298
Nigri PZ, Orlando FM, Gava ALW, Peccin MS, Cohen M
ORIGINAL ARTICLE
Assessment of quality of life of patients who underwent anterior
cruciate ligament reconstruction and a rehabilitation program
Avaliação da qualidade de vida de pacientes submetidos à reconstrução do ligamento
cruzado anterior e a um programa de reabilitação
Priscila Zeitune Nigri1, Flavia Machado Orlando2, Ana Lucia Wirz Gava3, Maria Stella Peccin4, Moises Cohen5
ABSTRACT
RESUMO
Introduction: Quality of life can be defined as the expression of a
conceptual model that tries to represent patient’s perspectives
and his/her level of satisfaction expressed by numbers. The
objective of this study is to evaluate the parameters of quality of
life of 23 patients who underwent surgery for anterior cruciate
ligament reconstruction. Methods: We adopted SF-36, a generic
health-related evaluation questionnaire, to obtain information
regarding several aspects of patients’ health conditions, and the
Lysholm questionnaire, specific to evaluate the symptoms and
function of the knee. The questionnaires were applied at two stages
of the treatment: pre- and postoperatively (after the rehabilitation
program). Results: Before surgery, the Lysholm questionnaire
presented the following results: excellent in 4% of the cases, good
in 22%, fair in 22%, and poor in 52%. After surgery (Lysholm e SF36) the correlation level was approximately 44% (p = 0.041).
Discussion: The correlation between the Lysholm and the SF-36
questionnaires showed the following: the lower the level of pain,
the higher the Lysholm score. The high scores presented by the
Lysholm questionnaire are directly proportional to physical and
emotional aspects, and to functional capacity. Conclusion:
Analysis of both questionnaires, as well as of their correlation,
showed some improvement in patients´ quality of life. We were
also able to demonstrate the importance and usefulness of applying
the two questionnaires at three different moments: before, during
and after physiotherapeutic intervention.
Introdução: Qualidade de vida pode ser entendida como a expressão
de um modelo conceitual que tenta representar a perspectiva de
um paciente ou seu grau de satisfação de forma quantificável. O
objetivo deste trabalho é avaliar os parâmetros de qualidade de
vida do ponto de vista de 23 pacientes submetidos à cirurgia de
reconstrução do ligamento cruzado anterior do joelho. Métodos:
Utilizou-se o questionário genérico de avaliação de qualidade de
vida SF-36, para obter informações relacionadas a vários aspectos
do estado de saúde; e o questionário Lysholm, específico para
avaliar sintomas e função do joelho. Esses foram aplicados em
duas etapas do tratamento: a primeira correspondente ao préoperatório e a segunda, ao pós-operatório (após acompanhamento
fisioterapêutico). Resultados: Constatou-se que no pré-operatório
o questionário Lysholm resultou em 4% excelente; 22% bom; 22%
regular; 52% ruim. Para os dados pós-operatórios (Lysholm e SF36), o grau de correlação foi aproximadamente 44% (p = 0,041).
Discussão: Ao fazer a correlação do questionário Lysholm com os
domínios do questionário SF-36, observamos que quanto menor o
nível álgico, maior a pontuação do Lysholm; a alta pontuação do
Lysholm é diretamente proporcional à dos aspectos físicos,
emocionais e capacidade funcional. Conclusão: Concluímos que
houve melhora na qualidade de vida na análise dos questionários
Lysholm e SF-36 e também na correlação de ambos. Demonstramos
o quanto é importante e necessária a utilização desses questionários
antes da, durante e após a intervenção fisioterapêutica.
Keywords: Quality of life; Physiotherapy; Anterior cruciate
ligament; Questionnaire; Orthopedics
Descritores: Qualidade de vida; Fisioterapia; Ligamento cruzado
anterior; Questionário; Ortopedia
Instituition: Instituto Cohen de Ortopedia, Reabilitação e Medicina do Esporte: Av. Lineu de Paula Machado, 660 - Cidade Jardim - CEP 05601-000 - São Paulo – SP – Tel.: (11) 3093-9000.
1
Physiotherapist of the Instituto Cohen de Ortopedia, Reabilitação e Medicina do Esporte - São Paulo (SP).
2
Physiotherapist from Universidade Paulista - São Paulo (SP).
3
Master´s degree in Health Psychology from UMESP (SP).
4
Physiotherapist of the Instituto Cohen de Ortopedia, Reabilitação e Medicina do Esporte. Master’s degree in rehabilitation, Ph.D. student in Science at the Universidade Federal de São Paulo (SP).
5
Post-doctorate degree and Lecturer at the Universidade Federal de São Paulo, Chief of the Sport Trauma Center of CETE - Universidade Federal de São Paulo (SP).
Corresponding author: Priscila Zeitune Nigri - Rua Tupi, 549 - apto11 – Pacaembu - CEP 01233-001 - São Paulo (SP) – Tel.: (11) 3826-4903/(11) 8182-4566 - Fax: (11) 3666-9458.
Received on March 2, 2004 – Accepted on August 28, 2004
einstein. 2004; 2(4):298-302
Assessment of quality of life of patients who underwent anterior cruciate ligament reconstruction and a rehabilitation program
INTRODUCTION
Quality of life can be understood as the expression of
a conceptual model that tries to represent the
perspective of a patient or his/her level of satisfaction
expressed by numbers. This concept started to be
applied in the United States after World War II aiming
to describe the effect caused by the acquisition of
material goods on people’s lives. Quality of life is
subjective since it is a concept based on individual
perspective, and it is multidimensional because it
encompasses different aspects of a person’s life, such
as physical and emotional aspects (psychometric
aspects). Subjectivity and multidimensionality are key
when quality of life is studied(1).
The present paper aims to assess the quality of life
of patients who were submitted to anterior cruciate
ligament reconstruction and physiotherapeutic
intervention. We applied two instruments: SF-36, a
generic health-related quality of life questionnaire, was
used to provide information related to several aspects
of patients´ health, such as their functional level, their
ability to perform activities of daily living, presence of
pain, fatigue and their emotional conditions; and the
Lysholm questionnaire, which is designed to study the
clinical outcome and to evaluate only the symptoms
and function of the knee.
Correlations between the Lysholm and the SF-36
questionnaires were statistically significant regarding
physical aspects, pain, and functional capacity, items
evaluated in both questionnaires(1). It is important to
emphasize that the lesion of the anterior cruciate
ligament is one of the most common and disabling
injuries of the knee, and it affects young adults more
often, when they are engaged in more intense sports
activities(2-3).
It is important to stress that when describing the
impairment of an individual’s quality of life or health
status and when assessing them in a broader manner,
it is possible to show how much that condition is
important to social or health aspects(4).
The main objective of this study is to assess the
parameters of quality of life from the point-of-view of
a group of patients in the postoperative stage of
reconstruction of the knee ligament that were
undergoing physiotherapeutic follow-up, and to verify
the existence or absence of specific changes in the
symptoms regarding the knee in the first months of
the rehabilitation program. Our other objectives are
to examine quality of life from the patients´ point-ofview; allowing us to assess the level of interference of
their condition on activities of daily living; to examine
patients´ acceptance regarding the rehabilitation
program, from physical to emotional aspects, at the
299
beginning and during physiotherapeutic actions; to
contribute to scientific literature since there are not
enough studies regarding quality of life.
METHODS
This is a longitudinal study carried out by means of
examining the questionnaires applied to a group of
patients that were undergoing rehabilitation program
at a private physiotherapy clinic located in the city of
São Paulo. The sample was made up of 23 patients (17
men and 6 women, age ranging from 14 to 52 years,
mean age of 31.4 years) who underwent reconstruction
of the anterior cruciate ligament and were undergoing
physical therapy follow-up, with diagnostics and surgery
performed by the same orthopedic surgeon, a specialist
in knee surgeries.
The Lysholm, “Lysholm Knee Scoring Scale”, is a
questionnaire originally written in English and
internationally accepted, that aims to study the clinical
outcome and to assess exclusively the symptoms and
functions of the knee. It was described by Lysholm in
1982, and was later modified(5), validated and translated
into Portuguese by Peccin (1). It contains eight questions,
with maximum and minimum scores distributed as
follows: “limp” (maximum: 5 points; minimum: 0 point);
“support” (maximum: 5 points; minimum: 0 point);
“locking” (maximum: 15 points; minimum: 0 point);
“instability” (maximum: 25 points; minimum: 0 point);
“pain” (maximum: 25 points; minimum: 0 point);
“swelling” (maximum: 5 points; minimum: 0 point);
“stair climbing” (maximum: 10 points; minimum: 0
point); “squatting” (maximum: 5 points; minimum: 0
point). Each question is objective and closed, and the
final score can be expressed by concept or by numbers:
excellent (95-100 points); good (84-94 points); fair (6583 points); poor (less or equal to 64 points)(1). The
terms used in this questionnaire cannot be changed;
therefore the technical term “claudicating” (claudicar,
in Portuguese) was changed to “to limp” (mancar, in
Portuguese) during the translation and validation
process, so that patients could better understand the
questionnaire. The term “to limp” (mancar) was used
in the questionnaire and in this study.
The SF-36 questionnaire – “Medical Outcomes
Study 36-item Short Form Health Survey” - was
developed in 1992 as a generic health-related
evaluation questionnaire, easy to be understood and
applied, without being too long (6) . It is a
multidimensional questionnaire that evaluates 36 items,
subdivided in 8 scales or components: functional
capacity (10 items), physical aspects (4 items), pain (2
items), general health status (5 items), vitality (4 items),
einstein. 2004; 2(4):298-302
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Nigri PZ, Orlando FM, Gava ALW, Peccin MS, Cohen M
social aspects (2 items), emotional aspects (3 items),
mental health (5 items), and one more assessment
question comparing the current health status to that
presented one year ago. It assesses both the negative
(disease or illness) and the positive (well-being) aspects.
This tool was translated into Portuguese and validated
by Ciconelli(7). Results found are converted into a 0to-100 scale, in which “0” corresponds to the worst
health condition, and “100”, to the best(4).
The Lysholm questionnaire was applied in the
preoperative period and for a 2-month follow-up
period; the same patients (except for patient N for
not living in Brazil) answered both the Lysholm and
the SF-36 questionnaires(5).
Patients selected for this study met the following
inclusion criteria (to make the sample more
homogeneous):
1– patients older than 14 years, with clinical diagnosis
of anterior cruciate ligament (ACL) lesion, either
isolated or combined;
2– signature of the informed consent term by the
patient or the person responsible for him/her;
3– patients with the same cultural and socioeconomic
level, to make the sample more homogeneous;
4 – patients operated by arthroscopy, using two surgical
techniques:
• ACL reconstruction with graft of the middle third
of the patella tendon (8) and fixation with an
interference screw,
• ACL reconstruction with graft of the tendons of
the semitendinosus and gracilis muscles, and femur
fixation with the “trans-fix®” system, and of the tibia
with interference screw and a clamp.
Following the preoperative evaluation, the 23 patients
were submitted to anterior cruciate ligament
reconstruction and to the same rehabilitation protocol
that emphasizes movement control, complete extension
recovery symmetrically to the contralateral knee, early
performance of the range of movement, and exercise
programs for the quadriceps femoris to recover normal
gait and for the posterior thigh muscles to help to protect
the graft and restore normal knee biomechanics(9).
SF-36 is a questionnaire in which parameters should
be assessed in a comparative and individualized
manner; however it was not routinely applied, and in
order to minimize this absence, we tried the correlate
results from SF-36 and the Lysholm questionnaires
after the surgery.
Data analysis was carried out using the paired t-test,
aiming to check the correlation between observations. The
paired t-test is adequate when we want to run a general
comparison of two population means: measures taken
before and after a certain intervention.
einstein. 2004; 2(4):298-302
RESULTS
Twenty-three patients (17 men and 6 women) who
underwent reconstruction of the anterior cruciate
ligament between June and September of 2003 were
assessed.
Results obtained in the pre- and postoperative
analysis of the Lysholm questionnaire are presented
in table 1. The score was classified according to the
following Lysholm standardization: excellent, good,
fair and poor.
Table 1. Comparative results: Lysholm applied in the pre- and postoperative
periods
Lysholm Scale
Preoperative
Postoperative
Excellent
Good
Fair
Poor
4%
22%
22%
52%
14%
23%
58%
5%
Analysis of the box plot (figure 1) for the pre- and
postoperative Lysholm data showed that there are
indications that quality of life is better in the
postoperative stage since the chart is more
homogeneous in that phase.
Figure 1. Box-plot describing Lysholm pre- and postoperative periods
Correlation analysis between the pre- and
postoperative Lysholm data was approximately 60%,
which is an average correlation (p = 0.04).
For the postoperative data (Lysholm and SF-36),
the correlation level was approximately 44%,
demonstrating an correlation (p = 0.041) (alpha = 5%,
t = 3.149 and p = 0.005).
Values obtained in the SF-36 questionnaire (in the
postoperative phase) are presented in table 2, which
shows the 8 scales of this questionnaire.
Assessment of quality of life of patients who underwent anterior cruciate ligament reconstruction and a rehabilitation program
301
Table 2. Comparative SF-36 (postoperative) aspects
Patient
A
B
C
D
E
F
G
H
I
J
K
L
M
O
P
Q
R
S
T
U
V
W
Functional
capacity
35
60
95
45
70
65
95
45
55
65
40
60
90
55
70
95
60
65
95
85
90
65
Physical
aspects
25
100
25
0
25
25
100
25
50
100
25
25
100
100
100
100
0
50
50
100
0
25
Pain
25
100
25
0
25
25
100
25
50
100
25
25
100
100
100
100
0
50
50
100
0
25
General health
score
87
90
82
90
100
87
80
77
87
82
87
87
100
92
62
100
87
87
85
77
87
72
DISCUSSION
The term quality of life has had several definitions
throughout the years, and it can be based on four key
principles: functional capacity, socioeconomic level,
satisfaction(10) and self-protection regarding health(11).
It can include a larger variety of potential conditions
that can affect the perception of individuals, their
feelings and behaviors related to their daily functioning;
including, but not limiting, their health status and the
medical interventions(12). It can also be understood as
a subjective concept, based on the perspective of the
individual. The patient is the person who can better
define his/her own quality of life and relate his/her
expectations, satisfaction and well-being(13).
In contrast to the piece of information given above,
other authors stated it is difficult to define quality of
life, as well as to measure it, since it can be affected by
cultural, ethical and religious values, as well as by
personal values and perceptions (14) . This is a
consequence of the lack of clear and unanimous
definition of this concept, given the different meanings
of the term, and little information about the assessment
tools available, which have generated disagreement
regarding the most appropriate methods to measure
it(15).
According to most of the literature, we show that
quality of life is affected by several factors related to:
strategies of psychosocial adaptation(16), traits of an
individual’s personality, the person’s history and
expectations towards life(17), their self-concept and self-
Vitality
40
70
65
90
90
80
80
25
65
65
45
25
75
100
30
80
45
65
80
90
60
75
Social
aspects
50
100
100
38
100
75
100
75
75
88
75
63
88
100
88
100
50
88
50
100
38
100
Emotional
aspects
0
67
67
67
33
100
100
100
100
100
100
0
100
100
100
100
0
100
33
100
100
100
Mental
health
44
80
80
84
96
84
96
60
88
72
60
44
96
84
32
80
52
76
88
100
80
80
efficiency(10), social support received from people who
are important to them, their locus of control(16), and
the perception of crisis’ control.
The rehabilitation program applied in the
postoperative period shows important concept-related
changes, compared to the current protocols. The main
landmark in physiotherapeutic management of ligament
reconstruction started in 1986, with the development
of fast protocols, and better knowledge of the
biomechanical behavior of the graft(4).
In our study, the application of the Lysholm tool
before surgery showed that most patients presented
poor results; but these improved in the postoperative
period as shown by the increased amount of fair results
indicating that the two-month treatment had been
effective. We should consider it was just the beginning
of the treatment (a six-month follow-up according to
the protocol performed) and, at that stage, the
treatment changed because the range of movement was
complete. From that moment on, great improvement
in quality of life, mainly in relation to the independence
of the patient (such as driving, walking and working) is
observed.
This is also confirmed by the pain score of SF-36 in
which it is possible to observe that for most patients,
the lower the level of pain, the higher the Lysholm
score. This shows that the correlation is effective
because patients with few symptoms of the knee present
low level of pain; therefore improving the patient’s
quality of life both in the physical and emotional
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Nigri PZ, Orlando FM, Gava ALW, Peccin MS, Cohen M
aspects. These two latter aspects are closely related since
physical problems affect the availability and willingness
of patients to carry on their activities of daily living;
therefore changing the emotional aspects. In this study,
this correlation shows that most patients with deficit
in physical aspects also present changes in the
emotional field; however, according to the response
of few patients, this correlation is not true. On the
other hand, it is possible to see that, when compared
to Lysholm, the correlation is correct since its high score
is directly proportional to physical and emotional
aspects.
In relation to functional capacity, it was possible
to observe the existing correlation among patients since
the best Lysholm scores correspond to an increasing
development of the functional capacity, which is in
accordance with our expectations since after two
months of treatment, the functional capacity begins
to reach the level presented before the lesion in the
anterior cruciate ligament.
When other SF-36 scales such as mental health,
vitality, general aspects of life and social aspects are
related to the Lysholm applied in the same date, they
show how differently each patient reacts to the same
question and to the same concept since the
questionnaire was applied in the same manner (notinduced) to all patients; therefore it is not possible to
have data correlation probably because the Lysholm
questionnaire does not have a specific question to
evaluate non-physical/functional states(18). Our findings
support those mentioned in the literature and prove
the importance of looking at the individual considering
every biopsychosocial aspect. It also reinforces the
importance of applying a generic questionnaire in order
to have a more truthful profile of the general state of
the individual’s health status (1) when specific
questionnaires are used to assess a disease.
CONCLUSIONS
The assessment of quality of life of patients submitted to
reconstruction of the anterior cruciate ligament and
physiotherapeutic treatment allowed us to conclude that:
1. The quality of life of patients that had undergone
ACL reconstruction improved in all parameters
assessed, when the specific knee score, the Lysholm,
was used.
2. The assessment of post-operative quality of life
measured by SF-36 showed that most values are
above the mean in all scales.
REFERENCES
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IMPLICATIONS
As a practical application of this study, we observed
that it is necessary to use objective parameters to assess
the quality of life in the pre- and postoperative periods;
therefore, we suggest its application to be performed
before, during, and after the physiotherapeutic
intervention.
On assessing its implication for research, we found
out that further studies – evaluating parameters of
quality of life of patients with anterior cruciate
ligament lesion conservatively or surgically-treated –
are necessary, using different objective and subjective
methods to assess the results, especially by carrying out
randomized clinical trials.
einstein. 2004; 2(4):298-302
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