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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.
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).
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.
Our study has shown that the Persian version of the PRWE is valid and reliable for patients with upper extremity conditions.
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.
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.
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).
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].
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.
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.
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.
Reliability and construct validity was performed using SPSS version 16 and the significance level of P-value was set at <0.05.
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 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).
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.
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].
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).
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).
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.