SCIENTIFIC ARTICLE

Cross-cultural Adaptation and Validation of the Korean

Version of the Michigan Hand Questionnaire

Young Hak Roh, MD, Bo Kyu Yang, MD, Jung Ho Noh, MD, PhD, Goo Hyun Baek, MD, PhD,Cheol Ho Song, MD, Hyun Sik Gong, MD, PhD

Purpose The Michigan hand questionnaire (MHQ) is increasingly being used and has beenadapted cross-culturally in some Western and Asian countries, but the validation process foran Asian translation of MHQ has not been well described. In this study, we translated andadapted the original MHQ cross-culturally to produce a Korean version, and then assessedthe validity and reliability of the Korean version of the MHQ.

Methods A total of 176 patients with common hand disorders completed the Korean versionof the MHQ and the Disabilities of the Arm, Shoulder, and Hand questionnaire. We includedthe pain score assessed by a visual analog scale during activity, range of motion, measure-ment of grip strength, and subjective assessment of the functional state by use of Cooney’sscale in the validation process.

Results There were no major linguistic or cultural problems during forward and backwardtranslations of the MHQ, except for a minor change owing to cultural discrepancies in eating,such as the dominant hand using a spoon and chopsticks instead of both hands using a knifeand fork. All subscales of the MHQ showed satisfactory internal consistency. The repro-ducibility test showed no significant difference. The construct validity revealed a moderateto strong correlation between every subscale of the Korean MHQ against DASH disabilitiesand symptoms. The aesthetic and satisfaction domains, unique domains of the MHQ, hadlittle correlation with the objective measure of the pain visual analog scale, grip strength,motion and subjective functional state.

Conclusions The Korean version of MHQ showed satisfactory internal consistency, test-retestreliability, and validity and demonstrated a significant correlation with the patient-basedupper extremity questionnaire and clinical assessment. We found the application and eval-uation of the instrument to be feasible and understandable among patients in Korea. (J HandSurg 2011;36A:1497–1503. Copyright © 2011 by the American Society for Surgery of theHand. All rights reserved.)

Type of study/level of evidence Diagnostic IV.

Key words Cross-cultural adaptation, Korean translation, Michigan Hand Questionnaire,validation.

From the Department of Orthopaedics, Hand and Upper Extremity Service, Seoul National UniversityBundang Hospital, Seongnam; and National Police Hospital, Seoul, Korea.

The authors thank Peter Jin Son, Jun Suk Lee, and Victoria Hill for recommendations on the cross-cultural adaptation process, and Yoon-Hee Kim for assistance in data collection.

Received for publication March 24, 2011; accepted in revised form June 7, 2011.

No benefits in any form have been received or will be received related directly or indirectly to the

Corresponding author: Hyun Sik Gong, MD, PhD, Department of Orthopaedic Surgery, Seoul Na-tional University Bundang Hospital, Gumi-dong 300, Seongnam-si, Gyeonggi-do, 463-707, Korea;e-mail: hsgong@snu.ac.kr.

0363-5023/11/36A09-0011$36.00/0doi:10.1016/j.jhsa.2011.06.006

subject of this article.

© ASSH � Published by Elsevier, Inc. All rights reserved. � 1497

1498 KOREAN VERSION OF MICHIGAN HAND QUESTIONNAIRE

AGROWING NUMBER of questionnaires have beenintroduced to evaluate hand function and dis-ability. These have ranged from objective

measures such as range of motion and gripstrength, to more subjective measures, such aspatient satisfaction and quality of life.1,2 Never-theless, there has been a trend toward patient self-reported instruments in clinical studies from clini-cian-based (performance-based) ones, because theformer better predicts the functional status of pa-tients and the latter may not represent the patient’sview or capture the full extent of the patient’sdisability.3

The Michigan Hand Questionnaire (MHQ) is ahand-specific and patient-based subjective measure as-sessing the patient’s perception of not only function, butalso pain, satisfaction, and appearance.4 The originalMHQ has been used with almost all types of handdisorders and has proven to be reliable, valid, andresponsive to a range of upper extremity conditionssuch as carpal tunnel syndrome, distal radius fracture,and rheumatoid arthritis.5–7 Conversely, a validatedAsian translation of MHQ is not well described, whichmay be restricted owing to linguistic or socioculturaldifferences. There is growing interest in publishingoutcome studies in the field of hand surgery in Koreaand in adhering to international standards by usingvalidated outcome questionnaires.8,9 However, to date,few validated Korean versions of orthopedic upper ex-tremity assessment instruments are available other thanDisabilities of the Arm, Shoulder, and Hand question-naire (DASH), and there is no Korean version of theMHQ. The MHQ is more region-specific than theDASH in that it has questions related to the hand andmay be more sensitive to functional changes in handdisorders.10 The MHQ assesses functional status andsymptoms separately, whereas the DASH has a com-bined scale of functions/symptoms. In addition, theMHQ has unique scales of patient satisfaction andaesthetics.

To introduce a patient-based instrument created froma different culture or language, a linguistically well-translated and culturally well-adapted process of cross-cultural adaptation is required to maintain the reliabilityand content validity of the instrument at a conceptuallevel across different cultures. The use of the hand andwrist is closely related to the activities of daily living,and sociocultural or linguistic differences in the activi-ties of daily living could affect the validity of thetranslated version of the MHQ.

In the present study, we aimed to translate and cross-

culturally adapt the original MHQ to produce a Korean

JHS �Vol A, Se

version in accordance with international standards andguidelines.11–13 Our hypothesis was that the Koreanversion of MHQ would maintain reliability and validityacross different languages and cultures.

MATERIALS AND METHODSThis study consisted of 2 phases: translation and cross-cultural adaptation of the MHQ to the Korean language,and validity and reliability testing for the Korean ver-sion of the MHQ.

Translation and cross-cultural adaptation

We performed cross-cultural adaptation of the MHQfollowing the guidelines of the American Academy ofOrthopedic Surgeons Outcome Committee.13 The pro-cess consists of 6 stages: translations, synthesis, backtranslations, expert committee review, pretesting, andsubmission and appraisal by a developer.

The MHQ developer group granted the authors per-mission to undertake a Korean translation of the MHQ.Two people translated the English version of the MHQinto Korean: an orthopedic surgeon and a professionaltranslator with no medical background. During a con-ference, these 2 versions were reconciled and combinedinto a single Korean version by 2 orthopedic surgeonsand 2 nurses. Subsequently, 2 bilingual native Englishspeakers (an orthopedic resident and a professionaltranslator) retranslated the reconciled version into Eng-lish. A consensus committee composed of 2 orthopedicsurgeons, 2 nurses, a native Korean teacher of English,and a professional translator reviewed the translationwith regard to its linguistic and cultural quality. Thediscrepancy was resolved by consensus to achieve aconceptual equivalence with the original MHQ. Thepre-final version of the Korean version of the MHQ wasfield-tested on 10 Korean outpatients with hand pain ora disability, and revealed no further difficulties in com-prehensibility.

Patients

We prospectively recruited patients from January 2010 toDecember 2010 at the senior authors’ (HSG’s and GHB’s)hospital. A total of 176 consecutive patients with commonhand problems were enrolled (Table 1) and all patientsprovided informed consent. The inclusion criteria wereage 18 years or older, ability to complete the question-naires, and Korean as a first language. Patients with com-bined shoulder or elbow problems in addition to a handinjury, neurologic disease, cognitive dysfunctions, and lan-guage difficulties were excluded.

A physician collected demographic and clinical data

at the first visit. Patients with fracture immobilization

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were examined 2 weeks after fracture immobilizationhad been discontinued. A clinical investigation of pa-tients included disease duration, pain score during ac-tivities (on a visual analog scale [VAS], 0 –100mm), range of motion by a goniometer, and gripstrength by a dynamometer. Grip strength wasmeasured using a Jamar dynamometer (AsimowEngineering, Los Angeles, CA) with the elbowflexed at 90° and the forearm in neutral rotation.The results were recorded in kilograms. The fol-lowing Cooney wrist score14 subscales were used:functional status (function) (range, 0 –25), range ofmotion (ROM) (range, 0 –25), and grip strength(range, 0 –25). All patients were given the Koreanversion of the MHQ before the Korean version ofthe DASH.15 We evaluated the comprehensibilityand acceptance of the questionnaire based on com-pliance.

Analysis of reliability and validity

Reliability, which is a measure of consistency, can bedivided into internal consistency and reproducibility.16

We tested internal consistency using Cronbach’s al-pha,17 which summarizes the internal correlation of allitems on a scale. A high coefficient (range, 0–1) indi-cates a more consistent scale, pointing to a more preciseevaluation of a defined parameter by the question. ACronbach’s alpha of 0.7 or higher is considered toindicate relevant internal consistency. To test the inter-

TABLE 1. Patients’ Demographic and ClinicalCharacteristics

Variable No. Mean (range)

Gender

Male 67

Female 109

Age (y) 49 (18–75)

Affected handRight/left/bilateral

66/83/18

Symptom duration (mo) 4 (0–39)

Diagnosis

Carpal tunnel syndrome 49

Distal radius fracture 35

Entrapment tenosynovitis 34

Scaphoid fracture 18

Benign soft tissue mass 17

Osteoarthritis 14

Other 9

nal consistency of each domain to the total score of

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MHQ, we reversed the “0 to 100” score of pain domainto a “100 to 0” score by subtracting the pain score from100, because higher scores indicate more pain for thepain scale, whereas high scores indicate better handperformance for the other 5 scales. We assessed repro-ducibility (test-retest), measured by administering thesame instrument to the same patient on 2 separateoccasions when no important dimensions of health hadchanged, by administering the Korean MHQ question-naire again to the same 82 patients 1 week later. Wedetermined the correlation between the total results ofboth tests using the intraclass correlation coefficient. Acorrelation coefficient (r) of 0 means no reproducibility,whereas a value of 1 indicates a perfect correlation.

We assessed validity, which is an index of how wella test measures what it is meant to,18,19 by calculatingthe Spearman correlation coefficients between theMHQ and supposed assessments of similar dimensionsor concepts. We hypothesized that the Korean MHQscore would have an association with the DASH dis-ability/symptom (D/S) score, DASH work score,DASH sports/music (S/M) score, function state, gripstrength, range of motion, and pain during activities.The DASH questionnaire is selected for construct va-lidity because it is one of the most well-known andfrequently used region-specific measures for the assess-ment of upper extremity disability, and has been shownto be reliable and valid in patients with various upperextremity disorders (both proximal and distal).20 TheDASH has been translated into Korean and shownsatisfactory reliability and validity among Korean-speaking patients with upper extremity problems.15

RESULTS

Translation and cross-cultural adaptation

The translators perceived no major linguistic or culturalproblems in the forward and back translations of theMHQ. We encountered some minor discrepancies insome items owing to cultural differences, and somewere adapted cross-culturally. Item 3 of question C inthe activities of daily living domain (II), “Eat with aknife and fork,” was a question regarding the daily useof both hands when eating. Korean people normally usea spoon and chopsticks, and use a knife and fork onlyoccasionally when they eat Western foods. Further-more, “a spoon and chopsticks” does not involve theuse of both hands at the same time and has a differentmeaning and connotation than the original question (useof both hands simultaneously). Therefore, we changedthe question to “taking a bowl and spoon using both

hands when taking a meal.”

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1500 KOREAN VERSION OF MICHIGAN HAND QUESTIONNAIRE

Analysis of reliability and validity

A total of 176 patients completed the questionnaire andwere investigated clinically. All subjects understood thetranslated items well enough to answer them withoutdifficulty. Table 2 lists the absolute values of all scores.Six patients did not respond to item 5 of question C inthe activities of daily living domain (II), which was“wash dishes.” (The ratio of unanswered questions was2.9%.) No item had a floor or ceiling effect. Theseeffects are considered to be present when more than20% of respondents achieved the lowest or highestpossible score.

The internal consistency of each item in all domainswas high (Cronbach’s alpha, range 0.79–0.97) (Table3), and that of each domain to the total score of theMHQ was 0.84. The elimination of 1 domain in all 6domains did not result in a value less than 0.79. Alldomains correlated with the total score of the MHQgreater than 0.5. The pain domain revealed the highestdomain-total correlation and the aesthetic domain re-vealed the lowest. We analyzed the test-retest reliabilityof the Korean version of the MHQ for 22 patients. Themean difference in the total scores between the 2 testswas 3.8 � 2.9; there was no significant difference. Theintraclass coefficients of each domain scores of theMHQ ranged from 0.88 to 0.96, and that of the totalscore was 0.94 (Table 4).

With respect to the construct validity, all domains of

TABLE 2. Absolute Value of All Scores

Score Mean � SD Range

MHQ

Overall hand function 48 � 28 0–100

Activities of daily living 67 � 30 0–100

Work performance 55 � 34 0–100

Pain 57 � 26 0–100

Aesthetic 55 � 30 0–100

Satisfaction 37 � 32 0–100

DASH

Disability/symptom 32 � 24 0–92

Work 45 � 38 0–100

Sports, music 24 � 35 0–100

(Cooney score subscale)

ROM 14 � 8 0–25

Grip power 14 � 8 0–25

Functional state 17 � 10 0–25

Pain VAS–activity 38 � 32 0–100

the Korean version of the MHQ showed moderate

JHS �Vol A, Se

(0.3 � r � 0.6) to strong (r � 0.6) convergentvalidity with the individual score of the DASH D/S(Table 5). The overall hand function domain showeda moderate correlation with the individual scores ofthe DASH D/S and the DASH work domain. Theactivities of daily living domain had a moderatecorrelation with the DASH D/S, the pain VAS andthe functional state. The work performance domainhad a strong correlation with the DASH D/S as wellas a moderate correlation with the DASH work, painVAS, and functional status. The pain domain had astrong correlation with the DASH D/S and pain VASas well as a moderate correlation with the DASHwork, functional state, ROM, and grip strength. Theaesthetic and satisfaction domains had moderate cor-relation with only the DASH D/S.

DISCUSSIONThe MHQ has been translated into some European andAsian languages (http://sitemaker.umich.edu/MHQ/translations) and adapted cross-culturally without majorlinguistic or cultural discrepancies.21,22 However, someminor discrepancies have been encountered in the Ko-rean translation owing to cultural differences, and somewere adapted cross-culturally. Most patients understoodthe translated questionnaires well enough to answerwithout difficulty. Some elderly male patients did notanswer item 5 in the activities of daily living domain(II), concerning “wash dishes,” because they rarelywash dishes. This may be because the society is influ-enced by traditional gender roles based on Confucian-ism; men tend to consider housework (cooking a meal,keeping a place tidy, washing dishes, and doing laun-dry) and child care as specifically a woman’s job.23,24

This tendency was observed in previous Korean cross-cultural adaptations of other questionnaires concerningactivities of daily living.15 In addition, within a cultureinfluenced by Confucianism, people in general havebeen taught not to express their feelings too much ordisclose their emotion in front of others.23 In this study,however, pain reports or satisfaction in patients withcarpal tunnel syndrome were comparable to those ofWestern studies.6,7 It is possible that the self-administered questionnaire could better reflect feelingsin patients who may have been reluctant to express theirfeelings in an interview.

The internal consistency of each item in all domainswas high (Cronbach’s alpha; range, 0.79–0.97) (Table3), which is similar to or somewhat less than the orig-inal MHQ (range, 0.86–0.97). A very high Cronbach’salpha score of approximately 1.0 is not necessarily good

because a high Cronbach’s alpha suggests some redun-

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KOREAN VERSION OF MICHIGAN HAND QUESTIONNAIRE 1501

dancy of questions in that the question does not providenew information. The internal consistency of each do-

TABLE 3. Internal Consistency of Korean-Version M

Question Mean Score � SD

I. Overall hand function 48 � 28

Right 66 � 33

Left 62 � 31

II. Activities of dailyliving

67 � 30

Right 82 � 27

Left 78 � 29

Both 74 � 27

III. Work performance 55 � 34

IV. Pain 57 � 26

V. Aesthetic 55 � 30

Right 67 � 27

Left 67 � 28

VI. Satisfaction 37 � 32

Right 62 � 37

Left 59 � 35

TABLE 4. Test-Retest Reliability of Korean-Version MHQ

ScaleMean Difference

(95% CI)Intraclass

Correlation

I. Overall handfunction

Right 3.12 (�1.09, 7.33) 0.93

Left 3.85 (�1.16, 8.86) 0.92

II. Activities of dailyliving

Right 2.52 (�1.50, 6.54) 0.95

Left �3.20 (�8.23, 1.83) 0.93

Both 4.12 (�0.38, 8.62) 0.91

III. Work performance 1.20 (�1.92, 4.32) 0.96

IV. Pain �2.10 (�6.31, 2.11) 0.93

V. Aesthetic

Right �1.80 (�11.01, 7.41) 0.88

Left 3.10 (�3.81, 11.01) 0.90

VI. Satisfaction

Right �2.10 (�5.20, 1.00) 0.95

Left �1.50 (�5.62, 2.62) 0.94

CI, confidence interval.

main to the total score of MHQ was also high (Cron-

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bach’s alpha, 0.84) and the aesthetic domain showedthe lowest corrected item-total correlation score, 0.51.This suggests the domain is relatively less related to theremaining domains and attests to the uniqueness of theaesthetic domain in the MHQ by measuring an outcomecharacteristic different from the other so-called func-tional domain. This might be expected because mostpatients had carpal tunnel syndrome, distal radius frac-ture, or tenosynovitis and did not have a distinct defor-mity. For example, a patient with severe hand pain fromcarpal tunnel syndrome or tenosynovitis might haveconsiderable difficulty in daily activity and work buthave no aesthetic discomfort. A proper test-retest inter-val is one where patients cannot remember the contentof the questionnaire without a change in disease state. Inthe present study, we chose a 1-week interval, consid-ering the chronic nature of the patient’s hand morbidity,and revealed a high intraclass correlation coefficient inthe test-retest population of 0.94.

With regard to the construct validity, all domains ofthe Korean version of the MHQ had moderate to strongconvergent validity with the individual score of DASHD/S. The DASH work had a moderate correlationwith the overall hand function, work performance,and pain; the DASH sports/music was not associ-ated with the MHQ. A low correlation between theMHQ and the DASH sports/music was previously

nbach’slpha

Domain-TotalCorrelation

Alpha When DomainRemoved

0.669 0.805

0.95

0.96

0.690 0.799

0.96

0.97

0.85

0.97 0.621 0.813

0.85 0.718 0.795

0.507 0.835

0.79

0.80

0.519 0.834

0.96

0.96

HQ

CroA

described in the validation process of other lan-

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1502 KOREAN VERSION OF MICHIGAN HAND QUESTIONNAIRE

guage versions, which showed that these 2 instru-ments reflect different type of activities.21 Thelowest correlation with the aesthetic domain mightbe expected because the MHQ is the only instrumentto provide information on the patient’s opinion of theaesthetics. The MHQ is believed to reveal the pa-tient’s opinion of his hand’s appearance and satisfac-tion, whereas the DASH cannot reflect them and hasa distinct advantage in assessing patients with a handdeformity such as rheumatoid arthritis.5

This study had several limitations. First, sensitivityto changes or responsiveness was not included, whichmight have added strength to the validation process.Second, we used only a region-specific instrument totest construct validity, instead of a generic health-related quality of life instrument, which reflects pa-tients’ mental or general health. However, a generalhealth assessment instrument may not be sensitive indetecting the amount of hand-specific disability, and weused the DASH and Cooney’s subscales scores.

We translated and adapted the MHQ cross-culturallyto the Korean language for patients with a hand disorderaccording to internationally accepted guidelines. De-spite some cultural differences, the Korean version ofthe MHQ proved to be a reliable, valid, and reproduc-ible measure of hand problems in Korean-speakingpatients.

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TABLE 5. Correlation of Korean-Version MHQ and

Scale

DASH D/SDASHWork DAS

r P r P r

Overall hand function �0.46 .00 �0.34 .00 0.0

Activities of daily living �0.59 .00 �0.26 .00 0.0

Work performance �0.61 .00 �0.38 .00 0.0

Pain 0.63 .00 0.40 .00 �0.0

Aesthetic �0.32 .00 �0.18 .01 0.0

Satisfaction �0.48 .00 �0.17 .02 0.2

735–743.

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her Measured Variables

Pain VASFunctional

StateRange ofMotion Grip Power

P r P r P r P r P

9 0.09 .55 0.07 .64 0.22 .35 0.20 .41

0 0.32 .03 0.31 .04 0.27 .24 0.37 .11

9 0.37 .02 0.34 .03 0.27 .28 0.35 .15

6 �0.60 .00 �0.56 .00 �0.58 .02 �0.59 .02

9 0.12 .42 0.10 .53 �0.25 .28 �0.12 .62

0 0.27 .07 0.28 .06 0.06 .79 0.01 .99

Ot

H S/M

4 .5

5 .5

0 .9

5 .4

0 .9

0 .0

2000:557�586.

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