Background – Back disability measures are considered important by stake-holders as they offer a means of evaluating the effect of low back pain. The Quebec Back Pain Disability Scale (QDS) is a commonly-used measure of back disability, but it has only been adapted into four languages.
Method – Using a combination of cross-cultural adaptation guidelines for self-reported measures, health professionals, methodologists and Arabic linguists voluntarily participated in cross cultural adaptation of the QDS. At least three different participants were included in each of four stages.
Results – A pre-final version of the Arabic QDS was developed. The equivalence of the adapted measure to the original QDS version was agreed by examining it from four perspectives: idiomatic, experiential, conceptual and semantic.
Implications – The pre-final version is ready to be tested in almost any Arabic speaking population. This will give the opportunity to gather data in the third most widely spoken language worldwide, representing a target population of more than 500 million people.
Conclusion – The QDS can be cross-culturally adapted into Arabic without losing any concepts of the original scale; this adapted scale is ready for further testing.
Patient-oriented outcome measures play an important role in the clinical management of patients with low back pain (LBP) (Davidson and Keating 2002). The World Health Organization defines activity limitations as “difficulties an individual may have in executing activities” (ICIDH 2000). To detect changes before and after a treatment session the physiotherapist usually uses a wide range of outcome measures that detect changes in, for example, function or level of pain (Muller et al 2006).
Physiotherapists around the world are concerned with their patients’ physical status and limitation of daily activities, issues which are of great importance to many stakeholders such as employers, surgeons, insurance companies or patients’ families (Hiebert and Nordin 2006, Greenough 2006). Physiotherapists commonly rely on self-reported patient oriented questionnaires and scales to describe the impact of LBP on activities of daily living (Davidson and Keating 2002).
There are many measures established in the literature which may be used to detect back disability in patients with LBP (Muller et al 2006). The Roland Morris Disability Questionnaire (RMDQ), the Oswestry Disability Index (ODI) and the Quebec Back Pain Disability Scale (QDS) are three of the measures most commonly used by clinicians to follow the course of a disease in individual patients with LBP (Davidson and Keating 2002, Muller et al 2006). There are many factors supporting the QDS as the preferred measure of choice for LBP patients. Firstly, it is the only measure that explains the methods behind the selection and generation of items within the scale itself (Muller et al 2006). The QDS authors used factor analysis, patients’ and experts’ surveys to select the twenty items included in the final version of the scale, reflecting ordinary activities of daily living which patients, as a direct result of their LBP, may experience difficulty performing (Kopec et al 1996, Muller et al 2006). Furthermore, from the psychometric properties perspective, it lacks floor effects (when data cannot take on a value lower than some particular number) when compared to the Oswestry scale, and also ceiling effects when compared to the RMDQ (Davidson and Keating 2002 and Muller et al 2006). If the scale had a ceiling effect, which normally happens when test items are not demanding enough for a group of patients severely affected by LBP, the scale would only be applicable to those patients with mild and moderate cases (Muller et al. 2006).
Commonly these measures are originally produced in English and then cross-culturally adapted into different languages and cultures (Costa et al 2007). These adaptations are important for patients whose first language is not English. There are many reasons given in the literature supporting adaptations for these measures. Firstly, it is important to understand that not everyone in the world speaks English; even countries like the United Kingdom or the United States have a significant percentage of non-English speaking residents (Costa et al 2007). Secondly, it is important to pay more attention to those non-English subjects who are commonly excluded from clinical trials conducted in English-speaking countries; the availability of adapted questionnaires may prevent this undesirable practice (Costa et al 2007). Thirdly, for those researchers who are conducting systematic reviews, the existence of adapted measures would be of great value in supporting the pooling of data from studies conducted in non-English-speaking countries (Wild et al 2005, Costa et al 2007). Lastly, from the perspective of limited resources and time, adaption of existing questionnaires is potentially more simple and efficient than researchers developing new questionnaires for their own countries (Costa et al 2007). Hence there is an argument for the cross cultural adaptation of the QDS.
Two sets of guidelines were amalgamated and used in this study: Beaton et al (2000) and Wild et al (2005). A full description of these guidelines can be accessed via these sources.
An expert committee comprising of health professionals, language experts and methodologists were recruited via purposive sampling by the lead author (TA) through existing personal and professional contacts. At least three participants were asked to join each stage of the study (Table 1).
Table 1: Participants
Forward translation(Stage 1)
Backward translation(Stage 3)
Experts committee(Stage 4)
Table 1: Participants
Translation and cultural adaptation
During Stage 1 the participants discussed and agreed that some questions within the scale should be changed to suit the targeted Jordanian culture but to bear in mind that these changes should not affect the concepts or expressions included in each of these questions.
Translators agreed that questions 7, 8, 9 and 12 (See the original version of the QDS) should be changed to suit the targeted culture. Forward translators (FWT) 1 and 2 changed Question 7 “Climb one flight of stairs?” to “Climb one shaheat of stairs?” as the word “shaheat” is a relatively common expression in the Jordanian culture with the same meaning.
Question 8 “Walk several blocks?” was changed to “Walk a distance of several buildings?” as the translators agreed that Jordanian people live in residential quarters instead of blocks. The problem here is that some residential quarters extend more than five kilometres, so to solve the problem they agreed that adding the words “A street in the neighbourhood” in parentheses beside the question would make the concept within the question clearer.
Question 9 “Walk several miles?” was also changed to “Walk several kilometres?” as all the translators agreed that the Jordanian people use the metric system and “kilometre” is the usual measure of distance in Jordan.
Finally, Question 12 “Run one block?” was changed for the same reason as Question 8. Generally, there was relative agreement regarding questions that it would be helpful to add alternatives and explanations beside a small number of questions to facilitate the process of capturing concepts and ideas for both the LBP patients and the management team.
In general, there were no issues facing the forward translators during stage 1.
Participants who were involved in this stage had little difficulty agreeing on the most suitable words from the three initial Arabic versions produced in Stage 1. Working from the three Arabic versions they chose the most appropriate words that fitted in with Jordanian culture; they also recommended some clarifications and alternatives in parentheses beside those questions with potential for misunderstanding and/or lost concepts.
The inclusion of different research students with and without a medical background helped to identify an important concept in Question 1 in the original scale, as they noticed that people in Jordan use three types of beds. The first is an ordinary bed where the patient goes from a lying position to a sitting position. Another bed is one where the mattress is directly on the floor, and people go from a lying position into the long sitting position, then they have to make a greater effort to stand than the ordinary bed users and the last type is the bunk bed (Alexander et al 2007). This point raised the need to make some clarification beside Question 1, so it was necessary to add “From a lying position to a sitting position with the feet on the floor”.
The researcher from SHU pointed out that the scoring system should be clearer in the Arabic version. He stated, “The scoring system should be clearer for both the patients and the physiotherapist, and it would be clearer if we added a number beside the choices, like “Somewhat difficult (2)”, these were supported by the previous four adaptations as they stated that the responses were similar, e.g. “somewhat difficult” and “fairly difficult”. The participants felt that adding a number besides responses would add clarity, in keeping with other literature (Moussavi et al 2006).
At the conclusion of this stage, an initial single Arabic version of the QDS was produced.
Participants who were included in this stage were unfamiliar with the scale before the study, except for the respiratory research student and she was included in two stages as she had previous experience with outcomes development and the core of her research study was outcome measures.
Three participants were included in this stage; the most important feature of this stage was quality monitoring which would determine if the quality of the translated version was approximately the same as the original English version. Words used in the adapted Arabic scale should not give different meanings or change concepts in any items included in the English version (Wild et al. 2005). As the Arabic language contains meanings and words that carry nearly the same weight as the English language, and to make sure external factors (e.g. researchers’ preferences or language style) and internal factors (e.g. lost concepts or experiences of ADL) did not affect the validity of the forward translations or reconciliation, three different versions of backward translation were produced by participants with/without medical background or academic connection to the study.
Some researchers have argued that translations into new language versions which have different concepts and content may affect the psychometric properties of the new scale compared to the original version of the scale; this should be avoided in Stages 3 and 4 by maintaining approximately similar characteristics between both versions of the scale (Beaton et al 2000, Wild et al 2005).
In Stage 3, translations could be conceptual or literal; for the purpose of validity checking participants were asked to translate literally from the common document produced in Stage 2 back into English (Wild et al 2005). The only point that participants changed in their translation were those already mentioned in Stage 1 e.g. “miles” to “kilometres” and “blocks” to “a street in a neighbourhood”. Also, it is important to report that the two back translators from SHU used the continuous form of verbs in their translations, like “getting up” or standing”; this may indicate that the Arabic words used imply an understanding of a continuous form of activity.
Stage 4 is considered an important stage in achieving a successful cross-cultural adaption. Four postgraduate physiotherapists were recruited and they suggested minor refinements which would make the adapted version more appropriate for the majority of the Arabic speaking patients with LBP.
The expert committee used the guidelines mentioned previously to examine the common document produced in Stage 2 together with all translations and adaptations in Stages 1 and 3 to reach a general agreement on the following points:
First, to preserve the QDS copyright there was general agreement between participants regarding the title, which should be translated literally directly into Arabic without any changes. As with other scales, like the French RMDQ (known in France as the EIFEL) many authors advise that the original name of a scale should be kept without changes (Costa et al. 2007).
Second, minor changes (e.g. adding numbers) were made to the introduction to make the Arabic QDS as easy as possible for the majority of Arabic individuals from various ages and backgrounds to understand. One of the back translators, BWT1, said “We would like this scale to be as suitable as we can for all Arabic speakers coming from different countries.” FWT 2 had spotted minor grammatical issues, and she and FWT1 suggested the use of native Arabic linguistics to overcome and correct any mistakes in the grammar or spelling; this was performed by a native Jordanian Arabic teacher who undertook proofreading for the scale later in this stage.
Third, Q1 from the common document (Stage 2) was again changed to “Get out of bed?” but to overcome the problem raised in Stages 1 and 2, the expert committee found it more appropriate to let the patients measure the level of disability according to his/her experiences. At the same time they recommended the inclusion of a physiotherapists’ manual for the Arabic QDS to explain and further discuss issues that might arise during the actual assessment process on two different occasions (two time intervals).
Fourth, Q4 was changed by the expert committee to “Sit for a while in a car?” as this is more appropriate for Arabic culture where the patient could be the driver or the person next to the driver in a car.
Fifth, Q7 was changed to “Climb stairs? (One unit of stairs)”. Again there was some inconsistency regarding the term “one flight of stairs” as no single word in Arabic could give the same meaning. BWT1 and BWT2 recommended highlighting this issue with a proper diagram and adequate explanation in the physiotherapists’ manual combined with the Arabic QDS. BWT1 said “This is the first time that I have come across this word (shaheat) and I find it more appropriate to change it to (one unit of the staircase)”. BWT2 agreed that she also knew the word from her friend but they did not usually use it in her community.
Also it is important to mention that BWT2 suggested “There is some sort of inconsistency in this scale, as the responses compare two different things at the same time, ‘Doable’ and ‘Difficulty’”. Also the FWT2 stated at this stage that “The majority of the activities are mainly related to the upper limbs (push, pull, lift, carry, ride, reach up, throw, take out, make your bed, and move a chair) which may suggest that the scale is concerned with upper limb activities more than patients’ mobility.”
Finally, minor changes were made to Q14 to match the changes related to Q1. Again, regarding one of the recommendations associated with Stage 4, that it would be more appropriate to combine the Arabic QDS with a physiotherapists’ manual which clarified the questions and suggested potential alternatives for ambiguous questions, the committee of experts agreed that the Arabic QDS could stand alone without a manual but that such a manual would increase the overall quality of the adapted version.
After four weeks, participants who were included in this study cross-culturally adapted the English QDS into the Arabic language and prepared it for piloting and testing in a targeted Arabic population.
Two important results were gained from this study. The first is that an Arabic version of the QDS is ready for testing in any Arabic culture. This adaptation has been agreed by an expert committee. All participants agreed that the new adapted version is equivalent to the original version from four perspectives; conceptual, idiomatic, experiential and semantic (Beaton et al 2000).
One of the limitations of the original QDS most commonly reported in the literature is the lack of validated cross-cultural adaptations to languages other than English, French, Brazilian, Iranian and Dutch. Muller et al (2006) showed that the QDS is an excellent scale that offers consistent answers and is well-focused on disability compared to other widely used measures like the ODI and RMDQ; if the QDS were combined with an independent pain assessment measure, it could be recommended for general LBP assessment (Muller et al 2006).
More than 280 million people from more than 22 countries in the Middle East and North Africa speak Arabic as a first language and 250 million people around the world speak it as a second language (Gordon and Grimes 2005, Saleem and Natour 2010), which makes it the third most commonly spoken language around the world after English and French (Saleem and Natour 2010). The research team took into consideration that the targeted population is diverse and comes from different cultural backgrounds. Hence the study employed Modern Standard Arabic, which is widely understood by the majority of the targeted population since it the version used in schools, universities, media, government and general workplaces (Gordon and Grimes 2005, Saleem and Natour 2010).
Alternatives and explanations were added to Questions 1,2,4,14,15 and16 as the expert committees agreed that these questions do not need adaptation but extra clarifications. Questions 7, 8, 9 and12 were adapted by the experts committees to suit the targeted population; it is also important to mention here that these questions also were adapted by all previous adaptations including the original scale when authors translated the French QDS into English (Kopec et al 1996, Costa et al 2007).
It is important to mention here that for the first part of the QDS scale, the information given after the title and before the twenty questions, both literal and conceptual translations were included, as sometimes during the adaptation process there are confusions or inconsistencies in the terms and words used within the scale. As an example, in the title itself the QDS is referred to as a scale, whilst the first few words of the first paragraph use the term “This questionnaire”, BWT2 said “This is a problem with the scale itself as researcher refer to the word scale when we change subjective statements into numbers”. To overcome issues like this one we returned to a paper published by Steven (1946) to resolve any semantic issues; he recommended keeping to literal translation where there were inconsistencies or inaccuracies.
To our knowledge there is no single test which can examine the quality of the work produced up to this Stage (Stage 4), but by following adaptation guidelines and using participants with different expertise, with and without a medical background or academic connection to the study, authors were able to validate this adaption and also achieve our quest to present an Arabic QDS measure of the highest possible quality. Completion of this study will be followed by piloting (Stage Five) and testing the psychometric properties of the adapted measure in Jordan (Stage Six).
The pre-final version is ready to be tested in almost any Arabic speaking population. This will give the opportunity to gather data in the third most widely spoken language worldwide, representing a target population of more than 500 million people.
The Arabic QDS successfully carries the same concepts and expressions as the original version and it includes alternatives and clarifications that increase its readability and generalisability. It is also important to mention that this is the first study which provides detailed descriptions of all decisions regarding cultural adaptation, which may be useful in informing other future adaptations of the same measure.
Funding Sources and Conflict of Interest
No organizations or institutions funded this study, which was written as a dissertation in partial fulfilment of a Master of Science degree in Applying Physiotherapy. There was no conflict of interest in any of the participants or researchers included in this study. All the data gathered in this study will be kept safe in a secure computer and will be used only for scientific investigations.
It is a pleasure to thank those who made this article possible; Professor Jacek Kopec, Mr. Mahmoud Saad, Mrs. Dania Quteshat and Mrs. Rasha Okasheh from the faculty of health and wellbeing, Dr. Jaf’ar Alqatawna, Sheffield Hallam University and also to Mr. Ibrahim Musa and Mr. Kahaled Qadori from Sukaina Authorized Translation Office as without their work and help I could not complete this study.
Alexander L, Hancock E, Agouris I, Smith F and MacSween A (2007) The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions. Spine,32(14);1508-1512
Beaton D, Bombardier C, Guillemin F and Ferraz M (2000) Guidelines for the process of cross-cultural adaptation of self-report measures. Spine,25(24);3186-3191
Chartered Society of Physiotherapy (CSP) United Kingdom (2009) Quebec back pain disability scale. [online] at: http://www.csp.org.uk/director/members/practice/clinicalresources/outcomemeasures/searchabledatabase.cfm?item_id=57011DC7E1A1B0DF9335700BCF335C84, Last accessed on 14th December 2010.
Costa L, Maher C and Latimer J (2007) Self-report outcome measures for low back pain: Searching for international cross-cultural adaptations. Spine,32(9);1028-1037
Davidson M and Keating J (2002) A comparison of five low back disability questionnaires: Reliability and responsiveness. Physical therapy,82(1);8-24
Fotolia (2010) [online] at: http://en.fotolia.com/id/4472854, last accessed on 14th December 2010.
Fritz J and Irrgang J (2001) A comparison of a modified Oswestry low back pain disability questionnaire and the Quebec back pain disability scale. Physical therapy, 81(2); 776-788
Gordon R and Grimes B (2005) Ethnologue: Languages of the world. Summer Institute of Linguistics International Dallas, TX. 15ed
Greenough C (2006) Outcome assessment: recommendations for daily practice. European spine journal, 15;S118–S123
Hiebert R and Nordin M (2006) Methodological aspects of outcomes research. European spine journal, 15;S4-S16
ICIDH-2 (2000). International classification of function, disability, and Health- prefinal draft full version. Geneva. World Health Organization
Kopec J (1995) Functional disability scales for back pain. Spine,20(17);1943-1949
Kopec J et al (1996) The Quebec back pain disability scale: conceptualization and development. Journal of clinical epidemiology,49(2);151-161
Melikoglu M, Kocabas H, Bilgilisoy M and Tuncer T (2009) Validation of the Turkish version of the Quebec back pain disability scale for patients with low back pain. Spine,34(6);219-227
Mousavi S, Parnianpour M, Mehdian H, Montazeri A and Mobini B (2006) The Oswestry disability index, the Roland-Morris disability questionnaire, and the Quebec back pain disability scale: Translation and validation studies of the Iranian versions. Spine, 31(14);454-464
Muller U, Roder C and Greenough C (2006) Back related outcome assessment instruments. European spine journal, 15;25-31
Rodrigues M, Michel-Crosato E, Cardoso J and Traebert J (2009) Psychometric properties and cross-cultural adaptation of the Brazilian Quebec back pain disability scale questionnaire. Spine,34(13);459-464
Saleem A and Natour Y (2010) Standardization of the Arabic version of the voice handicap index: An investigation of validity and reliability. Logopedics phoniatrics vocology,35(4);183-188
Schoppink L, van Tulder M, Koes B, Beurskens S and De Bie R (1996) Reliability and validity of the Dutch adaptation of the Quebec back pain disability scale. Physical therapy,76(3);268-275
Stevens S (1946) On the theory of scales of measurement. Science,103(2684),677-680.
Wild D et al (2005) Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: Report of the ISPOR task force for translation and cultural adaptation. Value in health, 8(2);94-104
Yvanes-Thomas M et al (2002) Validity of the French-language version of the Quebec back pain disability scale in low back pain patients in France. Joint bone spine,69(4);397-405