ahead of dementia, diabetes, prostate cancer, and need to understand its impact on Oa patients in cancer ta are consistent with order to guide decision making-to determine how those from the framingham study, which found that and what interventions are appropriate--in the among older (mean age -74 years)study partici- management of the disease. Measuring QOL pants, knee OA, taken alone, represented I of the 4 ther allows clinicians the opportunity to determine rgest causes of disability along with heart disease, the efficacy of a given intervention. Numerous depression, and stroke. A significant proportion instruments are currently available for measuring of the patient population in the framingham study different aspects of QOL in the Oa patient, includ- with knee Oa were unable to perform a variety ing those that measure general QOL, functional of activities of daily living, such as heavy home capacities, the experience of pain, and psychologi- chores (34% disabled), walking 1 mile(31%), stair cal dimensions of QOL. The most commonly used ing(10%), and grocery shopping(10%). In instrument specific to OA is the Western Ontario fact, the ability to walk I mile or to undertake light and McMaster Universities Osteoarthritis Index housekeeping was notably more restricted among (WOMAC). WOMAC is a 24-item self-report those with knee OA compared with matched questionnaire that addresses joint pain, stiffness, patients with heart disease. 3 and loss of function related to oa of the knee and It is interesting to note that the burden of Oa in hip 24-26 Since its initial validation, WOMAC has terms of functional deficits can affect areas beyond been widely used in clinical trials, and has been the immediate OA loci. For example, an analysis of repeatedly shown to provide utility as a measure participants in the Johnston County Osteoarthritis of patient QOL, response to treatment, prediction Project with joint-specific hand symptoms found that of treatment outcomes, as well as sensitivity to not only did they experience significant deterioration minimal perceptible clinical improvement. 4. An in performance-based functional status overall--as electronic touch-screen version of the WOMAC might be expected-but that the disability extended (the e-WOMAC) has shown similar responsiveness beyond that which one would intuitively associate to the paper version in Oa patients. 1 with hand OA. People with hand Oa symptoms in The Medical Outcomes Study 36-Item Short this study experienced significant deterioration in Form Health Survey (SF-36)provides an 8-scale performing both upper- and lower-extremity tasks. evaluation of physical and mental QOL based on 36 These results were based on both a self-report instru- questions. Although the SF-36 is not specific to ment(the Health Assessment Questionnaire [HAQI OA, it is, like WOMAC, widely used to guide OA Disability Index)as well as performance-based func- treatment in clinical trials, being fairly sensitive to tional measures(timed 5 chair stands"and gait minimal perceptible clinical improvement. 24.27429 32A neasured over an 8-foot walking course ) I more OA-specific instrument, the SF-36 Arthritis- A separate analysis of participants in the Johnston Specific Health Index, was developed to better knee OA, and the severity of knee pain in particu- not been widely adopted. ation, but to date has County Osteoarthritis Project found that having target the Oa patient popul ar, was associated with a high degree of functional Although both the WoMAC and SF-36 instru- impairment. Even mild knee pain was strongly ments function relatively well in assessing various associated with disability in performing 16 of the QOL domains in OA, WOMAC may be more 20 upper- and lower-extremity tasks included in the responsive than the SF-36 instrument to detecting HaQ disability index. For those with moderate-to- changes in function. 4 In fact, the validity of both severe pain, significant disability was observed with instruments has been challenged. 5 Although it all 20 tasks in the HAQ index(all P<.001). 12 should be noted that WOMAC is widely accepted The common presence of comorbidities within for its ability to measure pain and functional deficits the Oa patient population exerts additional deleteri- in OA, Stratford et al have questioned its validity ous effects on both physical functioning and pain in measuring pain. According to their analysis, the factors that comprise pain evaluation are not Measuring QoL in OA alid, while they state that the pain scale as a whole The necessity of measuring QOL arises from a is not internally consistent. The authors suggest S226 w第4瓶5 SEPTEMBER 2009Reports S226 n www.ajmc.com n september 2009 ahead of dementia, diabetes, prostate cancer, and breast cancer.22 These data are consistent with those from the Framingham study, which found that among older (mean age ~74 years) study partici￾pants, knee OA, taken alone, represented 1 of the 4 largest causes of disability along with heart disease, depression, and stroke.13 A significant proportion of the patient population in the Framingham study with knee OA were unable to perform a variety of activities of daily living, such as heavy home chores (34% disabled), walking 1 mile (31%), stair climbing (10%), and grocery shopping (10%).13 In fact, the ability to walk 1 mile or to undertake light housekeeping was notably more restricted among those with knee OA compared with matched patients with heart disease.13 It is interesting to note that the burden of OA in terms of functional deficits can affect areas beyond the immediate OA loci. For example, an analysis of participants in the Johnston County Osteoarthritis Project with joint-specific hand symptoms found that not only did they experience significant deterioration in performance-based functional status overall—as might be expected—but that the disability extended beyond that which one would intuitively associate with hand OA. People with hand OA symptoms in this study experienced significant deterioration in performing both upper- and lower-extremity tasks.11 These results were based on both a self-report instru￾ment (the Health Assessment Questionnaire [HAQ] Disability Index) as well as performance-based func￾tional measures (timed “5 chair stands” and gait measured over an 8-foot walking course).11 A separate analysis of participants in the Johnston County Osteoarthritis Project found that having knee OA, and the severity of knee pain in particu￾lar, was associated with a high degree of functional impairment.12 Even mild knee pain was strongly associated with disability in performing 16 of the 20 upper- and lower-extremity tasks included in the HAQ disability index.12 For those with moderate-to￾severe pain, significant disability was observed with all 20 tasks in the HAQ index (all P <.001).12 The common presence of comorbidities within the OA patient population exerts additional deleteri￾ous effects on both physical functioning and pain.10,23 Measuring QOL in OA The necessity of measuring QOL arises from a need to understand its impact on OA patients in order to guide decision making—to determine how and what interventions are appropriate—in the management of the disease. Measuring QOL fur￾ther allows clinicians the opportunity to determine the efficacy of a given intervention. Numerous instruments are currently available for measuring different aspects of QOL in the OA patient, includ￾ing those that measure general QOL, functional capacities, the experience of pain, and psychologi￾cal dimensions of QOL. The most commonly used instrument specific to OA is the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). WOMAC is a 24-item self-report questionnaire that addresses joint pain, stiffness, and loss of function related to OA of the knee and hip.24-26 Since its initial validation, WOMAC has been widely used in clinical trials, and has been repeatedly shown to provide utility as a measure of patient QOL, response to treatment, prediction of treatment outcomes, as well as sensitivity to minimal perceptible clinical improvement.24,27-30 An electronic touch-screen version of the WOMAC (the e-WOMAC) has shown similar responsiveness to the paper version in OA patients.31 The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) provides an 8-scale evaluation of physical and mental QOL based on 36 questions. Although the SF-36 is not specific to OA, it is, like WOMAC, widely used to guide OA treatment in clinical trials, being fairly sensitive to minimal perceptible clinical improvement.24,27-29,32 A more OA-specific instrument, the SF-36 Arthritis￾Specific Health Index, was developed to better target the OA patient population, but to date has not been widely adopted.33,34 Although both the WOMAC and SF-36 instru￾ments function relatively well in assessing various QOL domains in OA, WOMAC may be more responsive than the SF-36 instrument to detecting changes in function.24 In fact, the validity of both instruments has been challenged.35 Although it should be noted that WOMAC is widely accepted for its ability to measure pain and functional deficits in OA, Stratford et al have questioned its validity in measuring pain.35 According to their analysis, the factors that comprise pain evaluation are not valid, while they state that the pain scale as a whole is not internally consistent.35 The authors suggest 第 135 页