A Tool for Measuring Functional Outcomes
after Total Hip Arthroplasty
M. Kroll, S. Ganz, S. Backus, R. Benick, C. MacKenzie, and L. Harris
Purpose. To describe a functional milestone scale
[FMS) for measuring functional progression following
total hip arthroplasty and to demonstrate that this
scale meets accepted standards of scale construction.
Methods. Inter-observer reliability of the scale was
determined for 30 patients using a kappa coefficient
of concordance [k) for ordinal data, representing 221
pairs of observations. There were 79, 54, 44, and 44
pairs of observations for transfer, walker, crutch, and
stair ambulation, respectively.
Results. The k coefficient ranged from 0.82 to 0.91.
Agreement between therapists was almost perfect ac-
cording to the criteria of Feinstein.
Conclusions. The FMS exhibits substantial inter-
observer reliability and moderate to substantial valid-
ity. We have demonstrated its clinical applications as
well as showing it to be a useful management and
research tool.
Key Words: Function; Scale; Hip; Arthroplasty.
M. Kroll, MA, PT, was a Research Associate in the Departments
of Rehabilitation Services and Biomechanics, S. Ganz, MS, PT, is
the Assistant Director for the Department of Rehabilitation Services,
S. Backus, PT, is a Senior Research Physical Therapist in the Re-
habilitation Services Department, R. Benick, PT, is a Clinical Su-
pervisor in the Department of Rehabilitation, C. MacKenzie, MD,
is Assistant Attending in the Department of Medicine, and L. Harris,
MS, PT, is Associate Director of Administration at The Hospital for
Special Surgery, New York, New York.
Michael A. Kroll died on May 19, 1990.
Address correspondence to Sandy B. Ganz. MS, PT, Department
of Rehabilitation Services, The Hospital for Special Surgery, 535
East 70th Street, New York, NY 10021.
Submitted for publication May 24, 1993; accepted September 24,
1993.
0 1994 by the American College of Rheumatology
78
Total hip arthroplasty (THA) is a highly successful
surgical procedure in the treatment of arthritis of the
hip [l]. Early postoperative physical therapy protocol
consists of therapeutic exercise, transfer training, and
gait training with some form of external support on
level surfaces and stairs (Table 1). The primary goal
of treatment is to bring patients to their maximal level
of independence prior to discharge from the hos-
pital [I].
Careful documentation of functional progression is
necessary to assure that patients achieve the desired
functional level at an appropriate rate. There are no
established criteria or standardized methods of mea-
suring functional progression during hospitalization
after TI-IA. Many general functional status assessment
instruments used by rehabilitation practitioners have
been published, including the Barthel Index [Z], Katz
Index [3], Kenney Self-care Evaluation [4], Sickness
Impact Profile [5], Arthritis Impact Measurement Scale
(AIMS)[6],McMaster Health Questionnaire [7],Health
Assessment Questionnaire, and Functional Status In-
dex [Z-81. These global functional status indices have
been designed to measure multidimensional patient
outcomes that include but are not limited to sleep, rest,
eating, work performance, home, recreation, ambu-
lation, mobility, body care, household activities, dex-
terity, activities of daily living (ADL),anxiety depres-
sion, pain, social activity, and psychologic function.
These indexes take anywhere from 15 min to 30 min
to complete [6,9]. Scales are available that are specif-
ically designed for the inpatient rehabilitation setting,
i.e., the AIMS [lo]. However no scale has been found
to address functional progression during hospitaliza-
tion following THA. While considerable time and re-
sources can be saved by adopting an existing tool to
assess patient progress, different kinds of rehabilita-
tion facilities require different approaches and pro-
gram assessment. Before a newly developed scale is
0893-7524/94/$5.00
Arthritis Care and Research Measuring Functional Outcomes after Hip Arthroplasty 79

TABLE 1 The FMS was designed by and for physical thera-

Total Hip Arthroplasty Protocol
1. Ambulation: POD #2
DangIe (short interval)
Progress from standing, to ambulation
WBAT with appropriate assistive
device: i.e., cane
Progression of activities as tolerated
*Nan-cemented THR to be 20-3070
weight bearing
*THR with trochanteric osteotomy to
be minimal weight bearing
2. Exercise: POD #2
1. Gluteal isometrics
2. Quadriceps isometrics
3. Ankle exercises
4. Hip and knee flexion to 45"
5. Hip internal rotation to neutral
Initiation of the following exercises according to
patient's tolerance:
6. Straight leg raises
7. Knee flexion/extension in sitting
8. Home exercise program/precautions prior
to discharge
3. Sitting activities: 1. High chair-POD #3 or #4
as tolerated
Contraindications to treatment (consult physician]
1. Excessive drainage
2. Protime over 25
3. Phlebitis
put into widespread clinical use, the selection and
scaling of items, as well as the purpose and domain
of the scale need to be clearly defined. The reliability,
validity, and, if appropriate, responsiveness of the scale
must be demonstrated [11,12].
The purposes of this paper are (1)to describe a tool
for measuring functional progression during hospital-
ization after THA and (2) to demonstrate that this scale
meets the accepted standards of scale construction.
METHODS
In the development of this functional milestone scale
(FMS),the type and the purpose of the scale was clear-
ly defined. The purpose of this discriminative scale
was to differentiate between THA patients whose
functional improvement postoperatively followed the
normal rate of progression and those whose improve-
ment did not. This included patients who experienced
delays in attainment of functional independence as
well as those patients who achieved independence at
an accelerated rate.
pists to monitor concurrently the attainment of func-
tional milestones in a clinical setting. Additionally, the
FMS can be used as a research tool to compare groups
of THA patients on the basis of patient characteristics
such as age or diagnosis, where the rate of functional
progression is used as an outcome measure.
Items selected for the FMS needed to capture the
domain of interest. Twenty physical therapists whose
experience in orthopedics ranged from 1 to 15 years
with a mean of 5 years experience, determined by
consensual agreement the functional milestones se-
lected for the FMS. The FMS was to include specific
functional milestones that patients were routinely ex-
pected to achieve prior to discharge from the hospital.
The five milestones chosen were pertinent to the in-
dependence of the patient and were criteria for dis-
charge. In general, all THA patients are required to
(1)transfer in and out of bed, and (2) ambulate with
external support on level surfaces and stairs indepen-
dently prior to discharge from the hospital. Therefore
the five functional milestones selected for inclusion
in the FMS, from the lowest level of function to the
highest level of function, were 1)transfers, 2) walker,
3) crutch, 4) cane ambulation, and 5) negotiation of
stairs. Postoperative day of discharge was an addi-
tional milestone.
Each functional milestone was scaled into two levels
of achievement: assisted and unassisted. Assisted was
defined as requiring aid from another person to per-
form the functional milestone. This included physical
assistance, contact guarding, verbal cueing, and su-
pervision. Unassisted was defined as the ability to
successfully achieve the functional milestone with an
ambulatory aid (walker, crutch, cane) without the as-
sistance of another person. The need for ambulatory
aids was not scaled, as every patient discharged from
the hospital left with an assistive device. These des-
ignations pertaining to degree of assistance are similar
to those utilized by Mahoney and Barthel in the Bar-
the1 Index 121, as well as by Jette in the Functional
Capacity Evaluation (FCE) [13] but differ in that they
do not differentiate between levels of assistance.
A meaningful format utilizing a grid was devised
for patients who underwent THA (Figure 1).The form
was divided into three sections. The header section
contained height, weight, age, sex, and any co-morbid
factors that might influence functional progression. The
central grid was designed to monitor the achievement
of functional milestones on each postoperative day by
marking an X in the appropriate grid when the mile-
stone was achieved. The grid has a vertical axis con-
taining the hierarchicaIIy arranged milestones and the
horizontal axis listing the postoperative day. In this
80 KroJJ et aJ. Vol. 7, No. 2, June 1994

TOTAL HIP ARTHROPLASTY

~~ ~
- FUNCTIONAL MILESTONES
DEPARTMENT OF REHABILITATION SERVICES CEMENTED HYBRID POROUS
PHYSICAL THERAPY
DlAG N0 s IS PT
RIGHT/LEFT/BILAT EPI/SP IN/GEN
HT(IN) WT( LBS)

PCA: EPI IV PDN Y N VENOGRAM + -

COMPLICATIONS/CO-MORBI DITY/COMM ENTS

DISCHARGE
STAl R S UNAS S ISTE D*
STAIRS ASSISTED
CANE UNASSISTED*
CANE ASSISTED
CRUTCHES UNASSISTED*
CRUTCHES ASSISTED
WALKER UNASSISTED*
WALKER ASSISTED
TRANSFER UNASSISTED*
TRANSFER ASSISTED
DATE
DATE OF
SURGERY: P.0.D

COMMENTS

*UNASSISTED = Not requiring the presence of another person t o perform the activity

Figure 1. Total hip replacement milestone scale.

Arthritis Care and Research Measuring Functional Outcomes after Hip Arthroplasty 81

TABLE 2
Interrater Reliability in 30 Subjects

Observations
(n = 30) k coefficient
Transferring 79 0.89
Walker ambulation 54 0.89
Crutch ambulation 44 0.82
Stair ambulation 44 0.91
Overall 221 0.88

way, the course of functional progression could be

viewed at a glance relative to postoperative day. The
comment section was used to document any important
perioperative or postoperative information that may
affect the rate of functional progression. Documenta-
tion of factors such as age, gender, complications, other
joint involvement, preexisting disease, and type of
anesthesia were included on the scale, because they DATE I I I I I I I I I I I I I I I I I I I I I
potentially aff w t the rate of functional progression. 5111 1 1 2 1 3 1 l l S l 6 1 7 1 6 / ~ ~ 1 0 ~ 1 1 ~ 1 2 ~ 1 3 ~ 1 ~ ~ 1 ~ ~ 1 6 ~ 1

Postoperative day of discharge was documented so

that the length of stay could be monitored. We have
been using the FMS form at The Hospital for Special
Surgery for over 6 years representing over 4,000 total
hip replacements. Unlike the other indexes and scales
mentioned, which take up to 30 min to complete [14],
the FMS takes less than 2 min for the physical therapist
to complete.
Once the FMS was constructed, interobserver (be-
tween rater] reliability of the scale was determined.
A power study determined that 30 patients were re-
quired to ascertain interobserver reliability. Informed
consent was obtained. One physical therapist was as-
signed to treat the patient while another physical ther-
apist observed each treatment throughout the patient’s
hospital stay. Each therapist scored the patient inde-
pendently on their functional level for that day and
remained blinded to the other’s scores until the patient
was discharged. Agreement between pairs of thera-
pists was assessed using the kappa coefficient of con-
cordance for ordinal data [Ill. The following guide-
lines were used to determine the strength of kappa:
poor: 50; slight: 0-0.20; fair: 0.21-0.40; moderate: 0.41-
0.60; substantial: 0.61-0.80; and almost perfect: 0.81-
100 [ll].
RESULTS
Agreement between therapists on their designation
of level of assistance for each functional milestone
was determined for 30 patients representing 221 pairs
of observations, for transfer, walker, crutch, and stair
ambulation, respectively. The kappa coefficients were
0.88,0.89,0.82,and 0.91, respectively (Table 2). Agree-
ment between therapists was almost perfect according
to the criteria of Feinstein [ll].
The content validity was determined by the con-
sensual agreement of the inpatient staff on which mile-
stones were necessary for the patient to achieve after
THA. This type of validity does not lend itself to sta-
tistical verification [ll]. The FMS was determined to
have criterion validity if the therapist assessment of a
given functional milestone was in agreement with the
patient’s own assessment of his or her functional mile-
stone achievement. This validity was based on the
assumption that the criterion of therapist perception
of a patient’s functional level should be in concor-
dance with the criterion of patient perception. For the
patient self assessment, a modification of the func-
tional status index (FSI)was used because it contained
functional items that were the same as those in the
FMS [15]. A power study determined that 45 patients
were required for concurrent criterion validity.
Prior to surgery, 45 THA patients were instructed
in the use of the modified FSI (Figure 21. At the com-
pletion of each postoperative physical therapy treat-
ment, the treating therapist filled out the FMS. An
independent observer (another physical therapist who
82 Kroll et a].
did not have routine access to the patient’s chart) met
with the patient following the treatment session to
assist the patient in the completion of the modified
FSI. Although the independent observer was present
at the time the modified FSI was completed, no assis-
tance regarding the responses selected by the patient
was provided.
Agreement between therapist and patient responses
was assessed using the kappa coefficient of concor-
dance to the criteria listed above [ll].
Agreement between therapist and patient response
was determined for 589 pairs of observations repre-
senting at least 13 observations per patient for transfer,
walker, crutch, cane, and stair ambulation (Table 3).
The kappa coefficients indicated that there was sub-
stantial agreement for transferring and crutch ambu-
lation and moderate agreement for walker ambulation
and stair ambulation.
Because this was determined to be a discriminative
index as opposed to an evaluative index, determina-
tion of responsiveness was not applicable [ll].
DISCUSSION
To date, among the most useful clinical information
generated from the implementation of the FMS in
THA patients was the determination of expected func-
tional level that patients achieve on a given postop-
erative day. The compilation of data from the FMS in
large numbers of patients with osteoarthritis permitted
standards of functional recovery to be developed. In
309 unilateral THA patients who had an uncompli-
cated postoperative course, the average day of attain-
ment of each functional milestone * 2 standard de-
viations was determined (Figure 3). The FMS correlates
with length of stay. For walking unassisted the Spear-
man rank correlation was 0.5, P < 0.001. For stairs
unassisted the Spearman rank correlation was 0.8, P <
0.001. The correlation is strongest for the more difficult
tasks, as would be predicted.
Patients whose peri- or postoperative course in-
cluded cardiac dysfunction, urinary infection, pul-
monary embolism, symptomatic deep vein thrombosis,
or any other medical condition that resulted in an
interruption in routine physical therapy were classi-
fied as having a complicated course of stay and were
not included in this sample. However, future studies
will include various co-morbid states, postoperative
complications, and their correlation with FMS.
The reliability results addressed whether or not the
two therapists agreed on the need for assistance for a
given milestone. A high level of agreement existed
Vol. 7, No. 2, June 1994
TABLE 3
Validity of Items in 45 Subjects
Observations
(n = 45) k coefficient
242 0.74
Transferring
Walker ambulation 143 0.60
Crutch ambulation 97 0.62
Stair ambulation 97 0.45
Overall 589 0.60
between therapists for each milestone. The greatest
variation between therapists was in assessing unas-
sisted ambulation with crutches. This occasional dis-
agreement did not affect the overall level of concor-
dance of therapist with therapist. Of the 221 pairs of
observations, there were only 13 pairs of disagree-
ment.
The results of the criterion validity evaluation dem-
onstrated that there was moderate to substantial agree-
ment between the therapist decision on the patients’
need for assistance and the patients’ perceptions of
their own need for assistance. The milestones with
only moderate agreement were walker ambulation and
stairclimbing. In most cases (74 of 93 disagreements)
patients felt as if they were unassisted while the ther-
apist felt that they required assistance. This disagree-
ment may reflect the definition of the word “assis-
tance.” This discrepancy raises the question of whether
or not the criterion of patient perception of functional
level is appropriate for validation of the therapist rat-
ing. Ultimately, however, patient self perception is
what determines whether a patient will perform a
functional activity assisted or unassisted outside of a
physical therapy treatment session.
The standards determined for our institution are
useful in monitoring an individual patient’s course
after surgery. The deviations from the standard are
evident, signalling the need for frequent or aggressive
rehabilitation sessions so that the length of stay is not
unnecessarily prolonged. The 2-4-day range for the
day of achievement of each functional level (the mean
* 2 standard deviations] could be considered the lim-
its within which a unilateral THA patient with a di-
agnosis of osteoarthritis should remain with the stan-
dard physical therapy intervention. With the
information from the header section, standards of re-
covery need to be developed for such categories as
age, bilateral versus unilateral surgery, complicated
versus uncomplicated cases, revision cases versus pri-
mary procedures, and other various diagnostic groups.
Arthritis Care and Research
DISCHARGE
STAIRS UNASSISTED*
STAIRS ASSISTED
CANE UNASSISTED*
CANE ASS1 STED
CRUTCHES UNASSI STED*
CRUTCHES ASSISTED
WALKER UNASSISTED*
WALKER ASSISTED
TRANSFER UNASSI STED*
TRANSFER ASS1 STED
DATE
DATE OF
SURGERY: P.O.D.
Figure 3. Functional progression for 309 unilateral uncomplicated THA patients -t 2 SD (dark-shaded area represents
*
SD, light-shaded area represents 2 SD).
Outcome assessment such as the functional mile-
stones begin to focus attention on specific events in
patient care and away from the structure and process
traditionally examined in a quality assurance audit.
CONCLUSION
According to the criteria for scale development as
established by Kirshner and Guyatt, a scale for mon-
itoring functional progression in the postoperative pe-
riod after total joint arthroplasty has been established
[16].The FMS exhibits substantial interobserver re-
liability, moderate to substantial validity, and we have
demonstrated both its clinical applications as well as
its usefulness as a management and research tool.
We express our appreciation to Dr. Margaret Peterson for her
patience and assistance during this study. This study was approved
by The Hospital for Special Surgery institutional review board.
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