Validity and reliability of the portuguese version of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form

Abstracts

INTRODUÇÃO: O American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), frequentemente utilizado em pesquisas, embora tenha versão traduzida e adaptada para a língua portuguesa (ASES-PT), ainda não tinha a validade e a confiabilidade testadas. OBJETIVO: Investigar a validade, a confiabilidade e a consistência interna do ASES-PT para a função do ombro. MATERIAIS E MÉTODOS: Cinquenta indivíduos (26 mulheres; idade média, 39 ± 13 anos) participaram do processo de investigação da validade, e 38 (19 mulheres; idade média, 37 ± 13 anos) da investigação da confiabilidade, todos apresentando disfunção no ombro. Os participantes preencheram o Questionário Genérico de Qualidade de Vida SF-36 (SF-36), o Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) e o ASES-PT em dois momentos, com intervalo de sete dias. A validade convergente foi analisada pelo coeficiente de correlação rho de Spearman (ρ), a análise da confiabilidade intraexaminador utilizou o coeficiente de correlação intraclasse (CCI), e a consistência interna foi aferida pelo Alfa de Cronbach. RESULTADOS: Os escores do ASES-PT apresentaram correlação com os escores da versão do DASH (ρ = -0,69;P = 0,000) e com os domínios "capacidade funcional" (ρ = 0,50;P = 0,000), "limitações por aspectos físicos" (ρ = 0,43;P = 0,002) e "dor" (ρ = 0,60;P = 0,000) do SF-36. A confiabilidade intraexaminador do ASES-PT demonstrou-se adequada (CCI = 0,75;P = 0,000). A consistência interna (0,794) foi satisfatória. CONCLUSÃO: O estudo da validade e da confiabilidade do ASES-PT suporta sua utilização para a avaliação do ombro em indivíduos com disfunção nessa região.

dor de ombro; articulação do ombro; reprodutibilidade dos testes; validade dos testes; questionários

ORIGINAL ARTICLE

^IPhD in Production Engineering, Universidade Federal de Santa Catarina - UFSC; Professor of the Post-Graduation Program of Technology in Health, Pontifícia Universidade Católica do Paraná - PUCPR

^IIMaster's degree in Rehabilitation, Université de Montréal - CAN; Professor of the Physical Therapy Course, Centro Universitário Campos de Andrade - UNIANDRADE; Member of the Research Nucleus of the Physical Therapy Course, PUCPR

^IIIMaster's degree in Technology in Health, PUCPR

^IVUndergraduate student of Physical Therapy, PUCPR

Correspondence to

ABSTRACT

INTRODUCTION: The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), often used in research in Brazil, although translated and adapted to the Portuguese language, had not had its validity and reliability tested yet. Objective: To assess the validity, reliability, and internal consistency of the ASES-PT for shoulder dysfunction.

MATERIALS AND METHODS: Fifty individuals (26 women; mean age, 39 ± 13 years) participated in the validity assessment, and 38 (19 women; mean age, 37 ± 13 years old) in the reliability assessment, all having shoulder dysfunction. The participants completed the 36-Item Short-Form Health Survey (SF-36), the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), and the ASES-PT on two occasions with an interval of seven days. The convergent validity was assessed by use of the Spearman's rank correlation coefficient (ρ), and the analysis of the intrarater reliability used the intraclass correlation coefficient (ICC). The internal consistency was assessed by using Cronbach's alpha.

RESULTS: The ASES-PT scores correlated with the DASH scores (ρ = -0.69, P = 0.000) and with the "physical functioning" (ρ = 0.50, P = 0.000), "role limitation due to physical health" (ρ = 0.43, P = 0.002) and "bodily pain" domains (ρ = 0.60, P = 0.000) of the SF-36. The intrarater reliability of the ASES-PT proved to be adequate (ICC = 0.75, P = 0.000). The internal consistency (0.794) was satisfactory.

CONCLUSION: The validity and reliability study of the ASES-PT supports its use for assessing shoulder dysfunction.

Keywords: shoulder pain, shoulder joint, reproducibility of results, test validity, questionnaires.

INTRODUCTION

Shoulder pain is present in 14%-50% of the population.^1-3 It is estimated that two out of three individuals will have at least one episode of neck or shoulder pain during their lives.4 In addition, the incidence of shoulder pain is of eight new cases per year for every 100 workers of the industry and service sectors.⁵ Frequently, that pain and the reduced shoulder mobility have a negative effect on the patient's functional abilities, occupational activities, and quality of life.⁶

To assess and quantify the impact of the musculoskeletal changes on people's lives, functional assessments by use of questionnaires can be performed during treatment. Several questionnaires have been developed for evaluating the function of the upper limbs.⁷ Of those questionnaires, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) stands out because it was designed for patients with any shoulder dysfunction and specifically for that joint,⁸ in addition to being widely cited in the literature.^9,10 According to Brazilian studies, the ASES has been applied since 1988.¹¹ However, its translation and cultural adaptation for Brazilian Portuguese through the appropriate methodological process was only established in 2010.¹²

The original ASES has been elaborated by the Research Committee of the American Shoulder and Elbow Surgeons⁸ and comprises a physician assessment section and a patient self-report section. However, only the patient self-report section contributes to its final score.¹³ That section is composed by an item concerning pain, whose severity is assessed by use of a visual analogue scale (VAS) that ranges from "no pain at all" to "pain as bad as it can be", and 10 items concerning function, assessed by use of a four-category Likert scale. The score of each section corresponds to 50% of the final test score, which can range from 0 (no functionality) to 100 (normal function).

However, to ratify its use, the Portuguese version of the ASES (ASES-PT) should be investigated regarding its following characteristics: validity (i.e., the instrument's capacity to measure that which it is intended to measure); reliability (i.e., the instrument's capacity to be stable and reproducible); and internal consistency (i.e, the capacity of yielding consistent results in repeated measurements).

Thus, this study aimed at assessing the validity, reliability, and internal consistency of the ASES-PT in individuals with shoulder pain.

MATERIALS AND METHODS

Participants

Fifty individuals (26 women; mean age, 39 ± 13 years) were recruited from the school-clinics of the Pontifícia Universidade Católica do Paraná (PUCPR) for assessing the validity of the ASES-PT. All participants met the following criteria: 1) minimum age of 18 years; 2) clinical diagnosis of shoulder dysfunction; 3) neither neurological nor any musculoskeletal disease other than shoulder dysfunction; 4) no cognitive change; and 5) ability to read, understand, and complete the questionnaire studied. For assessing reliability, the sample comprised 38 individuals (19 women; mean age, 37 ± 13 years), due to sample loss of 12 individuals, who did not return to the second assessment. This study has been approved by the Ethics Committee in Research with Human Beings of the institution, according to the protocol number 5.257. All participants provided written informed consent.

Validity

To test the convergent validity, the scores obtained with the ASES-PT were correlated with those obtained with the Portuguese versions of the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH)¹⁴ and the 36- Item Short-Form Health Survey (SF-36),15 whose validity and reliability have already been shown.^14,15 The DASH is a questionnaire comprising 30 questions aimed at measuring the symptoms and physical disabilities related to the upper limbs.¹⁶ The Portuguese version of the SF-36 is a questionnaire with 36 questions regarding the patient's general quality of life, and covering eight domains (i.e., physical functioning, role limitation due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitation due to emotional problems, and mental health).¹⁵

Validity was assessed by use of the Spearman's rank correlation coefficient (ρ), which can range from +1 to -1. A +1 correlation indicates the existence of a perfect positive linear relationship between the variables, while a -1 correlation indicates the existence of a perfect negative linear relationship between the variables. A correlation is considered strong when ρ is greater than 0.60 or lower than -0.60;the correlation is moderate when that coefficient is between 0.30 and 0.60 or -0.30 and -0.60;and it is weak when that coefficient is between -0.30 and 0.30.¹⁷

Reliability

Reliability was tested by use of the intrarater reliability (i.e., test-retest reliability), with intraclass correlation coefficient 1,1 (ICC) and 95% confidence interval. The ICC measures the agreement between the variables studied, and ranges from 0 (no agreement) to 1 (total agreement). Reliability is adequate if ICC is greater than 0.70.¹⁸ Because it is a self-administered questionnaire, its interrater reliability was not assessed.

Internal consistency

Internal consistency, assessed by use of the Cronbach's alpha, was used to identify to what extent the different items of the questionnaire were associated between themselves. The total values of each item were calculated, as was the alpha's variation when some items were eliminated. The statistical analyses were performed with the SPSS software, version 10.0 for Windows (SPSS, Chicago, USA).

Experimental procedure

To assess validity, each participant completed the ASES-PT, DASH, and SF-36 questionnaires, randomly applied. Then, the participant was invited to return to the school-clinics after seven days to conclude the reliability assessment,19 without undergoing any physical therapeutic intervention during that period. Data from the first and second ASES-PT completion were used to assess internal consistency. During the assessments, the participants were always accompanied by one of the examiners.

RESULTS

The scores of the ASES-PT showed correlation with the scores of the Portuguese version of the DASH (ρ = -0.69; P = 0.000) and with the following SF-36 domains: "physical functioning" (ρ = 0.50; P = 0.000), "role limitation due to physical health" (ρ = 0.43; P = 0.002), and "bodily pain" (ρ = 0.60; P = 0.000). With the other SF-36 domains, the correlations with the ASES-PT were weak and non-significant (ρ < 0.35; Table 1).

In the first assessment with the ASES-PT, the mean of the scores was 60.1 ± 21.1, while, in the second assessment, that mean was 63.4 ± 20.7. The intrarater reliability of the ASES-PT proved to be adequate, as shown in Table 2 (ICC = 0.75;P = 0.000).

The results of the internal consistency of the instrument have shown good reliability indices for all items, with values greater than 0.70 and Cronbach's alpha of 0.794 (Table 3).

DISCUSSION

Measuring instruments are used during rehabilitation programs aimed at the following: obtaining initial information about the patient; elaborating the patient's treatment; monitoring possible changes in symptoms; and assessing the efficacy of the therapeutic procedures used. Despite the existence of its Portuguese version,¹² the ASES-PT had not undergone validation and reliability investigation.

In the present study, the convergent validity of the ASES-PT was demonstrated by use of its correlation with a specific instrument for the upper limbs (i.e., DASH) and a generic instrument (i.e., the SF-36 physical health domains).

The fact that the DASH specifically assesses the symptoms and physical disabilities of the upper limbs justifies the greater correlation of the ASES-PT with that questionnaire. The results are similar to those obtained with the English version of the ASES, which showed a strong correlation when compared with a questionnaire specific for shoulder pain and function (that is, the University of Pennsylvania Shoulder Score - Penn), (r = 0.78;P = 0.01).⁹ In addition, strong correlations between questionnaires specific for the shoulders have already been reported several times in the literature.^9,20-22

Similarly, the moderate and weak correlations between ASES-PT and the SF-36 domains observed in this study repeat the results obtained with the original version of the ASES, in which moderate correlation of the domains "physical functioning" (r = 0.41;P = 0.001) and "role limitation due to physical health" (r = 0.33;P = 0.008) was observed with the mean score of the physical components (r = 0.40;P = 0.001), in addition to the weak correlation of the "role limitation due to emotional problems" (r = 0.24;P = 0.21) and "mental health" (r = 0.05;P = 0.70) observed with the mean score of the mental components (r = 0.15;P = 0.25).⁹

Moderate correlations between different shoulder-specific questionnaires and the SF-36 physical health domains have already been reported in previous studies.^6,9,20 This can be explained by the fact that their items did not contemplate exclusively the activities of the upper limbs. The weak and non-significant correlations of the ASES-PT with the SF-36 emotional and mental components result from the fact that such measures assess different constructs.⁹

In the present study, the reliability of the ASES-PT proved to be adequate, as already observed with its English version.^9,23 However, the ICC of the Portuguese version was slightly lower than that of the English version (that is, 0.75 and 0.84, respectively). A possible explanation for that difference can be the different time intervals between the first and second application of the questionnaire. While the second assessment was applied one to three days after the first for the English version, for the Portuguese version, that interval was of seven days. Thus, a clinical change is more likely to have occurred in the participants between the assessments of the ASES-PT. However, it is worth noting that there is no consensus in the literature regarding the ideal time interval between the assessments to analyze reliability. While long time intervals can be influenced by changes in the patients' clinical findings, short time intervals can be influenced by memory biases.

Regarding internal consistency, the scale showed good indices for all the domains of the instrument, with values over 0.70, considered satisfactory according to the literature.^9,24,25 The overall reliability index of the instrument was greater than when calculated with the suppression of any item.

Even having assessed the validity, reliability, and internal consistency of the ASES-PT, its responsiveness should also be assessed, which has already been initiated by the authors of the present study to better support its use.

Because the use of questionnaires has been part of the health care routine, a careful analysis of their applicability in the various settings of the therapeutic practices is increasingly important.²⁶ The process of assessing the psychometric properties, which can promote an increase in the resolution potential of therapeutic practices aimed at with this study, is part of that analysis.

CONCLUSION

The ASES-PT is a questionnaire of rapid application, containing clear, objective questions written in a simple language, related to daily activities. In addition, the results of this study have shown the validity, reliability, and internal consistency of the ASES-PT, indicating its adequacy for assessing shoulder function in the clinical and research practice.

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Validity and reliability of the portuguese version of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form

Auristela Duarte de Lima Moser^I; Luiz Alberto Manfre Knaut^II; Talita Gnoato Zotz^III; Karoleen Oswald Scharan^IV

Publication Dates

• Publication in this collection
  25 May 2012
• Date of issue
  June 2012

History

• Received
  18 July 2011
• Reviewed
  05 Mar 2012