Reliability and Validity of the Indian (Telugu) Version of the Shoulder Pain and Disability Index

Shoulder complex pain is a common problem of musculoskeletal pain in the general population [1,2]. Shoulder joint disability will disturb the daily activity and quality of sleep [3,4].

In a World Health Organization (WHO) collaborated study, there was a crude prevalence rate of 30.13% of musculoskeletal pain in a South Indian community [5]. Shoulder pain and impaired function are the measures of burden in musculo skeletal disorders [6]. It has been observed that in the developing world, the complex factors such as modernisation and socioeconomics, would influence people to bear, adapt and manage the pain and disability arising from musculoskeletal disorders [5,6].

Range of Motion (ROM) and strength of muscle helps in evaluating shoulder performance. According to Bot SD et al., objective measurement is impractical as it requires a face-to-face contact and is also time consuming [7]. The treatment efficiency is assessed considering the outcome measures that are directly relevant to the patient [8].

Several shoulder disability questionnaires are used by many clinicians to evaluate the treatment and to measure follow up status. Disability of the Arm, Shoulder and Hand scale (DASH) [9], the American Shoulder and Elbow Surgeon Standardised Assessment Form (ASES) and the SPADI are commonly used scales to evaluate the shoulder disability [10].

The SPADI is easily applicable, valid, agreeable, reliable and interpretable with a good construct validity and minimal ceiling and flooring effects [11]. The SPADI is a self administered instrument for the painful shoulder that would evaluate the disability and pain [8].

The SPADI developed by Roach KE et al., is the English self-reported questionnaire which is easy to understand and requires only a short time to answer [12,13]. SPADI was developed for use in an outpatient setting and it was designed to measure the impact of shoulder pathology in terms of pain and disability for both current status and change in status over time. The questionnaire consists of only 13 items divided into two subscales, namely; ‘pain’ and ‘disability’ with five and eight questions, respectively. Each question was scored using a Visual Analogue Scale (VAS), with “no pain or no difficulty in doing an activity” at one end and “unbearable pain or so difficult it require help” at the other end. The scores are calculated according to the guidelines that were given by the author. This scale has been widely used and become a standard, reliable and a valid region-specific measure for the shoulder.

Owing to its standard validity and reliability, there was a need for cross cultural adaptation into a regional Indian language (Telugu). In addition, it was translated to many languages including German, Persian, Slovenian, Tamil, Italian and Brazilian [14-19]. For these reasons, the purpose of the present study was to translate English version and culturally adapt the SPADI to Telugu version and to assess its internal consistency and criterion validity. The study hypothesised that the SPADI would be a valid and reliable questionnaire to assess shoulder disability among Telugu people having shoulder pain.

This cross cultural adaptation study was conducted on 200 participants with shoulder pain and dysfunction who were recruited from the outpatient department of Susruta Institute of Physical Medicine and Rehabilitation, Hyderabad, India, after obtaining Institutional Ethical Approval and written informed consent. The present study was done for a period of one year (February 2016 to January 2017). Both men and women with symptomatic shoulder pain and restriction of ROM, older than 21 years, and who were able to read and understand Telugu were included. Participants with previous shoulder surgeries, neck pathology, disabling upper limb osteoarthropathic and neuropathic conditions along with the inability to read and understand Telugu were excluded from the study.

The permission for cross cultural adaptation of SPADI and to assess its reliability and validity of the Telugu scale were also granted by the original author. The participants were briefed about the procedure before responding to the scale. In the study, participant’s age, sex, duration of shoulder problem, pain, educational level, and presence of comorbidities were recorded from the interview and medical records. As per the guidelines of the AAOS outcomes committee, translation and cross cultural adaptation of SPADI was done [20].

The procedure consists of six stages as follows:

Stage I: Forward translation (English to Telugu) by an informed translator (i.e., health professional, T1) and uninformed translator (T2).

Stage II: Synthesis of T1 and T2, resolving any discrepancies, leading to version T-12.

Stage III: Back translation (Telugu to English) of the version T-12 by two native English speaking back translators (BT1 and BT2) who were unaware of the purpose of the instrument.

Stage IV: Expert committee review consisting of all four translators, one methodologist, and one language professional to reach a consensus on discrepancies or ambiguities, and to establish a prefinal version (Telugu).

Stage V: Test of the prefinal version.

The final stage of adaptation of the new questionnaire is testing the prefinal version in subjects/patients from the target setting.

Stage VI: Submission of documentation to the AAOS Committee.

The final stage in the adaptation process is to verify whether the recommended stages were followed or not.

A pilot study, including 60 patients was done using the prefinal version (Stage V). These participants were later included in the final analysis. Telugu Questionnaire was given to the participants and they were asked to mark the appropriate point on the scoring system, which represented their status of shoulder pain and disability.

In the present study, an investigator was present during scale administration without influencing the subject’s scoring on the questionnaire. The subscale scores were calculated by adding the item scores for that subscale and dividing this number by the maximum score possible for the items that were deemed applicable by the subject. This number was then multiplied by 100. If not applicable was marked by the subject in any item then it was not included in the maximum possible score and no score was calculated if more than two items were marked as ‘not applicable’. The score ranges from 0 to100 the higher the score, the greater the impairment to the shoulder function. The total SPADI score was calculated by the average score of pain and disability subscale scores [12]. After the completion of the telugu questionnaire, the active ROM of the shoulder was measured, using a standard universal goniometer [21]. The standard test positions were used for the goniometric measurements. The criterion validity of the questionnaire was calculated using range of motion values. The second assessment by the same investigator was scheduled at least 24 hours after the first session to assess test-retest reliability.

Data were analysed using SPSS for Windows version 20.0 (Statistical package for Social Sciences, IBM Inc. USA www.spss.com). The test-retest reliability of the total Telugu SPADI, pain and disability subscales was assessed using intraclass correlation coefficients at 95% confidence interval levels. Internal consistency of the Telugu SPADI was measured using Cronbach’s alpha coefficient. The criterion validity was assessed using Pearson correlation coefficients. A Chi-square test was used to compare the demographic data of the study population.

The mean and standard deviation of the age for male was 54.957±7.9695 and for female it was 55.971±8.6083. The sample consisted of 95 female and 105 male participants. The right shoulder was affected in 92 participants and left shoulder was affected in 108 participants. There was no significant difference in the incidence of shoulder dysfunction among male and female.

Test and Retest Mean±SD of total SPADI values were 81.3114±8.2308 and 79.8382±8.1768 [Table/Fig-1]. The ICC values for the SPADI pain score (0.9645), SPADI disability score (0.96342) and total SPADI (0.9792) which showed high reproducibility of the questionnaire [Table/Fig-2]. By normal standards, the association between the two variables would be considered statistically significant (p<0.05). The internal consistency of the Telugu SPADI pain subscale, disability subscale and total scale was excellent. Cronbach’s alpha coefficients were 0.88, 0.90 and 0.91, respectively.

Face validity was established in the original version (English) of the SPADI and was considered adequate for the Telugu SPADI after calculations, i.e., the content of the translated items were understandable and they are related to activities of the shoulder in daily living and could be used in the assessment of shoulder pain and function. Pearson’s correlation between the initial total SPADI score, individual pain score, individual disability score and the baseline active range of motion of shoulder was calculated to assess the criterion validity. The baseline active range of motion of shoulder scores are given in [Table/Fig-3].

There was a moderately strong negative correlation between shoulder range of motion and pain score (correlations ranged from -0.40394 to -0.5360), shoulder range of motion and disability score (correlations ranged from -0.3868 to -0.5403) and shoulder range of motion and total SPADI score (correlations ranged from -0.3500 to -0.5053) [Table/Fig-4]. The predictive criterion validity showed that it had a strongly high negative correlation.

The process of cross cultural adaptation of the SPADI was done through constant discussions with the original author, the primary researcher, and a linguistic specialist. There was no major problems encountered in the cross cultural adaptation into the Telugu language. However, there was a discussion for phrases such as “at its worst,” “highshelf,” “buttoning shirts,” “washing the neck and back,” and “back pocket.” Translating the questionnaire did not have much difficulty apart from a few words which have synonyms, such as the first leading questions Telugu word “thatukolenibujjamnoppi” can be interpreted as excessive, bad, or extent. In the same way the first question in the pain domain the Telugu word “bujjamnoppitheevratha” can be interpreted as very bad or worse as the first backward translator translated it. Later it was deliberated that “thatukolenianthabujjamnoppi” will be used to translate “at its worst.” A few words had been adapted for both sexes, for example buttoning the shirt. Thus, the Telugu question was adapted accordingly.

The translator reached a consensus for the selection of appropriate words to be used in the questionnaire and that could be easily understood by the Telugu speaking participants. While finalising the prefinal version, intra state variations of Telugu language and influence of English on the colloquially spoken Telugu language was taken into consideration. It takes five minutes for a patient to complete the questionnaire, as most of the questions are short and easy to understand. The reliability and internal consistency was excellent in both subscales and also the overall total score. The criterion validity of the Telugu SPADI shared a moderately strong negative correlation in pain, disability and total score which was comparable to the original version (English), which had a moderate to high correlation in negative direction.

The reliability of the total Telugu SPADI had an ICC value 0.979, which was higher than the total English SPADI (ICC=0.6552) but was similar to the Marathi SPADI (ICC=0.97), German (ICC=0.94), Slovenian SPADI (ICC=0.94), Tamil SPADI (ICC=0.95), Turkish SPADI (ICC=0.92), Brazilian SPADI (ICC=0.90-0.94) and Dutch SPADI (ICC=0.89) [12,22,14,16,17,23,19,24]. According to Bot SD et al., an ICC value of ≥0.90 allows the reliable assessment of individual participants [7]. This is clearly observed in the present study for the total score and both sub scores in the Telugu SPADI.

The internal consistency of the Telugu SPADI was excellent, similar to the original version (English) of Roach KE et al., Cronbach’s alpha=0.95 and other versions included Greek; Cronbach’s alpha=0.932, Tamil; Cronbach’s alpha=0.95, German; Cronbach’s alpha=0.95, Thai; Cronbach’s alpha=0.95 and Spanish; Cronbach’s alpha=0.92 [12,25,17,14,26,27].

There is no true “gold standard” to assess the criterion validity of the SPADI; hence, we compared the SPADI questionnaire with shoulder range of motion [14,24]. There was moderately strong negative correlation between shoulder range of motion and total SPADI score (r=-0.350 to -0.505) which was correlated with total SPADI of English version (r=-0.5455 to -0.8036) and Tamil version (r=-0.373 to -0.577), where as a weak correlation was showed with VAS score during Active Rom (r=0.065) in SPADI of Turkish version [17,12,23]. In a study conducted by Paul A et al., has showed a weak correlation between shoulder questionnaire scores (Dutch Shoulder Disability Questionnaire, United Kingdom Shoulder Disability Questionnaire, Shoulder Pain and Disability Index and the Shoulder Rating Questionnaire) and active shoulder movement (r=-0.02 to -0.44) [28].

Bot SD et al., evaluated 16 questionnaires and found that the correlations between the Simply Shoulder Test (SST), Shoulder Severity Index (SSI), American Shoulder and Elbow Surgeons Standardised Shoulder Assessment Form (ASES), SPADI, and Disability of the Arm Shoulder, and Hand (DASH) scale was high (>0.74) [7]. Similarly, Rodney TS et al., compared the University of California-Los Angeles Shoulder Scale, the Simple Shoulder Test, and the SPADI [29]. Three scales demonstrated good internal consistency, suggesting that all items for each scale measure the same construct. This was in agreement with the study and supported the results. Paul A et al., in there study on Four questionnaires (Dutch Shoulder Disability Questionnaire, United Kingdom Shoulder Disability Questionnaire, Shoulder Pain and Disability Index and the Shoulder Rating Questionnaire) showed that all had similar validity and confirmed that SPADI was the quickest to complete, without any significant change of scores in stable subjects [28].

The Telugu SPADI proved to be a valid and reliable tool for shoulder pain and function that can be implemented in clinical practice. The steps followed in cross culturally adapting the English SPADI and establishing the validity and reliability of the Telugu SPADI is as per the well accepted norms followed among researchers.

Limitations of the present study, there was no correlation done between SPADI and other questionnaires, since several tools have the ability to elicit different aspects of pain and functionality. The study was limited to only one health centre. Statistically, factor analysis of individual questions was not performed.

The study concluded that the converted version of the English SPADI into a regional Indian language (Telugu) is reliable and valid measure for shoulder pain and disability and it can be easily applied in the Telugu speaking population.

[1]. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Prevalence and incidence of shoulder pain in the general population; a systematic review Scand J Rheumatol 2004 33(2):73-81.10.1080/0300974031000466715163107  [Google Scholar]  [CrossRef]  [PubMed]

[2]. Natvig B, Picavet HS, The epidemiology of soft tissue rheumatism Best Pract Res Clin Rheumatol 2002 16(5):777-93.10.1053/berh.2002.026512473273  [Google Scholar]  [CrossRef]  [PubMed]

[3]. Dajpratham P, Ploypetch T, Kiattavorncharoen S, Boonsiriseth K, Prevalence and associated factors of musculoskeletal pain among the dental personnel in a dental school J Med Assoc Thai 2010 93(6):714-21.  [Google Scholar]

[4]. Jones S, Hanchard N, Hamilton S, Rangan A, A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder BMJ Open 2013 3(9):e00345210.1136/bmjopen-2013-00345224078753  [Google Scholar]  [CrossRef]  [PubMed]

[5]. Mathew AJ, Chopra A, Thekkemuriyil DV, George E, Goyal V, Nair JB, Impact of musculoskeletal pain on physical function and health-related quality of life in a rural community in south India: a WHO-ILAR-COPCORD-BJD India study Clin Rheumatol 2011 30(11):1491-97.10.1007/s10067-011-1824-021853278  [Google Scholar]  [CrossRef]  [PubMed]

[6]. Thumboo J, Chew LH, Lewin-Koh SC, Socioeconomic and psychosocial factors influence pain or physical function in Asian patients with knee or hip osteoarthritis Ann Rheum Dis 2002 61(11):1017-20.10.1136/ard.61.11.101712379527  [Google Scholar]  [CrossRef]  [PubMed]

[7]. Bot SD, Terwee CB, Van der Windt DA, Bouter LM, Dekker J, de Vet HC, Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature Ann Rheum Dis 2004 63(4):335-41.10.1136/ard.2003.00772415020324  [Google Scholar]  [CrossRef]  [PubMed]

[8]. Kirkley A, Griffin S, McLintock H, Ng L, The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability The American Journal of Sports Medicine 1998 26(6):764-72.10.1177/036354659802600605019850776  [Google Scholar]  [CrossRef]  [PubMed]

[9]. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C, Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity J Hand Ther 2001 14(2):128-46.10.1016/S0894-1130(01)80043-0  [Google Scholar]  [CrossRef]

[10]. King GJ, Richards RR, Zuckerman JD, Blasier R, Dillman C, Friedman RJ, A standardized method for assessment of elbow function. Research commitee, american shoulder and elbow surgeons J Shoulder Elbow Surg 1999 8(4):351-54.10.1016/S1058-2746(99)90159-3  [Google Scholar]  [CrossRef]

[11]. Torres-Lacomba M, Sánchez-Sánchez B, Prieto-Gómez V, Pacheco-da-Costa S, Yuste-Sánchez MJ, Navarro-Brazález B, Spanish cultural adaptation and validation of the shoulder pain and disability index, and the oxford shoulder score after breast cancer surgery Health Qual Life Outcomes 2015 13:6310.1186/s12955-015-0256-y26001890  [Google Scholar]  [CrossRef]  [PubMed]

[12]. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y, Development of a shoulder pain and disability index Arthritis Care Res 1991 4(4):143-49.10.1002/art.179004040311188601  [Google Scholar]  [CrossRef]  [PubMed]

[13]. Angst F, Schwyzer HK, Aeschlimann A, Simmen BR, Goldhahn J, Measures of adult shoulder function: disabilities of the arm, shoulder, and hand questionnaire (DASH) and its short version (QuickDASH), shoulder pain and disability index (SPADI), american shoulder and elbow surgeons (ASES) society standardized shoulder assessment form, constant (Murley) score (CS), simple shoulder test (SST), Oxford shoulder score (OSS), shoulder disability questionnaire (SDQ), and western ontario shoulder instability index (WOSI) Arthritis Care Res 2011 63(S11):S174-88.10.1002/acr.2063022588743  [Google Scholar]  [CrossRef]  [PubMed]

[14]. Angst F, Goldhahn J, Pap G, Mannion AF, Roach KE, Siebertz D, Cross-cultural adaptation, reliability and validity of the german shoulder pain and disability index (SPADI) Rheumatology 2007 46(1):87-92.10.1093/rheumatology/kel04016720638  [Google Scholar]  [CrossRef]  [PubMed]

[15]. Ebrahimzadeh MH, Birjandinejad A, Golhasani F, Moradi A, Vahedi E, Kachooei AR, Cross-cultural adaptation, validation, and reliability testing of the shoulder pain and disability index in the persian population with shoulder problems Int J Rehabil Res 2015 38(1):84-87.10.1097/MRR.000000000000008825305009  [Google Scholar]  [CrossRef]  [PubMed]

[16]. Jamnik H, Spevak MK, Shoulder pain and disability index: validation of slovene version Int J Rehabil Res 2008 31(4):337-41.10.1097/MRR.0b013e3282fcae0919008683  [Google Scholar]  [CrossRef]  [PubMed]

[17]. Jeldi AJ, Aseer AL, Dhandapani AG, Roach KE, Cross-cultural adaption, reliability and validity of an Indian (Tamil) version for the shoulder pain and disability index Hong Kong Physiotherapy Journal 2012 30(2):99-104.10.1016/j.hkpj.2012.06.001  [Google Scholar]  [CrossRef]

[18]. Marchese C, Cristalli G, Pichi B, Manciocco V, Mercante G, Pellini R, Italian cross-cultural adaptation and validation of three different scales for the evaluation of shoulder pain and dysfunction after neck dissection: university of california-los angeles (UCLA) shoulder scale, shoulder pain and disability index (SPADI) and simple shoulder test (SST) Acta Otorhinolaryngol Ital 2012 32(1):12-17.  [Google Scholar]

[19]. Martins J, Napoles BV, Hoffman CB, Oliveira AS, The brazilian version of shoulder pain and disability index: translation, cultural adaptation and reliability Rev Bras Fisioter 2010 14(6):527-36.10.1590/S1413-3555201000060001221340248  [Google Scholar]  [CrossRef]  [PubMed]

[20]. Beaton DE, Bombardier C, Guillemin F, Ferraz MB, Guidelines for the process of cross-cultural adaptation of self-report measures Spine 2000 25(24):3186-91.10.1097/00007632-200012150-0001411124735  [Google Scholar]  [CrossRef]  [PubMed]

[21]. Norkin CC, White DJ, Measurement of joint motion: a guide to goniometry 2016 5th edFA Davis  [Google Scholar]

[22]. Poovishnu Devi T, Khot S, Development of Marathi version cross-culture adaptation, reliability and validity of shoulder and disability index Int J Sci Res 2017 6(7):2088-92.10.21275/ART20175813  [Google Scholar]  [CrossRef]

[23]. Bicer A, Ankarali H, Shoulder pain and disability index: a validation study in Turkish women Singapore Med J 2010 51(11):865-70.  [Google Scholar]

[24]. Thoomes-de Graaf M, Scholten-Peeters GG, Duijn E, Karel Y, Koes BW, Verhagen AP, The dutch shoulder pain and disability index (SPADI): a reliability and validation study Qual Life Res 2015 24(6):1515-19.10.1007/s11136-014-0879-125471288  [Google Scholar]  [CrossRef]  [PubMed]

[25]. Vrouva S, Batistaki C, Koutsioumpa E, Kostopoulos D, Stamoulis E, Kostopanagiotou G, The greek version of shoulder pain and disability index (SPADI): translation, cultural adaptation, and validation in patients with rotator cuff tear J Orthop Traumatol 2016 17(4):315-24.10.1007/s10195-016-0425-827623841  [Google Scholar]  [CrossRef]  [PubMed]

[26]. Phongamwong C, Choosakde A, Reliability and validity of the thai version of the shoulder pain and disability index (Thai SPADI) Health Qual Life Outcomes 2015 13(1):13610.1186/s12955-015-0333-226337915  [Google Scholar]  [CrossRef]  [PubMed]

[27]. Luque-Suarez A, Rondon-Ramos A, Fernandez-Sanchez M, Roach KE, Morales-Asencio JM, Spanish version of SPADI (shoulder pain and disability index) in musculoskeletal shoulder pain: a new 10-items version after confirmatory factor analysis Health Qual Life Outcomes 2016 14(1):3210.1186/s12955-016-0436-426927584  [Google Scholar]  [CrossRef]  [PubMed]

[28]. Paul A, Lewis M, Shadforth MF, Croft PR, Van Der Windt DA, Hay EM, A comparison of four shoulder-specific questionnaires in primary care Ann Rheum Dis 2004 63(10):1293-99.10.1136/ard.2003.01208815361390  [Google Scholar]  [CrossRef]  [PubMed]

[29]. Roddey TS, Olson SL, Cook KF, Gartsman GM, Hanten W, Comparison of the university of california–los angeles shoulder scale and the simple shoulder test with the shoulder pain and disability index: single-administration reliability and validity Physical Therapy 2000 80(8):759-68.  [Google Scholar]