JBJS | Comparison of the Musculoskeletal Function Assessment Questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile Health-Status Measures*

The Journal of Bone & Joint Surgery, Volume 79, Issue 9

Articles | September 01, 1997

Comparison of the Musculoskeletal Function Assessment Questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile Health-Status Measures*

DIANE P. MARTIN, PH.D.†; RUTH ENGELBERG, PH.D.†; JULIE AGEL, M.A.†; MARC F. SWIONTKOWSKI, M.D.‡, SEATTLE, WASHINGTON

View Disclosures and Other Information

Investigation performed at Harborview Medical Center, Seattle, Valley Orthopedics Associates, Renton, and Northwest Orthopedics and Fracture Clinic, Spokane

The Journal of Bone & Joint Surgery. 1997; 79:1323-35

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Tables

References

text A A A

Abstract

We compared the reliability, validity, and responsiveness of the Musculoskeletal Function Assessment (MFA) questionnaire with those of three commonly used health-status measures: the Short Form-36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Sickness Impact Profile (SIP).The MFA, like the other health-status measures, demonstrated good reliability (intraclass correlation coefficients of more than 0.70), good sensitivity and specificity (more than 70 per cent), good criterion validity that correlated with physicians' ratings (p < 0.01), and good construct validity that correlated with the characteristics of the patients (p < 0.01). It also demonstrated better content validity than the other questionnaires, with no ceiling or floor effects for the total score. In addition, it was more responsive than the SF-36; for eight of the eleven comparisons, it was more efficient (relative efficiency of more than 2.00) in measuring changes in function between the baseline values and the values determined at the latest follow-up evaluation.These findings suggest that the MFA can be used to assess the health status of patients who have a musculoskeletal disorder.

Figures in this Article

Introduction

Introduction | Part I: Comparison of the MFA with the SF-36 and the WOMAC | Part II: Comparison of the MFA and the SIP | References

The Musculoskeletal Function Assessment (MFA), a new health-status questionnaire, is a tool for the evaluation of patients' perceptions about their physical, psychological, and social well-being⁶⁷. It was designed for use by patients who have disorders of the musculoskeletal system, such as fractures, soft-tissue injuries, repetitive-motion injuries, and osteoarthrosis. The stability, internal consistency, content validity, and criterion validity of the MFA have been reported previously^25,47.

We performed the current study in two parts. First, we compared the reliability, validity, and responsiveness of the MFA with those of the Short Form-36 (SF-36)^{45,46,56,57,63,64}, a generic health-status measure, and we compared the validity of the MFA with that of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)^6,7, a disease-specific health-status measure for patients who have osteoarthrosis. Second, we compared the validity of the MFA with that of the Sickness Impact Profile (SIP), a generic health-status measure used in many studies to assess the function of the musculoskeletal system^13-15,18,55.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were the National Institutes of Health and the National Institute of Child Health and Human Development.

†Departments of Health Services (D.P.M.) and Orthopaedics (R.E. and J.A.), Harborview Medical Center, University of Washington, Box 359798, 325 Ninth Avenue, Seattle, Washington 98104-2499.

‡Department of Orthopaedics and Surgery, University of Minnesota, 420 Delaware Street, Minneapolis, Minnesota 55455.

†Departments of Health Services (D.P.M.) and Orthopaedics (R.E. and J.A.), Harborview Medical Center, University of Washington, Box 359798, 325 Ninth Avenue, Seattle, Washington 98104-2499.

‡Department of Orthopaedics and Surgery, University of Minnesota, 420 Delaware Street, Minneapolis, Minnesota 55455.

View Larger

TABLE I DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA, SF-36, AND WOMAC WERE COMPARED*

*MFA = Musculoskeletal Functional Assessment, SF-36 = Short Form-36, and WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index.†The values are given as the number of patients with the percentage in parentheses, except for age, which is given as the mean and the standard deviation with the range in parentheses.‡NA = not applicable.§N = 327 for this category.

	MFA and	MFA and
	SF-36†	WOMAC†‡
Characteristic	(N = 444)	(N = 59)
Condition-specific groups
Injury of lower extremities	188 (42)	0
Injury of upper extremities	121 (27)	0
Injury of both upper and lower extremities	18 (4)	0
Repetitive-motion disorder	54 (12)	0
Osteoarthrosis	44 (10)	40 (68)
Rheumatoid arthritis	19 (4)	19 (32)

Female	223 (50)	38 (64)

Age (yrs.)	45.8 ± 16.52	60.4 ± 13.79
	(18.1—90.7)	(23.5—85.9)

Race
White	412 (93)	59 (100)
Other	32 (7)	0

Level of education completed
=8th grade	11 (2.5)	4 (7)
High school	140 (32)	22 (37)
Some college	192 (43)	28 (47)
Bachelor's or more advanced degree	101 (23)	5 (8)

Living alone	76 (17)	13 (22)

Current employment status
Working full-time	198 (45)	21 (36)
Working part-time because of health	17 (4)	0
Working part-time, not health-related	29 (7)	0
Employed but on sick leave	27 (6)	1 (2)
Retired	71 (16)	24 (41)
Unemployed	63 (14)	6 (10)
Homemaker	37 (8)	6 (10)
Other or no response	2 (0.5)	1 (2)

Injured at work§	58 (18)	NA

Annual income
0—$5000	30 (7)	1 (2)
$5001—$30,000	148 (33)	23 (39)
$30,001—$50,000	114 (26)	15 (25)
=$50,001	124 (28)	15 (25)
Other or no response	28 (6)	5 (9)

Change in income
Decreased	119 (27)	9 (15)
No change	309 (70)	50 (85)
Increased	10 (2.3)	0
No response	6 (1.4)	0

Health insurance
Managed care	44 (10)	8 (14)
Private	303 (68)	48 (81)
Medicare	65 (15)	23 (39)
Medicaid	32 (7)	4 (7)
Government programs (state and federal)	38 (9)	2 (3)
Other insurance	9 (2.0)	0
No insurance	43 (10)	0
Don't know	1 (0.2)	0

Receiving disability compensation	85 (19)	8 (14)

Involved in litigation	51 (11)	1 (2)

Add to My JBJS

TABLE I DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA, SF-36, AND WOMAC WERE COMPARED*

	MFA and	MFA and
	SF-36†	WOMAC†‡
Characteristic	(N = 444)	(N = 59)
Condition-specific groups
Injury of lower extremities	188 (42)	0
Injury of upper extremities	121 (27)	0
Injury of both upper and lower extremities	18 (4)	0
Repetitive-motion disorder	54 (12)	0
Osteoarthrosis	44 (10)	40 (68)
Rheumatoid arthritis	19 (4)	19 (32)

Female	223 (50)	38 (64)

Age (yrs.)	45.8 ± 16.52	60.4 ± 13.79
	(18.1—90.7)	(23.5—85.9)

Race
White	412 (93)	59 (100)
Other	32 (7)	0

Level of education completed
=8th grade	11 (2.5)	4 (7)
High school	140 (32)	22 (37)
Some college	192 (43)	28 (47)
Bachelor's or more advanced degree	101 (23)	5 (8)

Living alone	76 (17)	13 (22)

Current employment status
Working full-time	198 (45)	21 (36)
Working part-time because of health	17 (4)	0
Working part-time, not health-related	29 (7)	0
Employed but on sick leave	27 (6)	1 (2)
Retired	71 (16)	24 (41)
Unemployed	63 (14)	6 (10)
Homemaker	37 (8)	6 (10)
Other or no response	2 (0.5)	1 (2)

Injured at work§	58 (18)	NA

Annual income
0—$5000	30 (7)	1 (2)
$5001—$30,000	148 (33)	23 (39)
$30,001—$50,000	114 (26)	15 (25)
=$50,001	124 (28)	15 (25)
Other or no response	28 (6)	5 (9)

Change in income
Decreased	119 (27)	9 (15)
No change	309 (70)	50 (85)
Increased	10 (2.3)	0
No response	6 (1.4)	0

Health insurance
Managed care	44 (10)	8 (14)
Private	303 (68)	48 (81)
Medicare	65 (15)	23 (39)
Medicaid	32 (7)	4 (7)
Government programs (state and federal)	38 (9)	2 (3)
Other insurance	9 (2.0)	0
No insurance	43 (10)	0
Don't know	1 (0.2)	0

Receiving disability compensation	85 (19)	8 (14)

Involved in litigation	51 (11)	1 (2)

View Larger

TABLE II CEILING AND FLOOR SCORES FOR THE MFA, SF-36, AND WOMAC*

*MFA = Musculoskeletal Function Assessment, SF-36 = Short Form-36, and WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index.†The values are given as the number of patients with the percentage in parentheses.‡The scoring system for the SF-36 was reversed to match that of the MFA and the WOMAC, with 100 points indicating poor function and 0 points indicating good function.

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA and SF-36 (n = 444)
MFA
Total score	0—78	1 (0.2)	0
Self-care	0—83	140 (32)	0
Sleep and rest	0—100	148 (33)	11 (2.5)
Hand and fine motor skills	0—100	253 (57)	21 (5)
Mobility	0—95	36 (8)	0
Housework	0—100	98 (22)	9 (2.0)
Employment and work	0—100	223 (50)	98 (22)
Leisure and recreational activities	0—100	88 (20)	69 (16)
Family relationships	0—100	215 (48)	1 (0.2)
Cognition and thinking	0—100	310 (70)	33 (7)
Emotional adjustment, coping, and adaptation	0—95	3 (0.7)	0

SF-36‡
Physical functioning	0—100	53 (12)	5 (1.1)
Physical role functioning	0—100	135 (30)	168 (38)
Bodily pain	0—100	39 (9)	7 (1.6)
General health	0—100	42 (10)	1 (0.2)
Vitality	0—100	5 (1.1)	4 (0.9)
Social functioning	0—100	165 (37)	7 (1.6)
Emotional role functioning	0—100	260 (59)	74 (17)
Mental health	0—92	13 (2.9)	0

MFA and WOMAC (n = 59)
MFA
Total score	3—75	0	0
Self-care	0—83	13 (22)	0
Sleep and rest	0—83	15 (25)	0
Hand and fine-motor skills	0—100	19 (32)	6 (10)
Mobility	0—100	1 (2)	1 (2)
Housework	0—100	3 (5)	4 (7)
Employment and work	0—100	38 (64)	7 (12)
Leisure and recreational activities	0—100	9 (15)	4 (7)
Family relationships	0—90	18 (31)	0
Cognition and thinking	0—100	32 (54)	8 (14)
Emotional adjustment, coping, and adaptation	10—86	0	0

WOMAC
Pain	0—70	5 (8)	0
Stiffness	0—100	1 (2)	1 (2)
Physical function	0—84	2 (3)	0

Add to My JBJS

TABLE II CEILING AND FLOOR SCORES FOR THE MFA, SF-36, AND WOMAC*

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA and SF-36 (n = 444)
MFA
Total score	0—78	1 (0.2)	0
Self-care	0—83	140 (32)	0
Sleep and rest	0—100	148 (33)	11 (2.5)
Hand and fine motor skills	0—100	253 (57)	21 (5)
Mobility	0—95	36 (8)	0
Housework	0—100	98 (22)	9 (2.0)
Employment and work	0—100	223 (50)	98 (22)
Leisure and recreational activities	0—100	88 (20)	69 (16)
Family relationships	0—100	215 (48)	1 (0.2)
Cognition and thinking	0—100	310 (70)	33 (7)
Emotional adjustment, coping, and adaptation	0—95	3 (0.7)	0

SF-36‡
Physical functioning	0—100	53 (12)	5 (1.1)
Physical role functioning	0—100	135 (30)	168 (38)
Bodily pain	0—100	39 (9)	7 (1.6)
General health	0—100	42 (10)	1 (0.2)
Vitality	0—100	5 (1.1)	4 (0.9)
Social functioning	0—100	165 (37)	7 (1.6)
Emotional role functioning	0—100	260 (59)	74 (17)
Mental health	0—92	13 (2.9)	0

MFA and WOMAC (n = 59)
MFA
Total score	3—75	0	0
Self-care	0—83	13 (22)	0
Sleep and rest	0—83	15 (25)	0
Hand and fine-motor skills	0—100	19 (32)	6 (10)
Mobility	0—100	1 (2)	1 (2)
Housework	0—100	3 (5)	4 (7)
Employment and work	0—100	38 (64)	7 (12)
Leisure and recreational activities	0—100	9 (15)	4 (7)
Family relationships	0—90	18 (31)	0
Cognition and thinking	0—100	32 (54)	8 (14)
Emotional adjustment, coping, and adaptation	10—86	0	0

WOMAC
Pain	0—70	5 (8)	0
Stiffness	0—100	1 (2)	1 (2)
Physical function	0—84	2 (3)	0

View Larger

TABLE III CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SF-36 CATEGORIES*

*MFA = Musculoskeletal Function Assessment and SF-36 = Short Form-36. The ratings were based on a subset of fifty-seven patients. The categories for both questionnaires were selected for comparison with the physicians' ratings on the basis of a review of the items in each category by the research team.†The Physicians' ratings were assigned on an 11-point scale, with 0 points indicating best function and 11 points indicating poorest function.‡P < 0.001 for correlation with the physicians' rating.

Physicians' Rating†	MFA Category	Rho	SF-36 Category	Rho
Physical function: mobility of lower extremities	Mobility	0.60‡	Physical functioning	0.51‡
			Physical role functioning	0.22

Physical function: mobility of upper extremities	Hand and fine motor skills	0.61‡

Activities of daily living	Self-care	0.54‡	Physical functioning	0.44‡
	Hand and fine motor skills	0.23	Physical role functioning	0.37
	Housework	0.45‡	Bodily pain	0.29

Recreational leisure and activities	Leisure and recreational activities	0.55‡	Physical functioning	0.48‡
	Self-care	0.48‡	Physical role functioning	0.38
	Emotional adjustment, coping, and adaptation	0.43‡	Bodily pain	0.21
	Mobility	0.47‡

Emotional functioning	Emotional adjustment, coping, and adaptation	0.32	Social functioning	0.29
	Cognition and thinking	0.16	Emotional role functioning	0.27
	Family relationships	0.21	Mental health	0.28

Add to My JBJS

TABLE III CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SF-36 CATEGORIES*

Physicians' Rating†	MFA Category	Rho	SF-36 Category	Rho
Physical function: mobility of lower extremities	Mobility	0.60‡	Physical functioning	0.51‡
			Physical role functioning	0.22

Physical function: mobility of upper extremities	Hand and fine motor skills	0.61‡

Activities of daily living	Self-care	0.54‡	Physical functioning	0.44‡
	Hand and fine motor skills	0.23	Physical role functioning	0.37
	Housework	0.45‡	Bodily pain	0.29

Recreational leisure and activities	Leisure and recreational activities	0.55‡	Physical functioning	0.48‡
	Self-care	0.48‡	Physical role functioning	0.38
	Emotional adjustment, coping, and adaptation	0.43‡	Bodily pain	0.21
	Mobility	0.47‡

Emotional functioning	Emotional adjustment, coping, and adaptation	0.32	Social functioning	0.29
	Cognition and thinking	0.16	Emotional role functioning	0.27
	Family relationships	0.21	Mental health	0.28

View Larger

TABLE IV CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, SF-36 PHYSICAL FUNCTIONING SCORE, AND WOMAC PHYSICAL FUNCTION SCORE*

*MFA = Musculoskeletal Function Assessment, SF-36 = Short Form-36, and WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index.†Collected from responses to supplemental questions included with the MFA.‡P < 0.01 for correlation with the characteristic of the patients.

	MFA Total Score,	MFA Total Score,
	SF-36 Physical	WOMAC Physical
	Functioning Score	Function Score
Characteristic†	(N = 444)	(N = 59)
No. of comorbid conditions	0.47‡, 0.38‡	0.34‡, 0.32‡
Changes in activities	0.52‡, 0.46‡	0.49‡, 0.38‡
Perceived over-all health status	0.43‡, 0.39‡	0.46‡, 0.29

Add to My JBJS

TABLE IV CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, SF-36 PHYSICAL FUNCTIONING SCORE, AND WOMAC PHYSICAL FUNCTION SCORE*

	MFA Total Score,	MFA Total Score,
	SF-36 Physical	WOMAC Physical
	Functioning Score	Function Score
Characteristic†	(N = 444)	(N = 59)
No. of comorbid conditions	0.47‡, 0.38‡	0.34‡, 0.32‡
Changes in activities	0.52‡, 0.46‡	0.49‡, 0.38‡
Perceived over-all health status	0.43‡, 0.39‡	0.46‡, 0.29

View Larger

TABLE V COMPARISON OF THE RESPONSIVENESS OF THE MFA AND SF-36 ACCORDING TO STANDARDIZED RESPONSE MEANS AND RELATIVE EFFICIENCY STATISTICS*

*MFA = Musculoskeletal Function Assessment Questionnaire and SF-36 = Short Form-36.†The selected categories correlate at r > 0.60.‡Mean change in scores from the time of the baseline evaluation to the time of the follow-up divided by the standard deviation of individuals' changes in scores.§(MFA-category t test/SF-36-category t test)².

	Standardized	Relative
Instrument and Category†	Response Mean‡	Efficiency§
SF-36 physical functioning	0.37
MFA total score	0.74	4.06
MFA mobility	0.45	1.55
MFA housework	0.56	2.32
MFA leisure and recreational activities	0.56	2.39
MFA emotional adjustment, coping, and adaptation	0.64	3.11

SF-36 physical role functioning	0.45
MFA total score	0.74	2.72
MFA housework	0.56	1.56

SF-36 bodily pain	0.34
MFA total score	0.74	4.76
MFA emotional adjustment, coping, and adaptation	0.64	3.64

SF-36 social functioning	0.32
MFA total score	0.74	5.16
MFA family relationships	0.26	0.62

Add to My JBJS

TABLE V COMPARISON OF THE RESPONSIVENESS OF THE MFA AND SF-36 ACCORDING TO STANDARDIZED RESPONSE MEANS AND RELATIVE EFFICIENCY STATISTICS*

	Standardized	Relative
Instrument and Category†	Response Mean‡	Efficiency§
SF-36 physical functioning	0.37
MFA total score	0.74	4.06
MFA mobility	0.45	1.55
MFA housework	0.56	2.32
MFA leisure and recreational activities	0.56	2.39
MFA emotional adjustment, coping, and adaptation	0.64	3.11

SF-36 physical role functioning	0.45
MFA total score	0.74	2.72
MFA housework	0.56	1.56

SF-36 bodily pain	0.34
MFA total score	0.74	4.76
MFA emotional adjustment, coping, and adaptation	0.64	3.64

SF-36 social functioning	0.32
MFA total score	0.74	5.16
MFA family relationships	0.26	0.62

View Larger

TABLE VI DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA AND THE SIP WERE COMPARED*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile.†The values are given as the number of patients with the percentage in parentheses, except for age, which is given as the mean and the standard deviation with the range in parentheses.

	MFA and SIP†
Characteristic	(N = 60)
Condition-specific groups
Injury of lower extremity	27 (45)
Injury of upper extremity	27 (45)
Injury of both upper and lower extremities	6 (10)
Repetitive-motion disorder	0
Osteoarthrosis	0
Rheumatoid arthritis	0

Female	27 (45)

Age (yrs.)	38.3 ± 15.44
	(18.7—71.4)

Race
White	51 (85)
Other	9 (15)

Level of education completed
=8th grade	1 (2)
High school	24 (40)
Some college	25 (42)
Bachelor's or more advanced degree	10 (17)

Living alone	7 (12)

Current employment status
Working full-time	18 (30)
Working part-time because of health	3 (5)
Working part-time, not health-related	4 (7)
Employed but on sick leave	9 (15)
Retired	9 (15)
Unemployed	16 (27)
Homemaker	1 (2)
Other or no response	0

Injured at work	14 (23)

Annual income
0—$5000	3 (5)
$5001—$30,000	24 (40)
$30,001—$50,000	16 (27)
=$50,001	13 (22)
Other or no response	4 (7)

Change in income
Decreased	19 (32)
No change	40 (67)
Increased	1 (2)
No response	0

Health insurance
Managed care	5 (8)
Private	34 (57)
Medicare	5 (8)
Medicaid	10 (17)
Government programs (state and federal)	6 (10)
Other insurance	1 (2)
No insurance	6 (10)
Don't know	0

Receiving disability compensation	15 (25)

Involved in litigation	10 (17)

Add to My JBJS

TABLE VI DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA AND THE SIP WERE COMPARED*

	MFA and SIP†
Characteristic	(N = 60)
Condition-specific groups
Injury of lower extremity	27 (45)
Injury of upper extremity	27 (45)
Injury of both upper and lower extremities	6 (10)
Repetitive-motion disorder	0
Osteoarthrosis	0
Rheumatoid arthritis	0

Female	27 (45)

Age (yrs.)	38.3 ± 15.44
	(18.7—71.4)

Race
White	51 (85)
Other	9 (15)

Level of education completed
=8th grade	1 (2)
High school	24 (40)
Some college	25 (42)
Bachelor's or more advanced degree	10 (17)

Living alone	7 (12)

Current employment status
Working full-time	18 (30)
Working part-time because of health	3 (5)
Working part-time, not health-related	4 (7)
Employed but on sick leave	9 (15)
Retired	9 (15)
Unemployed	16 (27)
Homemaker	1 (2)
Other or no response	0

Injured at work	14 (23)

Annual income
0—$5000	3 (5)
$5001—$30,000	24 (40)
$30,001—$50,000	16 (27)
=$50,001	13 (22)
Other or no response	4 (7)

Change in income
Decreased	19 (32)
No change	40 (67)
Increased	1 (2)
No response	0

Health insurance
Managed care	5 (8)
Private	34 (57)
Medicare	5 (8)
Medicaid	10 (17)
Government programs (state and federal)	6 (10)
Other insurance	1 (2)
No insurance	6 (10)
Don't know	0

Receiving disability compensation	15 (25)

Involved in litigation	10 (17)

View Larger

TABLE VII CEILING AND FLOOR SCORES FOR THE MFA AND SIP*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile.†The values are given as the number of patients with the percentage in parentheses.

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA (n = 60)
Total score	2—86	0	0
Self-care	0—83	21 (35)	0
Sleep and rest	0—100	29 (48)	3 (5)
Hand and fine motor skills	0—100	38 (63)	3 (5)
Mobility	0—84	9 (15)	0
Housework	0—100	17 (28)	4 (7)
Employment and work	0—100	29 (48)	23 (38)
Leisure and recreational activities	0—100	16 (27)	12 (20)
Family relationships	0—90	35 (58)	0
Cognition and thinking	0—100	53 (88)	3 (5)
Emotional adjustment, coping, and adaptation	10—76	0	0

SIP (n = 60)
Total score	0—47	6 (10)	0
Sleep and rest	0—100	26 (43)	2 (3)
Emotional behavior	0—82	32 (53)	0
Body care and movement	0—40	19 (32)	0
Home management	0—87	26 (43)	0
Mobility	0—77	36 (60)	0
Social interaction	0—64	29 (48)	0
Walking	0—60	23 (38)	0
Alertness behavior	0—100	45 (75)	1 (2)
Communication	0—34	44 (73)	0
Work	0—70	30 (50)	0
Recreational activities	0—90	15 (25)	0
Eating	0—17	50 (83)	0

Add to My JBJS

TABLE VII CEILING AND FLOOR SCORES FOR THE MFA AND SIP*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile.†The values are given as the number of patients with the percentage in parentheses.

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA (n = 60)
Total score	2—86	0	0
Self-care	0—83	21 (35)	0
Sleep and rest	0—100	29 (48)	3 (5)
Hand and fine motor skills	0—100	38 (63)	3 (5)
Mobility	0—84	9 (15)	0
Housework	0—100	17 (28)	4 (7)
Employment and work	0—100	29 (48)	23 (38)
Leisure and recreational activities	0—100	16 (27)	12 (20)
Family relationships	0—90	35 (58)	0
Cognition and thinking	0—100	53 (88)	3 (5)
Emotional adjustment, coping, and adaptation	10—76	0	0

SIP (n = 60)
Total score	0—47	6 (10)	0
Sleep and rest	0—100	26 (43)	2 (3)
Emotional behavior	0—82	32 (53)	0
Body care and movement	0—40	19 (32)	0
Home management	0—87	26 (43)	0
Mobility	0—77	36 (60)	0
Social interaction	0—64	29 (48)	0
Walking	0—60	23 (38)	0
Alertness behavior	0—100	45 (75)	1 (2)
Communication	0—34	44 (73)	0
Work	0—70	30 (50)	0
Recreational activities	0—90	15 (25)	0
Eating	0—17	50 (83)	0

View Larger

TABLE VIII CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SIP CATEGORIES*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile. The ratings were based on a subset of twenty-seven patients. The categories for both questionnaires were selected for comparison with the physicians' ratings on the basis of a review of the items in each category by the research team.†The physicians' ratings were assigned on an 11-point scale, with 0 points indicating best function and 11 points indicating poorest function.‡P < 0.001 for correlation with the physicians' rating.§P < 0.01 for correlation with the physicians' rating.

Physicians' Rating†	MFA Category	Rho	SIP Category	Rho
Physical function: mobility of lower extremities	Mobility	0.64‡	Body care and movement	0.79‡
			Mobility	0.55§
			Walking	0.80‡

Physical function: mobility of upper extremities	Hand and fine motor skills	0.53§

Activities of daily living	Self-care	0.43	Body care and movement	0.39
	Housework	0.33	Home management	0.30
	Hand and fine motor skills	0.01	Eating	0.22

Recreational and leisure activities	Leisure and recreational activities	0.55§	Recreation	0.66‡
	Self-care	0.71‡	Body care and movement	0.70‡
	Mobility	0.54§	Mobility	0.61‡
	Emotional adjustment, coping, and adaptation	0.64‡

Emotional function	Emotional adjustment, coping, and adaptation	0.24	Emotional behavior	0.33
	Cognition and thinking	0.03	Communication	0.24
	Family relationships	0.37	Social interaction	0.28

Add to My JBJS

TABLE VIII CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SIP CATEGORIES*

Physicians' Rating†	MFA Category	Rho	SIP Category	Rho
Physical function: mobility of lower extremities	Mobility	0.64‡	Body care and movement	0.79‡
			Mobility	0.55§
			Walking	0.80‡

Physical function: mobility of upper extremities	Hand and fine motor skills	0.53§

Activities of daily living	Self-care	0.43	Body care and movement	0.39
	Housework	0.33	Home management	0.30
	Hand and fine motor skills	0.01	Eating	0.22

Recreational and leisure activities	Leisure and recreational activities	0.55§	Recreation	0.66‡
	Self-care	0.71‡	Body care and movement	0.70‡
	Mobility	0.54§	Mobility	0.61‡
	Emotional adjustment, coping, and adaptation	0.64‡

Emotional function	Emotional adjustment, coping, and adaptation	0.24	Emotional behavior	0.33
	Cognition and thinking	0.03	Communication	0.24
	Family relationships	0.37	Social interaction	0.28

View Larger

TABLE IX CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, AND SIP TOTAL SCORE*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile.†Collected from responses to supplemental questions included with the MFA.‡P < 0.001 for correlation with the characteristic of the patients.§Collected from the medical record.

	MFA Total Score	SIP Total Score
Characteristic	(N = 60)	(N = 60)
No. of comorbid conditions†	0.15	0.10
Changes in activities†	0.63‡	0.59‡
No. of operations§	0.50‡	0.41‡

Add to My JBJS

TABLE IX CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, AND SIP TOTAL SCORE*

	MFA Total Score	SIP Total Score
Characteristic	(N = 60)	(N = 60)
No. of comorbid conditions†	0.15	0.10
Changes in activities†	0.63‡	0.59‡
No. of operations§	0.50‡	0.41‡

Part I: Comparison of the MFA with the SF-36 and the WOMAC

Introduction | Part I: Comparison of the MFA with the SF-36 and the WOMAC | Part II: Comparison of the MFA and the SIP | References

Materials and Methods

Health-Status Instruments

The MFA comprises 101 items grouped into ten categories: self-care; sleep and rest; hand and fine motor skills; mobility; housework; employment and work; leisure and recreational activities; family relationships; cognition and thinking; and emotional adjustment, coping, and adaptation^25,47. Earlier versions of the questionnaire used in its developmental phase comprised 100 items. (There was one less item in the employment and work category.) Patients assess their function by answering "yes" or "no" to each item of the questionnaire. A score is calculated for each category and for the entire questionnaire, with each "yes" response assigned 1 point and each "no" response or unanswered question assigned 0 points. Scores range from 0 to 100 points, with high scores indicating poor function. The total score is not considered as one of the 101 items. The questionnaire can be completed in about fifteen minutes. The validity analyses require supplemental questions about sociodemographic characteristics such as race, education, income, marital status, health insurance, work status, comorbid conditions, health habits, and changes in life and health status.

The SF-36, which is the most frequently used health-status measure in the United States, is self-administered and can be completed in about ten minutes. It comprises thirty-six multiple-choice items grouped into eight subscales: physical functioning, role limitations due to physical health problems (physical role functioning), bodily pain, general health, vitality, social functioning, role limitations due to emotional problems (emotional role functioning), and mental health. The term subscales as used in the SF-36 is synonymous with the term categories as used in the MFA, the WOMAC, and the SIP. The questionnaire provides eight subscale scores but not a total score. The subscale scores are standardized and range from 0 to 100 points, with high scores indicating better function. The SF-36 has one item, reported health transition, that is not included in any of the subscales. This item is administered as a supplemental question with the instrument and may be used to measure changes in health status.

The WOMAC, a self-administered test for the evaluation of patients who have osteoarthrosis, comprises twenty-four multiple-choice items grouped into three categories: stiffness, pain, and physical function. This questionnaire is widely used to evaluate the effectiveness of operative and non-operative treatment of osteoarthrosis^3-10, and it can be completed in about ten minutes. The questions that were answered are ranked on a 5-point scale (with 1 point indicating the best function and 5 points, the worst), and the scores then are added together for each category. Use of a summary score is not recommended⁹.

Characteristics of the Patients

Of an eligible pool of 637 patients, 444 completed the MFA at both the baseline and the follow-up evaluation. Eighty patients (13 per cent) did not participate in the study: fifty-seven refused, and twenty-three either returned an incomplete survey or completed the survey after the baseline study period. An additional 113 patients (18 per cent) did not complete the follow-up survey: eighty-three could not be contacted because of an incorrect address or phone number, seven refused to complete the follow-up survey, and twenty-three either returned an incomplete survey or completed the survey after the follow-up administration period.

The 444 patients who were included in the study were at least eighteen years old and had a traumatic fracture or soft-tissue injury of the extremities, a history of a repetitive-motion disorder, osteoarthrosis, or rheumatoid arthritis. Patients were excluded if they had a head injury or a fracture of the spine with a residual neurological deficit; a neuromuscular disease; an amputation secondary to a systemic disease; a history of a stroke or cardiovascular disease with an acute episode in the preceding six months; end-stage renal disease, cancer, or acquired immunodeficiency syndrome; a serious psychiatric or cognitive limitation; or an inability to speak or understand English. All patients were selected from a level-I trauma center (Harborview Medical Center), a private orthopaedic clinic in the Seattle area (Valley Orthopedics Associates), or another such clinic located in eastern Washington (Northwest Orthopedics and Fracture Clinic). Consecutive patients who had a traumatic injury were recruited either during hospitalization or at the time of the first office visit after the injury. Consecutive patients who had a repetitive-motion disorder or osteoarthrosis were recruited at the time of the office visit.

The MFA and the SF-36 were administered by an interviewer (at the Harborview Medical Center) or were mailed to the patients (from the two private orthopaedic clinics) at two points in time. Only patients who completed both the baseline and the follow-up questionnaires were included in the analyses. To assess the test-retest reliability of the MFA and the SF-36, 268 patients (193 who had a traumatic injury and seventy-five from other categories) were mailed an additional MFA and SF-36 one week after the baseline evaluation.

The 327 patients who had a traumatic injury completed the surveys six months apart. Of these patients, fifty-seven (17 per cent) who visited their physician at the same time as the questionnaire was administered also were evaluated by their physician with use of a form designed specifically for this study. The physicians rated function of the lower and upper extremities, ability to carry out activities of daily living as well as recreational and leisure activities, and emotional coping and adjustment. Scores were assigned on the basis of an 11-point scale, with 0 points indicating the best function and 11 points, the poorest function.

The 117 patients who had a non-traumatic disorder (fifty-four who had a history of a repetitive-motion disorder, forty-four who had osteoarthrosis, and nineteen who had rheumatoid arthritis) completed the surveys at the time of the baseline office visit and three months later. At the follow-up visit, the sixty-three patients who had osteoarthrosis or rheumatoid arthritis also were asked to complete the WOMAC. Fifty-nine of these patients accurately completed the WOMAC, the MFA, and the SF-36, and they were included in the analysis of the WOMAC.

Criteria for Analysis

To facilitate comparison of the questionnaires, the category scores for each were standardized to range from 0 to 100 points, with 0 points indicating the best function and 100 points, the poorest function. The scores for the SF-36 were reversed to correspond with the scoring systems used for the MFA and the WOMAC. Many scores were not distributed normally; therefore, non-parametric statistics were used when appropriate.

Reliability was evaluated for both the MFA and the SF-36. Stability of the test-retest data was assessed with use of Spearman correlations and intraclass correlation coefficients^23,27. Because the Spearman correlations and the intraclass correlation coefficients were equivalent, only the latter are reported. We expected correlations between the test-retest data for the MFA and the SF-36 categories to be more than 0.70, the standard for adequate reliability for questionnaire development and group comparisons^31,51.

Validity was examined in terms of content, criteria, and construct^11,54. Questionnaires with good content validity are expected to have fewer categories or fewer categories with ceiling or floor effects^36,43,59,60. The lack of ceiling or floor effects demonstrates the appropriateness and comprehensiveness of a questionnaire. A floor effect occurs when the patient reports the poorest function for all or almost all items and receives the worst possible score (100 points), making it impossible to demonstrate deterioration in function over time for such a patient with use of the questionnaire. A ceiling effect occurs when the patient reports excellent function and receives the best score (0 points), making it impossible to show improvement in function over time.

Criterion validity is present when the scores correlate with an accepted measure of the condition being evaluated^12,52. We selected ratings by physicians as the accepted measure because they have been used effectively in clinical trials as well as for validation of health-status instruments^1,4,24,48,61. Scores for categories of the MFA and the SF-36 that were identified as conceptually similar to categories rated by the physicians were compared with the physicians' ratings. Because the physicians tended to use end points rather than the entire rating scale, we used non-parametric Spearman correlations. According to a standard suggested by Stewart and Ware⁵⁶ for the definition of meaningful correlations that support criterion validity, the categories for the MFA and the SF-36 were expected to correlate with the physicians' ratings at rho > 0.40 and p < 0.001.

Construct validity is present when a questionnaire can be used to accurately differentiate patients who are expected to vary with regard to important characteristics, such as limited function as opposed to few limitations. The construct validity of all three questionnaires was evaluated with use of a receiver operating characteristic curve analysis^{16,17,21,23,28,29,49,50,62,66}. This analysis shows the accuracy of an instrument with regard to correctly differentiating, across the full range of scores, patients who have a condition such as depression or insomnia from those who do not have the condition. The probability that an instrument will correctly identify patients who have a disease is defined as its sensitivity, and the probability that it will correctly identify those who do not have the disease is defined as its specificity. A curve is created by plotting the number of patients correctly identified as having the condition on the y axis and the number of patients incorrectly identified as having the condition on the x axis for each possible score. If a questionnaire allows correct classification of the patients, the line runs parallel to the y axis and then curves to the right. If a questionnaire is uninformative, the curve is drawn at a 45-degree angle. Values in the area under the curve range from 0.5 to 1.00, with 0.5 indicating that a questionnaire is not better than chance for the differentiation of patients and a value of 1.0 indicating that all patients are differentiated accurately. The values in the area under the curve, and the accompanying standard deviations, are useful for testing the differences between questionnaires.

For the receiver operating characteristic curve analysis, we divided the patients into groups on the basis of their responses to the question: "How much has your injury/arthritis changed your life?" Patients who answered "quite a bit" or "completely" on the 5-point scale were classified as having poor function, and those who answered "somewhat," "a little," or "not at all" were classified as having good function. We compared the specificity, sensitivity, and areas under the curve among the questionnaires with use of the baseline total score for the MFA and the physical function category scores for the SF-36 and the WOMAC. We expected the sensitivity and specificity of the questionnaires to be more than 0.70, and we evaluated the areas under the curve with use of a chi-square test to detect any significant differences⁶².

We also evaluated construct validity by correlating the questionnaire scores with the characteristics of the patients (number of comorbid conditions, perceived over-all health status, and changes in activities) identified from answers to supplemental questions included with the MFA. Comorbid conditions were presented in a checklist format, and patients indicated the conditions that applied to them. The perception of over-all health status was evaluated on the basis of the response to the question: "In general, would you say your health is excellent/very good/good/fair/poor?" Changes in activities were measured on the basis of the answer to the question: "Are your daily activities or work the same/different?" We expected patients who had more comorbid conditions, poorer perceived over-all health status, or changes in activities to receive poorer scores. With use of Pearson correlations, we correlated the total score for the MFA and the physical function category scores for the SF-36 and the WOMAC with the selected characteristics of the patients. We expected the correlations to be significant at p < 0.01.

Responsiveness, or the ability of the questionnaire to detect important clinical changes^26,27,37, was evaluated with use of the MFA and SF-36 categories that had similar items, at r > 0.60. Because the content of the two instruments was similar, we expected their responsiveness to change to be the same. For the MFA, we used the total score and the category scores for mobility; housework; leisure and recreational activities; emotional adjustment, coping, and adaptation; and family relationships. For the SF-36, we used the category scores for physical functioning, physical role functioning, bodily pain, and social functioning. We evaluated responsiveness with use of standardized response means (mean change in score/standard deviation of individuals' changes in score)^32,33,38,39 and relative efficiency statistics ([(instrument 1 t test)/(instrument 2 t test)]²)^17,39. We compared the magnitude of the standardized response means with use of the Cohen standard for the description of small effects (more than 0.2), moderate effects (more than 0.5), and large effects (more than 0.8)¹⁹. Because there are no standards for the comparison of health-status measures with use of relative efficiency statistics⁹, we considered a relative efficiency statistic of more than 2.00 as showing a difference in the efficiency of the questionnaire in detecting change.

Results

Characteristics of the Patients

The mean age of the 444 patients was forty-six years (range, eighteen to ninety-one years). Two hundred and twenty-two patients (50 per cent) were women, thirty-two (7 per cent) were non-white, and 151 (34 per cent) had completed twelve years of education or less (Table I). One hundred and seventy-three patients (39 per cent) were not working outside the home. Thirty patients (7 per cent) earned $5000 or less per year, and 124 (28 per cent) earned more than $50,000. One hundred and seventeen patients (26 per cent) had a non-traumatic musculoskeletal disorder. Of the 401 injuries in the remaining 327 patients, seven were arterial injuries, twenty-two were nerve injuries, and thirty-four were open fractures; the remaining 338 injuries were closed fractures. Two hundred and thirty-two injuries (58 per cent) were treated operatively. Of the 327 patients who had a traumatic injury, fifty-one (11 per cent of the series) were involved in litigation and eighty-five (19 per cent of the series) were receiving disability compensation.

The 193 non-respondents were not different from the 444 respondents in terms of gender, number of injuries, type of wound, number of operations, number of complications, or severity of the disorder. However, the non-respondents were older than the respondents (mean age [and standard deviation], 55 ± 19 years compared with 46 ± 17 years) and were more likely to have a repetitive-motion disorder (forty-four [23 per cent]) compared with fifty-four [12 per cent]) or osteoarthrosis (fifty [26 per cent]) compared with forty-four [10 per cent]). The non-respondents had fewer type-C fractures (fourteen [7 per cent]) compared with eighty-four [19 per cent]) and more type-B fractures (eighty-five [44 per cent]) compared with 120 [27 per cent]), according to the AO/Orthopaedic Trauma Association classification⁵².

Reliability

The MFA was slightly more reliable than the SF-36. Intraclass correlation coefficients ranged from 0.75 (for leisure and recreational activities) to 0.92 (for the total score) for the MFA and from 0.66 (for emotional role functioning) to 0.90 (for physical functioning) for the SF-36. The intraclass correlation coefficients were more than 0.80 for 65 per cent of the categories of both the MFA and the SF-36. Only one category in each questionnaire had an intraclass correlation coefficient of more than 0.90. Both questionnaires demonstrated sufficient test-retest reliability to support their use for monitoring and evaluating clinical interventions in groups of patients. With a single exception in each instrument—the total score of the MFA and the physical functioning score of the SF-36—neither questionnaire demonstrated sufficient reliability to support its use for comparisons or monitoring of individual patients⁵⁶.

Content Validity

The ceiling and floor effects were examined for the total score and the category scores of the MFA and the category scores of the SF-36 for all 444 patients (Table II). The total score of the MFA performed better than any of the category scores of the SF-36; no patient received a floor score of 100 points, and only one (0.2 per cent) received a ceiling score of 0 points. The best-performing categories of the SF-36 were mental health (no patient had a score of 100 points and thirteen [2.9 per cent] had a score of 0 points) and vitality (four patients [0.9 per cent] had a score of 100 points and five [1.1 per cent] had a score of 0 points).

There were fewer floor effects and more ceiling effects for the MFA than for the SF-36. The number of patients who received a floor score of 100 points ranged from none (for self-care; mobility; and emotional adjustment, coping, and adaptation) to ninety-eight (22 per cent) (for employment and work) for the MFA and from none (for mental health) to 168 (38 per cent) (for physical role functioning) for the SF-36. The large number of patients who scored at the floor level suggests that the latter category had an important floor effect. None of the categories of the MFA had such a strong floor effect.

The number of patients who received a ceiling score of 0 points ranged from three (0.7 per cent) (for emotional adjustment, coping, and adaptation) to 310 (70 per cent) (for cognition and thinking) for the MFA and from five (1.1 per cent) (for vitality) to 260 (59 per cent) (for emotional role functioning) for the SF-36. Despite the similar ranges of the number of patients who received a ceiling score, at least one-third of the patients had a score of 0 points for five of the ten categories of the MFA compared with only two of the eight categories of the SF-36.

The ceiling effects (indicating best function) and the floor effects (indicating poorest function) were analyzed for the MFA and the WOMAC for fifty-nine patients (Table II). The total score for the MFA, in contrast to the category scores for the WOMAC, had no ceiling or floor effects. The category scores for the WOMAC had fewer ceiling and floor effects than did those for the MFA. The number of patients who had a floor score of 100 ranged from none (for self-care; sleep and rest; family relationships; and emotional adjustment, coping, and adaptation) to eight (14 per cent) (for cognition and thinking) for the MFA and from none (for pain and physical function) to one (2 per cent) (for stiffness) for the WOMAC. The number of patients who had a ceiling score of 0 ranged from none (for emotional adjustment, coping, and adaptation) to thirty-eight (64 per cent) (for employment and work) for the MFA and from one (2 per cent) (for stiffness) to five (9 per cent) (for pain) for the WOMAC.

Criterion Validity

A larger number of category scores of the MFA correlated with the physicians' ratings than did those of the SF-36 (Table III); this difference was significant (p < 0.001). Eight of the twelve comparisons for the MFA and three of the eleven for the SF-36 correlated at rho > 0.40, a standard recommended for the testing of criterion validity⁵⁶. As might be expected, the physicians' ratings of emotional function did not correlate with the patients' assessments of emotional health on either the MFA or the SF-36.

Construct Validity

All of the questionnaires demonstrated good sensitivity and specificity, but the MFA performed the best (a sensitivity of 80 per cent and a specificity of 79 per cent compared with 76 and 69 per cent for the SF-36, and a sensitivity of 86 per cent and a specificity of 85 per cent compared with 77 and 76 per cent for the WOMAC); however, we could not detect a significant difference (p > 0.05, chi-square test) with the numbers available. These findings suggest that the questionnaires can be used to differentiate between patients who have poor function and those who have good function (area under the curve, more than 0.81).

The correlational analyses showed that the scores on all three questionnaires were related to the characteristics of comorbid conditions, changes in activities, and perceived over-all health status (Table IV). This finding was significant (p < 0.01) for all categories except the physical function score of the WOMAC, which did not correlate with perceived over-all health status but did correlate with comorbid conditions and changes in activities.

Responsiveness

The analysis of the standardized response means and the relative efficiency statistics showed the MFA to be more responsive to changes, between the time of the baseline evaluation and the time of the latest follow-up, in self-reported physical functioning than the SF-36 (Table V). On the basis of standardized response means, the total score and three of the categories of the MFA (housework; leisure and recreational activities; and emotional adjustment, coping, and adaptation) were moderately responsive (range, 0.56 to 0.74). The remaining two categories (mobility and family relationships) showed small effects (0.26 and 0.45). The four categories of the SF-36 were not as responsive, as demonstrated by small effects ranging from 0.32 (for social functioning) to 0.45 (for physical role functioning). The analyses of relative efficiency showed that the total and category scores of the MFA were more efficient (relative efficiency of more than 2.00) than the SF-36 for eight of the eleven comparisons. The MFA and the SF-36 were equally efficient for the three remaining comparisons.

Part II: Comparison of the MFA and the SIP

Introduction | Part I: Comparison of the MFA with the SF-36 and the WOMAC | Part II: Comparison of the MFA and the SIP | References

Materials and Methods

Health-Status Instruments

The MFA was described in Part I of this paper.

The SIP^13-15,18,55 is a general health-status questionnaire used to evaluate patients who have a musculoskeletal disorder^{2,20,22,35,40-42,65}. It can be completed in thirty minutes. It comprises 136 questions grouped into twelve categories: walking, body care and movement, mobility, social interaction, alertness behavior, emotional behavior, communication, sleep and rest, eating, home management, recreational activities, and work. As with the MFA, the questions are answered as either "yes" or "no." Each item is weighted, and the scores of all answered questions are combined. There are twelve category scores, two summary scores (physical and psychosocial), and a total score. The scores are standardized and range from 0 to 100 points, with 100 indicating the poorest function.

We evaluated the content, criteria, and construct validity for the MFA and the SIP with use of total and category scores. Non-parametric statistics were used whenever the scores were not normally distributed. The statistical methods used to evaluate the data were the same as for Part I.

Characteristics of the Patients

We recruited sixty-six patients who had sustained a traumatic injury of the upper or lower extremity, or both, and who were seen at a level-I trauma center (Harborview Medical Center) or at one of two private orthopaedic clinics (Valley Orthopedics Associates or Northwest Orthopedics and Fracture Clinic). The criteria for inclusion were the same as for Part I. Sixty (91 per cent) of the sixty-six patients agreed to participate in the study. The MFA and the SIP were administered once by an interviewer three months after the date of the injury. Twenty-seven patients (45 per cent) had visited their physician at the time of the study interview and were evaluated by the physician with use of the physician-rating form.

Results

Characteristics of the Patients

The sixty patients had a mean age of thirty-eight years (range, nineteen to seventy-one years). Twenty-seven patients (45 per cent) were women, nine (15 per cent) were non-white, and twenty-five (42 per cent) had completed twelve years of education or less (Table VI). Twenty-six patients (43 per cent) were not working outside of the home. Three patients (5 per cent) earned $5000 or less per year, and thirteen (22 per cent) earned more than $50,000. Ten patients (17 per cent) were involved in litigation, and fifteen (25 per cent) were receiving disability compensation. Of the eighty-seven injuries, two were nerve injuries, none were arterial injuries, and two were open fractures; the remaining eighty-three injuries were closed fractures. Fifty-one injuries (59 per cent) were treated operatively. The six non-respondents were similar to the respondents in terms of age, type of injury, and number of operations.

Content Validity

The total score of the MFA had no ceiling or floor effects (Table VII). The total score of the SIP also had no floor effects, but it did have ceiling effects (six patients [10 per cent] had a score of 0 points). For the category scores, the MFA had fewer ceiling effects and the SIP had fewer floor effects. Six of the ten categories of the MFA had a ceiling effect (more than one-third of the patients had a score of 0 points) compared with ten of the twelve categories of the SIP. In contrast, the categories of the SIP provided fewer floor effects, with patients receiving a score of 100 points for only two of the twelve categories compared with six of the ten categories of the MFA.

Criterion Validity

The correlations between the MFA and SIP responses and the physicians' ratings were similar, with six of the twelve comparisons revealing a significant association (p < 0.001 and p < 0.01; Table VIII). The physicians' ratings for mobility of the lower extremities, mobility of the upper extremities, and the ability to carry out recreational and leisure activities correlated with conceptually similar categories of both questionnaires. The physicians' ratings for activities of daily living and emotional function did not correlate with selected categories of either questionnaire.

Construct Validity

The receiver operating characteristic curve analysis demonstrated that the sensitivity and specificity of the total scores of the MFA and the SIP were 82 and 79 per cent compared with 77 and 76 per cent. Areas under the curve showed that the two questionnaires discriminated equally well between patients who had good function and those who had poor function; with the numbers available, we did not detect a significant difference between the areas under the curve (0.83 for the MFA compared with 0.82 for the SIP).

Correlations between the total scores of the MFA and the SIP and selected characteristics of the patients showed that both instruments were responsive to changes in activities and the number of operations (Table IX); this finding was significant (p < 0.001). Neither instrument was altered by the number of comorbid conditions.

Discussion

New questionnaires should be evaluated relative to existing ones with use of direct comparisons performed in the same patient population^{30,33,38,39,53,59,60,65}. The findings from these comparisons should help to clarify the strengths and weaknesses of each questionnaire for various types of patients, and they should help clinicians and researchers to make informed choices among health-status measures. The criteria used in direct comparisons include reliability, validity, and responsiveness^12,34,36. We compared the MFA with three health-status measures—the SF-36, the WOMAC, and the SIP—that are used to evaluate patients who have a musculoskeletal disorder^{3,6,7,17,21,24,58}. To be useful, the MFA must perform as well as or better than other questionnaires according to these criteria.

The SF-36 and the SIP are generic questionnaires designed for the assessment of functional outcomes in populations of patients. The WOMAC is a disease-specific health-status questionnaire designed for patients who have osteoarthrosis. The questionnaires have varying response formats: the SF-36 and the WOMAC employ multiple-choice items, and the SIP and the MFA require yes-or-no responses. Each questionnaire includes items from a number of domains, some of which are shared with other instruments and others of which are unique to that instrument. For example, the SIP, SF-36, and MFA all have categories for mobility, emotional adjustment, social adjustment, and work, while the WOMAC and the SF-36 both have categories for mobility and pain. However, only the SIP has categories for eating and alertness, only the WOMAC has a category for stiffness, only the SF-36 has a category for vitality, and only the MFA has categories for coping and fine motor skills. All of these questionnaires have been carefully tested and have been found to have good reliability, validity, and, to a lesser degree, responsiveness^{7,13,14,39,45,46,56}.

Our results show that the MFA is as reliable, valid, and responsive to changes in the functional status of patients who have a musculoskeletal disorder as are the SF-36, the WOMAC, and the SIP. In some categories, the MFA demonstrated better validity and responsiveness than the other questionnaires. The MFA and the SF-36 displayed equal reliability, with intraclass correlation coefficients consistently greater than 0.70 (the standard required for instruments used in group-level applications)⁴⁴. The total score of the MFA demonstrated better content validity than the SF-36, the SIP, or the WOMAC, with the fewest patients scoring at either the ceiling or the floor level. With regard to category scores, the WOMAC displayed the best content validity, with the fewest ceiling or floor effects for patients who had osteoarthrosis.

The criterion validity of the MFA was similar to that of the SIP, and the same number of category scores (six of twelve) correlated with the physicians' ratings (Table VIII). The criterion validity was better for the MFA than for the SF-36; more category scores of the MFA correlated with the physicians' ratings (eight of twelve compared with three of eleven) (Table III). All of the questionnaires displayed good construct validity, allowing differentiation of patients who had poor function from those who had good function. Category scores correlated (p < 0.01) with the patients' perception of their over-all health status, changes in activity, and number of operations. The MFA was more responsive than the SF-36 for measuring changes in function from the time of the baseline evaluation to the follow-up administration of the questionnaires. The total score and the category scores of the MFA were more efficient (relative efficiency of more than 2.00) than those of the SF-36 in eight of eleven comparisons. With use of standardized response means, the total score and three of the five categories of the MFA showed moderate effects, whereas all four of the SF-36 categories showed small effects.

On the basis of the findings in this study, we believe that the MFA is an appropriate questionnaire for evaluating the outcomes of patients who have a broad range of musculoskeletal disorders. It is reliable, it provides a wide range of relevant items, it correlates well with physicians' ratings of the functional status of the patient, it differentiates between groups of patients with and without dysfunction, and it is responsive to changes in function over time. The MFA, like the SF-36, the WOMAC, and the SIP, has been validated for use for groups rather than individuals⁴⁴.

The decision to use the MFA rather than another questionnaire depends on the goals of the investigator, the clinical setting, the population of patients, and the outcomes being measured. Investigators studying patients who have osteoarthrosis may be better served by the WOMAC, which has been validated for use for patients with this disease^3-10. Those seeking to compare the general health status of patients who have musculoskeletal disorders with that of patients who have asthma might select the SF-36 or the SIP because of the broad applicability and generalizability of these instruments to many patients who have a variety of conditions^45,46,56-58. However, the MFA may be the questionnaire of choice for the assessment of patients who have musculoskeletal disorders and are seen in the offices of orthopaedic or primary-care physicians.

References

Introduction | Part I: Comparison of the MFA with the SF-36 and the WOMAC | Part II: Comparison of the MFA and the SIP | References

Anderson, J. J.; Felson, D. T.; Meenan, R. F.; and Williams, H. J.: Which traditional measures should be used in rheumatoid arthritis clinical trials?. Arthrit. and Rheumat.,32: 1093-1099, 1989.321093 1989

Bell, M. J.; Bombardier, C.; and Tugwell, P.: Measurement of functional status, quality of life, and utility in rheumatoid arthritis. Arthrit. and Rheumat.,33: 591-601, 1990.33591 1990

Bellamy, N.: Pain assessment in osteoarthritis: experience with the WOMAC Osteoarthritis Index. Sem. Arthrit. and Rheumat.,18 (4 Supplement 2): 14-17, 1989.18 (4 Supplement 2)14 1989

Bellamy, N.; Buchanan, W. W.; and Grace, E.: Double-blind randomized controlled trial of isoxican vs. piroxicam in elderly patients with osteoarthritis of the hip and knee. British J. Clin. Pharmacol.,22 (Supplement 2): 149S-155S, 1986.22 (Supplement 2)149 1986

Bellamy, N.; Buchanan, W. W.; Goldsmith, C. H.; Campbell, J.; and Duku, E.: Signal measurement strategies: are they feasible and do they offer any advantage in outcome measurement in osteoarthritis?. Arthrit. and Rheumat.,33: 739-745, 1990.33739 1990

Bellamy, N.; Buchanan, W. W.; Goldsmith, C. H.; Campbell, J.; and Stitt, L. W.: Validation study of WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis. J. Orthop. Rheumatol.,1: 95-108, 1988.195 1988

Bellamy, N.; Buchanan, W. W.; Goldsmith, C. H.; Campbell, J.; and Stitt, L. W.: 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. J. Rheumatol.,15: 1833-1840, 1988.151833 1988 [PubMed]

Bellamy, N.; Goldsmith, C. H.; Buchanan, W. W.; Campbell, J.; and Duku, E.: Prior score availability: observations using the WOMAC Osteoarthritis Index. British J. Rheumatol.,30: 150-151, 1991.30150 1991

Bellamy, N.; Kean, W. F.; Buchanan, W. W.; Gerecz-Simon, E.; and Campbell, J.: Double blind randomized controlled trial of sodium meclofenamate (Meclomen) and diclofenac sodium (Voltaren): post validation reapplication of the WOMAC Osteoarthritis Index. J. Rheumatol.,19: 153-159, 1992.19153 1992 [PubMed]

Bellamy, N.; Buchanan, W. W.; Chalmers, A.; Ford, P. M.; Kean, W. F.; Kraag, G. R.; Gerecz-Simon, E.; and Campbell, J.: A multicenter study of tenoxicam and diclofenac in patients with osteoarthritis of the knee. J. Rheumatol.,20: 999-1004, 1993.20999 1993 [PubMed]

Benson, J., and Clark, F.: A guide for instrument development and validation. Am. J. Occup. Ther.,36: 789-800, 1982.36789 1982 [PubMed]

Bergner, M., and Rothman, M. L.: Health status measures: an overview and guide for selection. Ann. Rev. Pub. Health,8: 191-210, 1987.8191 1987

Bergner, M.; Bobbitt, R. A.; Carter, W. B.; and Gilson, B. S.: The Sickness Impact Profile: development and final revision of a health status measure. Med. Care,19: 787-805, 1981.19787 1981 [PubMed]

Bergner, M.; Bobbitt, R. A.; Pollard, W. E.; Martin, D. P.; and Gilson, B. S.: The Sickness Impact Profile: validation of a health status measure. Med. Care,14: 57-67, 1976.1457 1976 [PubMed]

Bergner, M.; Bobbitt, R. A.; Kressel, S.; Pollard, W. E.; Gilson, B. S.; and Morris, J. R.: The Sickness Impact Profile: conceptual formulation and methodology for the development of a health status measure. Internat. J. Health Services,6: 393-415, 1976.6393 1976

Berwick, D. M.; Murphy, J. M.; Goldman, P. A.; Ware, J. E., Jr.; Barsky, A. J.; and Weinstein, M. C.: Performance of a five-item mental health screening test. Med. Care,29: 169-176, 1991.29169 1991 [PubMed]

Bombardier, C., and Raboud, J.: A comparison of health-related quality-of-life measures for rheumatoid arthritis research. The Auranofin Cooperating Group. Controlled Clin. Trials,12 (Supplement 4): 243S-256S, 1991.12 (Supplement 4)243 1991

Carter, W. B.; Bobbitt, R. A.; Bergner, M.; and Gilson, B. S.: The validation of an interval scaling: the Sickness Impact Profile. Health Services Res.,11: 516-528, 1976.11516 1976

Cohen, J.: Statistical Power Analysis for the Behavioral Sciences, pp. 19-74. New York, Academic Press, 1977.

Deyo, R. A.: Measuring functional outcomes in therapeutic trials for chronic disease. Controlled Clin. Trials,5: 223-240, 1984.5223 1984 [PubMed]

Deyo, R. A., and Centor, R. M.: Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance. J. Chronic Dis.,39: 897-906, 1986.39897 1986 [PubMed]

Deyo, R. A., and Inui, T. S.: Toward clinical applications of health status measures: sensitivity of scales to clinically important changes. Health Services Res.,19: 277-289, 1984.19277 1984

Deyo, R. A.; Diehr, P.; and Patrick, D. L.: Reproducibility and responsiveness of health status measures. Statistics and strategies for evaluation. Controlled Clin. Trials,12 (Supplement 4): 142S-158S, 1991.12 (Supplement 4)142 1991

Deyo, R. A.; Inui, T. S.; Leininger, J. D.; and Overman, S. S.: Measuring functional outcomes in chronic disease: a comparison of traditional scales and a self-administered health status questionnaire in patients with rheumatoid arthritis. Med. Care,21: 180-192, 1983.21180 1983 [PubMed]

Engelberg, R.; Martin, D. P.; Agel, J.; Obremsky, W.; Coronado, G.; and Swiontkowski, M. F.: Musculoskeletal Function Assessment instrument: criterion and construct validity. J. Orthop. Res.,14: 182-192, 1996.14182 1996 [PubMed]

Fortin, P. R.; Stucki, G.; and Katz, J. N.: Measuring relevant change: an emerging challenge in rheumatologic clinical trials. Arthrit. and Rheumat.,38: 1027-1030, 1995.381027 1995

Guyatt, G.; Walter, S.; and Norman, G.: Measuring change over time: assessing the usefulness of evaluative instruments. J. Chronic Dis.,40: 171-178, 1987.40171 1987 [PubMed]

Hanley, J. A., and McNeil, B. J.: The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology,143: 29-36, 1982.14329 1982 [PubMed]

Hanley, J. A., and McNeil, B. J.: A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology,148: 839-843, 1983.148839 1983 [PubMed]

Hawker, G.; Melfi, C.; Paul, J.; Green, R.; and Bombardier, C.: Comparison of a generic (SF-36) and a disease specific (WOMAC) (Western Ontario and McMaster Universities Osteoarthritis Index) instrument in the measurement of outcomes after knee replacement surgery. J. Rheumatol.,22: 1193-1196, 1995.221193 1995 [PubMed]

Helmstadter, G. C.: Principles of Psychological Measurement, pp. 58-86. New York, Appleton-Century-Crofts, 1964.

Katz, J. N.; Gelberman, R. H.; Wright, E. A.; Lew, R. A.; and Liang, M. H.: Responsiveness of self-reported and objective measures of disease severity in carpal tunnel syndrome. Med. Care,32: 1127-1133, 1994.321127 1994 [PubMed]

Katz, J. N.; Larson, M. G.; Phillips, C. B.; Fossel, A. H.; and Liang, M. H.: Comparative measurement sensitivity of short and longer health status instruments. Med. Care,30: 917-925, 1992.30917 1992 [PubMed]

Kirshner, B., and Guyatt, G.: A methodological framework for assessing health indices. J. Chronic Dis.,38: 27-36, 1985.3827 1985 [PubMed]

Laupacis, A.; Bourne, R.; Rorabeck, C.; Feeny, D.; Wong, C.; Tugwell, P.; Leslie, K.; and Bullas, R.: The effect of elective total hip replacement on health-related quality of life. J. Bone and Joint Surg.,75-A: 1619-1626, Nov. 1993.75-A1619 1993

Liang, M. H.: Evaluation of function and health status in rheumatic diseases in clinical research and office practice. Postgrad. Adv. Rheumatol.,III-VIII: 1-10, 1988.III-VIII1 1988

Liang, M. H.: Evaluating measurement responsiveness. J. Rheumatol,22: 1191-1192, 1995.221191 1995 [PubMed]

Liang, M. H.; Fossel, A. H.; and Larson, M. G.: Comparisons of five health status instruments for orthopedic evaluation. Med. Care,28: 632-642, 1990.28632 1990 [PubMed]

Liang, M. H.; Larson, M. G.; Cullen, K. E.; and Schwartz, J. A.: Comparative measurement efficiency and sensitivity of five health status instruments for arthritis research. Arthrit. and Rheumat.,28: 542-547, 1985.28542 1985

MacKenzie, C. R.; Charlson, M. E.; DiGioia, D.; and Kelley, K.: Can the Sickness Impact Profile measure change? An example of scale assessment. J. Chronic Dis.,39: 429-438, 1986.39429 1986 [PubMed]

MacKenzie, E. J.; Burgess, A. R.; McAndrew, M. P.; Swiontkowski, M. F.; Cushing, B. M.; deLateur, B. J.; Jurkovich, G. J.; and Morris, J. A., Jr.: Patient-oriented functional outcome after unilateral lower extremity fracture. J. Orthop. Trauma,7: 393-401, 1993.7393 1993 [PubMed]

MacKenzie, E. J.; Cushing, B. M.; Jurkovich, G. J.; Morris, J. A., Jr.; Burgess, A. R.; deLateur, B. J.; McAndrew, M. P.; and Swiontkowski, M. F.: Physical impairment and functional outcomes six months after severe lower extremity fractures. J. Trauma,34: 528-539, 1993.34528 1993 [PubMed]

McHorney, C. A.: Methodological and psychometric issues in health status assessment across populations and applications. In Advances in Medical Sociology. Vol. 5, pp. 281-304. Greenwich, Connecticut, JAI Press, 1994.

McHorney, C. A., and Tarlov, A. R.: Individual-patient monitoring in clinical practice: are available health status surveys adequate?. Qual. Life Res.,4: 293-307, 1995.4293 1995 [PubMed]

McHorney, C. A.; Ware, J. E., Jr.; and Raczek, A. E.: The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med. Care,31: 247-263, 1993.31247 1993 [PubMed]

McHorney, C. A.; Ware, J. E., Jr.; Lu, J. F.; and Sherbourne, C. D.: The MOS 36-Item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med. Care,32: 40-66, 1994.3240 1994 [PubMed]

Martin, D. P.; Engelberg, R.; Agel, J.; Snapp, D.; and Swiontkowski, M. F.: Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument. J. Orthop. Res.,14: 173-181, 1996.14173 1996 [PubMed]

Meenan, R. F.; Anderson, J. J.; Kazis, L. E.; Egger, M. J.; Altz-Smith, M.; Samuelson, C. O., Jr.; Willkens, R. F.; Solsky, M. A.; Hayes, S. P.; Blocka, K. L.; Weinstein, A.; Guttadauria, M.; Kaplan, S. B.; and Klippel, J.: Outcome assessment in clinical trials. Evidence for the sensitivity of a health status measure. Arthrit. and Rheumat.,27: 1344-1352, 1984.271344 1984

Metz, C. E.: Basic principles of ROC analysis. Sem. Nucl. Med.,8: 283-298, 1978.8283 1978

Murphy, J. M.; Berwick, D. M.; Weinstein, M. C.; Borus, J. F.; Budman, S. H.; and Klerman, G. L.: Performance of screening and diagnostic tests. Application of receiver operating characteristic analysis. Arch. Gen. Psychiat.,44: 550-555, 1987.44550 1987 [PubMed]

Nunnally, J. C.: Psychometric Theory. Ed. 2, pp. 225-255. New York, McGraw-Hill, 1978.

Orthopaedic Trauma Association, Committee for Coding and Classification: Fracture and dislocation compendium. J. Orthop. Trauma,10, Supplement 1: 1996.10, Supplement 1 1996

Patrick, D. L., and Deyo, R. A.: Generic and disease-specific measures in assessing health status and quality of life. Med. Care,27 (Supplement 3): 217-S232, 1989.27 (Supplement 3)217 1989

Perrin, E. B.; Aaronson, N. K.; Alonso, J.; Burnam, A.; Lohr, K. H.; Patrick, D. L.; and Roberts, J.: Instrument review criteria. Med. Outcomes Trust Bull.,3: , 1995.3 1995

Pollard, W. E.; Bobbitt, R. A.; Bergner, M.; Martin, D. P.; and Gilson, B. S.: The Sickness Impact Profile: reliability of a health status measure. Med. Care,14: 146-155, 1976.14146 1976 [PubMed]

Stewart, A. L., and Ware, J. E., Jr.: Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, North Carolina, Duke University Press, 1992.

Stewart, A. L.; Hays, R. D.; and Ware, J. E., Jr.: The MOS Short-Form General Health Survey. Reliability and validity in a patient population. Med. Care,26: 724-735, 1988.26724 1988 [PubMed]

Stewart, A. L.; Greenfield, S.; Hays, R. D.; Wells, K.; Rogers, W. H.; Berry, S. D.; McGlynn, E. A.; and Ware, J. E., Jr.: Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. J. Am. Med. Assn.,262: 907-913, 1989.262907 1989

Stucki, G.; Liang, M. H.; Fossel, A. H.; and Katz, J. N.: Relative responsiveness of condition-specific and generic health status measures in degenerative lumbar spinal stenosis. J. Clin. Epidemiol.,48: 1369-1378, 1995.481369 1995 [PubMed]

Stucki, G.; Liang, M. H.; Phillips, C.; and Katz, J. N.: The Short Form-36 is preferable to the SIP as a generic health status measure in patients undergoing elective total hip arthroplasty. Arthrit. Care and Res.,8: 174-181, 1995.8174 1995

Tugwell, P.; Bombardier, C.; Buchanan, W. W.; Goldsmith, C.; Grace, E.; Bennett, K. J.; Williams, H. J.; Egger, M.; Alarcon, G. S.; Guttadauria, M.; Yarboro, C.; Polisson, R. P.; Szydlo, L.; Luggen, M. E.; Billingsley, L. M.; Ward, J. R.; and Marks, C.: Methotrexate in rheumatoid arthritis. Impact on quality of life assessed by traditional standard-item and individualized patient preference health status questionnaires. Arch. Intern. Med.,150: 59-62, 1990.15059 1990 [PubMed]

Vida, S.: A computer program for non-parametric receiver operating characteristic analysis. Computer Meth. and Prog. Biomed.,40: 95-101, 1993.4095 1993

Ware, J. E., Jr., and Sherbourne, C. D.: The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med. Care,30: 473-483, 1992.30473 1992 [PubMed]

Ware, J. E., Jr.; Snow, K. K.; Kosinski, M.; and Gandek, B.: SF-36 Health Survey: Manual and Interpretation Guide. Boston, The Health Institute, New England Medical Center, 1993.

Weinberger, M.; Samsa, G. P.; Tierney, W. M.; Belyea, M. J.; and Hiner, S. L.: Generic versus disease specific health status measures: comparing the Sickness Impact Profile and the Arthritis Impact Measurement Scales. J. Rheumatol.,19: 543-546, 1992.19543 1992 [PubMed]

Weinstein, M. C.; Berwick, D. M.; Goldman, P. A.; Murphy, J. M.; and Barsky, A. J.: A comparison of three psychiatric screening tests using receiver operating characteristic (ROC) analysis. Med. Care,27: 593-607, 1989.27593 1989 [PubMed]

World Health Organization: World Health Organization Constitution. In Basic Documents. Geneva, World Health Organization, 1948.

Topics

View Larger

TABLE I DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA, SF-36, AND WOMAC WERE COMPARED*

	MFA and	MFA and
	SF-36†	WOMAC†‡
Characteristic	(N = 444)	(N = 59)
Condition-specific groups
Injury of lower extremities	188 (42)	0
Injury of upper extremities	121 (27)	0
Injury of both upper and lower extremities	18 (4)	0
Repetitive-motion disorder	54 (12)	0
Osteoarthrosis	44 (10)	40 (68)
Rheumatoid arthritis	19 (4)	19 (32)

Female	223 (50)	38 (64)

Age (yrs.)	45.8 ± 16.52	60.4 ± 13.79
	(18.1—90.7)	(23.5—85.9)

Race
White	412 (93)	59 (100)
Other	32 (7)	0

Level of education completed
=8th grade	11 (2.5)	4 (7)
High school	140 (32)	22 (37)
Some college	192 (43)	28 (47)
Bachelor's or more advanced degree	101 (23)	5 (8)

Living alone	76 (17)	13 (22)

Current employment status
Working full-time	198 (45)	21 (36)
Working part-time because of health	17 (4)	0
Working part-time, not health-related	29 (7)	0
Employed but on sick leave	27 (6)	1 (2)
Retired	71 (16)	24 (41)
Unemployed	63 (14)	6 (10)
Homemaker	37 (8)	6 (10)
Other or no response	2 (0.5)	1 (2)

Injured at work§	58 (18)	NA

Annual income
0—$5000	30 (7)	1 (2)
$5001—$30,000	148 (33)	23 (39)
$30,001—$50,000	114 (26)	15 (25)
=$50,001	124 (28)	15 (25)
Other or no response	28 (6)	5 (9)

Change in income
Decreased	119 (27)	9 (15)
No change	309 (70)	50 (85)
Increased	10 (2.3)	0
No response	6 (1.4)	0

Health insurance
Managed care	44 (10)	8 (14)
Private	303 (68)	48 (81)
Medicare	65 (15)	23 (39)
Medicaid	32 (7)	4 (7)
Government programs (state and federal)	38 (9)	2 (3)
Other insurance	9 (2.0)	0
No insurance	43 (10)	0
Don't know	1 (0.2)	0

Receiving disability compensation	85 (19)	8 (14)

Involved in litigation	51 (11)	1 (2)

Add to My JBJS

TABLE I DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA, SF-36, AND WOMAC WERE COMPARED*

	MFA and	MFA and
	SF-36†	WOMAC†‡
Characteristic	(N = 444)	(N = 59)
Condition-specific groups
Injury of lower extremities	188 (42)	0
Injury of upper extremities	121 (27)	0
Injury of both upper and lower extremities	18 (4)	0
Repetitive-motion disorder	54 (12)	0
Osteoarthrosis	44 (10)	40 (68)
Rheumatoid arthritis	19 (4)	19 (32)

Female	223 (50)	38 (64)

Age (yrs.)	45.8 ± 16.52	60.4 ± 13.79
	(18.1—90.7)	(23.5—85.9)

Race
White	412 (93)	59 (100)
Other	32 (7)	0

Level of education completed
=8th grade	11 (2.5)	4 (7)
High school	140 (32)	22 (37)
Some college	192 (43)	28 (47)
Bachelor's or more advanced degree	101 (23)	5 (8)

Living alone	76 (17)	13 (22)

Current employment status
Working full-time	198 (45)	21 (36)
Working part-time because of health	17 (4)	0
Working part-time, not health-related	29 (7)	0
Employed but on sick leave	27 (6)	1 (2)
Retired	71 (16)	24 (41)
Unemployed	63 (14)	6 (10)
Homemaker	37 (8)	6 (10)
Other or no response	2 (0.5)	1 (2)

Injured at work§	58 (18)	NA

Annual income
0—$5000	30 (7)	1 (2)
$5001—$30,000	148 (33)	23 (39)
$30,001—$50,000	114 (26)	15 (25)
=$50,001	124 (28)	15 (25)
Other or no response	28 (6)	5 (9)

Change in income
Decreased	119 (27)	9 (15)
No change	309 (70)	50 (85)
Increased	10 (2.3)	0
No response	6 (1.4)	0

Health insurance
Managed care	44 (10)	8 (14)
Private	303 (68)	48 (81)
Medicare	65 (15)	23 (39)
Medicaid	32 (7)	4 (7)
Government programs (state and federal)	38 (9)	2 (3)
Other insurance	9 (2.0)	0
No insurance	43 (10)	0
Don't know	1 (0.2)	0

Receiving disability compensation	85 (19)	8 (14)

Involved in litigation	51 (11)	1 (2)

View Larger

TABLE II CEILING AND FLOOR SCORES FOR THE MFA, SF-36, AND WOMAC*

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA and SF-36 (n = 444)
MFA
Total score	0—78	1 (0.2)	0
Self-care	0—83	140 (32)	0
Sleep and rest	0—100	148 (33)	11 (2.5)
Hand and fine motor skills	0—100	253 (57)	21 (5)
Mobility	0—95	36 (8)	0
Housework	0—100	98 (22)	9 (2.0)
Employment and work	0—100	223 (50)	98 (22)
Leisure and recreational activities	0—100	88 (20)	69 (16)
Family relationships	0—100	215 (48)	1 (0.2)
Cognition and thinking	0—100	310 (70)	33 (7)
Emotional adjustment, coping, and adaptation	0—95	3 (0.7)	0

SF-36‡
Physical functioning	0—100	53 (12)	5 (1.1)
Physical role functioning	0—100	135 (30)	168 (38)
Bodily pain	0—100	39 (9)	7 (1.6)
General health	0—100	42 (10)	1 (0.2)
Vitality	0—100	5 (1.1)	4 (0.9)
Social functioning	0—100	165 (37)	7 (1.6)
Emotional role functioning	0—100	260 (59)	74 (17)
Mental health	0—92	13 (2.9)	0

MFA and WOMAC (n = 59)
MFA
Total score	3—75	0	0
Self-care	0—83	13 (22)	0
Sleep and rest	0—83	15 (25)	0
Hand and fine-motor skills	0—100	19 (32)	6 (10)
Mobility	0—100	1 (2)	1 (2)
Housework	0—100	3 (5)	4 (7)
Employment and work	0—100	38 (64)	7 (12)
Leisure and recreational activities	0—100	9 (15)	4 (7)
Family relationships	0—90	18 (31)	0
Cognition and thinking	0—100	32 (54)	8 (14)
Emotional adjustment, coping, and adaptation	10—86	0	0

WOMAC
Pain	0—70	5 (8)	0
Stiffness	0—100	1 (2)	1 (2)
Physical function	0—84	2 (3)	0

Add to My JBJS

TABLE II CEILING AND FLOOR SCORES FOR THE MFA, SF-36, AND WOMAC*

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA and SF-36 (n = 444)
MFA
Total score	0—78	1 (0.2)	0
Self-care	0—83	140 (32)	0
Sleep and rest	0—100	148 (33)	11 (2.5)
Hand and fine motor skills	0—100	253 (57)	21 (5)
Mobility	0—95	36 (8)	0
Housework	0—100	98 (22)	9 (2.0)
Employment and work	0—100	223 (50)	98 (22)
Leisure and recreational activities	0—100	88 (20)	69 (16)
Family relationships	0—100	215 (48)	1 (0.2)
Cognition and thinking	0—100	310 (70)	33 (7)
Emotional adjustment, coping, and adaptation	0—95	3 (0.7)	0

SF-36‡
Physical functioning	0—100	53 (12)	5 (1.1)
Physical role functioning	0—100	135 (30)	168 (38)
Bodily pain	0—100	39 (9)	7 (1.6)
General health	0—100	42 (10)	1 (0.2)
Vitality	0—100	5 (1.1)	4 (0.9)
Social functioning	0—100	165 (37)	7 (1.6)
Emotional role functioning	0—100	260 (59)	74 (17)
Mental health	0—92	13 (2.9)	0

MFA and WOMAC (n = 59)
MFA
Total score	3—75	0	0
Self-care	0—83	13 (22)	0
Sleep and rest	0—83	15 (25)	0
Hand and fine-motor skills	0—100	19 (32)	6 (10)
Mobility	0—100	1 (2)	1 (2)
Housework	0—100	3 (5)	4 (7)
Employment and work	0—100	38 (64)	7 (12)
Leisure and recreational activities	0—100	9 (15)	4 (7)
Family relationships	0—90	18 (31)	0
Cognition and thinking	0—100	32 (54)	8 (14)
Emotional adjustment, coping, and adaptation	10—86	0	0

WOMAC
Pain	0—70	5 (8)	0
Stiffness	0—100	1 (2)	1 (2)
Physical function	0—84	2 (3)	0

View Larger

TABLE III CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SF-36 CATEGORIES*

Physicians' Rating†	MFA Category	Rho	SF-36 Category	Rho
Physical function: mobility of lower extremities	Mobility	0.60‡	Physical functioning	0.51‡
			Physical role functioning	0.22

Physical function: mobility of upper extremities	Hand and fine motor skills	0.61‡

Activities of daily living	Self-care	0.54‡	Physical functioning	0.44‡
	Hand and fine motor skills	0.23	Physical role functioning	0.37
	Housework	0.45‡	Bodily pain	0.29

Recreational leisure and activities	Leisure and recreational activities	0.55‡	Physical functioning	0.48‡
	Self-care	0.48‡	Physical role functioning	0.38
	Emotional adjustment, coping, and adaptation	0.43‡	Bodily pain	0.21
	Mobility	0.47‡

Emotional functioning	Emotional adjustment, coping, and adaptation	0.32	Social functioning	0.29
	Cognition and thinking	0.16	Emotional role functioning	0.27
	Family relationships	0.21	Mental health	0.28

Add to My JBJS

TABLE III CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SF-36 CATEGORIES*

Physicians' Rating†	MFA Category	Rho	SF-36 Category	Rho
Physical function: mobility of lower extremities	Mobility	0.60‡	Physical functioning	0.51‡
			Physical role functioning	0.22

Physical function: mobility of upper extremities	Hand and fine motor skills	0.61‡

Activities of daily living	Self-care	0.54‡	Physical functioning	0.44‡
	Hand and fine motor skills	0.23	Physical role functioning	0.37
	Housework	0.45‡	Bodily pain	0.29

Recreational leisure and activities	Leisure and recreational activities	0.55‡	Physical functioning	0.48‡
	Self-care	0.48‡	Physical role functioning	0.38
	Emotional adjustment, coping, and adaptation	0.43‡	Bodily pain	0.21
	Mobility	0.47‡

Emotional functioning	Emotional adjustment, coping, and adaptation	0.32	Social functioning	0.29
	Cognition and thinking	0.16	Emotional role functioning	0.27
	Family relationships	0.21	Mental health	0.28

View Larger

TABLE IV CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, SF-36 PHYSICAL FUNCTIONING SCORE, AND WOMAC PHYSICAL FUNCTION SCORE*

	MFA Total Score,	MFA Total Score,
	SF-36 Physical	WOMAC Physical
	Functioning Score	Function Score
Characteristic†	(N = 444)	(N = 59)
No. of comorbid conditions	0.47‡, 0.38‡	0.34‡, 0.32‡
Changes in activities	0.52‡, 0.46‡	0.49‡, 0.38‡
Perceived over-all health status	0.43‡, 0.39‡	0.46‡, 0.29

Add to My JBJS

TABLE IV CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, SF-36 PHYSICAL FUNCTIONING SCORE, AND WOMAC PHYSICAL FUNCTION SCORE*

	MFA Total Score,	MFA Total Score,
	SF-36 Physical	WOMAC Physical
	Functioning Score	Function Score
Characteristic†	(N = 444)	(N = 59)
No. of comorbid conditions	0.47‡, 0.38‡	0.34‡, 0.32‡
Changes in activities	0.52‡, 0.46‡	0.49‡, 0.38‡
Perceived over-all health status	0.43‡, 0.39‡	0.46‡, 0.29

View Larger

TABLE V COMPARISON OF THE RESPONSIVENESS OF THE MFA AND SF-36 ACCORDING TO STANDARDIZED RESPONSE MEANS AND RELATIVE EFFICIENCY STATISTICS*

	Standardized	Relative
Instrument and Category†	Response Mean‡	Efficiency§
SF-36 physical functioning	0.37
MFA total score	0.74	4.06
MFA mobility	0.45	1.55
MFA housework	0.56	2.32
MFA leisure and recreational activities	0.56	2.39
MFA emotional adjustment, coping, and adaptation	0.64	3.11

SF-36 physical role functioning	0.45
MFA total score	0.74	2.72
MFA housework	0.56	1.56

SF-36 bodily pain	0.34
MFA total score	0.74	4.76
MFA emotional adjustment, coping, and adaptation	0.64	3.64

SF-36 social functioning	0.32
MFA total score	0.74	5.16
MFA family relationships	0.26	0.62

Add to My JBJS

TABLE V COMPARISON OF THE RESPONSIVENESS OF THE MFA AND SF-36 ACCORDING TO STANDARDIZED RESPONSE MEANS AND RELATIVE EFFICIENCY STATISTICS*

	Standardized	Relative
Instrument and Category†	Response Mean‡	Efficiency§
SF-36 physical functioning	0.37
MFA total score	0.74	4.06
MFA mobility	0.45	1.55
MFA housework	0.56	2.32
MFA leisure and recreational activities	0.56	2.39
MFA emotional adjustment, coping, and adaptation	0.64	3.11

SF-36 physical role functioning	0.45
MFA total score	0.74	2.72
MFA housework	0.56	1.56

SF-36 bodily pain	0.34
MFA total score	0.74	4.76
MFA emotional adjustment, coping, and adaptation	0.64	3.64

SF-36 social functioning	0.32
MFA total score	0.74	5.16
MFA family relationships	0.26	0.62

View Larger

TABLE VI DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA AND THE SIP WERE COMPARED*

	MFA and SIP†
Characteristic	(N = 60)
Condition-specific groups
Injury of lower extremity	27 (45)
Injury of upper extremity	27 (45)
Injury of both upper and lower extremities	6 (10)
Repetitive-motion disorder	0
Osteoarthrosis	0
Rheumatoid arthritis	0

Female	27 (45)

Age (yrs.)	38.3 ± 15.44
	(18.7—71.4)

Race
White	51 (85)
Other	9 (15)

Level of education completed
=8th grade	1 (2)
High school	24 (40)
Some college	25 (42)
Bachelor's or more advanced degree	10 (17)

Living alone	7 (12)

Current employment status
Working full-time	18 (30)
Working part-time because of health	3 (5)
Working part-time, not health-related	4 (7)
Employed but on sick leave	9 (15)
Retired	9 (15)
Unemployed	16 (27)
Homemaker	1 (2)
Other or no response	0

Injured at work	14 (23)

Annual income
0—$5000	3 (5)
$5001—$30,000	24 (40)
$30,001—$50,000	16 (27)
=$50,001	13 (22)
Other or no response	4 (7)

Change in income
Decreased	19 (32)
No change	40 (67)
Increased	1 (2)
No response	0

Health insurance
Managed care	5 (8)
Private	34 (57)
Medicare	5 (8)
Medicaid	10 (17)
Government programs (state and federal)	6 (10)
Other insurance	1 (2)
No insurance	6 (10)
Don't know	0

Receiving disability compensation	15 (25)

Involved in litigation	10 (17)

Add to My JBJS

TABLE VI DEMOGRAPHIC CHARACTERISTICS OF THE PATIENTS FOR WHOM RESPONSES TO THE MFA AND THE SIP WERE COMPARED*

	MFA and SIP†
Characteristic	(N = 60)
Condition-specific groups
Injury of lower extremity	27 (45)
Injury of upper extremity	27 (45)
Injury of both upper and lower extremities	6 (10)
Repetitive-motion disorder	0
Osteoarthrosis	0
Rheumatoid arthritis	0

Female	27 (45)

Age (yrs.)	38.3 ± 15.44
	(18.7—71.4)

Race
White	51 (85)
Other	9 (15)

Level of education completed
=8th grade	1 (2)
High school	24 (40)
Some college	25 (42)
Bachelor's or more advanced degree	10 (17)

Living alone	7 (12)

Current employment status
Working full-time	18 (30)
Working part-time because of health	3 (5)
Working part-time, not health-related	4 (7)
Employed but on sick leave	9 (15)
Retired	9 (15)
Unemployed	16 (27)
Homemaker	1 (2)
Other or no response	0

Injured at work	14 (23)

Annual income
0—$5000	3 (5)
$5001—$30,000	24 (40)
$30,001—$50,000	16 (27)
=$50,001	13 (22)
Other or no response	4 (7)

Change in income
Decreased	19 (32)
No change	40 (67)
Increased	1 (2)
No response	0

Health insurance
Managed care	5 (8)
Private	34 (57)
Medicare	5 (8)
Medicaid	10 (17)
Government programs (state and federal)	6 (10)
Other insurance	1 (2)
No insurance	6 (10)
Don't know	0

Receiving disability compensation	15 (25)

Involved in litigation	10 (17)

View Larger

TABLE VII CEILING AND FLOOR SCORES FOR THE MFA AND SIP*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile.†The values are given as the number of patients with the percentage in parentheses.

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA (n = 60)
Total score	2—86	0	0
Self-care	0—83	21 (35)	0
Sleep and rest	0—100	29 (48)	3 (5)
Hand and fine motor skills	0—100	38 (63)	3 (5)
Mobility	0—84	9 (15)	0
Housework	0—100	17 (28)	4 (7)
Employment and work	0—100	29 (48)	23 (38)
Leisure and recreational activities	0—100	16 (27)	12 (20)
Family relationships	0—90	35 (58)	0
Cognition and thinking	0—100	53 (88)	3 (5)
Emotional adjustment, coping, and adaptation	10—76	0	0

SIP (n = 60)
Total score	0—47	6 (10)	0
Sleep and rest	0—100	26 (43)	2 (3)
Emotional behavior	0—82	32 (53)	0
Body care and movement	0—40	19 (32)	0
Home management	0—87	26 (43)	0
Mobility	0—77	36 (60)	0
Social interaction	0—64	29 (48)	0
Walking	0—60	23 (38)	0
Alertness behavior	0—100	45 (75)	1 (2)
Communication	0—34	44 (73)	0
Work	0—70	30 (50)	0
Recreational activities	0—90	15 (25)	0
Eating	0—17	50 (83)	0

Add to My JBJS

TABLE VII CEILING AND FLOOR SCORES FOR THE MFA AND SIP*

*MFA = Musculoskeletal Function Assessment and SIP = Sickness Impact Profile.†The values are given as the number of patients with the percentage in parentheses.

		Ceiling Score	Floor Score
Instrument and Category	Range of Scores	(Best Function)†	(Worst Function)†
	(Points)
MFA (n = 60)
Total score	2—86	0	0
Self-care	0—83	21 (35)	0
Sleep and rest	0—100	29 (48)	3 (5)
Hand and fine motor skills	0—100	38 (63)	3 (5)
Mobility	0—84	9 (15)	0
Housework	0—100	17 (28)	4 (7)
Employment and work	0—100	29 (48)	23 (38)
Leisure and recreational activities	0—100	16 (27)	12 (20)
Family relationships	0—90	35 (58)	0
Cognition and thinking	0—100	53 (88)	3 (5)
Emotional adjustment, coping, and adaptation	10—76	0	0

SIP (n = 60)
Total score	0—47	6 (10)	0
Sleep and rest	0—100	26 (43)	2 (3)
Emotional behavior	0—82	32 (53)	0
Body care and movement	0—40	19 (32)	0
Home management	0—87	26 (43)	0
Mobility	0—77	36 (60)	0
Social interaction	0—64	29 (48)	0
Walking	0—60	23 (38)	0
Alertness behavior	0—100	45 (75)	1 (2)
Communication	0—34	44 (73)	0
Work	0—70	30 (50)	0
Recreational activities	0—90	15 (25)	0
Eating	0—17	50 (83)	0

View Larger

TABLE VIII CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SIP CATEGORIES*

Physicians' Rating†	MFA Category	Rho	SIP Category	Rho
Physical function: mobility of lower extremities	Mobility	0.64‡	Body care and movement	0.79‡
			Mobility	0.55§
			Walking	0.80‡

Physical function: mobility of upper extremities	Hand and fine motor skills	0.53§

Activities of daily living	Self-care	0.43	Body care and movement	0.39
	Housework	0.33	Home management	0.30
	Hand and fine motor skills	0.01	Eating	0.22

Recreational and leisure activities	Leisure and recreational activities	0.55§	Recreation	0.66‡
	Self-care	0.71‡	Body care and movement	0.70‡
	Mobility	0.54§	Mobility	0.61‡
	Emotional adjustment, coping, and adaptation	0.64‡

Emotional function	Emotional adjustment, coping, and adaptation	0.24	Emotional behavior	0.33
	Cognition and thinking	0.03	Communication	0.24
	Family relationships	0.37	Social interaction	0.28

Add to My JBJS

TABLE VIII CORRELATIONS BETWEEN PHYSICIANS' RATINGS, MFA CATEGORIES, AND SIP CATEGORIES*

Physicians' Rating†	MFA Category	Rho	SIP Category	Rho
Physical function: mobility of lower extremities	Mobility	0.64‡	Body care and movement	0.79‡
			Mobility	0.55§
			Walking	0.80‡

Physical function: mobility of upper extremities	Hand and fine motor skills	0.53§

Activities of daily living	Self-care	0.43	Body care and movement	0.39
	Housework	0.33	Home management	0.30
	Hand and fine motor skills	0.01	Eating	0.22

Recreational and leisure activities	Leisure and recreational activities	0.55§	Recreation	0.66‡
	Self-care	0.71‡	Body care and movement	0.70‡
	Mobility	0.54§	Mobility	0.61‡
	Emotional adjustment, coping, and adaptation	0.64‡

Emotional function	Emotional adjustment, coping, and adaptation	0.24	Emotional behavior	0.33
	Cognition and thinking	0.03	Communication	0.24
	Family relationships	0.37	Social interaction	0.28

View Larger

TABLE IX CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, AND SIP TOTAL SCORE*

	MFA Total Score	SIP Total Score
Characteristic	(N = 60)	(N = 60)
No. of comorbid conditions†	0.15	0.10
Changes in activities†	0.63‡	0.59‡
No. of operations§	0.50‡	0.41‡

Add to My JBJS

TABLE IX CORRELATIONS BETWEEN CHARACTERISTICS OF THE PATIENTS, MFA TOTAL SCORE, AND SIP TOTAL SCORE*

	MFA Total Score	SIP Total Score
Characteristic	(N = 60)	(N = 60)
No. of comorbid conditions†	0.15	0.10
Changes in activities†	0.63‡	0.59‡
No. of operations§	0.50‡	0.41‡