DOI: 10.5301/hipint.5000146
Hip Int 2014; 24 ( 5): 473-479
ORIGINAL ARTICLE
Translation, cross-cultural adaptation, and validation of the Turkish version of the Harris Hip Score Derya Çelik1, Canan Can2, Yasemin Aslan2, Hasan Huseyin Ceylan3, Kerem Bilsel3, Arzu Razak Ozdincler1 Istanbul University, Faculty of Health Science, Division of Physiotherapy and Rehabilitation, Istanbul - Turkey Istanbul University, Health and Science Institute, Division of Physiotherapy and Rehabilitation, Istanbul - Turkey 3 Bezmialem University, Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul - Turkey 1 2
Objectives: The Harris Hip Score (HHS) developed to assess function and pain from the perspective of patients hip pathologies. The purpose of this study was to translate and culturally adapt the HHS into Turkish, and thereby determine the reliability and validity of the translated version. Methods: The HHS was translated into Turkish in accordance with the stages recommended by Beaton. The measurement properties of the HHS were tested in 80 patients; 52 males, mean age 51 years (range 21-75 years) suffering from different hip pathologies. The test-retest reliability was tested in 58 patients; 28 males mean age, 52 years (range 30-73 years) after an interval of seven days. The Cronbach’s Alpha was used to assess internal consistency and the intra-class correlation coefficient (ICC) was used to estimate the test-retest reliability. Patients were asked to answer the Oxford Hip Score (OHS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the VAS and the Short Form-36 (SF-36) for the validity of the estimation. Results: The Turkish version of the HHS showed sufficient internal consistency (Cronbach’s alpha,0.70) and test-retest reliability (ICC = 0.91). The correlation coefficients between the HHS, the WOMAC and the OHS were 0.64 and 0.89 respectively. The highest correlations between the HHS and SF-36 were with the physical function scale (r = 0.72), and the lowest correlations were with the mental function scale (r = 0.10). We observed no floor or ceiling effects. Conclustion: The Turkish version of the HHS has sufficient reliability and validity to measure patientreported outcome for Turkish-speaking individuals with a variety of hip disorders. Keywords: Outcome measurements, Harris hip score, Reliability, Validity Accepted: March 14, 2014
INTRODUCTION Patient-reported outcomes are important tools for evaluating the effects of musculoskeletal conditions and treatments from the perspective of the patient. Many outcome measures have been developed for the assessment of hip pathologies, such as the Oxford Hip Score (OHS), Nonarthritic Hip Score, Hip and Groin Outcome Score, International Hip Outcome Tool, Hip Outcome Score, Hip Dysfunction and Osteoarthritis Score, and Merle d’Aubigné and Postel score (1-7). The Harris Hip Score (HHS) is a combined clinician/patient reported,
disease-specific score used to evaluate various hip pathologies and methods of treatment (1). The majority of literature reported outcome questionnaires were developed in English and therefore cannot be adapted to every culture. Many are already used as standards by the world scientific community, but the appropriate use of these tools depends on their adaptation to different languages and cultures while maintaining cultural equivalence (8). To avoid the potentially harmful distribution of new scores or scales that are not comparable with those available in the literature, a rigorous adaptation process is needed. Simply translating a previously validated instrument is insufficient
© 2014 Wichtig Publishing - ISSN 1120-7000
473
The Harris Hip Score validation to Turkish
(9). The availability of culturally equivalent outcome measures allows for multicentre cohort studies to be reliably conducted in different countries. Despite the fact that the HHS is the oldest scoring system, it remains the most widely used hip questionnaire. Many authors have used either the original or modified HHS in their recent studies of various hip pathologies, such as ligamentum and labral tears, revision of infected hip arthroplastyand hip fractures (10-14). In addition, the more frequent use of the HHS over other hip-specific instruments could be attributed to the fact that its underlying concept is similar to those of other generic measures (12). The HSS contains only 12 questions and little time is required for the patient to complete the questionnaire and for the practitioner to evaluate the results. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is (15) is the only validated hip pathology questionnaire translated into Turkish. The purpose of this study was to translate the English version of the HHS into Turkish and investigate the validity and reliability of the translated version.
MATERIALS AND METHODS The HHS was translated into Turkish and culturally adapted in accordance with the stages recommended by Beaton (16). Two Turkish individuals with a good command of English were responsible for the literary and conceptual translation of the HHS. The informed translator was a physical therapist and the uninformed translator was a teacher. Both translators’ mother tongue was Turkish and both were fluent in English. The translations were completed independently. Both translations were compared and reviewed by a bilingual person who highlighted any conceptual errors or inconsistencies in the translations in order to establish the first Turkish translation. Once the first Turkish translation had been agreed upon, two native English speakers with a good command of Turkish separately translated the finalised Turkish translation back into English. Both translators were unaware of the purpose of the study and had no access to the original scale. The back-translated version of the HHS was compared to the initial English version of the HHS by a committee comprising four translators, a methodologist, and a language professional. The committee reviewed four of the translations and compared any diversities or discrepancies. Any diversities or discrepancies were discussed with the translators. The committee 474
approved the Turkish version of the HHS. A pretest was undertaken in 20 patients (11 females, nine males; mean age 37 years (range17-60 years)) who fulfilled the eligibility criteria of the study for accuracy of wording and ease of understanding of the questionnaire. The physical therapist interviewed the patients after they had completed the questionnaire. The patients were questioned about their difficulties in understanding the questions immediately after completing the form. Questions that were difficult to understand were noted and the patients were asked for their recommendations regarding revision of these questions.
PATIENTS AND METHODS One hundred and twenty patients were included in the study. Twenty-two patients declined to participate. Eleven of the 98 patients had difficulty understanding the questions due to cognitive problems. Seven patients left 40% of the questionnaires empty and were excluded from the study. The remaining 80 patients (52 males; mean age 51 years (range 20-75 years)) with a variety of hip pathologies were recruited from Bezmialem Vakıf University, Department of Orthopaedics between March 2011 and January 2012. Bezmialem Vakıf University is one of the largest hospitals in Istanbul and patients comprise individuals from all cultures and income levels. The hospital is open to patients from both urban and rural communities. The inclusion criterion was the presence of a hip pathology such as arthritis, labral lesions, femoral impingement syndrome, arthroplasty or fractures. The exclusion criteria were the inability to complete the form because of cognitive impairment and illiteracy or lack of understanding of Turkish. Diagnoses were established by the physician based on a history, physical examination and diagnostic studies Table I. Before inclusion in the study group all participants were asked to read and sign an informed consent form that had been approved by the Ethics Committee at Istanbul University (IRB study protocol: 2011/875- 265). The patients were asked to complete the Turkish version of the HHS (Appendix), the OHS, the WOMAC, a visual analogue scale (VAS), and the Short Form Health Survery 36 (SF-36) (15, 17, 18). Questionnaires were given in random order to patients. Physical therapists administered the listed questionnaires to patients in waiting rooms after an appointment with an orthopedic surgeon. Patients were asked to complete the Turkish version of the HHS seven days after
© 2014 Wichtig Publishing - ISSN 1120-7000
Çelik et al
TABLE I - DEMOGRAPHICS OF THE PATIENTS N (%) Education Literate (but did not complete any school)
10 (8)
Primary school
47 (58.7)
High school
11 (13.7)
University degree
9 (11.2)
Master degree
2 (2.5)
Doctorate
1 (1.2)
Involved side Right hip
43 (53.7)
Left hip
37 (46.2)
Diagnosis Coxarthrosis Hip arthroplasty Congenital dislocation of the hip Avascular necrosis Edema of femoral head Femoral fracture Hip pain Hip effusion Hemophilic arthropathy Muscle tear Osteoporosis Pseudoarthrosis Acetabular cystic lesion
41 (51.2) 14 (17.5) 6 (7.5) 1 (1.2) 1 (1.2) 3 (3.7) 4 (5.0) 1 (1.2) 2 (2.5) 2 (2.5) 3 (3.7) 1 (1.2) 1 (1.2)
the first assessment to determine the test-retest reliability. To minimise the risk of short-term clinical change no treatment was provided during this period. The HHS contains 12 questions covering four domains: pain (44 points); function (47 points); deformity; and range of motion (9 points). This questionnaire was developed to assess the outcomes of young and middle-aged patients following hip arthroscopic debridement and was modified from the existing HHS developed for traumatic arthritis of the hip. Each question is answered using a Likert scale with an overall score ranging from 0 (extreme symptoms) to 100 (no symptoms) (1). A total HHS of
Hip Int 2014; 24 ( 5): 473-479
ORIGINAL ARTICLE
Translation, cross-cultural adaptation, and validation of the Turkish version of the Harris Hip Score Derya Çelik1, Canan Can2, Yasemin Aslan2, Hasan Huseyin Ceylan3, Kerem Bilsel3, Arzu Razak Ozdincler1 Istanbul University, Faculty of Health Science, Division of Physiotherapy and Rehabilitation, Istanbul - Turkey Istanbul University, Health and Science Institute, Division of Physiotherapy and Rehabilitation, Istanbul - Turkey 3 Bezmialem University, Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul - Turkey 1 2
Objectives: The Harris Hip Score (HHS) developed to assess function and pain from the perspective of patients hip pathologies. The purpose of this study was to translate and culturally adapt the HHS into Turkish, and thereby determine the reliability and validity of the translated version. Methods: The HHS was translated into Turkish in accordance with the stages recommended by Beaton. The measurement properties of the HHS were tested in 80 patients; 52 males, mean age 51 years (range 21-75 years) suffering from different hip pathologies. The test-retest reliability was tested in 58 patients; 28 males mean age, 52 years (range 30-73 years) after an interval of seven days. The Cronbach’s Alpha was used to assess internal consistency and the intra-class correlation coefficient (ICC) was used to estimate the test-retest reliability. Patients were asked to answer the Oxford Hip Score (OHS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the VAS and the Short Form-36 (SF-36) for the validity of the estimation. Results: The Turkish version of the HHS showed sufficient internal consistency (Cronbach’s alpha,0.70) and test-retest reliability (ICC = 0.91). The correlation coefficients between the HHS, the WOMAC and the OHS were 0.64 and 0.89 respectively. The highest correlations between the HHS and SF-36 were with the physical function scale (r = 0.72), and the lowest correlations were with the mental function scale (r = 0.10). We observed no floor or ceiling effects. Conclustion: The Turkish version of the HHS has sufficient reliability and validity to measure patientreported outcome for Turkish-speaking individuals with a variety of hip disorders. Keywords: Outcome measurements, Harris hip score, Reliability, Validity Accepted: March 14, 2014
INTRODUCTION Patient-reported outcomes are important tools for evaluating the effects of musculoskeletal conditions and treatments from the perspective of the patient. Many outcome measures have been developed for the assessment of hip pathologies, such as the Oxford Hip Score (OHS), Nonarthritic Hip Score, Hip and Groin Outcome Score, International Hip Outcome Tool, Hip Outcome Score, Hip Dysfunction and Osteoarthritis Score, and Merle d’Aubigné and Postel score (1-7). The Harris Hip Score (HHS) is a combined clinician/patient reported,
disease-specific score used to evaluate various hip pathologies and methods of treatment (1). The majority of literature reported outcome questionnaires were developed in English and therefore cannot be adapted to every culture. Many are already used as standards by the world scientific community, but the appropriate use of these tools depends on their adaptation to different languages and cultures while maintaining cultural equivalence (8). To avoid the potentially harmful distribution of new scores or scales that are not comparable with those available in the literature, a rigorous adaptation process is needed. Simply translating a previously validated instrument is insufficient
© 2014 Wichtig Publishing - ISSN 1120-7000
473
The Harris Hip Score validation to Turkish
(9). The availability of culturally equivalent outcome measures allows for multicentre cohort studies to be reliably conducted in different countries. Despite the fact that the HHS is the oldest scoring system, it remains the most widely used hip questionnaire. Many authors have used either the original or modified HHS in their recent studies of various hip pathologies, such as ligamentum and labral tears, revision of infected hip arthroplastyand hip fractures (10-14). In addition, the more frequent use of the HHS over other hip-specific instruments could be attributed to the fact that its underlying concept is similar to those of other generic measures (12). The HSS contains only 12 questions and little time is required for the patient to complete the questionnaire and for the practitioner to evaluate the results. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is (15) is the only validated hip pathology questionnaire translated into Turkish. The purpose of this study was to translate the English version of the HHS into Turkish and investigate the validity and reliability of the translated version.
MATERIALS AND METHODS The HHS was translated into Turkish and culturally adapted in accordance with the stages recommended by Beaton (16). Two Turkish individuals with a good command of English were responsible for the literary and conceptual translation of the HHS. The informed translator was a physical therapist and the uninformed translator was a teacher. Both translators’ mother tongue was Turkish and both were fluent in English. The translations were completed independently. Both translations were compared and reviewed by a bilingual person who highlighted any conceptual errors or inconsistencies in the translations in order to establish the first Turkish translation. Once the first Turkish translation had been agreed upon, two native English speakers with a good command of Turkish separately translated the finalised Turkish translation back into English. Both translators were unaware of the purpose of the study and had no access to the original scale. The back-translated version of the HHS was compared to the initial English version of the HHS by a committee comprising four translators, a methodologist, and a language professional. The committee reviewed four of the translations and compared any diversities or discrepancies. Any diversities or discrepancies were discussed with the translators. The committee 474
approved the Turkish version of the HHS. A pretest was undertaken in 20 patients (11 females, nine males; mean age 37 years (range17-60 years)) who fulfilled the eligibility criteria of the study for accuracy of wording and ease of understanding of the questionnaire. The physical therapist interviewed the patients after they had completed the questionnaire. The patients were questioned about their difficulties in understanding the questions immediately after completing the form. Questions that were difficult to understand were noted and the patients were asked for their recommendations regarding revision of these questions.
PATIENTS AND METHODS One hundred and twenty patients were included in the study. Twenty-two patients declined to participate. Eleven of the 98 patients had difficulty understanding the questions due to cognitive problems. Seven patients left 40% of the questionnaires empty and were excluded from the study. The remaining 80 patients (52 males; mean age 51 years (range 20-75 years)) with a variety of hip pathologies were recruited from Bezmialem Vakıf University, Department of Orthopaedics between March 2011 and January 2012. Bezmialem Vakıf University is one of the largest hospitals in Istanbul and patients comprise individuals from all cultures and income levels. The hospital is open to patients from both urban and rural communities. The inclusion criterion was the presence of a hip pathology such as arthritis, labral lesions, femoral impingement syndrome, arthroplasty or fractures. The exclusion criteria were the inability to complete the form because of cognitive impairment and illiteracy or lack of understanding of Turkish. Diagnoses were established by the physician based on a history, physical examination and diagnostic studies Table I. Before inclusion in the study group all participants were asked to read and sign an informed consent form that had been approved by the Ethics Committee at Istanbul University (IRB study protocol: 2011/875- 265). The patients were asked to complete the Turkish version of the HHS (Appendix), the OHS, the WOMAC, a visual analogue scale (VAS), and the Short Form Health Survery 36 (SF-36) (15, 17, 18). Questionnaires were given in random order to patients. Physical therapists administered the listed questionnaires to patients in waiting rooms after an appointment with an orthopedic surgeon. Patients were asked to complete the Turkish version of the HHS seven days after
© 2014 Wichtig Publishing - ISSN 1120-7000
Çelik et al
TABLE I - DEMOGRAPHICS OF THE PATIENTS N (%) Education Literate (but did not complete any school)
10 (8)
Primary school
47 (58.7)
High school
11 (13.7)
University degree
9 (11.2)
Master degree
2 (2.5)
Doctorate
1 (1.2)
Involved side Right hip
43 (53.7)
Left hip
37 (46.2)
Diagnosis Coxarthrosis Hip arthroplasty Congenital dislocation of the hip Avascular necrosis Edema of femoral head Femoral fracture Hip pain Hip effusion Hemophilic arthropathy Muscle tear Osteoporosis Pseudoarthrosis Acetabular cystic lesion
41 (51.2) 14 (17.5) 6 (7.5) 1 (1.2) 1 (1.2) 3 (3.7) 4 (5.0) 1 (1.2) 2 (2.5) 2 (2.5) 3 (3.7) 1 (1.2) 1 (1.2)
the first assessment to determine the test-retest reliability. To minimise the risk of short-term clinical change no treatment was provided during this period. The HHS contains 12 questions covering four domains: pain (44 points); function (47 points); deformity; and range of motion (9 points). This questionnaire was developed to assess the outcomes of young and middle-aged patients following hip arthroscopic debridement and was modified from the existing HHS developed for traumatic arthritis of the hip. Each question is answered using a Likert scale with an overall score ranging from 0 (extreme symptoms) to 100 (no symptoms) (1). A total HHS of
