J Orthop Sci (2013) 18:712–719
DOI 10.1007/s00776-013-0408-z

ORIGINAL ARTICLE

Reliability, validity, and responsiveness of the Japanese versionof the patient-rated elbow evaluation
Tadamasa Hanyu • Mikihiko Watanabe • Takashi Masatomi •Keiichiro Nishida • Teruhiko Nakagawa •Yasumasa Nishiura • Hiroyuki Ohi

Received: 31 January 2013 / Accepted: 16 April 2013 / Published online: 11 June 2013
Ó The Japanese Orthopaedic Association 2013

Abstract
Background The patient-rated elbow evaluation (PREE)
is a joint-specific, self-administered questionnaire consisting of a pain scale (PREE-P) and a functional scale (PREEF), the latter consisting of specific function (PREE-SF) andusual function (PREE-UF). The purpose of this study wasto cross-culturally adapt the PREE into Japanese (PREE-J)
and to test its reliability, validity, and responsiveness.
Methods A consecutive series of 74 patients with elbow
disorder completed the PREE-J, the Japanese version of thedisabilities of the arm, shoulder, and hand (DASH–JSSH)
questionnaire, and the official Japanese version of the
36-Item Short-Form Health Survey (SF-36). Of the 74
patients, 53 were reassessed for test–retest reliability 1 or
2 weeks later. Reliability was investigated in terms ofreproducibility and internal consistency. The validity of thePREE-J was examined by factor analysis, and correlation
coefficients were obtained using the PREE-J, DASH-JSSH,
For the Clinical Outcomes Committee of the Japanese Orthopaedic
Association and the Functional Evaluation Committee of the Japan
Elbow Society.
T. Hanyu (&)
Department of Orthopaedic Surgery, Nagaoka Red Cross
Hospital, 2-297-1 Senshu, Nagaoka, Niigata 940-2085, Japane-mail: ra-hanyu@nagaoka.jrc.or.jp
M. Watanabe
Department of Orthopaedic Surgery, Nihon Koukan Hospital,
Kawasaki, Japan
T. Masatomi
Osaka Yukioka Hospital Hand Center, Osaka, JapanK. Nishida
Department of Orthopaedic Surgery, Graduate Schoolof Medicine, Okayama University, Okayama, Japan123

and SF-36. Responsiveness was examined by calculating
the standardized response mean (SRM) and effect size after
elbow surgery in 53 patients.
Results Cronbach’s a coefficients for PREE-P, PREE-F,
and PREE were 0.92, 0.97, and 0.97, respectively, and thecorresponding intraclass correlation coefficients were 0.92,
0.93, and 0.94, respectively. Unidimensionality of PREE-P
and PREE-F was confirmed by factor analysis. The coefficients of correlation between PREE-P and PREE-F or
DASH–JSSH were 0.81 and 0.74, respectively; that between
PREE-F and DASH–JSSH was 0.86, and those between
DASH–JSSH and PREE-SF or PREE-UF were 0.85 and 0.82,
respectively. Moderate correlation was observed in ‘‘physicalfunctioning’’ for SF-36 and PREE-F (r = -0.69) or PREE
(r = -0.68). The SRMs/effect sizes of PREE-P (1.31/1.32)
or PREE (1.28/1.12) were more responsive than the DASH–
JSSH (0.99/0.85), ‘‘bodily pain’’ (-1.15/-1.43), and‘‘physical functioning’’ (-0.70/-0.44) in SF-36.
Conclusion The PREE-J represents a reliable, valid, andresponsive instrument and has evaluation capacities
equivalent to those of the original PREE.

T. Nakagawa
Department of Orthopaedic Surgery, The Fratemity Memorial
Hospital, Tokyo, Japan
Y. Nishiura
Department of Orthopaedic Surgery, University of Tsukuba,
Tsukuba, Japan
H. OhiHand Surgery and Microsurgery Center, Seirei Hamamatsu
General Hospital, Hamamatsu, Japan

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Introduction

Adaptation process

Traditional methods of reporting clinical outcomes include
data on complication and mortality rates, and these data
should be an integral part of any outcome study. Patient
self-administered questionnaires acquire data on a patient’s
experience of pain, functional disability, and general healthstatus. The collection of data by patient reports removes thepossibility of observer bias, as the questionnaires are selfadministered by the patient at each assessment. These
questionnaires do not replace traditional measures of clinical endpoints, but will be additions to data collection [1].
Patient questionnaires developed so far have focused on
general health and quality of life, such as the 36-Item
Short-Form Health Survey (SF-36) [2] or EuroQol (EQ5D) [3]. Several measures for the evaluation of upper
extremity function have also been developed [4–8]. Someof them are disease-specific [5], joint-specific [4] or regionspecific measures [6–8]. Especially for the wrist and handregion, the most commonly used outcome measuresdescribed in the literature are the disabilities of the arm,shoulder, and hand (DASH) questionnaire [6] and thepatient-rated wrist evaluation (PRWE) questionnaire [5].
The DASH score is the best instrument for evaluating
patients with disorders involving multiple joints of theupper limb. In the Japanese Society for Surgery of theHand (JSSH), the DASH questionnaire has been subjected
to cross-cultural adaptation, and a Japanese version of the
DASH–JSSH [9] has been developed. The PRWE questionnaire has also undergone cross-cultural adaptation, anda Japanese version of the PRWE (PRWE-J) has beendeveloped by the Impairment Evaluation Committee of the
JSSH. It has been reported that the PRWE-J has evaluation
capacities equivalent to those of the original PRWE [10],and it is now used for patients with wrist and handdisorders.
MacDermid has reported its reliability and validity forpatients with elbow pathology [11], and a German versionof the PREE is available [12].
We, the Functional Evaluation Committee of the Japan
Elbow Society, have completed cross-cultural adaptationand development of the Japanese version of the PREE
(PREE-J). The purpose of the present study was to test thereliability, validity, and responsiveness of the PREE-J, witha view to making it available for use in Japan.

Similarly to other transcultural adaptation projects, wefollowed a cycle of forward/backward translation [13]. The
English version of the PREE [11] was translated into
Japanese by two translators, one with and one without amedical background, whose first language was Japanese.
Then, the two forward translations were synthesized into asingle one after a review and discussion by the committee.
Parts of the PREE which were also found in the PRWE
were translated identically, since the PRWE-J had alreadybeen published and it was important to be consistent. This
Japanese version was translated back into English by twoother translators whose first language was English. After
we had compared those two back-translations with theoriginal PREE, we developed a temporary version of thePREE- J. After pilot testing, the final PREE-J version wasthen evaluated for reliability, validity, and responsiveness.

Materials and methods
Our aim was to adapt the PREE culturally for Japanesepatients, as the Functional Evaluation Committee of the
JSSH has done already for the PRWE-J.

PREE questionnaire
The PREE questionnaire contains two subscales: a pain
scale (PREE-P) and a functional scale (PREE-F). The
PREE-P consists of five items that have multiple choice
responses, which are scored from 0 point (no pain) to 10
points (worst possible). The pain score (0 = best to
50 = worst) is calculated as the sum of the scores for thefive individual items (4 items for intensity, 1 item forfrequency).
The PREE-F consists of a specific functional scale(PREE-SF) and a usual functional scale (PREE-UF). The
answers are rated from 0 point (no difficulty) to 10 points(unable to perform at all). The PREE-SF has eleven specific elbow functional activities and is calculated as thetotal sum of all eleven items (0 = best to 110 = worst).
The PREE-UF has four usual elbow functional activities
and is calculated as the total sum of all four items(0 = best to 40 = worst). The overall score for PREE-F(0 = best to 50 = worst) is calculated as the sum of PREESF and PREE-UF divided by three. The total PREE score is
the sum of PREE-P and PREE-F, greater pain and disability being indicated by a higher score (0 = best,
100 = worst).
Patients and setting
The study was conducted on a consecutive series of 74
patients with elbow disorders seen on an out-patient or
inpatient basis at six departments of orthopedic surgery inJapan (Table 1).
Informed consent was obtained from each patient toparticipate in this study. Minors had parental consent

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Table 1 Descriptive summary of subjects
Parameter

Entry

Test–
retestAfter
surgery

Rheumatoid arthritis

35

30

17

Osteoarthritis

8

6

6

Osteochondritis dissecans

6

6

5

Medial ligament injury

5

1

5

No. of subjects: 74
Sex(M/F): 39/35
Age (years), mean ± SD: 46.7 ± 20.7
(13–82)Affected side (right/left): 55/19
Diagnosis

Posterior impingement

2

0

2

Lateral epicondylitis

5

4

5

Cubital tunnel syndrome

4

1

4

Post-trauma contracture

3

3

3

Loose bodies in elbow joint

2

1

2

Olecranon fracture

2

0

2

Synovial osteochondromatosis

1

0

1

Rupture of biceps tendon

1

1

1

Total

74

53

53

instead. They answered the PREE-J questionnaire, theDASH–JSSH questionnaire, and the official Japanese version of the SF-36 (version 2.0). The data collected from the74 patients were used as baseline values. Among the 74
patients, 53 were readministered the PREE-J questionnaire
for test–retest reliability 1 or 2 weeks later. Fifty-threepatients who underwent surgery conducted by six elbow
surgeons answered the PREE-J, the DASH–JSSH, and SF36 questionnaires twice: preoperatively and 3 months after
surgery.
Assessment of reliability, validity, and responsiveness
Reliability was investigated by assessment of reproducibility and internal consistency based on the test–retest
method. The following analyses were conducted for
examination of validity. Factor analysis (principal axis
factoring) was conducted to examine the construct validity
and unidimensionality of the PREE-P and PREE-F. Completeness of the item responses for the PREE-J was also
examined.
Coefficients of correlation between the PREE-P or
PREE-F and the DASH–JSSH were obtained. The following hypotheses were examined to investigate concurrent validity: (1) the PREE-P would exhibit moderateassociation with DASH–JSSH; (2) the PREE-F (SF andUF) would exhibit the strongest association with DASH–
JSSH.

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Coefficients of correlation between the PREE-P or
PREE-F and the SF-36 were also obtained. The following
hypotheses were examined to investigate concurrent
validity: (1) the PREE-P would exhibit the strongest
association with ‘‘bodily pain’’ (SF36-BP) among the SF36 subscales; (2) the PREE-F (SF and UF) would exhibit
the strongest association with ‘‘physical functioning’’(SF36-PF) or ‘‘role-physical’’ (SF36-RP). Those threesubscales of the SF-36 were chosen because the correlation
between the DASH–JSSH and the three SF-36 subscales
was more than moderate [7, 10].
The responsiveness of the PREE-J, DASH–JSSH, andSF-36 was examined by calculating the standardized
response mean (SRM) (mean change/SD) [14] and effectsize (mean change/SD of baseline value) [15] after elbow
surgery in 53 patients.
The protocol of this study was reviewed and approvedby the institutional review board of Nagaoka Red Cross
Hospital prior to implementation.
Statistical analysis
Distribution of the PREE-J, DASH–JSSH, and SF-36, andages of the subjects were assessed. The interval measurements (age, PREE-J except PREE-SF, DASH–JSSH, all
subscales of the SF-36 except ‘‘physical functioning’’,‘‘social functioning’’, and ‘‘role-emotional’’) were normally distributed; the other interval measurements (PREESF, ‘‘physical functioning’’, ‘‘social functioning’’, and‘‘role-emotional’’ of the SF-36) were not normally distributed. Cronbach’s a was then used to assess the internalconsistency of the PREE-J (P and F). The instrument test–
retest reliability of the PREE-J (P and F) was assessed with
the intraclass correlation coefficient (ICC). All coefficientsof correlation among the PREE-J (P and F), DASH–JSSH,
and SF-36 were calculated using Spearman’s correlation (anonparametric test) because some subscales of the SF-36
were not normally distributed. Changes in measurements
after elbow surgery were assessed with a parametric test
(paired t test). All statistical analyses were conducted using
the Statistical Package for the Social Sciences (SPSS)
version 19.0J software package. Differences at P \ 0.05
were considered to be significant.

Results
Completeness of item responses
No patients had difficulty completing the PREE-J questionnaire. Of the 74 patients, 3 did not answer one or two
items (two failed to answer 2 items and 1 failed to answer
one item). The items that they failed to respond to were asEvaluation of PREE-J

715

Table 2 Scores for PREE, DASH, and SF-36

Table 3 Internal consistency of PREE-J
Instrument scale

No.

Cronbach’s aCronbach’s a range

PREE-P73

0.92

0.88–0.93

PREE-SF72

0.96

0.95–0.96

110b

PREE-UF72

0.92

0.88–0.92

0a40b

PREE-F72

0.97

0.97–0.97

a

50b

PREE

71

0.97

0.97–0.97

Instrument
scale

No.

Mean

SD

MedianMinimum

Maximum

PREE-P

73

22.4

12.7

24.0

0a

50b

PREE-SF

72

36.6

32.1

26.5

0a

PREE-UF

72

15.5

12.4

13.0

PREE-F

72

17.4

14.4

13.3

0

PREE

71

39.8

26.0

34.7

0.3

100b

a

80.8

DASH–
JSSH

74

34.8

23.8

31.8

0

SF36-PF_N

74

35.8

19.2

39.8

-14.4

57.8

SF36-RP_N

74

36.8

15.9

39.1

2.6

55.7

SF36-BP_N

74

37.7

9.4 35.4

21.5

61.7

SF36-GH_N

74

48.3

12.8

48.5

19.1

69.8

SF36-VT_N

74

49.4

11.1

49.8

27.4

69.1

SF36-SF_N
SF36-RE_N
SF36-MH_N

74
74
74

49.9
45.7
49.7

11.5
13.2

50.6
51.9

9.9 51.8

11.9
6.1
22.3

Table 4 Intraclass correlation coefficient of PREE-J
Instrument scale

All cases

RA cases

No.

ICC

No.

ICC

PREE-P

52

0.92

29

0.90

57.0

PREE-SF

51

0.93

29

0.86

56.1

PREE-UF

51

0.92

29

0.85

65.2

PREE-F

51

0.93

29

0.86

PREE

50

0.94

28

0.90

PREE-P pain scale of the Japanese version of PREE, -SF specificfunctional scale, -UF usual functional scale, -F functional scale,
DASH–JSSH disability/symptom scale of the Japanese version of thedisabilities of the arm, shoulder, and hand (DASH) questionnaire, SF36-PF_N standardized physical functioning subscale of the 36-Item
Short-Form Health Survey (SF-36), -RP_N standardized role-physicalsubscale, -BP_N standardized bodily pain subscale, -GH_N standardized general health subscale, -VT_N standardized vitality subscale, -SF_N standardized social functioning subscale, -RE_N
standardized role-emotional subscale, -MH_N standardized mental
health subscale

ICC intraclass correlation coefficient

follows: item 5 of the PREE-P (unanswered by one
patient), item 7 of the PREE-SF and item 4 of the PREEUF (unanswered by one patient), and item 10 of the PREESF and item 4 of the PREE-UF (unanswered by one
patient).
The mean, median, standard deviation, and range of thePREE-J, DASH–JSSH, and SF-36 are shown in Table 2.
Two, 7, 7, and 3 patients had a minimum disability score ofzero (ceiling) on the PREE-P, PREE-SF, PREE-UF, andPREE-F, respectively. One patient each had a maximum
disability score (floor) on the PREE-P, PREE-SF, PREEUF, PREE-F, and PREE, respectively. One patient had amaximum disability score on the PREE.

each item one by one, the range was 0.95–0.96. The acoefficient for the four items in the PREE-UF was 0.92
(n = 72); after eliminating each item one by one, the range
was 0.88–0.92. The a coefficient for the fifteen items in the
PREE-F was 0.97 (n = 72); after eliminating each item
one by one, the range was 0.97–0.97. The a coefficient for
the twenty items in the PREE was 0.97 (n = 71); after
eliminating each item one by one, the range was 0.97–0.97.
Among all of the above, no items were found to change theinternal consistency substantially.
Instrument test–retest reliability was assessed with theintraclass correlation (ICC) (Table 4). With regard to test–
retest reliability, 52 of the 53 patients assessed had no
missing items, and the mean period between the first andsecond tests was 12 ± 3 days (range 5–19 days). The ICC
for the PREE-P, PREE-SF, PREE-UF, PREE-F, and PREE
in all cases (n = 53) was 0.92, 0.93, 0.92, 0.93, and 0.94,
respectively. The ICC for the PREE-P, PREE-SF, PREEUF, PREE-F, and PREE in RA patients (n = 30) was 0.90,
0.86, 0.85, 0.86, and 0.90, respectively. All ICCs for the
PREE-J subscales and total scale indicated sufficient
reproducibility.

Reliability

Validity

Internal consistency was assessed using Cronbach’s acoefficient (Table 3). The a coefficient for the five items in
the PREE-P was 0.92 (n = 73); when calculated for eachof the five items by eliminating each of them one by one,the range was 0.88–0.93. The a coefficient for the elevenitems in the PREE-SF was 0.96 (n = 72); after eliminating

Factor analysis (principal axis factoring) was conducted toconfirm the unidimensionality of the PREE-P and PREE-F.
The first factor of the PREE-P had an eigenvalue (amountof variation in the total sample attributable to that factor) of
3.67, which accounted for 71 % of the total variance of thePREE-P scores (Fig. 1). The unidimensionality of theaMaximum health status scoresb

Minimum health status scores

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Fig. 1 Solid plot of the patient-rated elbow evaluation, pain scale(PREE-P) factors

Fig. 2 Solid plot of the PREE-F (where F represents the functional
scale) factors

Table 5 Component matrix of factor analysis for PREE-P
Item

Component

Pain-1

0.79

Pain-2

0.71

Pain-30.90

Pain-4

0.94

Pain-50.87

PREE-P was found to be strong as a result of the low
eigenvalue of the second factor (0.54) (Fig. 1). Assessmentof the first factor loading for each item showed that allitems had a loading of 0.4 or higher (Table 5).
The first factor of the PREE-F had an eigenvalue of
10.50, which accounted for 70 % of the total variance of
the PREE-F scores (Fig. 2). The second factor of thePREE-F had an eigenvalue of 1.03, which accounted for
7 % of the total variance of the PREE-F scores and 77 % of
the cumulative of PREE-F scores (Fig. 2). The third factorof the PREE-F had an eigenvalue of 0.65, which accounted
for 4 % of the total variance of the PREE-F scores.
Assessment of the first factor loading for each item showedthat all items had a loading of 0.4 or higher (Table 6).
Factor analysis indicated two factors in the PREE-F,
suggesting a bidimensional structure. When looking at thesecond factor loading for each item, all items pertaining tousual function had plus values. Although many items ofspecific function had minus values, three items related to
specific function had high plus values (Table 6). The bidimensionality of the PREE-F was not separated clearly into
PREE-SF and PREE-UF.

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Table 6 Component matrix of factor analysis for PREE-F
Item

Component
1

2

SF-1

0.89

-0.32

SF-2

0.84

-0.38

SF-3

0.87

0.29

SF-4
SF-5

0.83
0.89

-0.11
0.24

SF-6

0.72

-0.12

SF-7

0.83

0.08

SF-8

0.84

-0.28

SF-9

0.80

-0.18

SF-10

0.78

0.08

SF-11

0.78

0.23

UF-1

0.90

0.17

UF-2

0.84

0.23

UF-3

0.72

0.21

UF-4

0.79

0.30

SF specific functional scale of PREE-J, UF usual functional scale ofPREE-J

The coefficients of correlation between the PREE-P and
PREE-F or DASH–JSSH were 0.81 and 0.74, respectively(Table 7) (P \ 0.01). These results indicated moderatecorrelations between the PREE-P and the PREE-F andbetween the PREE-P and the DASH–JSSH. The coefficientof correlation between the PREE-F and DASH–JSSH was
0.86 (Table 7) (P \ 0.01), which indicated a strong

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Table 7 Correlation of PREE, DASH, and SF-36
Instrument scale

No.

Spearman’s correlation
PREE-P

PREE-SF

PREE-UF

PREE-F

PREE

PREE-P

73

PREE-SF71

0.80**

PREE-UF71

0.73**

0.85**

PREE-F71

0.81**

0.98**

PREE

71

0.94**

0.94**

0.87**

0.95**

DASH

73

0.74**

0.85**

0.82**

0.86**

0.84**

SF36-PF_N
SF36-RP_N

7373-0.59**-0.46**-0.69**-0.48**-0.66**-0.56**-0.69**-0.53**-0.68**-0.52**

DASH

0.92**-0.77**-0.54**

SF36-BP_N

73-0.65**-0.58**-0.60**-0.62**-0.66**-0.58**

SF36-GH_N

73-0.47**-0.55**-0.48**-0.55**-0.51**-0.52**

SF36-VT_N

73-0.48**-0.48**-0.44**-0.48**-0.50**-0.53**

SF36-SF_N

73-0.38**-0.43**-0.27*-0.39**-0.39**-0.40**

SF36-RE_N

73-0.63**-0.62**-0.52**-0.61**-0.64**-0.61**

SF36-MH_N

73-0.52**-0.47**-0.41**-0.48**-0.49**-0.54*** P \ 0.05, ** P \ 0.01

correlation between them. The coefficients of correlation
between the DASH–JSSH and PREE-SF or PREE-UF were0.85 and 0.82, respectively (Table 7) (P \ 0.01). These
results demonstrated strong correlations between the
PREE-SF and DASH–JSSH as well as between the PREEUF and DASH–JSSH, thus supporting the proposed
hypotheses (Table 7).
The correlations between the PREE-P score and thesubscales of the SF-36 scale ranged from -0.38 to -0.65(Table 7). A moderate correlation was observed between
the SF36-BP and PREE-P (r = -0.65). These results
supported the proposed hypotheses. The correlations
between the PREE-P and SF36-PF or SF36-RP were
somewhat weak, thus the proposed hypotheses were notsupported.
The correlations between the PREE-SF score and thesubscales of the SF-36 scale ranged from -0.43 to -0.69(Table 7). A moderate correlation was observed between
the SF36-PF and PREE-SF (r = -0.69), PREE-F (r =-0.69), or PREE (r = -0.68). These results supported the
proposed hypotheses. The correlations between the PREESF and SF36-BP or SF36-RP were somewhat weak, andthus the hypotheses were not supported.
The correlations between the PREE-UF score and thesubscales of the SF-36 scale ranged from -0.27 to -0.66(Table 7). A moderate correlation was observed between
the PREE-UF and SF36-PF (r = -0.66) or SF36-BP(r = -0.60), and thus supported the proposed hypotheses.
Multiple regression analysis of PREE adjusted by age
and sex was conducted because a significant difference(P \ 0.001) in mean age (±SD) was found between men(36 ± 19 years) and women (59 ± 15 years). The PREE

Table 8 Multiple regression of PREE
Parameter

B

SE B

b

P

95 % CI of B
Lower

Upper
88.00

Constant

43.20

22.17

0.06

-1.56

Age

0.18

0.14

0.14

0.22

0.41

1.02

Sex

-8.80

6.26

-0.16

0.17

-21.44

3.84

DASH

0.71

0.15

0.65

0

0.41

1.02

SF36_PF_N

0.33

0.24

0.22

0.19

-0.16

0.82

SF36_RP_N

0.08

0.16

0.05

0.61

-0.24

0.41

SF36_BP_N
SF36_GH_N

-0.73
-0.19

0.30
0.26

-0.25
-0.09

0.02
0.46

-1.34
-0.71

-0.12
0.33

SF36_VT_N

0.63

0.37

0.27

0.09

-0.10

1.35

SF36_SF_N

-0.04

0.24

-0.02

0.86

-0.54

0.46

SF36_RE_N

-0.43

0.26

-0.21

0.11

-0.91

0.11

SF36_MH_N

-0.34

0.42

-0.13

0.42

-1.18

0.50

2

R = 0.80 (n = 53)
B unstandardized coefficient, SE B standard error of B

scores were explained by the DASH scores and SF36-BP(Table 8).
ResponsivenessFifty-three patients who underwent elbow surgery completed the PREE, DASH–JSSH, and SF-36 at 3 months(mean ± SD: 98 ± 23 days) after surgery. The mean ageof those patients was 42 ± 20 years (range 13–77 years).
There were 32 men and 21 women. The calculated SRMs
and effect sizes of PREE-P, PREE-SF, PREE-UF, PREE-F,
PREE, DASH–JSSH, and SF36-BP (n = 53) were 1.31/

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Table 9 Standardized response means and effect size of PREE,
DASH, and SF-36
Instrument
scale

Total

Rheumatoid arthritis

No.

SRM

Effect
size

No.

SRM

Effectsize

PREE-P

53***

1.31

1.32

17***

2.31

2.06

PREE-SF

53***

0.94

0.81

17***

1.34

1.32

PREE-UF

53***

1.03

0.91

17***

1.41

1.29

PREE-F

53***

1.02

0.86

17***

1.44

1.35

PREE

53***

1.28

1.12

17***

2.21

1.75

DASH

53***

0.99

0.85

17***

1.12

0.94

SF36-PF_N

53***

-0.70

-0.44

17*

-0.56

-0.46

SF36-RP_N

53***

-0.68

-0.71

17

-0.38

-0.41

SF36-BP_N

53***

-1.15

-1.43

17***

-1.12

-1.29

SF36-GH_N

53***

-0.49

-0.32

17

-0.51

-0.32

SF36-VT_N

53*

-0.35

-0.37

17

-0.06

-0.07

SF36-SF_N

53**

-0.39

-0.37

17

-0.45

-0.49

SF36-RE_N

53*

-0.36

-0.31

17

-0.35

-0.40

SF36-MH_N

53

-0.25

-0.27

17

-0.12

-0.17

SRM standardized response means* Significant difference between the preoperative and postoperative
mean value (P \ 0.05)** Significant difference between the preoperative and postoperative
mean value (P \ 0.01)*** Significant difference between the preoperative and postoperative
mean value (P \ 0.001)

1.32, 0.94/0.81, 1.03/0.91, 1.02/0.86, 1.28/1.12, 0.99/0.85,
and -1.15/-1.43, respectively (Table 9). There were significant differences between the mean values of preoperative and postoperative PREE-P, PREE-SF, PREE-UF,
PREE-F, PREE, DASH–JSSH, and all subscales of the SF36 except for the ‘‘mental health’’ subscale (n = 53).
Among those patients who underwent surgery, 17 of 53
who had rheumatoid arthritis underwent total elbow
arthroplasty. The calculated SRMs and effect sizes of
PREE-P, PREE-SF, PREE-UF, PREE-F, PREE, DASH–
JSSH, and SF36-BP were 2.31/2.06, 1.34/1.32, 1.41/1.29,
1.44/1.35, 2.21/1.75, 1.12/0.94, and -1.12/-1.29, respectively (Table 9). There were significant differences
between the mean values of preoperative and postoperative
PREE-P, PREE-SF, PREE-UF, PREE-F, PREE, DASH–
JSSH, SF36-PF, and SF36-BP (n = 17).

Discussion
We had previously developed a Japanese self-administeredquestionnaire based on an English version of the Western
Ontario and McMaster Universities osteoarthritis index(WOMAC) to measure subjective function and pain statusof patients undergoing total knee arthroplasty [16]. With123

the cross-cultural translation and adaptation of the original
PREE, we produced a joint-specific instrument for subjective assessment of elbow pain and function in Japanesespeaking patients. The purpose of this study was to
examine the psychometric qualities of the PREE-J byassessing its psychometric standards in the areas of reliability, validity, and responsiveness.
Internal consistency was assessed using Cronbach’s acoefficient (Table 3). The a coefficients for pain, function,and total scores in PREE-J (0.92/0.97/0.97) were equivalent to those of the original version (data not shown) and
the German version (–/–/0.96) [12].
Instrument test–retest reliability was assessed with the
ICC (Table 4). The ICCs of the pain, function, and total
scores in PREE-J (0.92/0.93/0.94) were equivalent to thoseof the original version (0.88/0.89/0.95) [11], and the German version (0.73/0.82/0.80) [12]. This indicated that the
ICCs for the PREE-J subscales and total scale had sufficient reproducibility. Even in patients with RA whoshowed a diurnal variation and day-to-day variation, ICCs
had good scores (0.90/0.86/0.90) (Table 4).
The process of validation of the PREE-J questionnaire
has shown that it has validity similar to those of the German version and the original PREE. The strong correlations
between the PREE-J and DASH–JSSH supported thisvalidity (Table 7). Although the correlations between the
PREE-J and SF-36 were weak, bodily pain and physicalfunctioning assessed by SF-36 showed moderate correlation with the German version as well as the original PREE.
DASH–JSSH had higher correlations with physical functioning assessed by SF-36 than that assessed by PREE-J.
This is thought to be because the DASH covers a broader
region of the whole body than the PREE. These results
demonstrated that the PREE-J measures only one area of
health-related quality of life.
The pain scales of PREE-J exhibited high unidimensionality (Table 5; Fig. 1), and there was no low item-scalecorrelation. The loading of this scale was very high. These
results indicated that the pain scale of PREE-J has a highvalidation quality.
The functional scale of PREE-J exhibited bidimensionality (Table 6; Fig. 2), and there was no low item-scalecorrelation. However, the two factors could not be clearly
separated into specific function and usual function in the
PREE-J. Imaeda et al. [10] reported that the two factors in
the PRWE-J were clearly separatable into specific function(6 items) and usual function (4 items). Therefore, we would
like to consider changing some of the items related to
special function in the PREE-J.
Cohen’s rule-of-thumb for interpreting the ‘‘effect size
index’’ (a value of 0.2 is small, 0.5 moderate, and C0.8
large) can be applied to the SRM [14]. Imaeda et al. [10]reported that the SRMs/effect sizes of PRWE-P, PRWE-F

Evaluation of PREE-J

or PRWE were excellent: 1.7/2.2, 1.2/1.3, and 1.6/1.9,
respectively. In the present study, the responsiveness(SRM/ES) of the pain scale and functional scale of thePREE-J for the patients overall was excellent 3 months
after surgery, and larger than that of the DASH–JSSH.
The Kinemax Outcome Group reported that measurement of the SRM showed the Knee Society knee score to
be more responsive (SRM 2.2) than the WOMAC (SRM
2.0 for pain and 1.4 for function) and the SF-36 (SRM 1.0
for bodily pain and 1.1 for physical functioning). The Knee
Society function score was the least responsive measure(SRM 0.8). The WOMAC and SF-36 have high internalconsistency and are more responsive measures of the outcomes of total knee arthroplasty [17]. In this study, theresponsiveness of the pain and functional scale of thePREE-J for patients undergoing total elbow arthroplasty
were equivalent to the results 3 months after surgery.

Conclusions
We conclude that the Japanese version of PREE (PREE-J)
has evaluation capacities comparable to those of the original PREE. We expect that use of this scale in Japan for
self-assessment by patients receiving treatment will make ameaningful contribution to improving the outcomes ofpatients with elbow problems.
Conflict of interest None of the authors received any type of support, benefits, or funding from any commercial party related directly
to the subject of this article.

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