A Spanish translation of the Walking Impairment Questionnaire was validated for patients with peripheral arterial disease

doi:10.1016/j.jclinepi.2004.03.005

Journal of Clinical Epidemiology

Volume 57, Issue 12, December 2004, Pages 1305-1315

https://doi.org/10.1016/j.jclinepi.2004.03.005 Get rights and content

Abstract

Objectives

Walking impairment is a common manifestation of peripheral arterial disease (PAD). In this study we present evidence for the validity of our Spanish translation of the Walking Impairment Questionnaire (WIQ).

Methods

The WIQ was translated into Spanish by our team of researchers. Spanish-speaking patients in the Houston, TX, area completed Spanish versions of the WIQ and the SF-36. Evidence for convergent and discriminant validity of the WIQ was obtained from correlations between the WIQ and other measures. Spanish or English as the primary language defined language-speaking status.

Results

Among 403 patients, convergent validity evidence was strong for both English- and Spanish-speaking patients. For patients with PAD, the correlation between walking distance and physical functioning was 0.55 (P < .01) for English-speaking patients and 0.85 (P < .01) for Spanish-speaking patients. The correlations of walking impairment with emotional health measures ranged from 0.26 to 0.44 for English-speaking patients (P < .01) and from 0.34 to 0.78 for Spanish-speaking patients.

Conclusions

The WIQ scores correlated well with SF-36 components for both English- and Spanish-speaking patients. Our findings suggested that our translation process did not limit our ability to capture good-quality data. Further research is needed to determine what specific items in the WIQ or the SF-36 questionnaire warrant restructuring to increase their validity for use in diverse populations.

Introduction

Peripheral arterial disease (PAD) is chronic arterial insufficiency of the abdominal aorta and arteries of the lower extremities [1]. The disease can manifest as chronic leg symptoms and may result in a threatened limb.

PAD can exist in a clinically asymptomatic form or may manifest symptoms of atypical leg pain, intermittent claudication, rest pain, ulcers, or gangrene. Leg cramping, often confined to the calf and referred to as intermittent claudication, is commonly the presenting symptom for patients who are referred from their primary care doctor for noninvasive vascular lab studies. PAD can also present as the absence of pulses on a bedside exam, as the presence of classic ischemic ulcers with or without leg pain at rest, or as gangrene.

Walking impairment is common among patients with PAD [2], regardless of leg symptoms. In one study, patients with asymptomatic PAD were found to have significant compromise in walking ability [3]. The burden of walking impairment in a diverse population of patients screened for PAD has not been well defined. Most studies evaluating walking impairment have included English-speaking nonminority patients [4], [5], [6], [7]. To our knowledge, however, the validity of the widely used Walking Impairment Questionnaire (WIQ) [5] for assessing walking impairment in a primary care clinic population that includes Spanish-speaking patients has not been evaluated. We sought to ascertain convergent and discriminant validity evidence for our Spanish translation of the WIQ (Fig. 1) based on correlations between the WIQ and other measures—the Medical Outcomes Study Short-Form 36 Survey (SF-36) [8] and the ankle–brachial index (ABI)—in both English- and Spanish-speaking patients. With evidence of the validity for the Spanish translation of the WIQ, physicians can expand their assessment of PAD to patients with Spanish as their first language and subsequently improve the treatment of this debilitating disease.

Section snippets

Methods

We performed a cross-sectional screening study of patients who received care at one of four primary care clinics in Houston, TX [9]. We screened patients from the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) and three primary care clinics in the Harris County (Houston, TX) Hospital District, from September 2000 through August 2001. Bilingual research assistants contacted before patients (phone call) at the time of their clinic appointments.

Results

We approached a total of 457 patients, and 403 patients were enrolled. Within our cohort, we enrolled approximately one third of our patients from the MEDVAMC and the remainder of the patients from three sites in the Harris County Hospital District. Of the 403 patients enrolled, 67 (16.6%) had PAD. For patients with PAD, 34 of the 67 (50.7%) had disease in both legs. The population was nearly equally divided for race: 136 white, 136 African American, and 131 Hispanic. Eighty-one (61.8%) of the

Discussion

The WIQ scores, which are markers of walking impairment, correlated well with several SF-36 components, both physical and emotional, for both English- and Spanish-speaking patients; however, there were findings of compromised validity for some physical health measures and some emotional health measures among Spanish-speaking patients with PAD. These limitations warrant further discussion.

The psychometric properties of health status questionnaires have been assessed by determining various

Acknowledgments

The authors thank Mark Kuebeler, MS, for programming support.

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Cited by (26)

Gujarati translation, validity and reliability of Walking Impairment Questionnaire in people with intermittent claudication due to peripheral artery disease
2024, Journal of Vascular Nursing
The Walking Impairment Questionnaire (WIQ) is a common and easy-to-use assessment of walking incapacity in people with claudication due to peripheral artery disease (PAD). It has four subscales: pain severity, walking distance, walking speed, and ability to climb stairs. It has not been translated into Gujarati, which limits its use in Indian subjects.
This study aims to translate and assess the validity and reliability of a Gujarati version of WIQ.
This study had three phases: 1. Forward and backward translation and Cultural adaptation of WIQ into the Gujarati language by two independent translators, 2. Face and content validation by six clinical reviewers and 10 participants with PAD and Type II diabetes, 3. Concurrent and construct validity, test-retest reliability, and internal consistency of Gujarati, the WIQ was assessed on 160 participants with PAD and Type II diabetes who had a mean Ankle Brachial Index (standard deviation) <0.40 (0.1). The concurrent and construct validity of the WIQ was analyzed by correlating the WIQ distance and speed score with 6-minute walk distance (6MWD) and speed and WIQ total score with the Medical Outcome Study Questionnaire Short Form 36 (SF-36) score using Pearson's correlation coefficient. Test-retest reliability was analyzed using an intraclass correlation coefficient (ICC) with a seven-day interval between two questionnaire applications. Internal consistency of the total WIQ score was determined using Cronbach's alpha.
Following translation, the Gujarati WIQ was considered acceptable and understandable by people with PAD. There was excellent correlation between the WIQ distance score and 6-minute walk test distance (r = 0.95, P < .05)) , the WIQ speed score and 6-minute walk test speed score (r = 0.89, P < .05)) and the Gujarati WIQ total score and total score of physical functioning domain of SF- 36 (r = 0.99, P < .05). There was excellent test-retest reliability over 7 days for total WIQ score (ICC = 0.94). The Cronbach's alpha for internal consistency of 0.97 for total WIQ score were excellent. This demonstrates the sufficient homogeneity of the total questionnaire.
The Gujarati version of the WIQ is reliable and valid and can be used to assess self-reported walking impairment in Gujarati-speaking people with PAD and Type II Diabetes.
Google Maps offers a new way to evaluate claudication
2017, Journal of Vascular Surgery
Accurate determination of walking capacity is important for the clinical diagnosis and management plan for patients with peripheral arterial disease. The current “gold standard” of measurement is walking distance on a treadmill. However, treadmill testing is not always reflective of the patient's natural walking conditions, and it may not be fully accessible in every vascular clinic. The objective of this study was to determine whether Google Maps, the readily available GPS-based mapping tool, offers an accurate and accessible method of evaluating walking distances in vascular claudication patients.
Patients presenting to the outpatient vascular surgery clinic between November 2013 and April 2014 at the Ottawa Hospital with vasculogenic calf, buttock, and thigh claudication symptoms were identified and prospectively enrolled in our study. Onset of claudication symptoms and maximal walking distance (MWD) were evaluated using four tools: history; Walking Impairment Questionnaire (WIQ), a validated claudication survey; Google Maps distance calculator (patients were asked to report their daily walking routes on the Google Maps-based tool runningmap.com, and walking distances were calculated accordingly); and treadmill testing for onset of symptoms and MWD, recorded in a double-blinded fashion.
Fifteen patients were recruited for the study. Determination of walking distances using Google Maps proved to be more accurate than by both clinical history and WIQ, correlating highly with the gold standard of treadmill testing for both claudication onset (r = .805; P < .001) and MWD (r = .928; P < .0001). In addition, distances were generally under-reported on history and WIQ. The Google Maps tool was also efficient, with reporting times averaging below 4 minutes.
For vascular claudicants with no other walking limitations, Google Maps is a promising new tool that combines the objective strengths of the treadmill test and incorporates real-world walking environments. It offers an accurate, efficient, inexpensive, and readily accessible way to assess walking distances in patients with peripheral vascular disease.
Patient-reported outcome measures in vascular surgery
2015, Seminars in Vascular Surgery
Citation Excerpt :
It is one of the first disease-specific questionnaires for assessing functional status in PAD patients and, as such, is the most frequently reported PAD-specific QOL instrument in the literature [5]. It is available in many different languages, including English [48], Dutch [49], Spanish [50], Portuguese [51], Japanese [52], German [53], and Chinese [54], and is used throughout the world to assess treatment effects among patients with PAD. The WIQ consists of 22 items assessing four QOL domains, including pain, distance, walking speed, and stair climbing.
Patient-reported outcomes (PROs) after vascular surgery are becoming increasingly important in the current era of health care reform. Although a number of general quality of life instruments exist, vascular disease−specific instruments may provide more targeted data on how patients feel after specific interventions. Here we provide a review of both generic and disease-specific instruments focused on arterial conditions, including peripheral arterial disease, carotid arterial disease, and aortic disease, which have been described in the literature. While many different tools currently exist, there is a paucity of well-validated, specific instruments that accurately reflect functional and objective measures of patients’ arterial disease burden. A full understanding of the existing tools available to assess patients’ perceived lifestyle impact of their disease and its treatments is essential for both research and clinical purposes, and to highlight the need for additional work on this topic.
Assessing the quality of available patient reported outcome measures for intermittent claudication: A systematic review using the COSMIN checklist
2015, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Several modifications of the WIQ have emerged since its development in 1990.37 The symptoms subscale of the original version is currently often replaced by a stair climbing scale, but studies using a WIQ with an added Pain scale were also found.26,35,36,38–53 Owing to the different versions of the WIQ, it was sometimes possible to pool the evidence only per subscale, and not for the entire instrument (Table 7).
The aim was to critically appraise, compare, and summarize the quality of the measurement properties of all available disease specific patient reported outcome measures (PROMs) on health related quality of life and functional status validated in patients with intermittent claudication (IC).
A systematic search was carried out in Embase and Medline (last search November 18, 2013). The quality of the identified studies was assessed per measurement property according to the COnsensus-based Standards for the selection of health Measurements Instruments (COSMIN) checklist. Data on the measurement properties were extracted to determine a level of evidence per measurement property per instrument.
Forty three studies were found evaluating 10 health related quality of life and two functional status PROMs. Evidence for the existence of subscales (structural validity) and for internal consistency (interrelatedness of items within subscales) for PROMs was generally poor. Evidence for construct validity was limited. Accuracy and reproducibility of PROMs were often uncertain, since reliability studies were mostly performed in small patient samples. Responsiveness, or the ability of PROMs to detect change over time, was hardly ever studied.
The quality of the validation of most disease specific PROMs for IC is alarming, hampering all conclusion based on these PROMs. Considering the results, the PAD quality of life questionnaire (PADQOL), Intermittent claudication questionnaire (ICQ) and the Vascular quality of life questionnaire (VascuQol) might be appropriate PROMs for health related quality of life, while the Walking impairment questionnaire (WIQ) and Estimate ambulation capacity by history questionnaire (EACH-Q) appear suitable PROMs for functional status. However, all PROMs require further validation studies to fill the gaps in their measurement properties. The shortcomings highlighted in this review should be taken into account when interpreting PROM results.
Profile of patients with intermittent claudication in Spain. the VITAL Study
2013, Angiologia
La claudicación intermitente (CI) es frecuente entre la población occidental, incluida la española; sin embargo, sus características no son bien conocidas.
El objetivo del estudio es conocer el perfil de los pacientes españoles con CI.
Estudio prospectivo, observacional, transversal, multicéntrico y no aleatorizado sobre 1.641 claudicantes, divididos en 2 grupos: a) angiología y cirugía vascular (ACV) (n = 920), y b) atención primaria (MAP) (n = 721). Los pacientes fueron sometidos a un cuaderno de recogida de datos (CRD), analítica, índice tobillo/brazo (ITB), cuestionario Walking Impairment Questionaire (WIQ) y cuestionario europeo de calidad de vida (EQ-5D).
Fueron varones el 75,3%, de 68,3 ± 9,4 años, destacando sobremanera el elevado número de factores de riesgo cardiovascular y enfermedades asociadas (fundamentalmente cardiacas), más frecuente en el grupo ACV. El ITB de la serie 0,66 ± 0,19, inferior en grupo ACV (p = 0,001). Los porcentajes WIQ fueron: daños motores (48,57 ± 20,12), distancia (35,09 ± 25,73), velocidad (36,18 ± 22,83) y escaleras (41,76 ± 27,62), peores en lo relativo a los daños motores (p < 0,001) y distancia (p = 0,007) en el grupo ACV. La puntuación EQ-5D fue 0,57 ± 0,21, sin diferencias entre grupos.
Los pacientes españoles con CI presentan 3 características: alto riesgo cardiovascular, limitada capacidad para el ejercicio e importante reducción de la calidad de vida. Existen diferencias entre grupos, dado que los ACV tratan pacientes con enfermedad más avanzada.
Intermittent claudication (IC) is a very prevalent condition in Western countries including the population of Spain. However, little is known about the medical profile and quality of life (QoL) of the IC in Spain.
To determine the clinical characteristics and QoL in a large sample of Spanish patients with IC.
An observational, prospective, cross sectional and multicentre study was performed between October 2010 and January 2011, with 625 investigators recruiting 1,641 consecutive patients with claudication. The sample was divided into two groups: a) patients evaluated by vascular surgeons (VS) (n = 920), and b) patients evaluated by general practitioners (GP) (n = 721). Demographical and clinical characteristics, analytical findings (glucose levels and lipid metabolism) and the Ankle-Brachial Index (ABI) were recorded. Each patient included in the study also filled in two questionnaires: the Walking impairment Questionnaire (WIQ) and the European Quality of Life-5 Dimensions (EQ-5D).
The population mean age was 68.3 ± 9.4 years; in 75.3% of the cases the patients were males. The presence of risk cardiovascular factors (49.5% of diabetes; 76.9% of hypertension and 65.3% of dyslipemia) and comorbid conditions (in particular, cardiovascular diseases) were high. The mean ABI of the series was 0.66 ± 0.19. Patients in the VS group had more severe IC than patients from GP Group (ABI = 0.63 vs ABI = 0.71, P<.001). WIQ scores obtained were: a) walking distance = 35.09 ± 25.73; b) walking speed = 36.18 ± 22.83, and c) stair-climbing capacity = 41.76 ± 27.62. We only found significant statistical differences in walking distance between the VS Group and GP Group. The global EQ-5D score was 0,57 ± 0,21. No significant differences were observed between the VS and GP groups.
Spanish patients with IC showed three characteristics: high cardiovascular risk, limited ability to tolerate exercise, and reduction in the quality of their life. There are differences between groups; compared to general practitioners, vascular surgeons treated patients with more advanced disease.
Assessment of functional status and quality of life in claudication
2011, Journal of Vascular Surgery
Citation Excerpt :
The Walking Impairment Questionnaire (WIQ) was one of the first disease-specific questionnaires for assessing functional status in PAD patients and remains widely used.66 The WIQ was validated in several large studies and is available in many different languages.67-72 In the initial validation as well as in subsequent studies, the questionnaire results were correlated to treadmill measures of performance (ie, peak walking distance, peak oxygen consumption, and onset of claudication pain) in PAD patients.66
Treadmill walking is commonly used to evaluate walking impairment and efficacy of treatment for intermittent claudication (IC) in clinical and research settings. Although this is an important measure, it does not provide information about how patients perceive the effects of their treatments on more global measures of health-related quality of life (HRQOL).
PubMed/Medline was searched to find publications about the most commonly used questionnaires to assess functional status and/or general and disease-specific HRQOL in patients with peripheral artery disease (PAD) who experience IC. Inclusion criteria for questionnaires were based on existence of a body of literature in symptomatic PAD.
Six general questionnaires and seven disease-specific questionnaires are included, with details about the number of domains covered and how each tool is scored. The Medical Outcomes Study Short Form 36-item questionnaire and Walking Impairment Questionnaire are currently the most used general and disease-specific questionnaires at baseline and after treatment for IC, respectively.
The use of tools that assess functional status and HRQOL has importance in both the clinical and research areas to assess treatment efficacy from the patient's perspective. Therefore, assessing HRQOL in addition to treadmill-measured walking ability provides insight as to the effects of treatments on patient outcomes and may help guide therapy.

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: This article is the result of work supported with resources and the use of facilities at the Houston Center for Quality of Care and Utilization Studies, Houston Veterans Affairs Medical Center. Partial support for the development of the manuscript came from the Measurement Excellence Initiative (MEI), SDR 01-044.

¹: Dr. Collins was a recipient of a Robert Wood Johnson Minority Medical Faculty Development Award at the time that this work was completed.

²: Dr. O'Malley was an investigator at the Houston Center for Quality of Care and Utilization Studies at the time this work was completed.

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Original ArticleA Spanish translation of the Walking Impairment Questionnaire was validated for patients with peripheral arterial disease

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

J Vasc Surg

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment

JAMA

Functional status and mobility among elderly women with lower extremity arterial disease: the Study of Osteoporotic Fractures

J Am Geriatr Soc

Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease

J Vasc Med Biol

Exercise in the treatment of claudication: assessment and treatment of functional impairment

Vasc Med

Hospital vs home-based exercise rehabilitation for patients with peripheral arterial occlusive disease

Angiology

SF-36 physical and mental health summary scales: a user's manual

The prevalence of peripheral arterial disease in a racially diverse population

Arch Intern Med

The correlation between symptoms and non-invasive test results in patients referred for peripheral arterial disease testing

Vasc Med

SF-36 health survey: manual and interpretation guide

Techniques of attitude scale construction

Original Article
A Spanish translation of the Walking Impairment Questionnaire was validated for patients with peripheral arterial disease