Translation and cross-cultural adaptation of the Northwestern Dysphagia Patient Check Sheet to Brazilian Portuguese

Purpose: To present the translation and cross-cultural adaptation of the Brazilian version of the Northwestern Dysphagia Patient Check Sheet (NDPCS). Methods: The translation to Portuguese was performed by two Brazilian bilingual speech language pathologists, followed by a back translation conducted by a bilingual native speaker of the original language. Afterwards, the three versions were compared by a committee of three speech language pathologists. Initially, the final translated version of the NDPCS was applied with 35 volunteers aged between 62 and 92 years old (74.77±7.08), who had no dementia or complaints of swallowing disorder. After some adjustments, the instrument was applied with other 27 volunteers aged between 60 and 87 years old (76.56±7.07) with the same profile. Results: There was divergence in semantic equivalence in relation to one item, which was modified in the translated version. The tasks requested for observation during deglutition were adapted in relation to the solid food and the volumes used in pudding and liquid consistencies. The instrument maintained the same structure as the original version, with five categories and into 28 items, three brief variables, and four closures. Conclusion: The equivalence between the original and the translated version of the NDPCS was preserved after its translation and adaptation to Brazilian Portuguese. The validation process of the psychometric properties of the instrument is in progress. 370 Magalhães Junior HV, Pernambuco LA, Souza LBR, Ferreira MAF, Lima KC CoDAS 2013;25(4):369-74 INTRODUÇÃO A tradução e adaptação transcultural de instrumentos internacionais tem sido prática recorrente na Fonoaudiologia brasileira, dada a importância clínica e científica deste processo para a adequada aplicação dos procedimentos propostos para a população. No entanto, no País não existem publicações sobre validação de protocolos de rastreamento do risco para disfagia. Rastreamento significa a utilização de instrumentos para identificar precocemente características sugestivas de risco para uma provável doença, condição ou agravo em qualquer indivíduo, independente de seu estado de saúde, seguido de encaminhamento para confirmação diagnóstica e tratamento. Recomenda-se que os protocolos de rastreamento sejam de fácil aplicação, rápidos, com risco reduzido, baixo custo e capazes de produzir resultados com boa sensibilidade, ou seja, com o mínimo de falsos negativos. Em relação à disfagia orofaríngea, o principal propósito dos protocolos de rastreamento é reconhecer os casos que necessitam de uma avaliação específica e favorecer uma conduta clínica mais eficaz, que possibilite melhora no estado de saúde. Em sua maioria, os protocolos existentes são heterogêneos quanto ao método e direcionados a indivíduos acamados ou com doenças neurológicas, o que inviabiliza a definição de um padrão ouro de rastreamento. O protocolo Northwestern Dysphagia Patient Check Sheet (NDPCS), elaborado por Logemann, Veis e Colangelo, atende aos critérios apontados como fundamentais para um protocolo de rastreamento, pois é de fácil aplicação, tem baixo custo, é rápido, abrange questões pontuais sobre o que pretende investigar e apresenta valores de acurácia, sensibilidade e especificidade a partir de sua comparação com o exame de videofluoroscopia da deglutição, considerado um teste diagnóstico padrão ouro para disfagia. Apesar de poder ser utilizado como instrumento de rastreamento, o NDPCS requer uma breve avaliação funcional da deglutição com a oferta de alimentos em diferentes consistências e volumes além da textura sólida. Por envolver este tipo de avaliação, faz-se necessário que sua aplicação seja de responsabilidade do fonoaudiólogo por ser este o profissional habilitado a avaliar, classificar e realizar o diagnóstico funcional da deglutição e do processo de alimentação por meio da avaliação clínica fonoaudiológica. O NDPCS é composto por 28 itens, divididos em cinco categorias: história médica, aspectos comportamentais, função motora ampla, teste motor oral e observação de intercorrências durante as provas de deglutição. O resultado final é definido pela combinação de alguns itens e pode ter até quatro desfechos: presença de aspiração, dificuldade na fase oral, atraso na fase faríngea ou presença de alteração na fase faríngea. O objetivo deste estudo foi realizar a tradução e adaptação transcultural do NDPCS para o Português Brasileiro (PB). Esta é considerada a primeira etapa do processo de validação do instrumento, que terá sua aplicabilidade posteriormente atestada após a conclusão das etapas de validação psicométrica. MÉTODOS Para iniciar o processo de validação do NDPCS, a autora principal do estudo original foi previamente consultada e autorizou a realização do trabalho. Os critérios para tradução e adaptação transcultural seguiram quatro etapas, propostas por Peters e Passchier. Na primeira, dois fonoaudiólogos bilíngues na língua portuguesa e inglesa, cientes do objetivo da pesquisa, traduziram o protocolo para o PB, considerando a equivalência conceitual. O instrumento produzido nesta fase foi resultado da análise consensual das duas traduções. Na segunda etapa, foi realizada a retrotradução do protocolo por uma nativa de língua inglesa que não teve contato com a versão original e nem participou da etapa anterior. Recomenda-se que esta etapa seja realizada por pessoa cuja língua materna é a mesma dos autores do protocolo original para preservar a coerência de conteúdo e revelar eventuais falhas na adaptação para o contexto da cultura-alvo, bem como ambiguidades da versão original. Na terceira etapa, um comitê formado por três fonoaudiólogos bilíngues nas línguas portuguesa e inglesa, com experiência em disfagia e em motricidade orofacial, reuniu-se para comparar o protocolo original, a versão traduzida e a retrotraduzida. A função deste comitê foi verificar as equivalências nos aspectos semântico, idiomático, experimental e conceitual. As mudanças pertinentes foram realizadas por consenso pelos membros do comitê, o que culminou com a versão final (Anexo 1). Na quarta etapa, avaliou-se a clareza do instrumento para a população. Ele foi aplicado em 35 voluntários com 60 anos ou mais, de ambos os gêneros, sem diagnóstico clínico de demência ou queixa de disfagia, selecionados em um ambulatório de serviço público em Geriatria. Os itens não compreendidos pela população ou inapropriados para serem aplicados pelo avaliador foram novamente revistos pelo mesmo comitê referido na terceira etapa. Por consenso, o comitê analisou e verificou que os itens deveriam ser reformulados. Após esta análise, foi gerada uma segunda versão do instrumento, aplicada em 27 voluntários que não participaram da etapa anterior, mas tinham o mesmo perfil. Esta pesquisa foi aprovada pelo Comitê de Ética em Pesquisa do Hospital Universitário Onofre Lopes, da Universidade Federal do Rio Grande do Norte, sob no 464/10. Todos os participantes assinaram o Termo de Consentimento Livre e Esclarecido.

Initially, the final translated version of the NDPCS was applied with 35 volunteers aged between 62 and 92 years old (74.77±7.08),who had no dementia or complaints of swallowing disorder.After some adjustments, the instrument was applied with other 27 volunteers aged between 60 and 87 years old (76.56±7.07)with the same profile.Results: There was divergence in semantic equivalence in relation to one item, which was modified in the translated version.
The tasks requested for observation during deglutition were adapted in relation to the solid food and the volumes used in pudding and liquid consistencies.The instrument maintained the same structure as the original version, with five categories and into 28 items, three brief variables, and four closures.Conclusion: The equivalence between the original and the translated version of the NDPCS was preserved after its translation and adaptation to Brazilian Portuguese.The validation process of the psychometric properties of the instrument is in progress.

INTRODUCTION
The translation and cross-cultural adaptation of international instruments have become a common practice in Brazilian Speech Language Pathology and Audiology, given the clinical and scientific importance of this process for the proper application of the proposed procedures with the population (1) .However, there are no publications in Brazil concerning the validation of risk of dysphagia screening protocols.
Screening means to use instruments for the early identification of characteristics suggestive of risk for a probable disease, condition, or impairment in any individual, regardless of his or her health status, followed by the referral to diagnostic confirmation and treatment (2)(3)(4) .It is recommended that screening protocols be easy and fast to apply, with reduced risk, low cost, being able to produce sensitive results, that is, with few false negatives (5) .
Concerning oropharyngeal dysphagia, the main purpose of screening protocols is to recognize the cases that require specific evaluation and to favor a more efficient clinical practice, which can lead to improved health status (6) .Most existing protocols are heterogeneous regarding the method and addressed to bedridden patients or those with neurological conditions, which prevents the definition of a gold standard for screening (7) .
The Northwestern Dysphagia Patient Check Sheet (NDPCS), developed by Logemann, Veis, and Colangelo (8) , meets the criteria pointed out as being essential for a screening protocol due to its easy applicability, low cost, and speed, since it approaches punctual matters concerning what it intends to investigate and presents values for accuracy, sensitivity, and specificity from its comparison with the videofluoroscopy swallowing exam, which is considered as a gold standard exam for dysphagia (8) .
Even though it can be used as a screening instrument, the NDPCS requires a brief functional swallowing evaluation by offering food of different consistencies and volumes besides the solid texture.Since it involves this kind of evaluation, the speech language pathologist should be in charge of its application, because this professional is skilled to assess, classify, and conduct the functional diagnosis of swallowing and the eating process by means of a speech language therapy clinical evaluation (9) .
The NDPCS comprises 28 items, divided into five categories: medical history, behavioral variables, gross motor function, oral motor test, and observations during trial swallows.The final result is defined by the combination of some items and can have up to four closures: presence of aspiration, difficulties in the oral phase, delay of the pharyngeal phase, or presence of changes in the pharyngeal phase.
The objective of this study was to perform the translation and cross-cultural adaptation of the NDPCS to Brazilian Portuguese (BP).This is considered as the first step of the process to validate the instrument, whose applicability will be later confirmed, after the conclusion of psychometric validation stages (10) .

METHODS
To start the validation process of NDPCS, the main author of the original study was previously consulted and authorized the conduction of the work.The criteria for translation and cross-cultural adaptation followed four steps, proposed by Peters and Passchier (11) .
In the first step, two bilingual speech language pathologists, with knowledge of Portuguese and English, who were aware of the objective of the study, translated the protocol to BP, considering conceptual equivalence.The instrument produced at this step was a result of the consensual analysis of both translations.
In the second step, a back-translation of the protocol was performed by a native English speaker who did not see the original version nor participated in the previous stage.It is recommended that this stage be performed by a person whose mother tongue is the same as the authors' of the original protocol in order to preserve the coherence of the content and to reveal possible flaws in the adaptation for the context of the target culture, as well as ambiguities in the original version.
In the third step, a committee formed by three bilingual speech language pathologists, with knowledge of Portuguese and English, and experienced in dysphagia and orofacial motricity, was gathered to compare the original protocol, the translated, and the back-translated versions.The role of this committee was to check the equivalence regarding semantic, idiomatic, experimental, and conceptual features.The appropriate changes were performed with the consensus of the members of the committee, which led to the final version (Appendix 1).
In the fourth step, the clarity of the instrument for the population was assessed.It was applied with 35 volunteers aged 60 years or older, of both genders, without clinical diagnosis of dementia or complaints of dysphagia, selected in a public outpatient geriatric clinic.The items which were not understood by the population or considered as inappropriate to be applied by the evaluator were revised again by the same committee mentioned in the third step.By consensus, the committee analyzed and verified that the item should be reformulated.After this analysis, a second version of the instrument was created and applied with 27 volunteers who had not participated in the previous step, but had the same profile.
This research was approved by the Research Ethics Committee of the University Hospital Onofre Lopes, at Universidade Federal do Rio Grande do Norte, n. 464/10.All participants signed the informed consent.

RESULTS
The final version of the cross-cultural adaptation of the NDPCS (Appendix 1) maintained the 28 questions of the original version divided into five categories, as well as three brief variables and four possible closures.
Results concerning the changes and adaptations of the protocol are described in Chart 1.
In the stage that consisted of the comparison between the original protocol, the translated, and the back-translated Translation and adaptation of the NDPCS CoDAS 2013;25(4):369-74 versions, there was a divergence in semantic equivalence in relation to the original protocol in only one item.
In the first stage of application of the protocol with the target-population, the need to change the requested tasks in the domain "observations during trial swallows" was identified, so there were some adjustments in experimental equivalence.The need to adapt the food used to assess the swallowing of solid items was verified, since the proposal of the original (Lorna Doone cookie) was not part of the eating habits and culture of the Brazilian target-population.The choice was for half a "wafer" cookie, which was defined by the authors to be as close as possible to the original version.
In this same stage, the need to increase the offered volumes to 5 mL in pudding consistency was also observed, as well as to assess the swallowing of liquids in volumes of 3, 5, and 10 mL, without changing the objective of the instrument.

DISCUSSION
Literature is still heterogeneous as to screening proposals for oropharyngeal dysphagia (5) , especially in relation to the used procedures and to accuracy, sensitivity, and specificity patterns (8,12) .The American Speech-Language-Hearing Association (12) points out that dysphagia screening refers to a minimally invasive procedure, which can quickly provide information concerning how likely it is for the assessed individual to have oropharyngeal dysphagia, if there is indication of diagnostic evaluations, if it is safe or not to indicate an oral diet, and the need for nutrition and hydration support.The NDPCS protocol fulfills such requirements, so it was chosen to be submitted to the validation process.In this stage of translation and crosscultural adaptation, some adjustments to the Brazilian reality were necessary.
In the items that characterize the observation during trial swallows, the original version asks the participant to swallow the food in the following sequence of volumes and consistency: 1 mL of thin liquid, 1 mL of pudding, and one quarter of a Lorna Doone cookie, if the person can chew it.
In the translated version, volumes and consistencies were changed to 5 mL of pudding; 3, 5, and 10 mL of thin liquid and, finally, half a wafer cookie.This alteration respected the sequence of consistencies proposed by Clavé et al. (13) , when they stated that liquids should not be one of the first offered items, even for healthy people, since it is considered as the least safe consistency for deglutition.
The need to increase the volume of pudding consistency from 1 to 5 mL corroborates the statement that volumes close to the amount ingested naturally favor the perception of the swallowing dynamics concerning what usually happens during daily meals (14) .
In relation to solid food, it was necessary to adapt it to the cultural and economic reality of the Brazilian population.According to the Australian proposal (14) , which standardizes the terminology of food consistency and texture, the wafer cookie as well as the Lorna Doone cookie is classified as a soft solid.Items that are also in this category are those which have their texture altered after being cut, require minimum effort for incision, are chewable, and able to being humidified after blending (15) .
Besides, the wafer has a crunchy property (16) .This is an attribute of the solid texture, and is related to characteristics that are perceptible to human senses, such as hardness, ability to break, sound after being broken, and pressure during the first bite (16,17) .
All of this happens during the chewing cycle, when the information concerning changes in food texture are sent to the brain via oral, hearing, and memory sensors, so an image of its texture properties can be built (18) .During mastication, it is also possible to identify chewability, adhesivity, and viscosity of the food, considering humidity, greasiness, evaluation of size, and geometry of individual portions (16) .
Another important detail is that the texture of the wafer is favorable to being broken in small portions by the gums, which makes maceration easy when the assessed individual is edentulous and has no prosthesis.Maceration is defined as the process of crushing the food to prepare the bolus by using the tongue against the hard palate and the increased movement of adjacent structures (19) .
Concerning liquid, the amount of the first volume increased from 1 to 3 mL, and two other portions of 5mL and 10 mL were added in order to better analyze the organization of this consistency in the oral phase and to enable the better visualization of the laryngeal elevation at the clinical-functional evaluation.
This change was based on references of volumes used in other protocols that assess functional swallowing.Tohara et al. (20) discovered that 3 mL of liquid has 90% of sensitivity and 56% of specificity to indicate aspiration.Other studies (13,21) used the volumes of 5, 10, and 20 mL, while Yoshikawa et al. (22) considered the volume of 10 mL as the limit for deglutition to safely occur in a fragmented way within normality parameters.Therefore, this was the maximum limit established for the experimental equivalence of this instrument.Besides, Shaker et al. (23) referred that in elderly people with preserved laryngeal closure reflex, it is necessary to introduce more liquid in the pharyngeal region to stimulate this response when comparing them to younger individuals.So, the phenomenon was also taken into account to adjust the volumes of liquid consistency in the application of the instrument.
In the stage of translation and cross-cultural adaptation of the instrument, despite the divergence in relation to semantic and experimental equivalences, the content and objective of the original version were preserved.The translation and cross-cultural adaptation of a protocol is the first step in the validation process, because from that stage on the instrument can be addressed to the target-population of the language in question (24) .The translation and adaptation of foreign protocols by Brazilian speech language pathologists aims to minimize the lack of available validated instruments in the country, besides collaborating with the performance of cross-cultural studies (1) .
In relation to NDPCS, the authors of the original version reinforce that the protocol is used to detect the risk of presenting specific characteristics of dysphagia, but it does not determine the etiology of the problem nor should it be used as a single instrument to define conducts or therapeutic interventions.Once the presence of alterations is identified, the patient should be referred to specific diagnostic evaluation (8) .

CONCLUSION
The translation and cross-cultural adaptation of the NDPCS to BP were performed with experimental and semantic adaptations.The process to validate psychometric properties is in progress.
*HVMJ and LAP were in charge of the project and study design, as well as the project to translate the instrument, data collection, tabulation and analysis, and the elaboration of the manuscript; LBRS collaborated with the process of translating the instrument; MAFF and KCL oriented the study design and collaborated in the revision of the manuscript.

Chart 1 .
Modifications of the instrument during the process of translation and cross-