Clinical Rehabilitation

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Association between radiographic joint space narrowing, function, pain and

muscle power in severe osteoarthritis of the knee
Karen Barker, Sarah E Lamb, Francine Toye, Sarah Jackson and Sharon Barrington
Clin Rehabil 2004; 18; 793
DOI: 10.1191/0269215504cr754oa
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Clinical Rehabilitation 2004; 18: 793 -800

Association between radiographic joint space

narrowing, function, pain and muscle power in
severe osteoarthritis of the knee
Karen Barker Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford, Sarah E Lamb Interdisciplinary
Research Centre in Health, Coventry University, Francine Toye Physiotherapy Research Unit, Nuffield Orthopaedic Centre
NHS Trust, Oxford and Interdisciplinary Research Centre in Health, Conventry University, Sarah Jackson Department of
Radiology, Nuffield Orthopaedic Centre NHS Trust, Oxford and Sharon Barrington Physiotherapy Research Unit, Nuffield
Orthopaedic Centre NHS Trust, Oxford, UK

Received 28th May 2003; returned for revisions 13th October 2003; revised manuscript accepted 15th November 2003.

Objective: To examine the association between radiographic classification of severe

knee osteoarthritis and measurements of function, pain and power.
Design: Cross-sectional study.
Setting: Specialist orthopaedic hospital.
Subjects: One hundred and twenty-three patients on the waiting list for elective
knee arthroplasty.
Outcome measures: Weight-bearing antero-posterior radiographs scored for
severity of osteoarthritis using the Keligren and Lawrence scale. Function measured
using the function subscale of the WOMAC (Western Ontario and McMaster
Universities) index, timed tests of walking speed and sit-to-stand. Pain measured
using the pain subscale of the WOMAC index and a visual analogue scale. Extensor
strength of the lower limb measured with the leg extensor power rig.
Results: Within any radiographic grade there was considerable variation in function:
WOMAC function for patients with grade 2 mean 64 (47-86), grade 3 mean 47
(12-89) grade 4 mean 45 (2-92). There was poor correlation between radiographic
score function, pain or muscle power, with no statistically significant associations. A
wide range of scores was also seen within patients with the same radiographic
grade.
Conclusions: Radiographic score was not found to be closely associated with
function. Amongst patients with the same radiographic score there was considerable
variation in function, pain and power.

siotherapist or an orthopaedic surgeon. It has been

estimated that 7.5% of the population aged over 55
Osteoarthritis of the knee is one of the most years of age have some degree of knee pain and
common reasons for patients to suffer lower limb disability associated with radiographic changes'
disability and seek the advice of either a phy- and that 1.5% of older adults may have severe pain
and disability related to knee osteoarthritis.2 The
Address for correspondence: Karen Barker, Co-Director, signs and symptoms of knee osteoarthritis include
Physiotherapy Research Unit, Nuffield Orthopaedic Centre pain, limitation of joint range, joint stiffness and
NHS Trust, Oxford OX3 7LD, UK. e-mail: Karen.Barker@
inflammatory signs.3
noc.anglox.nhs.uk

Introduction

g Arnold 2004

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10. 1 191/026921 5504cr754oa

794 K Barker et al.

There is discordance in the medical literature

about how important radiographic features are in
evaluating knee osteoarthritis. Given the weight
that many surgeons attach to radiographic changes
when selecting patients for arthroplasty, or referring them for rehabilitation, it is important that we
have a clear understanding about the relationship
between function and radiographic changes.
A number of authors report that they have
failed to find a strong association between
pain scores and radiographic changes.4-9 Conversely, Lethbridge-Cejku et al.10 and McAlindon et
al." found that radiographic features of osteoarthritis were significantly associated with knee pain
and Cicuttini et al.7 reported some evidence for a
relationship between these two variables. Fewer
studies attempt to link radiographic changes with
function. Larsson et al.3 reported that radiographic diagnosis of osteoarthritis was not related
to functional capacity. Creamer et al.12 found that
function was determined by pain and obesity
rather than by structural changes as seen on
X-ray, and Bruyere et al.13 report that radiological
features were poor predictors of clinical outcome
in knee osteoarthritis.
It has been documented that patients with knee
osteoarthritis have decreased muscle strength compared with age-matched normals. This is generally
believed to be due to disuse atrophy caused
by decreased loading of the limb because of
pain 4- 17 and an association between quadriceps
weakness and disability has been suggested.18-
No reports of the relationship between radiographic joint space narrowing and leg extensor
power were found.
The aim of this study was to examine the
association between radiographic classification of
knee osteoarthritis and measurements of function,
pain and extensor power.

Methods
Patients on the waiting list for elective knee
arthroplasty were invited to take part in the study.
All had a clinical diagnosis of knee osteoarthritis
made by an orthopaedic surgeon and fulfilled the
ACR criteria for osteoarthritis.21

Antero-posterior radiographs in an erect weightbearing position were studied for 123 patients with
a diagnosis of knee osteoarthritis. These were
assessed independently by two of the authors,
one a radiologist (SJ), the other a physiotherapist
(KB). The Kellgren and Lawrence method of
classification was used where grade 0 = normal,
1 = doubtful osteophyte, 2 = definite osteophyte,
3 = moderate joint space narrowing and 4 = severe
joint space narrowing.22 The two raters were
blinded to any clinical information about the
patients. A subject was considered to exhibit
marked signs of osteoarthritis if they scored more
than 3 on the Kellgren and Lawrence scale.
Self-reported difficulty with function was measured using the 17-item function subscale of
the Western Ontario and McMaster Universities
(WOMAC) index.23 It asks patients to rate their
difficulty in completing tasks on a 5-point Likert
scale. The aggregation of the scored responses is
taken as the overall disability score, ranging from 0
to 68 (WOMAC-f). The subscale score was transformed to a range from 0 to 100, with a score of
100 indicating no dysfunction.24 Walking speed
was recorded over a 14-metre course, using a
digital handheld stopwatch. Patients were asked
to walk as quickly as they could. The number of
times that a patient could rise from a seated
position to standing and return to sitting in 1
minute was recorded. Measurements were taken
using a British standard height chair 49 cm from
the floor.
Pain severity was measured using the pain
subscale of the WOMAC index. This has five
items, scored on a 5-point Likert scale. An
aggregate score of the responses is taken as the
overall pain score, ranging from 0 to 20 (WOMACp). The subscale score was transformed to a range
from 0 to 100, with a score of 100 indicating no
pain.24 Subjects also rated pain over the 48-hour
period prior to their assessment using a 10-cm
visual analogue scale anchored with the numbers 0
and 10.25
Extensor strength of the lower limb was recorded by using the leg extensor power rig (BioMed International, Nottingham). This measure
has been shown to be reliable for patients with
osteoarthritis of the knee, prior to surgery.26'27
Subjects were seated in an upright position with
arms folded and the seat position determined by

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X-rays and measures offunction in OA 795

comfortable extension of the knee, in conjunction

with full depression of the foot pedal. The subject
was instructed to push against the footplate,
extending their leg with maximal effort. They
were asked to make 2-3 submaximal practice
pushes and then five maximal pushes. The less
symptomatic leg was tested first to familiarize
patients to the equipment. There was a rest period
of 20 seconds between efforts. The output was a
product of the force and the rate of force generation during the single leg extension.28 The highest
recorded power output was used. Body weight was
measured using a pair of calibrated bathroom
scales. The measure of LEP was summarized as
relative power (i.e., absolute power divided by
body weight (W/kg)), as this index has greater
functional relevance and allows comparison with
other studies.28'34
The presence of deformity was assessed visually
and categorized as no observable deformity, varus
deformity, valgus deformity and flexion deformity.
Data analysis
Data were analysed using the Statistical Package
for Social Sciences Release 11.5 (SPSS Inc.,
Chicago, IL, USA). The inter-rater agreement
between the two raters was calculated using the
weighted kappa statistic. Differences between the
groups of patients by radiographic grade were
examined using analysis of variance. Measures of
association between the radiographic score and the
measures of function, pain and leg extensor power
were examined using a Spearman's correlation

Within the group of patients scoring the same

Kellgren and Lawrence grade there was considerable variation in the measures of function, pain
and power. The mean and range of scores within
the different radiographic categories is summarized in Table 1. Figure 1 shows the spread of scores
within the radiographic groups for the WOMAC
function subscale. There were no statistically significant differences for these variables between the
three radiographic groups.
The patients had a mean age of 69.5 (SD 8.1)
years, with a mean symptom duration of 10.5 (SD
12.0) years. Sixty-six of the sample were female
(53.7%) and 57 male (46.3%). Deformity was
assessed visually: 42 patients (34%) had no observable deformity, 29 patients (24%) a varus
deformity, 23 patients (18%) a valgus deformity
and 29 patients (24%) a flexion deformity.
Measures of association between the radiographic score and the measures of function, pain
and leg extensor power are presented in Table 2; no
significant associations were found between radiographic score and any of these variables.

Discussion
The present study was conducted to investigate
whether patients' radiographic status was related to
their functional capability. This study concentrated
on patients who were already on the waiting list for
knee arthroplasty and thus represented the more

coefficient.

Clinical messages
Results
One hundred and twenty-three patients consented
to participate in the study. A further 55 patients
were eligible to take part in the study, but refused
consent. On radiographic assessment five (4%)
were graded 2 on the Kellgren and Lawrence scale,
35 (28.5%) grade 3 and 83 (67.5%) grade 4,
showing that the group was mostly categorized as
severe for radiographic changes. The inter-rater
agreement for scoring the radiographs was high
(kappa 0.88).

* There was considerable variation in the

measures of function, pain and power
amongst patients with the same radiographic score.
* Radiographic score did not predict function.
* Radiograph use should be restricted to
confirming diagnosis and assessment of
function addressed by direct measures,
rather than reliance on a presumed relationship.

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796 K Barker et al.

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2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

X-rays and measures offunction in OA 797

120

100.

assessed by an orthopaedic surgeon and placed

upon a waiting list for elective knee arthroplasty. In
the other studies the sample was recruited from
either the general population, or from outpatients
attending a hospital clinic. This may offer some

086

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Keligren & Lawrence group

Figure 1 Box and whisker plots showing spread of scores

for patient self-reported function using the WOMAC function
subscale within each radiographic grade. The area within the
box represents the percentage of patients falling within the
25th and 75th percentiles. The dark bar represents the
median score and the whiskers represent the spread of
scores.

severe end of the spectrum in terms of radiographic changes indicative of osteoarthritis. Unlike
other studies that have associated pain with radiographic changes using the Kellgren and Lawrence
scale,'0'29'30 no association was found between the
self-reported measures of pain and the radiographic grading.
The characteristics of the patient population
reflected a high score on the Kellgren and
Lawrence scale with 96% of the sample scoring 3
or 4. This is considerably higher than reported in
other studies,'0,30 and reflects the differing populations that the study samples were drawn from. In
this study all of the patients had already been

explanation for why the association between radiographic changes and function was poor. Van Baar
et al.3' and Creamer et al.'2 have postulated that
function bears a stronger relationship to radiographic change in patients with early disease. It is
also possible that by using a convenience sample,
bias was introduced. As participants were taken
sequentially from the waiting list the sample may
not be representative of the full spectrum of
function and pain for patients with any given
Kellgren and Lawrence grade. It is possible that
within the same Kellgren and Lawrence grade only
patients with more severe pain and disability were
placed on the waiting list, as surgeons may have
based their decision to place patients on the
waiting list on a combination of radiographic
and function characteristics.
The patients described here, especially those
with radiographic grades 3 and 4, demonstrated
relatively high disability as measured on
the WOMAC function and pain subscales. These
values were similar to those reported in other series
of patients before undergoing knee arthroplasty.32-34 The patients in our study were all
recruited from the knee arthroplasty waiting list
and may have been some months away from
receiving their surgery. However, Kelly et al.3
have demonstrated in a series of patients with
similar WOMAC scores that there was little
change in patient-reported pain or function from
the time that a patient was placed on a waiting list
until they actually received their surgery.

Table 2 Correlation coefficients showing associations between radiographic grade function and power

X-ray score
X-ray score
WOMAC-f
Sit-stand
Walk
WOMAC-p
Pain - VAS
Power (LEP)
*

p<0.01,

NS
NS
NS
NS
NS
NS

WOMAC-f

Sit-stand

Walk

WOMAC-p

Pain

NS

NS
0.361*

NS
0.348*

NS
0.807**
0.292*
0.357*

NS
0.640**
0.383*
0.394*
0.654**

0.391*

**p<0.05.
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VAS

Power (LEP)

NS
0.374*
0.392*
0.519**
0.388*
0.273*

798 K Barker et al.

Most reports of strength in osteoarthritis
have used isometric measures of quadriceps
strength. 15"17'18 The measurements of power derived using the leg extensor power rig and those of
quadriceps strength measured by maximum voluntary contraction have been shown to correlate
well.26 It has been postulated that the measurement of power is more sensitive to age and disease
related losses than that of strength, and is therefore
a more relevant measure.28 A further consideration
in selecting this method of measurement was the
fact that the generation of force is along the long
axis of the tibia, replicating loading found in
everyday activities, whereas in isometric testing
the loading is perpendicular to the bone. Leg
extensor power (LEP) correlated significantly
with the other measures of function, sit-to-stand,
walking and the WOMAC questionnaire, as reported by other authors.36 The values derived from
our sample of patients were low, with 11 patients
unable to register a reading. The mean value for leg
power (0.46 W/kg) was much lower than those
reported from the general population over 65,
where the mean score was 1.81 W/kg37; or in a
sample of elderly nursing home residents who had
a mean score of 1.02 W/kg.28 They were closer to
the values seen in a sample of patients measured
after surgical fixation of proximal femoral fracture
with a median score of 0.35 W/kg for the fractured
leg and 0.75 W/kg for the uninjured leg.36 The
values for LEP may also be low due to the
normalizing procedure used where the output is
divided by the patient's body weight. The weights
of the patients in this study were high, with a mean
of 83 kg, and a range of 50-120 kg. These weights
are significantly higher than those reported by
other authors using the LEP, perhaps reflecting the
immobility associated with severe osteoarthritis.
This study sought to find an association between
the radiographic changes of patients with moderate to severe joint space narrowing and common
measures of function, pain and power. It was
thought that the degree of radiographic change
might be used as a measure of osteoarthritis knee
severity, with predictive value regarding patients'
function. No such association was found with any
of the measures of function.
Orthopaedic surgeons continue to place much
weight on the use of radiographs when considering
patients for elective surgery, and their use has been

advocated as a diagnostic tool for knee osteoarthritis.31 In the rehabilitation setting, the finding of
such a wide range of function, pain and power
within a group of patients with the same radiograph score suggest that radiographs are likely to
be of limited benefit in predicting function. It is
suggested that less weight is placed on the presumed relationship with radiographs and function
measured by established patient-reported function
questionnaires or by direct measures of function.

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