# A  Comparison of the Modified Score for the Assessment of  Chronic Rheumatoid Affections of the Hands and  the Australian/Canadian Osteoarthritis Hand Index in  Hand Osteoarthritis Patients

Authors: Judith Sautner; Ingrid Andel; Bernhard Rintelen; Burkhard F. Leeb
Journal: International Journal of Rheumatology
 (2009)

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## Abstract

Objectives. To compare the modified score for the assessment and quantification of chronic rheumatoid affections of the hands (M-SACRAH) with the Australian/Canadian osteoarthritis hand index (AUSCAN) in hand osteoarthritis (HOA). Both are self-administered patient questionnaires, being designed to assess functional status, stiffness, and pain in affected patients, despite some differences in format, compass and arrangement of questions. Methods. 66 HOA patients (51 females), attending the outpatient clinic, were included. Patients completed the AUSCAN (15 visual analogue scales) (VAS) and the M-SACRAH (12 VAS).
Results. AUSCAN-pain amounted to a mean of 41.9 (±2.9 SEM), AUSCAN-stiffness to 53.1 (3.7) and AUSCAN function to 42.6 (3.2). M-SACRAH-function amounted to 25.4 (2.4), M-SACRAH-stiffness to 42.6 (3.0), and M-SACRAH-pain to 43.7 (3.1). The total mean M-SACRAH was 37.2 (2.4) (all P's<.0001). The three respective domains of the two scores correlated significantly: pain: r=0.73,
stiffness: r=0.75, and function: r=0.76 (all P's<.0001). The four identical items in both scores also correlated significantly. No significant gender specific differences were observed. Conclusion. Despite a different scope of items, a significant high correlation of these two scores evaluating HOA patients could be demonstrated. We conclude that both scores are equivalently valuable for the assessment of health status in these patients.


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## Body

## 1. Introduction

Hand
osteoarthritis  (HOA) is  a highly prevalent condition, which  can result in
considerable disability. [1] In comparison with the diagnostic and therapeutic
efforts concerning knee or hip OA, HOA was neglected for quite some time—either due to its unspectacularity or due to a number of difficulties in its diagnosis and
classification. Driven by European
Standing Committee  for International Clinical Studies including Therapeutics (ESCISIT),
separate evidence-based
recommendations for hip and knee OA were developed between 2000 and 2005. In
September 2005, the members of the EULAR OA task force met for the first time
to start developing recommendations primarily for the management and afterwards
for the diagnosis of HOA—thus emphasizing
the importance of this clinical topic [2, 3].Already in 1999,
the Osteoarthritis Research Society International (OARSI) agreed upon core outcomes for
clinical trials in hand osteoarthritis (HOA) and these efforts have been
renewed at the OARSI OA meeting in Boston
in December 2005 [4, 5]. These respective core outcomes include
pain, functional index, patient's global assessment (PGA), structure, number of painful
or tender joints, grip strength, and pinch strength. There was further agreement that
patients' self-reported difficulty with daily activities should be assessed
with a valid and reliable measure [4].Some efforts to
develop scoring systems for rheumatoid affections of the little finger joints
have been made in the past. Two of them, the algofunctional index functional
index for hand osteoarthritis (FIHOA) by Dreiser and the rheumatoid hand
functional disability scale by Duruoz only assess the functional handicap of
patients [6, 7]. These two scores, furthermore, are administered by
interviewers which might result in bias due to interaction between the patient
and the interviewer [8].We attempted to
create a self-administered instrument which did not only include a functional
index but also incorporated pain and stiffness and therefore designed the score
for the assessment and quantification of chronic rheumatic affections of the
hands, the SACRAH, in 1999 [9].Bellamy et al.
created a comparable score, following the well-established pattern of the WOMAC
and exclusively dealing with HOA, the AUSCAN [8, 10, 11]. In this
context, it seems questionable,
whether an instrument is capable of targeting HOA exclusively.As both AUSCAN and
M-SACRAH meet the requirements of the OARSI hand osteoarthritis core outcomes,
yet have been designed by different approaches, we compared both scores in one
HOA patient group to verify possible differences or similarities in the
assessment of the status and outcomes of these patients. Special emphasis of
our investigation was put on possible differences between the two scores concerning
their results in different genders. A further goal was to investigate possible
differences in the responsiveness of the two scores to therapeutic
interventions.


## 2. Material and Methods

Between August
2003 and April 2005, the four authors were assessing patients at the outpatient
clinic of our department. Having been diagnosed with HOA according to the ACR
criteria by one of the four, patients were included consecutively into the
study [12]. Thus, sixty six
outpatients completed both questionnaires.


### 2.1. Questionnaires under Comparison

#### 2.1.1. SACRAH/M-SACRAH

In brief, the
SACRAH encompasses 23 VAS (100 mm) covering the three categories functional
impairment (18 items), stiffness (2 items), and pain (4 items). This score has
been validated in 69 HOA and 103 RA patients [13].In 2004, we
presented a modified and shortened version of the SACRAH, the M-SACRAH to
simplify the questionnaire's use for the patient [14].The M-SACRAH—as well as its
predecessor, the SACRAH—has been
established and validated in German and also consists of 3 domains including 12
items, namely, 8 targeting function, 2 targeting stiffness, and 2 targeting
pain. It has, meanwhile, been translated to English according to
standardized procedures. Meanwhile, the questionnaire has been translated to
English and Serbocroatian according to standardized procedures and has been
validated in a Serbian patient group [15]. Data of the principal component analysis are given in Table  6.


#### 2.1.2. AUSCAN-Questionnaire

The AUSCAN has
been established in English, exclusively dealing with HOA patients and finally
published in 2002. It exists in a Likert version, a numerical rating scale (NRS),
and in a VAS format [8, 10, 11]. It comprises
15 items covering pain (n=5), stiffness (n=1), and function (n=9). The
distribution of questions among the three categories, however, is to some
extent different from the M-SACRAH.For the purpose of
this study, the VAS-version was used, as the M-SACRAH also encompasses
VAS-scales. As the AUSCAN questionnaire is not in the public domain and thus
not unrestrictedly available, the candidate items from the publication were
used to generate a German version for this specific study. This was done by two
professional English-German translaters, one translating the questionnnaire
from English into German, the other one translating it back into English. Since
the English translation from the German version matched the original AUSCAN
questionnaire, the German version was considered primarily valid for the use in
this study. The detailed items of the questionnaire are shown in Table1.
Construct validity of this German version was assessed carrying out principal
component analysis (Table 7).Table 1
Items and results of the AUSCAN. (Identical questions in both questionnaires are given in italics.)
Domain question mean (SEM)PainPain at rest35.8 (3.4)Pain at gripping45.7 (3.8)Pain at lifting46.3 (3.6)Pain at turning45.2 (3.8)Pain at squeezing36.7 (3.6)StiffnessMorning stiffness53.2 (3.7)Physical functionTurning taps/faucets on30.1 (3.3)Turning doorknob/handle24.8 (3.1)Doing up buttons35.0 (3.7)Fastening jewellery47.4 (4.2)Opening a new jar57.0 (4.1)Carrying full put one hand47.8 (4.1)Peeling vegetables/fruit37.4 (3.7)Picking up large heavy objects47.8 (4.1)Wringing out washcloths53.9 (4.1)Table 2
Items and results of the M-SACRAH.
(Identical questions in both questionnaires are given in italics.)
Domain question mean (SEM)FunctionLocking/unlocking of a door21.9 (2.6)Buttoning and unbuttoning shirt/blouse31.1 (3.2)Turning the water tap28.1 (3.1)Fastening or unfastening a zip24.1 (3.0)Tying shoelaces28.4 (3.3)Unscrewing cap of a tube of toothpaste26.7 (2.9)Turning the pages of a newspaper18.9 (2.3)Writing24.0 (2.8)StiffnessMorning stiffness53.8 (3.6)Stiffness later in the day following inactivity31.3 (3.1)PainPain during intensive work47.7 (3.6)Pain at times of inactivity39.6 (3.5)The main
difference between the two questionnaires relates to the importance of
stiffness and pain. While the AUSCAN distinguishes between pain on several
activities, the M-SACRAH asks for pain at work in general and for pain at rest.
Regarding stiffness only morning stiffness is covered by the AUSCAN. The
M-SACRAH, however, also asks for starting stiffness during the day.


#### 2.1.3. Completion of the Questionnaires and Further Assessments

After initial instruction by a nurse or a resident, as to how the questionnaires
should be tackled, the participants completed both forms without further assistance in random order, one right after arrival and the other one just before the assessment by the
physician, resulting in a mean time lag of half an hour. All questionnaires
were completed during outpatient department hours between 9 a.m. and 1 p.m. Patients thereafter
underwent a clinical examination with an assessment of their complete joint
status, also including patient's global assessment (PGA)and physician's
global assessment (PhGA) (100 mm VAS).PGA
was assessed by the treating physician, using the phrase “Please indicate how
severe you are compromised by your hand osteoarthritis during the last 48 hours!”


### 2.2. Statistical Methods

Statistical
evaluation was carried out using SPSS 11.0 for Windows. As all the relevant
parameters proved to be normally distributed according to Kolmogorov-Smirnoff
accomodation, parametric tests were applied. Results are presented as mean (±standard error of the mean  =  SEM) for continuous variables. Correlations of
continuous variables were performed using Pearson's correlation. Groups were
compared using the Student'st-test.
P-values <.05 were
considered statistically significant.In order to
evalutate dimensionality and factorial structure of both scores, and to reveal
whether scale items eventually cross-load on more than one factor, exploratory
factor analysis by principial component analysis (PCA) was performed (Tables5 and 6).Factor
analysis, including variations such as PCA, is a statistical approach which is
applied to analyze interrelationships among a large number of variables and to
explain these variables with respect to their common underlying dimensions
(factors). The objective is the attempt to condense information contained in a
number of original variables into a smaller set of variates (factors) with a
minimum loss of information [16]. Moreover, reliability as a measure of the
extent to which a variable or a set of variables is consistent in what it is
intended to measure was assessed by calculating Cronbach's alpha. The closer
the value comes to one, the stronger the connection between the different
variables is assumed. Values greater than 0.7 are generally regarded as markers
of high reliability.


## 2.1. Questionnaires under Comparison

### 2.1.1. SACRAH/M-SACRAH

In brief, the
SACRAH encompasses 23 VAS (100 mm) covering the three categories functional
impairment (18 items), stiffness (2 items), and pain (4 items). This score has
been validated in 69 HOA and 103 RA patients [13].In 2004, we
presented a modified and shortened version of the SACRAH, the M-SACRAH to
simplify the questionnaire's use for the patient [14].The M-SACRAH—as well as its
predecessor, the SACRAH—has been
established and validated in German and also consists of 3 domains including 12
items, namely, 8 targeting function, 2 targeting stiffness, and 2 targeting
pain. It has, meanwhile, been translated to English according to
standardized procedures. Meanwhile, the questionnaire has been translated to
English and Serbocroatian according to standardized procedures and has been
validated in a Serbian patient group [15]. Data of the principal component analysis are given in Table  6.


### 2.1.2. AUSCAN-Questionnaire

The AUSCAN has
been established in English, exclusively dealing with HOA patients and finally
published in 2002. It exists in a Likert version, a numerical rating scale (NRS),
and in a VAS format [8, 10, 11]. It comprises
15 items covering pain (n=5), stiffness (n=1), and function (n=9). The
distribution of questions among the three categories, however, is to some
extent different from the M-SACRAH.For the purpose of
this study, the VAS-version was used, as the M-SACRAH also encompasses
VAS-scales. As the AUSCAN questionnaire is not in the public domain and thus
not unrestrictedly available, the candidate items from the publication were
used to generate a German version for this specific study. This was done by two
professional English-German translaters, one translating the questionnnaire
from English into German, the other one translating it back into English. Since
the English translation from the German version matched the original AUSCAN
questionnaire, the German version was considered primarily valid for the use in
this study. The detailed items of the questionnaire are shown in Table1.
Construct validity of this German version was assessed carrying out principal
component analysis (Table 7).Table 1
Items and results of the AUSCAN. (Identical questions in both questionnaires are given in italics.)
Domain question mean (SEM)PainPain at rest35.8 (3.4)Pain at gripping45.7 (3.8)Pain at lifting46.3 (3.6)Pain at turning45.2 (3.8)Pain at squeezing36.7 (3.6)StiffnessMorning stiffness53.2 (3.7)Physical functionTurning taps/faucets on30.1 (3.3)Turning doorknob/handle24.8 (3.1)Doing up buttons35.0 (3.7)Fastening jewellery47.4 (4.2)Opening a new jar57.0 (4.1)Carrying full put one hand47.8 (4.1)Peeling vegetables/fruit37.4 (3.7)Picking up large heavy objects47.8 (4.1)Wringing out washcloths53.9 (4.1)Table 2
Items and results of the M-SACRAH.
(Identical questions in both questionnaires are given in italics.)
Domain question mean (SEM)FunctionLocking/unlocking of a door21.9 (2.6)Buttoning and unbuttoning shirt/blouse31.1 (3.2)Turning the water tap28.1 (3.1)Fastening or unfastening a zip24.1 (3.0)Tying shoelaces28.4 (3.3)Unscrewing cap of a tube of toothpaste26.7 (2.9)Turning the pages of a newspaper18.9 (2.3)Writing24.0 (2.8)StiffnessMorning stiffness53.8 (3.6)Stiffness later in the day following inactivity31.3 (3.1)PainPain during intensive work47.7 (3.6)Pain at times of inactivity39.6 (3.5)The main
difference between the two questionnaires relates to the importance of
stiffness and pain. While the AUSCAN distinguishes between pain on several
activities, the M-SACRAH asks for pain at work in general and for pain at rest.
Regarding stiffness only morning stiffness is covered by the AUSCAN. The
M-SACRAH, however, also asks for starting stiffness during the day.


### 2.1.3. Completion of the Questionnaires and Further Assessments

After initial instruction by a nurse or a resident, as to how the questionnaires
should be tackled, the participants completed both forms without further assistance in random order, one right after arrival and the other one just before the assessment by the
physician, resulting in a mean time lag of half an hour. All questionnaires
were completed during outpatient department hours between 9 a.m. and 1 p.m. Patients thereafter
underwent a clinical examination with an assessment of their complete joint
status, also including patient's global assessment (PGA)and physician's
global assessment (PhGA) (100 mm VAS).PGA
was assessed by the treating physician, using the phrase “Please indicate how
severe you are compromised by your hand osteoarthritis during the last 48 hours!”


## 2.1.1. SACRAH/M-SACRAH

In brief, the
SACRAH encompasses 23 VAS (100 mm) covering the three categories functional
impairment (18 items), stiffness (2 items), and pain (4 items). This score has
been validated in 69 HOA and 103 RA patients [13].In 2004, we
presented a modified and shortened version of the SACRAH, the M-SACRAH to
simplify the questionnaire's use for the patient [14].The M-SACRAH—as well as its
predecessor, the SACRAH—has been
established and validated in German and also consists of 3 domains including 12
items, namely, 8 targeting function, 2 targeting stiffness, and 2 targeting
pain. It has, meanwhile, been translated to English according to
standardized procedures. Meanwhile, the questionnaire has been translated to
English and Serbocroatian according to standardized procedures and has been
validated in a Serbian patient group [15]. Data of the principal component analysis are given in Table  6.


## 2.1.2. AUSCAN-Questionnaire

The AUSCAN has
been established in English, exclusively dealing with HOA patients and finally
published in 2002. It exists in a Likert version, a numerical rating scale (NRS),
and in a VAS format [8, 10, 11]. It comprises
15 items covering pain (n=5), stiffness (n=1), and function (n=9). The
distribution of questions among the three categories, however, is to some
extent different from the M-SACRAH.For the purpose of
this study, the VAS-version was used, as the M-SACRAH also encompasses
VAS-scales. As the AUSCAN questionnaire is not in the public domain and thus
not unrestrictedly available, the candidate items from the publication were
used to generate a German version for this specific study. This was done by two
professional English-German translaters, one translating the questionnnaire
from English into German, the other one translating it back into English. Since
the English translation from the German version matched the original AUSCAN
questionnaire, the German version was considered primarily valid for the use in
this study. The detailed items of the questionnaire are shown in Table1.
Construct validity of this German version was assessed carrying out principal
component analysis (Table 7).Table 1
Items and results of the AUSCAN. (Identical questions in both questionnaires are given in italics.)
Domain question mean (SEM)PainPain at rest35.8 (3.4)Pain at gripping45.7 (3.8)Pain at lifting46.3 (3.6)Pain at turning45.2 (3.8)Pain at squeezing36.7 (3.6)StiffnessMorning stiffness53.2 (3.7)Physical functionTurning taps/faucets on30.1 (3.3)Turning doorknob/handle24.8 (3.1)Doing up buttons35.0 (3.7)Fastening jewellery47.4 (4.2)Opening a new jar57.0 (4.1)Carrying full put one hand47.8 (4.1)Peeling vegetables/fruit37.4 (3.7)Picking up large heavy objects47.8 (4.1)Wringing out washcloths53.9 (4.1)Table 2
Items and results of the M-SACRAH.
(Identical questions in both questionnaires are given in italics.)
Domain question mean (SEM)FunctionLocking/unlocking of a door21.9 (2.6)Buttoning and unbuttoning shirt/blouse31.1 (3.2)Turning the water tap28.1 (3.1)Fastening or unfastening a zip24.1 (3.0)Tying shoelaces28.4 (3.3)Unscrewing cap of a tube of toothpaste26.7 (2.9)Turning the pages of a newspaper18.9 (2.3)Writing24.0 (2.8)StiffnessMorning stiffness53.8 (3.6)Stiffness later in the day following inactivity31.3 (3.1)PainPain during intensive work47.7 (3.6)Pain at times of inactivity39.6 (3.5)The main
difference between the two questionnaires relates to the importance of
stiffness and pain. While the AUSCAN distinguishes between pain on several
activities, the M-SACRAH asks for pain at work in general and for pain at rest.
Regarding stiffness only morning stiffness is covered by the AUSCAN. The
M-SACRAH, however, also asks for starting stiffness during the day.


## 2.1.3. Completion of the Questionnaires and Further Assessments

After initial instruction by a nurse or a resident, as to how the questionnaires
should be tackled, the participants completed both forms without further assistance in random order, one right after arrival and the other one just before the assessment by the
physician, resulting in a mean time lag of half an hour. All questionnaires
were completed during outpatient department hours between 9 a.m. and 1 p.m. Patients thereafter
underwent a clinical examination with an assessment of their complete joint
status, also including patient's global assessment (PGA)and physician's
global assessment (PhGA) (100 mm VAS).PGA
was assessed by the treating physician, using the phrase “Please indicate how
severe you are compromised by your hand osteoarthritis during the last 48 hours!”


## 2.2. Statistical Methods

Statistical
evaluation was carried out using SPSS 11.0 for Windows. As all the relevant
parameters proved to be normally distributed according to Kolmogorov-Smirnoff
accomodation, parametric tests were applied. Results are presented as mean (±standard error of the mean  =  SEM) for continuous variables. Correlations of
continuous variables were performed using Pearson's correlation. Groups were
compared using the Student'st-test.
P-values <.05 were
considered statistically significant.In order to
evalutate dimensionality and factorial structure of both scores, and to reveal
whether scale items eventually cross-load on more than one factor, exploratory
factor analysis by principial component analysis (PCA) was performed (Tables5 and 6).Factor
analysis, including variations such as PCA, is a statistical approach which is
applied to analyze interrelationships among a large number of variables and to
explain these variables with respect to their common underlying dimensions
(factors). The objective is the attempt to condense information contained in a
number of original variables into a smaller set of variates (factors) with a
minimum loss of information [16]. Moreover, reliability as a measure of the
extent to which a variable or a set of variables is consistent in what it is
intended to measure was assessed by calculating Cronbach's alpha. The closer
the value comes to one, the stronger the connection between the different
variables is assumed. Values greater than 0.7 are generally regarded as markers
of high reliability.


## 3. Results

Of the enrolled 66
patients, 51 (77%) were female, 15 (23%) male, their mean age was 58.3 (45–83) years, with a
mean disease duration of 40 (3–365) months. For
the radiological assessment, the Kellgren Lawrence classification was applied.
Four patients (6%) were Kellgren Lawrence stadium I, 16 (24%) in stadium II, 31
(47%) stadium III, and the remaining 15 patients (23%) in stadium IV. Patients
with isolated thumb base osteoarthritis were not included into the study.
Considering gender distribution, disease duration, and radiological status, the
patient group can be regarded representative for the overall HOA patients being
treated at our clinic. All patients were current users of either paracetamol or
NSAIDs. In eleven NSAID-treated patients, the currently used drug was changed
because of inefficacy at the time of their first assessment and subjects were
reassessed after a mean of 39 (±4 SEM) days. All patients were Caucasian and
their mother tongue was German. All of them gave written informed consent to be
enrolled into the study according to the declaration of Helsinki. The design of the study has been
approved by the local ethics  committee.The majority of
sixty two patients (94%) properly completed both questionnaires without missing
data. Four of the fifteen male patients (27%) completed M-SACRAH without any
problems but had incomplete AUSCAN questionnaires (e.g., they did not fill in
all physical function questions asserting never to perform these activities, i.e.,
closing bracelets) and were therefore excluded from further analysis.AUSCAN pain
amounted to 41.9 (±2.9 SEM), AUSCAN stiffness to 53.1 (3.7), and AUSCAN function
to 42.6 (3.2). M-SACRAH-function amounted to a mean of 25.4 (2.4),
M-SACRAH-stiffness to 42.6 (3.0), and M-SACRAH-pain to 43.7 (3.1). The mean
total M-SACRAH was 37.2 (2.4).The single domains of the two scores correlated significantly pain:r  =  0.73 (P<.0001),
stiffness r  =  0.75 (P<.0001), and function r  =  0.76
(P  <  0.0001).The four items
which are identical in both scores also correlated significantly:r=0.88 (P<.0001)
for “pain at rest,” r=0.78 (P<.0001) for “morning stiffness,” r=0.75 (P<.0001) for “turning taps,”
and r=0.80 (P<.0001) for “doing up buttons.”Gender-specific
results for the AUSCAN and M-SACRAH did not differ significantly. However, it
seems noteworthy that for all domains except the AUSCAN function a trend to
higher values was seen in male patients, see Table3.Table 3
Gender differences of the single domains.
Female patientsMale patientsP-valuesAUSCAN pain41.1 (3.3)45.9 (6.4).54MSACRAH pain43.3 (3.5)45.6 (5.4).77AUSCAN stiffness52.8 (4.1)54.4 (8.6).87MSACRAH stiffness42.4 (3.4)43.2 (6.6).92AUSCAN function43.2 (3.6)39.4 (6.9).65MSACRAH function24.2 (2.5)30.9 (6.6).28Changes of both
scores following a therapeutic change, for example, from an ineffective NSAID
to another one, were not statistically significantly different, however, the
respective changes of the mean values were well comparable for both items, see
Table4.Table 4
Mean difference (SEM = standard error of the mean) of domain scores before and after NSAID change due to inefficacy.
Pre-NSAID changePost-NSAID changeP-valuesAUSCAN pain52.7 (8.9)41.9 (7.2).16MSACRAH pain51.1 (9.5)41.7 (6.4).23AUSCAN stiffness57.8 (9.6)45.5 (8.3).19MSACRAH stiffness49.0 (6.6)36.5 (6.8).57AUSCAN function42.2 (10.2)44.9 (7.4).84MSACRAH function27.2 (6.9)1.3 (5.7).52Table 5
Correlations of single domains and total M-SACRAH with PGA/PhGA.
PGAPhGAAUSCAN painr  =  0.59 (P<.0001)r  =  0.56 (P<.0001)M-SACRAH painr  =  0.56 (P<.0001)r  =  0.50 (P  <  .0002)AUSCAN stiffnessr  =  0.49 (P  <  .0003)r  =  0.37 (P  <  .0059)M-SACRAH stiffnessr  =  0.53 (P<.0001)r  =  0.45 (P  <  .0007)AUSCAN functionr  =  0.55 (P<.0001)r  =  0.40 (P  <  .0025)M-SACRAH functionr  =  0.55 (P<.0001)r  =  0.46 (P  <  .0005)M-SACRAH totalr  =  0.65 (P<.0001)r  =  0.54 (P<.0001)Table 6
Principal component analysis of the M-SACRAH items.
Rotated component matrix (item loading).
QuestionComponent 1Component 2Component 3M-SACRAH 10.530.0030.949M-SACRAH 20.6020.5110.41M-SACRAH 30.6870.3280.237M-SACRAH 40.7850.2460.002M-SACRAH 50.6480.3640.031M-SACRAH 60.6860.3830.328M-SACRAH 70.845−0.048−0.022M-SACRAH 80.765−0.016−0.024M-SACRAH 90.1860.8080.051M-SACRAH 100.2010.790−0.061M-SACRAH 110.4960.5870.134M-SACRAH 12−0.200.8880.044Extraction method: principal component analysis.
Rotation method: varimax with Kaiser normalization.
The backgroud indicates questions loading on the same factor.Table 7
Principal component analysis of the AUSCAN items.
Rotated component matrix (item loading).
QuestionComponent 1Component 2Component 3AUSCAN 1−0.35−0.006−0.776AUSCAN 20.1690.9020.159AUSCAN 30.5390.6260.149AUSCAN 40.5800.598−0.099AUSCAN 50.2590.744−0.297AUSCAN 60.5390.4420.120AUSCAN 70.5510.4550.362AUSCAN 80.8980.109−0.184AUSCAN 90.8330.2860.297AUSCAN 100.7400.4620.329AUSCAN 110.6750.4990.309AUSCAN 120.3600.7120.396AUSCAN 130.8150.327−0.039AUSCAN 140.4390.6990.059AUSCAN 150.7600.4900.141Extraction Method: principal component analysis.
Rotation Method: varimax with Kaiser normalization.
The background indicates questions loading on the same factor.Mean PGA amounted
to 39 (±3 SEM), mean PhGA to 23 (2). Correlations between PGA and the single
domains of the AUSCAN and M-SACRAH as well as the total M-SACRAH reached
statistical significance. The same, PhGA and the single domains of either
instrument correlated significantly. The best correlation, however, could be
demonstrated for the total M-SACRAH and PGA (r  =  0.65; P<.0001), see
Table 5.Reliability
testing of both scores was carried out by Cronbach's alpha, which amounted to
0.916 for the total M-SACRAH and to 0.952 for the total AUSCAN, indicating high
internal consistency.The complete
results of exploratory factor analysis for the M-SACRAH items and AUSCAN items
are given in Tables6 and 7. This statistical procedure revealed both aggregate
scores to be three dimensional, while the respective single-domain scores were
found to be strictly one dimensional, see also the backgrounds within the
respective tables.


## 4. Discussion

M-SACRAH and AUSCAN, two self-administered patient
centered questionnaires, were compared in a group of HOA patients. We were able
to show an equal ability of either instrument to describe physical function,
pain, and stiffness in this specific patient group.To facilitate an
objective follow-up of patients suffering from HOA, the application of
appropriate aggregate scores to describe the patient's status has been
considered desirable aside the assessment of pain and functioning [5, 17].The M-SACRAH was
developed from its more complex predecessor, the SACRAH, which was constructed
using a Delphi approach including
rheumatologists and occupational therapists [13, 14]. The modified score
reduced item set was reached by excluding all items of the SACRAH, which
correlated with a coefficient of equal or more than 0.7. The AUSCAN in contrast
was developed by first collecting a large number of items through interviews
with 50 HOA patients. This item pool was rationalized according to prevalence,
frequency, and importance to the patient. Subsequently, 15 “candidate” items
were selected for the questionnaire. A second group of 24 “reserve” items was
kept for addressing a methodological issue relating early versus late item
reduction in index construction, which has not been published yet [8, 11].As the AUSCAN is not
unrestrictedly available, even for scientific purposes, a linguistic validation
procedure of these items had to be performed. However, if a questionnaire is
translated into another language, a linguistic validation is necessary but not
sufficient unless the psychometric characteristics have been verified. Thus,
the following psychometric evaluation can also be regarded as a proof of this
instrument validity [18].Both scores
encompass a comparable number of questions but put a different emphasis on the investigated
domains function, stiffness, and pain due to their development process. We,
therefore, decided to investigate as to whether these differences would take
effect on the results of the scores.The absolute
values indeed significantly differed with respect to the function and stiffness
domains. The differences in the function domain can be seen due to the
different scope of
questions addressing functions requiring physical force like holding a pan or
wringing out washcloths that are highlyer represented within the AUSCAN
questionnaire. Regarding stiffness, the results of the M-SACRAH were lower than
those of the AUSCAN obviously due to the presence of a second item “stiffness
later in the day following inactivity” which yields significantly lower results
than the item “morning stiffness” shared by both scores. Absolute values for
pain in contrast to the two other domains did not differ as the items “pain at
gripping,” “at lifting” and “at turning” of the AUSCAN obviously relate to “pain
during hard work” of the M-SACRAH.Despite these
differences regarding absolute values, however, an expected consistently
high correlation between the three domains of both instruments could be found
indicating that both scores describe the investigated cohort equally well.Internal
consistency, as assessed by Cronbach's alpha, was found excellent for both the
AUSCAN as well as the M-SACRAH, which indeed is caused by the high number of
items. As alpha can also be regarded as a measure of redundancy, the small
differences between both scores are based on the greater number of items
included into the AUSCAN, as commonly reliability coefficients of compositive
indices increase by an increasing number of single components [16].The consistently high correlation between the single
items of both instruments can be regarded a strong marker for convergent
validity.Discriminant validity has been tested in the SACRAH,
healthy controls serving as comparative group
[13].  Addressing this topic, recent data have revealed significant differences of the SACRAH as well as the M-SACRAH in HOA and RA patients [15]. Detailed data on validity and factor structure of the AUSCAN have been published in 2006
[19, 20].Despite no
significant difference between female and male patients' results, a predominance
of items addressing household activities in the AUSCAN was obvious.
Concordingly, we observed a considerable number of male patients (27%) who did
not complete one or more questions of the function domain of the AUSCAN, some
of them adding a written commentary that they would never perform such work.
Although the investigated number of male patients is small, a considerable part
of those considered the scope of the AUSCAN's items as not fully suitable
describing their difficulties in daily life. Thus, a detailed investigation of
this subject seems to be appropriate as, in addition, male patients tended to
score higher in the AUSCAN as well as in the M-SACRAH. Following a change of
NSAID due to inefficacy, neither the AUSCAN nor the M-SACRAH showed significant
changes, obviously due to the small number of patients. Nevertheless, changes
in the three domains of the two instruments were of the same magnitude and
toward the same direction. The responsiveness to therapy has been shown for the
AUSCAN and the SACRAH in previous publications [5, 13].The correlations
of both scores with PGA underline either ability to express the patient's
present situation. Among those, the strongest correlation could be found for
PGA and the total M-SACRAH, which can be regarded an advantage of this “total”
aggregate score. PhGA did not correlate that strongly with both instruments.
This can be seen in line with our findings about the different view of
physicians and patients concerning their present disease activity as well as
the respective changes in RA patients [21].An important
aspect of this study was to test the construct validity of both scores, which
was done by principal component analysis. Both scores, when analyzed as an
aggregate, appeared to be tridimensional instruments, reflecting the three
domains covered by the scores. Although no composite AUSCAN value was proposed,
it would be statistically justified to give [8]. As it is the case for the
M-SACRAH, an aggregate result of the AUSCAN is supposed to measure the severity
of the underlying disease [14].As expected, this statistical approach revealed a considerable number of
redundant questions. Thus, it would be possible to reduce the number of items
of both scores significantly according to these results. A possible future
perspective would be the validation of a short form (SF-) SACRAH or
AUSCAN in order to facilitate the application of these instruments in daily
routine [22].Recent
studies on the measurement of functioning in HOA patients have compared several
questionnaires (HAQ, AUSCAN, Cochin
scale, FIHOA, SACRAH, and AIMS2-SF) based on the International Classification of
Functioning, Disability, and Health (ICF) [23]. Among those, SACRAH and AUSCAN
showed the lowest diversity ratio, in contrast, AIMS2-SF the highest. The
authors conclude that clinicians, when selecting an instrument for
comprehensive measurement of functioning, are advised to include both one
instrument with a low diversity ratio (for disease specific aspects) and
another instrument with a high diversity ratio (for broader aspects of
functioning including some aspects of participation).Hand
osteoarthritis and its specific assessment and treatment have received less
attention than hip and knee OA in the past. Recent efforts to this entity
mirror an increasing scientific interest in HOA, ending up with the creation
and application of patient-centered
outcome measures [2, 3].Future research on HOA is expected to focus on good
longitudinal studies and improved interventions.In summary, apart
from the observed differences in absolute values, both instruments can be regarded
equally well able to describe physical function, pain, and stiffness of
patients suffering from HOA.
They may, therefore, both be considered equally
suitable as core items in the evaluation of these patients.



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