w w w . r b o . o r g . b r
Original
Article
Translation
and
cultural
adaptation
of
the
Hip
Outcome
Score
to
the
Portuguese
language
夽
,
夽夽
Liszt
Palmeira
de
Oliveira
a,∗,
Themis
Moura
Cardinot
b,
Letícia
Nunes
Carreras
Del
Castillo
a,
Marcelo
Cavalheiro
Queiroz
c,
Giancarlo
Cavalli
Polesello
caFaculdadedeCiênciasMédicasdaUniversidadedoEstadodoRiodeJaneiro,RiodeJaneiro,RJ,Brazil bUniversidadeFederalRuraldoRiodeJaneiro,Seropédica,RJ,Brazil
cFaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
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o
Articlehistory:
Received6April2013 Accepted13May2013 Availableonline27March2014
Keywords:
Hip Translation Questionnaires Evaluationofresults
a
b
s
t
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c
t
Objective:totranslatetheHipOutcomeScoreclinicalevaluationquestionnaire into Por-tugueseandculturallyadaptitforBrazil.
Methods:theHipOutcomeScorequestionnairewastranslatedintoPortuguesefollowingthe methodologyconsistingofthestepsoftranslation,back-translation,pretestingandfinal translation.
Results:thepretestingwasappliedto30patientswithhippainwithoutarthrosis.Inthe domainrelatingtoactivitiesofdailyliving,therewerenodifficultiesincomprehendingthe translatedquestionnaire.Inpresentingthefinaltranslationofthequestionnaire,allthe questionswereunderstoodbymorethan85%oftheindividuals.
Conclusion: theHipOutcomeScorequestionnairewastranslatedandadaptedtothe Por-tugueselanguageandcanbeusedinclinicalevaluationonthehip.Additionalstudiesare underwaywiththeobjectiveofevaluatingthereproducibilityandvalidityoftheBrazilian translation.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Traduc¸ão
e
adaptac¸ão
cultural
do
Hip
Outcome
Score
para
a
língua
portuguesa
Palavras-chave:
Quadril Traduc¸ão Questionários
Avaliac¸ãoderesultados
r
e
s
u
m
o
Objetivo:traduzirparaoportuguêseadaptarculturalmenteparaoBrasiloquestionáriode avaliac¸ãoclínicaHipOutcomeScore(HOS).
Métodos:oquestionárioHOSfoitraduzidoparaoportuguêscommetodologiaconstituída pelasetapasdetraduc¸ão,retrotraduc¸ão,pré-testeetraduc¸ãofinal.
夽
Pleasecitethisarticleas:deOliveiraLP,MouraCardinotT,NunesCarrerasDelCastilloL,CavalheiroQueirozM,CavalliPoleselloG. Traduc¸ãoeadaptac¸ãoculturaldoHipOutcomeScoreparaalínguaportuguesa.RevBrasOrtop.2014;49:297–304.
夽夽
WorkperformedintheDepartmentofSurgicalSpecialties,SchoolofMedicalSciences,UniversidadedoEstadodoRiodeJaneiro,Rio deJaneiro,RJ,Brazil.
∗ Correspondingauthor.
E-mail:lisztpalmeira@yahoo.com.br(L.P.deOliveira).
Resultados: opré-teste foiaplicadoa 30pacientescomdornoquadrilsemartrose.No domínio relacionadoa atividadesdevida diária,nãohouvedificuldadesde compreen-sãodoquestionáriotraduzido.Naapresentac¸ãodatraduc¸ãofinaldoquestionário,todas asquestõesforamcompreendidaspormaisde85%dospacientes.
Conclusão: oquestionárioHOPfoitraduzidoeadaptadoculturalmenteparaalíngua por-tuguesa epodeserusadonaavaliac¸ão clínicadoquadril.Estudosadicionaisestão em andamentocomoobjetivodeavaliarareprodutibilidadeevalidadedatraduc¸ãobrasileira. ©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Quality-of-lifeevaluationsare increasingly usedwithinthe field of healthcare, especially since it was proven that
Table1–Pretestappliedto30patients.
Questionsonactivitiesofdailyliving Nodifficulty atall
Slight difficulty
Moderate difficulty
Extreme difficulty
Unableto do
Not applicable
Not answered
Total
Standingfor15min 10 11 6 2 1 0 0 30
Gettingintoandoutofacar 4 12 7 7 0 0 0 30
Puttingonsocksandshoes 9 9 6 6 0 0 0 30
Goingupsteepslopes 6 12 3 8 0 1 0 30
Goingdownsteepslopes 9 9 11 1 0 0 0 30
Goingupaflightofstairs 9 10 1 10 0 0 0 30
Goingdownaflightofstairs 12 8 9 1 0 0 0 30
Steppingontoandoffcurbs 17 3 8 0 0 2 0 30
“Exaggerated”squatting 0 7 11 9 3 0 0 30
Gettingintoandoutofabathtub 11 5 1 4 0 9 0 30
Sittingfor15min 18 6 3 2 0 1 0 30
Startingtowalk 16 7 5 2 0 0 0 30
Walkingforapproximately10min 18 6 4 2 0 0 0 30
Walkingfor15minormore 6 14 7 3 0 0 0 30
Twisting/turningoftheaffectedleg 1 9 12 8 0 0 0 30
Turningoverinbed 6 10 11 3 0 0 0 30
Lighttomoderatework(standingand walking)
14 9 6 1 0 0 0 30
Heavywork(pushing/pulling,climbing, carrying)
3 3 15 5 1 3 0 30
Recreationalactivities 6 6 12 4 0 2 0 30
175 156 138 78 5 18 0 570
30.7% 27.4% 24.2% 13.7% 0.9% 3.2% 0.0% 100.0%
Questionsonsports Nodifficulty
atall
Slight difficulty
Moderate difficulty
Extreme difficulty
Unableto do
Not applicable
Not answered
Total
Running1.5km 2 7 8 3 9 1 0 30
Jumping 2 12 5 6 3 2 0 30
Swingingobjects,likeagolfclub 7 6 6 6 0 5 0 30
Landingonthegroundafterajump 3 9 4 3 5 6 0 30
Startingandstoppingrapidly 6 11 5 3 4 1 0 30
Abruptchangeofdirection/lateral movement
0 12 9 8 0 1 0 30
Low-impactactivitiessuchaswalking rapidly
8 8 9 3 2 0 0 30
Capacitytodoactivitieswithyournormal technique
8 12 3 2 4 1 0 30
Capacitytoparticipateinadesiredsport foraslongasyouwouldlike
0 6 8 8 6 2 0 30
36 83 57 42 33 19 0 270
13.3% 30.7% 21.1% 15.6% 12.2% 7.0% 0.0% 100.0%
informationaboutpatients’evolutionandmakingdecisions aboutthetreatmentthatismostindicated.
TheMedical Outcomes Study ShortForm questionnaire (SF-36)isagenericquality-of-lifemeasurementthatwas vali-datedforBrazilbyCiconellietal.6Itisoftenusedasareference point for other tests. However, despite being an excellent quality-of-lifequestionnaire,itislessspecificforconditions resultingfromdiseasesofthehip.5,7
Theclinicalassessmentmethodsmostfrequentlyusedfor degenerativehipdiseasesthathavebeentranslatedintothe PortugueselanguagearetheWesternOntarioandMcMasters Universities Osteoarthritis Index (WOMAC),8 the Lequesne algofunctional index9 and the Harris Hip Score.10 These areaimedatpatientswithmoderatetosevere osteoarthro-siswho present majorphysicalcapacitylimitations.When usedinyoungand activepopulations, theyoftenpresent a
so-calledceilingeffect,i.e.alargeproportionoftheindividuals evaluated reach the maximum score,which iserroneously interpretedasasatisfactoryresult.11
Hippain inyoung and physicallyactiveindividuals has received special attention since the importance of labral lesionsasoneofthefactorsinvolvedintheoriginof degen-erativehipjointdiseasewasrecognized.12,13In2005,Martin describedtheHipOutcomeScore(HOS),14ahipassessment questionnaire that was created with the aimof analyzing theresultsfromtherapeuticinterventionsinindividualswith acetabularlabraltearsandhighfunctionaldemands.15This questionnaireisconsideredtobevalidformeasuringfunction amongindividualsundergoinghiparthroscopywhopresent acetabularlabraltears.16,17
With few exceptions, these questionnaires were devel-oped in English-speaking countries, which makes it more
Table2–HipOutcomeScore(HOS)questionnaireinEnglish.
Hip Outcome Score (HOS)
Activity of Daily Living Scale
Please answer every question with one response that most closely describes to your condition within the past week.
If the activity in question is limited by something other than your hip mark not applicable (N/A). No
difficulty difficulty at all
Slight Moderate difficulty
Extreme difficulty
Unable to do
N/A
Getting into and out of an average car
Standing for 15 minutes
Putting on socks and shoes
Walking up steep hills
Walking down steep hills
Going up 1 flight of stairs
Stepping up and down curbs
Deep squatting
Sitting for 15 minutes
Walking initially
Rolling over in bed Going down 1 flight of stairs
Getting into and out of a bath tub
Walking approximately 10 minutes
Walking 15 minutes or greater
Because of your hip how much difficulty do you have wit
h: No
difficulty difficulty at all
Slight Moderate difficulty
Extreme difficulty
Unable to do
N/A
Table2(Continued)
Light to moderate work (standing, walking) Heavy work (push/pulling, climbing, carrying)
Recreational activities
How would you rate your current level of function during your usual
activities of daily living from 0 to 100 with 100 being
your level of function prior to yo ur hip problem and 0 being the inab ility to perform any of your usual daily activities?
Hip Ou
tcome Score (HOS)
Running one mile
Jumping
Swinging objects like a golf club
Landing
Starting and stopping quickly
Cutting/lateral movements .0%
Sports Scale
Because of your hip how much difficulty do you have with: No
difficulty at all
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to do
N/A
Low impact activities like fast walking
Ability to perform activity with your normal technique Ability to participate in your desired
sport as long as you would like
How would you rate your current level of function during your sports related activities from 0 to 100 with 100 being your
level of function prior to your hip problem and 0 being the inability to perform any of your usual daily activities?
.0 %
How would you rate your current level of function?
Normal
Nearly normal
Abnormal
Severely abnormal
difficulttousethemincountrieswherethelanguageisnot English. Moreover,between countries that speak the same language,their individual and culturallydistinct character-istics give rise to the need for assessmentinstruments to undergoadaptationstomakethemappropriateforthe cul-turalcontext ofthe target population.18 Thepresent study hadtheaimoftranslatingandculturallyadaptingtheHOS
quality-of-life questionnaire tothe Portugueselanguage of Brazil.
Methods
ofRiodeJaneiro(UniversidadedoEstadodoRiodeJaneiro), underthenumberCEP/HUPE:2674.Allthepatientsweregiven information about the objectives of the study before they signedthefreeandinformedconsentstatement.
HOSisaquestionnairerelatingtohippainthatcanbe self-administered.Itcontains28itemsdividedintotwosubscales: activitiesofdailyliving(ADL)andsportsactivities.
The method used for translating and culturally adapt-ing the HOS to the Portuguese language used the criteria describedbyGuilleminetal.18andrevisedbyBeatonetal.19 Theseconsistofaset ofstandardizedinstructionsfor cul-turaladaptationofquality-of-lifeinstruments,includingfour stages:initialtranslation,back-translation,consensus trans-lationandpretesting.
Theinstrument in English was translated into the Por-tugueselanguagebytwoindependenttranslatorswhowere orthopedistswithexperienceinhipsurgerywhowere famil-iarwiththeoriginallanguageandawareoftheaimsofthe study.Afterevaluationofthetwotranslations(T1andT2)and comparisonwiththe originalinstrument,thesewere com-binedintoasingledocumentcalledtheinitialtranslation(IT). Inthenextstage,the back-translationwasdone bytwo independenttranslatorswhowereunawareoftheobjectiveof thestudy.Thus,twoback-translationsintoEnglish(BT1and BT2)wereproduced fromthe IT.Acommitteeformedbya multidisciplinaryteamthenmettoanalyzethedivergences betweenthe original instrument and the translations and, fromthisprocess,toproducetheconsensustranslation(CT). During the review process on the translations, the semantic, idiomatic, experience/cultural and conceptual
equivalenceswereexamined.Thesemanticequivalencewas basedonevaluationofthegrammaticalandvocabulary equiv-alence,i.e.,betweenwords.Manywordsinonelanguagemay nothaveadequatetranslationsintootherlanguages,orverb tensesmaybeusedinsomelanguagesandnotinothers,such aswordslikedancingoreatingtranslatedintolanguagesthat donotusethepresentparticipleorgerundform.2,20Idiomatic equivalence,i.e.,thetranslationofcertainidiomatic expres-sions,isverydifficult.CertainexpressionsinEnglishlosetheir meaningcompletelywhentranslatedintoPortuguese,orthey may beunderstood withameaningother thanthat ofthe mother language.2,20 For agood translation,equivalenceof experience or cultureisimportant,so thatthe terms used are coherent withthe experience of lifeof the population forwhich thequestionnaireisdestined, withinitscultural context.Ifatermorsituationisfoundtobeoutsideofthe con-textorexperienceofthepopulation,itshouldbechanged.2,20 Some itemsused inevaluating quality oflife may present semanticequivalencebut nothaveconceptualequivalence. Forexample,inthesocialcontextofmanyculturesin devel-opingcountries, theterms “brother”or“aunt”mightmean morethanjustadegreeofkinship.Insuchcases,theterms presentingdivergenceofconceptualequivalence shouldbe replacedbymoreappropriatetermsthatexistinthelanguage intowhichthequestionnaireisbeingtranslated.2,20
Forthepretestingstage,30consecutivepatientswith com-plaints ofhip pain but without coxarthrosis were selected fromthehipoutpatientclinicoftheOrthopedicInstituteof Tijuca.Patientswereexcludediftheypresentedwiththe fol-lowing:(i)visualorcognitivedisordersthatimpededreading
Table3–HipOutcomeScore(HOS)questionnairetranslatedintothePortugueselanguage(HOS-Brazil).
Escore de resultados do quadril
Escala de atividades da vida diária
Por favor, responda todas as questões com uma resposta que melhor descreve suas condições na última semana.
Se a atividade em questão é limitada por algo diferente do que o seu quadril , marque não se aplica (N/A) .
Sem dificuldade
Pequena dificuldade
Modera da dificuldade
Extrema dificuldade
Não consegue
fazer N/A
Ficar de pé por 15 minutos
Entrar e sair do carro
Calçar meias e sapatos
Subir ladeira inclinada
Descer ladeira inclinada
Subir um lance de escada
Descer um lance de escada
Subir e descer do meio-fio
Agachamento exagerado
Table3(Continued)
Sentar por 15 minutos
Início da caminhada
Andar por aproximadamente 10 minutos
Andar por 15 minutos ou mais
Por causa do seu quadril, quanta dificuldade você tem para: Sem
dificuldade dificuldade dificuldade dificuldade consegue Pequena Moderada Extrema Não
fazer N/A
Girar/virar sobre a perna acometida
Virar -se na cama
Trabalho leve a moderado (ficar de pé e andar)
Trabalho pesado
(empurrar/puxar/escalar/carregar)
Atividades recreativas
Como você quantificaria seu nível funcional durante as atividades usuais da vida diária de 0 a 100, com 100 sendo seu nível de função antes do seu problema de quadril e 0 sendo a impossibilidade de fazer quaisquer atividades usuais da vida diár ia?
.0 %
Escore de resultados do quadril
Escala de esportes
Por causa do seu quadril, quanta dificuldade você tem para: Sem
dificuldade dificuldade dificuldade dificuldade consegue Pequena Moderada Extrema Não
fazer N/A
Correr 1,5 km
Pular
Balançar objetos, como numa tacada de golfe
Aterrisar no solo após salto
Iniciar e parar rapidamente
Mudança brusca de direção/movimentos laterais Atividades de baixo impacto, como andar rapidamente Capacidade de fazer atividades com sua técnica normal Capacidade de participar do seu esporte desejado durante o tempo que você gostaria
Como você quantificaria seu nível funcional durante as atividades esportivas, variando de 0 a 100, sendo 100 o nível de
função nessas atividades antes do problema de quadril e 0 a impossibilidade de fazer quaisquer atividades usuais
da vida diária?
.0 %
Como você quantifica seu nível funcional atual?
Normal
Quase normal
Anormal
andinterpretationofthequestionnaire;(ii)coxarthrosis, char-acterizedbya minimumjoint space ofless than 1.5mm21 and bysevere limitation ofhip range ofmotion.14 TheCT wasappliedtothese30patients.Thequestionsthatwerenot understoodbyatleast85%ofthepatientsweremodifiedto theextentthatwasnecessaryandwerethenpresentedagain toallthe patients,untilgood understandingwasachieved. Aftereliminationofallsituationsthatdidnotformpartofthe patients’day-to-daylives,andquestionsortermsthatwere notwell understood,theCTwasconsideredtobethefinal translationofthequestionnaire(FT).
Results
Inthepretesting,theCTwasappliedto30individualsinorder toassess comprehensionand semantic, idiomatic, cultural andconceptualequivalences.
Withregard tosemantic equivalence, verbsused inthe present continuous tense in the HOS questionnaire were translatedintoPortugueseintheinfinitive.Theonlywordin theoriginalquestionnairethatdidnothaveanexact transla-tionintothePortugueselanguagewasoneinthetitleofthe questionnaire.Thus,withinthecontext,theword“outcome” wastranslatedas“resultado”(result).
Regarding idiomaticequivalence, the HOS questionnaire didnotpresentanyidiomaticexpressionsthatnecessitated adaptationstoPortuguese.
Regardingculturalequivalence,onlyoneitem,ontheADL scale,wasslightlymodifiedforgreatercoherencewiththe cul-turalcontextoftheBrazilianpopulation.Item2oftheoriginal questionnairespeaksof“gettingintoandout ofanaverage car”,andthiswastranslatedas“entraresairdocarro” (get-tingintoandoutofacar),whichissufficienttotransmitthe ideaofasmalltomedium-sizedcar,whichaccountsforthe absolutemajorityofcarsinBrazil.
Regardingconceptualequivalence,whentheactivitiesof the originalquestionnairewere translatedinto Portuguese, theydidnotpresentanyneedforconceptualadaptations.
All theindividuals answered all ofthe questions inthe pretestandallofthequestionswereunderstoodbymorethan 85%oftheinterviewees(Table1).Thus,theCTdidnotneedto bemodifiedanditbecametheFT(HOS-Brazil).
Table2presentstheoriginalHOSquestionnaireandTable3
presentsHOS-Brazil,aftertranslationandculturaladaptation.
Discussion
Inevaluatingthesemanticequivalence,theoriginalHOS ques-tionnairewasseentousethepresentcontinuousverbtense, whichinthePortugueselanguagemayleadto“gerundismo”, i.e., improper use of the gerund. Thus, words like stand-ing, walking, sitting and running were translated as the infinitivesof theseverbs (stand, walk, sit and run), which in Portuguese are used to indicate the action without sit-uatingit intime.Alsoinrelationto semanticequivalence, in translating the term “deep squatting” in item 9 of the activitiesofdailyliving,itwasdecidedtotranslatethe adjec-tiveas“exagerado”(exaggeratedoroverdone),whichisused inPortuguese todenote aconnotation ofgreater intensity
and would bemoreeasilyunderstood bythe interviewees, such that the term was translated in the HOS-Brazil as “agachamentoexagerado”.Recentpublishedarticleson trans-lationsofquestionnairesusedinorthopedicshavefollowed thesamestrategy.10,22
Among the limitations of this study, we did not evalu-atetheschoolinglevelsoftheindividualswhoansweredthe questionnaire.Thisfactorcouldhaveledtodifficultyin under-standingthequestions,giventhatthepatientswereatapublic healthcareserviceinadevelopingcountry(social).Likewise, thelevel ofphysicalactivity couldhaveinterferedwiththe understandingofsportsmovements(“landingontheground afterajump”or“swingingobjects,likeagolfclub”).Allthe questionnaireswereappliedatasinglecenterthatperhaps didnotcompletelycorrespondtotherealitiesoftheBrazilian population.
Despite the growing interest inclinical studies on non-degenerativediseasesofthehip,manyobstacleshavebeen encounteredwithintheBraziliansettingwithregardto mak-ingassessmentsofgreaterprecisionontheresultsfromsuch studies.Thisparticularlysoinrelationtoobservational stud-ies on new therapeutic interventions such as arthroscopy, and this has resulted in stimulating translations and cul-turaladaptationsofspecificevaluationinstruments.8,10The absence of a specific instrument destined for evaluat-ing individuals with non-degenerative hip diseases who practicesportsthatisvalidatedinPortuguesemakesit dif-ficult to understand the various factors that makeup the problem.2,10
The HOS was created with the objective of evaluating theresultsfromtherapeuticinterventionsamongindividuals withhighfunctionaldemandswhopresentacetabularlabral tears.16,17 Sincethe HOS isaspecific questionnaireforhip conditions inactiveindividualsthat hasalreadybeen vali-datedandtestedinpopulationsthatusetheEnglishlanguage, ourhypothesisisthatitstranslation andvalidationforthe Portugueselanguage ofBrazil willbeviableand acceptable fortherealitiesofthiscountry.Becauseofthegrowing num-bersofhiparthroscopyproceduresperformedinBrazil,itis necessarytouseaninstrumentthathasbeentranslatedand culturallyadaptedforBrazilianPortugueseandwhich eval-uatesthequalityoflifeinthisspecificgroupofpatients,so astohavebetterknowledgeofthestateofthedisease and betterassessmentoftheresultsfrominterventionsthatare implemented.
Conclusion
The Hip Outcome Score questionnairewas translated and culturally adapted to the Portuguese language of Brazil and can be usedfor clinical evaluationson the hip. Addi-tional studies are underway with the aim of evaluating the reproducibility and validity of the Brazilian transla-tion.
Conflicts
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interest
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