title: The visual analogue WOMAC 3.0 scale--internal validity and responsiveness of the VAS version.
abstract: BACKGROUND
  Many people suffer with Osteoarthritis (OA) and subsequent morbidity. Therefore, measuring outcome associated with OA is important. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been a widely used patient reported outcome in OA. However, there is relatively little evidence to support the use of the Visual Analogue Scale (VAS) version of the scale. We aimed to explore the internal validity and responsiveness of this VAS version of the WOMAC.
  
  
  METHODS
  Patients with chronic hip or knee pain of mechanical origin, waiting for a hip or knee joint replacement completed the WOMAC as part of a study to investigate the effects of acupuncture and placebo controls. Validity was tested using factor analysis and Rasch analysis, and responsiveness using standardised response means.
  
  
  RESULTS
  Two hundred and twenty one patients (mean age 66.8, SD 8.29, 58% female) were recruited. Factor and Rasch analysis confirmed unidimensional Pain and Physical Functioning scales, capable of transformation to interval scaling and invariant over time. Some Differential Item Functioning (DIF) was observed, but this cancelled out at the test level. The Stiffness scale fitted the Rasch model but adjustments for DIF could not be made due to the shortness of the scale. Using the interval transformed data, Standardised Response Means were smaller than when using the raw, ordinal data.
  
  
  CONCLUSIONS
  The WOMAC Pain and Physical Functioning subscales satisfied unidimensionality and ordinal scaling tests, and the ability to transform to an interval scale. Some Differential Item Functioning was observed, but this cancelled out at the test level and, by doing so, at the same time removed the disturbance of unidimensionality. The scaling characteristics of sets of items which use VAS require further analysis, as it would appear that they can lead to spurious levels of responsiveness and scale compression because they exaggerate the distortion of the ordinal scale.
  
  
  BACKGROUND
  UKCRN study ID: 4881 ISRCTN78434638.
authors.affiliation: School of Health Sciences, University of Southampton, Highfield, Southampton, UK. P.Kersten@soton.ac.uk
authors.forename: Paula
authors.initials: P
authors.lastname: Kersten
authors.forename: Peter J
authors.initials: PJ
authors.lastname: White
authors.forename: Alan
authors.initials: A
authors.lastname: Tennant
mesh_terms: D000203:Activities of Daily Living; D015667:Acupuncture Analgesia / Q000706:statistics & numerical data; D000368:Aged; D018771:Arthralgia / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D003627:Data Interpretation, Statistical; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015207:Osteoarthritis, Hip / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D020370:Osteoarthritis, Knee / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D017063:Outcome Assessment, Health Care / Q000379:methods*; D010147:Pain Measurement / Q000379:methods*; D015990:Placebo Effect; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D006113:United Kingdom