Translation and cultural adaptation of the Penn Shoulder Score to Portuguese Language: PSS-Brazil

Abstracts

INTRODUÇÃO/OBJETIVO: Produzir a versão brasileira do questionário Penn Shoulder Score (PSS), destinado a avaliar a dor, a satisfação e a função dos indivíduos que apresentam condições dolorosas musculoesqueléticas do ombro. PACIENTES E MÉTODOS: O desenvolvimento da versão brasileira do questionário PSS se baseou no protocolo proposto pela American Academy of Orthopaedic Surgeons (AAOS) e na International Quality of Life Assessment (IQOLA), sendo constituído pelos estágios de tradução, síntese, retrotradução, revisão pelo Comitê, pré-teste e avaliação dos documentos pelo Comitê e autor do PSS. A versão original passou pelos processos de tradução e retrotradução, e um Comitê de especialistas finalizou a elaboração da versão pré-final do questionário PSS. Essa versão pré-final foi aplicada em uma amostra de noventa indivíduos com diagnóstico clínico de condições dolorosas musculoesqueléticas do ombro, de ambos os sexos e com idade acima de 18 anos. Nas aplicações, os pacientes foram questionados acerca de sua compreensão de cada item, e aqueles não compreendidos por 20% ou mais dos pacientes foram analisados e modificados pelo Comitê, havendo necessidade de três aplicações (n = 30) do questionário. RESULTADOS: A aplicação das versões pré-finais do PSS revelou as dificuldades encontradas pelos pacientes, as quais foram resolvidas pela transformação do questionário autoaplicável em um instrumento aplicado por entrevista. CONCLUSÃO: A tradução e a adaptação cultural geraram a versão brasileira final do questionário PSS.

qualidade de vida; questionários; tradução; ombro

ORIGINAL ARTICLE

^IGraduate student of Physiotherapy Course, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - FMRP-USP

^IIMaster Degree Student, FMRP-USP

^IIIProfessor of Physiotherapy, FMRP-USP

Correspondence to

ABSTRACT

INTRODUCTION/OBJECTIVE: To produce the Brazilian version of Penn Shoulder Score (PSS) designated to measure pain, satisfaction, and function of patients with shoulder painful musculoskeletal conditions.

PATIENTS AND METHODS: The Brazilian version development of PSS questionnaire was based on the protocol proposed by the American Academy of Orthopaedic Surgeons (AAOS) and International Quality of Life Assessment (IQOLA). The process consists of translation, synthesis, back-translation, expert Committee review, pretest and evaluation of documents by the Committee and author of the PSS. This pre-final version was administered to a sample of 90 subjects with clinical diagnosis of painful musculoskeletal shoulder, male and females, aged over 18 years. In applications, the patients were inquired about their understanding of each item, and items not understood by 20% or more of patients were analyzed and modified by the Committee, requiring three questionnaire applications (n = 30).

RESULTS: The application of pre-final versions of the PSS revealed the difficulties encountered by patients, which were resolved by transforming the self-applied questionnaire in an instrument applied through interview.

CONCLUSION: The translation and cultural adaptation resulted in the final Brazilian version of the PSS questionnaire.

Keywords: quality of life, questionnaires, translation, shoulder.

INTRODUCTION

The functional assessment instruments represent a primary outcome measure in assessing the condition and progress of patients, often used for studies aimed at examining the effectiveness of an intervention.^1-4 Traditionally, objective measures such as range of motion and muscle strength are used more often than subjective measures of questionnaires examining pain and disability.^5,6 However, it appears that the subjective data are as important as the objective data, ,⁷ because they can assess the impact of disease and effectiveness of intervention on quality of life of the individual.⁸

The increasing number of multinational and multicultural research in the interest of measuring the quality of life and effectiveness of treatments led to the development and validation of several questionnaires in English,⁹ which need to be translated and adapted for other languages, in order to allow comparison of results between studies with different populations¹⁰ and prevent the development of several instruments with similar evaluation purposes, making it difficult to determine which instrument to use in clinical practice and research.

There are several tools in English to assess painful musculoskeletal conditions of the shoulder joint complex, such as the Penn Shoulder Score,¹¹ American Shoulder and Elbow Surgeons Evaluation Form (ASES),¹² Shoulder Pain and Disability Index (SPAD),¹³ Disabilities of the Arm, Shoulder and Hand scale (DASH),¹⁴ and Western Ontario Rotator Cuff Index (WORC),¹⁵ among others. However, only DASH¹⁶ and WORC¹⁷ are translated and validated for the Portuguese of Brazil. This fact, combined with DASH non-specificity for shoulder and WORC specificity for a single shoulder dysfunction, justifies the need for translation of other questionnaires in order to evaluate different shoulder dysfunctions.

PSS was developed in 1999 to asses subjects with shoulder dysfunction, consisting of a 100-point scale that includes three domains: pain, satisfaction, and function. The pain and satisfaction subscales have, respectively, three items and one item assessed using a 10 Numeric Rating Scale (EN), where 0 corresponds to no pain and not satisfied, while 10 corresponds to the worst pain possible and very satisfied. The domain of function subscale contains twenty items, graded with a 4-point Likert scale, ranging from 0, which means "can not do at all" to 3 "without difficulty", with a maximum score of 60 points. The PSS score ranges from 0 to 100 points, with the maximum score indicating no pain, high satisfaction, and good function.¹⁸

Thus, considering the need to provide Brazil with other functional instruments, which are specific for the assessment of shoulder and its several dysfunctions, the purpose of this study is to produce a Brazilian version of the PSS questionnaire through translation and cultural adaptation of the original questionnaire.

PATIENTS AND METHODS

The PSS questionnaire was translated and adapted into Brazilian Portuguese based on the protocol proposed by Beaton et al.,⁹ used by the American Academy of Orthopaedic Surgeons (AAOS) and the International Quality of Life Assessment (QOL). To this end, it was obtained permission from the author to translate PSS original version and the process of translation consisted of six stages: through translation, synthesis, back translation, review by Multidisciplinary Committee, pretesting, and evaluation of documents by a Committee and PSS author. The study was approved by the Research Ethics Committee, process No 5.615/2007; and all patients who agreed to participate in the study signed an informed consent.

The first stage consisted of translating the original questionnaire by two foreign language teachers who have Portuguese as their mother tongue and fluency in English. One of the translators knew the purpose of translation and the other was unaware of it, which resulted in versions T1 and T2. In the second stage, it was developed a common translation (T12) through the analysis of the original questionnaire and translations T1 and T2, during a meeting with the initial translators and researchers. The third stage consisted of backtranslation; i.e., translation of T12 Portuguese version into English by two native translators with fluency in Portuguese, generating RT1 and RT2 versions.

A review of all versions (original, T1, T2, T12, RT1 and RT2) was performed during the fourth stage by a multidisciplinary Committee, composed of an orthopedist specialist in upper limbs, five physiotherapists, three of which do research on physical therapy evaluating shoulder musculoskeletal disorders, and the translators involved in the process, which consolidated all versions of the questionnaire and developed the pre-final version of the PSS-Brazil.

The fifth stage involved three pretests of PSS-Brazil pre-final version, with each version applied to 30 patients, resulting in a sample of 90 male and female patients, aged above 18 years, with different painful musculoskeletal conditions of the shoulder. Patients were enrolled voluntarily in the Rehabilitation Center and Outpatient Clinic of Hand and Microsurgery of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP). Consecutively, all patients who attended service were selected as long as they did not show involvement of neurological or rheumatic disease and, in the first and second pretests, illiterate persons and those unable to complete the self-applied questionnaire were also excluded, which did not happen with the third pretest that presented the questionnaire through an interview. After completing the pre-final version of PSS-Brazil, patients were interviewed by a researcher about their understanding of each item. The items that were not understood by 20% or more of patients were reformulated by the Committee, keeping the original concept of the instrument.^16,19

In the sixth and final stage, all documentation of the Brazilian version of PSS questionnaire was submitted to the Committee and the authors of the original version for approval of the translation and cultural adaptation process.

This study used descriptive statistics performed by mean values and percentages for demographic and clinical characteristics of patients, for each questionnaire item and for response option "Did not do before injury".

RESULTS

The process of transcultural adaptation produced the Brazilian version of the PSS questionnaire (^{Appendix I}). The clinical and demographic characteristics of patients who participated in all three pretests are presented in Table 1.

In the translation phase, the T12 version was obtained with some modifications made after the analysis of differences between T1 and T2 (Table 2), giving priority to terms and expressions more usual to the Brazilian population.

The back translations RT1 and RT2 showed great similarity between them and equivalence with the original version of PSS, indicating that the common translation o fT12 was satisfactory for the pre-final version of PSS, requiring only minor changes (Table 3).

At this stage, the third item of the domain function "Perform necessary toileting activities" was the focus of further discussion by the Committee on the need for specificity of some activities, which was considered unnecessary by the author of the original version.

The cultural adaptation revealed the need to change only a few items and structural aspects of PSS-Brazil pre-final version (Table 4). The pre-test I indicated the need to reformulate only items 13, 16, and 20 and the response option X "Did not do before injury". For items 12-16, the Committee decided to highlight the elevation level required by the activity and add the words "big bag of rice" in items 13 and 16, in order to make the weight of 5 kg more noticeable to the individual. In relation to item 20, the words "full time" were changed to "whole time" in bold, and the response option "X" was placed in a column immediately after the items.

Some function items on the original version of PSS are not specific for the affected arm and allowed the subject to associate the activity with the affected arm, unaffected arm, or with both arms. Thus, the author's permission was asked to specify the items associated with activities done with the affected arm, considering the importance of performing, in the context of rehabilitation, the functional assessment of the affected arm, and not the overall assessment of the subject.

The Committee decided to modify some items that have not reached the level of misunderstanding to be modified, in order to ensure better understanding. Thus, the satisfaction subscale score was reversed, making it similar to the pain scale, where the higher score indicates a worse situation of the patient, with "0" and "10" now representing "very satisfied" and "not satisfied", respectively. Item 9, "Open the door with the affected arm", was also changed to "Open/push the door with the affected arm", as 73.33% of patients thought only about the activity of turning the knob, instead of thinking about the activity of pulling/ pushing the door.

The pretest II showed, in general, higher rates of misunderstanding for the subscale of satisfaction and did not solve the remaining problems identified in the first pretest. Thus, the subscale scores of satisfaction returned to the original format, with 0 and 10 indicating, respectively, not satisfied and very satisfied. As decided by the Committee, in order to solve the remaining problems transforming the selfapplied questionnaire into an instrument applied by interview, a guidance material was prepared for the examiner on how to conduct the interview properly, paying attention to items that may not be understood.

As noted in the first pretest, it was necessary to change some items that have not reached the level of misunderstanding necessary for modification. Some patients scored item 10, "Carry a bag of groceries with the affected arm", with a greater degree of difficulty, while others felt that the item 11, "Carry a briefcase or small suitcase with the affected arm", more difficult. Thus, this confusion was resolved with the author's consent, and the items 10 and 11 changed to "Carry a book or briefcase, close to the body, with the affected arm" and "Carry a bag of groceries or briefcase with the affected arm".

The completion of pretest III showed to have solved all the problems described above, producing the final version of the PSS-Brazil.

DISCUSSION

The Brazilian version of PSS questionnaire (PSS-Brazil) was obtained by a careful cultural adaptation, comprising a wide age group and different educational levels, which probably favored the development of an easy understanding version. There was some difficulty for understanding the structure and items, which were solved by transforming the self-applied questionnaire into an instrument administered by interview, transferring to the examiner the responsibility for making the items understandable by the individual.

The process of transforming a self-applied questionnaire on application by interview was also recorded for other questionnaires translated into Brazilian Portuguese in Brazil.^20,23 Many Brazilian questionnaires are applied as an interview or provide some instructions for its completion, which is justified by Orfale et al.¹⁶ by the patient's lack of habit to complete self-administered questionnaires or by insufficient education, while Oku et al.²⁴ justify the interview to avoid the exclusion of patients who can not read or have vision impairment.

The translation stages, back translation, and synthesis showed no problems, with changes being made to ensure familiarity with the term and to achieve cultural equivalence with the Brazilian population. For example, we prefer the term blusa (blouse) instead of camisa (shirt) in Item 7, since in Portuguese the former is a unisex garment, while the latter is usually a male garment.

The Multidisciplinary Committee represented a key stage to prevent any liable aspect to misinterpretation by the individual during the pretest, since in that period the exchange of information with the author of the original version was constant.

The pretest stage showed major loss of data for the response option X "Did not do before injury", which may suggest that patients tend to consider that they performed all activities before the injury or that there is a need to quantify their disability. The latter explanation seems plausible when we observe that a modified application of the ASES used empty cells instead of numbers, preventing that a response option surpass the other.²⁵

Pretest repetitions also revealed that sequences with small changes, such as items 12 to 16, which only differ in the arm elevation level and amount of weight lifted, are often not distinguished by the individual. It is therefore important that the questionnaires used by the examiner interview offer guidance on which items require further attention in order to avoid misinterpretations.

Regarding item 20, it was observed that individuals tend to report the adjustments made in the way they do the work, instead of indicating if they have the ability to keep working throughout the journey. Although the disease impact at work can be reviewed by changing duties and reducing the working hours, as mentioned by the author of the original version, the PSS has the function of assessing only the ability to remain active throughout the day. Although the impact of illness at work can be assessed by change of duties and reduction of working hours, as mentioned by the author of the original version, PSS has the function of assessing only the ability to remain active throughout the workday.

The authors should be aware of possible factors contributing to inadequate interpretation of an item, even if this item does not reach the level of misunderstanding required to be changed, as observed in this study about the need to specify the assessment for the affected arm. This change was authorized by the author of the original version that agreed with the use of PSS to evaluate the functionality presented by the individual with the affected arm, which is fundamental to follow the progress of patients undergoing intervention.

CONCLUSION

The process of translation and cultural adaptation of PSS to Portuguese was performed properly and resulted in the Brazilian version of PSS. Despite the conclusion of its adapted translation, an analysis of the questionnaire psychometric properties is recommended in order to make it a reliable and valid instrument in Brazil.

ACKNOWLEDGEMENTS

The authors would like to thank the Programa Institucional de Bolsas de Iniciação Científica (PIBIC/CNPq) for financial support, and physical therapist Helga Tatiana Tucci for her cooperation as a member of the Expert Committee.

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Appendix I

Translation and cultural adaptation of the Penn Shoulder Score to Portuguese Language: PSS-Brazil

Barbara Valente Napoles^I; Carla Balkanyi Hoffman^I; Jaqueline Martins^II; Anamaria Siriani de Oliveira^III

Publication Dates

• Publication in this collection
  08 Sept 2010
• Date of issue
  Aug 2010

History

• Received
  28 Oct 2009
• Accepted
  27 May 2010