J Orthop Sci (2010) 15:509–517
DOI 10.1007/s00776-010-1477-x

Original article
Reliability, validity, and responsiveness of the Japanese version of thePatient-Rated Wrist Evaluation
TOSHIHIKO IMAEDA1, SHIGEHARU UCHIYAMA2, TAKURO WADA3, SHUJI OKINAGA4, TAKUYA SAWAIZUMI5,SHOHEI OMOKAWA6, TOSHIMITSU MOMOSE7, HISAO MORITOMO8, HIROYUKI GOTANI9, YUKIO ABE10, JUN NISHIDA11,
and FUMINORI KANAYA12 for the Clinical Outcomes Committee of the Japanese Orthopaedic Association andthe Functional Evaluation Committee of the Japanese Society for Surgery of the Hand
1

Department of Food and Nutritional Environment, College of Human Life and Environment, Kinjo Gakuin University, 2-1723 Omori,Moriyama-ku, Nagoya 465-8521, Japan2
Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan3
Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
4
Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, Japan
5
Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
6
Department of Orthopaedic Surgery, Ishin-kai Yao General Hospital, Yao, Japan
7
Department of Orthopaedics, Suwa Red Cross Hospital, Suwa, Japan
8
Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
9
Seikeikai Osaka Trauma and Microsurgery Center, Osaka, Japan10
Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Shimonoseki, Japan
11
Department of Orthopaedic Surgery, Iwate Medical University, Morioka, Japan
12
Orthopedic Surgery, Department of Clinical Neuroscience, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan

Abstract
Background. The Patient-Rated Wrist Evaluation is a regionspecific, self-administered questionnaire consisting of a pain
scale (PRWE-P) and a functional scale (PRWE-F), with thelatter consisting of specific function (PRWE-SF) and usualfunction (PRWE-UF). The PRWE was cross-culturally
adapted from the original English version by the Impairment
Evaluation Committee, Japanese Society for Surgery of theHand (JSSH). The purpose of this study was to test the reliability, validity, and responsiveness of the Japanese version of
PRWE (PRWE-J).
Methods. A consecutive series of 117 patients with wrist disorders completed the PRWE-J, the JSSH version of the Disabilities of the Arm, Shoulder, and Hand (DASH-JSSH)
questionnaire and the 36-Item Short-Form Health Survey(SF-36). Of the 117 patients, 71 were reassessed for test–retest
reliability 1 or 2 weeks later. Reliability was investigated byreproducibility and internal consistency. To analyze the validity, a factor analysis (principal axis factoring) of PRWE-J andcorrelation coefficients between PRWE-J and DASH-JSSH
were obtained. Responsiveness was examined by calculating
the standardized response mean (SRM) (mean change/SD)
and effect size (mean change/SD of baseline value) after open
surgery in 50 patients.
Results. Cronbach’s α coefficients for PRWE-P, PRWE-F, and
PRWE were 0.90, 0.95, and 0.95, respectively. The intraclasscorrelation coefficients (ICCs) for the same were 0.86, 0.93,
and 0.92, respectively. Unidimensionality of PRWE-P was confirmed. Bidimensionality of PRWE-F was confirmed and sepaOffprint requests to: T. Imaeda
Received: December 6, 2009 / Accepted: March 9, 2010

rated clearly into PRWE-SF and PRWE-UF. The correlation
coefficients between PRWE-P and PRWE-F or DASH-JSSH
were 0.63 or 0.63, respectively. The correlation coefficient
between PRWE-F and DASH-JSSH was 0.80. The correlation
coefficients between DASH-JSSH and PRWE-SF or
PRWE-UF were 0.76 or 0.73, respectively. Moderate correlation was observed in “physical functioning” for SF-36 and
PRWE-SF (r = −0.46), PRWE-F (r = −0.46), or PRWE (r =−0.46). The SRMs/effect sizes of PRWE-P, PRWE-F, or PRWE
were respectively excellent: 1.7/2.2, 1.2/1.3, 1.6/1.9.
Conclusions. The PRWE-J has evaluation capacities equivalent to those of the original PRWE.

Introduction
Health measurement scales are important patient
outcome tools to measure health status and evaluate
medical intervention.1 The arthritis impact measurement scale (AIMS) was developed in 19802 and has
been used for rheumatoid arthritis and distal radius
fracture after its revision. The AIMS covers physical,
social, and emotional well-being and was designed as anindicator of the outcome of care for arthritic patients.
The revised version is known as AIMS2 (AIMS 2ndversion).3
On the other hand, several measures for the evaluation of upper extremity function have been developed,4–8
especially for patients with wrist and hand disorders.
Some of them are disease-specific measures, such as the510

Brigham and Women’s Carpal Tunnel Questionnaire5 or
the Carpal Tunnel Syndrome Instrument.9,10 Others arejoint-specific4 or region-specific6–8 measures. Especiallyfor the wrist and hand region, the most commonly usedoutcome measures described in the literature11 are theDisabilities of the Arm, Shoulder, and Hand (DASH)
questionnaire 6 and the Patient-Rated Wrist Evaluationquestionnaire (PRWE).7 The PRWE score is the most
responsive instrument for evaluating the outcome inpatients with distal radius fractures, whereas the DASH
score is the best instrument for evaluating patients withdisorders involving multiple joints of the upper limb.11
The PRWE questionnaire has been used for distal
radius fracture,12 and now it is used for the trapeziometacarpal joint,13 scaphoid nonunion,14 proximal row
carpectomy,15 and distal radioulnar joint.16 The PRWE
is currently available in several versions, including North
American French,17 Chinese,18 Hong-Kong,19 German,20
and Swedish21 versions.
We, the Impairment Evaluation Committee of theJapanese Society for Surgery of the Hand (JSSH), havecompleted cross-cultural adaptation and developmentof the Japanese version of PRWE (PRWE-J). The
purpose of this study was to test the reliability, validity,
and responsiveness of the PRWE-J and to make the
PRWE-J available for use in Japan.

Materials and methods
In accordance with published guidelines,22 we organized
the PRWE-J committee, which consisted of translators,
researchers, and a methodologist. Our mission was toadapt the PRWE culturally into Japanese, as was done
for the DASH-JSSH.23,24
Adaptation process
The English version of the PRWE7 was translated into
Japanese by two translators whose first language is Japanese. One of them had no medical background, and theother did. Their two “forward” translations were synthesized into one after being reviewed and discussed by thecommittee. This Japanese version (prefinal version) wastranslated back into English by two other translators
whose first language is English. Both of them wereblinded to the concepts being investigated and had
no medical background. After we compared these two
back-translations with the original PRWE, we developed the PRWE-J (prefinal version 2). Then we
commenced the pilot test. After analyzing the pilot test
data, we modified the prefinal version 2 of PRWE-J
into a final version. The final PRWE-J version wasthen evaluated with regard to reliability, validity, andresponsiveness.

T. Imaeda et al.: Evaluation of PRWE-J

PRWE questionnaire
The PRWE questionnaire7 contains two subscales: apain scale (PRWE-P) and a functional scale (PRWE-F).
The PRWE-P consists of five items that have multiplechoice responses, which are scored from 1 point (mildest
pain) to 10 points (most severe pain). The pain score is
calculated as the sum of the scores for the five individual
items.
The PRWE-F consists of a specific function scale(PRWE-SF) and a usual function scale (PRWE-UF).
The answers are rated from 1 point (no difficulty withthe activity) to 10 points (cannot perform the activity atall). The PRWE-SF has six specific wrist functional
activities and is calculated as the total sum of all six
items. The PRWE-UF has four usual wrist functional
activities and is calculated as the total sum of all four
items. The overall score for PRWE-F was calculated as
the sum of PRWE-SF and PRWE-UF divided by two.
The total PRWE score is the sum of PRWE-P and
PRWE-F.
Patients and setting
The study was conducted on a consecutive series of 117
patients with a wrist or hand disorder seen on an outpatient or inpatient basis in seven orthopedic surgery
departments in Japan (Table 1). Exclusion criteria werethat the patients were <16 years old and/or they had
wrist disorders concomitantly with a forearm disorder.
The mean ± SD age was 50.0 ± 18.7 years (range 16–84
years).
The patients agreed to participate in this study. They
answered the PRWE-J questionnaire, the JSSH versionof the DASH (DASH-JSSH) questionnaire,23,24 the official Japanese version of the 36-Item Short-Form Health
Survey (SF-36; version 2.0),25 and the visual analogue
scale (VAS) (0–10 scale) for pain. The data collectedfrom the 117 patients were used as a baseline value.
Among the 117 patients, the 71 who had no treatment(e.g., medication or rehabilitation) during the consecutive visits were readministered the PRWE-J questionnaire 1 or 2 weeks later. Among them, 50 of the 70
patients who underwent open surgery by six hand surgeons answered the PRWE-J and the DASH-JSSH
questionnaires twice: preoperatively and postoperatively 3 months after surgery.
Assessment of reliability, validity, and responsiveness
Reliability was investigated by looking at the reproducibility and internal consistency based on the test–retest
method. The following analyses were conducted to
examine the validity. A factor analysis (principal axis
factoring) was conducted to examine the construct

T. Imaeda et al.: Evaluation of PRWE-J

511

Table 1. Descriptive summary of subjects
Parameter
No. of subjects: 117
Sex (M/F): 48/69
Age (years), mean ± SD: 15–86 (50 ± 19)
Affected side (right/left): 62/52; both sides 3
Hand dominancea (right/left): 108/3
Diagnosis
Distal radius fracture
Ulnocarpal abutment syndrome
TFCC lesion
Kienboeck’s disease
Trapezio-metacarpal osteoarthritis
Mid-carpal instabilityde Quervain’s disease
Scaphoid fracture
STT joint osteoarthritis
Wrist ligament lesion
Ganglion
DRUJ arthritis
Ulna styloid fracture
Others
Total

Main morbidity(no.)

Co-morbidity
(no.)

—
—
—
—
—

—
—
—
—
—
—
—
—
3
—
3
—
—
—
3
3
—
2
4
4
22

42
16
11
8
5
5
5
4
4
4
4
3
2
4
117

TFCC, triangular fibrocartilage complex; STT, scaphotrapezotrapezoidal; DRUJ, distal radioulnar
jointaSix patients had no record of hand dominancevalidity and the unidimensionality of the PRWE-P
and PRWE-F. Completeness of item responses of the
PRWE-J was examined.
Correlation coefficients between the PRWE-P and
PRWE-F and the DASH-JSSH were obtained. The
following hypotheses were examined to investigate
concurrent validity: (1) the PRWE-P would exhibit
moderate association with DASH-JSSH; (2) the
PRWE-F (SF and UF) would exhibit the strongest association with DASH-JSSH.
Correlation coefficients between the PRWE-P and
PRWE-F and the SF-36 were also obtained. The following hypotheses were examined to investigate concurrent
validity: (1) the PRWE-P would exhibit the strongest
association with “bodily pain” (SF-36-BP) among SF-36
subscales; (2) the PRWE-F (SF and UF) would exhibit
the strongest association with “physical functioning”(SF-36-PF) or “role-physical” (SF-36-RP). Those threesubscales of SF-36 were chosen because the correlation
between the DASH-JSSH and the three subscales of
SF-36 was more than moderate.7
The responsiveness of both the PRWE-J and DASHJSSH were examined by calculating the standardized
response mean (SRM) (mean change/SD)26 and effectsize (mean change/SD of baseline value)27 after open
surgery.

The protocol of this study was reviewed and approvedby the institutional review board of Nippon Medical
School prior to implementation.
Statistical analysis
Distribution of the PRWE-J, DASH-JSSH, SF-36, and
VAS for pain, ages of the subjects, and time required tofill out the PRWE-J questionnaire were assessed. Theinterval measurements (PRWE-J, DASH-JSSH, all subscales of SF-36 except physical functioning and age)
were normally distributed; the other interval measurements (physical functioning of SF-36, VAS for pain, andtime required to fill out the PRWE-J questionnaire)
were not normally distributed. Then, Cronbach’s α wasused to assess the internal consistency of PRWE-J (Pand F). The instrument test–retest reliability of PRWE-J(P and F) was assessed with the intraclass correlation
coefficient (ICC). All correlation coefficients among the
PRWE-J (P and F), DASH-JSSH, and SF-36 were calculated with use of Spearman’s correlation (nonparametric test) because some subscales of SF-36 were notnormally distributed. Changes in measurement after
carpal tunnel release were assessed with a parametric
test (paired t-test). All statistical analyses were conducted using the Statistical Package for Social Science

512

T. Imaeda et al.: Evaluation of PRWE-J(SPSS) version 17.0.J software. The critical values for
significance were set at P < 0.05.

Results
Completeness of item responses
No patients had difficulty completing the PRWE-J questionnaire. It took them 3 min 39 s, on average, to finishit (median 3 min 12 s; range 1–10 min). Most of thepatients considered all the items to be clear. Of the 117
patients, 4 did not answer one or more items. Amongthe four patients, one failed to answer four items andanother failed to answer two items. Each of the othertwo patients failed to answer one item. The items thatthey failed to respond to were as follows: Item 4 of
PRWE-P was left unanswered by two patients, items 4

and 5 of PRWE-SF were each unanswered by one
patient, item 3 of PRWE-UF was left unanswered by
one patient, and item 4 of PRWE-UF was unansweredby three patients.
The mean, median, standard deviation, and range of
the PRWE-J, DASH-JSSH, SF-36, and VAS for pain are
shown in Table 2. Two, eight, and two patients had theminimum disability score of zero (ceiling) on the PRWESF, PRWE-UF, and PRWE-F, respectively. A total of 5,26, 6, and 6 patients had a maximum disability score(floor) on the PRWE-P, PRWE-SF, PRWE-UF, and
PRWE-F, respectively. No patients had a minimum or
maximum disability score on the PRWE.
Reliability
Internal consistency was assessed by use of Cronbach’s
α coefficient (Table 3). The α coefficient for the five

Table 2. Scores for PRWE, DASH, SF-36, and VAS
Instrumental scale

No.

Mean

SD

MedianMinimum

Maximum

PRWE-P
PRWE-SF
PRWE-UF
PRWE-F
PRWE
DASH-JSSH
SF36-PF_N
SF36-RP_N
SF36-BP_N
SF36-GH_N
SF36-VT_N
SF36-SF_N
SF36-RE_N
SF36-MH_N
VAS

114
115
112
112
112
116
111
114
114
113
113
114
114
112
111

30.5
36.0
20.6
28.2
58.7
44.2
37.9
30.0
36.7
49.1
47.4
43.0
37.0
44.4
59.3

11.5
20.7
12.1
15.4
24.3
28.2
18.4
16.7
10.5
9.0
10.0
13.9
16.7
11.1
24.3

32
40
22
29.5
61.5
39.5
44.6
29.0
35.3
48.9
47.2
43.9
39.6
43.8
60

1
0a
0a
0a
5
0a
−11.8
1.7
17.2
28.9
19.5
4.5
5.6
14.6
6

50b
60b
40b
50b
99
100b
58.7
56.2
61.4
69.4
68.7
57.1
56.6
65.1
100b

PRWE-P, pain scale of the Japanese version of the Patient-Rated Wrist Evaluation (PRWE-J);
SF, Specific Functional scale; UF, Usual Functional scale; F, Functional Scale
DASH-JSSH, Disability/Symptom scale of the Japanese version of the Disabilities of the Arm,
Shoulder, and Hand (DASH) questionnaire
SF-36-PF_N, Standardized Physical Functioning subscale of the 36-Item Short-Form Health
Survey (SF-36); RP_N, Standardized Role–physical subscale; 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
VAS, visual analogue scale for pain (0–10 scale)a
Maximum health status scores (ceiling)b
Minimum health status scores (floor)

Table 3. Internal consistency
Instrument scale

No.

Cronbach’s α

Cronbach’s α range

PRWE-P
PRWE-SF
PRWE-UF
PRWE-F
PRWE

114
115
112
111
110

0.90
0.96
0.92
0.95
0.95

0.86–0.91
0.94–0.96
0.87–0.91
0.94–0.95
0.95–0.95

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513
Table 5. Component matrix of factor analysis for PRWE-P

Table 4. Intraclass correlation coefficient of PRWE
Instrument scale

No.

ICC

95% CI

Item

Component

PRWE-P
PRWE-SF
PRWE-UF
PRWE-F
PRWE

69
69
67
67
67

0.86
0.90
0.94
0.93
0.92

0.77–0.91
0.84–0.94
0.90–0.96
0.88–0.96
0.88–0.95

Pain-1Pain-2Pain-3Pain-4Pain-5

0.73
0.91
0.87
0.87
0.84

ICC, intraclass correlation coefficient; CI, confidence interval

items in the PRWE-P was 0.90 (n = 114); and whencalculated for each of the five items by eliminating each
item one by one, the range was 0.86–0.91. The α coefficient for the six items in the PRWE-SF was 0.96 (n =115); and after eliminating one by one, the range was
0.94–0.96. The α coefficient for the four items in the
PRWE-UF was 0.92 (n = 112); and after eliminating one
by one, the range was 0.87–0.91. The α coefficient forthe 10 items in the PRWE-F was 0.95 (n = 111); and after
elimination one by one, the range was 0.94–0.95. The αcoefficient for the 10 items in the PRWE was 0.95
(n = 110); and after eliminating one by one, the range
was 0.95–0.95. In all of the above, no items were foundto change the internal consistency substantially.
Instrument test–retest reliability was assessed with
the intraclass correlation coefficient (ICC) (Table 4).
There were 69 of 71 patients for the test–retest reliability who had no missing items, and the period between
the first and second tests was a mean of 8.0 ± 3.5 days
(range 1–18 days). The ICCs for the PRWE-P, PRWE-F,
and PRWE were 0.86 [95% confidence interval (CI)
0.77–0.91], 0.93 (95% CI 0.88–0.96), and 0.92 (95% CI
0.88–0.95), respectively. All ICCs for the PRWE-J subscales and total scale indicate sufficient reproducibility.

Fig. 1. Scree plot of the Patient-Rated Wrist Evaluation, Pain
Scale (PRWE-P) factors

Validity
A factor analysis (principal axis factoring) was conducted to confirm the unidimensionality of the PRWE-P
and PRWE-F. The first factor of the PRWE-P had aneigenvalue (amount of variation in the total sample
accounted for by that factor) 24 of 3.60, which explained
the 72% total variance of the PRWE-P scores (Fig. 1).
The unidimensionality of the PRWE-P was found to bestrong as a result of the low eigenvalue of the second
factor (0.55) (Fig. 1). When looking at the first factor
loading for each item, all items had loading of 0.4 orhigher (Table 5).
The first factor of the PRWE-F had an eigenvalue of
7.06, which explained the 71% total variance of the
PRWE-F scores (Fig. 2). The second factor of the
PRWE-F had an eigenvalue of 1.16, which explained
the 12% total variance of the PRWE-F scores andresulted in explaining 82% cumulative of PRWE-F
scores (Fig. 2). The third factor of the PRWE-F had an

Fig. 2. Scree plot of the PRWE-F (where F represents the
Functional Scale) factors

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T. Imaeda et al.: Evaluation of PRWE-J

eigenvalue of 0.44, which explained the 4% total
variance of the PRWE-F scores. A factor analysis indicates two factors in the PRWE-F, which means the
PRWE-F demonstrated a bidimensional structure.
When looking at the first factor loading for each item,
all items had loading of 0.4 or higher (Table 6). In addition, when looking at the second factor loading for each
item, all items of specific function had minus values andall items of usual function had plus values (Table 6). This
indicates that PRWE-F is composed of two types of
item: specific function and usual function.
The correlation coefficients between the PRWE-P
and the PRWE-F or the DASH-JSSH were 0.64 and
0.63, respectively (Table 7) (P < 0.01). These results
indicate moderate correlations between the PRWE-P
and the PRWE-F and between the PRWE-P and the
DASH-JSSH. The correlation coefficient between the
PRWE-F and DASH-JSSH was 0.80 (Table 7) (P <0.01), which indicates a strong correlation between
Table 6. Component matrix of factor analysis for PRWE-F
Component
Item

1

2

SF-1
SF-2
SF-3
SF-4
SF-5
SF-6
UF-1
UF-2
UF-3
UF-4

0.90
0.91
0.88
0.83
0.82
0.89
0.84
0.82
0.72
0.80

−0.22
−0.21
−0.17
−0.34
−0.29
−0.28
0.35
0.45
0.55
0.33

SF, Specific Functional scale of PRWE-J; UF, Usual Functional scaleof PRWE-J

them. The correlation coefficients between the DASHJSSH and PRWE-SF or the PRWE-UF were 0.76 and
0.73, respectively (Table 7) (P < 0.01). These results
demonstrate strong correlations between the PRWE-SF
and the DASH-JSSH as well as between the PRWE-UF
and the DASH-JSSH and support the hypotheses set
down in advance (Table 7).
The correlations between the PRWE-P score and thesubscales of the SF-36 scale ranged from −0.24 to −0.37(Table 7). The strongest correlation was observed in“bodily pain.” The correlations between the PRWE-P
and “bodily pain,” “role-physical,” and “physical functioning” were somewhat weak. These results do notsupport the hypotheses set down in advance.
The correlations between the PRWE-SF score andthe subscales of the SF-36 scale ranged from −0.16 to−0.46 (Table 7). A moderate correlation was observed
in “physical functioning” and the PRWE-SF (r = −0.46),
PRWE-F (r = −0.46) or PRWE (r = −0.46). These results
support the hypotheses set down in advance (Table 7).
The correlations between the PRWE-SF and “bodilypain” or “role-physical” in SF-36 were somewhat weak.
These results do not support the hypotheses set downin advance.
The correlations between the PRWE-UF score andthe subscales of the SF-36 scale ranged from −0.26 to−0.41 (Table 7). A moderate correlation was observedin the PRWE-UF and “physical functioning,” “bodily
pain,” and “role-physical” (r = −0.37, −0.40, and −0.40,
respectively.). These results support the hypotheses set
down in advance.
The correlation between the PRWE-P score and VAS
for pain was moderate (r = 0.66), and the correlation
between PRWE-F score and VAS for pain was moderate (r = 0.64) (Table 7).

Table 7. Correlation of PRWE, DASH, SF-36, and VAS
Spearman’s correlation
Instrument scaleNo.

PRWE-P

PRWE-SF

PRWE-UF

PRWE-F

PRWE

DASH

PRWE-P
PRWE-SF
PRWE-UF
PRWE-F
PRWE
DASH
SF36-PF_N
SF36-RP_N
SF36-BP_N
SF36-GH_N
SF36-VT_N
SF36-SF_N
SF36-RE_N
SF36-MH_N
VAS

114
113
110
110
110
113
112
112
111
111
112
112
110
109
114

0.59**
0.61**
0.64**
0.78**
0.63**−0.35**−0.28**−0.37**−0.35**−0.32**−0.30**−0.26**−0.24*
0.66**

0.76**
0.96**
0.92**
0.76**−0.46**−0.35**−0.33**−0.16−0.35**−0.38**−0.34**−0.36**
0.61**

0.91**
0.89**
0.73**−0.37**−0.40**−0.40**−0.26**−0.35**−0.41**−0.41**−0.34**
0.61**

0.97**
0.80**−0.46**−0.38**−0.36**−0.21*−0.39**−0.44**−0.38**−0.39**
0.64**

0.81**−0.46**−0.36**−0.37**−0.26**−0.39**−0.42**−0.36**−0.36**
0.70**−0.59**−0.52**−0.43**−0.20*−0.46**−0.56**−0.50**−0.46**
0.56***P < 0.05; **P < 0.01

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515

A multiple regression analysis of PRWE adjusted byage and sex was conducted because a statistical difference (P = 0.002) in age was found between means ± SD
for men (43 ± 18 years) and women (54 ± 18 years). The
PRWE scores were explained by the DASH score and
VAS for pain (Table 8).
ResponsivenessAmong the 70 patients who underwent open surgery, 50
completed the PRWE and the DASH-JSSH at 3 months(mean ± SD 105 ± 25 days) after the surgery. The mean
age of the subjects was 62 ± 14 years (range 21–86

years). There were 20 men and 30 women. The calculated SRMs and effect sizes of PRWE-P, PRWE-SF,
PRWE-UF, PRWE (n = 50), and DASH-JSSH (n = 50)
were 1.73/2.18, 1.13/1.29, 1.13/1.19, 1.55/1.92, and1.30/1.20, respectively (Table 9). There were statisticallysignificant differences between the mean value of preoperative and postoperative PRWE-P, PRWE-SF,
PRWE-UF, PRWE and DASH-JSSH (n = 50).
Among those subjected to the surgery, 24 of 50 had
distal radius fractures. The calculated SRMs and effectsizes of PRWE-P, PRWE-SF, PRWE-UF, PRWE, andDASH-JSSH were 1.81/2.05, 1.59/6.20, 1.50/1.75,
1.90/3.32, and 2.13/2.05, respectively (Table 9). There

Table 8. Multiple regression of PRWE
95% CI of B
Parameter

B

SE B

β

P

Lower

Upper

Constant
Age
Sex
DASH
SF36-PF_N
SF36-RP_N
SF36-BP_N
SF36-GH_N
SF36-VT_N
SF36-SF_N
SF36-RE_N
SF36-MH_N
VAS

29.71
0.05
−1.40
0.54
0.02
0.11
−0.21
−0.27
−0.13
0.14
0.13
−0.07
0.36

12.02
0.09
3.00
0.07
0.10
0.15
0.19
0.18
0.26
0.15
0.17
0.23
0.07

0.04
−0.03
0.65
0.02
0.08
−0.09
−0.11
−0.05
0.08
0.09
−0.03
0.35

0.02
0.58
0.64
0
0.81
0.49
0.26
0.13
0.62
0.38
0.44
0.76
0

5.81
−0.13
−7.37
0.39
−0.18
−0.20
−0.59
−0.62
−0.64
−0.17
−0.20
−0.54
0.22

53.62
0.23
4.56
0.68
0.23
0.41
0.16
0.08
0.38
0.44
0.46
0.39
0.50

R2 = 0.74 (n = 99)
B, unstandardized coefficient; SE B, standard error of B

Table 9. Standardized response means and effect size of PRWE and DASH
Total

Radius fracture

Instrument scale

No.

SRM

Effect size

No.

SRM

Effect size

PRWE-P
PRWE-SF
PRWE-UF
PRWE-F
PRWE
DASH
SF36-PF_N
SF36-RP_N
SF36-BP_N
SF36-GH_N
SF36-VT_N
SF36-SF_N
SF36-RE_N
SF36-MH_N
VAS

50***
50***
50***
50***
50***
50***
48***
49***
49***
48
49**
49***
49***
48***
49***

1.73
1.13
1.13
1.20
1.55
1.30
−0.56
−0.67
−0.79
−0.16
−0.41
−0.66
−0.75
−0.67
1.75

2.18
1.29
1.19
1.32
1.92
1.20
−0.54
−0.62
−0.95
−0.17
−0.50
−0.72
−0.65
−0.69
2.23

24***
24***
24***
24***
24***
24***
24***
24***
24**
24
24**
24***
24***
24***
24***

1.81
1.59
1.50
1.77
1.90
2.13
−0.80
−0.73
−0.61
−0.43
−0.68
−1.04
−0.91
−0.75
2.00

2.05
6.20
1.75
3.63
3.32
2.05
−0.85
−0.71
−0.67
−0.39
−0.94
−1.11
−0.77
−0.98
2.96

SRM, standardized response means* Significant difference between the preoperative and postoperative median values (P < 0.05)** Significant difference between the preoperative and postoperative median values (P < 0.01)*** Significant difference between the preoperative and postoperative median values (P < 0.001)

516

were statistical differences between the mean values ofpreoperative and postoperative PRWE-P, PRWE-SF,
PRWE-UF, PRWE, and DASH-JSSH (n = 24).

Discussion
The original PRWE questionnaire was cross-culturally
adapted into Japanese in accordance with a systematicstandardized approach.23 The purpose of this study was
to examine the psychometric qualities of the PRWE-J
by assessing its psychometric standards in the areas ofreliability, validity, and responsiveness.
The PRWE consists of a 5-item pain scale and a
10-item functional scale. It took patients a shorteramount of time to complete the PRWE-J than to complete the DASH-JSSH.24 The amount of time to complete the PRWE-J was equivalent to the time to complete
the North American French version of PRWE (3 min,range 5–7 min).17 This indicated that the questionnaire
was easy to understand. Whereas the DASH-JSSH has
ceiling and floor effects, a lack of both of these effects
in the PRWE-J ensures the validity of both subscales of
PRWE-J.
Internal consistency was assessed by use of Cronbach’s α coefficient (Table 3). The α coefficients for
pain, specific function, usual function, and total scoresin PRWE-J (0.90/0.96/0.92/0.95) were equivalent tothose of the original version (0.93/0.96/0.92/0.98),28 theChinese version (0.94/0.94/0.97/0.98),18 and the German
version (0.81/–/–/0.89).29
Instrument test–retest reliability was assessed with
the ICC (Table 4). The ICCs of the pain, specific function, usual function, and total scores in PRWE-J(0.86/0.90/0.94/0.92) were equivalent to those of theoriginal version (0.90/0.93/0.92/0.94),28 the Chineseversion (0.91/0.90/0.88/0.93),18 and the German version(0.86/–/–/0.94).29 This indicates that the ICCs for the
PRWE-J subscales and total scale have sufficient
reproducibility.
The validation process of the PRWE-J questionnaire
has shown that it has validity similar to those of theSwedish version22 and the original PRWE.28 The strong
correlations between the PRWE-J and DASH-JSSH
support this validity (Table 7). The weak correlations
between the PRWE-J and SF-36 failed to demonstrate
this validity, although the bodily pain and physical functioning of SF-36 have moderate correlation with theGerman version29 as well as the original PRWE.28
DASH-JSSH has higher correlations with the bodily
pain and physical functioning of SF-36 than PRWE-J.
This is thought to be because the DASH deals with abroader region of the whole body than the PRWE.
These results demonstrated that the PRWE-J measures
only one area of health-related quality of life.

T. Imaeda et al.: Evaluation of PRWE-J

The pain scale of PRWE-J exhibited high unidimensionality (Table 5, Fig. 1), and there was no low item–
scale correlation. The loading of this scale was very high.
These results show that the pain scale of PRWE-J has ahigh quality of validation.
The functional scale of PRWE exhibited bidimensionality (Table 6, Fig. 2). The two factors could beclearly separated into specific function and usual function. This means that the functional scale of PRWE-J
has a high quality of validation.
Cohen’s rule-of-thumb for interpreting the “effectsize index” (a value of 0.2 is small, 0.5 is moderate, and≥0.8 is large) can be applied to the SRM.26 The responsiveness (SRM/ES) of the pain scale and functional
scale of the PRWE-J for the patients overall were excellent 3 months after operation and were larger thanthose of the DASH-JSSH. The responsiveness of thepain scale and functional scale of the PRWE-J for
patients with a distal radius fracture were equivalent to
the results 3 months after operation.
We believe the strengths of this study are that
the PRWE-J demonstrated good reproducibility,
consistency, and validity. Moreover, it had good
responsiveness.

Conclusions
We concluded that the Japanese version of PRWE
(PRWE-J) has evaluation capacities comparable tothose of the original PRWE. We expect that use of thisscale in Japan for self-assessment by patients of treatment will contribute to meaningful improvement of outcomes for patients with wrist problems.
None of the authors of this manuscript has received any typeof support, benefits, or funding from any commercial party
related directly or indirectly to the subject of this article.

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