Group work - interpretation & responsiveness

This exercise requires that you have read the article:

van der Windt DA, van der Heijden GJ, de Winter AF, Koes BW, Deville W, Bouter LM. The responsiveness of the Shoulder Disability Questionnaire. Ann Rheum Dis. 1998;57(2):82-7. You can find it here.

Article summary

Some years ago, the responsiveness of the Shoulder Disability Questionnaire (SDQ) was evaluated in a general practice setting in patients with shoulder pain. The SDQ was compared with the Pain Severity Score (PSS) and Functional Status Questionnaire (FSQ).

The SDQ (shoulder Disability Questionnaire) consists of 16 items and is scored on a scale from 0–100, with higher scores indicating more severe disability (see Appendix 1 at the end of the page).

The PSS (Pain Severity Scale) is a single question about the severity of pain, scored on a scale of 0–10. The PSS is also converted to a scale of 0–100, with higher scores indicating more severe pain.

The FSQ (Functional Status Questionnaire) consists of a three-point scale (1: little discomfort during daily activities; 2: much discomfort during daily activities; 3: unable to perform daily activities).

Clinical improvements and deterioration were documented through self-reported changes since the beginning of the episode. No change and little improvement were considered clinical stability. Measurements were taken upon entrance into the study and at one and six months’ follow-up.

In the study, responsiveness was assessed in terms of Guyatt’s responsiveness ratio and a ROC curve. The most important findings are presented in Table 3 and Figure 1 (see below).

Table 3. Mean change scores (SD) and responsiveness ratios for the SDQ and PSS after 1 and 6 months.

* Substitution of missing values was conducted for patients reporting complete recovery: for 74 patients at one month (PSS only) and for 157 patients at six months (PSS and SDQ),
† Responsivess ratio: the ratio of the mean change score in clinically improved patients to the variability (SD) of change in scores in clinically stable patients.

Figure 1. ROC curves for change scores of the SDQ, PSS and FSQ at 1 month.

Note: True positive rate (sensitivity) and false positive rate (100-specificity) are for discriminating between patients reporting clinical improvement or clinical stability. Potential cut off points for the SDQ-change-score = 18.75: sensitivty 74%, specificity 77% (optimal trade off); SDQ-change-score = 40: (mean change in clinically improved patients) sensitivity 46%, specificity 98%.


1. How were the responsiveness ratios for the SDQ and PSS calculated? Can you check these calculations using the presented data?


Remember that Guyatt’s responsiveness statistic (GRS) is defined as:

GRS = (Scorepretest-Scoreposttest)improved patients/SDchange, stable patients

GRS = (Mean change-score)improved patients/SDchange, stable patients

2. What do think about the chosen external criterion? How would the responsiveness ratio change if the category ‘little improvement’ was considered ‘clinical improvement’?


Think about the validity of the external criterion (anchor).

Think about what would happen to the GRS if the dichotomisation of the anchor changed.

3. On the basis of the data in Table 3, draw an anchor-based MIC distribution after one month for the SDQ: distribution of scores for the group without clinically relevant improvement (stability) and distribution of scores for the group with clinically relevant improvement.

4. Estimate the MIC value with optimal sensitivity and specificity for the SDQ using the ROC curve.


Look carefully at Figure 1 and find the point closest to the left upper corner. Then you can estimate the sensitivity and specificity.

5. How would the MIC value change if the category ‘little improvement’ was considered ‘clinical improvement’?


Use the graph you drew in question 3. Some of the patiets would move from one graph to the other but how?

Appendix 1. The Shoulder Disability Questionnaire