title: Symptom assessment in knee osteoarthritis needs to account for physical activity level.
abstract: OBJECTIVE
  Pain is not always correlated with severity of radiographic osteoarthritis (OA), possibly because people modify activities to manage symptoms. Measures of symptoms that consider pain in the context of activity level may therefore provide greater discrimination than a measure of pain alone. We undertook this study to compare discrimination provided by a measure of pain alone with that provided by combined measures of pain in the context of physical activity across radiographic OA severity levels.
  
  
  METHODS
  This was a cross-sectional study nested within the Osteoarthritis Initiative (OAI). The population was drawn from 2,127 persons enrolled in an OAI accelerometer monitoring substudy, including those with and those without knee OA. Two composite pain and activity knee symptom (PAKS) scores were calculated as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score (plus 1) divided by a physical activity measure (step count for the first PAKS score [PAKS1 score] and activity count for the second PAKS score [PAKS2 score]). Symptom score discrimination across Kellgren/Lawrence (K/L) grades was evaluated using histograms and quantile regression.
  
  
  RESULTS
  A total of 1,806 participants (55.5% of whom were women) were included (mean ± SD age 65.1 ± 9.1 years, mean ± SD body mass index 28.4 ± 4.8 kg/m(2) ). The WOMAC pain score, but not the PAKS scores, exhibited a floor effect. The adjusted median WOMAC pain scores by K/L grades 0-4 were 0, 0, 0, 1, and 3, respectively. The adjusted median PAKS1 scores were 24.9, 26.0, 32.4, 46.1, and 97.9, respectively, and the adjusted median PAKS2 scores were 7.2, 7.2, 9.2, 12.9, and 23.8, respectively. The PAKS scores had more statistically significant comparisons between K/L grades than did the WOMAC pain score.
  
  
  CONCLUSIONS
  Symptom assessments incorporating pain and physical activity did not exhibit a floor effect and were better able to discriminate radiographic severity than an assessment of pain alone, particularly in milder disease. Pain in the context of physical activity level should be used to assess knee OA symptoms.
authors.affiliation: Baylor College of Medicine and Michael E. DeBakey VAMC, Houston, Texas.
authors.forename: Grace H
authors.initials: GH
authors.lastname: Lo
authors.affiliation: Tufts Medical Center, Boston, Massachusetts.
authors.forename: Timothy E
authors.initials: TE
authors.lastname: McAlindon
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.
authors.forename: Gillian A
authors.initials: GA
authors.lastname: Hawker
authors.affiliation: Tufts Medical Center, Boston, Massachusetts.
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Driban
authors.affiliation: Tufts Medical Center and Tufts University, Boston, Massachusetts.
authors.forename: Lori Lyn
authors.initials: LL
authors.lastname: Price
authors.affiliation: Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Jing
authors.initials: J
authors.lastname: Song
authors.affiliation: Memorial Hospital of Rhode Island and Alpert Medical School of Brown University, Pawtucket, Rhode Island.
authors.forename: Charles B
authors.initials: CB
authors.lastname: Eaton
authors.affiliation: University of Maryland School of Medicine, Baltimore.
authors.forename: Marc C
authors.initials: MC
authors.lastname: Hochberg
authors.affiliation: Ohio State University, Columbus.
authors.forename: Rebecca D
authors.initials: RD
authors.lastname: Jackson
authors.affiliation: University of Arizona, Tucson.
authors.forename: C Kent
authors.initials: CK
authors.lastname: Kwoh
authors.affiliation: University of California, San Francisco.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Nevitt
authors.affiliation: Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Dorothy D
authors.initials: DD
authors.lastname: Dunlop
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D009043:Motor Activity / Q000502:physiology*; D020370:Osteoarthritis, Knee / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D010147:Pain Measurement; D011859:Radiography; D012720:Severity of Illness Index; D063189:Symptom Assessment