Calista sat on the edge of a cushioned table. She looked up. Her right leg lay on the table wrapped thigh-to-ankle in white cotton with velcro straps. She wore Florida Gator flip-flops, white soccer shorts and she sat on the table with her other foot on the floor.
She had torn her anterior cruciate ligament during a college tournament game three days ago. Surgery over the weekend had repaired the ligament.
The surgery hadn’t hurt much but Calista was still upset from her injury. The immobilizer prevented her knee from bending. She had cried this morning while trying to put on her pants. She couldn’t walk very well either on her two crutches. While getting in her Mom’s car, she had almost fallen down. While her Mom looked on anxiously, Calista tried to laugh at herself but just started crying again.
Charlie introduced himself and exchanged brief pleasantries with Calista. She was better composed now and bantered easily with Charlie. He felt relaxed. He had thirty minutes to examine Calista and write up her plan of care. “That should be plenty of time”, Charlie thought.
He began his examination by visually inspecting Calista’s knee, ankle and hip. He took her range of motion. He tested her strength. He felt her lower leg for a pulse and checked her deep veins with careful probing. While Charlie performed these tasks he asked Calista, “I see that you have your most difficulty with putting on shoes and socks and getting in and out of he car. Is that correct?”
She gave him a curious glance, “Yes, I can’t bend my knee”.
Charlie saw her look, “I’m just going by the answers you put on this questionnaire.” He showed her his iPod opened to the tab with the Knee injury and Osteoarthritis Outcome Scale (KOOS). The radio buttons were all checked and the total score was already tallied at the bottom.
“I didn’t know how to answer some of those questions. It asked about Running which, obviously, I can’t do,” she tried to smile.
“You did fine”, Charlie said. “Your scores will improve as your knee gets better. This test helps me show your progress.” He paused, and then added, “It’s like a mutiple choice test for your knee,” he grinned and looked up at her.
She gave him another strange look. She thought he was teasing her.
Charlie saw his mistake. “Sorry, I’m kind of new to these questionnaires, too. We just started using them last year. I learned about them in school but I never used one until I started working at this clinic,” he looked at her to see if she was paying attention to him. She looked interested.
Emboldened, Charlie continued, “Believe it or not, the scores from these questionnaires accurately measure your progress. They’ve been tested on other young athletes with injuries like yours.”
“How will this help me?” asked Calista.
“Well, they help me determine when we can safely progress your treatment.” Charlie was silent a moment as if in thought. He added, “They’re also pretty helpful in writing up your initial evaluation. They save me a lot of time.”
“How so?”, she asked, encouragingly.
“Well, the computer writes your first two or three treatment goals based on your highest scores from the test. That saves a couple of minutes right there,” he showed her his iPod. Charlie opened a new tab labeled Goals. On it was written the following:
- Improve KOOS Sports/Recreation score from 65 to 73 in 10 visits.
- Improve KOOS Quality of Life score from 60 to 68 in 10 visits.
Charlie opened another tab, read for a moment and said, ”The average post-surgical KOOS score for Sports is about 60 and Quality of Life is about 55. It looks like you’re above average!” he grinned again.
Calista wasn’t going to let Charlie off that easily, ”But why does the computer set my goal so low? I want to get 100% better!”
“The computer sets your goal at something called the Minimum Clinically Important Difference. For the KOOS, research suggests 8 points is the minimum,” Charlie tried to sooth his patient. “When we reach your goal, the computer asks me if we should continue. If I say yes, you will fill out another KOOS and a new goal will be calculated. It’s a little like reaching the ten-yard line in football,” he ventured. This time she liked his analogy. She smiled and he beamed.
Calista wanted to move the conversation back to her knee but she asked Charlie one more question because he seemed so eager. “Why ten visits? My surgeon said three months.”
“Well, that’s the rules,” he said. “Its actually driven by Medicare policy which says Progress Notes every ten visits. Some clinics just want to make it easier to manage so they make every goal 10 visits. I can set that for more or less, if I want.”
“Hmmm,” said Calista. She was becoming bored with his technology. She definitely wanted Charlie to focus his attention back to her. She was glad he was competent and well-informed but she really just wanted her therapist to attend to her needs.