PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of abjsLink to Publisher's site
 
Arch Bone Jt Surg. 2017 July; 5(4): 243–249.
Published online 2017 July.
PMCID: PMC5592366

Psychometric Properties of the Persian Version of the Patient Rated Wris t Evaluation

Abstract

Background:

The patient-rated wrist evaluation (PRWE) score is one of the most common clinical instruments used as an outcome measurement tool for distal radius fractures and other upper extremity conditions. The purpose of this study was to translate the PRWE into its Persian version and to evaluate its validity and reliability in patients with upper extremity conditions.

Methods:

One hundred and fourthly one adult patients with upper extremity conditions participated in this ethical board approved study from August 2015 to May 2016. After translating the original version of the PRWE into Persian, all patients filled out the PRWE in addition to the VAS (Visual analogue scale) and DASH questionnaires. For evaluating reliability, after three days the researchers called back some of the patients who did not receive treatment or any changes in symptoms and asked them to complete the PRWE retest (104 patients).

Results:

Cronbach’s alpha was calculated as high as 0.934, implying very reliable internal consistency. After each item deletion, the Cronbach’s alpha was still constant (range: 0.926 to 0.936). Intraclass correlation coefficient was 0.952 and this showed excellent test-retest reliability. The correlation coefficient between the PRWE and DASH scores was strong. Multivariable analysis showed an association between the PRWE and years educated.

Conclusion:

Our study has shown that the Persian version of the PRWE is valid and reliable for patients with upper extremity conditions.

Keywords: Hand Surgery, Iran, Persian, PRWE, Psychometric properties, Translation, Validation, Wrist

Introduction

In today`s orthopedic surgery, outcome measures play an important role in assessment of patients, conditions before and after treatment. Outcome measures are classified according to their subjective or objective-based questions: patient reported (subjective) outcome measures (i.e. Mayo Wrist score, Quick-DASH or Oxford Elbow Score) or physician reported (objective) outcome measures (1, 2). Also, outcome measures can classify as general health questionnaires (i.e. SF-36, SF-12) or region specific ones (i.e. SPADI, MHOQ) (3, 4).

The Patient Reported Wrist Evaluation (PRWE) is region specific questionnaire with 15 items designed to measure wrist pain and disability in activities of daily living. It was developed by MacDermid in 1998 for clinical assessment and is used for specific wrist problems such as distal radius or scaphoid fractures (5). Although a large number of upper extremity outcome measures are available such as the Disabilities of the Arm, Shoulder and Hand (DASH), the Short Form (3,6) Health Survey (SF- 36), and the PRWE, the latter questionnaire seems to be the most compatible patient-related questionnaire for wrist conditions. The PRWE is shorter and simpler to complete than other general questionnaires (6-8).

To overcome language barriers and achieve standardized measures in assessment of patients it is logical to validate standard outcome questionnaires according to language and cultural issues of index population (9-11).

The aim of this study was to translate and validate the original version of the PRWE into Persian for many reasons. First, a unique measuring instrument is necessary in prevalent diseases like upper extremity conditions. Second, using the most responsive assessment tool can lead to choosing the most useful treatment. Finally, Farsi is spoken in some countries such as Iran, Afghanistan, and Tajikistan in addition to regions around Persian Gulf, Iraq, and Pakistan.

Materials and Methods

We conducted the study in 3 phases. In phase 1, translation and cultural adaptation was done according to guidelines provided by Beaton and Guillman (12). In phase 2, a pilot study performed to pretest the acceptability and difficulties in understanding the translated items. In phase 3, we administered the final version of the Persian PRWE to patients admitted at our hand clinic.

Patient Reported Wrist Evaluation

PRWE consists of 2 subscales: Pain subscales with 5 items rated from 0-50 (0-10 for each item) and Function subscale with 10 items which are further divided into 2 sections (6 and 4 items for specific and usual activities, respectively). The score of functional subscale differs from 0-50 (0-5 for each item) (8). The PRWE total score scale is from zero to 100 and the higher score implies a higher degree of pain and disability (13).

Translation

Cross- cultural adaptation of the PRWE was conducted using forward- backward translation method (12). First, two independent native Persian translators (one orthopedic surgeon and one English teacher) with a good command of English, translated the original version of the PRWE into Persian. After merging the two questionnaires, a native English interpreter who was not aware of original PRWE, back-translated the merged questionnaire into English. Then authors and translators confirmed its concordance with the original format. There were only minor discrepancies [Figure 1].

Pilot Study

To pretest the questionnaire, 20 patients tested the comprehensiveness of the final version to identify any ambiguity. There was not any difficulty in understanding the items.

Sample size

To calculate the sample size, we used the correlation between PRWE and DASH scores. With two tailed α=0.05 and considering the medium effect size for correlation (Ρ=0.3), a sample size of 134 patients will provide 95% power. Accounting for the potential for a few incomplete or invalid questionnaires, we planned to enroll 141 patients.

Patients

One hundred and forty one adult patients with upper extremity conditions participated in this study from August 2015 to May 2016. The study received Institutional Review Board (IRB) approval from Mashhad University of Medical Sciences before enrolment and patients consented verbally to participate in the study. The inclusion criteria were: age more than 18 with an upper extremity condition, Persian fluency and having been admitted to the hand clinic of our hospital.

On the first visit, all 141 patients filled out the Persian PRWE in addition to the Persian VAS (Visual analogue scale) and Persian DASH questionnaires. At the last stage of study to evaluating test-retest reliability, after 3 days the researchers called back 104 patients who did not receive treatment and asked them to complete the Persian PRWE again.

Statistical analysis

Reliability and construct validity was performed using SPSS version 16 and the significance level of P-value was set at <0.05.

Construct validity

Construct validity is the way in which the measuring instrument evaluates what it claims by testing its correlation with already validated measuring instruments which demonstrate that they are all measuring what they are supposed to measure (14). Construct validity was assessed by testing the Persian PRWE against the Persian DASH and VAS questionnaires. Depending on the score distribution, Spearman and Pearson’s correlations were used to calculate the correlation.

Reliability testing

Reliability is measurement of the stability of results or the degree of agreement between different raters. If results are similar under the same conditions, the test is said to be reliable (15). To test reliability, several tests are required. The first method to check the reliability is calculation of internal consistency. Internal consistency of tests was measured by the Cronbach’s test that considers the coefficient alpha. Cronbach’s alpha investigates reliability by estimating an item by the item’s internal consistency. By deletion of each item, correlation between scores of remained items and total score calculated. The limit point of the Cronbach’s alpha is often designated as 0.7 or 0.75 (16).

The intraclass correlation coefficient (ICC) is another method to check the reliability in validation studies. It is used for measuring reproducibility of results (17). For evaluating reproducibility, test-retest study performed by randomly inviting 104 patients to fill out the Persian PRWE questionnaire again 3 days later. Range of ICC differs from 0.00 to 1.00 and values closer to 1 are considers as a higher correlation (8).

Demographics

Demographic characteristics of patients are shown in [Table 1]; 50.4% of patients were men and 49.6% were women with a mean age of 34.1 years. The affected right hand showed a higher rate with 43.9% of patients, followed by the left hand with 41.1% and 15% in both hands. The majority of patients who were included in our study were non-smokers and non-addicts. Duration between injury and the first visit was estimated at 24.8 months. The mean scores of the DASH and VAS were 32.4 and 8.21, respectively.

Table 1
Demographic Characteristics of Patients (n=141)

Results

Internal consistency and test-retest reliability of the Persian PRWE are shown in Table 2. Cronbach’s alpha was calculated as high as 0.934, implying excellent reliability. After each item deletion, the Cronbach’s alpha was still constant (range: 0.926 to 0.936) as shown in Table 3. Intraclass correlation coefficient was 0.952 and this showed excellent test-retest reliability. The correlation coefficient between the PRWE and DASH scores was 0.841, indicating a strong correlation, and between the PRWE and VAS score was 0.544 [Table 4].

Table 2
Internal consistency and test- retest reliability of the Persian PRWE
Table 3
Statistics analysis after item deletion
Table 4
Construct validity expressed by Spearman’s Correlation between Persian PRWE and VAS, Pearson’s Correlation

Multivariable analysis showed an association between the PRWE and years educated P<0.034 [Table 5]. Levels of education may affect wrist disabilities through occupation, as more manual jobs are practical and sometimes requires less education. Also, having a higher education may lead to a higher patient’s collaboration due to social-economic issues (18).

Table 5
Multivariable analysis of factor affecting Persian PRWE

Discussion

The goal of our study was to assess the reliability and construct validity of the Persian PRWE in patients with upper extremity conditions. According to abovementioned study Persian PRWE has excellent reliability and good validity compared to already validated Persian DASH and VAS scores.

Nowadays different types of hand and wrist disorders have been known such as carpal tunnel syndrome, arthritis, tenosynovitis, and traumatic events like distal radius fracture which is among the most common types of fracture (19, 20). Treatment and surgical outcome of all mentioned disorders need to be evaluate by a reliable instrument, especially distal radius fracture in which treatment have been a struggle as there are many treatment options such as using internal fixation, external fixation, and casting alone (21, 22). One of the useful instrument is PRWE which has been recognized as an ideal questionnaire considering its proficiency to evaluate the outcome of treatment in addition to its uncomplicated content. Consequently, it has been translated into several languages; however, there is no Persian translated version [Table 6] (5, 8, 23-25).

Table 6
Results of PRWE validation by different languages

The translated versions of the PRWE are available in several languages including Brazilian, Finnish, Danish, Korean, German, Chinese, Japanese, Swedish, and Turkish [Table 6] (7, 8, 23-30). Although some of the mentioned translated versions of the PRWE were adapted cross-culturally, our Persian version received no such modifications (8, 23, 25, 28).

Previous studies on various translated versions of the PRWE have shown an excellent internal consistency and reproducibility (7, 8, 23-26). In our study, the Cronbach’s alpha was 0.934 and intraclass correlation coefficient was 0.952, indicating the excellent reliability of our study.

Many studies have used different questionnaires such as the SF-36, DASH, Quick-DASH, and VAS to measure construct validity (7, 8, 25, 28, 29). In our study, construct validity was determined comparing the PRWE with the VAS and DASH questionnaires. The correlation coefficient between the PRWE and DASH scores and the PRWE and VAS score were 0.841 and 0.544, respectively. One study showed the same results as our study regarding moderate correlation between the PRWE and VAS, although moderate correlation was between the function subscale of the PRWE and VAS and not the pain subscale (25). As the VAS scale uses the subjective method to evaluate the quality of a variable, it might obtain inaccurate results. However, the VAS has been recognized as the most sensitive tool for pain evaluation (31-33).

In multivariable analysis, we found that the PRWE scor4e was affected only by eduction level. The higher education levels may affect wrist disabilities due to less manual jobs as well as better collaboration for treatment (18).

There were some limitations in our study. This study was performed in only two medical centers and hence they cannot represent all the Persian population. Also, we administer a non-comprehensive questionnaire like VAS to assess construct validity. Although there has been good correlation between pain subscales and VAS score.

Our study has shown that the Persian version of the PRWE is valid and reliable for patients with upper extreme disabilities.

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

References

1. Ebrahimzadeh MH, Moradi A, Vahedi E, Kachooei AR, Birjandinejad A. Validity and reliability of the persian version of shortened disabilities of the arm, shoulder and hand questionnaire (quick-dash) Int J Prev Med. 2015;8(6):e59. [PMC free article] [PubMed]
2. Ebrahimzadeh MH, Kachooei AR, Vahedi E, Moradi A, Mashayekhi Z, Hallaj-Moghaddam M, et al. Validity and cross-cultural adaptation of the persian version of the oxford elbow score. Int J Rheumatol. 2014;2014:381237. [PMC free article] [PubMed]
3. Ebrahimzadeh MH, Birjandinejad A, Kachooei AR. Cross-cultural adaptation, validation, and reliability of the michigan hand outcomes questionnaire among persian population. Hand Surg. 2015;20(1):25–31. [PubMed]
4. Ebrahimzadeh MH, Shojaei BS, golhasani-Keshtan F, Soltani-Moghaddas SH, Fattahi AS, Mazloumi SM. Quality of life and the related factors in spouses of veterans with chronic spinal cord injury. Health Qual Life Outcomes. 2013;11(1):e48. [PMC free article] [PubMed]
5. MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma. 1998;12(8):577–86. [PubMed]
6. MacDermid JC, Richards RS, Donner A, Bellamy N, Roth JH. Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture. J Hand Surg Am. 2000;25(2):330–40. [PubMed]
7. Imaeda T, Uchiyama S, Wada T, Okinaga S, Sawaizumi T, Omokawa S, et al. Reliability, validity, and responsiveness of the Japanese version of the Patient-Rated Wrist Evaluation. J Orthop Sci. 2010;15(4):509–17. [PubMed]
8. da Silva Rodrigues EK, de Cassia Registro Fonseca M, MacDermid JC. Brazilian version of the patient rated wrist evaluation (prwe-br): cross-cultural adaptation, internal consistency, test-retest reliability and construct validity. J Hand Ther. 2015;28(1):69–75. [PubMed]
9. Kachooei AR, Ebrahimzadeh MH, Erfani-Sayyar R, Salehi M, Salimi E, Razi S. Short form-mcgill pain questionnaire-2 (sf-mpq-2): a cross-cultural adaptation and validation study of the persian version in patients with knee osteoarthritis. Arch Bone Jt Surg. 2015;3(1):45–50. [PMC free article] [PubMed]
10. Ebrahimzadeh MH, Vahedi E, Baradaran A, Birjandinejad A, Seyyed-Hoseinian SH, Bagheri F, et al. Psychometric properties of the persian version of the simple shoulder test (sst) questionnaire. Arch Bone Jt Surg. 2016;4(4):387–92. [PMC free article] [PubMed]
11. Ebrahimzadeh MH, Birjandinejad A, Golhasani F, Moradi A, Vahedi E, Kachooei AR. Cross-cultural adaptation, validation, and reliability testing of the Shoulder Pain and Disability Index in the Persian population with shoulder problems. Int J Rehabil Res. 2015;38(1):84–7. [PubMed]
12. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186–91. [PubMed]
13. Walenkamp MM, de Muinck Keizer RJ, Goslings JC, Vos LM, Rosenwasser MP, Schep NW. The minimum clinically important difference of the patient-rated wrist evaluation score for patients with distal radius fractures. Clin Orthop Relat Res. 2015;473(10):3235–41. [PMC free article] [PubMed]
14. Contributors W. Construct validity Wikipedia, The Free Encyclopedia. 2017 Available at: URL: https://en.wikipedia.org/w/index.php?title=Construct_validity&oldid=774377796 .
15. Contributors W. Reliability (statistics) Wikipedia, The Free Encyclopedia. 2017 Available at: URL: https://en.wikipedia.org/w/index.php?title=Reliability_(statistics)&oldid=776006196 .
16. Christmann A, Van Aelst S. Robust estimation of Cronbach’s alpha. J Multivar Anal. 2006;97(7):1660–74.
17. Bravo G, Potvin L. Estimating the reliability of continuous measures with Cronbach’s alpha or the intraclass correlation coefficient: toward the integration of two traditions. J Clin Epidemiol. 1991;44(4-5):381–90. [PubMed]
18. MacDermid JC, Donner A, Richards RS, Roth JH. Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture. J Clin Epidemiol. 2002;55(9):849–54. [PubMed]
19. Smith ME, Auchincloss J, Ali M. Causes and consequences of hand injury. the journal of hand surgery: british &european volume. J Hand Surg Br. 1985;10(3):288–92. [PubMed]
20. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand clinics. 2012;28(2):113–25. [PMC free article] [PubMed]
21. Mehta SP, MacDermid JC, Richardson J, MacIntyre NJ, Grewal R. A systematic review of the measurement properties of the patient-rated wrist evaluation. J Orthop Sports Phys Ther. 2015;45(4):289–98. [PubMed]
22. Moradi A, Ebrahimzadeh MH, Jupiter JB. Intra-articular fractures of the distal radius: bridging external fixation in slight flexion and ulnar deviation along articular surface instead of radial shaft. Tech Hand Up Extrem Surg. 2014;18(1):41–50. [PubMed]
23. Sandelin H, Jalanko T, Huhtala H, Lassila H, Haapala J, Helkamaa T. Translation and validation of the finnish version of the patient-rated wrist evaluation questionnaire (prwe) in patients with acute distal radius fracture. Scand J Surg. 2016;105(3):204–10. [PubMed]
24. Schonnemann JO, Hansen TB, Soballe K. Translation and validation of the danish version of the patient rated wrist evaluation questionnaire. J Plast Surg Hand Surg. 2013;47(6):489–92. [PubMed]
25. Kim JK, Kang JS. Evaluation of the Korean version of the patient-rated wrist evaluation. J Plast Surg Hand Surg. 2013;26(3):238–43. [PubMed]
26. Ozturk O, Sari Z, Ozgul B, Tasyikan L. Validity and reliability of the turkish “patient-rated wrist evaluation” questionnaire. Acta Orthop Traumatol Turc. 2015;49(2):120–5. [PubMed]
27. Wilcke MT, Abbaszadegan H, Adolphson PY. Evaluation of a swedish version of the patient-rated wrist evaluation outcome questionnaire: good responsiveness, validity, and reliability, in 99 patients recovering from a fracture of the distal radius. Scand J Plast Reconstr Surg Hand Surg. 2009;43(2):94–101. [PubMed]
28. Hemelaers L, Angst F, Drerup S, Simmen BR, Wood-Dauphinee S. Reliability and validity of the German version of “the Patient-rated Wrist Evaluation (PRWE)” as an outcome measure of wrist pain and disability in patients with acute distal radius fractures. J Hand Ther. 2008;21(4):366–76. [PubMed]
29. Wah JW, Wang MK, Ping CL. Construct validity of the chinese version of the patient-rated wrist evaluation questionnaire (prwe-hong kong version) J Hand Ther. 2006;19(1):18–26. [PubMed]
30. Mellstrand Navarro C, Ponzer S, Törnkvist H, Ahrengart L, Bergström G. Measuring outcome after wrist injury: translation and validation of the swedish version of the patient-rated wrist evaluation (prwe-swe) BMC Musculoskelet Disord. 2011;12:171. [PMC free article] [PubMed]
31. Downie WW, Leatham PA, Rhind VM, Pickup ME, Wright V. The visual analogue scale in the assessment of grip strength. Ann Rheum Dis. 1978;37(4):382–4. [PMC free article] [PubMed]
32. Kilinc AS, Ebrahimzadeh MH, Lafosse L. Subacromial internal spacer for rotator cuff tendon repair:“the balloon technique” Arthroscopy. 2009 Aug;25(8):921–4. [PubMed]
33. Moradi A, Ebrahimzadeh MH, Jupiter JB. Radial Tunnel Syndrome, Diagnostic and Treatment Dilemma. Arch Bone Jt Surg. 2015 Jul;3(3):156–62. [PMC free article] [PubMed]

Articles from Archives of Bone and Joint Surgery are provided here courtesy of Mashhad University of Medical Sciences