Brazilian version of the Chelsea Critical Care Physical Assessment: translation, cross-cultural adaptation and evaluation of its clinimetric properties

ABSTRACT

Purpose:  To translate, cross-culturally adapt and evaluate the clinimetric properties of the Chelsea Critical Care Physical Assessment for the functional evaluation of patients admitted to intensive care units in Brazil.

Methods:  The steps involved in the translation and cross-cultural adaptation of the instrument included the following: initial translation, synthesis, back-translation, review by an expert committee and pretesting. Intra- and interrater reliability and agreement were analyzed with data generated from physical therapists’ assessments of the same group of patients with the translated and adapted instrument (n = 30). The evaluations were performed by two physical therapists who independently and blindly obtained scores from the patients. Qualitative analysis was performed by the review committee with the expert-adapted and expert-synthesized translation of the Chelsea Critical Care Physical Assessment scale into Portuguese, and the content validity index was calculated.

Results:  Agreement was achieved between the translations of the Chelsea Critical Care Physical Assessment scale into Brazilian. Conceptual, idiomatic, semantic and experimental equivalences between the original and translated versions were obtained, resulting in the Brazilian version of the instrument, called the Avaliação Física em Cuidados Intensivos Chelsea, with a content validity index of 0.91. Evaluation of the clinimetric properties revealed evidence of high degrees of agreement and reliability, as all properties had an intraclass correlation coefficient above 0.75. The total intraclass correlation coefficient was 0.99.

Conclusion:  A version of the Chelsea Critical Care Physical Assessment scale can be reliably used in Brazil for functional assessment following its translation and cross-cultural adaptation to Brazilian Portuguese and shows evidence of excellent interrater reliability.

Keywords:
Physical therapy modalities; Mobility limitation; Surveys and questionnaires; Intensive care units

INTRODUCTION

During hospitalization in the intensive care unit (ICU), most patients are exposed to several etiological factors that contribute to the development of ICU-acquired muscle weakness (ICU-AMW) and corresponding neuromuscular changes. Thus, there is a growing need to explore and understand aspects related to morbidity following discharge and the rehabilitation process to identify the future condition of patients early and minimize the consequences of ICU admission. Impairment of physical function is a significant condition affecting patients who are ultimately discharged from the ICU; a consideration of the impact of ICU stay on functional capacity and independence would provide information on the limitations that patients may experience in performing functional activities related to activities of daily living.(¹-³)

The Chelsea Critical Care Physical Assessment (CPAx) is an instrument used to assess the functionality of ICU patients. The CPAx instrument has important components for assessing patient functionality, and it is the only instrument designated for patient functional assessment in the ICU that covers respiratory function. In addition, according to the International Classification of Functioning, Disability and Health (ICF), the CPAx instrument most encompasses the domains related to this classification, indicating its importan ce for the evaluation of the functionality of ICU patients.(⁴.⁵)

The CPAx consists of ten items related to physical function, each of which is rated from complete dependence to complete independence (e.g., 0 - 5 points). The total score ranges from 0 - 50, where 50 represents complete independence across all domains. The clinimetric properties of the original instrument have already been published, with good results. (⁴,⁵) Cultural adaptation of an instrument indicates that both the language and the meaning of the items in the adapted version are consistent with those of the original document and is also associated with the evaluation of consistency and validity.(⁶)

In addition to ensuring cross-cultural adaptation of an instrument, tests should be performed to verify the clinimetric properties, such as validity and reliability, of the modified version. Clinimetry involves a set of rules that govern the structure of the indices, the choice of variables present in the tool or instrument, and the evaluation of the consistency and validity of the instrument.(⁶) Reliability, reproducibility, validity, how well the results align with those of the gold standard version of the instrument, ease of use, and sensitivity in detecting clinical changes are among the clinimetric characteristics that should be taken into account when choosing assessment instruments for ICU patients.(⁷) Reliability refers mainly to the stability, internal consistency and equivalence of a measurement with respect to the original version. The criteria for this evaluation include reproducibility and internal consistency.(⁸) The first refers to the ability to reproduce the measurements obtained with the instrument when it is used on different occasions (intra- and interexaminer reproducibility). Internal consistency, on the other hand, indicates the homogeneity of an instrument, that is, that it must address different aspects of the same construct. The aspects contained in the instrument must be associated with each other, and the score of each item must be correlated with the total score of the instrument.(⁹)

Thus, considering the impact that the ICU admission process has on patient functionality, the importance of evaluating the clinimetric properties as a quality criterion of an instrument, and the preliminary results regarding the cross-cultural adaptation of the CPAx instrument for use in Brazil, this study aimed to translate, cross-culturally adapt and evaluate the clinimetric properties of the CPAx.

METHODS

This cross-sectional study was performed according to the Guidelines for Reporting Reliability and Agreement Studies. Dr. Evelyn J. Corner, author of the original instrument, was consulted prior to conducting this study and authorized the translation and cross-cultural adaptation of the instrument. The study was submitted to and approved by the Research Ethics Committee of the Universidade Universidade Federal de Santa Catarina (UFSC). with CAAE: 57260316.8.0000.0121, under opinion no. 2,109,718. This study was conducted in the 15-bed general ICU of Hospital Universitário Professor Polydoro Ernani de São Thiago (Florianópolis, SC), UFSC, and in the 12-bed general ICU of Hospital Estadual Governador Celso Ramos (Florianópolis, SC). Both hospitals are public.

The Chelsea Critical Care Physical Assessment instrument

The CPAx instrument, developed and validated by Corner et al.(⁴,⁵) for evaluating the functionality of ICU patients, has key components for this purpose and is the only functional evaluator approved for use in the ICU that includes aspects of respiratory function. The CPAx consists of ten items related to physical function, each of which can be assigned one of six scores ranging from complete dependence (0) to independence (5). The total score ranges from 0 - 50, where 50 represents complete independence. A radar plot can also be drawn for the score, providing a rapid, illustrated representation of the functions evaluated, emphasizing those for which patients experience greater difficulty and therefore less independence.

The instrument assesses respiratory function, cough, mobility in bed, transfer from the supine to sitting position, ability to remain seated, standing balance, sitting and standing, ability to transfer to a chair/armchair, ambulation and handgrip strength. Following its development, the clinimetric properties of the instruments were evaluated, yielding good results regarding interexaminer reliability (Cohen's κ = 0.988) and internal consistency (Cronbach's α = 0.798). Similarly, assessment of the construct validity of the CPAx indicated that the scores were associated with long-term recovery and rehabilitation.

Translation and cross-cultural adaptation

Stage I - Initial translation

The original version of the instrument was independently translated by two native Portuguese (Brazilian)-speaking professionals proficient in English. Translator 1 (T1) was a health care professional experienced in assessing the functionality of ICU patients and was aware of the concepts examined in the translated instrument. Translator 2 (T2) was also a health professional but did not have knowledge or information about the concepts being worked on in the instrument.

Stage II - Synthesis

Versions T1 and T2 were compared and analyzed by a third bilingual translator (native Brazilian Portuguese speaker), a health professional with experience in assessing the functionality of patients admitted to the ICU and the researcher responsible for the study and overseeing the translators of stage I, to obtain a single text (T1.2). After discussion of the issues addressed, the translated version T1.2 was accepted.

Stage III - Back translation

This stage refers to the back-translation of the T1.2 consensus version into English by two independent translators, RT1 and RT2. The translators are native English speakers who are proficient in Portuguese. Of these, one works in the health area and had knowledge of the concepts addressed in the instrument, and the other was unaware of the original version and was not from the area (professor with a degree in languages).

Stage IV - Review by an expert committee

A committee of experts, consisting of four health professionals (three of whom participated in stages I and II), evaluated the clarity, relevance, coherence and meanings of the items in the adapted versions. The equivalences (semantic, idiomatic, cultural and conceptual) among all the items of the instrument (consensus document T1.2) with respect to the original were evaluated. All versions of the instrument (original, translations and back-translations) were provided to the experts. The consensus among the experts for each of the equivalences was obtained by calculating the content/consensus validity index (CVI). The threshold index for agreement among experts was set to 0.80; items that did not reach the threshold CVI were discussed until a consensus was reached and any discrepancies were resolved. This stage yielded the prefinal version of the instrument.

Stage V - Pretest

In this phase, the translated version of the instrument (prefinal version) was tested. Specifically, four professional physical therapists working in ICUs (two with more than five years of experience and two with less than five years of experience) were trained to apply the instrument through a face–to–face meeting with the author of the present study and through e-learning made available via the web by the authors of the original instrument.

This stage aimed to evaluate whether the CPAx items could be understood by the evaluator in practice (apparent validation).(¹⁰) Each physical therapist was instructed to fill out a form in which they recorded their understanding of the topic names (0 = not understandable, 1 = somewhat understandable and 2 = understandable), questions, and response options and their suggestions for improving understanding. For items considered "poor" or "not understandable", that is, those whose mean did not reach "2", the physical therapists were asked to provide suggestions or comments. After the professionals’ suggestions were gathered and reviewed by the researcher responsible for this study, the final version of the CPAx was generated.

Clinical evaluation of the Chelsea Critical Care Physical Assessment Scale

A convenience sample of patients admitted to the ICU of Hospital Universitário Professor Polydoro Ernani de São Thiago and Hospital Estadual Governador Celso Ramos, Florianópolis, SC, from May 2017 to January 2018 was included to evaluate the adapted instrument. All patients or their legal guardians agreed to participate by signing an informed consent form. The inclusion criteria were age between 20 and 59 years and Brazilian nationality. Patients with previous functional deficits, amputees, those expected to remain in the ICU for less than 48 hours, pregnant women and those who did not agree to participate in the study were excluded. The patients were evaluated on admission to the ICU, weekly during the hospitalization period and at discharge from the unit, according to Corner et al.(⁴)

Data analysis

Qualitative analyses were performed by the review committee, in which the experts adapted and synthesized the translation of the CPAx scale into Portuguese. The normality of the data was analyzed with the Shapiro–Wilk test and the Kolmogorov–Smirnov test. Data from quantitative analyses are expressed as the means and standard deviations or absolute values and percentages.

In the quantitative analysis of the content validity performed by the committee of experts, the CVI was calculated. In this study, to be considered equivalent, the item or instrument had to meet a minimum CVI of 0.8 among the experts.(¹¹) A 3-point scale was used to analyze the understanding of the instrument by the physical therapists (that is, during the pretest), with 0 (zero) being the lowest score and 2 (two) the highest score. The sum of the points and the mean for each item of the instrument, as well as the overall mean of comprehension of all the items (in this case, 71 items), were calculated.

For interexaminer reliability, two independent physical therapists (experienced in the use of scales to assess ICU patient functionality) evaluated the same group of patients using the Brazilian version of the CPAx. The two physical therapists assessed each patient once on the same day (with a 30-mintue interval between assessments) while being blinded to the results obtained by the other therapists. Reliability was assessed via the intraclass correlation coefficient (ICC) (for numerical variables) and the kappa coefficient (κ) (ordinal variables), as well as their weights. Values greater than 0.8 were considered to indicate good reliability. Bland–Altman plots were used to visualize the agreement between the evaluators, where the difference between the two evaluators and the average between the two evaluators were first calculated. From the difference, the bias was calculated, which indicates how much the differences deviate from the zero value, i.e., the smaller and closer to zero, the smaller the bias is.

Internal consistency was assessed with Cronbach's α, in which values > 0.70 were established as evidence of good internal consistency. For all the statistical tests, a significance level of 5% was adopted. The data were analyzed with the Statistical Package for Social Science (SPSS) software, version 20.0.

RESULTS

A total of 31 patients were included in the present study; these patients were predominantly male (67.7%), with a mean age of 53 ± 13 years, and most had a neurological diagnosis (Table 1). A total of 239 evaluations were performed, with a mean of 4.87 evaluations per patient.

Table 1
Characterization of the sample involved in the evaluation of interexaminer reliability

Variables
Age (years)		51.3 ± 7.2
Male sex		16 (53.3)
SAPS III		61 ± 12.7
SAPS III %		43.6 ± 22.2
Origin
	Emergency	19 (63.3)
	Surgical center	10 (33.3)
	Infirmary	01 (3.3)
Reason for admission
	Surgical	8 (26.7)
	Neurological	10 (33.3)
	Respiratory	7 (23.3)
	Other	2 (6.5)
Used IMV		25 (80.6)
CPAx on ICU admission		8.55 ± 14.57
High CPAP in the ICU		30.08 ± 12.94

• SAPS III - Simplified Acute Physiology Score 3; IMV - invasive mechanical ventilation; CPAx - Chelsea Critical Care Physical Assessment; ICU - intensive care unit. SAPS% refers to the result of the formula applied to predict the risk of patient mortality. Numerical variables are presented as the means ± standard deviations; categorical variables are presented as absolute and relative frequencies (%).

After the analysis of versions T1 and T2 of the instrument, the discrepancies and issues addressed were discussed, resulting in a single text (T1.2). The main aspects addressed were "cough", "movements while sitting", "standing balance", "sitting to standing" and "ambulation." Table 1S (Supplementary Material - Brazilian version) summarizes this process.

The analysis by the expert committee revealed an overall CVI of 0.91. The means of the CVI by equivalence (for all elements) was 0.96 for semantic equivalence, 0.94 for idiomatic equivalence, 0.92 for conceptual equivalence, and 0.85 for cultural equivalence.

Most CPAx CVI results (mean semantic, idiomatic, conceptual and cultural equivalence of each element) were above 0.8. Items that achieved a value below 0.8 were discussed to achieve equivalence. The aspects in need of revision and modification were as follows: instrument title (0.75); respiratory function level 1 (0.75); cough levels 0 (0.75), 1 (0.75), 3 (0.68), 4 (0.75) and 5 (0.62); moving in bed level 0 (0.75); and transfer from bed to chair level 5 (0.75). Although most of the elements evaluated generally received CVI scores higher than 0.8, which would indicate an acceptable level of agreement among the experts, a need for grammatical changes, word inversion within sentences and replacement of some terms by synonyms was suggested by the experts, some of which are shown in table 2S (Supplementary Material - Brazilian version). After the pretest stage, the physical therapists reported a few interpretation problems, but these did not affect the assessments. The overall mean of the comprehension score for all instrument items was 1.92. For 15 of the 71 elements evaluated, the average was 1.83, and for 8 elements, the average was 1.66.

The ICC of the CPAx was 0.997, indicating a high level of agreement. Table 2 shows the values of the kappa coefficients.

Table 2
Interexaminer reliability in terms of the kappa coefficient of the Chelsea Critical Care Physical Assessment (Brazilian version)

Variable	Kappa	Kappa weighted
Respiratory function	1.00	1.00
Cough	0.958	0.994
Ability to roll over in bed	0.791	0.978
Change from supine to seated position at bedside	0.742	0.965
Movement involving the sitting position (e.g.. maintaining balance while sitting on the edge of the bed/sitting down without support)	0.782	0.965
Standing balance	0.952	0.994
Change from sitting to standing position (initial position: ≥ 90° hip flexion)	0.690	0.946
Transfer from bed to chair	0.865	0.982
Ambulation	1.00	1.00
Grip strength	1.00	1.00

The agreement of the CPAx total score between the evaluators is demonstrated in Bland–Altman plots (Figure 1). In the analysis of internal consistency, a Cronbach's α of 0.974 was obtained for the instrument, indicating excellent precision in the measurements. Table 3 shows the analysis for each CPAx function evaluated.

Figure 1
Bland–Altman plot of differences and means between the evaluators’ scores for the Chelsea Critical Care Physical Assessment.

Table 3
Analysis of internal consistency

Variable	Mean ± SD	Alpha item total	Alpha if item is deleted
Respiratory function	1.51 ± 1.53	0.70	0.98
Cough	1.88 ± 1.65	0.83	0.97
Ability to roll over in bed	0.92 ± 1.64	0.89	0.97
Change from supine to seated position at bedside	0.69 ± 1.47	0.93	0.97
Movement involving the sitting position (e.g., maintaining balance while sitting on the edge of the bed/sitting down without support)	0.71 ± 1.5	0.96	0.97
Standing balance	0.55 ± 1.42	0.91	0.97
Change from sitting to standing position (initial position: ≥ 90° hip flexion)	0.47 ± 1.26	0.92	0.97
Transfer from bed to chair	0.47 ± 1.26	0.92	0.97
Ambulation	0.45 ± 1.19	0.93	0.97
Hand grip strength	0.78 ± 1.5	0.88	0.97

• SD - standard deviation.

An example of the radar plot of the CPAx for a 49-year-old patient with a "respiratory" diagnosis at admission and who was hospitalized for 12 days is shown in figure 1S (Supplementary Material).

DISCUSSION

This study aimed to officially translate, cross-culturally adapt, and clinimetrically evaluate a Brazilian Portuguese version of the CPAx scale, called the Avaliação Física em Cuidados Intensivos Chelsea. The simple translation of a tool does not guarantee its use in clinical practice, as it is necessary to ensure suitable cultural adaptation of the original version.(¹²) Maher et al. emphasized that the adaptation of a new instrument can be more practical and effective than the creation of a brand new evaluation tool, which is the reason why we decided to adapt the CPAx.(⁹)

The functions assessed by the instrument include respiratory function, cough, mobility in bed, transfer from the supine to sitting position, ability to remain seated, standing balance, sitting and standing, transfer to a chair or armchair, ambulation and hand grip strength.

The adapted instrument showed excellent intra- and interexaminer reliability. Corner et al. evaluated the ability of the CPAx to assess the functional recovery of burn patients admitted to the ICU. The authors evaluated 30 patients who had been hospitalized for more than 48 hours just before admission (retrospective data), on the day of admission to the ICU, and at discharge from the unit and hospital. The results revealed that the CPAx seems to be able to detect improvements in the functionality of patients recovering from severe burns in the acute phase.(¹³)

In the study by Betteridge et al., the feasibility and usefulness of implementing measures to assess the outcomes of rehabilitation in an ICU focused on liver patients were evaluated. The authors applied three different assessment tools, the Rehabilitation Complexity Scale (RCS), the ICU Mobility Scale (IMS) and the CPAx, on the fifth day after admission to the unit, on the day of rehabilitation and on the day of ICU discharge. The study revealed that all measures were easy to use and reflected significant improvements in the patients from the beginning to the end of rehabilitation, indicating that they are useful measures for this context.(¹⁴) Whelan et al. conducted a study involving 26 patients admitted to the ICU of a public hospital in South Africa, with the objectives of establishing the effect of the use of the CPAx in the ICU and during hospital stay in the care of critically ill patients. The results of the study revealed that the use of the CPAx had no influence on the length of stay in the ICU or the hospital in a small sample of surgical and trauma patients. The authors suggested, on the basis of their results, that the instrument seems to be more useful in the care of patients recovering from surgical procedures than in those who have suffered complex traumatic injuries.(¹⁵)

The present study revealed a high degree of agreement and reliability in the analyses performed in the Brazilian version of the CPAx, with excellent agreement as well as interrater reliability for most of the evaluated domains. In the present study, we obtained an overall ICC of 0.997, which demonstrates high interrater reliability as well as high internal consistency.

An important factor to consider is the ICF, in which the term "functionality" encompasses all body functions (organic functions and body structure), activities (performance of a task or action by an individual) and participation (involvement of an individual in a real-life situation). and is conceived as a dynamic interaction between health states (diseases, disorders, injuries, traumas, etc.) and contextual factors. Therefore, patient functionality should be evaluated by considering the aspects of the ICF, and the choice of instrument should encompass these aspects.(¹⁶) In this context, the CPAx instrument most encompasses the domains of the ICF, revealing its consistency in the evaluation of the functionality of patients admitted to the ICU.(¹)

Notably, the literature describes different scales for the evaluation of the functionality of critically ill patients admitted to the ICU that have been validated for Brazilian Portuguese, such as the Perme Scale,(¹⁷) ICU Mobility Scale,(¹⁷) ICU Functional Status Scale (PFIT)(¹⁸) and Outcome of Functional Rehabilitation in Intensive Care,(¹⁹) which have different evaluative factors and are thus able to adapt better to specific populations and times.

We believe that an important future direction is the analysis of the minimally relevant clinical difference in the CPAx, which was similarly evaluated by Kenji Nawa et al. with the use of the Perme Scale. The authors reported that an increase of 6 points or more was associated with significant clinical improvement.(²⁰)

The strength of this study is the adequate methodology for the translation and validation process, resulting in clearly presented data and consequent ease of interpretation, both for those who will use the instrument in the field of care and for whose who seek to use the scale for research. Notably, CPAx is also the only instrument that includes an assessment of respiratory function and handgrip strength and that includes a detailed scoring scale regarding the levels of functionality, allowing better patient characterization. In addition, a radar plot can be drawn, providing a rapid, illustrated representation of the functions evaluated, highlighting those for which patients have greater difficulty and thus experience less independence. Moreover, the CPAx is one of the instruments that most incorporates the ICF.

A possible limitation of the present study is the mean age of the patients included; however, this factor may be explained by the reference values for handgrip strength published for the Brazilian population at the time of writing this manuscript. In addition, other clinimetric properties, such as floor and ceiling effects, were not evaluated.

We hope that this study will help professionals working in the intensive care unit achieve better functional evaluation, therapeutic targeting and outcome evaluation of critically ill patients.

CONCLUSION

The Brazilian version of the Chelsea Critical Care Physical Assessment scale, called the Avaliação Física em Cuidados Intensivos Chelsea, may be used by professionals working in the intensive care unit to reliably assess functionality because it was expertly translated, cross-culturally adapted and evaluated in terms of its clinimetric properties.

• Publisher's note
• Excerpt from the Doctoral Thesis presented to the Universidade Federal de Santa Catarina, Postgraduate Program in Nursing. Florianópolis (SC), 2018.

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Edited by

• Responsible editor:
  Dimitri Gusmao-Flores https://orcid.org/0000-0003-2847-8439

Publication Dates

• Publication in this collection
  25 Apr 2025
• Date of issue
  2025

History

• Received
  30 Jan 2024
• Accepted
  17 June 2024