Abstracts

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic autoimmune disease that affects all synovial joints, with progressive and irreversible joint destruction.¹1. MacGregor AJ, Silman AJ. Rheumatoid arthritis: classification and epidemiology. In: Klippel JH, Dieppe PA, eds. Rheumatology. 2nd ed. London: Mosby; 1998. p. 5.2.2-6. Hand dysfunction and deformities are some of the most common manifestations of this disease and they are an important cause of morbidity, since they interfere with individuals' capacity to perform self-care, work productivity and social interactions.²2. O'Dell JR. Therapeutic strategies for rheumatoid arthritis. N Engl J Med. 2004;350(25):2591-602. ^{, 3}3. Toyama S, Tokunaga D, Fujiwara H, et al. Rheumatoid arthritis of the hand: a five-year longitudinal analysis of clinical and radiographic findings. Mod Rheumatol. 2014;24(1):69-77. A variety of methods have been used to evaluate general health status in RA patients but few have been designed to access particularly the hands.⁴4. Waljee JF, Chung KC, Kim HM, et al. Validity and responsiveness of the Michigan Hand Questionnaire in patients with rheumatoid arthritis: a multicenter, international study. Arthritis Care Res (Hoboken). 2010;62(11):1569-77.

The Michigan Hand Outcomes Questionnaire (MHQ) is a hand evaluation instrument that was conceived at the University of Michigan in 1998 using psychometric principles.⁵5. Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am. 1998;23(4):575-87. This is a self-administered instrument that has 37 items that evaluate six domains: overall hand function, activities of daily living, work performance, pain, esthetics and patient satisfaction with hand function. This instrument is intended for use among individuals with hand and wrist conditions and injuries, including arthritis. The right and left hand can be evaluated separately. It takes nearly 15 minutes to complete and has been found to be valid and reliable for measuring hand function in RA patients.⁴4. Waljee JF, Chung KC, Kim HM, et al. Validity and responsiveness of the Michigan Hand Questionnaire in patients with rheumatoid arthritis: a multicenter, international study. Arthritis Care Res (Hoboken). 2010;62(11):1569-77.

5. Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am. 1998;23(4):575-87. ^{- 6}6. Poole JL. Measures of hand function: Arthritis Hand Function Test (AHFT), Australian Canadian Osteoarthritis Hand Index (AUSCAN), Cochin Hand Function Scale, Functional Index for Hand Osteoarthritis (FIHOA), Grip Ability Test (GAT), Jebsen Hand Function Test (JHFT), and Michigan Hand Outcomes Questionnaire (MHQ). Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S189-99. The MHQ has been also translated into other languages such as German,⁷7. Knobloch K, Kuehn M, Papst S, Kraemer R, Vogt PM. German standardized translation of the michigan hand outcomes questionnaire for patient-related outcome measurement in Dupuytren disease. Plast Reconstr Surg. 2011;128(1):39e-40e. Turkish⁸8. Öksüz Ç, Akel BS, Oskay D, Leblebicioğlu G, Hayran KM. Cross-cultural adaptation, validation, and reliability process of the Michigan Hand Outcomes Questionnaire in a Turkish population. J Hand Surg Am. 2011;36(3):486-92. and Korean.⁹9. Roh YH, Yang BK, Noh JH, et al. Cross-cultural adaptation and validation of the Korean version of the Michigan hand questionnaire. J Hand Surg Am. 2011;36(9):1497-503.

OBJECTIVE

The objectives were to translate and cross-culturally adapt the original MHQ to produce a Brazilian Portuguese version, and to assess its validity.

METHODS

Type of study and sample

This was a validation study that was approved by the Research Ethics Committee of the Evangelic Society of Curitiba, Paraná, and all participants gave their signed consent prior to the interview.

Data were gathered between September 2010 and September 2012 and 60 patients were included: 30 patients to test the understanding of the initial version (used for translation and cultural adaptation) and another 30 patients to test reproducibility and construct validity. This was a convenience sample. The number used was chosen in accordance with the guidance of Beaton et al.,¹⁰10. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91. which has been used in other published papers to test the cultural validation and reproducibility of other questionnaires.¹¹11. Bähler C, Bjarnason-Wehrens B, Schmid JP, Saner H. SWISSPAQ: validation of a new physical activity questionnaire in cardiac rehabilitation patients. Swiss Med Wkly. 2013;143:w13752.

12. Jennings F, Toffolo S, de Assis MR, Natour J. Brazil Patient Knowledge Questionnaire (PKQ) and evaluation of disease-specific knowledge in patients with rheumatoid arthritis. Clin Exp Rheumatol. 2006;24(5):521-8.

13. Chiari A, Sardim CC, Natour J. Translation, cultural adaptation and reproducibility of the Cochin Hand Functional Scale questionnaire for Brazil. Clinics (Sao Paulo). 2011;66(5):731-6. ^{- 14}14. Florindo AA, Latorre MR, Santos EC, et al. Validity and reliability of the Baecke questionnaire for the evaluation of habitual physical activity among people living with HIV/AIDS. Cad Saude Publica. 2006;22(3):535-41.

All the patients investigated were users of the public healthcare system (Brazilian National Health System, SUS).

Translation and cultural adaptation

Two independent native speakers of Brazilian Portuguese who were fluent in English translated the original MHQ from English to Brazilian Portuguese in the manner recommended by Guillemin et al.¹⁵15. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46(12):1417-32. and by the guidelines of the American Academy of Orthopedic Surgeons Outcome Committee.¹⁰10. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91. This translation was reviewed by a committee composed of two rheumatologists and a physiotherapist, which then reached a consensus regarding the Brazilian Portuguese version. This version was then backtranslated to English by two native English speakers who did not know the initial questionnaire. This version was compared with the original version and was demonstrated to be semantically equivalent.

This version of the MHQ in Brazilian Portuguese (which was considered to be the test version) was administered to 30 patients with rheumatoid arthritis, who were selected from the Rheumatology Outpatient Clinic of the Evangelical University Hospital in Curitiba, Paraná, taking into account the American College of Rheumatology (ACR) classification criteria.¹⁶16. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31(3):315-24. We included patients of both genders, between 18 and 60 years of age, who were chosen according to appointment order and their willingness to participate in the study. All the patients had RA with hand and wrist involvement and their disease had been diagnosed more than one year earlier. We excluded patients with other associated rheumatic diseases, other upper limb musculoskeletal conditions, previous hand or wrist surgery, previous hand or wrist trauma in the last month or neurological diseases.

With regard to cultural equivalence, the patients' degree of understanding was measured by a yes/no answer to the question: "Do you understand what is being asked for"? Any items that were not understood by 20% of the respondents would be revised by the expert committee and the new version would be retested on 30 patients. The proportion of 20% was defined in accordance with what had been used in previous, similar published papers.¹²12. Jennings F, Toffolo S, de Assis MR, Natour J. Brazil Patient Knowledge Questionnaire (PKQ) and evaluation of disease-specific knowledge in patients with rheumatoid arthritis. Clin Exp Rheumatol. 2006;24(5):521-8. ^{, 13}13. Chiari A, Sardim CC, Natour J. Translation, cultural adaptation and reproducibility of the Cochin Hand Functional Scale questionnaire for Brazil. Clinics (Sao Paulo). 2011;66(5):731-6. ^{, 17}17. Napoles BV, Hoffman CB, Martins J, de Oliveira AS. Translation and cultural adaptation of the Penn Shoulder Score to Portuguese Language: PSS-Brazil. Rev Bras Reumatol. 2010;50(4):389-407. ^{, 18}18. Tamanini JT, D'Ancona CA, Botega NJ, Rodrigues Netto N. Validação do "King's Health Questionnaire" para o português em mulheres com incontinência urinária [Validation of the Portuguese version of the King's Health Questionnaire for urinary incontinent women]. Rev Saude Publica. 2003;37(2):203-11.

Reproducibility

A new group of 30 patients was selected using the same inclusion and exclusion criteria, after the MHQ had been tested and semantic and cultural equivalence had been attained. These patients were evaluated three times. In the first interview, two examiners administered the questionnaire on the same day to check inter-rater reproducibility. In the second interview, which was conducted 15 days later, one of the first reviewers reapplied the MHQ with the intention of verifying the inter-assessment reproducibility. The internal consistency of the multi-item subscales was assessed.

Construct validity

The construct validity was tested in the first interview through simultaneous application of the Disability of the Arm, Shoulder and Hand questionnaire (DASH),19 Visual Analogue Scale (VAS) of pain,²⁰20. Ferraz MB, Quaresma MR, Aquino LR, et al. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol. 1990;17(8):1022-24. COCHIN Hand Function Scale¹³13. Chiari A, Sardim CC, Natour J. Translation, cultural adaptation and reproducibility of the Cochin Hand Functional Scale questionnaire for Brazil. Clinics (Sao Paulo). 2011;66(5):731-6. and Health Assessment Questionnaire (HAQ).²¹21. Ferraz MB, Oliveira LM, Araujo PM, Atra E, Tugwell P. Crosscultural reliability of the physical ability dimension of the health assessment questionnaire. J Rheumatol. 1990;17(6):813-7. These instruments had already been validated for Brazilian Portuguese and they assess dysfunctions of the upper limbs (DASH and COCHIN) and general function among rheumatoid arthritis patients (HAQ).

Statistical analysis

We used descriptive statistical analysis showing the mean and standard deviation of the data. Intraclass correlation coefficient (ICC) evaluation and Bland-Altman analysis were used to assess the interobserver and intra-observer reproducibility. Internal consistency was assessed by means of Cronbach's alpha test. The Spearman correlation test was used to investigate the construct validity.

Calculations were done with the aid of the GraphPad Prism 6.0 software (GraphPad Software, Inc, La Jolla, CA, USA) and SPSS 17.0 (Chicago, IL, USA).

RESULTS

Thirty patients diagnosed with RA according to the ACR criteria¹⁶16. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31(3):315-24. were selected and participated in the initial phase of the interview. Over 80% of the patients understood all the questions in the questionnaire. The translation of the MHQ into Brazilian Portuguese, with cultural equivalence, is attached (^{Appendix 1} Appendix 1. Brazilian version of the Michigan Hand Outcomes Questionnaire ). Another 30 patients were evaluated to verify the reproducibility, internal consistency and construct validity.

There were no losses in applying the protocol. All the patients who agreed to participate completed the whole evaluation, and the evaluator checked whether each questionnaire had been completed before releasing the patient. About 30% of the patients who were invited to participate in the study did not accept the invitation and thus were not included. Table 1 shows the demographic and clinical data on the participating patients.

Table 2 shows that there were strong correlations between the results obtained in the intra and inter-examiner evaluations, with ICC ranging from 0.841 to 0.967 in the intra-examiner evaluation and ICC ranging from 0.753 to 0.921 in the inter-examiner evaluation (95% confidence interval). No patient had medication prescriptions chaged in the interval between test and retest. Only in the field of ADLs (activities of daily living) relating to the right hand was the correlation found to be lower, i.e. 0.611, which is a moderate inter-rater association. Also in Table 2, it can be seen that Cronbach's alpha was greater than 0.908 for all areas, thus indicating that the questionnaire had good internal consistency.

Table 3 and Figure 1 show the strong intra and inter-rater correlation for both hands in the final outcome from the MHQ.

Table 4 demonstrates the correlation between the domains of the MHQ and other instruments such as HAQ, DASH, DASH Work, COCHIN and VAS for pain. Taking into account the dominant hand, it can be seen that for all items of the MHQ, moderate and strong correlations (r_s ranging from -0.41 to -0.89) were found.

DISCUSSION

RA is a chronic systemic disease that causes joint damage especially in the wrist and small joints of the hands. Decreased joint mobility, reduced grip strength and deformities occur early in the disease and are some of the major determinants of the disease outcome.²²22. Dellhag B, Hosseini N, Bremell T, Ingvarsson PE. Disturbed grip function in women with rheumatoid arthritis. J Rheumatol. 2001;28(12):2624-33. Hand dysfunction is an important cause of disability in RA cases, and therefore it is important to evaluate hand joint damage in order to institute effective treatment.²³23. Arreguín Reyes R, López López CO, Alvarez Hernández E, et al. Evaluation of hand function in rheumatic disease. Validation and usefulness of the Spanish version AUSCAN, m-SACRAH and Cochin questionnaires. Reumatol Clin. 2012;8(5):250-4.

A growing number of questionnaires for evaluating hand function and the impact of RA on patients' quality of life have been introduced.²⁴24. Singh H, Kumar S, Talapatra P, et al. Assessment of hand functions in rheumatoid arthritis using SF-SACRAH (short form score for the assessment and quantification of chronic rheumatoid affections of the hands) and its correlation to disease activity. Rheumatol Int. 2012;32(11):3413-9. ^{, 25}25. Horng YS, Lin MC, Feng CT, et al. Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire in patients with hand injury. J Hand Surg Am. 2010;35(3):430-6. What a patient feels can be expressed in different ways, since discomfort, pain and disability are individual and subjective concepts.²⁶26. Badalamente M, Coffelt L, Elfar J, et al. Measurement scales in clinical research of the upper extremity, part 1: general principles, measures of general health, pain, and patient satisfaction. J Hand Surg Am. 2013;38(2):401-6; quiz 406. ^{, 27}27. Badalamente M, Coffelt L, Elfar J, et al. Measurement scales in clinical research of the upper extremity, part 2: outcome measures in studies of the hand/wrist and shoulder/elbow. J Hand Surg Am. 2013;38(2):407-12. Therefore, these questionnaires allow measurement of symptoms more objectively and enable comparison of these data between different researchers or by a single researcher, at different times of the disease in the same patient.²⁸28. Fitzpatrick R, Fletcher A, Gore S, et al. Quality of life measures in health care. I: Applications and issues in assessment. BMJ. 1992;305(6861):1074-7. ^{, 29} 29. Klokkerud M, Hagen KB, Kjeken I, et al. Development of a framework identifying domains and elements of importance for arthritis rehabilitation. J Rehabil Med. 2012;44(5):406-13.There are two possible ways to obtain a questionnaire that can be used in a certain language: creation of a questionnaire for a particular ethnic group; or translation and validation of a questionnaire that was previously developed for another language.¹⁵15. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46(12):1417-32. This second option, in addition to being more economical in terms of time and resources, allows comparison of data obtained in different countries.

The MHQ measures individuals' perceptions of their hands in terms of function, appearance, pain and satisfaction. These last three items provide an advantage for this questionnaire over the COCHIN Rheumatoid Hand Disability scale, which does not include them. Pain control and esthetics have been demonstrated to be important motivators for surgical interventions in RA patients.³⁰30. Chung KC, Kotsis SV, Kim HM, Burke FD, Wilgis EF. Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities. J Hand Surg Am. 2006;31(2):289-94. The MHQ also discriminates between the right and left hand in each performance domain, a distinction that is not offered by the Disability of the Arm, Shoulder and Hand questionnaire (DASH).¹⁹19. Orfale AC, Araújo PM, Ferraz MB, Natour J. Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the Disabilities of the Arm, Shoulder and Hand Questionnaire. Braz J Med Biol Res. 2005;38(2):293-302. ^{, 25}25. Horng YS, Lin MC, Feng CT, et al. Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire in patients with hand injury. J Hand Surg Am. 2010;35(3):430-6. DASH is also a general arm instrument.¹⁹19. Orfale AC, Araújo PM, Ferraz MB, Natour J. Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the Disabilities of the Arm, Shoulder and Hand Questionnaire. Braz J Med Biol Res. 2005;38(2):293-302.

We present here a Brazilian Portuguese version for MHQ. We have followed the validation process proposed in the guidelines of the American Academy of Orthopedic Surgeons Outcome Committee.¹⁰10. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91. The steps of translation and back-translation did not show any major linguistic or cultural discrepancies. Furthermore, the internal consistency of each item in all domains was high (Cronbach's alpha ranging from 0.86 to 0.96).

In this study, we chose a test-retest interval of two weeks. RA is a chronic disease and we believed that over a two-week period, no important changes to the disease status would occur but that this would be long enough for a patient not to recall the content of the instrument from the first interview. None of the patients had any changes in medication over this interval. Both the intraclass correlation (ranging from 0.84 to 0.96) and the interclass correlation (ranging from 0.61 to 0.92) were high, as can be seen in Figure 1.

Concerning the construct validity, we compared the Brazilian Portuguese version of MHQ with DASH, COCHIN, VAS for pain and HAQ. We found moderate to high correlations between these instruments and most of the MHQ domains, except for the following: esthetics, which showed weak correlations with HAQ, DASH and DASH Work; ADL, which showed a weak correlation with VAS; and satisfaction, which showed a weak correlation with HAQ. Since the MHQ is the only instrument that evaluates esthetics and satisfaction, this explains the weak correlation found.

One weakness of this study is that only 30 patients were included in each phase. However, this disadvantage was minimized by achieving a Cronbach's alpha for internal consistency that was higher than 0.90. Calculating Cronbach's alpha in future studies using this tool will certainly help support its validity.

Another weakness to be taken into account is the lack of economic profile information for the patients in our dataset. Although this does not affect the validation of the questionnaire, it does preclude comparisons of this characteristic in future studies.

CONCLUSION

We conclude that the Brazilian Portuguese version of the MHQ was successfully translated and adapted, with very good internal consistency, reliability and construct validity.

REFERENCES

Appendix 1. Brazilian version of the Michigan Hand Outcomes Questionnaire

Publication Dates

History