Transcultural adaptation into Portuguese of an instrument for pain evaluation based on the biopsychosocial model

Introduction: Pain is an individual experience influenced by multiple interacting factors. The “biopsychosocial” care model has gained popularity in response to growing research evidence indicating the influence of biological, psychological, and social factors on the pain experience. The implementation of this model is a challenge in the practice of the health professional. Objective: To perform the transcultural adaptation of the SCEBS method into Brazilian Portuguese. Methods: The instrument was translated and applied to 50 healthy subjects and 50 participants with non-specific chronic pain in the spine. The process of cross-cultural adaptation included the following steps: transcultural adaptation, content analysis of the scale, pre-test, revision, back-translation review, cross-cultural adaptation, revised text correction and final report. Results: The translated and adapted 51-item Portuguese version of the SCEBS method produced an instrument called SCEBS-BR. In the assessment by the target * MRPS: BS, e-mail: monique.julio@hotmail.com LCN: PhD, e-mail: leandro.nogueira@ifrj.edu.br NAMF: PhD, e-mail: neymeziat@gmail.com RO: PhD, e-mail: ostendorp.rob@gmail.com FJJR: PhD, e-mail: felipe.reis@ifrj.edu.br Santos MRP, Nogueira LC, Meziat-Filho NA, Oostendorp R, Reis FJJ. 184 Fisioter Mov. 2017 Dec;30(Suppl 1):S183-95 population, 50 adult users of the Brazilian Unified Health System answered the questionnaire and showed good understanding of the instrument on the verbal rating scale. Conclusion: The SCEBS-BR was proved to be easily understandable, showing good semantic validation regardless of schooling level or age, and can be considered adequate for clinical use.


Introduction
The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" [1].Recently, Williams and Craig [2] suggested an update to this definition: "a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive and social components".In both definitions, pain is an experience that involves different domains that go beyond the simple response to a stimulus.
Despite the importance of recognizing pain as a multifactorial construct, it is still common for health professionals to direct their efforts towards the investigation and treatment of biological factors in pain management.The fragmentation of biological, psychological, social, and environmental factors contributes to difficulties in understanding the broader contexts of pain and its management [1,3,4].Currently, the biopsychosocial model (BPS) aims to integrate these multiple factors and their contributions to health conditions.
Since the introduction of the BPS model, there has been a considerable shift towards the use of this model for the diagnosis and treatment of musculoskeletal disorders such as lower back and neck pain [5,6].Indeed, the biomedical model, focused on anatomical structures and biomechanics, is not enough to explain many symptoms of pain conditions [7,8].In the biopsychosocial perspective, biological variables, psychological condition, and social setting are dynamically related to pain, disability, and emotional disorders [9 -11].Consequently, pain can be seen as the result of the influence of biological, cognitive, and emotional factors, and the environment [5].
Despite recognizing in pain, the interaction of several factors, health professionals may experience difficulties in addressing all necessary aspects.The SCEBS method (Somatic, Cognition, Emotion, Behavior and Social) is an instrument that is easy to apply in clinical practice that presents questions to address the patient's experience within the BPS model.The main purpose of the SCEBS method is to be a guide for clinical interview based on the BPS model that contains questions comprising the three dimensions of pain: Somatic or biological, psychological (Cognition, Emotion, Behavior) and Social [12].In Brazil, there is currently no instrument to guide clinicians to consider all aspects of the BPS model in the assessment of patients with lower back or neck pain.Therefore, the objective of the present study was to perform the cross-cultural adaptation of the SCEBS method into Portuguese.We believe that the availability of this instrument as an evaluation guide can help to facilitate a patient-centered approach, therapistpatient communication, and adherence to treatment by people with lower back and neck pain.

Study design
This study is characterized as a transcultural adaptation.All the ethical aspects of the CNS / MS 466/2012 resolution were respected, and the project was approved by the Ethics and Research Committee of the Instituto Federal do Rio de Janeiro (IFRJ) and registered (CAEE 59001316.9.0000.5268).All participants signed the informed consent form and were informed about the nature of the study and the protocol.

Procedures
The process of cross-cultural adaptation included the following steps: preparation, translation, reconciliation (synthesis), back-translation, backtranslation review, harmonization (comparison of backward versions), cross-cultural adaptation (content analysis; pre-test, revised text) and final version, respecting the methodology recommended for this study design [13 -15].
The original SCEBS method was translated from English into Portuguese by two native English translators, fluent in Portuguese and experienced in translation (T1 and T2).In the reconciliation stage (synthesis), the researchers analyzed the T1 and T2 versions together with the original questionnaire, giving rise to the T12 version.
In the back-translation step, two independent backtranslators (RT1 and RT2) participated, one having English as a mother tongue and fluency in Portuguese and the other having Brazilian Portuguese as a mother tongue and fluency in English, neither of whom participated in the translation step.This step was performed to produce the RT12 version.All versions (original, T1, T2, T12, RT1, RT2, RT12) were reviewed by the Translation Group and the Committee of Experts.The Committee of Experts followed the guidelines of Beaton et al. [14], being oriented to carry out the careful reading of the instrument and its versions to propose changes and corrections, evidencing the reasons.The goal of this step was to obtain clear and accessible language.Semantic equivalence principles were considered, such as the referential meaning of the words used and the general meaning of the questions, as well as the response options or orientation of the instrument originating from the translation.
The pre-test of the pre-final version of the SCEBS method had the objective of eliminating any item not comprehended by more than 20% of the sample, following the recommendations of Nusbaum et al. [16].
At this moment a pre-test version of the instrument was applied to asymptomatic and symptomatic individuals.The asymptomatic group comprised people of both genders, with no age limit, and without chronic musculoskeletal pain.The symptomatic group comprised volunteers of both genders, aged over 18 years, with acute, subacute or chronic pain classified as non-specific pain (without defined clinical diagnosis), located in the lumbar or neck regions, who were in treatment in the physiotherapy service of the IFRJ-Campus, Realengo.Participants with significant cognitive impairment were not considered eligible for the study due to the possibility of this compromising their understanding of the instructions.In the case of individuals with reading difficulties, the evaluator read out the instructions, questions, and options.In both groups the selection was performed for convenience.
The guiding question for this early stage was, "Did you understand the sentence?"The participant should indicate a value on a 5-point Likert scale with a minimum value of "0" ("I understood just a little") and a maximum value of "4" ("I completely understood").It was established that the first three values (0, 1, and 2) would be considered indicators of insufficient understanding and, in this case, the sentence should be reviewed by the research team [17].In the sixth step of the study, all reports were submitted to the Expert Committee and evaluated, and a final version was sent to the original author for approval.The final version of the instrument was reviewed by a specialist in Portuguese.

Data analysis methodology
Data were tabulated in a spreadsheet and analyzed using SPSS 20 software for Windows.Data from variables gender, schooling, degree of comprehension of the sentences were presented as absolute and relative frequency measures.Age was presented as mean and standard deviation.

Phases of transcultural translation and adaptation
The instrument was translated and adapted by a group of translators, back translators and specialists (three physiotherapists, an occupational therapist, two psychologists, and a physician).All specialists have more than five years of experience in the management of people with musculoskeletal pain.
During the back-translation phase, adaptations were made to make the translation of the SCEBS method as simple and comprehensible as possible.In this sense, the expression queixas was replaced by sintomas in most of the items, in order to differentiate the symptom itself from the act of complaining.In the somatic dimension, the sentence Quais são a natureza in item 3 was modified to Quais são os tipo, in order to facilitate understanding of the question.In item 5 the definite article os was replaced by the demonstrative pronoun esses, to represent the symptoms mentioned by the individual himself.In item 7 the word mover was changed to movimentar, and the word rigidez in item 8 was changed to dificuldade para se movimentar because the word rigidez alone is not clear enough.
Regarding the psychological dimension, on the cognition axis the word própria was removed from item 13 to avoid redundancies, and dos seus sintomas was added at the end of the sentence.To make the meaning of item 14 clearer, the pronoun você was inserted at the beginning of the sentence.In item 17 the phrase nesses momentos was replaced by nos momentos que tem os sintomas.In the subtitle Ideias sobre influência pessoal sobre as queixas, the phrase sobre as queixas was replaced by nas queixas.In item 19, in order to make the question clearer, the phrase Você pessoalmente tem has been replaced by Você acha que tem.In item 20 the phrase você é capaz was modified to você acha que é capaz.Item 21 was modified from Se é, como to Se sim, de que maneira?for clarity.And in item 23 the sentence os problemas são resolvidos has been replaced by os seus sintomas melhoram since the question is related to persistent pain.
Regarding the emotion axis of the psychological dimension, in item 25 the end of the sentence como você se sente was extended to como você se sente em relação a eles, and in item 26 the phrase as queixas perturbam was changed to você acha que seus sintomas afetam.In items 27, 28, and 29 the question você está was replaced by você se sente (in item 27) and by você se considera (in items 28 and 29) so as not to induce the answer.
On the behavioral axis of the psychological dimension, in item 31 the condition se tem was modified to quando tem because the original sentence could imply that the individual has or does not have the symptoms, which was not the purpose of the question.In item 35, to the question Até que ponto?was added os sintomas prejudicam suas atividades, with the intention of making the meaning clearer and less dependent on the previous question.In item 36 the verb tense deixou was changed to deixa, with the purpose of keeping a consistent verb tense in every question.In item 38 the word sobre was replaced by em relação a in order to adjust the sentence.
The verb notam has been replaced by percebem in items 39 (from the psychological dimension, in the behavior axis), 42 and 43 (from the social dimension) to leave the questions clearer.The subtitle Conversando sobre os problemas has been changed to Falando sobre as queixas since the individual will be reporting their complaints.
Finally, in the social dimension, item 47, Seu parceiro tem ideia do motivo das suas queixas, has been changed as follows: Para o seu parceiro, de onde é que surgem os seus sintomas?This was to facilitate understanding and reduce the range of possible responses.Table 1 illustrates the transcultural adaptation of the SCEBS method.

Você é capaz influenciar positivamente as suas queixas?
Are you able to positively influence in your complaints?
In the pre-test, the pre-final version of the instrument was tested to evaluate semantic, idiomatic, experimental, and conceptual equivalences.All items were satisfactorily understood, both by the control group and by the symptomatic group, with the items all presenting scores above 4 points.In the healthy group only question Q15 (mean = 4.38, SD = 0.98) had a mean value lower than 4.5 points.In the symptomatic group, Q21 (mean = 4.34, SD = 1.33),Q21 (mean = 4.24, SD = 1.34), and Q24 (mean = 4.42, SD = 1.31) obtained mean values lower than 4.5 points.The final version of the instrument is presented in Figure 1. Figure 2 shows the questionnaire in English.

Discussion
The semantic translation and validation of the SCEBS method proved to be adequate even though there were differences in schooling and mean age among the groups included in this study.The comprehension level obtained using the transcultural adaptation process was considered satisfactory for application of the final version in clinical practice.We included a sample young and undergraduate students in the healthy group to consider as a gold standard in the understanding of the items.We emphasize that the availability of this method can help to guide health professionals in the use of the BPS model when interviewing patients with lumbar or neck pain.It should be noted that this method is of clinical importance because the BPS model considers the individual to be a complex system, the health of which is subject to multi-factor interactions [18].
To date, the SCEBS method is the first instrument to be submitted to the process of cross-cultural adaptation into Brazilian Portuguese that guides the professional to the assessment of the patient based on the BPS model.The implementation of the SCEBS method in clinical practice may facilitate the patientprofessional relationship by scaffolding discussion of different factors that contributes to illness, establishing concrete information, and constructing a safe and open relationship [19].
We emphasize the importance of such an expanded perspective in the evaluation of people with pain because the BPS factors all contribute to the transition and persistence of pain and central sensitization [20 -22].Neurophysiological changes in central pain processing may be responsible for or influenced by behavioral, emotional, social, and cognitive changes [23].For example, catastrophizing [24], pain-related anxiety [25], depressive feelings and stress [26], and decreased self-efficacy [23] are known to contribute to pain and restriction in daily activities [27].In this way, the initial examination should take into account both the biological factors that can contribute to bottom-up stimuli as well as the psychosocial (Conclusion) ones that contribute with facilitating mechanisms (top-down).Therefore, a complete clinical BPS assessment is necessary to understand the pain experience and allow an individualized and patientcentered approach.
However, evaluation based on the BPS model and identification of the multiple factors that influence pain can be difficult, with some factors being valued more than others.Oostendorp et al. [12] observed that experienced physiotherapists who believed that they were applying the BPS model in their assessments did not address several aspects of the psychosocial dimensions.During the evaluation, 98.1% of the professionals investigated information regarding the somatic dimension.However, regarding the psychological and social dimension, the approach was inadequate, with 42.5% of professionals addressing aspects related to cognition, 37.9% behavior, 26.8% emotions, and 17.6% social aspects.
Despite recognition of the need to implement the BPS model in clinical practice, there is still a great distance between theory and practice [27 -30].In a study conducted in Australia with physiotherapists experienced in the management of people with musculoskeletal disorders, participants emphasized that limited knowledge about what psychosocial factors mean, limited training within this model, lack of formal training, and the need of additional specific tools were the main difficulties in adopting the BPS model.The SCEBS method may encourage clinicians to adopt a broader evaluation model, as well as being a tool of easy applicability and comprehension [12,21].
Wijma et al. [26] describe in a practical way the use of the SCEBS method in BPS evaluation of patients with persistent pain, and emphasize that the instrument is able to define which BPS factors are contributing to the chronicity of pain and to direct the most effective treatment plan.The recommendation of the Dutch College of General Practitioners (NHG) is that the dimensions of the SCEBS method should be used as parameters for monitoring individuals with persistent pain [19].
The main limitations of this study involved the impossibility of more complex analysis in addition to semantic validation, such as the psychometric evaluation of the instrument, and the impossibility of comparing this study with validated translations into other languages as there are only two considered original, one in Dutch and one in English [12].The SCEBS method was applied only to people with lower back pain and neck pain, and it is necessary to further adapt it to other populations with other painful conditions, especially those of nonmusculoskeletal origin.

Conclusion
The process of cross-cultural adaptation of the SCEBS method gave rise to an instrument that proved to be easy to understand.The final version obtained adequate semantic validation, independent of schooling or age variables, and can be considered adequate for clinical use.

Table 1 -
The transcultural adaptation of the SCEBS method expect from me? O que você espera de mim?What do you expect from me? O que você espera de mim?

Table 1 -
The transcultural adaptation of the SCEBS method