CORR Insights®: What Are Culturally Relevant Activities of Daily Living in the Asian-Indian Population? A Survey of 402 Patients With Knee Pain

Where Are We Now?

Working in four culturally different countries—India, South Korea, the United States, and United Arab Emirates—made me realize that the “ideal” treatment for a disease is beyond the knowledge available in books, scientific meetings, operating rooms, and VuMedi. When offering treatment for a disease, the decision-making process is perhaps best done in clinics while listening to and understanding a patient’s perspective about and expectations from the treatment. I have witnessed patients in their mid-70s with chronic knee pain expecting to walk to a park with their grandchildren in India, hike Hallasan (the highest mountain peak in South Korea), return to skiing next winter in the United States, or be able to walk to the community mosque and pray in the United Arab Emirates. It would be a mistake to think that the expectations of these patients in any way represent those of patients with knee pain in every region, country, city, or community; these experiences, however, highlight the wide variation in patient expectations we might encounter in our practices among patients of similar ages with similar knee conditions. It is thus important for orthopaedic surgeons to know what daily recreational activities are relevant to patients from different cultures and ethnic groups they might encounter in practice.

With this as background, in this month’s Clinical Orthopaedics and Related Research®, an exciting study by Kulkarni et al. [4] highlights the most relevant activities of daily living reported by 402 patients with knee pain from western India. This survey-based study identified that simple daily activities like standing without assistance, getting up with support, toilet use, sitting cross-legged, praying (sitting on a chair or the floor), and yoga were among the most important daily and recreational activities for Asian-Indian people, irrespective of age and gender.

Based on these discoveries [4], surgeons treating patients of Indian subcontinent origin could include the activities that are most relevant to patients with knee pain in pretreatment counseling to set realistic treatment expectations. The study by Kulkarni et al. [4] could lead to the development of culture-specific or region-specific modifications to patient-reported outcome tools that are commonly used to evaluate orthopaedic diseases by considering activities of daily living relevant to each population.

Where Do We Need To Go?

Surgeons use numerous treatment modalities for patients with chronic knee pain: pain medications, physical therapy, intra-articular injections, osteotomies around the knee, and knee arthroplasty, among others. The success of treatment depends on matching each to the correct patient based on his or her clinical and radiologic findings. For instance, a patient with primary, advanced-stage tricompartmental knee osteoarthritis with severe pain that persists despite nonsurgical efforts might be an “ideal” candidate for TKA. But despite experiencing improvement in pain and function after a technically well-done TKA, about 20% of patients are dissatisfied with the intervention. To reduce the incidence of residual pain and improve satisfaction after TKA, various surgeon-related and prosthesis-related factors have been modified, such as prosthesis design, mini-incision techniques, computer-assisted navigation, robot-assisted navigation, and patient-specific instrumentation. However, so far, these modifications to TKA have not consistently and predictably improved function and satisfaction, according to the patients’ perspectives [1, 5]. Similarly, for the nonoperative treatment of knee osteoarthritis, there has been a rise in stem cell clinics worldwide. Such clinics have lucrative business models promising a “cure” for the disease without much scientific evidence to support the idea that stem cells really improve patients’ function or reduce their pain more than placebo injections do [3].

The failure of recent technologic advances to further improve patient function and satisfaction after the treatment of knee pain makes me wonder whether we should take a step back and evaluate patient-related factors that can help improve patient satisfaction. One of the key factors related to satisfaction after treatment is setting patient expectations [2]. This is where Kulkarni et al.’s study [4] brings a fresh perspective to the treatment of knee pain; it reminds us of the importance of discussing individual patient expectations as an indispensable part of pretreatment counseling. With the rise in population migration and globalization, it is common for healthcare professionals to treat patients from different regions and ethnicities. Unfortunately, there is a striking deficiency in available studies on activities of daily living that are relevant to patients with knee pain who are from varying ethnic groups.

How Do We Get There?

We need more studies of different regional populations with knee pain and their desired daily activities and expectations after treatment. It may be better to design such studies for specific treatments such as TKA. Future studies should also consider evaluating activities based on the religious and cultural practices of patients in each major region. Patients who reside in urban and rural areas may vary in their expected activities of daily living. For instance, compared with the study by Kulkarni et al. [4], which was conducted in an urban setting in India, a similar study of patients in rural areas might find that squatting is a key desired activity for toilet use, because western-style toilets are rare in rural India. The disparity in daily and recreational activities among people from different ethnic groups also makes it crucial to modify the current commonly used generic patient-reported outcome measures to include questions that are relevant to a specific ethnic group.

It may be difficult for physicians to capture all aspects of patient expectations in a visit, especially during a busy day. One way to educate patients is to provide them with educational material (such as booklets or YouTube videos) on what to expect after treatment [6]. Physicians should also set aside time to address any specific questions a patient may have after reviewing the educational material. In my experience, patients who are well heard and informed before treatment in order to have realistic expectations tend to be satisfied postoperatively, even those with residual pain.