Elsevier

Injury

Volume 42, Issue 3, March 2011, Pages 253-258
Injury

Measuring wrist and hand function: Common scales and checklists

https://doi.org/10.1016/j.injury.2010.11.050Get rights and content

Abstract

Introduction

A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers’ confidence in the choice and application of these outcome instruments.

Methods

A literature search (1950–January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n = 341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist.

Results

We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties.

Conclusions

The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve.

Introduction

A 35-year-old motorcyclist presents with ulnar-distal wrist pain. Upon physical examination, you note ulnar pain on axial loading of the wrist and clicking. Radiographs reveal positive ulnar variance. Before performing wrist arthroscopy for ulnocarpal impingement, you tell the patient that these injuries can lead to progressive stiffness and delayed functional consequences. You want to select an appropriate functional outcome measure that can communicate how treatment impacts his ability to perform day-to-day activities, to participate in social activities, and to fulfil societal expectations; however, the process of selecting the instrument is overwhelming.

The plethora of available instruments across a broad spectrum of hand and wrist problems has led to a lack of standardisation in applications, including clinical trials, which has implications for the generalisability of results.19, 25 Concurrent evaluation covering aspects of injury from a number of instruments can inform, from pain and fatigue through to broader aspects of the patient's physical, psychological and social well-being.10, 12 There are disputes in the literature on how to best incorporate the patient's preferences and concerns; however, central to this debate is that appropriate measures in a trial are those that particularly address patients’ concerns.14, 17 For a decade now, the American Association of Orthopaedic Surgery (AAOS) has been involved in the development and dissemination of musculoskeletal instruments to assess the effectiveness of treatment regimens in clinical and in research settings (www.aaos.org-research-outcomes-outcomesmain.asp). In so doing, the AAOS advocates the appraisal of instrument content and provides the researcher with evidence for measurement properties, including reliability and validity in relation to the study population, which are prerequisites for appropriate instrument selection.10 Several initiatives have been proposed to assess health status instruments.33, 38 Only recently, the COSMIN study has been published. International consensus was reached on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes.29 This taxonomy explains relationships between measurement properties that were considered relevant. For instance, internal consistency is placed under the category of reliability because it only informs of the measure's extent to which the items assess the same construct, but not necessarily what it is actually measuring (which would have placed this term otherwise under the construct of validity) (Table 1).29

The responsibility of the researcher and clinician is to first formulate their research question then select a standardised instrument that addresses the primary aims of the trial. Instrument content should be scrutinised because not always do titles of instruments and their constituent scales reflect what the instrument purports to measure.41 For instance, two instruments may be measuring physical function in patients with distal radius fractures; however, one may ask about the level of help a person needs to perform specific tasks whilst, the other may ask about degree of difficulty experienced by the respondents with tasks. The purpose of this paper is to steer the reader through published reviews of patient outcome measures, in the hand and wrist literature, using quality criteria in a helpful way. Finally, we will summarise important points to consider in the selection of these instruments.

Section snippets

Search strategy

The literature search was conducted by a professional librarian (* St. Michael's Hospital, Toronto) using Ovid Medline (1950–Week 13 2010), EMBASE (1980–Week 13 2010), Health and psychosocial instruments (1985–January 2010). The search strategy included the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life) or disability evaluation or

Results

Combined databases yielded 331 results with 10 additional reviews provided by experts. Ten eligible reviews were identified, 3 of which were systematic reviews (2 hand injury and 1 on wrist injury) (Table 2). The review by Van de Ven-Stevens et al.39 was graded with a high recommendation with 6 out of the 7 categories in the quality assessment of the review fulfilled. Included in this review were 23 instruments, which assess function for the hand. The one systematic review on the wrist did not

Features of high graded systematic review of clinimetric properties

Van de Ven-Stevens et al. conducted a systematic review of outcomes assessing activities in patients with hand injury.39 Two reviewers independently screened English or Dutch articles that were found using Medline, Cochrane Library, Picarta, Occupational Therapy-seeker and CINAHL databases published between 2001 and 2006. Specific instrument names, clinimetric properties and year were used as terms in the search strategy. Their inclusion criteria were: (1) adequate description of the target

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