Translation and transcultural adaptation of the modified Harris Hip Score

Abstracts

OBJETIVO: As artroscopias do quadril têm sido utilizadas tanto para fins diagnósticos, como para fins terapêuticos, fazendo parte do arsenal rotineiro dos cirurgiões do quadril. Devido a necessidade de avaliação dos resultados artroscópicos, Byrd propôs a modificação do "Harris Hip Score", realizando a avaliação da dor e função. O objetivo deste estudo foi traduzir e adaptar transculturalmente o protocolo de avaliação do "Harris Hip Score" modificado por Byrd, utilizado nas artroscopias do quadril. MÉTODO: O método utilizado constituiu em: 1) tradução inicial, 2) retrotradução, 3) pré - teste e 4) teste definitivo. RESULTADOS: A versão em português foi aplicada em 30 pacientes com afecções do quadril para verificar o nível de compreensão do protocolo. Foram realizadas mudanças e substituições de termos e expressões que não foram entendidas pelos pacientes durante o pré-teste e realizada a versão final em consenso. Novamente a versão final do questionário foi aplicada com 100% de entendimento pelos pacientes. CONCLUSÃO: disponibiliza-se assim a versão final em português do questionário "Harris Hip Score" modificado por Byrd. A validação desta versão já está em desenvolvimento.

Tradução (processo); Artroscopia; Quadril; Qualidade de vida

ORIGINAL ARTICLE

Translation and transcultural adaptation of the modified Harris Hip Score

Rodrigo Pereira Guimarães; Débora Pinheiro Lédio Alves; Thiago Leonardi Azuaga; Nelson Keiske Ono; Emerson Honda; Giancarlo Cavalli Polesello; Walter Ricioli Junior; Lucia Emi Ueno; Nilza Aparecida Almeida De Carvalho

Department of Orthopedics and Traumatology of Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo(FCMSCSP), São Paulo, Brazil

^{Mailing address}

ABSTRACT

OBJECTIVE: Hip arthroscopy has been used for diagnostic as well as therapeutic purposes, and it is part of the daily arsenal of hip surgeons. Due to the need for arthroscopic evaluation of the results, Byrd proposed a modification of the Harris Hip Score by assessing pain and function. This study aimed to translate and cross-culturally adapt the evaluation protocol of the modified Harris Hip Score used in hip arthroscopies.

METHOD: The method used consisted of: 1) an initial translation, 2) a back translation, 3) a pre-test and 4) a final test.

RESULTS: The Portuguese version was used with 30 patients with hip disorders to determine the level of comprehension of the protocol. Expressions which were not understood by patients during the pre-test were modified or replaced, and the final version was obtained by consensus. The final version of the questionnaire was used once again, with 100% understanding by patients.

CONCLUSION: Thus we arrived at the final Portuguese version of the modified Harris Hip Score questionnaire. Verification of the validity of this version is already in progress.

Keywords: Translating. Arthroscopy. Hip. Quality of life.

INTRODUCTION

Hip arthroscopy first appeared in 1931, initially performed by Burman on cadavers.¹ This procedure continued unsuccessful until the 1980s, when it attracted attention in the United State once again, with the development of medical instruments by James Glick and Thomas Sampson that allowed better access to the hip joint.^2-4

It has been used both for diagnostic purposes such as: biopsy, diagnosis of painful hips in children, evaluation of juvenile chronic arthritis, evaluation of the osteoarthritic hip, among others; and for therapeutic purposes such as: articular debridement for pain relief in osteoarthrosis, removal of free bodies, cleaning and debridement in septic arthritis, ligament injuries, correction of lesions of the acetabular labrum, femoroacetabular impact among others and is part of the routine therapeutic arsenal of hip surgeons.^5-7

A considerable number of quality of life questionnaires related to health have been developed in the last 25 years and are today essential tools in the analyses of scientific research. Due to the growing number of multicentric, multinational and multicultural surveys, the need for adaptation of quality of life questionnaires for use in other languages has increased rapidly.

The cultural adaptation of quality of life questionnaires for use in another country, culture and/or language calls for a method for the translation and equivalence of the original questionnaire.⁸ Nowadays it is known that if a questionnaire is to be used in several cultures, the items should not only be translated, but also adapted culturally to preserve the validity of the tool.^8,9

In 1969 Harris¹⁰ created a scale to evaluate the functionality and quality of life of patients undergoing hip arthroplasty, known as the "Harris Hip Score" (HHS).

A scale with a maximum of 100 points, it evaluates pain, function, deformity and motion. Pain and function have the highest weight - 44 and 47 points respectively - while range of motion and deformity, with a lower weight, receive maximum values of 5 and 4 points.¹⁰

Function is evaluated by questions about daily life activities and gait, including limp, use of walking aid and maximum distance covered⁶. A total score below 70 points is considered a poor result, 70 to 80 reasonable, 80 to 90 good and 90 to 100 excellent.¹⁰

Due to the need for evaluation of the arthroscopic results, Byrd proposed the modification of the Harris Hip Score, evaluating pain (44 points) and function (47 points). The multiplication by constant "1,1" results in a possible total score of 100 points. The criteria of deformity (4 points) and range of motion (5 points) were eliminated because neither one of these two parameters are main indications of hip arthroscopy.

Although among the most frequently used, the Harris Hip Score modified by Byrd was not translated and adapted culturally for use in the Portuguese language.

The aim of this study is to perform the translation and transcultural adaptation of the Harris Hip Score assessment protocol modified by Byrd, used in hip arthroscopies.

MATERIALS AND METHODS

The method for translation and cultural validation of the Harris Hip Score modified by Byrd used the criteria described by Guillemin et al.¹¹ These criteria will be described below.

Initial Translation

The original English version of the Harris Hip Score modified by Byrd was translated into Portuguese by two independent and qualified translators (sworn translators). A committee of four orthopedists was formed with the purpose of analyzing and discussing the two translations, and evaluated each item of the questionnaire, aiming to observe possible distortions and its applicability to the patients' situation. Version number 1 was produced in Portuguese with a basis on this evaluation.

Back-translation

In the back-translation stage, version number 1 was translated into the original language by another two independent translators, native speakers of English, with knowledge of the two languages (Portuguese and English) and without knowledge of the study objective.

The two translations obtained were then evaluated by the committee mentioned in the previous stage, with the objective of determining discrepancies between the original version and the translations of version number 1. Based on this evaluation we arrived at version number 2 in Portuguese.

Pre-Test

This stage consists of the application of version number 2 in Portuguese, which maintained the conceptual characteristics of the original questionnaire, aiming to verify the equivalence of the final version of the instrument and evaluated errors and deviations committed in its translation.

Thirty patients with hip disorders were submitted to the application of version number 2, for evaluation of questionnaire comprehension. With no situations that were not part of their everyday life, issues or terms that were not well understood, version number 2, in Portuguese, became the final version of the translated questionnaire.

Final Test

We reapplied the final version of the questionnaire to the same thirty patients selected.

Patients

This study group consisted of 30 patients with hip disorders, who are having treatment follow-up in the hip surgery outpatient department of Santa Casa de São Paulo.

Criteria for Participation in the Study

Hip disorder, irrespective of gender and race and between 20 and 45 years of age.

Application of the Questionnaires

The study protocol consists of the application of the final version of the Harris Hip Score modified by Byrd. The protocol was presented to the patient, and conducted by the coordinator of the study by means of a simple interview.

Evaluation of the Measurement Properties of the Versions of the Harris Hip Score Modified by Byrd for the Portuguese Language:

DATA ANALYSIS

We carried out a descriptive statistical analysis for the socio-demographic and clinical characterization of the population studied in the different stages of the study.

PROCEDURES

The questionnaire was applied in interview form and the mean questionnaire administration time was 9 minutes, ranging between 6 and 12 minutes.

The authors of the survey read the items of the questionnaire to the patients. These had to answer whether they understood and comment on what they had grasped from each item.

With the performance of this pre-test they obtained a new modified and updated version. This version was then applied to another 30 patients to refine the test with explicitness and comprehension of the questionnaire, and finally, the Brazilian version of the Harris Hip Score modified by Byrd was defined.

RESULTS

The consensual version was formulated with some alterations in this translation phase, from the meeting between the two sworn translators and the investigators.

In the back-translation phase, translator and investigators evaluated and compared the original version, the consensual version in Portuguese and the back-translation to define the final version. Grammatical alterations were made to some items in this stage to acquire equivalence among words and between languages as well as cultural adaptation.

The final version in Portuguese was defined after the result of this test, with cultural adaptation for the Brazilian population of the HHS modified by Byrd.

Table 1 presents the items of the original version, of the translations, of the back-translations and of the consensus version of the HHS (pre-test).

DISCUSSION

From disorders of the osteoarticular system, diseases that affect the hip joint are among the most frequent forms. Alteration of the structure and function of the joint, involvement of the articular cartilage, underlying bone and soft tissues are common.^1,12 Pain is the main symptom and at the beginning of the disease, manifests mainly when the joint is called upon and can present relief with rest. Pain chronicity can produce psychosocial limitation in addition to physical disability.¹³

The instruments for evaluation of quality of life have been used more and more often in the studies of the various diseases and can be applied in hip disorders as a mechanism that provides better knowledge of the status of the disease and better evaluation of results of interventions performed.¹⁴

However these instruments, which are more classical, were developed in the English language, and in our opinion and as is also being proposed in literature¹¹, should be adapted to the cultural reality of the target audience, enhancing the value of semantic equivalence and not the literal equivalence between terms, which does not always prove more advantageous in expressing concepts or situations of the population that we study.

Accordingly, we adopted the proposal of Guillemin et al.¹¹, and in the application phase of the translated questionnaire, made use of a committee of health professionals, which performed the detailed revision of the questionnaire. Some terms such as gait and claudication were modified to walk and limping, respectively.

We believe that the use of qualified professionals to do the translations, in all the stages, associated with the application of the translated questionnaires to the target audience, allows a specialized committee to arrive at the consensual version that best applies to the cultural situation of the local population.

CONCLUSION

With the preparation of the Brazilian version of the Harris Hip Score modified by Byrd we obtained one more standardized instrument adapted to the Brazilian culture for evaluation of the quality of life of patients with hip disorders.

REFERENCES

Article received on 6/9/09 and approved on 11/12/09

All the authors declare that there is no potential conflict of interest referring to this article.

Study conducted at Irmandade da Santa Casa de Misericórdia de São Paulo -Director of the Orthopedics Department -Prof. Dr. Osmar Avanzi.

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Publication Dates

• Publication in this collection
  20 Dec 2010
• Date of issue
  2010

History

• Received
  09 June 2009
• Accepted
  12 Nov 2009