@Osalje:  Sir, you mean OA grading. Descriptive grading of clinical changes (pain,deformity, instability, ROM) is possible but it would not be precise: i.e. mild, moderate, severe. But I do not think we should not use at least X-rays, to make our grading and classification more exact. Furthermore, when using periodic roentgenograms we can follow the dynamics of OA.  

@ Tanchev; thank you  Sir for the  response.  I am in agreement with you regarding the precision of radiograph in grading knee osteoarthritis disease severity. The reason for my question is predicated on my current research on knee osteoarthritis.  I was wondering if I can classify the disease severity into mild, moderate or severe after clinical evaluation of patients symptoms before reviewing the radiological reports.

This may be difficult as there are patients who have severe pain and their X-rays are not severe and others whose radiological picture shows severe degeneration and their symptoms are not corresponding to this. There are many times surgeons turn down the operation of a joint replacement to patients with severe radiological picture but without presence of pain. But pain is an subjective measure in some cases. Deformity may be severe (varus or valgus) but even this as may not corresponding with the pain may not be of value. ROM can be a measure of severity but without pain may not be characterised as moderate or severe. Instability is not so common in OA as usually the ligaments are very stiff. In other words without pain cannot be fully recognised as mild, moderate or severe, because is the pain that drives patients to doctors and not deformities or lack of ROM. The latter usually are accepted by patients as part of the aging process if they do not feel pain. And pain is not all the time an objective finding. It is known that presence of night pain and pain during motion within the house confirm the necessity of a total knee replacement but in the presence of all the above clinical findings and also with the comparison of radiological findings. Someone can talk about and grade the severity of deformity or of limited movement, but without objective pain may not grade holistically the severity of the knee OA to the true picture of it.

@ Zafiropoulos,  thanks for the insightful contribution.

I thank you, for giving me the opportunity to answer your interesting question.

Pain rules in many ways, and yet it may not be the best way to grade or classify the severity of the disease after a clinical evaluation. X-rays gives you a clear idea of the conditions of the joint but may not suggest patient's level of pain or actual physical limitations.

In general, radiological information is used during a clinical consultation to identify the severity level of knee OA. However, the confirmation of radiological OA is not necessarily an indication of symptomatic knee OA. Symptomatic knee OA, which is clinically more important, requires consistent limitation in activities of daily living and presence of joint pain on most of the days of the previous month. Some clinical and epidemiological studies have reported several cases of people with structural change, based on radiological information, who indicate mild or no pain, whereas others with higher levels of joint pain may not have severe radiographic indices of OA. Therefore, radiographic imaging of the knee OA seems to be an invaluable tool for the assessment and diagnosis of disease severity, but not joint pain. Joint pain due to knee OA is interpreted as a unique and subjective experience lived by the individual; therefore, self-reported tools developed to assess pain are important for both research and clinical use.

I believe you could develop a different evaluation system to classify knee OA as mild, moderate and severe (or a similar classification) as apart of a clinical assessment. But keep in mind that your new system should take in consideration several factors, you must first select which factors are the most important "clinically speaking" considering that this is your objective and also consider other factors such as physical activity and physiological factors.

I would go this way:

I would use WOMAC questionnaire and OARSI questionnaire (this is not as old as the WOMAC but is excellent)

I would assess activities of daily living - stairs test, walking (6 MWT), balance (TUG)

Pain - I would use the VAS for pain - but I would also assess pain while they are doing their tasks and right after.

Muscle strength assessment - there are several ways to assess thigh muscle and also gluts (find the most reliable, simple and quicker)

If you combine all in a single assessment - you will be able to develop a new classification strategy for rehab professionals and suggest which patients could benefit from rehabilitations and which ones could not.

Good Luck and if you have a chance: read these two articles below, they will give you a great help.

Kamary

Article Changes in self-reported disability after performance-based ...

Article Assessment of knee pain in obese and non-obese individuals w...

@ Coriolano, thanks for the mind-blowing suggestions as well as the attached articles. You actually provided me with a new horizon as regards my question and opened up a research idea on development of a tool that clinicians can use to assess disease severity in knee osteoarthritis patients. I will appreciate if I could discuss this further with you. 

Thanks to you and everyone that has participated in  the discussion so far.

Happy to help!

Dear Colleague, Without X-ray, CT scan or ultrasound, you can not get a true picture of the extent of osteoarthritis.

Who will do the endoprosthesis without data CT or X-ray?

Clinical symptoms - this addition to objective data.

Severity of Knee osteoarthritis should actually be measured without radiographs by measuring the loss of function due to same. After all, it is loss of knee function affecting his quality of life which brings the patient to the clinician!

There are multiple knee function scoring systems available which would enable this measurement, e.g. KOOS, SF-36, WOMAC, Oxford knee score........!

KOOS remains one of the most validated scoring system out of these.

Attaching a couple of articles comparing/reviewing these knee function rating scales/instruments. Hope you find these useful!

Dear colleagues! Of course, it is possible for the joint function to judge the quality of life of the patient and recommend him to treatment based on the patient's complaints.

The classification is needed to select the diagnostic algorithm and objective data on the state of the knee joint for the purpose pathogenetically based treatment. All -KOOS scale, SF-36, WOMAC, Oxford knee score.- is beautiful, but the supporting material, they complement the objective data and easy to evaluate the results of treatment!

It is clear that many of us will diverge in opinions and this is why research is so beautiful. We may diverge to find what is the best to the population.

Indeed, radiological information is extremely important and it has revolutionized medicine. However, the scales indicated above (KOOS, SF-36, WOMAC, Oxford) are more than beautiful, these scales are the best way to assess function (degree of daily activity) and pain. While radiological information provide a visual assessment of the real condition of the joint, it is not capable to perceive the level of daily activities and pain. We know that pain is the most important aspect of OA. A patient with mild pain not necessary will have a mild OA. Most studies diverge their opinions when trying to correlate pain and OA severity using x-rays. Some studies indicate that it is not correlation or very week correlation, while other studies suggest that there is a correlation. There is no agreement within the scientific community.

As a rehabilitation professional, I do like to use as many resources as I can: radiological, perceived scales and functional tests. But I was never misguided when following only patient perception and a functional test, particularly functional tests. I always recommended students to performed at least a modified 2 MWT,  or if time allows 6 MWT, at different sessions (different days) in order to obtain the real functional condition  of the person being tested - not without mentioning that this is also the best time to capture the most accurate level of pain - assessed during the test.

The functional test and level of pain obtained after 3 session at different days on different weeks will tell you the real condition of a patient independent of his radiological information.

Furthermore, there are several studies that cannot correlate muscle strength and severity of knee OA or Hip OA in patients with mild to moderate levels of OA. The reason is that muscle atrophy or decrease in muscle mass may start at a later stage. But again, even using MRI This is not yet answered completely.

Therefore, I say that x-ray and CT scans are great ways to classify the condition of the joint. But the condition of the joint (between mild to moderate and several times between moderate to severe) may not represent the real condition of the patients. Lets remember what is been treated here, joint or individual?

We are caring for an individual with a knee OA, therefore we cannot just assess the imaging test and make a judgment of his/her true condition.

Finally, x- rays may not be as costly, but CT scans are and it should be used when necessary.

 Best regard to my fellow scientists,

Kamary

Dear colleagues! Nobody can abolish the complex examination of the patient to decide on the severity of gonarthrosis .Anamnez, scale, clinical, patient complaints, X-ray, CT scan (if necessary) - all important! We talked about the classification of the severity of osteoarthritis of the knee. I am sure that no X-ray, ultrasound can not accurately determine the stage of osteoarthritis. Perhaps at one stage and synovitis pain will be expressed more than in 2 stages without inflammatory changes. The pain and X-ray stage does not always have a direct relationship. The discussion began with a question whether it is possible to determine the stage of clinical manifestations of osteoarthritis (classify). I think that is impossible. I apologize, but this is my point of view.

Classification means objectivity.  Pain is subjective. Pain measurement can determine functionality. Functionality is more  or less subjective although this can be argued. 

Classification of OA needs clear pictures (X-rays). Someone will be necessary to combine the clinical with the radiological if has to determine the stage of OA. It will be the same if we would ask to classify on clinical grounds only the severity of a fracture and how we will think this has to treated and the choice of our implants.

 Dear, Diachkova G.V there is no need to apologize, As I mentioned, the beauty of research is the differences in opinion to find the best outcome.

I truly appreciate your comments, I also learn from them.

Kamary

George, I agree with you and as I mentioned on my long comment above, x-rays are very important. We are not questioning whether pain is subjective or x-ray objective. I do not question the relevance of imaging tests.

I am just indicating that classifying OA clinically is possible and this is my point of view. And please lets not talk about fractures, it is not the view of the discussion. I also agree that combining x-ray and subjective measurements is interesting. But as I already explained above - it has been done and there is no consensus in the literature. Functional tests are not more or less subjective, they are as objective as you can measure your capacity of walking every day from your house to the nearest park. If you are consistent - stats will tell you in numbers (speed, time...) this is how you can replicate the activities you do every day and be able to judge whether this capacity has been diminished in comparison to other people same age with no OA or compared to yourself. Yet. many people with moderate to severe OA (classified on x-ray) maintain similar levels of activities compared to those with mild OA. How do you explain that? I think we do great using x-rays, but don' t you agree that an individual is much more than an knee image and therefore, we could classify OA as it affects the individual's general quality of life, rather than be attained to his knees? A we know total joint replacement is an elective surgery. If I am fine and moving around and keeping up with my routine, do I really need surgery only based on my x-ray imaging? We both know that this is not how surgery decision is made.

Best regards,

 Kamary

Dear Participants,

I read the discussions and learnt a lot. If I may specify the question asked is can OA knee be classified without radiographs? " Can knee osteoarthritis disease severity be classified without a radiograph? " 

How can knee osteoarthritis disease severity be clinically classify? is the main question asked.

My answer to the question is yes it can be classified without a radiograph by understanding the pain of the patient(very good discussion above), understanding the disability due to the pain and the arthritis(very good points above noted) and a physical examination to assess the changes in the joint affected.

Pain is a subjective symptom and the other parameters are objective. As already mentioned several methods of scoring are available for both. Examination findings will provide objective evidence of anatomical and pathological involvement. As surgeons we will look at alignment,ROM,ligament status,fixed deformities,wasting and correctable deformities.

Some of these are prognostic for the outcome following treatment.You can even classify some of these objective clinical findings e.g. varus of the knee grade 1 -3 depending on the clinical varus of the knee on standing.Use of intermalleolar distance and distance between the medial condyles of the femur also can be used to assess and classify deformity.

All this can be done before x-rays to arrive at a clinical diagnosis yes. the classification would be mild/moderate and severe or operative/no-operative management. 

Imaging contributes significantly to clinical correlation and guides management especially surgical as you well know.

So I hope your question is answered. The take home messages were very good in this discussion. Thanks for sharing.

Severity of knee OA is classified with imagen studies in terms of severity of articular damage. Severity of knee OA can not be classified according to severity of symptoms because there are many phenotypes of disease. Kellgren Lawrence grading system is still a useful form to classify severity of disease. MRI has evolved to detect disease in initial stages but its expensive. The employment of serum, urine and synovial biomarkers is still under investigation to be used as a tool not only for early diagnoses, but to classify severity and efficacy of intervención.