Research Report

Questionnaire to Identify Knee

Symptoms: Development of a Tool to
Identify Early Experiences Consistent
With Knee Osteoarthritis

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Jessica M. Clark, Bert M. Chesworth, Mark Speechley, Robert J. Petrella,
Monica R. Maly
J.M. Clark, MSc, Graduate Pro-
gram in Health and Rehabilitation
Background. Current diagnostic procedures for knee osteoarthritis (OA) identify Sciences, Western University, Lon-
individuals late in the disease process. A questionnaire may be a useful and inexpen- don, Ontario, Canada.
sive method to screen for early symptoms of knee OA.
B.M. Chesworth, PT, PhD, School
of Physical Therapy and Depart-
Objective. The purpose of this study was to develop a brief, self-administered ment of Epidemiology and Biosta-
questionnaire for clinical and research settings to identify emerging knee problems in tistics, Schulich School of Medi-
people who could benefit from conservative interventions. cine & Dentistry, Western
University.
Design. This prospective study utilized a mixed-methods approach. M. Speechley, PhD, Department
of Epidemiology and Biostatistics,
Methods and Results. Questionnaire items were generated from interview Schulich School of Medicine &
data from individuals with emerging chronic knee problems. These items were Dentistry, Western University.
reviewed by 16 rheumatology experts, resulting in a 35-item draft questionnaire. To R.J. Petrella, MD, PhD, Depart-
reduce the number of items, questionnaires were mailed to 228 adults, aged 40 to 65 ment of Family Medicine, Schulich
years, with evidence of ongoing knee problems. One hundred thirteen completed School of Medicine & Dentistry,
Western University.
questionnaires were returned (63.1% response rate), with 105 usable questionnaires.
Using principal components analysis, the number of items was reduced to a final M.R. Maly, PT, PhD, Institute for
13-item version, the Questionnaire to Identify Knee Symptoms (QuIKS). The QuIKS Applied Health Sciences, McMas-
ter University, 1400 Main St West,
has 4 subscales: medications, monitoring, interpreting, and modifying. The QuIKS Room 435, Hamilton, Ontario,
demonstrated strong internal consistency. Canada L8S 1C7. Address all cor-
respondence to Dr Maly at:
Limitations. A sampling bias among respondents who provided data for item mmaly@mcmaster.ca.
reduction likely means that the QuIKS reflects those who self-report knee problems [Clark JM, Chesworth BM,
to a health care provider, which may not be generalizable to the population. Speechley M, et al. Questionnaire
to identify knee symptoms: devel-
Conclusions. The QuIKS is a short, self-administered questionnaire used to pro- opment of a tool to identify early
experiences consistent with knee
mote activity by identifying the experiences associated with early symptoms consis-
osteoarthritis. Phys Ther. 2014;94:
tent with knee OA, such as monitoring intermittent symptoms, interpreting the 111–120.]
meaning of these symptoms, modifying behaviors, and including the use of medica-
© 2014 American Physical Therapy
tions. If future work validates the QuIKS, its use in developing samples could expand
Association
our understanding of early disease and improve interventions.
Published Ahead of Print:
September 5, 2013
Accepted: August 30, 2013
Submitted: March 4, 2013

Post a Rapid Response to

this article at:
ptjournal.apta.org

January 2014 Volume 94 Number 1 Physical Therapy f 111

Questionnaire to Identify Knee Symptoms
K
nee osteoarthritis (OA) is the
leading cause of chronic disabil-
ity in older, noninstitutional-
ized adults.1 Current diagnostic pro-
cedures for knee OA identify
individuals late in the disease pro-
cess when structural joint changes
are irreversible.2,3 Spector and Hart4
described the need to identify indi-
viduals with early knee OA in order
to find effective interventions to
reduce the long-term impacts of this
disease. Improving our understand-
ing of early knee OA could provide
opportunities for early, conserva-
tive interventions that prevent the
progression of knee OA toward
disability.
Without a definition, the process of
identifying individuals with early
signs and symptoms of knee OA is
complicated. Soft tissue defects in
cartilage, subchondral bone, and
synovium are identifiable with mag-
netic resonance imaging (MRI) and
are likely associated with early struc-
tural changes in the knee joint.5–7
However, MRI is expensive, with
limited infrastructure, in Canada.8
Biochemical changes to cartilage and
increased levels of some inflamma-
tory markers also are consistent with
the onset of painful symptoms.9,10
Concentrations of these biological
markers of knee OA are most fre-
quently assessed from blood and
urine. Unfortunately, these measures
are not specific to the knee joint but
rather estimate levels of general
inflammation anywhere in the
body.10
A questionnaire may be useful in
screening for early symptoms of
knee OA. Questionnaires have been
used to estimate the prevalence of
knee OA in large populations,11–13
develop cohorts of patients with
diagnosed knee OA, and identify
people at risk of developing knee
OA.14 However, the majority of these
questionnaires were developed
using the current diagnostic criteria
112 f Physical Therapy Volume 94
that identify advanced knee OA, so
they may not be appropriate for
detecting individuals with early dis-
ease.11–13 Marra and colleagues15
used a pharmacist-administered
questionnaire to identify knee OA in
customers looking for pain manage-
ment information at a pharmacy.
This questionnaire identified undiag-
nosed knee OA in more than 80% of
customers with knee pain, and the
majority of these customers had
early signs of disease. However, their
study included only customers over
60 years of age, which could limit
the ability to identify younger indi-
viduals with early symptoms.
The main purpose of this study was
to develop a brief, self-administered
questionnaire that could be used in a
clinical or research environment in
order to identify emerging knee
symptoms in adults who could ben-
efit from conservative intervention
to minimize degenerative knee joint
changes. A secondary objective was
to establish the internal consistency
of the subscales. We hypothesized
that a self-administered questionnaire
would contain subscales that demon-
strate strong internal consistency.
Method
Questionnaire development involved
3 steps. First, potential items were
generated using existing qualitative
data.16 Second, Canadian experts in
rheumatology reviewed and revised
the items. Third, the revised question-
naire was administered to family med-
icine patients who reported a history
of knee pain. Principal components
analysis (PCA) of these data reduced
the number of items in the question-
naire.
Item Generation
Maly and Cott16 interviewed 26 par-
ticipants between the ages of 41 and
65 years with chronic, intermittent
knee pain. For this work, recruit-
ment occurred in 2 stages. First, 10
people diagnosed with knee OA
Number 1
within the previous 6 months were
identified. From these interviews,
consistent symptoms of an emerging
knee problem were compiled. Sec-
ond, posters featuring these symp-
toms were placed in fitness centers,
sport medicine clinics, and pharma-
cies. The 16 participants recruited
were screened for the American Col-
lege of Rheumatology clinical crite-
ria for knee OA, although no formal
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diagnosis was made.16 Analysis of
data from the 26 participants identi-
fied 4 stages in the process of recog-
nizing emerging knee problems. The
interview transcripts were read to
(1) develop a list of experiences for
each stage and (2) develop potential
questionnaire items that represent
these experiences, framed in the lan-
guage used by participants.
To elicit responses relating to the
frequency and intensity of symptoms
and behaviors, a Likert scale was
chosen.17 Five response options
were chosen to allow a neutral
response. Some items assessed
agreement from “strongly disagree”
(0) to “strongly agree” (4). Fre-
quency items were anchored with
“never” (0) and “always” (4). Two
weeks was selected as the time ref-
erence because patients undergoing
arthroscopic knee surgery accurately
recalled their pain status 2 weeks
prior to surgery.18
Expert Review
Canadian experts in knee OA were
invited to review the questionnaire.
Three participants in each of the fol-
lowing groups were recruited:
researchers, rheumatologists, ortho-
pedic surgeons, family physicians,
physical therapists, and consumers.
Potential participants were consid-
ered experts if they were a member
of the Canadian Arthritis Network,
including the Consumer Advisory
Council, or if they contributed to
peer-reviewed publications in OA as
the corresponding author and main-
tained a clinical practice.
January 2014

We utilized a published method to
optimize response rates.19 Briefly,
this approach involved 4 contacts: a
pre-notice, a questionnaire package,
a postcard reminder, and a replace-
ment questionnaire with a reminder
letter. Experts were asked to critique
the content and the scoring system.
Expert reviewer comments were cat-
egorized, and a draft of the question-
naire was created, consisting of a
cover page and 35 items covering 3
sections: medications and treat-
ments, activities, and living with
knee problems.
Item Reduction
Medical charts dated 1999 –2009
were reviewed at a family medicine
clinic to identify patients with knee
problems. The clinic is located in
southwestern Ontario and includes 6
general physicians. Three inclusion
criteria were applied: participants
had to be between 40 and 65 years of
age, have at least 1 health examina-
tion in the previous 3 years, and have
a history of acute or chronic knee
pain lasting 2 weeks or longer. Evi-
dence of knee pain included docu-
mented subjective complaints of
knee pain, diagnostic tests such as
radiology, and referral for surgical or
rheumatology consultation for knee
pain. Exclusion criteria included
diagnosis of knee OA because these
individuals would have more
advanced disease than the target
population, gout, rheumatoid arthri-
tis, chronic low back pain, chronic
hip or foot problems, or major
comorbidities such as cancer, stroke,
or knee surgery.
We sought to recruit 6 participants
for each potential questionnaire item
(35 items ⫻ 6 participants).20 After
adjusting for nonresponse (30%) and
ineligibility (10%), a sample size esti-
mate of 294 participants was deter-
mined. The same mail-out method
described for expert reviewers
above was utilized. In addition to
administering the questionnaire
January 2014
Questionnaire to Identify Knee Symptoms
items, descriptive data regarding
age, sex, body mass, height, previous
injury, family history, and the Knee
Injury and Osteoarthritis Outcome
Score were collected.21
Data Analysis
Patient demographic and question-
naire responses were entered into
SPSS 16 (SPSS Inc, Chicago, Illinois).
Questionnaire responses were evalu-
ated for missing data. Any item left
unanswered by more than 10% of the
respondents was excluded. Partici-
pants who returned questionnaires
with more than 10% of the items not
completed also were excluded.
Before any imputation, the missing
values were assessed using Little’s
Missing Completely at Random
(MCAR) test to determine the appro-
priateness of the techniques.22 Ques-
tionnaires with fewer than 10% miss-
ing values were imputed using the
expectation maximization (EM)
method.
Principal components analysis was
used to extract components to rep-
resent the underlying constructs of
emerging knee problems. A compo-
nent describes a group of items that
together explore a similar construct.
The goal was to identify the impor-
tant items that explain a high propor-
tion of variance in the questionnaire
scores. First, a correlation matrix
was created to assess the degree of
inter-item correlation. The majority
of correlations should be greater
than .3 to indicate an appropriate
dataset for PCA.23 Second, the sam-
pling adequacy was determined,24
and communalities were inspected.
High communalities among items
(average ⬎0.7) indicate that a com-
mon construct is being measured by
the questionnaire.25 Third, using
eigenvalues greater than 1 as the cut-
off,26 components were extracted to
determine a final solution. Eigenval-
ues represent the ratio of shared vari-
ance to unique variance explained
by each component.27 Components
Volume 94
with eigenvalues greater than 1
imply that more common than
unique variance is explained by that
component.
Once the desired components were
extracted, the fourth step was to
rotate the solution to create a pattern
where items load strongly on one
factor and weakly on others, thus
improving interpretation. An oblique
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rotation was applied first to estimate
the correlation between compo-
nents. If the oblique solution sug-
gested the correlations between
components were low to moderate,
an orthogonal rotation was applied.
After rotation, not all of the rotated
components were meaningful. Sev-
eral runs of PCA were required to
obtain an interpretable solution, a
common technique.23 The compo-
nents were examined, and the
researchers decided to rerun the
analysis, restricting the number of
components to improve the clarity
of the overall solution.
The final step was to interpret the
component structure. The goal was
to interpret the groupings of items
into components. Component load-
ings represent the correlation coeffi-
cients of each item and the compo-
nent they represent.23 An item that
loads strongly on one component
suggests that the item represents
that component, whereas items with
low loadings do not.23 Hair28 recom-
mended that loadings ⬎0.6 are con-
sidered high and loadings ⬍0.4 are
low. Comrey and Lee29 suggested
that loadings ⬎0.71 (explaining 50%
of the variance) are excellent. Inter-
pretation of the solution is subjec-
tive, and researchers may consider
experience to decide which compo-
nents to retain.30 The retained items
in each component were examined
to understand the underlying
domains that represent emerging
chronic knee problems. In the final
draft of the questionnaire, the Ques-
tionnaire to Identify Knee Symptoms
Number 1 Physical Therapy f 113
Questionnaire to Identify Knee Symptoms

Table 1. ments, activities, and living with

Patients Excluded From the Study Via Chart Audit at the Family Medicine Clinica knee problems.
Exclusion n (%)
Item Reduction
Age ⬎65 y 1,588 (51.8)
In total, 3,293 charts were audited at
Age ⬍40 y 531 (17.3)
the local family medicine clinic to
Healthy knees 399 (13.0) identify 228 potential participants
Inconsistent visits to a physician 220 (7.2) (Tab. 1). One hundred thirteen of
Chronic low back pain or back osteoarthritis 217 (7.1) the potential 228 participants com-
Unstable mental health and depression 64 (2.1)
pleted and returned the question-
naire and descriptive items, which

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Major comorbities—eg, multiple sclerosis, stroke, heart attack 54 (1.8)
translated to a response rate of
Chronic hip pain or hip osteoarthritis 51 (1.7)
63.1%. Of these, data from 8 partici-
Chronic foot pain 46 (1.5) pants with more than 10% missing
Diagnosis of knee osteoarthritis 45 (1.5) values were excluded from the anal-
Gout or rheumatoid arthritis 41 (1.3) ysis to minimize imputation biases.
Knee surgery—total knee replacement or high-tibial osteotomy 13 (0.4)
Age, sex, body mass index, and his-
tory of these excluded participants
Undergoing cancer treatments 12 (0.4)
were examined to determine
Recent motor vehicle accident causing referred pain throughout body 8 (0.2)
whether there was a consistent
Communication difficulties—English as a second language, blind 4 (0.1) trend or differences with the group
Total number of patients excluded 3,065 (100) that returned completed question-
a
Some participants met more than one exclusion criterion. naires. Six of the 8 participants were
women, but no other trend and no
differences between these 8 respon-
dents and the remaining sample
(QuIKS), the components repre- Expert Review were identified. The characteristics
sented the individual subscales. Overall, a response rate of 69.6% was of the remaining 105 respondents
achieved (16 of 23 experts). Respon- are listed in Table 2. The respon-
The final objective was to assess the dents included consumers with OA dents were overweight, with nearly
internal consistency reliability (ICR) from the Canadian Arthritis Network half reporting a family history of
of the subscales retained in the final Consumer Advisory Council, physi- arthritis and a previous injury to the
version of the QuIKS. Internal con- cal therapists, health researchers knee. Scores on the Knee Injury and
sistency is one measure of reliability (including one with self-reported Osteoarthritis Outcome Score
and assesses the average correlation symptoms consistent with our cur- (KOOS) indicated respondents were
between items on a questionnaire. A rent knowledge of knee OA), rheu- experiencing some mild to moderate
minimum internal consistency of 0.7 matologists, family physicians, ortho- limitations due to their knee
would be adequate.24 Reliability anal- pedic surgeons, and researchers problems.
ysis was performed using the raw with expertise in questionnaire
scores of items retained in the final design and validation. Experts pro- Of the draft 35 items completed by
version of the QuIKS and using Cron- vided recommendations in the fol- 105 participants, there was no evi-
bach alpha for each subscale. lowing areas: scaling and clinical util- dence to remove any specific item
ity, identification of unclear or due to incompleteness. The MCAR
Results ambiguous items, wording changes, test results were not significant, indi-
Item Generation additional constructs to consider, cating all values were missing com-
Questionnaire items developed from response options, inappropriate pletely at random. Questionnaires
interview transcripts were grouped items, and labeling of response from 14 participants contained
into categories of interpreting knee scales. Addressing all of these issues, missed items; however, these ques-
symptoms, monitoring knee pain, a draft questionnaire was created for tionnaires were all missing less than
modifying activities in response to pilot testing with patients at the fam- 6% of values and, therefore, were
knee problems, and planning for the ily medicine clinic. This draft con- retained for analysis after imputa-
future. A total of 33 items were cir- sisted of 35 items organized into 3 tion. Missing values for these 14
culated to experts for review. sections: medications and treat- questionnaires were imputed using
the EM function in SPSS. This EM

114 f Physical Therapy Volume 94 Number 1 January 2014

 Questionnaire to Identify Knee Symptoms

function is a multiple imputation Table 2.

technique, giving researchers a Demographic Characteristics and Knee Injury and Osteoarthritis Outcome Score
highly probable value and limits (KOOS) for the 105 Respondentsa
potential biases associated with Men Women Total
other imputation techniques.31 Variable (nⴝ46) (nⴝ59) (Nⴝ105)

Age (y), X (SD) 52.1 (7.1) 52.2 (6.4) 52.2 (6.7)

Using a standard eigenvalue cutoff of BMI (kg/m2), X (SD) 28.7 (4.7) 26.8 (5.9) 27.6 (5.5)
1, the first PCA identified 8 compo- b
Bilateral/unilateral knee problems 18/28 28/30 46/58b
nents that explained more than 73% b
Family history of arthritis (yes/no) 15/31 36/22 51/53b
of the variance in the draft 35 items.
The initial, unrotated 8-component Previous injury (yes/no) 21/25 24/35 45/60

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solution was difficult to interpret as KOOS scores, X (SD)
many of the items cross-loaded on Symptoms 54.7 (12.2) 54.0 (13.0) 54.3 (12.6)
several components. The initial, Pain 77.3 (19.3) 76.7 (17.5) 77.0 (18.3)
8-component solution was rotated to
Activities 83.1 (18.5) 86.1 (14.3) 84.8 (16.2)
improve interpretation of the
Sports and recreation 65.8 (24.1) 71.2 (27.0) 68.7 (25.7)
retained items and the representa-
tive components. An oblique rota- Quality of life 60.8 (21.2) 66.1 (21.4) 63.8 (21.3)

tion was performed first, which a

allowed components to be corre-
lated. Consistent with the guidelines
proposed by Hair,28 items that
loaded ⱖ0.6 were indicative of a
strongly loaded item. Items that
cross-loaded (loaded on more than 1
component simultaneously) were
not retained. As well, component
Scores on the KOOS are normalized to 100%, where a score of 0 represents significant disability and
a score of 100 represents no impairments. BMI⫽body mass index.
b
Reported subtotals are less than the totals because data for one participant were missing from the
returned questionnaires.
Table 3.
Final Four-Component, Oblique Rotation Solution of the Questionnaire to Identify
Knee Symptoms (QuIKS)a
Component

loadings less than 0.33 (explaining Item 1 2 3 4

10% of the variance in that compo- I take pills before I do some activities to prevent knee 0.94
nent) were removed. Low correla- pain.

tions existed among the compo- I carry pills with me just in case my knees start to hurt. 0.85
nents; therefore, an orthogonal I take pills after I do some activities to reduce knee 0.70
rotation was applied to the solution pain.
in an attempt to improve interpreta- My knees hurt after sitting or standing for long periods 0.90
tion of the component structure. of time.

My knees feel stiff after sitting or standing for long 0.87

Within both oblique and orthogonal periods of time.

rotations, there were 3 clear, well- I notice my knee pain when kneeling. 0.63
defined components. A clear, I suspect my knee problems are the result of getting 0.83
defined component should consist older.

of at least 3 items that load strongly I suspect my knee problems are arthritis. 0.77
on only that component.30 The 3 I consult my doctor about my knee problems. 0.53 ⫺0.41
defined components were: (1) activ- I talk to family and friends about my knee problems. 0.51 ⫺0.33
ity modification due to knee prob-
I am considering stopping a favorite activity due to my ⫺0.86
lems, (2) awareness of knee prob- knees.
lems related to activity, and (3) use I participate in certain activities less often to avoid ⫺0.84
of medication to manage pain. The aggravating my knees.
remaining 5 components were I am considering changing my exercise routine due to ⫺0.83
poorly defined. The PCA was my knee problems.
repeated by progressively restricting a
Relatively high component loadings (correlation of item to component) were observed for the final
the solution until all of the compo- 13-item solution. Loadings ⬍0.33 were removed to enhance visualization of the solution.
nents were clearly defined.

January 2014 Volume 94 Number 1 Physical Therapy f 115

Questionnaire to Identify Knee Symptoms

Table 4. lems. The final version of the QuIKS

Total Variance Explained by the Four-Component Questionnaire to Identify Knee is presented in the Appendix.
Symptoms (QuIKS) Solutiona
% of Cumulative The final objective was to assess the
Component Eigenvalue Variance % internal consistency reliability of the
1 5.13 39.46 39.46 4 subscales retained in the final ver-
2 1.58 12.12 51.58 sion of the QuIKS. The medications,
monitoring, interpreting, and modi-
3 1.40 10.46 62.04
fying subscales demonstrated Cron-
4 1.29 9.92 71.96
bach alphas of .818, .827, .734, and
5 0.78 5.97 77.93 .866, respectively.

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6 0.54 4.18 82.11

7 0.51 3.96 86.07 Discussion

8 0.42
9 0.39
10 0.34
11 0.25
12 0.22
13 0.19
a
Four components had eigenvalues greater than 1 and were retained, explaining nearly 72% of the
variance in the 13-item solution.
The final version of the question-
naire (ie, QuIKS) was composed of
13 items (Tab. 3). Principal compo-
nents analysis was performed on this
4-component solution to confirm the
appropriateness of the retained
items (Tab. 4). Consistent with an
eigenvalue cutoff of 1, the final set of
items suggested retaining 4 compo-
nents. Nearly 72% of the variance in
the item scores could be explained
using the shortened, 13-item solu-
tion (Tab. 5).
Individual summative subscale
scores for each of the subscales were
chosen for the QuIKS rather than an
3.20 89.26
3.02 92.28
2.64 94.91
1.95 96.87
1.67 98.53
1.47 100.00
aggregate score to improve individu-
alization for each respondent. A high
score on the medications subscale
indicated individuals were using
medications to manage their knee
pain. A high score on the monitoring
subscale indicated individuals were
increasingly aware of their knee
problems. A high score on the inter-
preting subscale indicated individu-
als were actively thinking about their
knee problems. Finally, a high mod-
ifying subscale score indicated
patients were considering or imple-
menting adjustments of their behav-
iors in response to their knee prob-
The primary objective of this study
was to develop a brief, self-
administered questionnaire, for clin-
ical and research environments, to
identify emerging knee symptoms in
individuals who could benefit from
conservative interventions. The
QuIKS was generated from the expe-
riences of people reporting emerg-
ing knee symptoms consistent with
knee OA.16 There was a strong focus
throughout the development of the
QuIKS on clinical utility. Experts
emphasized the importance of a
short and self-administered instru-
ment to minimize burden on the
health care provider.17 Principal
components analysis of data from an
independent sample was used to
reduce potential items to the final
13-item questionnaire. No reports of
reliability assessment were found for
the other knee OA detection ques-
tionnaires.11–13,15 Thus, the QuIKS
has potential to identify samples of
people with emerging knee symp-
toms that suggest risk for incident
knee OA. Identifying these samples

Table 5.
Mean (Standard Deviation) Scores for the Four Questionnaire to Identify Knee Symptoms (QuIKS) Subscales Identified by
Principal Components Analysis (N⫽105)
Men Women Unilaterala Bilaterala Total
QuIKS Subscale (nⴝ46) (nⴝ59) (nⴝ58) (nⴝ46) (Nⴝ105)

Medications (/12) 1.7 (2.7) 2.2 (2.8) 1.5 (2.5) 2.6 (3.0) 2.0 (2.8)

Monitoring (/12) 7.9 (3.0) 7.6 (3.1) 6.7 (3.2) 9.0 (2.4) 7.7 (3.1)

Interpreting (/16) 7.5 (3.7) 7.8 (3.2) 7.0 (3.7) 8.5 (2.9) 7.7 (3.4)

Modifying (/12) 5.5 (3.3) 4.9 (3.1) 4.8 (3.5) 5.6 (3.0) 5.2 (3.3)
a
One respondent did not complete the question about unilateral vs bilateral knee symptoms.

116 f Physical Therapy Volume 94 Number 1 January 2014


will enable researchers to study early
symptomatic disease and evaluate
how interventions such as exercise
affect disease progression when
implemented at the point of emerg-
ing symptoms.
Recently, these 4 questionnaires
were developed primarily to deter-
mine prevalence estimates in large
population studies and to develop
cohorts for studies of knee
OA.11–13,15 These questionnaires
identified individuals with advanced
knee OA rather than intermittent
symptoms typical of early knee OA.
The items in these tools determine
the frequency, intensity, and dura-
tion of knee symptoms and ask
respondents about a previous physi-
cian diagnosis of arthritis. Although
these questionnaires were not devel-
oped from patient input, 3 research
groups consulted patients to infor-
mally test the items before the ques-
tionnaires were administered to their
target population.11–13 By compari-
son, the QuIKS delved into the con-
sequences of these symptoms. This
focus on the patient experience of
recognizing emerging symptoms
may be important when seeking to
identify early knee problems. The
risks of excluding the patient per-
spective include missing key experi-
ences and constructs that are impor-
tant to discovering a chronic knee
problem. For example, self-
management with medications is
important to the experience of recog-
nizing emerging knee problems. The
pharmacist-administered approach
used by Marra et al15 effectively cap-
tures this experience; however, 2 of
the other questionnaires are lacking
items relating to medication use.
The QuIKS is limited to identifying
only emerging symptomatic knee
OA and cannot identify early-stage
asymptomatic structural disease.
Many people with signs of structural
disease on radiographs or MRI scans
do not experience symptoms.32 For
January 2014
Questionnaire to Identify Knee Symptoms
example, among 44 adults with no
history of knee pain, knee injury, or
bone or joint disease, 12 had osteo-
phytes, 5 had cartilage lesions, and
all but 1 participant had meniscal
abnormality in the knee detected on
MRI scans.33 Similarly, in 85 middle-
aged men and women who were
healthy, cartilage defects noted on
MRI scans were highly prevalent.34
The QuIKS would not identify any of
these cases. This inability to detect
asymptomatic structural disease sug-
gests that the QuIKS will fail to
detect a highly prevalent phenotype
of emerging knee OA. However, in
OA, structural disease is poorly
related to disability and quality of
life; symptoms, particularly pain, are
critical determinants of quality of
life.35 Because it focuses on symp-
toms, the QuIKS has potential to
identify those with emerging knee
problems that have the greatest risk
for disability and reduced quality of
life as a result of knee OA.
Screening and monitoring tech-
niques are well-established for other
chronic diseases, such as stroke,
heart disease, and cancer36,37 to pro-
mote early identification. Although
OA is not associated with high rates
of mortality as in these conditions, it
is associated with high rates of long-
term disability and reduced quality of
life.1 Routine physical examinations
assess risk factors for cardiovascular
disease with tests of blood pressure,
blood glucose, and cholesterol
levels.36
No simple test exists for knee OA.
Screening people who may be early
in the OA disease process could
increase the benefit they would
receive from physical therapy. Phys-
ical therapists believe they can be
more effective in altering the natural
history of OA with the opportunity
to start treatment early rather than
late. The QuIKS may be a useful
screening tool for identifying individ-
uals with an increased potential for
Volume 94
knee OA, as components from the
physical examination such as age,
obesity, previous injury, and family
history will be augmented with infor-
mation about symptom recognition
and interpretation. To interpret the
emergence of intermittent knee
problems, individuals seek causal
factors and input from formal and
informal sources to improve their
long-term knee health. As reflected
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in the QuIKS, older adults with OA
assessed their own health by com-
paring their levels of pain and disabil-
ity with their peers.38 Individuals
with family or friends who are famil-
iar with knee OA may be more likely
to discuss their pain. There is wide-
spread evidence that many older
adults with chronic musculoskeletal
pain do not seek help from health
care professionals.39,40 Among indi-
viduals with knee pain lasting more
than 4 weeks in the last year, only
25% sought care from a physi-
cian.41,42 The lack of health care con-
sultation remains an important bar-
rier to managing pain and disability
in patients with emerging chronic
knee problems. Previous research
has indicated older adults are more
accepting of knee pain than younger
adults, as many older individuals
believe pain is a natural part of the
aging process.43,44 Younger adults
were more concerned that knee pain
could be a pathological problem,
and they may be more likely to seek
care for their early symptoms.45
The findings must be considered in
light of the limitations of this study.
There was no interrater reliability of
the chart audit to identify potential
study participants as only 1 auditor
(J.M.C.) read all charts. Problems
with consistent chart reporting and
difficulty reading charts have been
identified.46 Based on the model by
Maly and Cott,16 many individuals
will engage in interpreting and being
careful for many years before seek-
ing care. As a result, many individu-
als with intermittent symptoms may
Number 1 Physical Therapy f 117
Questionnaire to Identify Knee Symptoms
have not yet discussed their con-
cerns with their physician and
would not have been included in this
study. The sample size of 105 partic-
ipants was the minimum number
required to obtain a successful solu-
tion.20 The imputation of question-
naires with fewer than 6% missing
values could contribute to potential
bias, though the use of the EM func-
tion would minimize this effect. The
response rate of 63.1% is somewhat
low. A relatively low response rate
could mean we have not adequately
sampled the population to make gen-
eralizations about individuals with
emerging knee problems.
Additionally, PCA requires some sub-
jective input by the researchers25;
therefore, it is possible that another
researcher could find a slightly differ-
ent solution. Decisions regarding the
number of components to retain, the
cut-off values for component load-
ings, and the rotation options are set
by the researchers. It is important to
confirm these results in another
independent sample, as validity and
reliability estimates are commonly
overestimated in the development
sample.25 Finally, it is possible the
retention of the “consulting with my
doctor” item in the final analysis
reflected a bias in the PCA due to the
sampling procedures. Although
there is some evidence that patients
may not recall their medical his-
tory,46 it likely influenced the results.
Future research should seek to vali-
date the predictive validity of the
QuIKS for knee OA. For example,
comparing the presence of structural
disease on MRI scans in those with
high versus low scores on the QuIKS
may be useful in validating the tool,
although the potential discordance
between structural and symptomatic
disease may limit this design. Pro-
spective, longitudinal studies that
compare markers of disease progres-
sion, including pain, incidence of
structural knee OA on MRI, and dis-
118 f Physical Therapy Volume 94
ability in those with high versus low
QuIKS scores, would be ideal. Such
work would enhance the clinical
utility of the tool if it could be shown
that the probability of developing
definitive knee OA increases with
QuIKS scores. If the QuIKS is vali-
dated, future work could utilize the
QuIKS to develop samples of people
with emerging knee symptoms for
studies that document the early
stages of clinical disease and studies
that evaluate whether interventions
such as exercise are more effective
in people with emerging knee symp-
toms compared with those with
advanced disease.
All authors provided concept/idea/research
design and writing. Ms Clark and Dr Maly
provided data collection. Ms Clark, Dr Ches-
worth, Dr Speechley, and Dr Maly provided
data analysis. Dr Chesworth and Dr Maly
provided project management. Dr Maly pro-
vided fund procurement. Dr Petrella pro-
vided study participants and facilities/equip-
ment. Dr Chesworth and Dr Petrella
provided institutional liaisons. Dr Chesworth
and Dr Speechley provided consultation
(including review of manuscript before
submission).
This work was approved by the University of
Western Ontario Research Ethics Board and
the Lawson Health Research Institute Clinical
Research Impact Committee.
This study was funded, in part, by a Natural
Sciences and Engineering Research Council
Discovery Grant (#353715 MRM).
DOI: 10.2522/ptj.20130078
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Number 1 Physical Therapy f 119
Questionnaire to Identify Knee Symptoms

Appendix.
Questionnaire to Identify Knee Symptomsa

Instructions

Circle one number to answer each question. If you are unclear about how to answer a question, please give your
best answer.

Medications

The following statements describe things you might do to manage your knee pain with medications.

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Circle the number that best describes how often each statement applies to you in the last 2 weeks.

Never Rarely Sometimes Often Always

1. I take pills before I do some activities to prevent knee pain. 0 1 2 3 4

2. I take pills after I do some activities to reduce knee pain. 0 1 2 3 4

3. I carry pills with me just in case my knees start to hurt. 0 1 2 3 4

Monitoring

The following statements describe how you may monitor your knee symptoms.

Circle the number that best describes your agreement with each of the following statements in the last 2 weeks.

Strongly Strongly
Disagree Disagree Neutral Agree Agree

4. I notice knee pain when kneeling. 0 1 2 3 4

5. My knees feel stiff after sitting or standing for long periods of time. 0 1 2 3 4

6. My knees hurt after sitting or standing for long periods of time. 0 1 2 3 4

Interpreting

The following statements describe how you may interpret your ongoing knee symptoms.

Circle the number that best describes your agreement with each of the following statements in the last 2 weeks.
Strongly Strongly
Disagree Disagree Neutral Agree Agree

7. I talk to family and friends about things I can do about my knee problems. 0 1 2 3 4

8. I consult my doctor about my knee problems. 0 1 2 3 4

9. I suspect my knee problems are the result of getting older. 0 1 2 3 4

10. I suspect my knee problems are arthritis. 0 1 2 3 4

Modifying

The following statements describe how you may modify activities in response to knee pain.

Circle the number that best describes your agreement with each of the following statements in the last 2 weeks.

Strongly Strongly
Disagree Disagree Neutral Agree Agree

11. I participate in certain activities less often to avoid aggravating my knees. 0 1 2 3 4

12. I am considering stopping a favorite activity due to my knees. 0 1 2 3 4

13. I am considering changing my exercise routine due to my knee problems. 0 1 2 3 4

a
The questionnaire may not be used or reproduced without written permission of the authors.

120 f Physical Therapy Volume 94 Number 1 January 2014