W2 A Patient-Focused Wrist Outcome Instrument—the Adelaide Questionnaire

Measuring the outcome after distal radius fracture is an essential part of clinical practice.^1,2 The primary purpose is to provide information regarding the response of the patient to fracture management and rehabilitation.³ This information is used for other purposes as well, such as to focus clinical practice by assisting with setting of treatment goals, developing management plans, aiding with patient motivation,^4,5 justifying service provision, documenting continuous improvement strategies, and benchmarking.^6,7

Outcome measurement after distal radius fracture is a challenging activity because the wrist is an anatomically compact and biomechanically complex region of the body.⁸ Little is known about the bony morphology and capsular, ligamentous, and muscular contributions to wrist function compared with other joints, such as the knee and the hip. Preliminary findings on wrist kinematics and proprioception have been reported more recently.^9–12 Further work in these areas and in the musculotendinous contribution to wrist stability and motion is required, however, so that outcome instruments accurately reflect the structure and function of the wrist.

Many instruments have been developed to evaluate the outcome after distal radius fracture.¹³ Until the late 1990s, these instruments primarily assessed impairments, such as wrist range of motion, grip strength, and pain. In theory, however, a linear relationship does not exist between wrist impairments, such as range of wrist motion, and the ability to perform daily activities.¹⁴ An extreme clinical example is after total wrist fusion, when patients have no wrist movement. Most patients report, however, that they are able to perform most daily activities despite this impairment.¹⁵ Consequently, there has been a shift over the past decade to evaluate functional aspects of a wrist disorder, by specifically gathering information from patients regarding their ability to perform daily activities.¹⁶ This information is most frequently gained from administration of a standardized, clinimetrically sound questionnaire.¹ This procedure also directly evaluates why patients present for treatment because their wrist typically interferes with their ability to perform daily activities.^15,17

Four questionnaires are currently used in clinical practice to evaluate the outcome after distal radius fracture: the Disabilities of the Arm, Shoulder, and Hand (DASH),¹⁸ the patient-rated wrist evaluation (PRWE),¹⁹ the Michigan Outcomes Questionnaire (MHOQ),²⁰ and the Modified Mayo Wrist Scoring System.²¹ The Modified Mayo Wrist Scoring System evaluates four variables—pain, satisfaction, range of motion, and grip strength—and does not evaluate the patient’s ability to perform daily activities. Scores for these variables are tallied and categorized as excellent, good, fair, and poor. This scoring system reports the end result of treatment, without a point of reference to baseline data. Baseline data are important so that magnitude of change that has occurred during the treatment period can be evaluated^5,22 because not all individuals are symptom-free before distal radius fracture.^23,24 For these reasons, the Modified Mayo Wrist Scoring System may be able to discriminate between individuals based on the final result of impairment variables, but cannot evaluate change in the ability to perform daily activities over time in individuals with distal radius fractures.

DASH, PRWE, and MHOQ are used in clinical and research settings to evaluate impairments (e.g., pain intensity) and the functional consequences (i.e., the ability to perform daily activities) after distal radius fracture.^25–27 Anecdotal reports suggest that there are three major limitations of these questionnaires, all which center around the evaluation of daily activities:

Development of the Adelaide Questionnaire

A new wrist outcome instrument, the Adelaide Questionnaire, was developed to address the limitations of existing instruments.³³ Specifically, the Adelaide Questionnaire assesses from the patient’s perspective the actual ability to perform daily activities after distal radius fracture and other unilateral musculoskeletal wrist disorders. The questionnaire was developed based on the results of a large qualitative study of individuals with wrist injuries^23,33 and has undergone subsequent psychometric evaluation with excellent results (Table W2-1).^24,33–35

TABLE W2-1 Psychometric Properties of the Adelaide Questionnaire

The Adelaide Questionnaire consists of three components (Fig. W2-1), as follows³⁴:

1. A standardized component, which assesses an individual’s ability to perform 25 daily activities, before the wrist injury and during the current episode. Response options include “yes” (I have difficulty performing this daily activity), “no” (I don’t have difficulty performing this daily activity), “haven’t tried” (I haven’t tried performing this daily activity), and “not applicable” (I do not normally perform this daily activity). Information is gained regarding daily activities normally performed, whether they are difficult now, or whether they are being avoided compared with the patient’s preinjury status. A simplistic scoring system was developed for this section based on the number of “yes” responses before injury and currently. The scores range from 0 to 25, where 0 represents no activity limitation, and 25 represents severe activity limitation.

2. An optional individualized component, which gains information regarding the amount of difficulty with up to five important daily activities that are specified by the patient. This section is completed when difficulty is experienced with daily activities other than the activities contained in the standardized component.^24,34 Scores represent the magnitude of activity limitation associated with important daily activities not previously evaluated. They range from 0 (no activity limitation) to 50 (severe activity limitation associated with extremely important tasks). This section also contains a question on compensatory mechanism use for each of the nominated daily activities.

3. A demographic component, which gains information on the patient, such as age, gender, and hand dominance.

FIGURE W2-1 The Adelaide Questionnaire.

From Bialocerkowski,³³ reproduced with permission from Andrea Bialocerkowski.

Detailed instructions regarding scoring of the Adelaide Questionnaire can be found in the article by Bialocerkowski and colleagues.³⁴

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Galeazzi Fracture-Dislocations W3 Biomechanics and Biology of Plate Fixation of Distal Radius Fractures Management of Lost Pronosupination Bone-Ligament-Bone Reconstruction The Dorsal Ligaments of the Wrist Hemi-resection Interposition Arthroplasty

Fractures and Injuries of the Distal Radius and Carpus The Cutti