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VALIDITY AND RELIABILITY OF THREE GENERIC OUTCOME MEASURES FOR HAND DISORDERS
VALIDITY AND RELIABILITY OF THREE GENERIC OUTCOME MEASURES FOR HAND DISORDERS R. SHARMA and J. J. DIAS From the Leicester Hand Surgery Service, Leicester Group of Hospitals, Leicester, UK
This is an assessment of three different outcome measures for the hand: the Hand Clinic Questionnaire (HCQ); the Patient Evaluation Measure (PEM); and the Hand Outcome Survey Sheet (HOSS). Each measure has been tested for its reliability and validity. The results suggest that the PEM and the HCQ are comparably consistent but the PEM is more reproducible. Both the PEM and HOSS are valid questionnaires. The PEM is suitable for use in an outpatient clinic and as a postal questionnaire. The HOSS may be used for research or audit especially when the injury has been measured using the Hand Injury Severity Score. Journal of Hand Surgery (British and European Volume, 2000) 25B: 6: 593–600 Clinicians, therapists and researchers need an outcome measure that is simple, valid and robust to assess patients with a hand ailment. Outcome measures used in hand surgery in the UK are usually administered by physiotherapists and occupational therapists (Bradley, 1993), and surgeons do not commonly use them. Furthermore, some of these measures have not been validated and different versions are often used. There are a number of objective assessments described for the hand, but most of them are time-consuming and they are rarely used in routine clinical practice. The most common assessments are grip strength, range of motion (ROM) and two-point discrimination (2PD). Specific function tests such as the Purdue peg board test, total active and total passive motion (TAM and TPM) assessment and the Moberg’s pickup test are used only occasionally. The Jebsen test, which has been extensively validated, is used by only 48% of the American Hand Therapists (King and Walsh, 1990). The use of these assessments even among therapists is occasional and patchy (Bradley, 1993). A comprehensive functional assessment is considered incomplete without a subjective assessment that includes patient satisfaction and assesses simple aspects of psychological reactions (Macey and Burke, 1995). Appearance, influence on work and other identifiable distress factors associated with a hand problem also cannot be ignored (Swanson et al., 1994). An ideal outcome measure should identify and possibly measure the impairment (altered health status) and disability. It needs to be sensitive (able to correctly identify an abnormality), specific (able to correctly identify a normal presentation), relevant, robust, simple, comparable and reproducible (Macey and Kelly, 1993). If such measures were available, they would complement the objective tests performed by surgeons and therapists during clinic attendances. There has been a proliferation of self-administered questionnaires to assess outcomes in clinical medicine. These assess many factors that can influence the outcome of intervention, many of which were not routinely measured in the past. For example the DASH (Disabilities of the Arm, Shoulder and Hand) (Hudak
et al., 1996) and the MHI (Michigan Hand Index) (Chung et al., 1998) are two assessment forms recently introduced in the USA. Three different forms that are currently in use in various centres in the UK have been tested in our outpatient clinic. Two of the three forms are self-administered questionnaires, and one is completed by the doctor. The Hand Clinic Questionnaire (HCQ) was developed in Oswestry, UK and the Patient Evaluation Measure (PEM) was reported by Macey and Burke (1995). The doctor-administered form is called the Hand Outcome Survey Sheet (HOSS), and this is modelled on the Hand Injury Severity Scoring system (HISS) (Campbell and Kay, 1996).
METHODS The Hand Clinic Questionnaire has eight questions addressing pain, stiffness, neurological change, use of the hand and appearance. There is an additional question that investigates whether the questionnaire was easy to understand. Each question has four answers ranging from good to poor for the attribute being measured (Appendix 1). The Patient Evaluation Measure uses visual analogue scales and has three parts. The first part seeks the patient’s opinion on the delivery of care. The second part is entitled ‘‘How your hand is now’’ (Hand Health Profile) and has ten questions concerning feeling, cold sensitivity, pain frequency, use for fiddly (fine dextrous) activities, movement, grip strength, activity, use for work, appearance and general attitude. The third part has three questions, which cover the overall assessment of outcome (Appendix 2). The HOSS is a doctor-administered form and combines both subjective and objective measures. The HISS (Campbell and Kay, 1996) measures the injury in four tissues: integument, skeletal, motor and neural. These four tissues and their degree of impairment form the basis for measuring the outcome in the HOSS. For each tissue a few cardinal outcomes are listed which are then assessed on a scale ranging from ‘‘a’’ to ‘‘d’’ as shown in Appendix 3. For example a flexor tendon 593
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injury will have an outcome that is assessed for the integument, the motor and the joint function categories. An appropriate distress level is marked for the particular outcome category depending on the skin healing, tendon glide and the associated joint function. The only objective assessment on this form is grip strength. This is measured by using a calibrated Jamar analogue dynamometer and is recorded for both the hands (the normal and the affected). Reliability Reliability was assessed by statistical analysis of the test results for reproducibility and internal consistency. The reproducibility was assessed by test-retest of the questionnaire. The patients were asked to fill out each questionnaire before seeing the doctor and once again after the consultation with an interval of at least 1 hour. The HOSS was re-administered by recalling the patient into the clinic after 1 hour. This time interval between completing the first and the second form was assumed to be long enough for patients to forget what they had entered in the first questionnaire, but not so long that an actual change in the disorder could occur. As multiple forms were being studied it was felt that a minimum of 1 hour was adequate. Patients were unaware that they would be asked to fill out each form twice. The answers of the first test were compared with the repeat test and the degree of agreement was calculated by measuring the weighted kappa value (k) (Landis and Koch, 1977). The k values range from 71, representing complete disagreement between the two tests, to þ1 which represents complete agreement between them (Dias et al., 1991). A kappa value of 0 signifies that the level of agreement between the two tests was that which would have been expected by chance alone. The grading method used in this study is given in Table 1. Measuring the internal consistency assesses the relationship between different questions on a form to each other. This is expressed as a coefficient, Cronbach’s alpha (a), which is the level of agreement between various questions. The different questions on each of the forms measure different aspects of hand health (in this study) and produce an overall picture of the state of the hand. A high a indicates a high internal consistency, but a perfect correlation (a=1) indicates that the items together are addressing a rather narrow aspect of a Table 1—Guidelines for the interpretation of the value of k (slightly adapted from Landis and Koch, 1977; Altman, 1991) Value of k
Strength of agreement
5 0.20 0.21–0.40 0.41–0.60 0.61–0.80 0.81–1.00
Poor Fair Moderate Good Very good
particular attribute. Hence it is suggested that the value of a should be above 0.70 but not higher than 0.90 (Streiner and Norman, 1995). The value of a for the HCQ and the PEM was calculated. Validity Validity of a measure is an assessment of the extent to which the questionnaire measures what it purports to measure. This was assessed by calculating and comparing the means of grip strength with each distress level of the HOSS and the strength of questions in the HCQ and PEM. Grip strength, measured using the Jamar analogue dynamometer, is a reliable general measure of hand outcome that has been validated (Mathiowetz et al., 1984). RESULTS A total of 35 patients recruited from the hand clinic at the Leicester Royal Infirmary were tested. This clinic manages trauma and elective hand cases, which range from fractures, tendon and neurovascular injuries for trauma, to reconstructive procedures for elective cases. The selection criterion was a patient attending the hand clinic for a follow-up appointment with an unilateral hand affliction and agreeing to take part in this study. There were 15 female and 20 male patients with an average age of 35 years (range, 11–81 years). Reliability Reproducibility by weighted kappa value (k) The mean k for the HCQ was 0.80 (Table 2). All but two k values had a ‘‘very good’’ agreement with values of 40.81. The item on ‘‘strength’’ (k=0.33) had fair agreement and that on ‘‘sensation’’ (numbness) (k=0.57) had moderate agreement. The PEM had a mean k of 0.83 and its ten questions specific to hand function (‘‘Hand Health Profile’’ – section 2), all had ‘‘good’’ or ‘‘very good’’ agreement (Table 3). The HOSS Table 2—k values for hand clinic questionnaire Question
k
95% CI
Pain frequency Pain severity Stiffness Strength Sensation (numbness) Sensation (pins/needles) Use Appearance Questionnaire
0.86 0.92 0.92 0.33 0.57 0.91 0.82 0.84 1
0.66 0.85 0.84 0.05 0.30 0.81 0.67 0.67 0.01
Mean
0.80
0.65 to 0.94
CI: confidence intervals.
to to to to to to to to to
1.05 0.99 1.00 0.61 0.83 1.02 0.96 1.02 1
HAND OUTCOME MEASURE VALIDATION
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Table 3—k values for the patient evaluation measure Question
k
Table 4—Internal consistency by Cronbach’s Alpha for the hand clinic questionnaire 95% CI Corrected item total correlation*
a value if item deleted**
0.45 0.59 0.50 0.53 0.48 0.60 0.60 0.16 70.07
0.73 0.71 0.73 0.72 0.73 0.71 0.72 0.77 0.78
a value for the complete questionnaire
0.76
Question
Treatment Same doctor Knew my case Chance to talk Listened to me Informed me
0.90 0.83 0.88 0.70 0.77
0.74 0.68 0.73 0.43 0.56
to to to to to
1.05 0.98 1.03 0.97 0.98
Hand Health Profile Feeling Pain in cold/damp Pain Use for fiddly Movement (flexible/stiff) Grip strength Activities Work Appearance (concern) Think (concern)
0.81 0.68 0.93 0.86 0.80 0.88 0.77 0.91 0.91 0.80
0.68 0.37 0.88 0.76 0.61 0.75 0.60 0.82 0.82 0.63
to to to to to to to to to to
0.93 0.99 0.98 0.96 0.98 1.01 0.93 1.00 1.00 0.96
Mean k for Hand Health Profile
0.83
0.69 to 0.97
Overall assessment Treatment satisfaction Generally (satisfaction) Better or worse
0.78 0.82 0.94
0.57 to 0.99 0.56 to 1.09 0.89 to 0.99
Mean k for the whole questionnaire
0.83
0.67 to 0.99
CI: confidence intervals.
form may not have any recorded mark if the hand was normal and for most patients only a few boxes were ticked. The agreement between the distress levels recorded on the first and the repeat forms was only moderate with a k of 0.49 with 95% confidence intervals of 0.16 and 0.83.
Internal consistency by Cronbach’s alpha value (a) The internal consistency for the individual scores in the HCQ and the PEM were assessed using a. Table 4 shows the alpha values for the HCQ and Table 5 shows the alpha values for the PEM. The ‘‘corrected item total correlation’’ column in each table is the Pearson correlation coefficient between the score for the individual item and the sum of the scores on the remaining items. For example, in Table 5 the correlation between the score on ‘‘same doctor’’ and the sum of the scores of the other questions is only 70.09. This indicates that there is not much of a correlation between the item ‘‘same doctor’’ and the other items. However the item ‘‘satisfaction generally’’ had a very high correlation (0.09) with other items. The column ‘‘alpha if item deleted’’ shows how each item affects the reliability of the scale. For example if the item ‘‘same doctor’’ is eliminated it causes the a of the scale to increase from 0.88 (a for the whole scale without any elimination) to 0.90. This will expectedly increase the reliability of the
Pain frequency Pain severity Stiffness Strength Sensation (numbness) Sensation (pins/needles) Use Appearance Questionnaire ease
*: correlation of the particular question with each other. **: the resultant a value for the whole questionnaire if that particular question is removed.
scale. The a for the HCQ was 0.76 and for the PEM was 0.88. Validity Calculating the grip strength in the affected hand as a percentage of the normal hand and using this as a ‘‘gold standard’’ outcome measure assessed validity. It was expected that a hand with a low distress level would have a high percentage of grip strength. The measured grip strength at various distress levels in the HOSS, and the particular questions on grip strength from the HCQ and the PEM were chosen and assessed. The data for the distress levels and the associated grip strength measurements are not normally distributed, hence a Spearman’s correlation coefficient was calculated. A two-tailed test for the significance was performed (Table 6). The HOSS and the PEM correctly identified that when the hand was strong the patients were usually not distressed. The correlation coefficient for the PEM and the HOSS was significant at 0.40, whereas that of the HCQ at 0.14 was not significant. The non-significant correlation of the HCQ is consistent with the mean values dropping down from 33 to 18, then back up to 31 and 27 through the four distress levels (Table 6). Simplicity The number of questions attempted in each form assessed the simplicity of each outcome measure. The HCQ in addition has a separate question to assess the ‘‘ease of understanding the questionnaire’’ which was recorded by all patients as ‘‘easy to understand’’. All the forms were relatively easy to use and it is difficult to rank the levels of ease because of the different formats and also because different assessors were involved. Doctors completed the HOSS forms while the patients filled out the HCQ and the PEM. We found the HOSS
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Table 5—Internal consistency by Cronbach’s Alpha for the Patient Evaluation Measure Question Treatment Same doctor Knew my case Chance to talk Listened to me Informed me
Corrected item total correlation
a if item deleted
70.09 0.04 0.38 0.08 0.27
0.90 0.89 0.88 0.88 0.88
0.60 0.13 0.61 0.71 0.70 0.55 0.83 0.76 0.73 0.82
0.87 0.89 0.87 0.86 0.87 0.87 0.86 0.86 0.86 0.86
Hand Health Profile Feeling Pain in cold/damp Pain Use for fiddly Movement (flexible/stiff) Grip strength Activities Work Appearance (concern) Think (concern)
Corrected item total correlation
a if item deleted
0.66 0.36 0.65 0.77 0.56 0.72 0.78 0.77 0.64 0.76
0.90 0.91 0.90 0.89 0.90 0.89 0.89 0.89 0.90 0.89 a for this section 0.91
Overall assessment Treatment satisfaction Generally (satisfaction) Better or worse
0.55 0.90 0.54
0.87 0.86 0.87
a for the complete questionnaire
0.88
The statistics in the table in italics are the a statistics for the Hand Health Profile section of the questionnaire calculated independently from the rest of the questionnaire.
Table 6—The validation of the grip strength question in the Hand Clinic Questionnaire and the Patient Evaluation Measure and the distress level in Hand Outcome Survey Sheet Item and scale
Measured grip strength (kg) mean (SD)
HCQ Strength: My My My My
hand hand hand hand
or or or or
arm arm arm arm
has normal strength is a little weak is very weak is completely weak
33 18 31 27
39 31 30 34 26 13 19
SD: Standard deviation. *: correlation not significant. **: correlation significant at 0.05 level (two-tailed).
36 28 28 7
0.137*
0.496
70.401**
0.017
70.399**
0.018
(9) (3) (6) (7) (18) (9) (16)
HOSS Distress levels: a. Normal b. Mild c. Moderate d. Severe
Two-tailed significance
(7) (13) (11) (16)
PEM The grip in my hand is now: 1 strong 2 3 4 5 6 7 weak
Spearman’s correlation coefficient
(14) (14) (13) (7)
HAND OUTCOME MEASURE VALIDATION
simple to complete and it did not intrude in the running of the clinic, as in most cases only one box had to be completed.
DISCUSSION Assessing the outcome of intervention is the only way to monitor the effectiveness of the intervention and the quality of care. This task is difficult for the hand and several techniques have been developed to look at outcomes of injury or intervention. Most are specific to a single anatomical region or a single disorder. An outcome measure is difficult to standardize owing to the wide variations in clinical presentation with respect to age, sex, occupation, personality, diagnosis and management. It is thus pertinent to look for an outcome measure that is simple and records objective and subjective measures. The aspiration is for a questionnaire that is 100% sensitive, 100% specific, timely, universally applicable, universally available and constantly comparable (Macey and Kelly, 1993). In general we believe that, for routine use, a patient-completed questionnaire is the most efficient way of collecting outcome information. Specific outcome measures need to be used for audit and comparative studies but could not be routinely used in busy hand clinics. The chosen outcome measures (HCQ, PEM and the HOSS) in this study have been assessed for reliability (reproducibility and internal consistency) and validity. The PEM was more reliable than the HCQ because of its higher k and a values. Their reproducibility, k, (PEM 0.83 and HCQ 0.80) were comparably close, but the internal consistency, a, (PEM 0.88 and HCQ 0.76) was higher for the PEM. According to the guidelines for interpretation of these values (Altman, 1991), the reliability for the PEM is ‘‘very good’’ and that for the HCQ is ‘‘good’’ (Table 1). We feel that the better reliability of the PEM is due its visual analogue scale, which is simple and easy to understand, and is used uniformly throughout the form. The HCQ on the other hand has four different statements for each question which require careful reading, hence patient literacy and comprehension become important prerequisites. Furthermore, each question in the HCQ has four distress levels. For example the question on ‘‘Strength’’ has four possible answers: normal strength, slightly weak, very weak and completely weak (Appendix 1). A difference of a single interval in such a scale will theoretically affect the result by 25%, and this will have a profound impact on the reproducibility estimate. This is reflected by this question having only fair (k=0.33) reproducibility. In contrast the PEM questions are answered by placing a single point on a scale of 1 to 7, and the same pattern is maintained for all the questions. A slight error in marking will not produce such an inappropriate score. Interestingly, the answers for the question on the ‘‘strength of the hand’’ in the HCQ did not appear to
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match the grip strength actually recorded. This could be due to the fact that the HCQ has only four interval answers as compared to seven in the PEM. It has been suggested that there is increased precision in using seven rather than four intervals (Fitzpatrick et al., 1998) and this may account for the lack of correlation between the HCQ and grip strength. The HOSS had only a moderate reproducibility in spite of the same doctor repeating the same assessment. Although definitions of the distress categories are given, it is possible that the subjective nature of most of the clinical assessments in the form may account for the differences in recording. We feel this could also be due to the large choice of clinical criteria available for marking in the form. There is no universally accepted method for assessing the validity of questionnaires but we believe that it is appropriate to use grip strength when assessing hand outcomes. Grip strength of the affected hand provides an indication of the state of the hand at any given time and therefore could be considered as an overall outcome measure for hand disorders. Grip strength has been validated for strength evaluations (Mathiowetz et al., 1984) using the Jamar grip meter, but is not a completely robust assessment of hand function and the measurements can fluctuate by between 19% and 24% (Young et al., 1989). Expressing the grip strength as a percentage of the opposite hand would theoretically counter variations in the equipment, mood of the patient, state of the hand and other effects such as the time of day. There are no agreed standards as to how strong a correlation should be between an outcome assessment on a form and its objective measurement in order to establish construct validity for the outcome measure. It has been suggested that, given typical levels of reliability for patient-based variables, a correlation coefficient of 0.60 may be strong evidence in support of construct validity (Fitzpatrick et al., 1998). The correlation of 0.40 (significant at 0.05) for the PEM and the HOSS can be considered as reasonable evidence in support of construct validity. However, the HCQ with a correlation of 0.14 (not significant) is poor by comparison and hence its validity is not proven. Based on these findings we feel that the PEM and the HOSS are reasonably valid, whereas the HCQ is not. These three outcome measures allow the accumulation of data for a wide range of disorders. The PEM and the HCQ have the advantage that they can be completed by the patient at home, thus obviating the need to attend an outpatient clinic and allowing the hospital to deliver care more economically. In contrast the HOSS has to be completed by a doctor, and thus outcome of treatment usually has to be assessed in clinic. We therefore feel that the HOSS should be reserved for audit purposes, particularly where the injury severity has also been measured using the HISS form. In summary, all the three studied techniques of assessing outcomes have their own strengths and
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weaknesses and all would be of assistance in maintaining the quality of care and continuing education. For general use, our preference is the Patient Evaluation Measure (PEM), which provides a simple, easy, reliable, internally consistent and reasonably valid method of assessing the outcomes for hand disorders. Acknowledgement We wish to thank Mr N.A. Taub, Lecturer in Medical Statistics, University of Leicester, for his help with the statistics in this study.
References Altman DG. Practical statistics for medical research, Chapman and Hall, 1991, 403–405. Bradley A (1993). An evaluation of current methods used in the assessment of outcomes in hand surgery. British Journal of Hand Therapy, 1: 4–7. Campbell DA, Kay SPJ (1996). The Hand Injury Severity Scoring System. Journal of Hand Surgery, 21B: 295–298. Chung KC, Pillsbury MS, Walters MR, Hayward RA (1998). Reliability and validity testing of the Michigan Hand Outcomes questionnaire. Journal of Hand Surgery, 23A: 575–587. Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ (1988). Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility. Journal of Bone and Joint Surgery, 70B: 299–301. Fitzpatrick R, Davey C, Buxton MJ, Jones DR (1998). Evaluating patient-based outcome measures for use in clinical trials. Health Technology Assessment, 2(14): 26–33. Hudak PL, Amadio PC, Bombardier C (1996). Development of an upper extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder, and Hand). American Journal of Industrial Medicine, 29: 602–608. King TI, Walsh WW (1990). Computers in hand therapy practice. Journal of Hand Therapy, July–September: 157–159. Landis RJ, Koch GG (1977). The measurement of observer agreement for categorical data. Biometrics, 33: 159–174. Macey AC, Burke FD (1995). Outcomes of hand surgery. Journal of Hand Surgery, 20B: 841–855. Macey A, Kelly C. The Hand. In: Pynsent PB, Fairbank JCT, Carr A (Eds) Outcome measures in orthopaedics. Oxford, Butterworth-Heinemann, 1993: 174–197. Mathiowetz V, Weber K, Volland G, Kashman N (1984). Reliability and validity of grip and pinch strength evaluations. Journal of Hand Surgery, 9A: 222–226. Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use, 2nd edn. New York, Oxford University Press, 1995: 65. Swanson AB, Goran-Hagert C, Swanson G (1987). Evaluation of impairment in the upper extremity. Journal of Hand Surgery, 12A: 896–926. Young VL, Pin P, Kraemer BA, Gould RB, Nemergut L, Pellowski M (1989). Fluctuation in grip and pinch strength among normal subjects. Journal of Hand Surgery, 14A: 125–129.
APPENDIX 1
I occasionally have stiffness Every day I have some stiffness I have constant daily stiffness 4. Strength My hand My hand My hand My hand
or or or or
arm arm arm arm
has normal strength is a little weak is very weak is completely weak
5. Sensation: numbness My hand or arm feels normal My hand or arm in places is slightly numb My hand or arm in places is severely numb My hand or arm in places has no feeling
& & & & & & & & & & &
6. Sensation: ‘‘pins and needles’’ I have no ‘‘pins and needles’’ in my hand or arm & I occasionally get ‘‘pins and needles’’ in my hand or arm & I often get ‘‘pins and needles’’ in my hand or arm & I have constant ‘‘pins and needles’’ in my hand or arm & 7. Use of my arm or hand I have normal use of my arm or hand There are a few things I cannot do There are many things I cannot do I can do nothing with my arm or hand
& & & &
8. Appearance of my arm or hand My arm or hand looks normal My arm or hand looks slightly abnormal My arm or hand looks very abnormal My arm or hand looks grossly abnormal or ugly
& & & &
Thank you and finally About this questionnaire It was easy to understand It was difficult to understand but I managed It was impossible and I needed help
& & &
Your comments please APPENDIX 2 Patient Evaluation Measure (PEM) Part 1: Treatment Please put a circle around the number that is closet to the way you feel about how things have been for you. There are no right or wrong answers. 1. Throughout my treatment I have seen the same doctor 1 2 3 4 5 6 7 every time not at all
Hand Clinic Questionnaire 1. Pain: frequency I have no pain in my arm or hand I occasionally get pain in my arm or hand I often get pain in my arm or hand I have constant or daily pain in my arm or hand
& & & &
2. When the doctor saw me, he or she knew about my case 1 2 3 4 5 6 7 very well not at all
2. Pain: severity (leave blank if you have no pain) The pain in my arm or hand is mild The pain in my arm or hand is moderate The pain in my arm or hand is severe The pain in my arm or hand is excruciating
& & & &
4. When I did talk to the doctor, he or she listened and understood me 1 2 3 4 5 6 7 very much not at all
3. Stiffness in one or more joints of the arm or hand I have no stiffness
&
3. When I was with the doctor, he or she gave me the chance to talk 1 2 3 4 5 6 7 as much as I wanted not at all
5. I was given information about my treatment and progress 1 2 3 4 5 6 7 as much as I wanted not at all
HAND OUTCOME MEASURE VALIDATION
599
8. For WORK, my hand is now 1 2 3 4 5 no problem
Part 2: How your hand is now (Hand Health Profile) 1. The FEELING in my hand is now 1 2 3 4 5 6 normal
7 abnormal
6
7 useless
9. When I look at the appearance of my hand now, I feel 1 2 3 4 5 6 7 unconcerned embarrassed and self-conscious
2. When my hand is cold and/or damp, the PAIN is now 1 2 3 4 5 6 7 non-existent unbearable
10. Generally, I think about my hand I feel 1 2 3 4 5 6 7 unconcerned very upset
3. Most of the time, the PAIN in my hand is now 1 2 3 4 5 6 7 non-existent unbearable
Part 3: Overall assessment
4. When I try to USE my hand for fiddly things, it is now 1 2 3 4 5 6 7 skillful clumsy
1. Generally, my treatment at the hospital has been 1 2 3 4 5 6 7 very satisfactory very unsatisfactory
5. Generally, when I MOVE my hand it is 1 2 3 4 5 6 7 flexible stiff
2. Generally, my hand is now 1 2 3 4 5 very satisfactory
6. The GRIP in my hand is now 1 2 3 4 5 6 strong
3. Bearing in mind my original injury or condition, my hand is now 1 2 3 4 5 6 7 better than I expected worse than I expected
7 weak
7. For everyday ACTIVITIES, my hand is now 1 2 3 4 5 6 7 no problem useless
6
Are there any other comments you wish to make? Thank you very much indeed for your help
APPENDIX 3 THE HOSS THUMB INDEX
LONG
RING
Name:
SMALL
PALM
DORSUM
WRIST
R
L
Date:
Age/Sex: Diagnosis:
a Normal: b Mild:
Not affecting function
c Moderate: Some functional defect OR interferes with work d Severe:
7 very unsatisfactory
Marked function defect. Unable to use
A. INTEGUMENT Defect
Cold sens
Stiff
Swelling
Pain
HAND
Dorsum a b c d a b c d
a b c d a b c d a b c d
Palm a b c d a b c d
a b c d a b c d a b c d
DIGIT
Dorsum a b c d a b c d
a b c d a b c d a b c d
Pulp a b c d a b c d
a b c d a b c d a b c d
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THE JOURNAL OF HAND SURGERY VOL. 25B No. 6 DECEMBER 2000
B. SKELETON Healing BREAK
a Lax
JOINT
a
b
c
b
c
Deformity d
Subluxation d
a
b
c
d
a
b
c
d
NonUnion a
b
Dislocation a
b
c
d
c
d
Swelling
a b c d a b c d
Stiff a
b
c
Swelling d
Pain
Pain
a b c d a b c d
C. MOTOR Trigger
Lag
Disrupted
Adherent
Swelling
Pain
Extensor
a
b
c
d
a
b
c
d
a
b
c
d
a
b
c
d
a b c d a b c d
Flexor
a
b
c
d
a
b
c
d
a
b
c
d
a
b
c
d
a b c d a b c d
D. NERVE 0 1 2 3 4 5 0 1 2 3 4 5
MRCS (1-5) a
b
c
d
MRCM (1-5) a
b
c
d
Tingling
Swelling
a b c d a b c d a b c d
F. GRIP STRENGTH Normal Hand
Pain
Injured Hand
Form filled by:
Received: 28 July 1999 Accepted after revision: 17 March 2000 Mr J. J. Dias, Department of Orthopaedics, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK. # 2000 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2000.0398, available online at http://www.idealibrary.com on
This is an assessment of three different outcome measures for the hand: the Hand Clinic Questionnaire (HCQ); the Patient Evaluation Measure (PEM); and the Hand Outcome Survey Sheet (HOSS). Each measure has been tested for its reliability and validity. The results suggest that the PEM and the HCQ are comparably consistent but the PEM is more reproducible. Both the PEM and HOSS are valid questionnaires. The PEM is suitable for use in an outpatient clinic and as a postal questionnaire. The HOSS may be used for research or audit especially when the injury has been measured using the Hand Injury Severity Score. Journal of Hand Surgery (British and European Volume, 2000) 25B: 6: 593–600 Clinicians, therapists and researchers need an outcome measure that is simple, valid and robust to assess patients with a hand ailment. Outcome measures used in hand surgery in the UK are usually administered by physiotherapists and occupational therapists (Bradley, 1993), and surgeons do not commonly use them. Furthermore, some of these measures have not been validated and different versions are often used. There are a number of objective assessments described for the hand, but most of them are time-consuming and they are rarely used in routine clinical practice. The most common assessments are grip strength, range of motion (ROM) and two-point discrimination (2PD). Specific function tests such as the Purdue peg board test, total active and total passive motion (TAM and TPM) assessment and the Moberg’s pickup test are used only occasionally. The Jebsen test, which has been extensively validated, is used by only 48% of the American Hand Therapists (King and Walsh, 1990). The use of these assessments even among therapists is occasional and patchy (Bradley, 1993). A comprehensive functional assessment is considered incomplete without a subjective assessment that includes patient satisfaction and assesses simple aspects of psychological reactions (Macey and Burke, 1995). Appearance, influence on work and other identifiable distress factors associated with a hand problem also cannot be ignored (Swanson et al., 1994). An ideal outcome measure should identify and possibly measure the impairment (altered health status) and disability. It needs to be sensitive (able to correctly identify an abnormality), specific (able to correctly identify a normal presentation), relevant, robust, simple, comparable and reproducible (Macey and Kelly, 1993). If such measures were available, they would complement the objective tests performed by surgeons and therapists during clinic attendances. There has been a proliferation of self-administered questionnaires to assess outcomes in clinical medicine. These assess many factors that can influence the outcome of intervention, many of which were not routinely measured in the past. For example the DASH (Disabilities of the Arm, Shoulder and Hand) (Hudak
et al., 1996) and the MHI (Michigan Hand Index) (Chung et al., 1998) are two assessment forms recently introduced in the USA. Three different forms that are currently in use in various centres in the UK have been tested in our outpatient clinic. Two of the three forms are self-administered questionnaires, and one is completed by the doctor. The Hand Clinic Questionnaire (HCQ) was developed in Oswestry, UK and the Patient Evaluation Measure (PEM) was reported by Macey and Burke (1995). The doctor-administered form is called the Hand Outcome Survey Sheet (HOSS), and this is modelled on the Hand Injury Severity Scoring system (HISS) (Campbell and Kay, 1996).
METHODS The Hand Clinic Questionnaire has eight questions addressing pain, stiffness, neurological change, use of the hand and appearance. There is an additional question that investigates whether the questionnaire was easy to understand. Each question has four answers ranging from good to poor for the attribute being measured (Appendix 1). The Patient Evaluation Measure uses visual analogue scales and has three parts. The first part seeks the patient’s opinion on the delivery of care. The second part is entitled ‘‘How your hand is now’’ (Hand Health Profile) and has ten questions concerning feeling, cold sensitivity, pain frequency, use for fiddly (fine dextrous) activities, movement, grip strength, activity, use for work, appearance and general attitude. The third part has three questions, which cover the overall assessment of outcome (Appendix 2). The HOSS is a doctor-administered form and combines both subjective and objective measures. The HISS (Campbell and Kay, 1996) measures the injury in four tissues: integument, skeletal, motor and neural. These four tissues and their degree of impairment form the basis for measuring the outcome in the HOSS. For each tissue a few cardinal outcomes are listed which are then assessed on a scale ranging from ‘‘a’’ to ‘‘d’’ as shown in Appendix 3. For example a flexor tendon 593
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injury will have an outcome that is assessed for the integument, the motor and the joint function categories. An appropriate distress level is marked for the particular outcome category depending on the skin healing, tendon glide and the associated joint function. The only objective assessment on this form is grip strength. This is measured by using a calibrated Jamar analogue dynamometer and is recorded for both the hands (the normal and the affected). Reliability Reliability was assessed by statistical analysis of the test results for reproducibility and internal consistency. The reproducibility was assessed by test-retest of the questionnaire. The patients were asked to fill out each questionnaire before seeing the doctor and once again after the consultation with an interval of at least 1 hour. The HOSS was re-administered by recalling the patient into the clinic after 1 hour. This time interval between completing the first and the second form was assumed to be long enough for patients to forget what they had entered in the first questionnaire, but not so long that an actual change in the disorder could occur. As multiple forms were being studied it was felt that a minimum of 1 hour was adequate. Patients were unaware that they would be asked to fill out each form twice. The answers of the first test were compared with the repeat test and the degree of agreement was calculated by measuring the weighted kappa value (k) (Landis and Koch, 1977). The k values range from 71, representing complete disagreement between the two tests, to þ1 which represents complete agreement between them (Dias et al., 1991). A kappa value of 0 signifies that the level of agreement between the two tests was that which would have been expected by chance alone. The grading method used in this study is given in Table 1. Measuring the internal consistency assesses the relationship between different questions on a form to each other. This is expressed as a coefficient, Cronbach’s alpha (a), which is the level of agreement between various questions. The different questions on each of the forms measure different aspects of hand health (in this study) and produce an overall picture of the state of the hand. A high a indicates a high internal consistency, but a perfect correlation (a=1) indicates that the items together are addressing a rather narrow aspect of a Table 1—Guidelines for the interpretation of the value of k (slightly adapted from Landis and Koch, 1977; Altman, 1991) Value of k
Strength of agreement
5 0.20 0.21–0.40 0.41–0.60 0.61–0.80 0.81–1.00
Poor Fair Moderate Good Very good
particular attribute. Hence it is suggested that the value of a should be above 0.70 but not higher than 0.90 (Streiner and Norman, 1995). The value of a for the HCQ and the PEM was calculated. Validity Validity of a measure is an assessment of the extent to which the questionnaire measures what it purports to measure. This was assessed by calculating and comparing the means of grip strength with each distress level of the HOSS and the strength of questions in the HCQ and PEM. Grip strength, measured using the Jamar analogue dynamometer, is a reliable general measure of hand outcome that has been validated (Mathiowetz et al., 1984). RESULTS A total of 35 patients recruited from the hand clinic at the Leicester Royal Infirmary were tested. This clinic manages trauma and elective hand cases, which range from fractures, tendon and neurovascular injuries for trauma, to reconstructive procedures for elective cases. The selection criterion was a patient attending the hand clinic for a follow-up appointment with an unilateral hand affliction and agreeing to take part in this study. There were 15 female and 20 male patients with an average age of 35 years (range, 11–81 years). Reliability Reproducibility by weighted kappa value (k) The mean k for the HCQ was 0.80 (Table 2). All but two k values had a ‘‘very good’’ agreement with values of 40.81. The item on ‘‘strength’’ (k=0.33) had fair agreement and that on ‘‘sensation’’ (numbness) (k=0.57) had moderate agreement. The PEM had a mean k of 0.83 and its ten questions specific to hand function (‘‘Hand Health Profile’’ – section 2), all had ‘‘good’’ or ‘‘very good’’ agreement (Table 3). The HOSS Table 2—k values for hand clinic questionnaire Question
k
95% CI
Pain frequency Pain severity Stiffness Strength Sensation (numbness) Sensation (pins/needles) Use Appearance Questionnaire
0.86 0.92 0.92 0.33 0.57 0.91 0.82 0.84 1
0.66 0.85 0.84 0.05 0.30 0.81 0.67 0.67 0.01
Mean
0.80
0.65 to 0.94
CI: confidence intervals.
to to to to to to to to to
1.05 0.99 1.00 0.61 0.83 1.02 0.96 1.02 1
HAND OUTCOME MEASURE VALIDATION
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Table 3—k values for the patient evaluation measure Question
k
Table 4—Internal consistency by Cronbach’s Alpha for the hand clinic questionnaire 95% CI Corrected item total correlation*
a value if item deleted**
0.45 0.59 0.50 0.53 0.48 0.60 0.60 0.16 70.07
0.73 0.71 0.73 0.72 0.73 0.71 0.72 0.77 0.78
a value for the complete questionnaire
0.76
Question
Treatment Same doctor Knew my case Chance to talk Listened to me Informed me
0.90 0.83 0.88 0.70 0.77
0.74 0.68 0.73 0.43 0.56
to to to to to
1.05 0.98 1.03 0.97 0.98
Hand Health Profile Feeling Pain in cold/damp Pain Use for fiddly Movement (flexible/stiff) Grip strength Activities Work Appearance (concern) Think (concern)
0.81 0.68 0.93 0.86 0.80 0.88 0.77 0.91 0.91 0.80
0.68 0.37 0.88 0.76 0.61 0.75 0.60 0.82 0.82 0.63
to to to to to to to to to to
0.93 0.99 0.98 0.96 0.98 1.01 0.93 1.00 1.00 0.96
Mean k for Hand Health Profile
0.83
0.69 to 0.97
Overall assessment Treatment satisfaction Generally (satisfaction) Better or worse
0.78 0.82 0.94
0.57 to 0.99 0.56 to 1.09 0.89 to 0.99
Mean k for the whole questionnaire
0.83
0.67 to 0.99
CI: confidence intervals.
form may not have any recorded mark if the hand was normal and for most patients only a few boxes were ticked. The agreement between the distress levels recorded on the first and the repeat forms was only moderate with a k of 0.49 with 95% confidence intervals of 0.16 and 0.83.
Internal consistency by Cronbach’s alpha value (a) The internal consistency for the individual scores in the HCQ and the PEM were assessed using a. Table 4 shows the alpha values for the HCQ and Table 5 shows the alpha values for the PEM. The ‘‘corrected item total correlation’’ column in each table is the Pearson correlation coefficient between the score for the individual item and the sum of the scores on the remaining items. For example, in Table 5 the correlation between the score on ‘‘same doctor’’ and the sum of the scores of the other questions is only 70.09. This indicates that there is not much of a correlation between the item ‘‘same doctor’’ and the other items. However the item ‘‘satisfaction generally’’ had a very high correlation (0.09) with other items. The column ‘‘alpha if item deleted’’ shows how each item affects the reliability of the scale. For example if the item ‘‘same doctor’’ is eliminated it causes the a of the scale to increase from 0.88 (a for the whole scale without any elimination) to 0.90. This will expectedly increase the reliability of the
Pain frequency Pain severity Stiffness Strength Sensation (numbness) Sensation (pins/needles) Use Appearance Questionnaire ease
*: correlation of the particular question with each other. **: the resultant a value for the whole questionnaire if that particular question is removed.
scale. The a for the HCQ was 0.76 and for the PEM was 0.88. Validity Calculating the grip strength in the affected hand as a percentage of the normal hand and using this as a ‘‘gold standard’’ outcome measure assessed validity. It was expected that a hand with a low distress level would have a high percentage of grip strength. The measured grip strength at various distress levels in the HOSS, and the particular questions on grip strength from the HCQ and the PEM were chosen and assessed. The data for the distress levels and the associated grip strength measurements are not normally distributed, hence a Spearman’s correlation coefficient was calculated. A two-tailed test for the significance was performed (Table 6). The HOSS and the PEM correctly identified that when the hand was strong the patients were usually not distressed. The correlation coefficient for the PEM and the HOSS was significant at 0.40, whereas that of the HCQ at 0.14 was not significant. The non-significant correlation of the HCQ is consistent with the mean values dropping down from 33 to 18, then back up to 31 and 27 through the four distress levels (Table 6). Simplicity The number of questions attempted in each form assessed the simplicity of each outcome measure. The HCQ in addition has a separate question to assess the ‘‘ease of understanding the questionnaire’’ which was recorded by all patients as ‘‘easy to understand’’. All the forms were relatively easy to use and it is difficult to rank the levels of ease because of the different formats and also because different assessors were involved. Doctors completed the HOSS forms while the patients filled out the HCQ and the PEM. We found the HOSS
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Table 5—Internal consistency by Cronbach’s Alpha for the Patient Evaluation Measure Question Treatment Same doctor Knew my case Chance to talk Listened to me Informed me
Corrected item total correlation
a if item deleted
70.09 0.04 0.38 0.08 0.27
0.90 0.89 0.88 0.88 0.88
0.60 0.13 0.61 0.71 0.70 0.55 0.83 0.76 0.73 0.82
0.87 0.89 0.87 0.86 0.87 0.87 0.86 0.86 0.86 0.86
Hand Health Profile Feeling Pain in cold/damp Pain Use for fiddly Movement (flexible/stiff) Grip strength Activities Work Appearance (concern) Think (concern)
Corrected item total correlation
a if item deleted
0.66 0.36 0.65 0.77 0.56 0.72 0.78 0.77 0.64 0.76
0.90 0.91 0.90 0.89 0.90 0.89 0.89 0.89 0.90 0.89 a for this section 0.91
Overall assessment Treatment satisfaction Generally (satisfaction) Better or worse
0.55 0.90 0.54
0.87 0.86 0.87
a for the complete questionnaire
0.88
The statistics in the table in italics are the a statistics for the Hand Health Profile section of the questionnaire calculated independently from the rest of the questionnaire.
Table 6—The validation of the grip strength question in the Hand Clinic Questionnaire and the Patient Evaluation Measure and the distress level in Hand Outcome Survey Sheet Item and scale
Measured grip strength (kg) mean (SD)
HCQ Strength: My My My My
hand hand hand hand
or or or or
arm arm arm arm
has normal strength is a little weak is very weak is completely weak
33 18 31 27
39 31 30 34 26 13 19
SD: Standard deviation. *: correlation not significant. **: correlation significant at 0.05 level (two-tailed).
36 28 28 7
0.137*
0.496
70.401**
0.017
70.399**
0.018
(9) (3) (6) (7) (18) (9) (16)
HOSS Distress levels: a. Normal b. Mild c. Moderate d. Severe
Two-tailed significance
(7) (13) (11) (16)
PEM The grip in my hand is now: 1 strong 2 3 4 5 6 7 weak
Spearman’s correlation coefficient
(14) (14) (13) (7)
HAND OUTCOME MEASURE VALIDATION
simple to complete and it did not intrude in the running of the clinic, as in most cases only one box had to be completed.
DISCUSSION Assessing the outcome of intervention is the only way to monitor the effectiveness of the intervention and the quality of care. This task is difficult for the hand and several techniques have been developed to look at outcomes of injury or intervention. Most are specific to a single anatomical region or a single disorder. An outcome measure is difficult to standardize owing to the wide variations in clinical presentation with respect to age, sex, occupation, personality, diagnosis and management. It is thus pertinent to look for an outcome measure that is simple and records objective and subjective measures. The aspiration is for a questionnaire that is 100% sensitive, 100% specific, timely, universally applicable, universally available and constantly comparable (Macey and Kelly, 1993). In general we believe that, for routine use, a patient-completed questionnaire is the most efficient way of collecting outcome information. Specific outcome measures need to be used for audit and comparative studies but could not be routinely used in busy hand clinics. The chosen outcome measures (HCQ, PEM and the HOSS) in this study have been assessed for reliability (reproducibility and internal consistency) and validity. The PEM was more reliable than the HCQ because of its higher k and a values. Their reproducibility, k, (PEM 0.83 and HCQ 0.80) were comparably close, but the internal consistency, a, (PEM 0.88 and HCQ 0.76) was higher for the PEM. According to the guidelines for interpretation of these values (Altman, 1991), the reliability for the PEM is ‘‘very good’’ and that for the HCQ is ‘‘good’’ (Table 1). We feel that the better reliability of the PEM is due its visual analogue scale, which is simple and easy to understand, and is used uniformly throughout the form. The HCQ on the other hand has four different statements for each question which require careful reading, hence patient literacy and comprehension become important prerequisites. Furthermore, each question in the HCQ has four distress levels. For example the question on ‘‘Strength’’ has four possible answers: normal strength, slightly weak, very weak and completely weak (Appendix 1). A difference of a single interval in such a scale will theoretically affect the result by 25%, and this will have a profound impact on the reproducibility estimate. This is reflected by this question having only fair (k=0.33) reproducibility. In contrast the PEM questions are answered by placing a single point on a scale of 1 to 7, and the same pattern is maintained for all the questions. A slight error in marking will not produce such an inappropriate score. Interestingly, the answers for the question on the ‘‘strength of the hand’’ in the HCQ did not appear to
597
match the grip strength actually recorded. This could be due to the fact that the HCQ has only four interval answers as compared to seven in the PEM. It has been suggested that there is increased precision in using seven rather than four intervals (Fitzpatrick et al., 1998) and this may account for the lack of correlation between the HCQ and grip strength. The HOSS had only a moderate reproducibility in spite of the same doctor repeating the same assessment. Although definitions of the distress categories are given, it is possible that the subjective nature of most of the clinical assessments in the form may account for the differences in recording. We feel this could also be due to the large choice of clinical criteria available for marking in the form. There is no universally accepted method for assessing the validity of questionnaires but we believe that it is appropriate to use grip strength when assessing hand outcomes. Grip strength of the affected hand provides an indication of the state of the hand at any given time and therefore could be considered as an overall outcome measure for hand disorders. Grip strength has been validated for strength evaluations (Mathiowetz et al., 1984) using the Jamar grip meter, but is not a completely robust assessment of hand function and the measurements can fluctuate by between 19% and 24% (Young et al., 1989). Expressing the grip strength as a percentage of the opposite hand would theoretically counter variations in the equipment, mood of the patient, state of the hand and other effects such as the time of day. There are no agreed standards as to how strong a correlation should be between an outcome assessment on a form and its objective measurement in order to establish construct validity for the outcome measure. It has been suggested that, given typical levels of reliability for patient-based variables, a correlation coefficient of 0.60 may be strong evidence in support of construct validity (Fitzpatrick et al., 1998). The correlation of 0.40 (significant at 0.05) for the PEM and the HOSS can be considered as reasonable evidence in support of construct validity. However, the HCQ with a correlation of 0.14 (not significant) is poor by comparison and hence its validity is not proven. Based on these findings we feel that the PEM and the HOSS are reasonably valid, whereas the HCQ is not. These three outcome measures allow the accumulation of data for a wide range of disorders. The PEM and the HCQ have the advantage that they can be completed by the patient at home, thus obviating the need to attend an outpatient clinic and allowing the hospital to deliver care more economically. In contrast the HOSS has to be completed by a doctor, and thus outcome of treatment usually has to be assessed in clinic. We therefore feel that the HOSS should be reserved for audit purposes, particularly where the injury severity has also been measured using the HISS form. In summary, all the three studied techniques of assessing outcomes have their own strengths and
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weaknesses and all would be of assistance in maintaining the quality of care and continuing education. For general use, our preference is the Patient Evaluation Measure (PEM), which provides a simple, easy, reliable, internally consistent and reasonably valid method of assessing the outcomes for hand disorders. Acknowledgement We wish to thank Mr N.A. Taub, Lecturer in Medical Statistics, University of Leicester, for his help with the statistics in this study.
References Altman DG. Practical statistics for medical research, Chapman and Hall, 1991, 403–405. Bradley A (1993). An evaluation of current methods used in the assessment of outcomes in hand surgery. British Journal of Hand Therapy, 1: 4–7. Campbell DA, Kay SPJ (1996). The Hand Injury Severity Scoring System. Journal of Hand Surgery, 21B: 295–298. Chung KC, Pillsbury MS, Walters MR, Hayward RA (1998). Reliability and validity testing of the Michigan Hand Outcomes questionnaire. Journal of Hand Surgery, 23A: 575–587. Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ (1988). Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility. Journal of Bone and Joint Surgery, 70B: 299–301. Fitzpatrick R, Davey C, Buxton MJ, Jones DR (1998). Evaluating patient-based outcome measures for use in clinical trials. Health Technology Assessment, 2(14): 26–33. Hudak PL, Amadio PC, Bombardier C (1996). Development of an upper extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder, and Hand). American Journal of Industrial Medicine, 29: 602–608. King TI, Walsh WW (1990). Computers in hand therapy practice. Journal of Hand Therapy, July–September: 157–159. Landis RJ, Koch GG (1977). The measurement of observer agreement for categorical data. Biometrics, 33: 159–174. Macey AC, Burke FD (1995). Outcomes of hand surgery. Journal of Hand Surgery, 20B: 841–855. Macey A, Kelly C. The Hand. In: Pynsent PB, Fairbank JCT, Carr A (Eds) Outcome measures in orthopaedics. Oxford, Butterworth-Heinemann, 1993: 174–197. Mathiowetz V, Weber K, Volland G, Kashman N (1984). Reliability and validity of grip and pinch strength evaluations. Journal of Hand Surgery, 9A: 222–226. Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use, 2nd edn. New York, Oxford University Press, 1995: 65. Swanson AB, Goran-Hagert C, Swanson G (1987). Evaluation of impairment in the upper extremity. Journal of Hand Surgery, 12A: 896–926. Young VL, Pin P, Kraemer BA, Gould RB, Nemergut L, Pellowski M (1989). Fluctuation in grip and pinch strength among normal subjects. Journal of Hand Surgery, 14A: 125–129.
APPENDIX 1
I occasionally have stiffness Every day I have some stiffness I have constant daily stiffness 4. Strength My hand My hand My hand My hand
or or or or
arm arm arm arm
has normal strength is a little weak is very weak is completely weak
5. Sensation: numbness My hand or arm feels normal My hand or arm in places is slightly numb My hand or arm in places is severely numb My hand or arm in places has no feeling
& & & & & & & & & & &
6. Sensation: ‘‘pins and needles’’ I have no ‘‘pins and needles’’ in my hand or arm & I occasionally get ‘‘pins and needles’’ in my hand or arm & I often get ‘‘pins and needles’’ in my hand or arm & I have constant ‘‘pins and needles’’ in my hand or arm & 7. Use of my arm or hand I have normal use of my arm or hand There are a few things I cannot do There are many things I cannot do I can do nothing with my arm or hand
& & & &
8. Appearance of my arm or hand My arm or hand looks normal My arm or hand looks slightly abnormal My arm or hand looks very abnormal My arm or hand looks grossly abnormal or ugly
& & & &
Thank you and finally About this questionnaire It was easy to understand It was difficult to understand but I managed It was impossible and I needed help
& & &
Your comments please APPENDIX 2 Patient Evaluation Measure (PEM) Part 1: Treatment Please put a circle around the number that is closet to the way you feel about how things have been for you. There are no right or wrong answers. 1. Throughout my treatment I have seen the same doctor 1 2 3 4 5 6 7 every time not at all
Hand Clinic Questionnaire 1. Pain: frequency I have no pain in my arm or hand I occasionally get pain in my arm or hand I often get pain in my arm or hand I have constant or daily pain in my arm or hand
& & & &
2. When the doctor saw me, he or she knew about my case 1 2 3 4 5 6 7 very well not at all
2. Pain: severity (leave blank if you have no pain) The pain in my arm or hand is mild The pain in my arm or hand is moderate The pain in my arm or hand is severe The pain in my arm or hand is excruciating
& & & &
4. When I did talk to the doctor, he or she listened and understood me 1 2 3 4 5 6 7 very much not at all
3. Stiffness in one or more joints of the arm or hand I have no stiffness
&
3. When I was with the doctor, he or she gave me the chance to talk 1 2 3 4 5 6 7 as much as I wanted not at all
5. I was given information about my treatment and progress 1 2 3 4 5 6 7 as much as I wanted not at all
HAND OUTCOME MEASURE VALIDATION
599
8. For WORK, my hand is now 1 2 3 4 5 no problem
Part 2: How your hand is now (Hand Health Profile) 1. The FEELING in my hand is now 1 2 3 4 5 6 normal
7 abnormal
6
7 useless
9. When I look at the appearance of my hand now, I feel 1 2 3 4 5 6 7 unconcerned embarrassed and self-conscious
2. When my hand is cold and/or damp, the PAIN is now 1 2 3 4 5 6 7 non-existent unbearable
10. Generally, I think about my hand I feel 1 2 3 4 5 6 7 unconcerned very upset
3. Most of the time, the PAIN in my hand is now 1 2 3 4 5 6 7 non-existent unbearable
Part 3: Overall assessment
4. When I try to USE my hand for fiddly things, it is now 1 2 3 4 5 6 7 skillful clumsy
1. Generally, my treatment at the hospital has been 1 2 3 4 5 6 7 very satisfactory very unsatisfactory
5. Generally, when I MOVE my hand it is 1 2 3 4 5 6 7 flexible stiff
2. Generally, my hand is now 1 2 3 4 5 very satisfactory
6. The GRIP in my hand is now 1 2 3 4 5 6 strong
3. Bearing in mind my original injury or condition, my hand is now 1 2 3 4 5 6 7 better than I expected worse than I expected
7 weak
7. For everyday ACTIVITIES, my hand is now 1 2 3 4 5 6 7 no problem useless
6
Are there any other comments you wish to make? Thank you very much indeed for your help
APPENDIX 3 THE HOSS THUMB INDEX
LONG
RING
Name:
SMALL
PALM
DORSUM
WRIST
R
L
Date:
Age/Sex: Diagnosis:
a Normal: b Mild:
Not affecting function
c Moderate: Some functional defect OR interferes with work d Severe:
7 very unsatisfactory
Marked function defect. Unable to use
A. INTEGUMENT Defect
Cold sens
Stiff
Swelling
Pain
HAND
Dorsum a b c d a b c d
a b c d a b c d a b c d
Palm a b c d a b c d
a b c d a b c d a b c d
DIGIT
Dorsum a b c d a b c d
a b c d a b c d a b c d
Pulp a b c d a b c d
a b c d a b c d a b c d
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THE JOURNAL OF HAND SURGERY VOL. 25B No. 6 DECEMBER 2000
B. SKELETON Healing BREAK
a Lax
JOINT
a
b
c
b
c
Deformity d
Subluxation d
a
b
c
d
a
b
c
d
NonUnion a
b
Dislocation a
b
c
d
c
d
Swelling
a b c d a b c d
Stiff a
b
c
Swelling d
Pain
Pain
a b c d a b c d
C. MOTOR Trigger
Lag
Disrupted
Adherent
Swelling
Pain
Extensor
a
b
c
d
a
b
c
d
a
b
c
d
a
b
c
d
a b c d a b c d
Flexor
a
b
c
d
a
b
c
d
a
b
c
d
a
b
c
d
a b c d a b c d
D. NERVE 0 1 2 3 4 5 0 1 2 3 4 5
MRCS (1-5) a
b
c
d
MRCM (1-5) a
b
c
d
Tingling
Swelling
a b c d a b c d a b c d
F. GRIP STRENGTH Normal Hand
Pain
Injured Hand
Form filled by:
Received: 28 July 1999 Accepted after revision: 17 March 2000 Mr J. J. Dias, Department of Orthopaedics, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK. # 2000 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2000.0398, available online at http://www.idealibrary.com on