Artigo Original
Hipólito Virgílio Magalhães Junior1
Leandro de Araújo Pernambuco1
Lourdes Bernadete Rocha de Souza1
Maria Angela Fernandes Ferreira2
Kenio Costa de Lima2
Keywords
Validation studies Translations Cross-cultural comparison Screening programmes Deglutition Deglutition disorders
Descritores
Estudos de validação Traduções Comparação transcultural Programas de rastreamento Deglutição Transtornos de deglutição
Correspondence address:
Hipólito Virgílio Magalhães Junior Centro de Ciências da Saúde da Universidade Federal do Rio Grande do Norte, Departamento de Fonoaudiologia. R. General Gustavo Cordeiro de Farias, s/nº, Petrópolis, Natal (RN), Brasil, CEP: 59010-180.
E-mail: h.vmagalhaes@gmail.com
Received: 10/11/2012
Study carried out at the Speech Language Pathology and Audiology Department, Universidade Federal do Rio Grande do Norte – UFRN – Natal (RN), Brazil.
(1) Speech Language Pathology and Audiology Department, Universidade Federal do Rio Grande do Norte – UFRN – Natal (RN), Brazil.
(2) Graduate Program in Collective Health, Universidade Federal do Rio Grande do Norte – UFRN – Natal (RN), Brazil.
Conlict of interests: nothing to declare.
adaptation of the Northwestern Dysphagia Patient
Check Sheet to Brazilian Portuguese
Tradução e adaptação transcultural do
Northwestern Dysphagia Patient Check Sheet
para o português brasileiro
ABSTRACT
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 inal 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 proile. Results:
There was divergence in semantic equivalence in relation to one item, which was modiied 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 ive 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.
RESUMO
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 scientiic 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 iden-tiication 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 conirmation and treatment(2-4). 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 speciic evaluation and to favor a more eficient 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 deinition 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, sin-ce it approaches punctual matters consin-cerning what it intends to investigate and presents values for accuracy, sensitivity, and speciicity from its comparison with the videoluoroscopy 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 evalua-tion 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 cate-gories: 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 aspi-ration, 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 trans-lation 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 irst 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, consi-dering 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 pro-tocol in order to preserve the coherence of the content and to reveal possible laws 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 inal version (Appendix 1).
In the fourth step, the clarity of the instrument for the po-pulation 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 mentio-ned in the third step. By consensus, the committee analyzed and veriied 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 proile.
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 inal version of the cross-cultural adaptation of the NDPCS (Appendix 1) maintained the 28 questions of the original version divided into ive 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.
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-popula-tion. 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 speciicity patter-ns(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 fulills such requirements, so it was chosen to be submitted to the validation process. In this stage of translation and cross-cultural 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, inally, 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 irst 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 classiied 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 humidiied 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 irst bite(16,17).
All of this happens during the chewing cycle, when the infor-mation 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, consi-dering 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 deined 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 irst volume increa-sed 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-func-tional 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 speciicity 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.
Chart 1. Modifications of the instrument during the process of translation and cross-cultural adaptation
Steps Protocol domains Item/tasks of the original version Modification/adaptation to Brazilian Portuguese
Type of cultural equivalence Third – comparison between the
original protocol, the translated, and back-translated versions
Oral motor test Facial weakness(item 16) Orofacial tonicity Semantic
Fourth – first application of the protocol in the target-population
Observations during trial
swallows
1mL thin liquid, 1mL pudding, ¼ Lorna Doone cookie
(if chewing was possible)
5 mL of pudding; 3, 5, and 10 mL of water; ½
wafer cookie
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 relex, 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 irst 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 speciic characteristics of dysphagia, but it does not determine the etiology of the problem nor should it be used as a single instrument to deine conducts or therapeutic interventions. Once the presence of alterations is identiied, the patient should be referred to speciic diagnostic evaluation(8).
CONCLUSION
The translation and cross-cultural adaptation of the NDPCS to BP were performed with experimental and se-mantic 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.
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Appendix 1. Brazilian version of the protocol Northwestern Dysphagia Patient Check Sheet
NOME_____________________________________________________________________________DATA______________ SEXO___________IDADE_____________ DATA DE NASCIMENTO ____________ PROFISSÃO_______________________ ENDEREÇO________________________________________________________________________TELEFONE_________
- História Médica Não sugestivo Sugestivo
1. História de pneumonia recorrente 2. Picos de temperatura frequentes 3. Problema de pneumonia aspirativa
4. Intubação de longa duração (1 s ou +) ou traqueostomia (6 m ou +)
- Aspectos Comportamentais 5. Estado de alerta
6. Cooperação
7. Atenção/habilidade de interação 8. Consciência do problema de deglutição 9. Consciência das secreções
10. Habilidade de manusear secreções - Função Motora Ampla
11. Controle postural 12. Fatigabilidade - Teste Motor Oral
13. Anatomia e fisiologia oral, faríngea e laríngea 14. Habilidade para seguir direções
15. Disartria
16. Tonicidade orofacial 17. Apraxia oral
18. Sensibilidade orofacial 19. Contração faríngea no gag 20. Deglutição de saliva 21. Tosse e pigarro voluntários
Observação durante as provas de deglutição: 5 mL de pastoso grosso; 3, 5 e 10 mL de água; meio biscoito wafer
22. Apraxia da deglutição 23. Resíduo oral 24. Tosse e pigarro
25. Atraso na deglutição faríngea 26. Redução na elevação laríngea 27. Voz molhada
28. Múltiplas deglutições por bolo alimentar
Três variáveis resumidas das categorias acima
Total de itens sugestivos das 28 variáveis nas 5 categorias: ____
Total de itens sugestivos nos aspectos comportamentais e função motora ampla:____
Observações
Presença de Aspiração ( ) Item 24
( ) Item 24 + Item 1 ( ) Item 24 + Item 26 ( ) Item 26 + Item 1
Presença de dificuldade na fase oral da deglutição ( ) Item 15
Atraso na fase faríngea da deglutição ( ) Mais de 8 itens “sugestivos”
( ) Mais de 8 itens “sugestivos” + Item 16 ( ) Mais de 8 itens “sugestivos” + Item 25 ( ) Item 25 + Item 16
