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      Association of the sense of coherence with physical and psychosocial health in the rehabilitation of osteoarthritis of the hip and knee: a prospective cohort study

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          According to Antonovsky’s salutogenic concept, a strong sense of coherence is associated with physical and psychological health. The goal of this study was to analyze the association of Antonovsky’s sense of coherence with physical and psychosocial health components in patients with hip and knee osteoarthritis before and after in- and outpatient rehabilitation.


          Prospective cohort study with 335 patients, 136 (41%) with hip and 199 (59%) with knee osteoarthritis. The outcome was measured by Short Form-36 (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Sense of Coherence (SOC-13). Baseline scores of the SF-36 and WOMAC scales and the observed effect sizes after rehabilitation were correlated with the baseline SOC-13. These correlations of the SF-36 scales were compared to the Factor Score Coefficients for the Mental Component Summary of SF-36, which quantify the factor load on the psychosocial dimension. Predictive impact of the baseline SOC-13 for the SF-36 and WOMAC scales (baseline scores and effect sizes) was then determined by multivariate linear regression controlled for possible confounders.


          At baseline, the SOC-13 correlated with the WOMAC scores between r = 0.18 (stiffness) and r = 0.25 (pain) and with the SF-36 scores between r = 0.10 (physical functioning) and r = 0.53 (mental health). The correlation of these SF-36 correlation coefficients to the Factor Score Coefficient of the SF-36 Mental Component Summary was r = 0.95. The correlations for the effect sizes (baseline → discharge) with the baseline SOC-13 global score were all negative and varied between r = 0.00 (physical functioning) and r = −0.19 (social functioning). In the multivariate linear regression model, the explained variance of the SF-36 scores by the baseline SOC-13 increased continuously from physical to psychosocial health dimensions (from 12.9% to 29.8%). This gradient was consistently observed for both the baseline scores and the effect sizes. The results of the WOMAC were consistent with the physical health scales of SF-36.


          The sense of coherence was associated with psychosocial health dimensions but hardly with physical health. The higher the load of a scale on the psychosocial dimension the higher was its correlation to the sense of coherence. This is in contrast to the idea of Antonovsky who predicted high associations with both mental and physical health.

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          Most cited references 21

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          The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research.

          To develop the Self-Administered Comorbidity Questionnaire (SCQ) and assess its psychometric properties, including the predictive validity of the instrument, as reflected by its association with health status and health care utilization after 1 year. A cross-sectional comparison of the SCQ with a standard, chart abstraction-based measure (Charlson Index) was conducted on 170 inpatients from medical and surgical care units. The association of the SCQ with the chart-based comorbidity instrument and health status (short form 36) was evaluated cross sectionally. The association between these measures and health status and resource utilization was assessed after 1 year. The Spearman correlation coefficient for the association between the SCQ and the Charlson Index was 0.32. After restricting each measure to include only comparable items, the correlation between measures was stronger (Spearman r = 0.55). The SCQ had modest associations with measures of resource utilization during the index admission, and with health status and resource utilization after 1 year. The SCQ has modest correlations with a widely used medical record-based comorbidity instrument, and with subsequent health status and utilization. This new measure represents an efficient method to assess comorbid conditions in clinical and health services research. It will be particularly useful in settings where medical records are unavailable.
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            The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip.

            Clinical criteria for the classification of patients with hip pain associated with osteoarthritis (OA) were developed through a multicenter study. Data from 201 patients who had experienced hip pain for most days of the prior month were analyzed. The comparison group of patients had other causes of hip pain, such as rheumatoid arthritis or spondylarthropathy. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop different sets of criteria to serve different investigative purposes. Multivariate methods included the traditional "number of criteria present" format and "classification tree" techniques. Clinical criteria: A classification tree was developed, without radiographs, for clinical and laboratory criteria or for clinical criteria alone. A patient was classified as having hip OA if pain was present in combination with either 1) hip internal rotation greater than or equal to 15 degrees, pain present on internal rotation of the hip, morning stiffness of the hip for less than or equal to 60 minutes, and age greater than 50 years, or 2) hip internal rotation less than 15 degrees and an erythrocyte sedimentation rate (ESR) less than or equal to 45 mm/hour; if no ESR was obtained, hip flexion less than or equal to 115 degrees was substituted (sensitivity 86%; specificity 75%). Clinical plus radiographic criteria: The traditional format combined pain with at least 2 of the following 3 criteria: osteophytes (femoral or acetabular), joint space narrowing (superior, axial, and/or medial), and ESR less than 20 mm/hour (sensitivity 89%; specificity 91%). The radiographic presence of osteophytes best separated OA patients and controls by the classification tree method (sensitivity 89%; specificity 91%). The "number of criteria present" format yielded criteria and levels of sensitivity and specificity similar to those of the classification tree for the combined clinical and radiographic criteria set. For the clinical criteria set, the classification tree provided much greater specificity. The value of the radiographic presence of an osteophyte in separating patients with OA of the hip from those with hip pain of other causes is emphasized.
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              Responsiveness of the WOMAC osteoarthritis index as compared with the SF-36 in patients with osteoarthritis of the legs undergoing a comprehensive rehabilitation intervention.

              To compare the responsiveness of the condition-specific Western Ontario and McMaster Universities osteoarthritis (OA) index (WOMAC) and the generic Short Form-36 (SF-36) in patients with OA of the legs undergoing a comprehensive inpatient rehabilitation intervention. A prospective follow up study of consecutively referred inpatients of a rehabilitation clinic was made. The patients included fulfilled the American College of Rheumatology criteria for knee or hip OA and underwent both passive and, particularly, active physical therapy for three to four weeks. Responsiveness assessment was performed using the standardised response mean (SRM), effect size, and Guyatt's responsiveness statistic between admission and discharge (end of rehabilitation) and then again between admission and three months later. For pain and function the SRMs were stratified by sex and OA joint. Effects were tested by the t test and SRMs of different scales were compared by the jack knife test. At the three month follow up, complete data were obtained for 223 patients. In general, the three responsiveness statistics showed a similar order of responsiveness. For both instruments, the pain scales were more responsive than the function scales. The responsiveness of the pain scale of both instruments was comparable (SRM=0.723 for WOMAC and SRM=0.528 for SF-36 at the end of rehabilitation; SRM=0.377 for WOMAC and SRM=0.468 for SF-36 at the three month follow up). In the measurement of function, the WOMAC was significantly more responsive than the SF-36 (SRMs, end of rehabilitation: 0.628 v 0.249; three month follow up: 0.235 v -0.001). Responsiveness tended to be higher in women and in knee OA than in men and hip OA. Both instruments, the WOMAC and the SF-36, capture improvement in pain in patients undergoing comprehensive inpatient rehabilitation intervention. Functional improvement can be detected better by the WOMAC than by the SF-36. All the other scales of both instruments were more weakly responsive.

                Author and article information

                BMC Musculoskelet Disord
                BMC Musculoskelet Disord
                BMC Musculoskeletal Disorders
                BioMed Central
                4 May 2013
                : 14
                : 159
                [1 ]Research department, Rehabilitation clinic “RehaClinic”, Bad Zurzach, 5330, Switzerland
                Copyright © 2013 Benz et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Research Article


                physical and psychosocial health, rehabilitation, sense of coherence, osteoarthritis, knee, hip


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