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Brazilian Journal of Physical Therapy

Print version ISSN 1413-3555

Braz. J. Phys. Ther. vol.17 no.5 São Carlos Sept./Oct. 2013  Epub Sep 10, 2013

https://doi.org/10.1590/S1413-35552012005000108 

Original Articles

The Brazilian version of the SRS-22r questionnaire for idiopathic scoliosis

Paula M. F.  Camarini1 

Giselle C. L.  Rosanova1 

Bruna S.  Gabriel1 

Priscila E. S.  Gianini1 

Anamaria S.  Oliveira1 

1Department of Biomechanics, Medicine and Rehabilitation of Locomotor Apparatus, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil


ABSTRACT

BACKGROUND:

The SRS-22r questionnaire is a well-accepted instrument used to measure health-related quality of life in patients with idiopathic scoliosis. No validated tool exists in Brazil for idiopathic scoliosis, and the use of the SRS-22r in non-English Laguage contries requires its transcultural adaptation.

OBJECTIVE:

The objective of this study was to culturally adapt the translated Brazilian version of the SRS-22r questionnaire and to determine its reliability using statistical tests for internal consistency and test-retest reliability.

METHOD:

The transcultural adaptation process was carried out according to the recommendations of the American Academy of Orthopedic Surgeons. The pre-final version was administered to 44 patients with idiopathic scoliosis. The mean age of the participants was 18.93 years and the mean curve magnitude was 54.6°. A subgroup of 30 volunteers completed the questionnaire a second time one week later to determine the scale's reproducibility. Internal consistency was determined using Cronbach's alpha coefficient, and the test-retest reliability was determined using the Intraclass Correlation Coefficient (ICC).

RESULTS:

No floor effects were observed using the Brazilian version of the SRS-22r. Ceiling effects were observed in the Pain and Satisfaction with Management domains. The internal consistency values were very good for 3 domains and good for 2 domains. The ICC values were excellent for all domains.

CONCLUSIONS:

The high values of internal consistency and ICC reproducibility suggest that this version of the questionnaire can be used in Brazilian patients with idiopathic scoliosis.

Key words: quality of life; scoliosis; questionnaires; rehabilitation

Introduction

In the past few years, assessing Health-Related Quality of Life (HRQoL) based on a patient's perception of their condition and its treatment effects has raised interest among physicians and researchers1 - 3. Objective measures, although highly useful, are weakly related to patients' actual concerns, which include concerns about their symptoms and the functional, social and psychological aspects of their condition4 - 7. Hence, subjective measures can be an important complement to a traditional clinical evaluation7 , 8, and as a result, many instruments aimed at assessing such subjective measures have been developed9.

Idiopathic scoliosis is a tridimensional deformity that primarily affects females. Previous studies have shown that this condition negatively impacts patients' quality of life10 , 11. Scoliosis was previous related to altered self-image and mental health, and to functional limitations and pain3 , 6 , 10 - 14. For these reasons, it is important to measure patients' quality of life.

HRQoL is primarily measured using self-administered questionnaires. Psychometric properties of these scales, such as score distribution, validity, reliability and sensibility, must be determined15 - 18.

A well-accepted tool in the evaluation of patients' perception of their condition is the Scoliosis Research Society-22 (SRS-22) questionnaire. This questionnaire was developed in English, is specific for patients with idiopathic scoliosis15, and has been validated in patients with adult scoliosis, including patients with de novo scoliosis19 - 21. The original SRS HRQoL instrument was developed by Haher et al.22 and had 24 questions. Following several modifications to improve its psychometric properties, it became the SRS-22 version1 , 15. This version had acceptable validity, reliability and sensibility values15 , 23 , 24. However, Asher et al.25 demonstrated that the internal consistency of the Function domain decreased when administered to patients under 18 years old. For this reason, the questionnaire was altered once more and was renamed the Revised Scoliosis Research Society-22 (SRS-22r). This questionnaire has 22 questions divided into five domains: function/activity, pain, self-image/appearance, mental health and satisfaction with management. Each domain contains five questions, except the satisfaction with management domain, which contains two questions. Each item can be scored from 1 (worst possible) to 5 (best possible). The function/activity, pain, self-image and mental health domains have a total score ranging from 5 to 25. The satisfaction with management domain has a total score ranging from 2 to 10. The maximum total score is 110 and the results are expressed as a mean2 , 15.

With a few exceptions, self-evaluation questionnaires have been developed for use in English-speaking countries. In order for the questionnaire to be used in a country with a different culture and language, it is not enough to merely translate it from the original language because the simple translation can alter the conceptual equivalence of the original instrument3 , 6 , 16 - 18 , 26 - 29. The development of a new version requires transcultural adaptation to account for existing cultural and language differences. Moreover, the conception of quality of life varies among different cultures. Rosanova et al.30 verified that the Brazilian version of the SRS-22r questionnaire has satisfactory concurrent validity. This was determined by correlating the Brazilian tool with the Brazilian SF-36 questionnaire. However, the cross-cultural adaptation steps were not described. Additionally, the questionnaire's reliability, which is an important psychometric property, was not reported.

Thus, the aim of this study was to describe the cultural adaptation of the SRS-22r questionnaire for the Brazilian Portuguese language and to determine its reliability. This report will provide more complete information about the questionnaire.

Method

Forty-four volunteers, 40 females and 4 males, participated in this study. Participants were recruited by convenience from orthopedic private practices, public orthopedic clinics in the region and the school hospital of the Ribeirão Preto Medical School. Patients were contacted by three of the authors, who also administered the questionnaires. Clinical diagnostics were assessed by orthopedic surgeons. In addition, posterior-anterior standing radiographic images were used to measure each patient's Cobb angle. The mean age of the participants was 18.93 years (ranged from 12 to 36 years) and their average magnitude of scoliosis curve was 54.6° Cobb angle (ranged to 10 to 92° Cobb angle). Four female patients underwent surgery and reached 20.5° Cobb of correction in average. The postoperative curves of these four patients were used in the calculation of the average magnitude of the scoliotic curve. Illiterate patients and patients under 12 years old were excluded due to their limited ability to properly understand or read the questionnaire26. Individuals with any other musculoskeletal impairments or neurologic pathologies were excluded.

This study protocol was approved by the Ethics Committee for Research Involving Humans Beings of the Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil (approval number 9853/2005). The volunteers signed an Informed Consent prior to study participation. For those individuals under 18 years old, parents or legal guardians signed this document to consent to participation.

Cultural adaptation

The SRS-22r questionnaire was subjected to the cultural adaptation process proposed by Beaton et al.26 and recommended by the American Academy of Orthopedic Surgeons (AAOS).

Two independent translations, T1 and T2, were initially performed by two native Brazilian bilingual translators. Next, a synthesis of these two translations, the T-12 version, was produced. Afterwards, the synthesis was translated back into the English language independently by two American translators living in Brazil, resulting in the back-translations BT1 and BT2. This process is used to determine if the translated version reflects the original content of the questionnaire. Next, an expert committee composed of two orthopedic physicians, two physical therapists and one English Language teacher (non-native) revised the T-12 version, the back-translations and the original questionnaire. The committee examined the discrepancies with the aim of resolving them through a consensus and producing a pre-final version of the Brazilian questionnaire. The group's decisions were made with the goal of achieving semantic, idiomatic, experimental and conceptual equivalence with the original instrument. Some alterations were needed to adjust the tool to assess Brazilian patients with idiopathic scoliosis.

The pre-final version was administered to 44 volunteers with idiopathic scoliosis. Patients were instructed to not answer questions that they did not understand or questions that did not apply to themselves. The expert committee could have been required to meet once more to judge and propose changes for answer items or whole questions that were not answered by more than 15% of participants (6 or more volunteers). Proposed changes would maintain the original concept and a new pretesting would be repeated until all questions have good level of understanding16. The Brazilian Scoliosis Research Society Revised Questionnaire (SRS-22r) can be seen in Appendix 1. The score sheet is presented in Appendix 2.

Data analysis

Reliability measures included statistics measuring internal consistency and test/retest reproducibility. Internal consistency was assessed with Cronbach's alpha statistic and test/retest reliability was determined using the Intraclass Correlation Coefficient (ICC 2.1).

Floor effects were not seen in any domain of the questionnaire. Ceiling effects were observed in the Pain and Treatment Satisfaction domains.

Results

Test of the pre-final version

After administering it to forty-four individuals with idiopathic scoliosis, the questionnaire was analyzed for its level of comprehension. Campos et al.16 posit that the misunderstood questions or those that did not apply for more than 15% of the studied sample should be changed to preserve their cultural equivalence. In this study, a question would be changed if at least 6 participants did not answer it. The pre-final version of the Portuguese SRS-22r did not require alterations because no question was left unanswered by more than 15% of the participants in the studied sample.

However, during this phase, a deficiency was noted by the interviewer in the Brazilian version of question 11, as follows:

"Which one of the following best describes your pain medication use for back pain?"

None

Non-narcotics weekly or less (e.g.: aspirin, diclofenac, dipyrone)

Non-narcotics daily (e.g.: aspirin, diclofenac, dipyrone)

Narcotics weekly or less (e.g.: amitriptyline)

Others

Medication: ___________________________________

Use (the whole week or less or everyday): _______________

Of the ten volunteers who affirmed consuming medication for back pain, four chose the last answer "others", but the blank space was used to indicate infrequent drug intake, or drug intake only when pain was present. This item, however, holds the lowest score in the question, representing the worst option. The committee assumed that these patients chose this item because they did not understand the previous higher-score items indicating less frequent medication usage. Based on the Spanish version proposed by Bago et al.2, the items in this question were changed as follows:

"Which one of the following best describes your pain medication use for back pain?"

None

Non-narcotics weekly or less (e.g.: aspirin, diclofenac, dipyrone or others)

Non-narcotics daily (e.g.: aspirin, diclofenac, dipyrone or others)

Narcotics weekly or less

Narcotics daily

Table 1 presents the average scores for the 44 volunteers for each domain. The minimum and maximum average scores for each domain and the score distributions are also shown.

Table 1 Domain descriptions for the SRS-22 questionnaire. 

Domain Average Standard
Deviation
Minimum
Score
Maximum
Score
%
floor effect
%
ceiling effect
Function / activity 4.08 0.75 1.8 5 0 15.90
Pain 3.99 0.87 1.2 5 0 25
Self-image 3.53 0.83 1.2 5 0 4.54
Mental health 3.73 0.75 1.8 5 0 2.27
Management
satisfaction
4.28 0.83 2 5 0 36.36

Reliability

The test/retest reliability calculation was carried out using data from thirty of the forty-four volunteers enrolled in the pre-final test. The ICC (2.1) values are presented in Table 2. All domains had excellent ICC values, above 0.90.

Table 2 Intraclass correlation coefficient for test/retest reliability. 

(95%)
Domain ICC Inferior Superior
Function / Activity 0.94 0.89 0.98
Pain 0.93 0.89 0.98
Self-image 0.92 0.87 0.98
Mental health 0.92 0.87 0.98
Management satisfaction 0.96 0.93 0.99

The internal consistency values are presented in Table 3. The domains Pain (0.80), Self-image (0.82), and Mental Health (0.85) had very good internal consistency. Internal consistency values were good for the Function (0.77) and Management Satisfaction domains (0.70).

Table 3 Internal consistency, represented by Cronbach's alpha values. 

Domain Cronbach’s
alpha
Cronbach’s
alpha for the
original
SRS-22
Function / Activity 0.77 0.86
Pain 0.80 0.92
Self-image 0.82 0.75
Mental health 0.85 0.90
Management satisfaction 0.70 0.88

Unlike in the original and Spanish versions, question 15 had little influence on the internal consistency values in the Function domain. Without this question, Cronbach's alpha decreases from 0.77 to 0.75.

Discussion

The important characteristics of a questionnaire are its score distribution and its psychometric properties, specifically reliability, validity and responsiveness15. A previous study published by Rosanova et al.30 determined the concurrent validity of the Brazilian version of the SRS-22r questionnaire by correlating it to the Brazilian version of the SF-36 questionnaire. The authors verified that the instrument has satisfactory concurrent validity; therefore, this tool is able to measure what it intends to measure.

The current study complements the previous work by Rosanova et al.30 with two important additions. One novel addition is the description of the cross-cultural adaptation process used to translate the instrument to the Brazilian Portuguese language. This process is important for adjusting the new version to target the local population. Beaton et al.26 state that the cultural adaptation process maintains the content validity of the questionnaire, preserving the same concepts across various cultures. For this reason, the Brazilian version of the SRS-22r questionnaire was subjected to the cultural adjustment process proposed by these authors and the steps of this process are presented in this study.

The original version of SRS-22 was culturally adapted to Spanish2 , 31, Turkish32, Japanese33, Chinese34 , 35, French Canadian36, German9 and Greek37.

No domain in the Portuguese Language (Brazil)-adapted questionnaire demonstrated a floor effect, as found to German and Canadian versions. However, previous studies that have produced versions of the SRS-22 questionnaire, including the original version, reported low floor effect values. Such studies enrolled larger samples, resulting in more opportunities for a floor effect to occur.

The Brazilian questionnaire exhibited ceiling effects in the Pain and Management Satisfaction domains. This effect was also noted in the original version and in most of the SRS-22 questionnaires adapted for other countries. The original, Spanish, Turkish and German versions also presented a high percentage of ceiling effects for these domains. This indicates that in such domains there is limited ability to distinguish different levels of scoliosis severity. Significative percentage of the sample showing a ceiling effect in the Pain domain can be explained by the absence of pain in idiopathic scoliosis during adolescence and early adulthood. The high ceiling effect in the Treatment Satisfaction domain may reflect patients' confidence in the recruitment hospital, where most patients in this study are treated9 , 32 , 34. However, unlike the original version, the Brazilian questionnaire was not administered by the operating orthopedic surgeon, but rather by three physical therapy students who were not involved with patients' treatment. This decreases the potential for response bias in the Treatment Satisfaction domain15.

The second important addition that complements the work of Rosanova et al.30 is the Brazilian instrument's reliability. Test/retest reliability values were considered excellent. All domains had ICC values above 0.90, which was also true of the original, Spanish and Chinese versions13 , 37.

Cronbach's alpha values for all domains are above 0.70 and thus considered satisfactory. However, the original SRS-22 has better internal consistency values. According to Bago et al.2, it is typical for culturally adapted questionnaires to have slightly inferior internal consistency than the original tool.

Asher et al.25 observed that questions 15 and 18 decreased the internal consistency of the Function domain in the original SRS-22 when applied to individuals younger than 18 years old. A similar phenomenon occurred using the Spanish2 and Turkish32 versions. Despite this, the authors maintained question 15 unaltered because it assesses the important concept of financial difficulties related to scoliosis, and altered question 18. Hence, the SRS-22 was then named the SRS-22 revised version (SRS-22r). In the Brazilian version, question 15 had a slight influence on the internal consistency value of the Function domain. Without this question, Cronbach's alpha decreased from 0.77 to 0.75. Question 18 was translated and adjusted according to the revised version of the SRS-22r questionnaire during the adaptation process for the Brazilian version.

Question 11 in the Brazilian version decreased the internal consistency of the Pain domain. Cronbach's alpha increased from 0.80 to 0.85 after removing question 11. This is consistent with the observation that some volunteers experienced difficulty with this question during the pre-final test. Of the ten patients who reported medication usage, four answered the question incorrectly. Hence, the authors believe that if most of the volunteers consumed medications for back pain, or if the study sample were larger, there would be more participants with problems with that question. The problems occurred because these items are presented as a consumption frequency scale for medication, increasing from the first to the last item. The last item, "others", receives the worst score. However, three patients chose this item as their answer and reported that they use common medication "sometimes" or "when in pain". This way, they have a lower score than they would have if they were answering the question correctly. As mentioned in the Results section, question 11 has been updated in a similar manner to that recommended by Bago et al.2 In the latest validation studies of the English version of the SRS-22r questionnaire25 , 38, question 11 reflects this change. For the sake of completeness it would be desirable to test the Brazilian version once again. However, we believe that published results using the updated question #112 , 25 , 38 and our experience detailed here make this unnecessary.

Finally, the questionnaire seemed simple and practical, and its psychometric characteristics were similar to those of the original questionnaire. All questions were answered by more than 15% of patients. These results suggest that the tool is properly adjusted for use in the population of Brazilian patients with idiopathic scoliosis.

Acknowledgements

The authors would like to thank Mr. A. Asher, from the Department of Orthopedic Surgery of the Kansas University Medical Center, for his valuable comments during manuscript preparation. The authors also would like to thank the Fundação de Amparo à Pesquisa do Estado de São Paulo – FAPESP (2005/56130-3).

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Appendix A

Appendix B

Received: March 13, 2013; Revised: April 05, 2013; Accepted: April 08, 2013

Correspondence: Paula Maria Ferreira Camarini Rua Conselheiro Saraiva, 95, Centro CEP: 13480-190, Limeira, SP, Brasil e-mail: paula_camarini@yahoo.com.br

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