Rev. Bras. Reumatol. vol.57 número3

r e v b r a s r e u m a t o l . 2017;57(3):274–277

ww w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Brief

communication

Use

of

the

Lower

Extremity

Functional

Scale

(LEFS-Brazil)

questionnaire

compared

to

Lequesne

Algofunctional

Index

for

definition

of

knee

and

hip

osteoarthritis

severity

Uso

do

questionário

Lower

Extremity

Functional

Scale

(LEFS-Brasil)

em

comparac¸ão

com

o

Índice

Algofuncional

de

Lequesne

para

definic¸ão

de

gravidade

na

osteoartrite

de

joelho

e

quadril

João

Paulo

M.

Santos

_,

_Rubens

_A.

_da

_Silva

_,

_Marcos

_Tadeu

_P.

_Fernandes

,

Regina

Célia

Poli-Frederico

_,

_Denis

_C.

_Santos

_,

_Rodrigo

_A.C.

_Andraus

_,

Thais

Maria

F.

Fernandes

_,

_Karen

_B.P.

_Fernandes

a_{UniversidadeNortedoParaná(UNOPAR),Londrina,PR,Brasil} b_{IrmandadedaSantaCasadeLondrina(ISCAL),Londrina,PR,Brasil} c_{UniversidadeEstadualdeLondrina(UEL),Londrina,PR,Brasil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received7July2015 Accepted18April2016 Availableonline2August2016

Introduction

Osteoarthritis(OA)isachronicjointdiseasewithahigh preva-lenceintheelderly.1_{OAaffectsmoreoftenthehipandknee,}

compromisingimportantaspectsinactivitiesofdailyliving suchaswalking,transpositionofobstacles,homecareand workactivities.2

Severalquestionnaireshaveemergedtoevaluatethe func-tionalcapacityofpatientswithOA,whichstandoutbytheir simplicityand the abilitytoevaluatetheperceptionofthe

∗ _{Correspondingauthor.}

E-mail:karenparron@gmail.com(K.B.Fernandes).

individualaboutthediseaseandhis/herlimitations.3_Inthis

context,theLequesneAlgofunctionalIndex(translatedand validatedforthePortuguese)hasaspecialemphasis,bybeing an instrument internationallyrecommended bythe World Health Organizationtoassesspainand functionofthe hip andknee,4,5_{Lequesne’sIndexiswidelyusedinEurope,}6_being

oftenusedaspartofaclinicalevaluation.7

Another questionnaire, the Lower Extremity Functional Scale(LEFS),7_{withaversiontranslatedandvalidatedforthe}

Portuguese (LEFS-Brazil),8 _{has excellentreliability and high}

internal consistency and is considered a reliable and easy

http://dx.doi.org/10.1016/j.rbre.2016.07.010

2255-5021/©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

rev bras reumatol.2017;57(3):274–277

275

instrumenttobeappliedbothforresearchandforthe reha-bilitationofpatientswithOA.9

Althoughthereisevidencetodemonstratetheapplicability oftheLEFSquestionnaireinpatientswithOAofthekneeand hip,thereisagapintheabilityoftheinstrumentto discrim-inatebetweendifferentdegreesofseverityofosteoarthritis. Thus,thisstudy aimedtoestablish acutoffpointfor iden-tifyingsevere functional impairmentfor the LEFS-Brazil in elderlypatientswithhipand/orkneeOA,usingasabasisthe LequesneAlgofunctionalIndex.

Method

Ethicalaspects

TheprojectwasapprovedbytheResearchEthicsCommitteeof theUniversityofNorthernParana(OpinionNo.135016).The selectedsubjectswereinformed abouttheobjectivesofthe studyandsignedaConsentform,agreeinginparticipatingin thestudy.

Studydesignandsample

This is a cross-sectional analytical study, based on crite-ria established by the STROBE list – Strengthening the Reportingof ObservationalStudies in Epidemiology,10 _with

aconvenience sampleofsecondarydatafrom EELO (Study of Aging and Longevity) project. The EELO project was a thematic project developed by the Universidade do Norte do Paraná (UNOPAR) that aimed to evaluate the indica-torsofthe health statusof elderlysubjects in Londrina, a northerncityofParana. Moreinformationcan befoundat

http://www2.unopar.br/sites/eelo.Thisstudywasconducted

inLondrina,sincetheelderlypopulationofthiscity repre-sents12%ofthe totalpopulation, anumber similartothat foundinotherdevelopedcountries.11,12

ThetotalsampleofEELOprojectconsistedof508 individ-uals,basedontheSampleCalculationforFinitePopulations formula,whichisrepresentativeofthe43,610elderlylivingin LondrinaandregisteredinBasicHealthUnits(SUS).Ofthese seniors,113ofbothgendersreportedhavinghipand/orknee OA,andthatwerephysicallyindependent,accordingto Spir-dusoclassificationsystemforFunctionalStatus(levels3and 4).13

Eligibilitycriteriaofthestudypopulation

The inclusion criteria were: being elderly (age over 60 years), had participated in EELO project, having reported hipand/orkneeOA inthe EELOproject,confirmedby clin-ical examination previously performed by an orthopedist followingthe criteriaproposed bythe American Collegeof Rheumatology,14,15 _{plusconfirmationbyradiographic}

exam-inationperformedbyaspecialistphysician,accordingtothe criteriadescribedbyVasconcelosetal.16

Theexclusioncriteriawere:havingother rheumatic dis-easesaffectingthelowerlimbs(suchasrheumatoidarthritis, gout,andfibromyalgia,determinedbyself-report), osteoporo-sisinthelowerlimbs(verifiedbybonedensitometrywithaT score<-2,517_{carriedoutsubsequentlytotheEELOProjectand}

evaluatedclinicallybyanorthopedist),hip orknee replace-ment(assessedbyself-report),strokesequelae,orParkinson disease (checkedbyself-report),or havinganyother injury that would compromise the locomotor system (such as a tendinopathy,determinedbyself-report).

Clinicalandradiographicevaluation

Thediagnosisandclassificationofsymptoms15,16 _of

individ-uals who reported OA were determined byan orthopedist. Subsequently,onlyindividualsdiagnosedwithOAunderwent radiographicexaminationsofthehipsandkneesinthesupine position,withfrontalandsideviews,basedonthecriteriaof KellgrenandLawrence18_{;allindividualswhoweresubmitted}

tothestudywerewithgradeII(mildOA)toIV(advancedOA).A specialistwasresponsiblefortheclassificationofthese sub-jectsincategoriesrelating tothe radiographicfindings;this professionalwasblindedtotheanalyzedoutcomes.

Evaluationoffunctionality

Twoinstrumentstoevaluatethefunctionalstatusofelderly patientswithOAwereemployed:theLequesneAlgofunctional Index,translatedandvalidatedforthePortuguese,which con-tains11questionsinvolvingpain,discomfortandfunctional limitation,6_{withscoresrangingfrom0to24(noinvolvement}

atalltoanextremelysevereimpairment)5_;theother

instru-mentusedwastheLEFS-Brazil(LowerExtremityFunctional Scale) questionnaire, which contains 20 specific questions relatedtomusculoskeletalconditionsofthelowerlimbs.In this latterinstrument, the questions relate toactivities of daily living and each question can be classified from 0 to 4 (from extremely difficult, to with no difficulty for carry-ing outactivities)and itsscoresrange from0to80 points, withthevalueof80pointsrepresentingmaximumfunctional capacity.9

Statisticalanalysis

IBMSPSS(StatisticalPackageforSocialSciences,SPSSInc., Chicago)version20.0wasusedforstatisticalanalysisofthe results,anda95%confidenceintervalandasignificancelevel of5%(p<0.05)wereadoptedforalltests.

Initially,descriptivestatisticswerecarriedoutto charac-terize the sample.Then,the cutoffpointforthe definition ofsevereconditionofosteoarthritisthroughLEFS-Brazilwas determined using anROC (Receiver Operating Characteris-tic)curve,andthecategoriesoftheLequesneAlgofunctional Indexwereusedasabaselinetool.

Inaddition,theSpearman’scorrelationtestwasappliedin ordertoverifytherelationshipbetweentheLequesne Algo-functional Indexand LEFS-Brazil,consideringthat thedata isnotnormallydistributedoncethesedatahavearosefrom questionnaires.

Results

276

1.0

0.8

0.6

0.4

0.2

0.0

0.6 0.4

0.2 0.0

1-specificity

Sensitivity

1.0 0.8

Fig.1–ROCcurveforLEFSforseverefunctional impairment.

wereincluded infinal sample.Ofthese,36 (34.3%)hadhip OA,42(40.0%)hadkneeOAand27(25.7%)hadhipandknee OA.Thesampleconsistedof32men(30.5%)and73women (69.5%)withameanageof70.83±6.06yearsandameanBMI of28.71±5.16.Theelderlysubjectshadamedianof11.5(1stQ: 6.25;3rdQ:17.50)fortheLequesneAlgofunctionalIndexanda medianof48.00(1stQ:35.00;3rdQ:61.00)fortheLEFS-Brazil.

Thedata from the ROC curve was used to identifythe severestatusofosteoarthritisfromLEFS-Brazil,basedonthe Lequesne questionnaire and it is shown in Fig. 1. It was observedthat,foracutoffpointof48,theareaunderthecurve was0.94,withagooddiscriminatorypower ofthispointto characterizemoreseverecaseswithgoodsensitivity(84.4%) andspecificity (81.7%),and withpositiveand negative pre-dictive values of69.89 and 87.50, respectively. Moreover, a correlationbetweentheLequesnequestionnairesand LEFS-Brazil(rS=−0.86,p<0.001)wasobservedandisshowninFig.2.

80

60

40

20

0

0.00 10.00 20.00

Lequesne

LEFS

30.00

Fig.2–CorrelationbetweenLEFSeLequesne

AlgofunctionalIndex.

Discussion

Thisstudy aimedtoidentifysevere statusofosteoarthritis usingtheLEFS-Brazilscore,basedonLequesneAlgofunctional Index. Our findings have demonstrated the existenceof a strong correlation betweenthe questionnairesused, allow-ingtoidentifytheseverestatusoffunctionalimpairmentfor theLEFS-BrazilinelderlypatientswithOA.Thiscategorization couldfacilitatetheclassificationoffunctionalimpairmentof theseindividuals,providingadditionalcriteriatocheckthe impactofthetherapeuticapproachesinactivitiesofdaily liv-ingofelderlypatientswithOA.

Therearemanyquestionnairesassessingindividualswith knee and/orhipOA,withemphasisfortheLequesne Algo-functionalIndexthatreflectsthefunctionalimpairmentand thepainfulpictureoftheindividualinhis/herdailylife,being aninstrumentwithexcellentpsychometricproperties.5,19

Severalstudieshaveevaluatedtheresponsiveness, reliabil-ity,constructvalidityandconvergentvalidityoftheLequesne Indexagainstanotherquestionnaire(WOMAC).20–23

Inapreviousstudy,24_{weobservedthattheLEFS}

question-naireshowsastrongcorrelationwiththeLequesneIndexand alsowithWOMAC,confirmingitsvalidityasaclinicaltoolfor theanalysisoffunctionalimpairmentinelderlypatientswith OA.However,the definitionofcut-off pointsinits scaleof severityofOAhavenotbeenpreviouslypublished,andthese findingscould haveaclinicalrelevance,bothforevaluation andforanalysisoftheeffectivenessofinterventionsinthis patientgroup.

Despite the WOMAC questionnaire being widely used in OA and recommended by the American College of Rheumatology,5_{thereisnodescriptionofcut-offpointsfor}

theseverityofthedisease;thus,thisinstrumentcouldnotbe usedinobtainingtheaccuracyofanalysisproposedinthis study.

Aslimitationsofourstudy,wecanhighlightthesample sizeandthecross-sectionaldesignofthestudyasthe follow-upofthesesubjectswasnotperformed.Anotherimportant aspect isthatthe LEFSquestionnaireisnotan instrument recommendedbytheAmericanCollegeofRheumatologyor bytheEuropeanLeagueofRheumatology.However,LEFSmay representapromisingalternativecomparedtotheWOMAC, becauseit hasgoodinternalconsistencyandisableto dis-criminateissuessuchaspainandfunctionassupportedby thefindingsbyPuaetal.25

ItmaybenotedthattheLEFSquestionnairecanbeusedas amethodforassessingtheprogressionandefficacyof treat-mentofOA,asithastwomainpropertiesoftheinstruments forfunctionalstatusmeasurement8_{:(1)documentationofthe}

outcome oftherapeuticinterventions,toensurethequality and establish clinical standards; and (2) LEFS helps in set-tingobjectivesand targetsforthe treatment,inadditionto measuringtheindividual’sfunctionalprogress.

Conclusion

rev bras reumatol.2017;57(3):274–277

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Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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