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Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC

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GENERAL DESCRIPTION
Purpose 1 To assess pain, stiffness, and physical function in patients with hip and / or knee osteoarthritis (OA) Content The WOMAC consists of 24 items divided into 3 subscales:

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Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing Stiffness (2 items): after first waking and later in the day Physical Function (17 items): stair use, rising from sitting, standing, bending, walking, getting in / out of a car,

shopping, putting on / taking off socks, rising from bed, lying in bed, getting in / out of bath, sitting, getting on / off toilet, heavy household duties, light household duties Developer/contact information

Nicholas Bellamy, Centre of National Research on Disability and Rehabilitation medicine, University of Queensland, Department of Medicine, Level 3, Mayne Medical School, Herston Road, Brisbane Queensland 4006, Australia. Email: n.bellamy@uq.edu.au.

 Requests to use the WOMAC and for User Guides can be submitted at:www.womac.org Number of items in scale 24 items
Versions:

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The WOMAC is available in 5-point Likert-type and 100mm Visual Analog formats . 2 3, 4 The WOMAC has been validated for telephone and computerized / electronic administration. Short forms of the WOMAC function subscale have been developed, but these have not been extensively used 5-8 or validated . Validation of a proposedWOMAC short form for patients with hip osteoarthritis. Bilbao A, Quintana JM, Escobar A, Las Hayas C, Orive M. Health Qual Life Outcomes. 2011 Sep 21;9:75 The WOMAC is available in over 65 alternate language forms, including: Arabic , Chinese , Dutch , Finnish ,
13-15 16-18 19 20 21 22 23, 24 25, 26 9 10 11 12

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French-Canadian , German , Hebrew , Italian , Korean , Moroccan , Spanish , Swedish , 27 28, 29 Thai , and Turkish . Populations The WOMAC was developed for use among patients with knee and / or hip OA, but it has been used among patients 30 31 32 with different conditions, including: low back pain , rheumatoid arthritis , juvenile rheumatoid arthritis , systemic 33 a31 lupus erythematosus , and fibromyalgi . The WOMAC has been extensively used in both observational / epidemiological studies and to examine changes following treatments including pharmacotherapy, arthroplasty, exercise, physical therapy, knee bracing, and acupuncture.

WHO ICF COMPONENTS

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b28016 (pain in joints), b289 (sensation of pain, other specified and unspecified), b134 (sleep functions), b7603 (supportive functions of arm or leg), b7800 (sensation of muscle stiffness),b7808 (sensations related to muscles and movement functions, other specified), d4100 (lying down), d4101 (squatting), d4103 (sitting), d4105 (bending), d4150 (maintaining a lying position, d4153 (maintaining a sitting position), d4154 (maintaining a standing position), d4400 (picking up), d4102 (transferring oneself while lying), d450 (walking), d4500 (walking short distances),d4501 (walking long distances), d4502 (walking on different surfaces), d4551 (climbing), d4559 (moving around unspecified), d498 (mobility, other specified), d5101 (washing whole body), d530 (toileting), d5402 (putting on footwear), d5403 (taking off footwear), d6200 (shopping), d699 (domestic life, unspecified), d9208 (recreation and leisure, unspecified), d6408 (doing housework)

ADMINISTRATION
Method Patient report questionnaire can be completed in person, over the telephone, or by computer. The use of the WOMAC has also been validated for delivery via mobile phone (m-WOMAC). Osteoarthritis Index delivered by mobile phone (m-WOMAC) is valid, reliable, and responsive. Bellamy N, Wilson C, Hendrikz J,

and function. stiffness=0-200. Overall.86-0. stiffness. Adequate test-retest reliability has also been confirmed for the German and Swedish versions of the WOMAC 16.Whitehouse SL. respectively . and 0. Cronbach's alphas for the Visual Analog format were 0. User guide available . Training to interpret Minimal. and physical function 26 subscales. respectively. In the same study. respectively . and 0.91 for function (not calculated for the stiffness subscale). with a 1-week interval.014). Interpretation of Scores Higher scores on the WOMAC indicate worse pain. On the Likert Scale version. and 0. the possible range of scores is therefore 0-100. Score Range. Overall. physical function=0-1700.91 for pain and 36 stiffness and 0. Corresponding values for the Visual Analog format were 0.org. Cronbach's alphas for the Likert Scale format of the WOMAC were 0. Equipment needed Copy of instrument. Licensing processes and costs are determined on the basis of information specific to each research project. a request can be submitted at www.91.61.68 for the total score. . mild moderate. Epub 2010 Jul 6. Among patients with arthroscopically assessed knee OA (n=52). Among patients in the Swedish Knee Arthroplasty Registry (n=1.48. Most commonly. ICC's) were 0. 0. Method of Scoring The WOMAC is typically scored by hand. These correspond to an ordinal scale of 0-4.98 for physical function . and functional limitations.58. Items are summed for each subscale. Davis T. with possible ranges as follows: pain=0-20.64(2):182-90. respectively .95 for the pain. and 0.7. and function subscales. Kendall's TAU-C for Likert Scale formats were 0.J Clin Epidemiol. Availability/cost The WOMAC is a proprietary health status questionnaire protected by copyright and trademark.81 for pain and 0. and 0. 0. However.9035 0. SCORING Responses Scale. 0. but the stiffness 37 subscale has shown low test-retest reliability .64. the test-retest reliability (intraclass correlation coefficients. Ruler.92 for pain.68 for pain.74. 0. In the clinical trial of nonsteroidal anti-inflammatory drugs for patients with hip or knee OA (n=57) . severe. n=1. EDC Study Group.64. 0. For each item. Norms available There are no clear norms available. Time to Score 5-10 minutes Training to score 1 Minimal.95.68. 2011 Feb. 0. stiffness. Intraclass Correlations (ICC's.womac .89-0. a ruler is used to measure the distance (in mm) from the left end marker to the patient's mark. On the Visual Analog version. In the Swedish Knee Arthroplasty Registry.92. Training: 1 Minimal instruction needed.90. 25. Patel B. The 100mm Visual Analog version uses anchors of no pain/stiffness/difficulty and extreme pain/stiffness/difficulty.014) over a 36 3-week period were 0. stiffness=0-8. test-retest reliability of the WOMAC pain subscale has been variable across studies but generally meets the minimum standard. Dennison S. for pain. In a small randomized controlled trial of 2 nonsteroidal anti-inflammatory drugs among patients with knee and hip OA (N = 57).89. User Guide provides instructions . stiffness. stiffness. the scores are summed for items in each subscale. PSYCHOMETRIC INFORMATION Reliability Internal consistency. To obtain permission to use the WOMAC for research purposes.-0. if using Visual Analog format. and extreme. The Likert Scale version uses the following descriptors for all items: none. physical function=0-68. stiffness. results support the internal consistency of the WOMAC 37 subscales . using the conventions described above. and function subscales. Cronbach's alphas were 0. 35 Test-retest.72. other methods of aggregating scores have been used . resulting in possible ranges as follows: pain=0-500. Time to administer/complete Approximately 12 minutes. test-retest reliability has been more consistent and stronger for the physical function subscale. and 0. a total WOMAC score is created by summing the items 1 for all three subscales.

205). 53. 52. potentially leading to weaknesses in the ability of the physical function subscale to detect change when there is a 47 weak association between pain and function. MCID17% (17% improvement from baseline). 57 responsiveness to change than corresponding SF-36 subscales . Version V. Stevens J.75 for improvement . some studies have found inadequate factorial validity of the WOMAC pain and physical function subscales.78 and for inter-rater reliability. Hill J. Bischoff HA.55). MCID values must be viewed cautiously because of limitations in methodology for calculating these values and should not be considered absolute thresholds. COMMENTS AND CRITIQUE The WOMAC is one of the most widely utilized self-report measures of lower extremity symptoms and function. and MCID tertile (low. 52.51-1.62-0. In another study. studies support the adequacy of the measurement properties of the WOMAC.63.2002. 24-39% of participants reached MCID based on these criteria . Based on these two studies.193).0 Osteoarthritis Index J Rheumatol. Factorial / domain. 39 reviews of existing instruments. Bellamy N. REFERENCES 1. Other studies have shown that items on the physical function subscale did not load unequivocally on that factor. It has been studied over a period of almost 30 years in many different contexts and patient populations. Australia 2002. J Rheumatol. A comparative study of telephone versus onsite completion of the WOMAC 3. worse outcomes from 50 51 knee arthroplasty . Bellamy N. Specifically. 40 knee OA (n = 317 & 2. 54 stair climbing. 3. based on pre-specified criteria). it has been argued that the ability of the WOMAC physical function scale to detect change may be particularly limited in situations where 45. 53 constructs . stiffness (r =0. 1997. Several studies have shown that WOMAC and SF-36 subscales with similar constructs have moderate to high correlations. In a study of outpatients with knee or hip OA. 2. 0. Prior reviews 37. 2002.104). In that 60 study. 55 have summarized the performance of the WOMAC with respect to responsiveness in these trials .67. Band P. 0. Pilcher L. Brisbane. Sensitivity / Responsiveness. Huber J. patients who were satisfied with knee arthroplasty had better WOMAC total. and high. Overall.24:2413. Bellamy N. medium. provide an overview of this argument . one study of patients with hip and knee OA awaiting arthroplasty (n= 474) 41 failed to support a single-item solution for the pain subscale .97 . Osteoarthritis Cartilage. investigators used three definitions of MCID to calculate the frequency of clinically important improvement in function over 30 months in Multicenter Osteoarthritis 60 Study (MOST)participants .9mm to -32. Campbell J. while lower correlations were observed between subscales with less similar 38. 50 and physical function scores than those who were not satisfied (n=1.0 Osteoarthritis Index. 47 there is a low correlation or “mismatch”• between physical function and pain severity . Second.64. Mahmood Z. there is little 37 evidence regarding the measurement properties of the stiffness subscale. Overall. Speilberger J. 52 severe knee OA . In a study of patients undergoing hip arthroplasty (n=78). Theiler R.33 for worsening and 58 0. Clinical evaluation of the WOMAC 3. Kroesen S.Rater. The WOMAC has been extensively used in the context of clinical trials. the MCIDs on the WOMAC VAS format 59 ranged from -7. patients with post-traumatic knee OA vs. 10:479-481. Validation study of a computerized version of the Western Ontario and McMaster Universities VA3.56). and function (r =0. 29:783-786. and there are abundant data regarding its utility and measurement properties. 4.6mm . Pua et al. . ICCs for intra-rater reliability ranged from 0. High correlations and overlapping items between 45-47 the pain and physical function subscales may pose measurement problems. The three definitions were: MCID26% (26% improvement from baseline). and joint range of motion among older adults with knee and hip OA . 0. Responsiveness varies according to 37 subscales and type of intervention . and some items from the pain and physical function 13.53-0. in which the WOMAC was administered by an 38 interviewer. Criterion. 56. Clinically Important Differences In a study of patients with hip and knee OA undergoing comprehensive inpatient rehabilitation. studies have shown that the WOMAC pain and function subscales exhibit comparable or greater 38. Two studies found statistically significant Spearman correlations between patient satisfaction with knee 48. WOMAC Osteoarthritis Index User Guide. Campbell J. First. However. Validity Content/face. for which further exploration is warranted. Development of the WOMAC involved expert opinion (including rheumatologists and epidemiologists). and its test-retest reliability has been low . and surveys of patients with hip and / or knee OA . Stewart C.0 OA Index in numeric rating scale format using a computerised touch screen version. The WOMAC has been shown to distinguish well between patients with better vs. pain. The WOMAC has shown significant Spearman correlations with performance scores for walking. and patients with mild / moderate vs. the minimal clinically important differences (MCIDs) for WOMAC global and subscale scores ranged from 0. Construct.67-0. 42-45 subscales tended to load together on a factor (n =66-474). rising from a chair. suggesting that a clinically important improvement is frequent in individuals with or at high risk for knee OA. 0. Bellamy N.48) subscales (n =108 & 1. 49 arthroplasty and WOMAC pain (r =0. normal controls . The factor structure of the WOMAC has been confirmed in some studies of patients with hip and 31. though two potential weaknesses have been debated.

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Bellamy N. 1999. 25. del Mar Guzman M. 2008. Clin Orthop. van der Slikke RM. reliability. J Rheumatol. 29. et al. Bogoch ER.26:1641-1645. Soderman P. pain and stiffness scores: evidence for the role of low back pain. 45(5):453-461. Hirayama T. Jolles BM. Goldsmith CH. Validation of the Western Ontario and McMaster University Osteoarthritis Index in Asians with osteoarthritis in Singapore. Rattanachaiyanont M. 41. 1988. 466(1):167-178. Wolfe F. 34. Malchau H.12:225-231. 31. 5:231-241. 58(9):563-568. Harder M. 33. Young NL. 2007. Javier Toyos F. 27. 43. 37. Kennedy DM. Kolopack P. 1986. Clin Rheumatol. Wright JG. reliability. Tuzun EH. 50:239-246. Klassbo M. Ewert T. 39. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties.71(1):39-46. 28. Lohmander LS. 2005. Stratford PW. J Rheumatol. 40. 1999. Meijers WG. 15:1833-1840. Validity. Guzel R. Seydaoglu G. Spadoni GF. 2001. 30.2004. Guler-Uysal F. Campbell J. Chew LH. A preliminary evaluation of the dimensionality and clinical importance of pain and disability in osteoarthrits of the hip and knee. Lindgren L. Kong SX. Buchanan WW. Villanueva I. 15:266-272. and Health (ICF). Stucki G. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. validity.Clin Rheumatol.28(4):210-215. Bellamy N. Reliability. J Clin Epidemiol. Disability. Benink RJ. rheumatoid arthritis. Rheumatology (Oxford).2010. fatigue and depression in osteoarthritis. 2005. 11(7):519-523. 36. Osteoarthritis Cartilage. 2001. Thumboo J. Woodhouse LJ. 38. Osteoarthritis Cartilage. 32. Osteoarthritis Cartilage. Aytar A. Stitt LW. Weigl M. Journal of Clinical Epidemiology. Matsuno T. Acta Orthopaedica Scandinavica 2000. Navarro F. linking osteoarthritis-specific health-status measures to the International Classification of Functioning. a categorical scaled version of the Western Ontario and MacMaster Universities Osteoarthritis (WOMAC) Index: Spanish versions. and responsiveness in patients with arthroscopically assessed osteoarthritis. 2006. Rasch analysis of the Western Ontario MacMaster questionnaire (WOMAC) in 2205 patients with osteoarthritis. 2003. Health-related quality of life in patients with systemic lupus erythematosus after medium to long-term follow-up of hip arthroplasty. WOMAC osteoarthritis index. 1999. Lehmann S. McConnell S. Clin Rheumatol. Angst F. Robertsson O. Validation of a modified Thai version of the Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis. 1997. Minami A. and fibromyalgia. 2006. Cieza A. 83:339-344. 26. Kuptniratsaikul V. de Vet HC. A prospective evaluation and validation study. 42. 35. Measurement properties of the WOMAC LK 3.24. rheumatoid arthritis and fibromyalgia. Ann Rheum Dis. Self-reported physical functioning was more influenced by pain than performance-based physical functioning in knee osteoarthritis patients. Aeschlimann A.1 pain scale. Western Ontario and MacMaster Universities. Daskapan A. Lupus: 2007. Appropriate questionnaires for knee arthroplasty: results of a survey of 360 patients from the Swedish knee arthroplasty registry J Bone Joint Surg Am. Basaram S. Roos EM. 2001. Quality of life after TKA for patients with juvenile rheumatoid arthritis. Osteoarthritis Cartilage. Eker L. Arthritis Rheum. Ryd L. Bayramoglu M. Terwee CB. and comparison of the WOMAC osteoarthritis index and Lequesne algofunctional index in Turkish patients with hip or knee osteoarthritis. Wolfe F. symptom counts. . Relative efficiency and validity properties of a visual analog vs. van Lummel RC. Determinants of WOMAC function. Soh CH. 32:1324-1330. Validity and reliability of Swedish WOMAC osteoarthritis index: a self-administered disease-specific questionnaire (WOMAC) versus generic instruments (SF-36 and NHP). Ito H. Osteoarthritis Cartilage.13:28-33. 16(5):318-232. Buchanan WW. The factor subdimensions of the Western Ontario and McMaster Universityies Osteoarthritis Index (WOMAC) help to specify hip and knee osteoarthritis. Dunbar MJ.38(4):355-361. 59:724-731.Epub ahead of print. Acceptability. Davis AM. Tanino H. Scand J Rheumatol. 9:440-446. Ariza-Ariza R. A comparison of different indices of responsiveness. validity and responsiveness of the Turkish version of WOMAC osteoarthritis index.

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