e

SCIENTIFIC ARTICLE

Cross-Cultural Adaptation, Validation, and Reliability

Process of the Michigan Hand Outcomes Questionnaire

in a Turkish Population

Çigdem Öksüz, PtPhD, Burcu Semin Akel, PtPhD, Deran Oskay, PtPhD, Gursel Leblebicioglu, MD, PhD,K. Mutlu Hayran, MD, PhD

Purpose The Michigan Hand Outcomes Questionnaire (MHQ) is a domain-specific question-naire that was developed to be used as a standardized instrument capable of measuringoutcomes for patients with all types of hand disorders. The purpose of this study was todevelop the Turkish version of the MHQ and to examine whether it is a valid and reliabletool for assessing the outcomes in hand disorders.

Methods Translation and back-translation of the MHQ were performed, according to pub-lished guidelines. A total of 70 patients with hand complaints completed the final version ofthe MHQ and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaireTurkish version (DASH-T) twice, on their first visit and after an interval of 7 days. Visualanalog scale (VAS) results for pain intensity and grip strength measurements of theindividuals were also taken in both assessments consecutively.

Results Translation and back-translation revealed no major difficulties. The Turkish versionof the MHQ met set criteria of reliability and validity. The intraclass correlation coefficientof the test–retest reliability for the 6 subscales ranged from 0.79 to 0.96. The internalconsistency of the MHQ, estimated by Cronbach’s alpha, ranged from 0.85 to 0.96 for allsubscale scores. There were high to moderate correlations between MHQ and DASH scoresand VAS and grip strength scores of the injured side.

Conclusions The Turkish version of the MHQ has excellent test–retest reliability and validity,and it is an adequate and useful instrument for measuring functional disability in handdisorders of Turkish-speaking patients. (J Hand Surg 2011;36A:486–492. Copyright © 2011by the American Society for Surgery of the Hand. All rights reserved.)

Key words Cross-cultural adaptation, Michigan Hand Outcomes Questionnaire, outcomemeasures, Turkish version.

Haaf

MANY OBJECTIVE OUTCOME methods, such assensibility, grip and pinch strength, range ofmotion, and dexterity tests, have been used to

valuate physical function in upper extremity disorders.

From the Hacettepe University, Faculty of Health Science, Department of Physiotherapy andRehabilitation, Samanpazari Ankara, Turkiye; Gazi University, Faculty of Health Science, De-partment of Physiotherapy and Rehabilitation, Besevler Ankara, Turkiye; Hacettepe University,Faculty of Medicine, Department of Orthopedics and Traumatology, Samanpazari Ankara, Tur-kiye; Hacettepe University, Faculty of Medicine, Department of Preventative Oncology, Saman-pazari Ankara, Turkiye.

Received for publication November 6, 2010; accepted in revised form November 9, 2010.

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

owever, none of these assessment methods reflect thectual use of the upper extremity in daily living. Self-dministered questionnaires were introduced to assessunctional outcomes subjectively.1,2 These question-

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: Çigdem Öksüz, PtPhD, Hacettepe Universitesi Saglik BilimleriFakültesi Fizyoterapi ve Rehabilitasyon Bölümü, 06100 Samanpazari Ankara, Turkiye;e-mail: cigdemoksuz@yahoo.com.

0363-5023/11/36A03-0018$36.00/0

doi:10.1016/j.jhsa.2010.11.016

TURKISH VERSION OF THE MICHIGAN HAND QUESTIONNAIRE 487

naires provides information on the patient’s perceptionof symptoms and functional status.2

Most of the functional status questionnaires are con-structed in English. Cross-cultural adaptation of vali-dated outcome instruments has been advocated to facil-itate their use in international, multicenter clinicaltrials.3 Direct translation of questionnaires into otherlanguages does not guarantee maintenance of validity.It is well recognized that, if measures are to be usedacross cultures, the items must be not only translatedlinguistically but also adapted culturally to maintain thecontent validity of the instrument across different cul-tures. To maintain the validity of the original instru-ment, while taking into consideration important culturaldifferences, a specific methodology has been developedfor the adaptation process.3,4 This would also reduce theneed for developing new instruments that have the samepurpose.5

The MHQ is a domain-specific questionnaire thatwas developed to be used as a standardized instrumentcapable of measuring outcomes for patients with alltypes of hand disorders.6 It was developed to measurehealth state domains that are important to patients withhand disorders. The instrument can be used to evaluatea patient before hand surgery and to monitor functionafter the surgery. The validity, reliability, and respon-siveness have been reported for a variety of upperextremity conditions.1,7–9

The purpose of the study was to perform cross-cultural adaptation of MHQ and examine whether it isa valid and reliable tool for assessing the outcomes inhand disorders. The process of translation and adapta-tion is stated in detail to guide other researchers who areinterested in translating a widely available outcomesinstrument for international application.

MATERIALS AND METHODSThe study was divided into 2 phases. First, theEnglish version of the MHQ was translated intoTurkish and the MHQ was developed through across-cultural adaptation process. Second, theMHQ was tested on patients with hand problems toverify its reliability and validity.

Translation and cross-cultural adaptation

The cross-cultural adaptation process was performed byfollowing the guidelines provided by Ruberto et al andBeaton et al.4,10 Two forward translations were carriedout by independent translators from English to theirnative language, which is Turkish. The first unified

version with appropriately represented correspondence

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of all items was obtained by checking the 2 forwardtranslations. This version was then back-translated by 2independent translators whose native language wasEnglish. The 2 back-translators had not seen the origi-nal English text of the MHQ and were not aware of thepurpose of the study. The 2 back-translations were thenreviewed by 2 of the authors of this article to ascertainthat the attained translation was comprehensible and inaccordance with the original English version. The at-tained Turkish translation’s cultural adaptation require-ment was determined by the team, including the 2translators whose native language is English, a linguis-tic scientist, and physiotherapists. This team checkedthe English and Turkish translations again to control themeaning differences and inconsistencies.

A near-final version was created and subjected tofield testing on 30 patients (16 women, 14 men) withdifferent hand injuries. This version was finalized afterslight changes were made by consensus.

Patients

This study was conducted between January 2009 andDecember 2009. The sample consisted of 70 patients(28 male, 42 female) with an average age of 42 � 11years (range, 21–56 y) with different hand problems ofat least 4 weeks’ duration. Patients were referred to theoutpatient department of physiotherapy or occupationaltherapy at Hacettepe University, Faculty of Health Sci-ences. The diagnoses were confirmed by the departmentof orthopedics, and appropriate diagnostic work-ups,including radiological and neurophysiologic investiga-tions done by orthopedists at Hacettepe University.

Patients (1) who were unable to read or write inTurkish, (2) who had cognitive dysfunction, (3) whohad neurologic disease, (4) whose symptoms hadchanged between the first and second measurements,(5) who were unable to complete the questionnaireindependently, (6) who had any open wound or skinlesion, and (7) who had elbow and/or shoulder prob-lems in addition to hand injury were excluded from thestudy. Patients who had hand surgery were included inthe study at least 4 weeks after the surgery.

Written, informed consent was obtained from allparticipating patients at their first visit. The study con-forms to the Helsinki Declaration.

Procedure

Data were collected on the day of the patient’s initialvisit by a physical therapist experienced in hand reha-bilitation. During the patients’ initial visit to the clinic,the MHQ, the DASH-T, and grip strength measure-

ments with J-Tech Tracker Functional Capacity Evalu-

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488 TURKISH VERSION OF THE MICHIGAN HAND QUESTIONNAIRE

ation System (Salt Lake City, UT) were administered tothe patients. Pain intensity was assessed with the VAS.

The MHQ is a hand-specific outcomes questionnairethat has 57 items in 6 domains: (1) overall hand func-tion, (2) activities of daily living, (3) pain, (4) workperformance, (5) aesthetics, and (6) patient satisfac-tion.6 There is also a demographic section asking ques-tions about patients’ gender, ethnic background, workstatus and income. Each item is scored using a scale of1 to 5. Each domain gets scores ranging from 0 to 100,with 0 being the worst and 100 being the best acceptedresult, except the pain domain. For pain, a higher scoreindicates more pain. The scoring method is describedby the original authors of the MHQ. All domains exceptwork performance and pain assess each hand separatelyand are scored according to the affected hand. Recentmodification of the MHQ asks about pain for each handseparately. There is no scoring adjustment for handdominance.1

The DASH is an upper extremity–specific outcomemeasure with high validity to measure patients’ percep-tion of disabilities and symptoms. It has 3 modules:DASH Function/Symptoms (DASH-FS), DASH Work(DASH-W), and DASH Sports/Music (DASH SM).The DASH produces scores between 0 and 100 for eachmodule, in which a high DASH score indicates severedisability.11 The DASH has been shown to be reliableand valid in patient populations with various upperextremity disorders and has been translated into variouslanguages (http://www.dash.iwh.on.ca). The DASHcross-cultural adaptation into Turkish, validity, and re-liability study was performed by Duger et al.12

Grip strength was measured with the Grip TrackModule of J-Tech Tracker Functional Capacity Evalu-ation System (Salt Lake City, UT). Patients sat on achair with shoulders and wrist in neutral position andthe elbow in 90° of flexion. They were asked to squeezethe device as hard as possible and were vocally encour-aged. According to the recommendations of the Amer-ican Society of Hand Therapy, 3 attempts were done,and an average score was calculated for the affectedhand. If there was a bilateral hand injury, the dominantside has been accepted as the most affected side.13

The intensity of pain was evaluated using the 0–10cm VAS.

All assessments were completed by asking patientstwice, with an interval of 7 days (retest). It was assumedthat the clinical situation did not change during thisperiod. To minimize the risk of short-term clinicalchange, no treatment in clinic was provided to these

patients during the retest interval.

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Statistical analyses

All data analyses were done with SPSS software (SPSSversion 17.0; Chicago, IL). Continuous variables weredescribed by mean (x) and SD. Categorical data aregiven as counts and percentages.

Reliability

Two types of reliability (test–retest and internalconsistency) were assessed. Instrument test–retestreliability was assessed with the interclass corre-lation coefficient. The interclass correlation coef-ficient can vary from 0.000 to 1.00, in whichvalues of 0.60 to 0.80 are regarded as evidence ofgood reliability and those above 0.80 indicatingexcellent reliability.

The internal consistency of the multi-item sub-scales was assessed by calculating Cronbach’s al-pha values for the MHQ subscales. A Cronbach’salpha value equal to or greater than 0.7 is generallyregarded as satisfactory.14

Validity

Validation studies were assessed by construct validity,which means that the scales in the questionnaire behaveas expected. The construct validity was assessed bycomparing the results of the MHQ with the Turkishversions of the DASH, VAS, and grip strength of theinjured hand. The Spearman’s rank correlation wasused to assess the association between domains. Coef-ficient correlations greater than 0.6, from 0.6–0.3, andless than 0.3 were considered strong, moderate, andlow, respectively.15

RESULTS

Adaptation

Forward and back translation of the MHQ revealed nomajor problems or language difficulties. The parts ofthe questionnaire were translated without difficulty, ex-cept response parts of overall hand function and activ-ities of daily living (ADL). Turkish translation of “fair”and “poor” in the hand function part and the terms“somewhat” and “moderately” in the ADL part had thesame meaning. Suitable words cover the meaning of thewords according to where the disability scale is placed.Other words except “pick up” in item 2 of the ADLdomain did not need any change where they all met theneeds and problems of Turkish people with injury. Theitem “pick up a coin” had the direct Turkish translation“bozuk para almak,” which is back-translated as “take acoin.” As it did not cover the exact meaning of the item,another verb giving the meaning of “pick up” was

substituted.

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TURKISH VERSION OF THE MICHIGAN HAND QUESTIONNAIRE 489

All the subjects understood the translated items wellenough to answer them without difficulty. It took only3 to 4 minutes to complete the questionnaire.

Patient characteristics

Of the 70 patients, 66 patients were right handed, and29 injuries were to the right hand. Participants had avariety of common hand complaints, including 24 pa-tients with nerve injury, 19 patients with fractures, 24patients with soft tissue problems (6 with tendon inju-ries, 3 with ligament injuries, 12 with tendinitis, 3 withtrigger finger), and 3 patients with other problems.

Descriptive statistics for the MHQ, DASH, VAS,and grip strength scores obtained during the initial visitand follow-up are summarized in Table 1.

Reliability testing

Test–retest reliability: All patients completed the question-naire for a second time after 1 week to assess thetest–retest reliability of the MHQ. The results of theintraclass correlation for the test–retest reliability areshown in Table 2. Scores of 1 indicate perfect correla-tion, and scores of 0 indicate no correlation. All thecorrelation coefficients showed good correlation be-tween the answers, but the correlation coefficients ofthe items related to work had lower correlation.

The mean differences in the scores between the 2administrations were less than 6 points in all subscales.Mean differences in the scores that are closer to 0indicate better agreement. The 95% confidence inter-vals were close to 0 in all the scales.

Internal consistency: The internal consistency of the MHQwas assessed with Cronbach’s alpha coefficient, usingthe data obtained from the initial MHQ assessment. Theinternal consistency of the MHQ, estimated by the

TABLE 1. Descriptive Statistics for the MHQ,DASH, VAS, and Grip Strength Scores ObtainedDuring the Initial Visit and Follow-Up

Parameters

Baseline Follow-Up

X SD X SD

MHQ 69.18 18.37 66.18 21.69

DASH Function/symptom 40.68 23.98 37.00 22.55

DASH Work 49.38 28.15 42.10 26.66

DASH Sports/music 44.41 26.62 44.16 24.00

VAS 5.14 2.30 4.84 2.04

Grip, injured 14.52 9.45 15.14 9.02

Grip, noninjured 25.77 10.43 27.00 11.28

internal consistency coefficient (Cronbach’s alpha),

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ranged from 0.85 to 0.96 for all subscale scores. Athreshold value of 0.80 was considered acceptable. In-ter-item correlations measured by Cronbach’s alpha areshown in Table 2.

Construct validity: Correlation between MHQ and DASHscores and VAS and grip strength scores of the injuredside were tested for construct validity. Table 3 showsthe correlations between MHQ subscale scores andDASH subscale scores and VAS and grip strengthscores. There were weak to moderate correlations be-tween the MHQ subscale scores and DASH scores andhand grip strength scores. The best correlation wasfound between the MHQ ADL domain score and theDASH function/symptom score.

DISCUSSIONHand therapists and hand surgeons are increasinglyinterested in the problems that patients experience inperforming daily activities. The DASH and MHQ arefound to be valid and reliable questionnaires that can beused to measure activity limitations in general upperextremity injuries.16 It is now recognized that if mea-sures are to be used across cultures, the items must benot only translated well linguistically but also adaptedculturally to maintain the content validity of the instru-ment at a conceptual level across different cultures.4

The Turkish version of the DASH is a reliable and validinstrument for the domain-specific outcome measure inTurkish-speaking patients with upper extremity com-plaints.12 In this study, Turkish adaptation of the MHQwas performed following the systemic, standardizedapproach of Beaton et al and Ruberto et al.4,10

Our findings showed that the adaptation of the MHQto the Turkish language has produced an instrument thathas test–retest reliability and demonstrates concurrentand construct validity. The levels of test–retest reliabil-ity of the MHQ were found excellent. It was similar tothe other studies.1,6,17,18

In many studies, the sample size (30 subjects) is notadequate for studying the reliability or validity of theinstrument. However, when statistical estimates are de-rived from small samples, confidence intervals will bewide, reflecting a high degree of uncertainty in theprecision of the reliability coefficient.19,20 Terwee et alsuggested that a sample size of at least 50 subjectsshould be used.20 Therefore, it was thought that thenumber of patients taken for the study is sufficient toconduct validity and reliability analysis.

Internal consistency is an important measurementproperty for questionnaires that intend to measure asingle underlying concept by using multiple items.21

Internal consistency results of the new version of MHQ

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490 TURKISH VERSION OF THE MICHIGAN HAND QUESTIONNAIRE

was high, subscales of MHQ were found to be inter-correlated, and results were similar to those obtainedwith other versions of the MHQ. This indicates thehomogeneity of the subscales and conceptual equiva-lence of the Turkish version.

The lowest internal consistency is found in the aes-thetics part of the scale. This was the only subparameterthat many of the subjects misunderstood. Subjects in-formed us about the confusion between items in thepilot study. Because the first question is the opposite ofthe remaining 4 questions, subjects could give contra-dictory answers to the question. Even if subjects were

TABLE 2. Test-Retest and Inter-Item Correlation o

MHQ Baseline X � SD Follow

Overall hand function

Right 71.28 � 25.36 72.1

Left 66.71 � 29.64 72.0

Activities of daily living

Right 70.35 � 31.19 75.1

Left 73.22 � 31.06 74.8

Both 65.35 � 22.15 69.5

Aesthetic

Right 77.85 � 24.14 81.8

Left 76.78 � 27.21 77.8

Satisfaction

Right 67.97 � 30.33 70.4

Left 66.00 � 30.85 56.5

Work performance 41.21 � 26.88 43.3

Pain 41.07 � 25.66 39.1

TABLE 3. Spearman’s Correlation of MHQ With D

DASH Function/Symptom (n � 70)

DASH Sports/Music (n � 32)

r Value p Value r Value p Value

Overall handfunction

�0.46 .00 �0.07 .67

Activities ofdaily living

�0.66 .00 0.03 .86

Workperformance

�0.48 .00 �0.01 .93

Pain 0.48 .00 0.27 .13

Aesthetic �0.33 .00 0.04 .81

Satisfaction withhand function

�0.44 .000 �0.13 .47

informed about the variance of the answers and in-

JHS �Vol A, M

structed to pay attention what is written in the answers,this contradiction can lead to low internal consistency inthe clinical setting. It is suggested to inform subjects topay attention to this part of the scale, especially in theTurkish population.

When an instrument is reliable, it produces consis-tent, reproducible results on repeated administration.21

To establish reliability, a correlation coefficient is cal-culated, and it is found to be high for the MHQ. Thelowest interclass correlation coefficient was found inwork performance. Most of the women who partici-pated in the study were housewives, and they have the

Q

X � SD Intraclass Correlation Cronbach’s Alpha

24.82 0.82 0.88

28.14 0.95 0.94

27.03 0.89 0.96

31.56 0.92 0.95

21.91 0.91 0.87

24.31 0.95 0.76

27.94 0.96 0.79

27.85 0.91 0.94

30.74 0.94 0.96

26.68 0.79 0.94

26.87 0.91 0.85

, VAS, and Grip Strength

DASH Work(n � 44)

VAS(n � 50)

Grip, Injured(n � 53)

Value p Value r Value p Value r Value p Value

0.18 .23 �0.47 .00 0.32 .01

0.36 .01 �0.31 .02 0.52 .00

0.40 .00 �0.23 .10 0.34 .01

0.27 .06 0.33 .01 �0.13 .33

0.24 .10 �0.12 .40 0.35 .01

0.22 .13 �0.32 .02 0.30 .02

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ASH

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responsibility to take care of the housework and

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TURKISH VERSION OF THE MICHIGAN HAND QUESTIONNAIRE 491

children. For this reason, even in a short time, theyintend to begin the housework. In addition, menhad to begin work quite early because they aremostly afraid to lose jobs. These characteristics ofthe population might lead to the change in workperformance.

In the determination of construct validity, the DASHquestionnaire is selected to be a gold standard measure,as it is accepted to be an often-used, qualified, reliable,validated, standardized instrument when clinometricproperties of instruments used in hand injuries are re-viewed. The DASH is suitable for any type of upperextremity injury and is widely accepted, promoting theexchangeability of results in clinical evaluation andresearch.2,22,23 The MHQ was found to be correlatedmoderately with the DASH in a Turkish population, butthis correlation supports the construct validity of theMHQ questionnaire as a measure of health status. Thelevel of correlation of the MHQ measurement to theDASH is consistent with findings of the validationstudies.

The DASH music/sports part was not found to becorrelated with the MHQ. This might be a result of thelow number of respondents in the music/sports part. It isalso thought that DASH is advantageous to reflect dis-ability in recreational activities, whereas the MHQ can-not reflect the difficulty in this area. The DASH workpart was well correlated with the ADL, work perfor-mance, and pain parts of MHQ. The high correlation ofthe DASH work part and the MHQ work performancepart expresses the validity of the instrument in thisspecific field.

In the analyses for concurrent validity of the MHQ,there was a high correlation between VAS and MHQ,except in the aesthetics and work performance parts ofMHQ. There was also high correlation between theMHQ and grip strength of the injured hand. This resultexpresses the validity of MHQ with the clinical instru-ments as a whole.

The lowest correlation was with the aesthetics part ofMHQ. This was an expected result, as MHQ is the onlyinstrument that gives information about the patients’reflections about aesthetics. The highest correlation waswith the ADL part, which supports the information thatphysical findings such as pain and strength affect theactivity limitations, and MHQ reflects this finding. TheDASH also consists of 21 ADLs and, therefore, reflectsactivity limitations. The high correlation shows thatMHQ has the same strength to show activitylimitations.

The study protocol consisted of face-to-face inter-

view, and participants were asked to indicate all items

JHS �Vol A, M

that were not clear. This might have induced subjects topay more attention for each item and prevented themfrom giving wrong answers. They did not actually havemuch difficulty answering them, and it took 3 to 4minutes to fill out the entire questionnaire. Subjectsfound the language to be clear and understandable.They said that the questions reflected all of the prob-lems they are faced with.

The DASH and the MHQ both assess physical healthand pain symptoms. A notable advantage of the MHQis that hand dominance is taken into consideration withrespect to overall hand function, ADL, pain, and satis-faction with hand functions. A score is obtained forboth right and left hands, and if both hands are affected,the right and left hand function scores are averaged. TheMHQ contains a specific question or scale on aesthetics,which is an item belonging to the International Classi-fication of Function-domain “personal factors,’’ and itis considered an important item for hand-injured per-sons. For all the questionnaires, a disadvantage of theMHQ is the complexity of the instrument and thelengthy nature of the questionnaire.6,21,23

Optimal measurement tool selection depends highlyon the situation, the purpose of the assessment, and thetype of hand injury.16,21 Because of the advantages ofthe MHQ, it might be preferred to the DASH in specificcases. The Turkish version of the DASH questionnaireand the Turkish version of the MHQ will permit com-parison among numerous studies in a wide variety ofpatients with upper extremity complaints in the Turkishpopulation.

REFERENCES1. Kotsis SV, Lau FH, Chung KC. Responsiveness of the Michigan

Hand Outcomes Questionnaire and physical measurements in out-come studies of distal radius fracture treatments. J Hand Surg 2007;32A:84–90.

2. Smet LD, Kesel DR, Degreef I, Debeer P. Responsiveness of theDutch version of the DASH as an outcome measure for carpal tunnelsyndrome. J Hand Surg 2007;32B:74–76.

3. Ware JE Jr, Keller SD, Gandek B, Brazier JE, Sullivan M. Evalu-ating translations of health status questionnaires. Methods from theIQOLA project. International Quality of Life Assessment. Int JTechnol Assess Health Care 1995;11:525–551.

4. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines forthe process of cross-cultural adaptation of self-report measures.Spine 2000;25:3186–3191.

5. Deyo RA, Andersson G, Bombardier C, Cherkin DC, Keller RB, LeeCK, et al. Outcome measures for studying patients with low backpain. Spine 1994;19(18 Suppl):2032–2036.

6. Chung KC, Pillsburry SM, Walters MR, Hayward RA. Reliabilityand validity testing of the Michigan Hand Outcomes Questionnaire.J Hand Surg 1998;23A:575–587.

7. Chung KC, Kotsis VS. Outcomes of multiple micro vascular toetransfer for reconstruction in 2 patients with digitless hands: 2- and4- year follow up case reports. J Hand Surg 2002;27A:652–658.

8. Chung KC, Kotsis VS, Kim HM. Predictors of functional outcomes

arch

492 TURKISH VERSION OF THE MICHIGAN HAND QUESTIONNAIRE

after surgical treatment of distal radius fractures. J Hand Surg2007;32A:76–83.

9. Klein RD, Kotsis VS, Chung KC. Open carpal tunnel release usinga 1-centimeter incision: technique and outcomes for 104 patients.Plast Reconstr Surg 2003;111:1616–1622.

10. Ruperto N, Ravelli A, Pistorio A, Malattia C, Cavuto S, Gado-WestL, et al. Paediatric Rheumatology International Trials Organisation.Cross-cultural adaptation and psychometric evaluation of the Child-hood Health Assessment Questionnaire (CHAQ) and the ChildHealth Questionnaire (CHQ) in 32 countries. Review of the generalmethodology. Clin Exp Rheumatol 2001;19(4 Suppl 23):1–9.

11. Hudak PL, Amadio PC, Bombardier C, The Upper Extremity Col-laborative Group (UECG). Development of an upper extremity out-come measure: the DASH (Disabilities of the Arm, Shoulder, andHand). Am J Indust Med 1996;29:602–608.

12. Düger T, Yakut E, Öksüz Ç, Yörükan S, Bilgütay BS, Ayhan Ç, etal. Kol omuz ve el sorunlarý (Disabilities of the Arm, Shoulder andHand—DASH) anketi Türkçe uyarlamasýnýn uyarlamasınıngüvenirliligi ve geçerligi. Fizyoterapi ve Rehabilitasyon 2006;17:99–107.

13. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, RogersS. Grip and pinch strength: normative data for adults. Arch PhysMed Rehabil 1985;66:69–74.

14. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York:

McGraw-Hill, 1994:394–416.

JHS �Vol A, M

15. Hinkle DE, Wiersma W, Jurs SG. Applied statistics for the behav-ioral sciences. 5th ed. Boston, MA: Houghton Mifflin, 1998.

16. van de Ven-Stevens LA, Munneke M, Terwee CB, Spauwen PH, vander Linde H. Clinimetric properties of instruments to assess activitiesin patients with hand injury: a systematic review of the literature.Arch Phys Med Rehabil 2009;90:151–169.

17. Amadio PC. Outcome assessment in hand surgery and hand therapy:An update. J Hand Ther 2001;14:63–67.

18. van der Giesen FJ, Nelissen RG, Arendzen JH, de Jong Z, Wolter-beek R, Vliet Vlieland TP. Responsiveness of the Michigan HandOutcomes Questionnaire-Dutch language version in patients withrheumatoid arthritis. Arch Phys Med Rehabil 2008; 89:1121–1126.

19. Heras PC, Burke FD, Dias JJ, Bindra R. Outcome measurement inhand surgery: report of a consensus conferences. Br J Hand Ther2003;8:70–80.

20. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, DekkerJ, et al. Quality criteria were proposed for measurement properties ofhealth status questionnaires. J Clin Epidemiol 2007;60:34–42.

21. Schoneveld K, Wittink H, Takken T. Clinimetric evaluation ofmeasurement tools used in hand therapy to assess activity andparticipation. J Hand Ther 2009;22:221–235.

22. Durand MJ, Vachon B, Hong QN, Loisel P. The cross-culturaladaptation of the DASH questionnaire in Canadian French. J HandTher 2005;18:34–39.

23. Naidu SH, Panchik D, Chinchilli VM. Development and validationof the hand assessment tool. J Hand Ther 2009;22:250–256.

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