Validity and Responsiveness of the Michigan
Hand Questionnaire in Patients With Rheumatoid
Arthritis: A Multicenter, International Study
JENNIFER F. WALJEE,1KEVIN C. CHUNG,1H. MYRA KIM,2PATRICIA B. BURNS,3FRANK D. BURKE,4
E. F. SHAW WILGIS,5AND DAVID A. FOX1
Objective. Millions of patients experience the disabling hand manifestations of rheumatoid arthritis (RA), yet few
hand-specific instruments are validated in this population. Our objective was to assess the reliability, validity, and
responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with RA.
Methods. At enrollment and at 6 months, 128 RA patients with severe subluxation of the metacarpophalangeal joints
completed the MHQ, a 37-item questionnaire with 6 domains: function, activities of daily living (ADL), pain, work,
aesthetics, and satisfaction. Reliability was measured using Spearman’s correlation coefficients between time periods.
Internal consistency was measured using Cronbach’s alpha. Construct validity was measured by correlating MHQ
responses with the Arthritis Impact Measurement Scales 2 (AIMS2). Responsiveness was measured by calculating
standardized response means (SRMs) between time periods.
Results. The MHQ demonstrated good test–retest reliability (r ? 0.66, P < 0.001). Cronbach’s alpha scores were high for
ADL (? ? 0.90), function (? ? 0.87), aesthetics (? ? 0.79), and satisfaction (? ? 0.89), indicating redundancy. The MHQ
correlated well with AIMS2 responses. Function (r ? ?0.63), ADL (r ? ?0.77), work (r ? ?0.64), pain (r ? 0.59), and
summary score (r ? ?0.74) were correlated with the physical domain. Affect was correlated with ADL (r ? ?0.47), work
(r ? ?0.47), pain (r ? 0.48), and summary score (r ? ?0.53). Responsiveness was excellent among arthroplasty patients
in function (SRM 1.42), ADL (SRM 0.89), aesthetics (SRM 1.23), satisfaction (SRM 1.76), and summary score (SRM 1.61).
Conclusion. The MHQ is easily administered, reliable, and valid to measure rheumatoid hand function, and can be used
to measure outcomes in rheumatic hand disease.
Rheumatoid arthritis (RA) is a systemic inflammatory au-
toimmune disease that results in substantial disability and
premature death for more than 1 million individuals in the
US (1). Rheumatic hand disease is caused by progressive
and irreversible inflammation of the synovial tissue, and
joint destruction occurs early in the course of disease.
Hand deformity and dysfunction is the most common
manifestation of RA; 70% of patients with RA experience
disfiguring and painful rheumatoid hand deformities. Up
to 30% of patients have radiographic evidence of disease
at the time of diagnosis, and more than 60% have radio-
graphic joint changes within 2 years of diagnosis (2). Un-
like other chronic diseases, such as osteoarthritis or hy-
pertension, patients are typically diagnosed with RA in
young adulthood, and this disease profoundly interferes
with their future work productivity, their ability to per-
form activities of daily living (ADL), and their social in-
teractions. On a societal level, the effect of these lost wages
and expensive medical therapies consumes approximately
$3.6 billion per year (3,4). Unfortunately, a standardized,
hand-specific instrument to measure rheumatoid hand
function remains elusive, and there are few accepted
guidelines for defining hand disability among RA patients.
A variety of methods have been used to describe health
ClinicalTrials.gov identifier: NCT00124254.
Supported in part by a grant from the National Institute of
Arthritis and Musculoskeletal and Skin Diseases (R01-
AR047328). Dr. Chung’s work was supported by a Midca-
reer Investigator Award in Patient-Oriented Research (K24-
1Jennifer F. Waljee, MD, MPH, MS, Kevin C. Chung, MD,
MS, David A. Fox, MD: University of Michigan Health Sys-
tem, Ann Arbor;2H. Myra Kim, ScD: University of Michi-
gan, Ann Arbor;
Michigan Medical Center, Ann Arbor;4Frank D. Burke, MD:
Pulvertaft Hand Centre, Derby, UK;5E. F. Shaw Wilgis, MD:
Curtis National Hand Center, Baltimore, Maryland.
Address correspondence to Kevin C. Chung, MD, MS,
Section of Plastic Surgery, University of Michigan Health
System, 2130 Taubman Center, SPC 5340, 1500 East Medical
Submitted for publication January 15, 2010; accepted in
revised form May 24, 2010.
3Patricia B. Burns, MPH: University of
Arthritis Care & Research
Vol. 62, No. 11, November 2010, pp 1569–1577
© 2010, American College of Rheumatology
outcomes related to the hand manifestations of RA. These
have ranged from objective measures, such as painful joint
counts or grip strength, to more subjective measures, such
as patient satisfaction scores and quality of life measures.
Although single, objective measures of function, such as
range of motion, degree of finger extension lag, grip
strength, and pinch power, are relatively simple to obtain,
they often do not capture the full extent of patient disabil-
ity. More complex functional tests can include a battery of
tasks, such as the Jebsen-Taylor Test, the Grip Ability Test,
or the Arthritis Hand Function Test (5–7). These may
provide a better assessment of difficulty with ADL, but
often do not account for other important end points such
as pain, aesthetics, and patient satisfaction (8).
Patient perception of health status as measured by self-
administered instruments has been shown to be a better
predictor of functional status and disability compared
with objective measures (9). Many instruments have been
used to define patient-related outcomes in patients with
RA, ranging from general quality of life to hand-specific
surveys. General health assessment instruments, such as
the visual analog scale, the Short Form 36 and its deriva-
tions, and the Health Assessment Questionnaire, may offer
a global assessment of functioning, but they are not sensi-
tive to detect the amount of patient disability related spe-
cifically to RA or to hand dysfunction (8,10–12). Other
authors have used hypothetical scenarios to explore
patient-related outcomes, using utility measures to esti-
mate future quality of life. Although such models are use-
ful in decision analyses, they are often difficult to imple-
ment in clinical practice and the concepts may be
challenging for the patients to grasp (13,14). An ideal
instrument should be hand specific, and include not only
patient perception of function, but also measures of pain,
satisfaction, and hand appearance.
We have prospectively evaluated patients with RA from
3 centers in the US and the UK to determine patient
outcomes following surgical intervention (silicone arthro-
plasty) for metacarpophalangeal (MCP) joint deformity us-
ing the Michigan Hand Questionnaire (MHQ). We have
achieved excellent long-term followup in this sample, and
we have a unique opportunity to describe the reliability,
validity, and responsiveness of the MHQ in patients with
RA. The MHQ is a self-administered questionnaire that
contains 37 items and requires approximately 15 minutes
to complete, and has been used successfully in the RA
population in prior work (15–25). We hypothesize that the
MHQ will accurately and reliably define rheumatoid hand
performance, and effectively measure clinical change in
hand function over time.
SUBJECTS AND METHODS
The study sample consisted of patients diagnosed with RA
by their rheumatologists and referred to one of the follow-
ing 3 institutions: The University of Michigan (Ann Arbor,
Michigan), the Curtis National Hand Center (Baltimore,
Maryland), and the Pulvertaft Hand Centre (Derby, UK).
The study sample is part of a larger prospective study
supported by the National Institutes of Health regarding
the use of silicone MCP joint arthroplasty (SMPA) for joint
deformities due to RA, which has been described in detail
elsewhere (26,27). Patients were included in the study if
they were diagnosed with RA, had severe MCP joint de-
formity, and were deemed appropriate candidates for sur-
gical reconstruction. Additionally, subjects were eligible if
they were age ?18 years and able to complete the study
questionnaire in English. Patients were excluded from the
study if their comorbid conditions prohibited surgery,
they experienced additional hand conditions (swan-neck
and boutonniere deformities, extensor tendon ruptures)
that would require intervention beyond SMPA, or they
had previously undergone MCP joint replacement. After
enrollment, participants either elected to receive an SMPA
or remained as controls. Data were collected from the
subjects at the time of enrollment and at a 6-month follow-
up time. The study protocol was approved by the Institu-
tional Review Boards at the University of Michigan, the
Curtis National Hand Center, and the Pulvertaft Hand
All of the subjects completed the MHQ, which has been
previously validated for use in a wide range of patient
samples (15–20). The MHQ yields an overall summary
score of hand function, as well as scores for 6 specific
scales: hand function, ability to complete ADL, pain, work
performance, aesthetics, and patient satisfaction. Scores
for each domain range from 0–100, and higher scores
indicate better performance for all domains with the ex-
ception of pain.
The subjects also completed the Arthritis Impact Mea-
surement Scales 2 (AIMS2) questionnaire, a 45-item, self-
administered outcomes tool designed to assess health
status in patients with inflammatory arthritis and osteoar-
thritis (28). The AIMS2 is designed to provide a global,
self-reported assessment of patient health status and yields
information in 4 domains, including physical functioning,
affect, symptom, and social interaction. Scores range from
1–10, with lower scores reflecting better health.
All of the subjects underwent the following assessments
to provide objective and reproducible measures of hand
function at baseline and subsequent followup: grip
strength, lateral pinch, 2-point pinch, and 3-point pinch,
all measured in kilograms. Subjects also completed the
Jebsen-Taylor Test, which is a 7-part, standardized test
designed to assess a subject’s ability to complete everyday
hand-related tasks (29). The writing portion was not in-
cluded in this analysis due to difficulty of interpretation
relating to hand dominance. Time to complete each task
was measured in seconds.
Outcomes. Reliability. Reliability was defined as the
ability of an instrument to consistently or precisely mea-
sure a concept of interest (30). In this study, we measured
2 aspects of reliability of the MHQ: the test–retest reliabil-
ity of the MHQ and the internal consistency of the 6 scales
within the MHQ. Test–retest reliability implies that the
survey yields similar results from consecutive administra-
tion to a subject. To determine the test–retest reliability of
the MHQ, we compared responses for each domain of the
MHQ at baseline and at the 6-month followup interval. We
used responses regarding the symptomatic hand of the
1570 Waljee et al
control patients who did not undergo SMPA and the non-
operated hand of the SMPA patients. The degree of corre-
lation between the consecutive responses was assessed
using Spearman’s correlation coefficients. Additionally,
we used paired t-tests to determine the average difference
in score for each domain between these time periods to
determine if these means were significantly different.
A mean difference of 0 indicates perfect test–retest
We determined the internal consistency, or homogene-
ity, of the items included in each scale of the MHQ by
calculating Cronbach’s alpha for each of the 6 scales in the
MHQ. Cronbach’s alpha is a measure of the homogeneity
of items within a scale, and is based on the number of
items included and their degree of correlation according to
the following formula:
N ? ? c
?? ? ? ?N ? 1? ? ? c?
where N ? the number of items in the scale, ? ? ? the
average variance between subjects in the sample, and ? c ?
the average covariance between items among the subjects
in the sample. Cronbach’s alpha values range from 0–1,
with higher values indicating greater internal consistency.
In general, Cronbach’s alpha values between 0.6 and 0.8
are considered acceptable (31). Values greater than 0.8
indicate that there may be redundancy of items in the
scale. Cronbach’s alpha values that are less than 0.6 indi-
cate that items in the scale are not adequately related to
one another to measure a concept (31). The MHQ queried
patients regarding their performance in each domain sep-
arately for the right and left hand, and we stratified our
analysis by hand dominance.
Validity. Validity was defined as the ability of an instru-
ment to accurately measure a concept of interest. For ex-
ample, patients who score poorly on the MHQ, indicating
worse function, would be expected to also have poor per-
formance in other aspects of hand functioning, such as
strength and dexterity with specific tasks. Three important
types of validity exist: content validity, criterion validity,
and construct validity.
Content validity, or face validity, describes the extent to
which an instrument appears logical or capable of measur-
ing an outcome of interest to experts within a particular
field. The MHQ was developed with strict attention to
psychometric principles. It has been validated in a variety
of acute and chronic hand conditions and translated into
several languages, and therefore is considered appro-
priate to measure outcomes among patients with RA
Criterion validity describes the extent to which an in-
strument compares with the accepted reference standard.
For patients with RA, there is no established standard to
measure health outcomes related to hand dysfunction.
Therefore, construct validity is often used to establish the
validity of outcomes questionnaires.
Construct validity describes the extent to which the
scales in the survey instrument behave as expected. For
example, patients who report high pain scores would be
expected to endorse difficulty with functioning, ADL, and
work performance. We established a priori hypothetical
relationships between the scales of the MHQ and used
Spearman’s correlation coefficients to test construct valid-
ity against each scale of the MHQ. Additionally, we com-
pared responses to the MHQ among SMPA and control
patients with their responses to the AIMS2 questionnaire,
an existing, validated measure of health status in RA pa-
tients, in order to establish the construct validity.
Responsiveness. Responsiveness was defined as the
ability of an instrument to detect important changes in an
outcome of interest over time (33). Because the greatest
change after surgery occurs within 6 months after SMPA
surgery, we used paired t-tests to compare mean scores at
baseline and at the 6-month followup for each scale and
for the summary score. In order to compare the change in
scores over time using a standardized method, we calcu-
lated the standardized response mean (SRM) for each scale
of the MHQ. Ideally, a more sensitive instrument should
have a higher SRM (34). Using Cohen’s effect size defini-
tion, we assumed that an SRM of 0.2 corresponds to a
small effect size, 0.5 corresponds to a medium effect size,
and 0.8 corresponds to a large effect size (35). The respon-
siveness of the MHQ was determined separately for SMPA
patients and for control patients. Finally, we compared the
responsiveness of the MHQ with the responsiveness of
each domain of the AIMS2 survey as an additional valida-
Statistical analysis. Descriptive statistics were gener-
ated to describe the sociodemographic characteristics of
the study sample. Statistical significance was set at an
alpha level of 0.05. All of the analyses were conducted
using Stata, version 10.1. (StataCorp).
The characteristics of the study sample are detailed in
Table 1. Of the 160 patients enrolled, 128 patients com-
pleted followup at 6 months, with a loss to followup rate of
20%. The majority of the patients were white (97%),
women (74%), and right-hand dominant (91%), with a
mean age of 60.9 years. Approximately 26% had less than
a high school education, and 70% earned an annual in-
come of less than $60,000 per year.
Table 1. Characteristics of the study sample
(n ? 128 patients)*
Age, mean ? SD years
Education, less than high school
Income, less than $60,000 annual
Right hand dominance
60.9 ? 9.16
* Values are the number (percentage) unless otherwise indicated.
SMPA ? silicone metacarpophalangeal joint arthroplasty.
Responsiveness and Validity of the MHQ in RA Patients1571
The test–retest reliability of the MHQ was measured by
calculating the correlation between responses to the MHQ
at baseline and at 6 months of followup (Table 2). Re-
sponses regarding the affected hand of the control patients
and the nonoperated hand of the case patients were used
for this portion of the analysis, and the results are stratified
to reflect the differences between these 2 groups. Overall,
correlations between responses for each time period were
high, indicating good reliability of the MHQ. Among the
control patients, responses for work performance were
most strongly correlated (r ? 0.75, P ? 0.001), as well as
aesthetic appearance (r ? 0.70, P ? 0.001), patient satis-
faction (r ? 0.70, P ? 0.001), and the summary MHQ score
(r ? 0.75, P ? 0.001). Responses regarding function (r ?
0.63, P ? 0.001) and ADL (r ? 0.63, P ? 0.001) were the
least strongly correlated (r ? 0.61). Among the case pa-
tients, responses were highly correlated for ADL (r ? 0.79,
P ? 0.001) and patient satisfaction (r ? 0.76, P ? 0.001).
Responses regarding aesthetics were the least well corre-
lated (r ? 0.50, P ? 0.001). Figure 1 describes the mean
differences between scores for each scale between time
points of administration. Figure 1A describes the mean
difference in responses for the affected hand of control
patients. Overall, the differences in score between each
administration were small, without statistically significant
differences between the time periods. Figure 1B describes
the mean difference in responses regarding the nonoper-
ated hand of the patients who underwent SMPA. Interest-
ingly, responses regarding the control hand were signifi-
cantly different between each time period for all domains,
with the exception of pain. These patients reported higher
improved scores regarding function (baseline mean 51.3,
followup mean 60.5; P ? 0.001), ADL (baseline mean 44.2,
followup mean 56.7; P ? 0.001), work (baseline mean 41.9,
followup mean 52.3; P ? 0.002), aesthetics (baseline mean
50.5, followup mean 59.7; P ? 0.006), and patient satis-
faction (baseline mean 44.2, followup mean 53.4; P ?
Reliability of the MHQ was also assessed by determining
the internal consistency of items within each scale of the
MHQ, as measured by Cronbach’s alpha, stratified by hand
dominance (Table 3). As described above, the ideal value
for Cronbach’s alpha should lie between 0.6 and 0.8. Cron-
bach’s alpha values that are less than 0.6 indicate hetero-
geneity among items in the scale, and values greater than
0.8 indicate redundancy of items within a scale. Across all
of the domains, Cronbach’s alpha values were similar by
hand dominance. For the MHQ, Cronbach’s alpha scores
were within the ideal range for aesthetics (? ? 0.75 for
right hand, right-hand dominant; ? ? 0.78 for left hand,
left-hand dominant). Cronbach’s alpha was high for ADL
(? ? 0.91 for right hand, right-hand dominant; ? ? 0.87 for
left hand, left-hand dominant), function (? ? 0.86 for right
hand, right-hand dominant; ? ? 0.83 for left hand, left-
hand dominant), pain (? ? 0.85 for right hand, right-hand
dominant; ? ? 0.81 for left hand, left-hand dominant),
satisfaction (? ? 0.89 for right hand, right-hand dominant;
? ? 0.90 for left hand, left-hand dominant), and work
performance (? ? 0.91 for right-hand dominant; ? ? 0.88
for left-hand dominant). These high values may indicate
that redundant items exist within the scales of the MHQ.
To test the construct validity of the MHQ, we tested the
responses to each scale against the other scales in the MHQ
to determine if each scale behaves in an expected manner
using Spearman’s correlation coefficients (Table 4). For
example, we would expect a higher correlation between
function and ability to complete ADL than between aes-
Figure 1. The mean difference in responses for each scale of the
Michigan Hand Questionnaire measured at baseline and at 6
months of followup. A, Patients who did not undergo silicone
metacarpophalangeal joint arthroplasty (symptomatic hand; n ?
77). B, Patients who underwent silicone metacarpophalangeal
joint arthroplasty (control hand; n ? 51). ADL ? activities of daily
Table 2. Test–retest correlation comparing baseline and
6-month followup scores for the 6 domains of the
MHQ (n ? 128 patients)*
hand (n ? 77)
hand (n ? 51)
Activities of daily
* MHQ ? Michigan Hand Questionnaire; SMPA ? silicone meta-
carpophalangeal joint arthroplasty.
1572Waljee et al
thetics and ability to complete ADL. For the majority of
scales, responses to the MHQ were correlated with the
other scales in the expected direction. For example, func-
tion was more correlated with ADL (r ? 0.83), work per-
formance (r ? 0.65), and pain (r ? ?0.65) than with aes-
thetics (r ? 0.43). As expected, aesthetics was least
correlated with work performance (r ? 0.38). Satisfaction
was correlated most strongly with function (r ? 0.81) and
ADL (r ? 0.73) than with pain (r ? ?0.69), aesthetics (r ?
0.41), or work performance (r ? 0.54).
To further assess construct validity, we compared re-
sponses to each scale of the MHQ with responses to the
AIMS2 domains, as well as objective measures of hand
functioning (Table 5). As expected, function (r ? ?0.63),
ADL (r ? ?0.77), work performance (r ? ?0.64), pain (r ?
0.59), and summary MHQ score (r ? ?0.74) were strongly
correlated with the physical domain of the AIMS2 survey.
The affect domain of the AIMS2 was most strongly corre-
lated with the summary MHQ score (r ? ?0.53), and the
symptom domain of the AIMS2 was most strongly corre-
lated with pain (r ? 0.70). The social domain was not well
correlated with any of the MHQ scales. This suggests that
the MHQ may not capture some elements of the effect of
RA on social interaction and patient affect that are mea-
sured by the AIMS2.
The MHQ was also correlated well with objective mea-
sures of functioning, including grip and pinch strength
and the Jebsen-Taylor score (Table 5). The function, ADL,
and satisfaction domains were most highly correlated with
these measures; aesthetics was the least correlated. For
example, correlations were highest with Jebsen-Taylor
scores (function r ? ?0.50, ADL r ? ?0.50, satisfaction r ?
?0.38; P ? 0.001) and palmar pinch (function r ? 0.45,
ADL r ? 0.47, satisfaction r ? 0.32; P ? 0.001). Summary
MHQ score was most correlated with grip strength (r ?
0.34, P ? 0.12), palmar pinch (r ? 0.37, P ? 0.001), and
Jebsen-Taylor score (r ? ?0.46, P ? 0.001).
We calculated the responsiveness of the MHQ to detect
clinical change in hand function over the 6-month study
period. The summary MHQ score and scores for each scale
of the MHQ at baseline and at the 6-month followup and
the SRMs for each scale of the MHQ are shown in Table 6.
As expected, the MHQ demonstrated strong responsive-
ness to clinical change in the group of patients who un-
derwent SMPA. SRMs were high for function (SRM 1.42),
ADL (SRM 0.89), aesthetic appearance (SRM 1.23), satis-
faction (SRM 1.76), and the summary MHQ score (SRM
Table 3. Internal consistency of the Michigan Hand
Questionnaire in rheumatoid arthritis patients as
measured by Cronbach’s alpha (n ? 128), stratified by
Activities of daily living
Table 4. The correlation between the 6 scales of the MHQ to test the construct validity of the MHQ (n ? 128)*
Summary MHQ score
* MHQ ? Michigan Hand Questionnaire; ADL ? activities of daily living.
Responsiveness and Validity of the MHQ in RA Patients 1573
1.61). Responsiveness was lower for pain (SRM 0.63) and
work performance (SRM 0.47). Responsiveness was higher
for all domains of the MHQ when compared with that of
the AIMS2 instrument among patients who have under-
gone SMPA. With respect to the control patients, changes
for all of the measures over a 6-month time period were
modest, and there were no statistically significant differ-
ences between mean scores for any measure. Work perfor-
mance was the most responsive measure over time (SRM
0.14), although this is overall a very low effect. Because
these patients did not undergo surgical reconstruction, we
would not expect to see a large change in their hand
performance over this brief period of time.
The MHQ is a hand-specific outcome measurement tool
that has been extensively studied in a variety of acute and
Table 5. The correlation of the 6 scales of the Michigan Hand Questionnaire with the AIMS2 domains and objective measures
of hand functioning (n ? 128)*
AIMS2Objective hand function testing
Physical AffectSymptom Social
* AIMS2 ? Arthritis Impact Measurement Scales 2; ADL ? activities of daily living.
Table 6. Responsiveness of the MHQ to clinical change over a 6-month followup period*
Baseline, mean ? SD 6 months, mean ? SD
SMPA patients (n ? 51)
Controls (n ? 77)
38.3 ? 18.4
37.6 ? 23.0
36.6 ? 27.4
41.9 ? 23.0
48.2 ? 26.3
34.3 ? 22.4
27.6 ? 20.2
62.7 ? 20.8
65.2 ? 20.3
55.9 ? 29.4
52.3 ? 29.1
33.4 ? 24.9
71.0 ? 23.5
65.6 ? 25.0
3.6 ? 2.4
3.8 ? 1.9
5.3 ? 2.8
4.1 ? 2.1
3.2 ? 2.3
3.5 ? 2.0
5.0 ? 2.7
3.8 ? 2.0
56.8 ? 19.0
59.5 ? 18.8
59.8 ? 23.5
59.7 ? 22.9
35.2 ? 25.6
49.2 ? 24.8
48.3 ? 25.8
58.3 ? 20.2
59.2 ? 21.2
60.3 ? 25.9
62.3 ? 27.6
32.5 ? 26.0
51.3 ? 23.1
49.0 ? 26.2
2.3 ? 1.8
2.9 ? 1.8
4.2 ? 2.4
3.4 ? 1.3
2.4 ? 2.0
2.7 ? 1.7
4.0 ? 2.6
3.7 ? 1.5
* MHQ ? Michigan Hand Questionnaire; SRM ? standardized response mean; SMPA ? silicone metacarpophalangeal joint arthroplasty; ADL ?
activities of daily living; AIMS2 ? Arthritis Impact Measurement Scales 2.
† By paired t-test comparing 6 months with baseline.
‡ Calculated using the following formula: (6-month followup mean ? baseline mean)/SD of the change.
1574Waljee et al
chronic hand conditions, including nerve compression,
distal radius fractures, Dupuytren’s disease, and osteo-
arthritis (15–20). The MHQ is ideal for use in the RA
population because it specifically encompasses measures
of aesthetics and pain control, which have been demon-
strated to be important motivators for surgical therapy
among patients with RA (36,37).
The MHQ demonstrated good test–retest reliability
among the control patients, with minimal change in scores
between survey administrations without statistically sig-
nificant differences. Interestingly, patients who underwent
SMPA reported significantly higher improved scores for
the control, nonoperated hand across all of the MHQ do-
mains with the exception of pain. The perioperative expe-
rience has a profound influence on a patient’s perception
of their disease and disability. Other authors have also
reported similar phenomena among patients with other
chronic health conditions such as paralysis and renal fail-
ure (38–40). These biases should be taken into consider-
ation when using any health outcomes instrument, includ-
ing the MHQ.
Overall, the 6 scales of the MHQ demonstrated excellent
internal consistency, although item redundancy exists
within the MHQ domains. This indicates that the MHQ
may be well suited for item reduction in the future, which
may improve response rates by shortening the time to
complete the survey. The ADL, work performance, and
pain scales of the MHQ were correlated in the expected
direction with the AIMS2 instrument, particularly with
respect to the physical domain. The function, ADL, satis-
faction, and summary MHQ score were well correlated in
the expected direction with objective measures of hand
functioning, including grip and pinch strength and the
Jebsen-Taylor Test score. Finally, the MHQ showed excel-
lent responsiveness among patients who underwent
SMPA arthroplasty, and it was able to detect change in
hand performance over a 6-month time period. As ex-
pected, changes in hand performance as measured by the
MHQ among patients who had not undergone surgery
were modest over the 6-month followup period.
Other methods for assessing the extent of disability re-
lated to rheumatic hand disease include describing the
extent of anatomic deformity using scoring algorithms
based on clinical examination or radiographic evidence of
joint destruction. For example, the Hand Index uses sim-
ple hand measurements of the span and lateral height of
the open and closed hand to create a standardized measure
of deformity (41). The Joint Alignment and Motion Scale
score and the mechanical joint score can be used to define
hand deformity and dysfunction at the bedside, but are
subject to observer variation (42,43). Radiographic evi-
dence of disease and disease progression has been defined
by other instruments such as the Sharp score (44). These
measures have the advantage of documenting the progres-
sion of disease over time, but do not adequately predict the
clinical manifestations of disease such as pain, occupa-
tional disability, and the need for joint replacement (45).
Although describing anatomic deformity may be helpful as
part of a global assessment of disability, it is problematic
when taken alone because many patients are able to retain
excellent hand functioning despite deformity. Pain, joint
instability, and exercise tolerance are more predictive of
physical functioning and general health perception among
patients with RA than clinical or radiologic joint appear-
To our knowledge, the MHQ is the first self-adminis-
tered instrument validated in patients with RA that com-
prehensively gathers information on functional ability and
the ability to complete daily and occupational activities, as
well as patient satisfaction, pain, and aesthetic hand ap-
pearance. It is the only questionnaire validated in this
population that can adjust for hand dominance and the
differences in hand disability between both hands. The
MHQ queries patients regarding their left and right hands
separately in each performance domain. Furthermore, the
MHQ includes a separate item regarding hand dominance
(right-hand dominant, left-hand dominant, or both). Re-
sponses to this item can then be used to stratify patients by
hand dominance for subsequent analyses, or to adjust for
hand dominance in multivariate analyses. Several upper
extremity–specific instruments have been used to measure
hand function in patients with rheumatism. The Disabili-
ties of the Arm, Shoulder, and Hand questionnaire has
been used to study patients with rheumatism, but its va-
lidity and responsiveness have not been documented in
this population (47). Furthermore, it does not make a dis-
tinction between right and left hand disability and focuses
on the entire upper extremity, not specifically hand dys-
function. The Patient-Rated Wrist Evaluation Question-
naire has been used to study pain and function among RA
patients, but focuses primarily on wrist, not hand, dys-
function, which frequently coexist in patients with rheu-
matism (48). The Cochin Rheumatoid Hand Disability
scale has been developed to measure the effectiveness of
surgery on rheumatoid hand functioning with respect to
ADL, and has been shown to be valid in this population
and sensitive to changes in disease state (49,50). It does
not, however, include important aspects of the patient
experience, including an assessment of pain, patient sat-
isfaction, or aesthetics (50,51).
Our findings are consistent with previous, smaller stud-
ies regarding the use of the MHQ to describe hand disabil-
ity among patients with RA. In comparison with the Aus-
tralian/Canadian Osteoarthritis Hand Index and the
Sequential Occupational Dexterity Assessment, the MHQ
yields reproducible results and is uniquely suited to mea-
sure outcomes in patients with RA because it can discern
disability in both hands (24). Although the MHQ was less
responsive to clinical change among control patients be-
cause, expectedly, the control patients should not have
changes in hand performance, it demonstrated excellent
responsiveness among patients undergoing SMPA. These
results are consistent with prior work using the MHQ to
measure outcomes in Dutch patients with RA. In this
study, the MHQ demonstrated excellent responsiveness to
clinical change over time, particularly in the domains of
patient satisfaction and hand aesthetics (22).
Our study has several notable limitations. First, criterion
validity cannot be assessed because there is no previously
accepted “gold standard” instrument for measuring hand
function among patients with RA. Additionally, the pro-
gression of rheumatoid hand dysfunction may be too slow
Responsiveness and Validity of the MHQ in RA Patients 1575
to detect appreciable clinical change, and longer followup
may be needed to understand the responsiveness to
change of the MHQ in patients who have not undergone
surgery. However, we were able to demonstrate excellent
responsiveness among patients who underwent surgical
intervention. Finally, our sample size prevented us from
stratifying our results based on disease severity and effects
of medical and occupational therapies, which may have
influenced our results. Our current data are limited by a
lack of information regarding disease characteristics and
C-reactive protein level) or the use of corticosteroids. Fu-
ture studies will include such variables and will allow us
to evaluate the performance of the MHQ in the context of
Nonetheless, this study demonstrates that the MHQ is an
essential instrument to understand the extent of disability
of rheumatic hand disease. The MHQ offers clinicians a
systematic approach to defining patient disability. Addi-
tionally, the MHQ can be incorporated into future studies
regarding the effectiveness of RA therapies because it of-
fers a comprehensive assessment of hand functioning and
patient-centered outcomes. In conclusion, the MHQ is an
easily administered, reliable, valid tool to measure rheu-
matoid hand function, and an essential instrument to sys-
tematically guide clinical decision making and assess the
quality of care of rheumatic hand disease.
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be submitted for publication. Dr.
Chung had full access to all of the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
Study conception and design. Chung, Burke, Wilgis, Fox.
Acquisition of data. Chung, Burns, Burke, Wilgis.
Analysis and interpretation of data. Waljee, Chung, Kim, Burke,
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