SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
The
Brazilian
version
of
the
Constant–Murley
Score
(CMS-BR):
convergent
and
construct
validity,
internal
consistency,
and
unidimensionality
夽
Rodrigo
Py
Gonc¸alves
Barreto
a,∗,
Marcus
Levi
Lopes
Barbosa
b,
Marcos
Alencar
Abaide
Balbinotti
c,
Fernando
Carlos
Mothes
d,
Luís
Henrique
Telles
da
Rosa
a,
Marcelo
Faria
Silva
aaPost-graduationPrograminRehabilitationSciences,UniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UFCSPA),PortoAlegre,
RS,Brazil
bUniversidadeFEEVALE,NovoHamburgo,RS,Brazil cQuebecUniversityatTrois-Rivières,Trois-Rivières,Canada
dGroupofShoulderSurgery,IrmandadeSantaCasadeMisericórdiadePortoAlegre(ISCMPA),PortoAlegre,RS,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received26September2015
Accepted10November2015
Availableonline26May2016
Keywords:
Clinimetrics Assessment
Factoranalysis
Validity Shoulder
a
b
s
t
r
a
c
t
Objectives:TotranslateandculturallyadapttheCMSandassessthevalidityoftheBrazilian
version(CMS-BR).
Methods:Thetranslationwascarriedoutaccordingtotheback-translationmethodbyfour
independenttranslators.Theproducedversionsweresynthesizedthroughextensive
anal-ysisandbyconsensusofanexpertcommittee,reachingafinalversionusedforthecultural
adaptation.Afieldtestwasconductedwith30subjectsinordertoobtainsemantic
con-siderations.Forthepsychometricanalyzes,thesamplewasincreasedto110participants
whoansweredtwoinstruments:CMS-BRandtheDisabilitiesoftheArm, shoulderand
Hand(DASH).TheCMS-BRandDASHscorerangefrom0to100points.Forthefirst,higher
pointsreflectbetterfunctionandforthelatter,theinverseistrue.Thevaliditywasverified
byPearson’scorrelationtest,theunidimensionalitybyfactorialanalysis,andtheinternal
consistencybyCronbach’salpha.
Results:Theexplainedvariancewas60.28%withfactorloadingsrangingfrom0.60to0.91.
TheCMS-BRexhibitedstrongnegativecorrelationwiththeDASHscore(−0.82,p<0.05),
Cronbach’salpha0.85,anditstotalscorewasstronglycorrelatedwiththepatient’srangeof
motion(0.93,p<0.001).
Conclusion:TheCMSwassatisfactorilyadaptedforBrazilianPortugueseanddemonstrated
evidenceofvaliditythatallowsitsuseinthispopulation.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
夽
ThisstudywasperformedatUniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UFSCPA),PortoAlegre,RS,Brazil.
∗Correspondingauthor.
E-mail:rodrigopyy@gmail.com(R.P.G.Barreto).
http://dx.doi.org/10.1016/j.rbo.2015.11.004
0102-3616/©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle
undertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
2255-4971
http://dx.doi.org/10.1016/j.rboe.2016.08.017
Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Pós-Graduação em Ciências da Reabilitação, Porto Alegre, RS, Brazil
Versão
brasileira
do
Constant-Murley
Score
(CMS-BR):
validade
convergente
e
de
constructo,
consistência
interna
e
unidimensionalidade
Palavras-chave:
Clinimetria Avaliac¸ão
Análisefatorial
Validade Ombro
r
e
s
u
m
o
Objetivos: TraduzireadaptarculturalmenteoConstant-MurleyScore(CMS)everificara
validadedaversãobrasileira(CMS-BR).
Métodos:Atraduc¸ãofoifeitadeacordocomométododeretrotraduc¸ãoporquatrotradutores
independentes.Asversõesproduzidasforamsintetizadasporanáliseextensivaeconsenso
deumcomitêdeespecialistasegeraramumaversãofinalusadaparaaadaptac¸ãocultural.
Fez-seumtesteemcampocom30sujeitosparaobservac¸ãodepossíveisconsiderac¸ões
emrelac¸ãoàsemântica.Paraaposterioranálisepsicométrica,ampliou-seaamostrapara
110participantesqueresponderamadoisinstrumentos:CMS-BReDisabilitiesoftheArm,
ShoulderandHand(DASH).OCMS-BReoDASHvariamde0a100pontos.Paraoprimeiro,
altaspontuac¸õesrefletemmelhorfunc¸ão,paraosegundo,ocontrário.Avalidadefoi
verifi-cadacomotestedecorrelac¸ãodePearson,aunidimensionalidadecomaanálisefatoriale
aconsistênciainternacomoAlfadeCronbach.
Resultados: A variânciaexplicadafoi de 60,28%com cargasfatoriais entre0,60 e0,91.
OCMS-BRdemonstroucorrelac¸ãoforteenegativacomoDASH(-0,82,p<0,05),comoalfa
deCronbachde0,85eseuescoretotaltevecorrelac¸ãofortecomaamplitudedemovimento
dospacientes(0,93,p<0,001).
Conclusão:OCMS-BRfoiadaptadodeformasatisfatóriaedemonstrouevidênciasdevalidade
quepermitemseuusonessapopulac¸ão.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Shoulder pain accounts for an expressive prevalence in
consultations with a general practitioner or orthopedic
surgeons.1,2Thesepatientsoftenpresentvariouscomplaints,
likemobilitydeficits andpain,3 whichdirectlyaffectupper
limbfunction.Inordertoperformanascomprehensive
clin-icalassessmentaspossibleisrecommendedthatpatientbe
assessedwithinstrumentsthatallowinferencesabout
func-tion.Thefunctionisaconstruct,alatentvariablethatcannot
bedirectlyobserved.Therefore,theutilizationoffunctional
scoresistheadequateoptiontomeasureit.4,5
Thereareabout34scoresforshoulderfunctionassessment
but the Constant–Murley score (CMS), originally published
in the English language, is one of the most used.4,6,7 The
CMS is a non-specific score that covers different domains
ofshoulderfunction(pain,activitiesofdailyliving,rangeof
motionand power)being higherscoresindicativeofbetter
function.6–8Thisinstrumentisacompoundscorecontaining
foursubscales:threeself-reportedsubscalesandone
shoul-der elevation strength subscale which is performed by an
externalassessor.8Thenomenclatureofthe“power”subscale
containedintheoriginalversionoftheCMSwasposteriorly
changedto“strength”,aswellasthetestpositionwaschanged
toelevationinscapularplane.9
Theappropriateuseofaninstrumentofevaluationimplies
the correct verification of its validity.10,11 The evidence of
validity characterize the relationship among items of the
scoreandbetweenitemsandtotalscore.Italsoindicatesthe
extentinwhichtheinstrumentexplainstheconstructunder
assessment.Thisprocessensuresanadequaterepresentation
oftheconstructmeasuredbythefunctionalscore.12,13
Psychometric properties of the original version of the
CMS such as reliability, floor and ceiling effects,
conver-gent and criterion validity have been verified. Despite the
comprehensiveinvestigationofthevalidityofthescore,its
dimensionalstructurewasinvestigatedbeforetheadaptation
ofthestrengthsubscaleandthefactoranalysisevincedthat
thescorewasnotunidimensional.14 Theseaforementioned
featurescouldaffecttheinterpretationofmeasurementofthe
construct.5,12,15
Theuseofaninstrumentofevaluationinanotherculture
orlanguagemustbeprecededbyanappropriateprocessof
translationandculturaladaptation.Furthermore,evidenceof
validitymustbeproperlyverifiedintheadaptedversion.
Cur-rently,atranslatedand adaptedversionofCMSisavailable
onlyfortheDanish16,17language.ThereisnoversionofCMS
intheBrazilianPortugueselanguage.Therefore,theaimofthis
studywastranslate,culturallyadaptandverifytheconvergent
andconstructvalidity,internalconsistencyanddimensional
structureoftheadaptedversion.
Methods
Theprocessoftranslationwasperformedaccordingthe
back-translationmethod10,11 andfollowingtheCOSMINchecklist
forensure the methodological qualityof the psychometric
analysis.18
TherecommendationspublishedbyConstantetal.9were
dynamometer.Inthisstudyanisometricdynamometermodel
MicroFET2TM (HogganHealthIndustries,USA)witha
sensi-tivityof0.05kg(0.1lb),measuringupto136.05kg(300lb)was
utilizedinthestrengthsubscale.
Translationandculturaladaption
The process oftranslation occurred in four steps:
transla-tion, back translation, analysis of preliminary version and
fieldtest.Initially,twoexpertandindependentBrazilian
Por-tuguesenativelanguagetranslatorsprovidedtwotranslated
versionsoftheoriginalCMS.Theseversionswereunifiedfor
aconsensusbetweenauthorsandtranslators.
Afterward, the unified translated version was
back-translated by two expert and independent English native
languagetranslators.Both translatorshadnoaccesstothe
originalCMS.Theseversionswereunifiedbyconsensusofthe
authorsgroup.Thenextstepinvolvedthe establishmentof
afullyculturallyadaptedversiontakingaccountallexistent
versionsobtainedfrom thepreviousstepsthrougha
multi-disciplinaryexpertscommitteemeeting.Finally, inorderto
collectsemanticconsiderations,theBrazilianLanguage
ver-sionofCMS(CMS-BR)wasappliedinasampleof30subjects
withsimilarcharacteristicsofthemainstudy.
Participants
Theparticipantswereselectedfromprivatepracticeclinicsof
PortoAlegreandNovoHamburgo,Brazil.Thisstudyreceived
approvalfromtheResearchEthicsCommitteeofthe
propo-nentinstitution (studynumber 992-12)and all participants
signedwritteninformedconsentpriortotheenrollment.
Ahundredandtenpatients(55male)olderthan18years
old, with any diagnoses of clinical shoulder dysfunction
(exceptinstability)andabletoreadandanswertothe
ques-tionnairewereincluded.Patientswithcognitiveimpairments,
peripheralorcentralnervedamageordiagnoseofnerve
dys-functionwere excluded ofthestudy. Themean ageofthe
includedindividualswas48.50(15.13)andrangedbetween18
and83years.
Statisticalanalysis
Adescriptiveanalysisofallvariableswasperformed.
Categor-icaldatawereexpressedasabsoluteorrelativefrequencies
andquantitativevariablesasmeansandstandarddeviations.
Clinimetricanalysis
Evidence of validity was analyzed through the following
statements5,12,18,19:
Forinternalconsistency,Cronbach’salphatestconsidered
thevalue>0.80asideal.20,21Theconvergentvaliditywas
ver-ifiedthroughPearson’scorrelationbetweenthetotalscores
oftheCMS-BRandtheBrazilianversionoftheDisabilitiesof
thearm,shoulderandhandscore(DASH)22adoptingar≥0.70
andap≤0.05tosatisfythiscondition.12,18Theconstruct
valid-itywasverifiedbythePearsoncorrelationtestbetweenthe
rangeofmotionofall subjectsandtheCMS-BRfinal score.
Thehypothesiswasthatthepoorfunctionalstatuswouldbe
associatedwithalessactiverangeofmotionintheassessed
shoulder.5
Since the CMS-BR presupposes the assessment ofonly
oneconstruct(shoulderfunction)and onefactorextraction
wasindicatedasthebettersolutionthroughscreeplotand
the total explainedvariance (eigenvalue), a factor analysis
with an exploratory principal component analysis with a
one-factorsolutionwasperformedtoverifythedimensional
structure.Finally,thisanalysisconsideredsomeassumptions
andrelatedtestsprevioustoitsrealization15,19:
• TheKaiser–Meyer–Olkin(KMO)coefficientmustbe>0.70;
• Thedeterminantofthecorrelationmatrixmustnotbezero,
butavalueclosesttozero;
• Barlett’ssphericitytestmusthaveap≤0.05;
• Thecommunalityvaluemustbe≥0.4.23,24
Results
The list of conditions of all included individuals can be
observedinTable1.TheCMS-BRwasobtainedthrough
ade-quatetranslationprocessfollowingrecommendationsofthe
literature.Onlyonemodificationwasmadeintheactivitiesof
dailylivingsubscaletoimprovetheunderstandingofthe
CMS-BR.Specifically,inthelastquestionaboutwhichisthearm
elevationlevelwithoutpain,theexpression“uptoxiphoid”
was replacedby“uptoheart level” (“aoníveldocorac¸ão”in
BrazilianPortuguese)ascanbeobservedinAppendix1.
Regardinginternalconsistency,amoderatetostrong
cor-relation was observed in each item-total correlation. The
mean CMS-BR score was 49.69 (28.12) and the Cronbach’s
alphawas0.85.Thealphadidnotsignificantlyincreasewith
thehypotheticalexclusionofanyitem,confirmingthescore
arrangementofitems.Moreover,therewasnofloorand
ceil-ingeffects,whenmorethan15%oftherespondentsachieves
thehighestorlowestpossiblescores(Table2).
TheCMS-BRandBrazilianDASHpresentedasignificantly
strongnegativecorrelation(r=−0.82,p≤0.001).Thedirection
Table1–Listofconditions.
Conditions Absolute
frequency
Relative frequency
OAAC 4 3.64%
OAGH 1 0.91%
Adhesivecapsulitis 15 13.64%
SIS 26 23.64%
Proximalfractureofhumerus 9 8.18%
ACD 2 1.82%
RCT 22 20.00%
BursectomyplusAcromioplasty 2 1.82%
Rotatorcuffrepair 16 14.55%
Calcifictendinitis 3 2.73%
Suprascapularnerverelease 1 0.91%
Healthy 9 8.18%
Total 110 100%
Table2–Item-totalstatistics.
Item Min Max Mean(SD) Item-total
correlation
Alphaifitem deleted
Pain 0 15 8.46(4.37) 0.49 0.84
Sleep 0 2 0.88(0.73) 0.63 0.85
Work 0 4 2.56(1.42) 0.57 0.85
Leisure 0 4 2.26(1.45) 0.61 0.84
Levelofelevation 2 10 5.98(2.84) 0.80 0.82
Flexion 0 10 5.24(3.50) 0.83 0.81
Abduction 0 10 4.91(3.36) 0.86 0.81
Externalrotation 0 10 5.53(3.81) 0.74 0.82
Internalrotation 0 10 5.55(3.61) 0.69 0.82
Strength 0 35 8.32(10.04) 0.75 0.88
SD,standarddeviation.RecommendedCronbach’sAlpha:≥0.80.
ofthisassociationisdueDASHscoringsystemwhichhigher score isindicative ofpoor shoulderfunction conversely to CMS-BR.Moreover,theCMS-BRand therangeofmotionof theparticipantswerestronglyrelated(r=0.93,p≤0.001), con-firmingtheapriorihypothesisthatpoorfunctionalstatusis relatedtolessactiverangeofmotion.
ThedimensionalstructureoftheCMS-BRwastestedby fac-toranalysiswithanexploratoryprincipalcomponentanalysis withone-factorsolution. All assumptionsforthetest real-izationwerefulfilled. Theexplainedvariancebyone-factor extractionwas60.28%.Thecommunalitiesrangedfrom0.36 (pain)to0.83(Table3).
Discussion
This was the first study to translate and culturally adapt
the CMS to Brazilian Portuguese. The preliminary
ver-sion of CMS-BR was extensively analyzed by physicians,
orthopedic-traumaresidents,physicaltherapists,anurseand
a statistician, comprising nine professionals with different
backgroundsandwasappliedin30patients.Moreover,
impor-tant evidences ofvaliditywere testedin the CMS-BR such
asinternalconsistency,convergentvalidityanddimensional
structure.
Theanalysisshowed thatthe CMS-BR presentedahigh
internalconsistency(Cronbach’salpha=0.85).Thealphadid
Table3–Communalitiesandfactorialloadsofitems.
Item Communalities Factorial
load
Abduction 0.83 0.91
Flexion 0.80 0.89
Levelofelevation 0.74 0.86
Strength 0.65 0.80
Externalrotation 0.65 0.80
Internalrotation 0.57 0.75
Leisure 0.49 0.70
Sleep 0.47 0.68
Work 0.44 0.66
Pain 0.36 0.60
Recommendedvalueforcommunality:≥0.40.
notincreasewiththehypotheticalexclusionofanyitem con-firming the layout of the adapted score. Interestingly, the internalconsistencyoftheoriginalCMSrangedfrom0.60to 0.75.25,26 Asystematicreviewsuggestedthat thelowalpha
valuesmay indicatethat the CMS itemsmeasuredifferent
aspectsofshoulderfunction.27Todate,thereisnoobjective
datatoexplainthemarkedobserveddifferencesinthealpha
valuesbetweentheCMSandCMS-BR.However,the
modifica-tionsproposedin20089mightplayaroleonit.Furthermore,
amoderatetostrongcorrelationwasobservedineach
item-totalcorrelation(Table2).
Regardingconvergentvalidity,theCMS-BRdemonstrateda
strongnegativecorrelation(r=−0.82,p≤0.001)withthe
Brazil-ianversionoftheDASHscore,althoughtheCMSpresenteda
lowtomoderateassociationwithDASH.27Theconstruct
valid-itywasconfirmedthroughthesignificantlystrongcorrelation
(r=0.93,p≤0.001)betweenCMS-BRscoreandrangeofmotion.
Thehypothesisraisedbytheauthorsseemstotally
appropri-atedsincetherangeofmotionisanimportantcharacteristic
fortheshoulderjointandfrequentlyimpairedinthe
major-ityofshoulderdysfunctions.TheDanishversionoftheCMS
alsodemonstratedastrongcorrelationwiththeOxford
Shoul-derScore(r=0.76).Inspiteofthesimilarvaluesfoundinboth
adaptedversions,ourreferencestandardscorewasthe
Brazil-ianDASH–awidelyusedinmyriadofshoulderconditions
–whiletheOxfordShoulderScoreismoresuitedtoassess
surgicalpopulationsandproximalhumerusfractures.6,28
The factor analysis of the CMS-BR evinced that the
amount of variance explained by one-factor solution was
60.28%,ensuringthattheCMS-BRmettheone-dimensionality
criterion.15IntheoriginalCMS,thefactoranalysiswitha
two-factorsolutionwasperformedbyonlyonestudy.14However,
theauthors didnotreportneitherthefactor loads northe
adoptedcriterion toanalysis.According toourimpression,
possiblythe lackofstandardization, mainlyin thepain or
strengthsubscales,could justifythese discrepanciesinthe
dimensionalstructure.Astandardizedprocessof
implemen-tationwasadoptedfortherealizationofourstudyfurtherthe
recommendationsaforementioned.
Otherpsychometricpropertieswerepublishedaboutthe
original CMS. Floor and ceiling effects were analyzed and
thestrengthsubscalereportedaconsiderableflooreffect.29
Manypatients were unabletohold the properposition for
wasobservedinanother studythat assessedpatients with
adhesivecapsulitis.30Althoughthestrengthsubscaleaccount
for25% oftotal score, this not seemed to interfere inthe
reliabilityforpainandstrengthsubscales.25,31 Recently,the
minimallyimportantchangewasverifiedtopatientswith
sub-acromialpain.32
Eventhatinthepresentstudy somepropertieshavenot
been analyzed, the CMS-BR have satisfactory tested four
importantattributesofvalidityandfigureamongtheBrazilian
adaptedscoreswithmorepsychometricsverifications.Puga
etal.33performedasystematicreviewwhichanalyzed
psycho-metricpropertiesofallpublishedscoresadaptedtoBrazilian
Portugueseuntil2011.Ofconcernisthefactthatallincluded
studiesinthisreviewdidnotanalyzemorethanoneattribute
ofvalidity,whichhampersclinicalandresearchusefulnessof
theseinstruments.
Conversely,the psychometricpropertiesofthe Brazilian
versionofthePennShoulderScorewererecentlyverified.34
Theauthors reportedacomprehensiveanalysisofthe
psy-chometric properties of this instrument, such as internal
consistency,measurementerror,constructvalidityandfloor
and ceiling effects. Furthermore, Moser et al.35 analyzed
internal consistency, convergent validity and reliability of
the Brazilianversion of the American Shoulderand Elbow
Surgeons(ASES)score.Adequateresultsthatsupportthe
uti-lizationofbothscoreswereobserved.
Netoetal.36performedthetranslationandcultural
adap-tationoftheSimpleShoulderTest forBrazilianPortuguese
(SST-BR). However, some methodological issues must be
considered.In the preliminaryversion analysis, the expert
committeewascomposed foronephysicianand six
trans-lators.Actually,current recommendations suggest thatthe
expertcommitteemustbecomposedbydifferent
profession-als,inorder toprovideanascompleteaspossibleadapted
version tothe target population.10,11 Theauthors also
per-formedthedimensionalstructureverificationoftheSST-BR.
However,anexploratoryandasubsequentconfirmatory
fac-toranalysiswereperformedwithathree-factorsolutionin
oppositiontotheoriginalmeasurementconceptofthescore.
Ourstudy exhibitssomelimitations. Theverification of
reproducibility (agreement and reliability), responsiveness,
minimumdetectablechangeandminimallyimportantchange
werenotperformed.Nonetheless,firstlyisimportantensure
thatthescorereallymeasuresthetargetconstruct(function),
andaftertoanalyzemorevalidityproperties.
Conclusion
Fromtheresultsaforementioneditwasevincedthatthe
CMS-BRwassatisfactoryadaptedtoBrazilianPortugueseculture.
Moreover,theCMS-BRhasadequateconvergentandconstruct
validity,internalconsistencyandadequatedimensional
struc-ture that supportits utilization in clinical practice forthe
evaluationofpatientswithshoulderdysfunctions.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgments
WewouldliketothankPTGiovanniFerreiraandMSc.Caroline
RobinsonfortheEnglishlanguagereview.WealsothankPT
CarlosVicentedaSilvafortheartisticadjustmentsinthe
pre-liminaryversionofthescore.Wewouldliketosincerelythank
MD Fábio Matsumotobythe helpinincluding hispatients
from theprivateclinic.Finally, wearegratefultoDr.Roger
Emerybyhissupportduringalltranslationprocess.
Appendix
A.
Supplementary
data
Supplementary materialassociatedwiththis articlecanbe
foundintheonlineversionavailableatdoi:doi:10.1016/j.rbo.
2015.11.004.
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