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Original Article
Quality of life in patients with knee and hip osteoarthritis
Calidad de vida en pacientes con artrosis de rodilla y/o cadera
M. Bernad-Pinedaa,
Corresponding author
mbernadp@hotmail.com

Corresponding author.
, J. de las Heras-Sotosb, M.V. Garcés-Puentesc
a Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Traumatología. Hospital Universitario La Paz, Madrid, Spain
c Servicios Integrales de Gestión Médica (SIGEMED), Madrid, Spain
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It is the most prevalent arthropathy throughout the world and knee and&#47;or hip involvement is the most common reason for walking disability among the elderly&#44; from all races and geographical areas&#46; In industrialized countries&#44; 80&#37; of the population aged over 65 suffers osteoarthritis&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> with a higher prevalence being observed in the group aged between 70 and 79 years&#44; and 33&#46;7&#37; of cases affecting the knee&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The prevalence of osteoarthritis of any joint among the general Spanish population is of 24&#37;&#44; with a male&#58;female ratio of 3&#58;1 among those older than 60 years&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The prevalence of symptomatic knee osteoarthritis among patients aged over 20 years is of 10&#46;2&#37;&#44; whilst radiological osteoarthritis could reach 34&#37;&#46; Coxarthrosis is relatively frequent after the ages of 50&#8211;55 years&#46; According to the series&#44; at this age it can be appear in between 20&#37; and 30&#37; of the population&#46; If we take into account the fact that the hip fulfills a key role in the balance and support of the body&#44; coxarthrosis can be considered as one of the most disabling types of osteoarthritis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Clinically&#44; osteoarthritis is characterized by joint pain&#44; morning rigidity for a period &#60;30<span class="elsevierStyleHsp" style=""></span>min&#44; limitation of mobility&#44; crepitus&#44; joint instability&#44; functional disability&#44; occasional hemorrhage and a variable degree of local inflammation&#46; The symptoms are insidious and remit with rest&#46; Once the disease advances&#44; pain can be constant when any physical activity is performed and persist for several hours afterwards&#46; Pain&#44; which is accompanied by functional disability&#44; has a mechanical origin&#44; is triggered by use of the joint&#44; especially after it has been inactive&#44; decreases with exercise&#44; reappears when the activity is prolonged and improves with rest until its disappearance&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The progression of osteoarthritis causes a limitation of the activity of the affected joint which&#44; if persistent&#44; will become a permanent functional disability&#44; with all the negative consequences for the patient&#44; whose daily life and work activity&#44; and therefore quality of life will be affected&#46; Osteoarthritis cannot be cured definitively&#44; so treatment strategies aim to reduce the pain and improve the function of the affected limb&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are no Spanish reference data which estimate the quality of life of patients with osteoarthritis&#44; so the objective of this study was to assess the quality of life of patients with knee and hip osteoarthritis through self-assessments and to determine the perception of physicians about the quality of life of these patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">This was an observational&#44; cross-sectional&#44; multicenter study&#44; whose initial calculated population was of 2100 patients who fulfilled the following inclusion criteria&#58; age 50 years or over&#44; having been diagnosed with knee and&#47;or hip osteoarthritis prior to the study through radiological assessment&#44; and who attended consultation at the various Autonomous Regions of the Spanish territory between October 15th 2011 and May 15th 2012&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Out of the 700 physicians who worked at hospitals or health centers specializing in Rheumatology or Traumatology&#44; who considered themselves to have knowledge and experience in knee and hip osteoarthritis and who were invited to participate in the study&#44; 628 responded within the time established previously and according to the protocol&#46; The coordinators of the study contacted the specialists based on geographical criteria&#44; in order to ensure a proportional representation of the entire country&#46; The recruitment of patients was carried out by researchers in a random manner&#46; Each researcher had to recruit 3 patients on different days&#44; the first who attended consultation and fulfilled the inclusion and exclusion criteria&#46; We excluded patients with terminal disease and those unable to understand the instructions of the questionnaires and give their consent&#44; as well as those who suffered any pain not related to knee and&#47;or hip osteoarthritis&#44; with a VAS over 30&#46; After collecting the demographic data from each patient&#44; they completed a questionnaire and also indicated the following clinical variables&#58; location of the osteoarthritis&#44; level of radiological involvement of the joint according to the scale by Kellgren&#47;Lawrence&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> time of evolution of pain&#44; history of falls with and without fractures within the last year&#44; location of fractures&#44; result of the Timed Up &#38; Go test<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and presence of other rheumatologic diseases&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">After providing their informed consent in writing&#44; each patient completed the Western Ontario and McMaster Universities Osteoarthritis Index&#44; version LK 3&#46;0 &#40;WOMAC&#41;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> and the Medical Outcomes Survey Short Form&#44; version 2 &#40;SF-12v2&#41;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> questionnaires&#46; The physicians completed the SF12v2 questionnaire according to their perception of the quality of life of each patient and without knowing their responses&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The WOMAC questionnaire is the most frequently used self-administered specific instrument to asses both the symptoms and functional capacity of patients with knee and&#47;or hip osteoarthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It contains 24 items covering 3 dimensions&#58; pain&#44; stiffness and functional capacity in general&#46; The lowest score represents less pain and rigidity and better functional capacity&#46; Following the instructions of the authors of the translation and adaptation of the WOMAC questionnaire&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> all doubtful responses due to a position of a mark outside the box were resolved by selecting the closest one&#46; In some exceptional cases in which the mark was equidistant between 2 boxes&#44; we selected the highest score&#46; We considered as non-valid scales the lack of a response by patients to 2 pain items&#44; 2 rigidity items or 4 functional capacity items&#46; When patients left 1 pain item&#44; 1 rigidity item and between 1 and 3 functional capacity items blank&#44; we substituted the missing datum from the item by the average value of the completed items&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The SF-12v2 questionnaire comprises 12 items assessing 8 dimensions defined from the SF-36 questionnaire&#46; The responses are Likert type scales with 3&#8211;6 options assessing the intensity or frequency&#46; The responses given by patients and by researchers were standardized and recoded to obtain 2 summary components&#58; physical &#40;SCP&#41; and mental &#40;SCM&#41;&#44; through the application of an algorithm which transformed the scores of each individual and standardized them to make them comparable&#46; This action was carried out by QualityMetric Incorporated &#40;USA&#41;&#44; a company which applied the original algorithm of the authors of the questionnaire&#44; since it is the only valid and available one for the 2&#46;0 version of the SF-12&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The data were digitalized into a protected&#44; secure and normalized database&#46; Once registered&#44; the data collection sheets were kept in specific archives&#46; We carried out a statistical analysis of the total sample&#44; divided by age into 3 groups&#58; 50&#8211;59&#44; 60&#8211;69 and &#8805;70 years and also according to the location of the osteoarthritis&#58; knee and hip&#46; For the numerical variables&#44; we calculated central tendency&#44; dispersion and distribution measurements&#46; For the nominal and categorical variables&#44; we calculated the frequency&#44; created contingency tables and calculated the Pearson&#39;s Chi&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We used score estimation and by 95&#37; confidence intervals &#40;CI&#41; &#40;type <span class="elsevierStyleSmallCaps">I</span> error of 5&#37;&#41; in order to obtain both the sociodemographic profile of the patients and the distribution of the characteristics of osteoarthritis&#46; We assessed the correlation between the scores of the responses of patients to the WOMAC and SF-12v2 questionnaires and those obtained by physicians in the SF-12v2 questionnaire&#46; The analysis of the WOMAC questionnaire included the calculation of the mean values for each of the 3 dimensions&#58; pain&#44; rigidity and functional capacity and their comparison with the means of the scores of the subgroups by age and location of the osteoarthritis using a 1-factor ANOVA and a <span class="elsevierStyleItalic">post hoc</span> test to identify the significant intergroup differences&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In order to detect the factors associated to variability of the WOMAC and SF-12v2 scores&#44; we carried out a stepwise&#44; multiple regression analysis&#46; The independent variables were selected by fixing an initial significance level of 0&#46;10 and 0&#46;05 to include them in the definitive model&#46; We also assessed the multicolinearity of the final model&#46; The statistical analysis was conducted using the software package SPSS 13&#46;0 for Windows&#46; A level of statistical significance of 0&#46;05 was applied in all the tests conducted&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The total number of patients included in the final sample was 1849 corresponding to 48 provinces and 16 Spanish Autonomous Regions&#46; We excluded 35 patients who did not fulfill the age stipulated in the study protocol&#46; Of these&#44; 57&#46;1&#37; were females&#44; with a mean age of 69&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;4 years &#40;95&#37; CI&#58; 69&#46;3&#8211;70&#46;5&#41;&#46; The mean age of the males in the sample was 67&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;4 years &#40;95&#37; CI&#58; 67&#46;1&#8211;68&#46;6&#41;&#46; Up to 45&#46;4&#37; of the sample had completed primary studies&#44; 19&#46;3&#37; had no studies and the rest had completed mandatory secondary education&#44; vocational training or above&#46; A total of 46&#46;9&#37; had retired a mean 10&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7 years earlier &#40;95&#37; CI&#58; 9&#46;6&#8211;10&#46;5&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A total of 61&#46;5&#37; of the patients suffered osteoarthritis in the knee&#44; 19&#37; in the hip and 19&#46;5&#37; in both locations&#46; According to the Kellgren&#47;Lawrence scale&#44; 20&#46;2&#37; and 34&#46;4&#37; of patients presented severe or moderate osteoarthritis&#44; respectively&#46; In 23&#46;1&#37; cases&#44; the radiological osteoarthritis involvement was moderate or minimal and in the remaining 22&#46;3&#37; it had been assessed radiologically&#44; but the corresponding value to the Kellgren&#47;Lawrene scale was absent&#46; A total of 75&#46;8&#37; patients lived with someone&#44; and during the past year 20&#46;4&#37; had been admitted to hospital&#44; 22&#46;6&#37; had suffered a fall&#44; resulting in fracture in 34&#37; of cases&#46; In total there were 50 fractures in 209 patients &#40;11&#46;3&#37;&#41;&#46; Moreover&#44; 34 &#40;1&#46;84&#37;&#41; and 7 &#40;0&#46;38&#37;&#41; patients suffered 2 and 3 fractures&#44; respectively&#46; The location of these fractures was&#58; Colles &#40;37&#46;3&#37;&#41;&#44; hip &#40;24&#46;4&#37;&#41;&#44; vertebral &#40;12&#46;9&#37;&#41; and knee &#40;8&#46;7&#37;&#41;&#46; The addition of humeral&#44; tibial or fibular&#44; foot and hand fractures corresponded to 16&#46;7&#37;&#46; A further 26&#46;7&#37; presented diagnosis of osteoporosis and between 4&#37; and 8&#37; of patients also suffered polymyalgia&#44; arthritis or fibromyalgia&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents other clinical characteristics of the studied sample&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In total&#44; 99&#46;24&#37; of patients responded to the WOMAC questionnaire&#59; the scores are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The rate of response of patients to the SF-12v2 questionnaire was of 95&#46;89&#37;&#44; whilst the figure for researchers was 96&#46;32&#37;&#46; The mean HRQoL scores obtained through the SF-12v2 were lower compared to the reference value for the US&#44; which is 50&#46; The perception by patients of their health status differed from that of their physicians in the dimensions&#58; physical function&#44; body pain and general health&#44; which is reflected in the SCP &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The WOMAC scores were significantly correlated with those of the SF12-v2 in the dimensions assessing physical health&#44; both from the perception of patients &#40;pain&#58; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>0&#46;627&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; rigidity&#58; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>0&#46;586&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;&#46;001 and functional capacity&#58; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>0&#46;736&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and of researchers &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>0&#46;514&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>0&#46;493&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 and <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;595&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; respectively&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The analysis of the sample grouped by ages showed that the frequency of fractures associated to falls was 12&#37; in the group aged between 50&#8211;59 years&#44; 21&#46;2&#37; in the group aged between 60&#8211;69 years and 66&#46;8&#37; among patients aged &#8805;70 years&#46; The WOMAC scores worsened significantly as age increased &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Both patients and researchers assigned worse scores in physical and mental health assessed through the SF-12v2 to the group of patients aged 70 years or over&#44; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; in relation to the other two&#44; younger age groups&#41; and also a worse score in the physical component for patients aged between 60 and 69 years &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; than the group aged under 60 years&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">When analyzing the sample grouped by the location of osteoarthritis into 3 groups&#58; knee&#44; hip and both knee and hip&#44; we found a frequency of fractures of 40&#46;6&#37; among patients with knee osteoarthritis&#44; 20&#46;8&#37; among those with hip osteoarthritis and 38&#46;6&#37; among patients with osteoarthritis in both locations&#46; The scores of the 3 dimensions assessed by the WOMAC revealed a significant difference between the 3 groups&#44; with the worse assessment found in the group of patients with osteoarthritis in both locations&#46; According to the assessment of patients through the SF-12v2 questionnaire&#44; osteoarthritis in both locations worsened physical and mental health when compared to the presence of osteoarthritis in a single joint &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The same result was obtained through the responses of researchers&#44; but&#44; in addition&#44; their scores showed a significant difference &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; between patients with knee osteoarthritis and patients with hip osteoarthritis in the dimensions of body pain&#44; general health and social function&#44; which corresponded to the physical component&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The result of the multivariate analysis of the association between the WOMAC scores and the characteristics of patients is presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Both the Kellgren&#47;Lawrence scale and the Timed UP &#38; Go test were significantly associated with the WOMAC in its 3 dimensions&#44; as well as with the scores of the SF-12v2 &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; In this case&#44; age and the time of evolution of knee pain also showed a significant association&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">This study assessed the perception of quality of life among patients with knee and hip osteoarthritis from the perspectives of both patients and physicians&#46; This is the most extensive study on quality of life in patients with knee and hip osteoarthritis conducted in Spain&#44; both in terms of number of patients and in scope&#44; as it included researchers and patients from 16 Spanish Autonomous Regions&#44; so we estimate that its results could be considered as reference values for the Spanish population aged 50 years and older&#44; with knee and&#47;or hip osteoarthritis&#46; The selection of patients limited by age&#44; was based on the prevalence of knee<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and hip osteoarthritis among the Spanish population and on the clinical criteria of the ACR which are the most extensively used and validated&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Collection of sociodemographic and clinical data was carried out through a specially designed instrument&#44; whereas the quality of life of patients with osteoarthritis was assessed with the WOMAC questionnaire&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> which is a specifically adapted and validated instrument for the Spanish population&#44; and widely used in clinical practice&#46; The SF-12v2 questionnaire&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> in its Spanish version&#44; was applied as a generic instrument to assess HRQoL&#44; as it reproduces the reliability and validity of the SF-36 and because it is the questionnaire recommended to assess samples of over 500 individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Since we did not have reference values for the SF-12v2 for the general Spanish population&#44; we proceeded like other authors&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> that is&#44; the scores were standardized and recoded according to the values of the American population&#44; as recommended to compare the data from populations of different countries&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">As for the validation of the Spanish version of the WOMAC&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> where the results are correlated to the dimensions of the generic SF-36 questionnaire&#44; in this study we observed a significant correlation of the WOMAC with the dimensions of the SF-12v2 which assess physical health&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Both patients and researchers gave higher scores to HRQoL in its mental dimension than to quality of life related to physical health of patients with osteoarthritis&#44; with similar SCM values in both groups &#40;48&#46;34 <span class="elsevierStyleItalic">vs</span> 48&#46;25&#44; respectively&#41;&#46; This result agrees with the assessment obtained using the SF-12v2 questionnaire&#44; among the Spanish diabetic population&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">One of the objectives of this study was to contrast the values of the SF-12v2 as completed independently by patients and researchers in order to compare their perceptions of the health of patients&#46; The results indicate that physical health perceived by physicians was better than that indicated by patients&#44; since the score in three of the dimensions assessing the physical component was significantly higher than that assigned by the patients &#40;SCP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;61 <span class="elsevierStyleItalic">vs</span> 35&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;53&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">HRQoL as assessed by the SF-12v2 and WOMAC questionnaires became worse as the age of the patients increased&#44; becoming more evident in the scores which measured physical function in patients aged &#8805;70 years&#44; which could be explained by the fact that osteoarthritis is a progressive disease and&#44; in addition&#44; in this group of patients&#44; the time of evolution of pain may have been longer&#46; This result corroborates the objective tests conducted on all patients&#46; Older patients presented the highest percentage of radiological evidence of severe osteoarthritis determined by the Kellgren&#47;Lawrence scale&#44; and also required more time to conduct the Timed Up &#38; Go test&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> a simple test which is recommended for use in medical consultation with elderly patients<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> to assess functional capacity&#44; and which easily detects physical limitations in these patients with hip and knee osteoarthritis&#46; The test has proven&#44; adequate sensitivity and specificity to identify patients at risk of falls in certain studies&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The WOMAC score in the dimension of pain was similar among patients with osteoarthritis in the hip and knee&#44; but worsened when both joints were affected&#46; Rigidity was greater and a worse functional capacity was observed among patients who suffered osteoarthritis in the hip or in both locations than among patients who suffered knee osteoarthritis&#46; The perception of quality of life by patients with knee or hip osteoarthritis was similar&#44; but significantly worse among patients with osteoarthritis in both locations&#46; The researchers agreed with patients in their assessments of HRQoL and the scores indicate that patients with hip osteoarthritis suffer more body pain&#44; have worse general health and social function than patients with knee osteoarthritis&#46; In a study which assessed the perception of HRQoL following total knee and hip arthroplasties&#44; patients in the knee group perceived a worse quality of life than patients in the hip group in the preoperative period&#46; However&#44; 1 year after the arthroplasty&#44; this perception became inverted&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Our results suggest that the scale of radiological osteoarthritis degrees by Kellgren&#47;Lawrence and the Timed Up &#38; Go test which objectively determine joint damage and functional capacity&#44; respectively&#44; are the most influential factors in the score of the 3 dimensions of the WOMAC questionnaire&#58; pain&#44; rigidity and functional capacity and to a similar extent among patients with osteoarthritis in the knee&#44; hip and both locations&#46; The level of education was a factor with an inverse and significant influence on the perception of pain by patients with knee osteoarthritis and a direct relationship was observed between the body mass index and rigidity among patients with knee and hip osteoarthritis&#44; probably due to the fact that joint function is worse among overweight patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The values of the Kellgren&#47;Lawrence scale and the Timed Up &#38; Go test&#44; in addition to age&#44; had the greatest influence on the scores of the items of the SF-12v2 which assessed physical health&#44; according to the information obtained from patients and their physicians&#46; The need to assess the level of osteoarthritis through objective tests was determining for the selection of researchers&#44; since specialists are most frequently responsible for requesting radiological tests&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Regarding mental health&#44; both patients and researchers included as a determining factor the time of evolution of pain&#46; It is known that patients with chronic pain suffer a progressive reduction of social life and happiness&#44; as the time suffering physical pain and perceiving a reduction of their autonomy increases&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The studied sample represented the Spanish population and the distribution according to Autonomous Regions was proportional to each of their populations&#44; but this was not adhered to strictly in all cases&#44; thus representing a limitation of this study&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">We assessed the comorbidity of osteoporosis&#44; polymyalgia&#44; arthritis and fibromyalgia&#46; Only the presence of osteoporosis appeared as a factor affecting the functional capacity of patients with hip osteoarthritis&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The decrease in quality of life reported by patients with knee and hip osteoarthritis was perceived in a similar manner by the rheumatologists and traumatologists&#46; These results could be considered as reference values for the Spanish population aged 50 years or above and suffering knee and&#47;or hip osteoarthritis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Level of evidence</span><p id="par0170" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">III</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of people and animals</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and&#47;or subjects referred to in the work&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The pharmaceutical company &#8220;Laboratorios Farmac&#233;uticos ROVI&#8221; financed the printing&#44; distribution and collection of questionnaires&#44; but did not participate in data analysis and the drafting of the manuscript&#46;</p></span></span>"
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          "identificador" => "xres366177"
          "titulo" => array:6 [
            0 => "Abstract"
            1 => "Objective"
            2 => "Materials and methods"
            3 => "Results"
            4 => "Discussion"
            5 => "Conclusion"
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        1 => array:2 [
          "identificador" => "xpalclavsec345814"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres366176"
          "titulo" => array:6 [
            0 => "Resumen"
            1 => "Objetivo"
            2 => "Material y m&#233;todo"
            3 => "Resultados"
            4 => "Discusi&#243;n"
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          "titulo" => "Palabras clave"
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          "titulo" => "Level of evidence"
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          "titulo" => "Ethical responsibilities"
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              "identificador" => "sec0035"
              "titulo" => "Protection of people and animals"
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              "titulo" => "Right to privacy and informed consent"
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          "identificador" => "xack91326"
          "titulo" => "Acknowledgements"
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        12 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-02-04"
    "fechaAceptado" => "2014-04-09"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec345814"
          "palabras" => array:4 [
            0 => "Knee osteoarthritis"
            1 => "Hip osteoarthritis"
            2 => "Quality of life"
            3 => "WOMAC Osteoarthritis Index"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec345815"
          "palabras" => array:4 [
            0 => "Artrosis de rodilla"
            1 => "Artrosis de cadera"
            2 => "Calidad de vida"
            3 => "Cuestionario WOMAC"
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        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the quality of life in patients with knee and hip osteoarthritis through self-assessment and those made by the physician&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An observational and cross-sectional multicenter study in which 628 traumatologists or rheumatologists evaluated 1849 patients with knee and&#47;or hip osteoarthritis&#44; aged &#8805;50 years old&#44; and representative of 49 Spanish provinces&#46; Each researcher evaluated three patients and also completed the SF-12v2 health questionnaire&#46; The patients completed the WOMAC and SF-12v2 questionnaires&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The patients were 68&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;5 years old&#44; 61&#46;5&#37; had knee osteoarthritis&#44; 19&#37; had hip osteoarthritis&#44; and 19&#46;5&#37; in both locations&#46; Older patients and those who had both knee and hip osteoarthritis had a poorer quality of life&#44; according to patients and researchers&#46; Physical health perceived by the researchers was better than patients reported &#40;36&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;6 and 35&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;53&#59; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and the mental health score was similar between physicians and patients&#46; Kellgren&#47;Lawrence scale and test Timed Up &#38; Go predict better the quality of life&#44; assessed by WOMAC and SF-12v2 questionnaires&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This is the Spanish study on quality of life in osteoarthritis of the knee and hip of larger amplitude and number of patients&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">These results could be considered as reference values of Spanish population aged &#8805;50 years with knee or hip osteoarthritis&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar la calidad de vida de pacientes con artrosis de rodilla y cadera a trav&#233;s de autovaloraciones y las realizadas por el m&#233;dico&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; transversal y multic&#233;ntrico en el que 628 traumat&#243;logos o reumat&#243;logos evaluaron a 1&#46;849 pacientes con artrosis de rodilla y&#47;o de cadera con edad m&#237;nima de 50 a&#241;os&#44; distribuidos en 49 provincias espa&#241;olas&#46; Cada investigador evalu&#243; a tres pacientes y cumpliment&#243; el cuestionario de salud SF-12v2&#46; Los pacientes respondieron los cuestionarios WOMAC y SF-12v2&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los pacientes ten&#237;an de 68&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;5 a&#241;os de edad&#44; el 61&#44;5&#37; ten&#237;a artrosis de rodilla&#44; el 19&#37; de cadera y el 19&#44;5&#37; en ambas localizaciones&#46; Los pacientes de m&#225;s edad y los que ten&#237;an artrosis de rodilla y de cadera presentaban peor calidad de vida&#44; seg&#250;n la opini&#243;n de los pacientes y los investigadores&#46; La salud f&#237;sica percibida por los m&#233;dicos fue mejor que la manifestada por los pacientes &#40;36&#44;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;6 y 35&#44;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;53&#59; respectivamente&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y la puntuaci&#243;n del componente mental de salud asignada por los pacientes y los m&#233;dicos fue similar&#46; La Escala de Kellgren&#47;Lawrence y el test Timed Up &#38; Go pronostican mejor la calidad de vida evaluada con los cuestionarios WOMAC y SF-12v2&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Este es el estudio espa&#241;ol sobre calidad de vida en artrosis de rodilla y cadera de mayor envergadura por amplitud y n&#250;mero de pacientes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Estos resultados podr&#237;an ser considerados como valores de referencia de poblaci&#243;n espa&#241;ola de 50 a&#241;os o mayores con artrosis de rodilla y&#47;o de cadera&#46;</p>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0045">Please cite this article as&#58; Bernad-Pineda M&#44; de las Heras-Sotos J&#44; Garc&#233;s-Puentes MV&#46; Calidad de vida en pacientes con artrosis de rodilla y&#47;o cadera&#46; Rev Esp Cir Ortop Traumatol&#46; 2014&#59;58&#58;283&#8211;289&#46;</p>"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Mean score of the dimensions of pain&#44; rigidity and functional capacity assessed with the WOMAC questionnaire according to age groups&#46; The values of <span class="elsevierStyleItalic">P</span> indicate statistically significant differences compared to the younger group&#46;</p>"
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          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">95&#37; CI&#58; 95&#37; confidence interval&#59; BMI&#58; body mass index&#59; SD&#58; standard deviation&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">68&#46;07&#8211;68&#46;93&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">76&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">11&#46;38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75&#46;67&#8211;76&#46;72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;74&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#46;70&#8211;28&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">14&#46;98&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">95&#37; CI&#58; 95&#37; confidence interval&#59; SD&#58; standard deviation&#59; WOMAC&#58; Western Ontario and McMaster Universities Osteoarthritis Index&#44; version LK 3&#46;0&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;45&#8211;8&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rigidity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;72&#8211;3&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Functional capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;92&#8211;33&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Score in the WOMAC questionnaire for knee and hip osteoarthritis completed by patients&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">95&#37; CI&#58; 95&#37; confidence interval&#59; SD&#58; standard deviation&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dimensions of SF-12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Minimum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Maximum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">SCP</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;82&#8211;35&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Researchers&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;34&#8211;37&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">SCM</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;85&#8211;48&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Researchers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;76&#8211;48&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">95&#37; CI&#58; 95&#37; confidence interval&#59; WOMAC&#58; Western Ontario and McMaster Universities Osteoarthritis Index&#44; version LK 3&#46;0&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WOMAC score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">&#946;</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Value of <span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pain &#40;R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#46;23&#59; F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">116&#46;77&#46; P&#60;&#46;001&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kellgren&#47;Lawrence scale&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;233&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;009&#8211;1&#46;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Level of studies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;0&#46;673&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;0&#46;867 to &#8722;0&#46;479&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Timed Up &#38; Go test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;044&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;032&#8211;0&#46;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Rigidity &#40;R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#46;21&#59; F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">69&#46;27&#46; P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;<span class="elsevierStyleItalic">001&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kellgren&#47;Lawrence scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;614&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;486&#8211;0&#46;742&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Timed Up &#38; Go test&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;010&#8211;0&#46;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Time of evolution of knee pain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;049&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;023&#8211;0&#46;075&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Functional capacity &#40;R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#46;26&#59; 214&#46;24&#46; p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#46;001&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kellgren&#47;Lawrence scale&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;843&#8211;6&#46;303&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;211&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;169&#8211;0&#46;254&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;3&#46;183&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kellgren&#47;Lawrence scale&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;4&#46;061&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Timed Up &#38; Go test&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;097&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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ISSN: 19888856
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