PAST PRESENT FUTURE
1990 - 1992 (Cutbill, J.W., Bray, R.C., Thorne, P. & Bryant, H. Knee problems: an epidemiologic study, Clinical Journal of Sport Medicine, (2), 121-125, 1992.) We completed a study of knee problems seen by 120 primary care physicians in Calgary, Alberta, Canada, that concluded the average frequency of knee problems seen by such physicians is in the range of 0.8% to 3.7% of all patients seen. These results indicate that a range estimate of 110 to 500 knee problem patients are seen each week in Calgary, Alberta. This does not include those patients presenting to hospital emergency departments, walk-in clinics and sport medicine centres. Thus, anterior knee pain is a commonly encountered complaint that is often seen in physically active patients, both young and old.
1992 - 1995 Concurrent with the above study, we were embarking upon an extensive, two-year, four round consensus process using the Delphi method with sixteen international experts (from the clinical fields of sport medicine, family medicine, rheumatology and orthopaedics) in AKP. The Delphi method confirmed that a paucity of consensus exists in the following areas: definition of AKP, assessment procedures, diagnostic tools and management protocols. The results from the consensus process assisted in developing preliminary consensus clinical statements. These statements are integrated into a patient history questionnaire and a physician examination sheet to be evaluated in a clinical setting by both physicians and patients. The on-going refinement of the consensus statements in clinical settings will eventually lead to the development of clinical practice guidelines (CPG's).
1994 - 1995 (Cutbill, J.W., Bray, R.C., Thorne, P., Ladly, K.O., Verhoef, M.J., Clinical practice guidelines for AKP: a consensus study. Proceedings of the Canadian Academy of Sport Medicine Annual Meeting, February, 1995.) Dr. John Cutbill presented the initial consensus results from the AKP Delphi consensus study at the CASM - ACMS conference in Banff, Alberta. The presentation was in the Sport Injury and Rehabilitation category. To view this abstract, click on the link above.
1994 - 1996 (Cutbill JW, Ladly KO, Bray RC, Thorne P, & Verhoef MJ. Anterior knee pain: a review. Clinical Journal of Sport Medicine, 7(1): 40-45, 1997.) A comprehensive review of literature in knee pain was completed by our research team. This review clarified that there is no established definition of anterior knee pain and limited consensus in the categories of classification, assessment, diagnostic tests and management protocols. The plethora of interchangeable knee pain diagnoses was also discussed and information pertaining to AKP was illuminated.
There are currently five projects underway in the AKP research office. Each project is helping to evaluate our clinical statements in their evolution towards CPG's or illuminating key areas in the assessment and management of AKP.
1) Patient History Questionnaire: A clinically oriented patient history questionnaire has been developed with information from current literature reviews, expert consensus and AKP patient feedback. The questionnaire was refined in a clinical setting and has been automated onto a database at the University of Calgary Sport Medicine Centre patient education room. This computer automated assessment tool is being utilized by sport medicine centre patients that experience knee pain. The responses from this patient history questionnaire, combined with the physician examination information, are being input into an extensive database linking patient history and patient symptoms to preliminary suggestions and / or common assessment techniques. This tool may assist in using more effective and standardized protocols for assessment and treatment, increasing patient and physician satisfaction, expediting physician decision-making and providing recommendations for management of AKP.
The patient history questionnaire is available through this web site. Please trial it if you experience knee pain, or if you are a physician, please allow your knee pain patients to complete the form. Your comments and / or suggestions would be appreciated.
2) Physician Examination Form: A physician examination form was developed from consensus information, current scientific literature and the trialing physicians comments and / or suggestions. Participating physicians are currently clinically pre-trialing the form, the content, relevance of questions, ease of use, and format are being evaluated. When agreement is obtained, the form will be computer automated so patient and physician information can be input into the database. The physician examination form will include a lower limb assessment of alignment, range of motion, strength, flexibility, tenderness, joint stability, investigative measures and managment procedures. The form is an extensive compilation of information, but analogous to the patient history questionnaire, it will assist the physician in ordering diagnostic tests and provide recommendations on management.
3) Diagnostic Tools: There is consensus that standard radiographic testing is important in performing an evaluation, giving confirmation or providing additional information to the physician. The type and number of radiographic assessments will be evaluated and included in the final consensus guideline. Dr. Ian Stiell (1996) evaluated a decision rule to identify fractures of the knee and reducing the use of radiography. He found the decision rule to be 100% sensitive for the detection of fracture. We envision the CPG's for diagnostic tests to be suggestions for ordering x-rays, computed tomography (CT), magnetic resonance imaging (MRI), scintigraphy, ultrasonography or arthroscopy that would be based upon the patient history and physical exam. These guidelines will undergo a multi-phase development process until they are shown reliable and valid.
4) Management: The consensus results for management of AKP suggest that conservative measures should be the primary step advocated to a patient and surgical intervention considered secondary. The scientific literature and the consensus results suggest that patient counselling, activity modification, muscle rehabilitation, stretching, taping, bracing and orthotics are key ingredients to conservative treatment. The envisioned AKP CPG's will present the physician with options of care that are shown to be effective based upon the information provided from the patient history questionnaire, physician examination form and diagnostic results.
5) Consensus Process Paper: A scientific paper detailing the process that we underwent to develop our preliminary clinical consensus statements is now complete. This paper describes the Delphi technique, the information obtained in the four rounds of data collection, analysis of the feedback from the 16 international experts and the overall results. This process took over two years to develop and are the first, to our knowledge, compilation of information that will lead to the development of AKP CPG's. We are currently in the process of submitting this paper.
The AKP research group is developing the foundation for AKP clinical practice guidelines. The work is currently being done through the University of Calgary Sport Medicine Centre and the Canadian Forces Base Edmonton. The preliminary phases of consensus statement development will be confined to the Calgary, Alberta area. When the initial CPG's are established, they will be implemented in both Calgary and Edmonton in a non-randomized controlled trial. The AKP research project will undoubtedly undergo many phases of development which will assist in validating the CPG's and testing levels of sensitivity to our guidelines. We have received monetary and technical support from The University of Calgary Sport Medicine Centre, The University of Calgary Olympic Oval Fund, and The Department of National Defense. Our projected timelines thus far are:
a) The computer automated patient history form is being used at the University of Calgary Sport Medicine Centre and a paper version is implemented at Lindsay Park Sports Clinic and Canadian Forces Base Edmonton. This tool is helpful to establish a large AKP patient database. The physician examination form is being pre-tested at the U of C Sport Medicine Centre and the Lindsay Park Sport Clinic. We will use the expertise of the participating physicians, researchers, feedback from participating patients and continual literature reviews to maintain a current base of knowledge and use of applicable tools.
b) A non-randomized controlled trial (with before and after measures) will be conducted in the latter months months of 1998 at the two major sport medicine centres in Alberta. The Glen Sather University of Alberta Sports Medicine Clinic (Edmonton) will act as our control site and The University of Calgary Sport Medicine Centre (Calgary) will be the intervention site. Physicians will initially assess and manage patients presenting with AKP using their current standards of practice for a five month interval. After a one-month introduction to our developed AKP guidelines, physicians at the intervention site will utilize the AKP guidelines to assess and manage knee disorders. This phase will provide the necessary information we will require for a subsequent multicentre randomized controlled trial.
We wish to conduct a multicentre randomized controlled trial with primary care physicians in general practice throughout the province of Alberta. This phase will be a culmination of all the work and analysis done in the previous phases.
We plan to evaluate the following areas prior to implementing the AKP CPG's and following the utilization of the AKP CPG's.
a) health care utilization costs
b) rates and extent of patient recovery
c) patient-physician encounters
d) frequency and extent of diagnostic tests ordered
e) time involved for the physician to make a diagnosis
f) patient satisfaction about their care and management
The measurement tools are:
a) Alberta Health Care Cost Analysis
b) Western Ontario and McMaster Universities (WOMAC) scale
c) Patient-physician encounters
d) Diagnostic tests ordered
e) Time to diagnosis
f) Patient satisfaction
g) Physician perception of the usefulness of the guidelines
h) Physician compliance
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