Scand J Rheumatol 1999;28:210±5

WOMAC Osteoarthritis Index

Reliability, validity, and responsiveness in patients with arthroscopically assessed osteoarthritis

E.M. Roos1, M. KlaÈssbo2, and L.S. Lohmander3

1
Institute of Musculoskeletal Disease, Department of Physical Therapy, Lund University, 2Department of Physical Therapy, SaÈf¯e
Hospital, and Department of Surgical Sciences, Section of Rehabilitation Medicine, Karolinska Institute, Stockholm, 3Institute of
Musculoskeletal Disease, Department of Orthopedics, Lund University Hospital, Sweden

Objective: To validate the WOMAC Osteoarthritis Index for use in Sweden.

Methods: Test-retest reliability, internal consistency, validity, and responsiveness was determined in 52 patients (mean age 48 (20 ± 69)) with
arthroscopically assessed cartilage damage of the tibio-femoral knee joint.
Results: All WOMAC scales were internally consistent with Cronbach's alpha coef®cients of 0.83, 0.87, and 0.96 pre-operatively. Test-retest
reliability was satisfactory with intraclass correlation coef®cients of 0.74, 0.58, and 0.92. As hypothesized worse post-operative but not pre-
Scand J Rheumatol Downloaded from informahealthcare.com by Michigan University on 11/08/14

operative outcomes were associated with radiographic OA. In comparison with the SF-36 the expected correlations were found when
comparing items measuring similar and dissimilar constructs, supporting the concepts of convergent and divergent construct validity. Three
months after arthroscopy signi®cant mean improvement was seen in all WOMAC scales (pv0.0004).
Conclusion: The Swedish version of WOMAC is a reliable, valid, and responsive instrument with metric properties in agreement with the
original widely used version.

Key words: WOMAC Osteoarthritis Index, outcome, knee osteoarthritis, validation, Sweden, arthroscopy

Outcome instruments, which measure at the dis- We report on the linguistic validation of a Swedish
ability and handicap level, should be used to version of WOMAC Osteoarthritis Index, and
determine if therapeutic interventions satisfy the present data on its metric properties.
For personal use only.

needs of the patients. Several instruments for

assessment of symptoms and function of the lower
extremity in subjects with hip or knee osteoarthrosis
Patients and methods
(OA) have been constructed and validated (1 ± 4).
The instruments differ both in layout and in what is WOMAC Osteoarthritis Index
being measured, and how to make quantities out of
The WOMAC measures three separate dimensions:
qualities.
Pain (5 questions), Stiffness (2 questions), and
The Western Ontario and MacMaster Universities
Function (17 questions), Table I. The original
(WOMAC) Osteoarthritis Index is a widely used self-
WOMAC is available in two formats, Visual Analog
administered health status measure assessing pain,
Scales and Likert-boxes, with similar metric proper-
stiffness, and function in patients with OA of the hip
ties. From our clinical experience the format
or knee (1). The WOMAC Osteoarthritis Index has
employing 5 Likert-boxes was preferred and chosen
been extensively tested for reliability, validity, and
for the Swedish version. A summary score was
responsiveness (1, 5 ± 7). To enable comparison
calculated for each dimension, as for the original
between assessments made in different countries,
version of WOMAC, with maximum scores of 20, 8
these measures need not only be translated, but also
and 68 for the Likert version (10). However, to
adapted for use in different cultures (8). The
enable comparison across subscales and to other
WOMAC is currently available in German (9),
outcome instruments, the summed scores were
French, Spanish, and Italian (10). Versions for use
transformed into a 0 to 100 scale, an approach also
in many additional countries are currently being
used by others (9, 11). In uniformity with other
validated (Nicholas Bellamy, personal communica-
outcome measures used in orthopedics, 100 was
tion 1998). Additional testing is needed to make sure
considered the best possible outcome (12 ± 18).
that the clinimetric properties of the new versions are
100 indicating no symptoms or functional dis-
comparable to the properties of the original version.
ability and 0 indicating extreme symptoms and
Ewa Roos, Department of Physical Therapy, Box 5134, S-220 05 functional disability. The time frame to consider
Lund, Sweden when answering the questionnaire was set to ``last
Received 3 November 1998 week''. Missing values were treated according to the
Accepted 24 February 1999 WOMAC User's Guide (10).

210 # 1999 Scandinavian University Press on license from Scandinavian Rheumatology Research Foundation
 Swedish version of WOMAC

Table I. The 24 items included in the WOMAC questionnaire. Table II. Pre-operative characteristics of the study group.

Pain Study group

How much pain do you have
Walking on ¯at surface Patients (males) 52 (27)
Going up or down stairs Median age (range) 48 (20 ± 69)
At night while in bed Weight*, median kg (range) 80 (54 ± 114)
Sitting or lying Height*, median cm (range) 176 (157 ± 199)
Standing upright BMI, median (range) 26 (21 ± 36)
Currently taking NSAIDs** or 16
Stiffness
analgesics because of knee* (n)
How severe is your stiffness after ®rst wakening in the morning
How severe is your stiffness after sitting, lying, or resting later in *Self-reported data.
the day **Non-steroidal anti-in¯ammatory drugs.
Function
What degree of dif®culty do you have criteria were involvement of other joints affecting
Descending stairs lower extremity or back function (n~3). Pre-
Ascending stairs
Rising from sitting operative questionnaire data were available for 52
Standing patients ®lling the inclusion or exclusion criteria
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Bending to ¯oor (Table II). Of these, weight-bearing radiographs

Walking on ¯at were available for 32 patients. The radiographs were
Getting in/out of car classi®ed according to the recommendations of
Going shopping
Putting on socks/stockings the Osteoarthritis Research Society (21). Eighteen
Rising from bed patients had advanced radiographic signs of tibio-
Taking off socks/stockings femoral OA, comparable with a Kellgren and
Lying in bed Lawrence grade 2 or higher (22). All subjects
Getting in/out of bath reported lowered activity level because of knee
Sitting
Getting on/off toilet problems, and the median duration of symptoms
Heavy domestic duties was 1 year, ranging from less than three months to
For personal use only.

Light domestic duties more than ten years.

Linguistic validation. The WOMAC was indepen- Metric properties

dently translated into Swedish and back translated
into English in three separate processes initiated by
the two ®rst authors and a health related outcomes
specialist (8, 19). These three versions of WOMAC
were used to evaluate subjects with hip and knee
OA at different sites in Sweden. When learning of
the three different versions of WOMAC, it was
decided that a committee should review the exist-
ing versions and agree upon a common version.
Study design
To evaluate the Swedish version of WOMAC
Osteoarthritis Index, questionnaires including back-
ground variables, were mailed to 200 consecutive
patients on the waiting list for knee arthroscopy at
the Department of Orthopedics at Lund University
Hospital, Sweden. The Ethics Committee at the
Medical Faculty of Lund University approved the
study.
Inclusion criteria were (a) having cartilage damage
of the tibio-femoral joint as seen at arthroscopy and
(b) being able to complete questionnaires in Swedish
(n~55). Cartilage damage was de®ned as Beguin
and Locker grade III or IV, that is an open lesion
with bone contact or exposed bone (20). Exclusion
Reliability. To assess test-retest reliability, the
patients were asked to complete the WOMAC
twice pre-operatively. Thirty-®ve of the original 52
subjects completed the WOMAC twice within the
stipulated two to ten days. Intraclass correla-
tion coef®cients (23) of the two pre-operative
administrations of the corresponding subscales
Pain, Stiffness, and Function were calculated.
Internal consistency, or inter-item correlation, was
calculated on the second pre-operative administra-
tion by Cronbach's alpha (24). Reliability coef®-
cients of 0.75 or more are considered excellent
(25).
Validity. For the purpose of determining construct
validity, Spearman's correlation coef®cients were
used to compare the pre-operative administration
of the WOMAC subscales Pain, Stiffness, and
Function to the subscales Bodily Pain and Physical
Function of the Short Form 36-item of the Medi-
cal Outcome Study (SF-36) (12). The SF-36 is a
well validated, widely used, generic health status
questionnaire assessing physical and mental health
in eight different subscales. A moderate correlation
was expected. Mc Dowell and Newell (26) have

211
 E.M. Roos et al.
noted, in a review of rating scales and question-
naires, that correlation coef®cients for construct
validity often fall between 0.20 and 0.60 and rarely
are above 0.70. To determine divergent construct
validity, comparisons of the three subscales of
WOMAC were made to the question 11 a of the
SF-36 (``I seem to get sick a little easier than other
people'', de®nitely true ± de®nitely false). This
health concept is not associated to symptoms or
functional limitations of OA, and correlations close
to 0 were expected. The Swedish acute version 1.0
of the SF-36 (27) was used.
It was hypothesized that more symptoms and
functional limitations would be present in those
patients who had signs of radiographic knee OA,
than in those who lacked these signs. This hypothesis
was tested by the use of Mann-Whitney test for two
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independent groups. Additionally, it was hypothe-
sized that subjects with radiographic OA would not
bene®t as much from the arthroscopic procedures as
would the other patients. This hypothesis was tested
by the use of Wilcoxon matched pairs signed rank
sum test.
Responsiveness. To assess post-operative change,
the WOMAC was mailed to the patients three
months post-operatively. We expected that the
For personal use only.
arthroscopy would induce a change in patients'
perception of symptoms and function that could
be measured by the questionnaires. Post-operative
change was assessed by Wilcoxon matched pairs
signed rank sum test. Effect size, de®ned as mean
score change divided by the standard deviation of
the pre-operative score (28), and standardized
response mean, de®ned as mean score change
divided by the standard deviation of that score
change (29) were used to de®ne the responsiveness
of the questionnaire. Effect sizes over 0.8 are con-
sidered large (30).
Results
When comparing the preliminary versions of
WOMAC, few differences were noted. The authors
agreed upon a common Swedish version*. The
reviewed version was tested for clearness of the
language, ambiguities, and the ability of subjects
with hip or knee OA to complete the questionnaire
without assistance. One adaptation to Swedish
conditions was made after this testing procedure,
the question ``What degree of dif®culty do you have
getting in/out of bath'' was changed to ``getting in/
out of bath/shower''. This adaptation was made after
ÐÐÐÐÐÐÐÐÐÐÐÐÐ
* The Swedish version of the WOMAC Osteoarthritis Index is
available from the ®rst author or from the Internet:
www.QLMed.org/WOMAC
212
discussions with the originator of WOMAC Osteo-
arthritis Index (Nicholas Bellamy, personal commu-
nication 1997) and according to the descriptions
supplemented in the WOMAC User's Guide (10).
Reliability
Thirty-®ve of the original 52 subjects completed
WOMAC twice within the stipulated two to ten days
with a mean of 5.1¡2.2 (2 ± 10) days. The intraclass
correlation coef®cients of the three dimensions Pain,
Stiffness, and Function were 0.74, 0.58, and 0.92,
respectively. Cronbach's alpha, calculated on the
second pre-operative administration, for the three
dimensions were 0.83, 0.87, and 0.96, respectively.
Validity
SF-36. As expected moderate correlations were
found when comparing corresponding subscales of
WOMAC Osteoarthritis Index and SF-36. When
comparing WOMAC Osteoarthritis Index to the
SF-36 question ``I seem to get sick a little easier
than other people'', a construct the WOMAC
Osteoarthritis Index is not supposed to measure,
the expected correlations close to zero were found
(Table III).
Radiographs. No signi®cant difference was seen in
pre-operative or post-operative WOMAC scores
between patients with and without radiographic
changes of OA (Table IV). However, patients with-
out radiographic signs of OA reported signi®cant
improvement in the subscales Pain and Stiffness
post-operatively, which was not the case for the
patients with radiographic signs of OA. The
improvement in the subscale Function was similar
for both groups (Table IV).
Responsiveness
Post-operative data were available for 40 patients. In
29 patients a partial meniscectomy was performed, in
Table III. Spearman's correlation coef®cients determined when
comparing WOMAC to SF-36. All correlations at or above 0.40
were signi®cant (pv0.002).
SF-36 WOMAC WOMAC WOMAC
Pain Stiffness Function
Subscale Physical Function 0.40 0.45 0.64
Subscale Bodily Pain 0.67 0.44 0.65
Question 11 a. ``I seem to get 0.08 ± 0.21 0.03
sick a little easier than other
people'' de®nitely true ±
de®nitely false (1 ± 5)
 Swedish version of WOMAC

Table IV. Pre- and postoperative mean (SD) WOMAC scores for the subset who had weight-bearing knee radiographs classi®ed with
regard to features of OA (n~32). P-values are given for the comparison between OA and no OA groups at different times and for the
pre-operative to post-operative difference.

Pre-operative Post-operative Pre-postoperative

Mean (SD) Mean (SD) difference
OA No OA p-value OA No OA p-value OA No OA
n~18 n~14 n~14 n~10 p-value p-value

Pain 49 46 0.7 53 64 0.3 0.14 0.02

(19) (18) (20) (27)
Stiffness 58 58 0.9 66 72 0.5 0.08 0.02
(24) (26) (26) (29)
Function 57 58 0.8 64 70 0.6 0.05 0.06
(16) (22) (22) (23)

5 cartilage shaving or drilling, in 2 a synovial plica indicating suf®cient reliability. The task force of the
was removed, and in 4 subjects no procedure was Osteoarthritis Research Society has recommended
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carried out. Signi®cant improvement was seen for
the total group in all three WOMAC subscales
(pv0.0004) with effect sizes of 0.51 to 0.71 and
standardized response means of 0.63 to 0.70 for the
three subscales (Table V).
Discussion
Patient-relevant outcome measures should be ade-
quately standardized and permit quanti®cation.
For personal use only.
outcomes to be measures in clinical trials of OA (32).
The WOMAC subscales Pain and Function are
included in these recommendations. The WOMAC
subscale Stiffness, however, was considered vague
and was only recommended as an optional measure.
Construct validity is usually determined in com-
parison with other well-validated outcome measures
for similar or dissimilar constructs. The SF-36 is
such a well-validated generic outcome measure
previously used for validation purposes. As expected

They should also be valid for the disease and from the literature (26), correlations between 0.4 and
patients of interest and have high reliability and 0.7 were found when comparing similar constructs.
responsiveness (31). The WOMAC Osteoarthritis Correlations of the Swedish version of the WOMAC
Index has through extensive testing proven to be when compared with SF-36 was in agreement with
such an outcome measure and is widely used today. results reported of the German validation process
To improve the comparison of clinical studies where correlations of 0.30 to 0.79 were found for
between countries, versions of the WOMAC similar constructs and correlations of 0.02 to ± 0.06
Osteoarthritis Index adapted for use in different for dissimilar constructs (9).
countries are needed. Self-reported symptoms and function do not
The test-retest reliability coef®cient of the correlate strongly to the presence of radiographic
WOMAC subscale Stiffness was lower than for the knee osteoarthritis (33, 34), which was con®rmed by
subscales Pain and Function. This was expected this study. Thus, patients with knee symptoms of
since similar ®ndings have been reported for the different origin reported similar levels of symptoms
original version (1) and the German version (9). and functional limitations. However, following
However, the inter-item correlation of the two arthroscopy, pain and stiffness did not improve
questions included in the subscale Stiffness was high signi®cantly from the pre-operative levels in patients
and comparable to the other WOMAC subscales, with radiographic signs of OA. In contrast, a
signi®cant improvement was noted following arthro-
Table V. Mean pre- and postoperative WOMAC scores, p-values
effect sizes (ES), and standardized response mean (SRM) for the scopy for patients without radiographic signs of OA.
40 subjects where post-operative data was available. Thus, we did not observe any short-term bene®t of
the arthroscopic procedure for the patients with knee
WOMAC subscale Pre-op Post-op P-value ES SRM pain and radiographic OA. Previous reports on the
Mean(SD) Mean(SD)
bene®ts of arthroscopic procedures in this category
Pain 49 65 0.0002 0.71 0.70 of patients have been con¯icting (35 ± 37). Follow-up
(23) (28) data was available for 77% of included patients, a
Stiffness 56 71 0.0004 0.65 0.70 response rate somewhat higher than previously
(24) (25) received in questionnaire studies regarding health
Function 63 73 0.0001 0.51 0.63
(21) (22) status of the general Swedish population (38).
The relevance of the items included in the

213
 E.M. Roos et al.
WOMAC Osteoarthritis Index for elderly patients
with OA of the hip or knee has previously been
determined through well-structured processes (1, 5,
39). However, one validates not the measuring
instrument itself but the measuring instrument in
relation to the purpose for which it is being used
(40). In the present study the WOMAC was
administered to younger patients with less advanced
OA. The results indicate that WOMAC is a suf®cient
outcome instrument also for this group. However,
for patients with OA of younger age or with a more
active life-style, the addition of subscales assessing
sport and recreation function and knee-related
quality of life to the WOMAC is suggested, since
this addition markedly improved sensitivity in such
patients with post-traumatic OA (41). When sport
and recreation function and knee-related quality of
Scand J Rheumatol Downloaded from informahealthcare.com by Michigan University on 11/08/14
life have been assessed in addition to WOMAC in
patients undertaking reconstruction of the ACL or
meniscus surgery, higher responsiveness has been
found (15, 42). By analogy with these ®ndings a
higher responsiveness should be possible to reach
also in this patient population by assessing sport and
recreation function and knee-related quality of life.
In conclusion, the Swedish version of WOMAC
has metric properties that are well in agreement with
the original version of WOMAC Osteoarthritis
For personal use only.
Index. Further testing is required to fully validate
the Swedish version of WOMAC Osteoarthritis
Index. However, this can only be done through
repeated use of the measure in different groups of
patients and under different conditions.
Acknowledgements
Supported by The Medical Faculty and University Hospital in
Lund, The Swedish Foundation for Health Care Sciences and
Allergy Research, The Swedish Rheumatism Association, The
Swedish Sports Confederation (Sports Research Council), The
Zoega Foundation, and the Swedish Medical Research Council.
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