.2	0.37
Peak knee adduction moment (Nm/kg)	0.7 ± 0.2	0.4 ± 0.1	0.0019
^a Values obtained using one-tailed Mann-Whitney U test

The present results supported the hypothesis that pain pattern would affect gait characteristics in patients with symptomatic end-stage knee OA. The most important finding of the present study was that patients with possible or likely NP had atypical gait pattern including low KAM and less tendency of stiffening knee during gait, compared to patients without NP.

Recently, patient dissatisfaction is a highly disputed issue in total knee arthroplasty (TKA)[17, 18]. Based on previous literatures, preoperative PD-Q and PCS can be beneficial tools to evaluate whether patients have typical OA-related pain or NP. Forsythe ME et al. investigated a total of 55 patients with a primary diagnosis of knee OA, who were scheduled to undergo TKA, and concluded that preoperative PCS scores were shown to predict chronic postoperative pain at 24 months after TKA[19]. In addition, Warner SC et al. evaluated a total of 1151 patients with hip or knee OA before and after the surgery, and suggested that PD-Q appeared to be a useful tool in capturing factors that would contribute to postoperative satisfaction[20]. Some previous literatures have been available on the relationship between postoperative patient satisfaction and patient-reported questionnaire[21, 22]. However, correlation between gait analysis and patient-reported questionnaire in patients with knee OA has not investigated so far.

It has been well known that high KAM peak values are observed in early stance phase of patients with knee OA[12–16]. Baliunas AJ et al. analyzed the gait of 31 knee OA patients, and showed that peak values of KAM were significantly higher in knee OA group compared to healthy subjects[12]. In addition, patients with knee OA often show a typical stiffening gait pattern that improves dynamic knee stability to overcome joint laxity by decreasing knee flexion-extension excursion during mid-stance phase and increasing co-contraction of antagonist muscle[23, 24]. Similar gait pattern is known in patients with knee joint laxity due to ACL deficiency and has been reported as a risk of developing knee OA[25, 26]. In this study, although all subjects had at least grade 3 OA, patients with possible or likely NP did not show these typical gait characteristics of knee OA. Moreover, these patients also have atypical characteristics of OA-related pain, such as low VAS during gait and high helplessness score in PCS. Hochman et al. reported that depressive symptoms and pain catastrophizing may contribute to central sensitization, and were associated with the presence of NP symptoms[5]. Orthopaedic surgeons should take care of the prognosis of patients with such atypical OA-related pains.

Several limitations should be described in the present study. First, the number of patients with possible or likely NP was small. Thus, the sample size is not sufficient to make a statistically significant conclusion. Second, all subjects in this study were candidates for TKA with end-stage OA. Therefore, this result could be applied only for the patients with severe knee OA. Finally, though the gait characteristics patients with OA were shown, the postoperative outcome of those patients is still unknown. However, to our knowledge, this is the first study to investigate correlation between gait analysis and patient-reported questionnaire in patients with knee OA. Therefore, the results of the current study are considered to contain useful information, when considering the correlation between gait characteristics and patient-reported questionnaire in patients with knee OA.

Patients with possible and likely NP had atypical gait pattern including low KAM and less tendency of stiffening knee during gait, compared to patients without NP. Preoperative PD-Q can be a beneficial tool to evaluate whether patients have typical OA-related gait pattern or not.

OA: knee osteoarthritis; PD-Q: pain detect questionnaire; PCS: pain catastrophizing scale; KAM: knee adduction moment; BMI: body mass index; KSS: Knee Scoring System; NP: neuropathic pain; GRF: ground reaction force; ACL: anterior cruciate ligament; TKA: total knee arthroplasty

Acknowledgement:

The authors gratefully acknowledge the valuable contribution of Aiko Sakurai, RPT, PhD, Kohei Nishizawa, RPT, Satoshi Imai, RPT, Mr. Ryoji Hayakawa, Kaneda Kazuya, MD, Miss Hiroko Arai and Mrs. Sumi Yamashita.

Funding

This study was supported by Japanese Society for Musculoskeletal Medicine

Availability of data and materials

All supporting data can be provided based on request to the authors.

Authors’ contributions

KH designed the study. YI, SK and KK accumulated the data. YN and TN coordinated and supervised data collection. KH,YI and KK analyzed the data. KH drafted the manuscript. All authors (KH, YI, KK, SK, YN and TN) contributed to interpretation of the findings. All authors participated in reviewing and editing the manuscript, and approved the final manuscript.

Ethics approval and consent to participate

This study was approved by the Ethics Committee and Institutional Review Board of Keio University Hospital (IRB No. 20080054 and 20190116).

Consent for publication

Not applicable.

Competing interests

None of the authors had any conflict of interest regarding this manuscript.

Author details

¹Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, 160-8582, Japan

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No competing interests reported.

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Gait Characteristics Based on Pain Detect Questionnaire and Pain Catastrophizing Scale in Patients with Knee Osteoarthritis

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