Psychometric Properties Of The Mayo Elbow Performance Score
Rheumatol Int (2015) 35:1015–1020DOI ORIGINAL ARTICLE - VALIDATION STUDIESPsychometric properties of the Mayo Elbow Performance ScoreDerya CelikReceived: 10 September 2014 / Accepted: 19 December 2014 / Published online: 31 December 2014 Springer-Verlag Berlin Heidelberg 2014Abstract To translate and culturally adapt the MayoElbow Performance Score (MEPS), a widely used instrument for evaluating disability associated with elbow injuries, into Turkish (MEPS-T) and to determine psychometricproperties of the translated version. The MEPS was translated into Turkish using published methodological guidelines. The measurement properties of the MEPS-T (construct validity and floor and ceiling effects) were tested in91 patients with elbow pathology. The reproducibility ofthe MEPS-T was tested in 59 patients over 7–14 days. Theresponsiveness of the MEPS-T was tested in a subgroup of46 patients diagnosed with lateral epicondylitis and whoreceived conservative treatment for 6 weeks. The interclass correlation coefficient (ICC) was used to estimate thetest–retest reliability. The construct validity was analyzedwith the disabilities of the arm, shoulder and hand (DASH),Visual Analog Scale (VAS) and the Short Form 36 (SF-36).Effect size (ES) was used to assess the responsiveness. Thedistribution of floor and ceiling effects was determined.The MEPS-T showed very good test–retest reliability (ICC0.89). The correlation coefficients between the MEPS-Tand DASH and VAS were 0.61 and 0.53, respectively(p 0.001). The highest correlations were between theMEPS-T and the mental component summary (r 0.47,p 0.001) and role emotional (r 0.45, p 0.001). TheMEPS-T ES, 0.50, was moderate (95 % CI 0.33–0.62). Weobserved no ceiling or floor effects. The MEPS-T represents a valid, reliable and moderately responsive instrumentfor evaluating patients with elbow disease.D. Celik (*)Division of Physiotherapy and Rehabilitation, Faculty of HealthSciences, Istanbul University, 34740 Bakırköy, Istanbul, Turkeye-mail: ptderya@hotmail.comKeywordsMEPS-T · Reliability · ValidityIntroductionPatient-reported outcome (PRO) measures provide insightsfrom the patient’s perspective into the impact of disease andtreatment on their health and quality of life. PRO measures arecategorized as generic or disease- or joint-specific. Genericmeasures often reflect health-related quality of life questionsthat are relevant across different diseases and populations. Incontrast, specific measures include areas of importance relatedto a specific disease. In clinical studies, both generic and disease-specific measures are often included, with disease-specific measures often considered the primary outcome [1].Numerous PRO measures to evaluate elbow dysfunction have been described, but there is no universal agreementregarding which PROs should be used because many of themlack reliability data [2]. This problem may be due to the factthat it is difficult for any single scoring system to adequatelycapture the impact of disease and treatments related to the fullspectrum of elbow pathology. The PROs that have been usedto assess elbow diseases include the Mayo Elbow PerformanceScore (MEPS), Oxford elbow score (OES), Disabilities of thearm, shoulder and hand (DASH), Visual Analog Scale (VAS)and the patient-rated tennis elbow evaluation (PRTEE) [3–6].Short-Form Health Survey (SF-36) is a generic score that canbe used to establish a health profile of the patients with elbowpathology [7]. The MEPS, designed to measure pain, stability, range of motion and the patient’s ability to accomplishfunctional tasks, is one of the most commonly used physicianbased and joint-specific elbow rating system [3].Before instruments that evaluate outcome measurescan be used in different regions of the world, they mustbe translated, culturally adapted, and retested to ensure13
1016Rheumatol Int (2015) 35:1015–1020Table 1 Demographics of the patientsn 91 %Age, years (mean SD)Female/maleDuration of symptomsInvolved rGovernment officialLaborer42.9 11.9 years49/428.1 1.2 months70/21TeacherMassage nerDiagnosisLateral epicondylitisMedial epicondylitis9 (9.9)4 (4.4)7 (7.7)7 (7.7)5 (5.5)3 (3.3)6 (6.6)26 (28.5)6 (6.5)10 (10.9)8 (8.8)55 (60.4)5 (5.5)Olecranon bursitisContractureOsteoarthritis4 (4.4)9 (9.9)11 (12.0)Radial head fracture7 (7.7)committee approval date: December 23, 2011, IRB studyprotocol: 2011/2092-880). The study included patientsseen between March 2012 and January 2013 at IstanbulUniversity Department of Orthopedics and Traumatology. The eligibility criteria were as follows: (1) 18 yearsof age or older; (2) elbow pathology including lateral andmedial epicondylitis, bursitis, contractures, osteoarthritisor radial head fracture and (3) the ability to read and writein Turkish. The diagnoses were established by a physicianbased on the patient history, physical examination anddiagnostic imaging results. Maudsley’s and Cozen’s Testfor lateral epicondylitis and Golfer’s elbow test for medialepicondylitis were performed. X-rays has been taken todiagnose arthritis and fractures of the elbow joint. Rangeof motion was evaluated for the presence of contracture(Table 1). The patients with a history of inflammatoryarthritis, neuropathic pain and gross structural abnormality of the elbow or any acute condition were excluded.In the first assessment, 91 patients with elbow pathologycompleted the MEPS-T (see the Appendix) and the previously validated Turkish versions of the DASH, SF-36 andVAS [9, 10].Administration of PRO measuresMethodsThe physical therapists administered the questionnairesin a random order to the patients in a waiting room afterthe patient’s appointment with an orthopedic surgeon. The“range of motion” and “instability” subscales of the MEPST were assessed by the same physical therapist in the firstand second assessments. The second assessment, in whichthe patients were asked to complete the MEPS-T again,occurred 7–14 days after the first MEPS-T to determine thetest–retest reliability of the MEPS-T. To minimize the riskof short-term clinical change, no treatment was providedduring this period. Responsiveness was assessed in a subgroup of 46 patients diagnosed with lateral epicondylitiswho had conservative treatment for 6 weeks at the clinic.The patients were assessed at baseline and after 6 weeks oftreatment.Translation and cross‑cultural adaptationStatistical analysisTranslation and cross-cultural adaptation of the MEPS wasperformed in five stages, as described by Beaton [8]. TheTurkish version of the MEPS was named “MEPS-T.”All statistical analyses were performed with Stata version11. (Stata Corp. LP., TX., USA). Descriptive statisticswere calculated for all variables. These included frequencycounts and the percentage for nominal variables and measures of central tendency (means and medians) and dispersion (standard deviations and ranges) for continuous variables. The measurement properties analyzed in this study forthe instruments included internal consistency, test–retestreliability, construct validity and ceiling and floor effects.Values expressed as mean SD or nthe validity of the revised instruments [8]. In addition, thecross-cultural adaptations may contribute to a better understanding of the measurement properties of the outcomemeasures. Therefore, the purpose of this study was to translate and culturally adapt the English version of the MEPSinto Turkish and investigate the reliability, validity andresponsiveness of the translated version.ParticipantsInformed consent was obtained from all of the participantsin the study; the informed consent form was approvedby Istanbul University Research Foundation (Ethics13
Rheumatol Int (2015) 35:1015–10201017Test–retest reliabilityResponsivenessTest–retest reliability represents a scale’s capability ofyielding consistent results when administered on separate occasions during a period when an individual’s statushas remained stable [11]. The patients who reported “nochange” in their condition between the first and secondassessments were included in the analysis of test–retestreliability. Interclass correlation coefficient (ICC) was calculated using a 2-way mixed model ANOVA. The valuesof 0.4 or greater were considered satisfactory (specifically,r 0.81–1.0 was excellent, 0.61–0.80 was very good,0.41–0.60 was good, 0.21–0.40 was fair and 0.00–0.20 waspoor) [12, 13].Responsiveness determines whether an instrument candetect clinical changes. Effect size (ES) was determinedby calculating the differences in the means of baseline andfollow-up data, divided by the standard deviation at baseline. A value between 0.20 and 0.50 was considered to besmall effects, between 0.51 and 0.80 moderate effects, andbetween higher than 0.80 large effects [14].AgreementNo difficulties were encountered in translating the questionnaire, and the back translation corresponded very wellto the original version. The questions were very simple tounderstand for the patients, so there was no need for cultural adaptation.Agreement was assessed with the standard error of measurement (SEM) and minimal detectable change (MDC).The ICC was used to calculate the SEM, which is anindex of measurement precision. The SEM was calculated as SD (1 ICC). The MDC refers to the minimalamount of change that is within measurement error. TheSEM was used to determine the MDC at the 95 % limitsof confidence (MDC95 %) and was calculated using the formula 1.96 2 SEM [14].ValidityValidity is represented by the extent to which a scoreretains its intended meaning and interpretation [15]. In thisstudy, we examined three aspects of validity: construct,convergent/divergent and content validity. Evidence forconstruct validity of the Turkish MEPS-T was providedby determining its relationship with the DASH, VAS andthe PCS of the SF-36. The PF, RP and PCS of the SF-36domains were used to assess convergent validity. Evidencefor divergent validity was provided by determining therelationships with the MH, RE and MCS domains of theSF-36. Pearson correlation coefficients were calculated toassess construct and convergent/divergent validity. Contentvalidity was assessed by the distribution of the scores andoccurrence of ceiling and floor effects. Floor and ceilingeffects of the MEPS-T at the first and second completionof the form were assessed by calculating the proportion ofpatients scoring the minimum or maximum values on thescale relative to the total number of patients. We considered scores between 0 and 10 % being minimum scores andscores between 90 and 100 % to be maximum scores. Floorand ceiling effects were considered to be relevant if greaterthan 30 % of the patients had a score at the limits of thescale [16].ResultsTranslation and cross‑cultural adaptationMeasurement properties and testingTable 1 provides the demographic and clinical characteristics of the patients. The descriptive statistics for the scoresat baseline and at the second assessment of the MEPS-T areprovided in Table 2. The mean SD duration of symptomsTable 2 Descriptive statistics for the patient-reported outcome measuresMEPS-T1 (first assessment)MEPS-T2 (second assessment)DASHVASSF-36 (PF)SF-36 (RP)SF-36 (BP)SF-36 (GH)SF-36 (VT)SF-36 (SF)SF-36 (RE)SF-36 (MH)SF-36 (PCS)SF-36 (MCS)Mean SD95 % CI58.2 12.659.7 13.244.3 17.73.6 3.358.9 22.321.5 13.741.1 22.151.0 21.651.1 23.769.8 23.540.1 20.258.0 18.436.1 62.4–77.227.3–52.952.1–63.333.2–39.043.6 9.740.7–46.6The Turkish version of the patient-reported outcome measures wasused in this studyBP bodily pain, GH general health perceptions, MCS mental component scale, MH mental health, PCS Physical Component Scale, PFphysical functioning, RE emotional role functioning, RP physical rolefunctioning, SF social function, VT vitality13
1018Rheumatol Int (2015) 35:1015–1020Table 3 Correlation between MEPS and other outcome measures inthe literature and present studyAgreementOutcomesThe SEM and MDC were 4.1 and 11.3, cal conditionSEVASESPresent studyDASHVASSF-36 (PF)SF-36 (RP)SF-36 (BP)SF-36 (GH)SF-36 (VT)SF-36 (SF)SF-36 (RE)SF-36 (MH)SF-36 (PCS)MEPS-T0.68*0.77*0.77*0.59*0.83* 0.61** Construct validityThe MEPS-T results correlated well with the resultsobtained using the DASH and VAS (r 0.61 andr 0.53, respectively; p 0.001). The correlationsbetween the results using the MEPS-T and the SF-36 arepresented in Table 3. The MEPS-T was most strongly associated with the BP and MCS scales (r 0.58 and r 0.43,respectively; p 0.05) of the SF-36. However, the MEPS-Tshowed poor and fair correlation with the PF and RP scalesof the SF-36 (r 0.18 and r 0.25, respectively).Floor and ceiling effects* p 0 .05); level of significance is only reported for the data of thecurrent studyThe floor and ceiling effects and the number of itemsanswered were identical during the test and retest examinations. None of the patients’ scores were at the maximal or minimal value of the overall MEPS-T, indicatingthat there was no floor or ceiling effect. However, thesubscales of the MEPS-T that were analyzed dependedon the diagnosis. The “range of motion” and “stability”subscales of the MEPS-T showed high ceiling effectsin patients with lateral epicondylitis. Of the 55 patientsin the subgroup, 31 and 42 % reported maximal scoresin the “range of motion” and “stability” subscales,respectively.** p 0.01); level of significance is only reported for the data of thecurrent studyResponsivenessSF-36 (MCS)0.43**MEPS-T Mayo Elbow Performance Score—Turkish, DASH disabilities of the arm, shoulder and hand, VAS visual analog scale, SEV subjective elbow value, BP bodily pain, GH general health perceptions,MCS mental component scale, MH mental health, PCS PhysicalComponent Scale, PF physical functioning, RE emotional role functioning, RP physical role functioning, SF social function, VT vitalitywas 8.1 1.2 months. Ninety-one patients (42 males;mean SD age: 49.2 11.9 years; range 18–67 years)completed all of the questionnaires at the first assessment.Thirty-two of these patients did not return to the clinic forthe second assessment. Therefore, of the 91 patients whoparticipated at the first assessment, 59 patients (28 males;mean age: 42.8 10.6 years; range 20–65 years) participated in the second assessment for the test–retest reliabilityanalysis. Responsiveness was analyzed in the 46 patients(23 males; age: 42.8 8.0 years; range 31–58) diagnosedwith lateral epicondylitis.Test–retest reliabilityThe average SD interval between the two assessmentswas 9.4 2.4 days. The test–retest assessment had an ICCof 0.89, indicating excellent reliability.13For the 46 patients with lateral epicondylitis, the baselinescores of the MEPS-T were compared with the scoresobtained after 6 weeks of treatment. The mean standard deviation of the baseline and post-treatment MEPST scores were 68.7 14.4 and 76.0 14.0, respectively, which resulted in a moderate (ES of 0.50, 95 % CI0.33–0.62).DiscussionThis study test–retest reliability, validity and responsiveness data for the MEPS-T are provided. Based on our sample, the MEPS-T demonstrated acceptable levels of reliability, validity and responsiveness as a PRO questionnairefor Turkish-speaking individuals.The test–retest reliability of the MEPS-T was excellent (ICC 0.89), comparable to that reported previously
Rheumatol Int (2015) 35:1015–1020by Cusick et al [17]. The time interval between repeatmeasurements is an important issue when determiningtest–retest reliability. In general, the interval betweenrepeat administrations for a PRO measure should be relatively brief (3–7 days) when the condition being measured is expected to change rapidly [11]. However, shorttest–retest intervals carry the risk of patients ‘‘becomingfamiliar with the questions’’ and simply answering basedon memory of the first assessment. Although longer intervals can decrease this possibility, other factors need to beconsidered to prevent bias in such studies. Because thepain and function subscales of the MEPS consist of onlynine questions, patients could easily remember the questions over a short time interval. In this study, an intervalof 7–14 days was chosen to decrease the likelihood ofthis possibility and also to ensure an individual’s condition had not changed. Similarly, Cusick et al. used a 2- to3-week interval for retest assessment for the MEPS. TheMDC was determined to be 11.3, indicating that a changeof less than this value on repeated administrations ofthe MEPS-T should be considered a reflection of measurement error rather than a true change in the patient’scondition.Recent studies attempting to validate the MEPS havefocused on determining the relationship of MEPS withPROs, including the OES, subjective elbow value (SEV),American Shoulder and Elbow Surgeons (ASES) and) [17–19]. In these studies, the highest levels of association werewith the ASES and the function and social–psychologicalconditions of the OES (r 0.83, r 0.77, r 0.77, respectively). Schneeberger et al. [19] used SEV for validity andfound a very good correlation value (r 0.59). In the present study, the DASH and the VAS were used for validityestimation and found to have a very good (r 0.61) andgood (r 0.53) correlation, respectively. To determineconvergent and divergent validity, we determined the levelof associations between the scores on the MEPS-T and theeight domains and two summary scores for the SF-36. TheMEPS-T was more strongly related to concurrent measuresof MCS (r 0.43) and BP (r 0.58) than to concurrentmeasures of PF (r 0.18) and PCS (r 0.33). There is noliterature with which to compare our results.Ceiling effects occur when a measure’s highest scoreis unable to assess a patient’s level of ability. This canbe especially common for PROs used on multiple occasions, thereby decreasing the likelihood that the testing instrument has accurately measured the intended1019subscales. In this study, the patients’ “range of motion”and “instability” subscales were already high at the baseline because these symptoms are not typical in patientswith lateral epicondylitis. Although many recent studies have used MEPS to assess lateral epicondylitis [20–23], we believe that MEPS is of limited use for lateralepicondylitis and it is not the best tool to use to assesspatients with this condition. A disease-specific PRO suchas the PRTEE should be considered for assessment oflateral epicondylitis.Responsiveness, based on the completion of the MEPST at baseline and after 6 weeks of treatment, indicated anES of 0.50 (95 % CI 0.33–0.62). Responsiveness has previously been reported after different elbow surgeries witha standardized response mean (SRM) of 1.26 and ESbetween 0.98 and 2.71 [19, 24], which is considered highcompared to our result. These findings also suggest thatMEPS-T is not the ideal PRO measure to assess patientswith lateral epicondylitis.One limitation of the study is that this is the first translation and cross-cultural adaptation study using the MEPS. Inaddition, physicometric properties of the original Englishversion of the MEPS have not been reported. Therefore,we could not compare our results with those of previousstudies.ConclusionThe MEPS-T is brief and easy to administer and interpret,with a minimal investment of time required for the clinician or researcher. The MEPS-T is a reliable, valid andmoderately responsive instrument that can be used as aPRO measure for Turkish-speaking individuals with elbowdisease.Clinical massagesThe MEPS-T has sufficient reliability, validity and responsiveness, with values similar to those reported. The MEPST can be used as a PRO measure for Turkish-speaking individuals with various elbow pathologies.Acknowledgments The author would like to thank Nilgun Turkeland Gulten Cetik for their excellent work during data collection.Conflict of interestNone.13
1020Rheumatol Int (2015) 35:1015–1020AppendixSee Table 4.Table 4 Mayo Dirsek Performans SkoruPuanAğrı (45 puan)YokHafifOrtaŞiddetliHareket açıklığı (20 puan) 100 fleksiyon50–100 fleksiyon 50 fleksiyonStabilite (10 puan)StabilHafif instabilite ( 10 varus-valgus laksitesi)Tam instabilite ( 10 varus-valgus laksitesi)Günlük Fonksiyon (25 puan)Saç tarayabilmeYemek yiyebilmeHijyen aktivitelerini yapabilmeÜstünü giyebilmeAyakkabı giyebilmeToplam puan4530150201551510555555100Mükemmel 90–100 puan; İyi 75–89 puan; Orta 60–74 puan; Kötü 60puanın altındaReferences1. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL,Dekker J, Bouter LM, de Vet HC (2007) Quality criteria wereproposed for measurement properties of health status questionnaires. J Clin Epidemiol 60:34–422. Longo UG, Franceschi F, Loppini M, Maffulli N, Denaro V(2008) Rating systems for evaluation of the elbow. Br Med Bull87:131–1613. Morrey BF, An KN (1993) Functional evaluation of the elbow.In: Morrey BF (ed) The elbow and its disorders. WB Saunders,Philadelphia, pp 74–834. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J et al(2008) The development and validation of a patient-reportedquestionnaire to assess outcomes of elbow surgery. J Bone JointSurg Br 90:466–4735. Macdermid J (2005) Update: the patient-rated forearm evaluationquestionnaire is now the patient-rated tennis elbow evaluation. JHand Ther 18:407–4106. Hudak PL, Amadio PC, Bombardier C (1996) Development of anupper extremity outcome measure: the DASH (disabilities of thearm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 29:602–608137. Ware JE Jr, Sherbourne CD (1992) The MOS 36-item short-formhealth survey [SF-36] Conceptual framework and item selection.Med Care 30:473–4838. Beaton DE, Bombardier C, Guillemin F, Ferraz MB (2000)Guidelines for the process of cross-cultural adaptation of selfreport measures. Spine (Phila Pa 1976) 25:3186–31919. Duger T, Yakut E, Oksuz C (2006) The reliability and validityof Turkish version of DASH questionnaire. Physiother Rehabil17:99–10710. Kocyigit H, Aydemir O, Fisek G (1999) Reliability and validityof Turkish version of short form SF-36. Med Treat 12:102–10611. Marx RG, Menezes A, Horovitz L, Jones EC, Warren RF (2003)A comparison of two time intervals for test–retest reliability ofhealth status instruments. J Clin Epidemiol 56:730–73512. Kane RL (1997) Outcome measures. Understanding health careoutcomes research. Aspen, Gaithersburg, pp 17–1813. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–17414. De Vet HC, Terwee CB, Bouter LM (2003) Current challenges inclinimetrics. J Clin Epidemiol 56:1137–114115. Irrgang JJ, Marx RG (2007) Clinical outcomes in sport and exercise physical therapies. In: Kolt GS, Synder-Mackler L (eds)Physical therapies in sports and exercise. Elsevier, Edinburgh, pp206–21916. Nunnally JC, Bernstein IR (1994) Psychometric theory, 3rd edn.McGraw-Hill, New York17. Cusick MC, Bonnaig NS, Azar FM, Mauck BM, Smith RA(2014) Throckmorton TW2. Accuracy and reliability of the MayoElbow Performance Score. J Hand Surg Am 39:1146–115018. de Haan J, Goei H, Schep NW, Tuinebreijer WE, Patka P, denHartog D (2011) The reliability, validity and responsiveness ofthe Dutch version of the Oxford elbow score. J Orthop Surg Res30(6):3919. Schneeberger AG, Kösters MC, Steens W (2014) Comparisonof the subjective elbow value and the Mayo Elbow PerformanceScore. J Shoulder Elbow Surg 23:308–31220. Raeissadat SA, Rayegani SM, Hassanabadi H, Rahimi R,Sedighipour L, Rostami K (2014) Is Platelet-rich plasma superior to whole blood in the management of chronic tennis elbow:one year randomized clinical trial. BMC Sports Sci Med Rehabil18(6):1221. Dzugan SS, Savoie FH 3rd, Field LD, O’Brien MJ, You Z (2012)Acute radial ulno-humeral ligament injury in patients withchronic lateral epicondylitis: an observational report. J ShoulderElbow Surg 21:1651–165522. Kim JW, Chun CH, Shim DM, Kim TK, Kweon SH, Kang HJ,Bae KH (2011) Arthroscopic treatment of lateral epicondylitis: comparison of the outcome of ECRB release with andwithout decortication. Knee Surg Sports Traumatol Arthrosc19:1178–118323. Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM(2010) A prospective randomized study comparing a forearmstrap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg 19:508–51224. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J, CarrA (2012) Specificity and responsiveness of patient-reported andclinician-rated outcome measures in the context of elbow surgery,comparing patients with and without rheumatoid arthritis. OrthopTraumatol Surg Res 98:652–658
spectrum of elbow pathology. The PROs that have been used to assess elbow diseases include the Mayo Elbow Performance Score (MEPS), Oxford elbow score (OES), Disabilities of the arm, shoulder and hand (DASH), Visual Analog Scale (VAS) and the patient-rate
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