Abstract

Introduction

In the past few years, assessing Health-Related Quality of Life (HRQoL) based on a patient's perception of their condition and its treatment effects has raised interest among physicians and researchers¹1. Asher MA, Lai SM, Burton DC. Further Development and Validation of the Scoliosis Research Society (SRS) Outcomes Instrument. Spine (Phila Pa 1976). 2000;25:2381-6. PMid:10984792. http://dx.doi.org/10.1097/00007632-200009150-00018
http://dx.doi.org/10.1097/00007632-20000...

2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... ^{- 3}3. Danielsson AJ, Wiklund I, Pehrsson K, Nachemson AL. Health-Related Quality of Life in Patients With Adolescent Idiopathic Scoliosis: A Matched Follow-up at Least 20 Years After Treatment With Brace or Surgery. Eur Spine J. 2001;10:278-88. PMid:11563612 PMCid:PMC3611508. http://dx.doi.org/10.1007/s005860100309
http://dx.doi.org/10.1007/s005860100309... . Objective measures, although highly useful, are weakly related to patients' actual concerns, which include concerns about their symptoms and the functional, social and psychological aspects of their condition⁴4. Feise RJ, Donaldson S, Crowther ER,Menke JM, Wright JG. Construction and Validation of the Scoliosis Quality of Life Index in Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976). 2005;30:1310-1315. PMid:15928558. http://dx.doi.org/10.1097/01.brs.0000163885.12834.ca
http://dx.doi.org/10.1097/01.brs.0000163...

5. Kirkley A, Griffin S. Development of Disease-Specific Quality of Life Measurement Tools. Arthroscopy. 2003;19:1121-8. PMid:14673455. http://dx.doi.org/10.1016/j.arthro.2003.10.028
http://dx.doi.org/10.1016/j.arthro.2003....

6. Padua R, Padua S, Aulisa L, Ceccarelli E, Padua L, Romanini E, et al. Patient Outcomes After Harrington Instrumentation for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2001;26:1268-73. PMid:11389396. http://dx.doi.org/10.1097/00007632-200106010-00019
http://dx.doi.org/10.1097/00007632-20010... ^{- 7}7. Padua R, Padua L, Ceccarelli E, Romanini E, Bondì R, Zanoli G, et al. Cross-Cultural Adaptation of the Lumbar North American Spine Society Questionnaire for Italian-Speaking Patients With Lumbar Spinal Disease. Spine (Phila Pa 1976). 2001;26:E344-7. PMid:11474366. http://dx.doi.org/10.1097/00007632-200108010-00012
http://dx.doi.org/10.1097/00007632-20010... . Hence, subjective measures can be an important complement to a traditional clinical evaluation⁷7. Padua R, Padua L, Ceccarelli E, Romanini E, Bondì R, Zanoli G, et al. Cross-Cultural Adaptation of the Lumbar North American Spine Society Questionnaire for Italian-Speaking Patients With Lumbar Spinal Disease. Spine (Phila Pa 1976). 2001;26:E344-7. PMid:11474366. http://dx.doi.org/10.1097/00007632-200108010-00012
http://dx.doi.org/10.1097/00007632-20010... ^{, 8}8. Dawson J, Carr A. Outcomes Evaluation in Orthopaedics. J Bone Joint Surg Br. 2001;83:313-135. http://dx.doi.org/10.1302/0301-620X.83B3.12148
http://dx.doi.org/10.1302/0301-620X.83B3... , and as a result, many instruments aimed at assessing such subjective measures have been developed⁹9. Niemeyer T, Schubert C, Halm HF, Herberts T, Leichtle C, Gesicki M. Validity and Reliability of an Adapted German Version of Scoliosis Research Society-22 Questionnaire. Spine (Phila Pa 1976). 2009;34:818-21. PMid:19365251. http://dx.doi.org/10.1097/BRS.0b013e31819b33be
http://dx.doi.org/10.1097/BRS.0b013e3181... .

Idiopathic scoliosis is a tridimensional deformity that primarily affects females. Previous studies have shown that this condition negatively impacts patients' quality of life¹⁰10. Freidel K, Petermann F, Reichel D, Steiner A, Warschburger P, Weiss HR. Quality of life in Women With Idiopathic Scoliosis. Spine (Phila Pa 1976). 2002;27:E87-E91. PMid:11840115. http://dx.doi.org/10.1097/00007632-200202150-00013
http://dx.doi.org/10.1097/00007632-20020... ^{, 11}11. Schwab F, Dubey A, Pagala H, Gamez L, Farcy JP. Adult Scoliosis: A Health Assessment Analysis by SF-36. Spine (Phila Pa 1976). 2003;28:602-606. PMid:12642769. http://dx.doi.org/10.1097/01.BRS.0000049924.94414.BB
http://dx.doi.org/10.1097/01.BRS.0000049... . Scoliosis was previous related to altered self-image and mental health, and to functional limitations and pain³3. Danielsson AJ, Wiklund I, Pehrsson K, Nachemson AL. Health-Related Quality of Life in Patients With Adolescent Idiopathic Scoliosis: A Matched Follow-up at Least 20 Years After Treatment With Brace or Surgery. Eur Spine J. 2001;10:278-88. PMid:11563612 PMCid:PMC3611508. http://dx.doi.org/10.1007/s005860100309
http://dx.doi.org/10.1007/s005860100309... ^{, 6}6. Padua R, Padua S, Aulisa L, Ceccarelli E, Padua L, Romanini E, et al. Patient Outcomes After Harrington Instrumentation for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2001;26:1268-73. PMid:11389396. http://dx.doi.org/10.1097/00007632-200106010-00019
http://dx.doi.org/10.1097/00007632-20010... ^{, 10}10. Freidel K, Petermann F, Reichel D, Steiner A, Warschburger P, Weiss HR. Quality of life in Women With Idiopathic Scoliosis. Spine (Phila Pa 1976). 2002;27:E87-E91. PMid:11840115. http://dx.doi.org/10.1097/00007632-200202150-00013
http://dx.doi.org/10.1097/00007632-20020...

11. Schwab F, Dubey A, Pagala H, Gamez L, Farcy JP. Adult Scoliosis: A Health Assessment Analysis by SF-36. Spine (Phila Pa 1976). 2003;28:602-606. PMid:12642769. http://dx.doi.org/10.1097/01.BRS.0000049924.94414.BB
http://dx.doi.org/10.1097/01.BRS.0000049...

12. Goldberg MS, Mayo NE, Poitras B, Scott S, Hanley J. The Ste-Justine Adolescent Idiopathic Scoliosis Cohort Study. Part II: Perception of Health, Self and Body Image, and Participation in Physical Activities. Spine (Phila Pa 1976). 1994;19:1562-72. PMid:7939992. http://dx.doi.org/10.1097/00007632-199407001-00004
http://dx.doi.org/10.1097/00007632-19940...

13. Parent EC, Hill D, Moreau M, Mahood J, Raso J, Lou E. Score Distribution of the Scoliosis Quality of Life Index Questionnaire in Different Subgroups of Patients With Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976). 2007;32:1767-77. PMid:17632398. http://dx.doi.org/10.1097/BRS.0b013e3180b9f7a5
http://dx.doi.org/10.1097/BRS.0b013e3180... ^{- 14}14. Payne WK 3rd, Ogilvie JW, Resnick MD, Kane RL, Transfeldt EE, Blum RW. Does Scoliosis Have a Psychological Impact and Does Gender Make a Difference?. Spine (Phila Pa 1976). 1997;22:1380-1384. PMid:9201842. http://dx.doi.org/10.1097/00007632-199706150-00017
http://dx.doi.org/10.1097/00007632-19970... . For these reasons, it is important to measure patients' quality of life.

HRQoL is primarily measured using self-administered questionnaires. Psychometric properties of these scales, such as score distribution, validity, reliability and sensibility, must be determined¹⁵15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030...

16. Campos CC, Manzano GM, Andrade LB, Castelo A Fº, Nóbrega JAM. Tradução e Validação do Questionário de Avaliação de Gravidade dos Sintomas e do Estado Funcional na Síndrome do Túnel do Carpo. Arq Neuropsiquiatr. 2003;61:51-55. PMid:12715019. http://dx.doi.org/10.1590/S0004-282X2003000100009
http://dx.doi.org/10.1590/S0004-282X2003...

17. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol. 1999;39:143-50. ^{- 18}18. Padua R, Padua L, Ceccarelli E, Romanini E, Zanoli G, Bondì R, et al. Italian Version of the Roland Disability Questionnaire, specific for low back pain: cross-cultural adaptation and validation. Eur Spine J. 2002;11:126-9. PMid:11956918 PMCid:PMC3610499. http://dx.doi.org/10.1007/s005860100262
http://dx.doi.org/10.1007/s005860100262... .

A well-accepted tool in the evaluation of patients' perception of their condition is the Scoliosis Research Society-22 (SRS-22) questionnaire. This questionnaire was developed in English, is specific for patients with idiopathic scoliosis¹⁵15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030... , and has been validated in patients with adult scoliosis, including patients with de novo scoliosis¹⁹19. Baldus C, Bridwell KH, Harrast J, Edwards C 2nd, Glassman S, Horton W, et al. Age-Gender Matched Comparison of SRS Instrument Scores Between Adult Deformity and Normal Adults. Are all SRS Domains Desease Specific? Spine (Phila Pa 1976). 2008;33:2214-8. PMid:18794764. http://dx.doi.org/10.1097/BRS.0b013e31817c0466
http://dx.doi.org/10.1097/BRS.0b013e3181...

20. Bridwell KH, Berven S, Glassman S, Hamill C, Horton WC 3rd, Lenke LG, et al. Is the SRS-22 Instrument Responsive to Change in Adult Scoliosis Patients Having Primary Spinal Deformity Surgery? Spine (Phila Pa 1976). 2007;32:2220-5. PMid:17873814. http://dx.doi.org/10.1097/BRS.0b013e31814cf120
http://dx.doi.org/10.1097/BRS.0b013e3181... ^{- 21}21. Bridwell KH, Cats-Baril W, Harrast J, Berven S, Glassman S, Farcy JP, et al. The Validity of the SRS-22 Instrument in an Adult Spinal Deformity Population Compared With the Oswestry and SF-12. Spine (Phila Pa 1976). 2005;30:455-61. PMid:15706344. http://dx.doi.org/10.1097/01.brs.0000153393.82368.6b
http://dx.doi.org/10.1097/01.brs.0000153... . The original SRS HRQoL instrument was developed by Haher et al.²²22. Haher TR, Gorup JM, Shin TM, Homel P, Merola AA, Grogan DP, et al. Results of the Scoliosis Research Society Instrument for Evaluation of Surgical Outcome in Adolescent Idiopathic Scoliosis. A Multicenter Study of 224 Patients. Spine (Phila Pa 1976). 1999;24:1435-40. PMid:10423788. http://dx.doi.org/10.1097/00007632-199907150-00008
http://dx.doi.org/10.1097/00007632-19990... and had 24 questions. Following several modifications to improve its psychometric properties, it became the SRS-22 version¹1. Asher MA, Lai SM, Burton DC. Further Development and Validation of the Scoliosis Research Society (SRS) Outcomes Instrument. Spine (Phila Pa 1976). 2000;25:2381-6. PMid:10984792. http://dx.doi.org/10.1097/00007632-200009150-00018
http://dx.doi.org/10.1097/00007632-20000... ^{, 15}15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030... . This version had acceptable validity, reliability and sensibility values¹⁵15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030... ^{, 23}23. Asher MA, Lai SM, Burton D, Manna B. Scoliosis Research Society-22 Patient Questionnaire: Responsiveness to Change Associated With Surgical Treatment. Spine (Phila Pa 1976). 2003;28:70-3. PMid:12544959. http://dx.doi.org/10.1097/00007632-200301010-00016
http://dx.doi.org/10.1097/00007632-20030... ^{, 24}24. Asher MA, Lai SM, Burton D, Manna B. Discrimination Validity of the Scoliosis Research Society-22 Patient Questionnaire. Spine (Phila Pa 1976). 2003;28:74-78. PMid:12544960. http://dx.doi.org/10.1097/00007632-200301010-00017
http://dx.doi.org/10.1097/00007632-20030... . However, Asher et al.²⁵25. Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS-22 Health-Related Quality of Life Questionnaire Function Domain. Spine (Phila Pa 1976). 2006;31:593-7. PMid:16508558. http://dx.doi.org/10.1097/01.brs.0000201331.50597.ea
http://dx.doi.org/10.1097/01.brs.0000201... demonstrated that the internal consistency of the Function domain decreased when administered to patients under 18 years old. For this reason, the questionnaire was altered once more and was renamed the Revised Scoliosis Research Society-22 (SRS-22r). This questionnaire has 22 questions divided into five domains: function/activity, pain, self-image/appearance, mental health and satisfaction with management. Each domain contains five questions, except the satisfaction with management domain, which contains two questions. Each item can be scored from 1 (worst possible) to 5 (best possible). The function/activity, pain, self-image and mental health domains have a total score ranging from 5 to 25. The satisfaction with management domain has a total score ranging from 2 to 10. The maximum total score is 110 and the results are expressed as a mean²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... ^{, 15}15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030... .

With a few exceptions, self-evaluation questionnaires have been developed for use in English-speaking countries. In order for the questionnaire to be used in a country with a different culture and language, it is not enough to merely translate it from the original language because the simple translation can alter the conceptual equivalence of the original instrument³3. Danielsson AJ, Wiklund I, Pehrsson K, Nachemson AL. Health-Related Quality of Life in Patients With Adolescent Idiopathic Scoliosis: A Matched Follow-up at Least 20 Years After Treatment With Brace or Surgery. Eur Spine J. 2001;10:278-88. PMid:11563612 PMCid:PMC3611508. http://dx.doi.org/10.1007/s005860100309
http://dx.doi.org/10.1007/s005860100309... ^{, 6}6. Padua R, Padua S, Aulisa L, Ceccarelli E, Padua L, Romanini E, et al. Patient Outcomes After Harrington Instrumentation for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2001;26:1268-73. PMid:11389396. http://dx.doi.org/10.1097/00007632-200106010-00019
http://dx.doi.org/10.1097/00007632-20010... ^{, 16}16. Campos CC, Manzano GM, Andrade LB, Castelo A Fº, Nóbrega JAM. Tradução e Validação do Questionário de Avaliação de Gravidade dos Sintomas e do Estado Funcional na Síndrome do Túnel do Carpo. Arq Neuropsiquiatr. 2003;61:51-55. PMid:12715019. http://dx.doi.org/10.1590/S0004-282X2003000100009
http://dx.doi.org/10.1590/S0004-282X2003...

17. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol. 1999;39:143-50. ^{- 18}18. Padua R, Padua L, Ceccarelli E, Romanini E, Zanoli G, Bondì R, et al. Italian Version of the Roland Disability Questionnaire, specific for low back pain: cross-cultural adaptation and validation. Eur Spine J. 2002;11:126-9. PMid:11956918 PMCid:PMC3610499. http://dx.doi.org/10.1007/s005860100262
http://dx.doi.org/10.1007/s005860100262... ^{, 26}26. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine (Phila Pa 1976). 2000;25:3186-91. PMid:11124735. http://dx.doi.org/10.1097/00007632-200012150-00014
http://dx.doi.org/10.1097/00007632-20001...

27. Bullinger M, Alonso J, Apolone G, Leplège A, Sullivan M, Wood-Dauphinee S, et al. Translating Health Status Questionnaires and Evaluating Their Quality: The IQOLA Project Approach. J Clin Epidemiol. 1998;51:913-23. http://dx.doi.org/10.1016/S0895-4356(98)00082-1
http://dx.doi.org/10.1016/S0895-4356(98)...

28. Chaory K, Fayad F, Rannou F, Lefèvre-Colau MM, Fermanian J, Revel M, et al. Validation of the French version of the fear avoidance belief questionnaire. Spine (Phila Pa 1976). 2004;29:908-13. PMid:15082995. http://dx.doi.org/10.1097/00007632-200404150-00018
http://dx.doi.org/10.1097/00007632-20040... ^{- 29}29. Guillemin F, Bombardier C, Beaton D. Cross-Cultural Adaptation of Health-Related Quality of Measures: Literature Review and Proposed Guidelines. J Clin Epidemiol. 1993;46:1417-1432. http://dx.doi.org/10.1016/0895-4356(93)90142-N
http://dx.doi.org/10.1016/0895-4356(93)9... . The development of a new version requires transcultural adaptation to account for existing cultural and language differences. Moreover, the conception of quality of life varies among different cultures. Rosanova et al.³⁰30. Rosanova GC, Gabriel BS, Camarini PM, Gianini PE, Coelho DM, Oliveira AS. Concurrent Validity of the Brazilian Version of SRS-22r with Br-Sf-36. Rev Bras Fisioter. 2010;14(2):121-6. PMid:20464160. http://dx.doi.org/10.1590/S1413-35552010005000012
http://dx.doi.org/10.1590/S1413-35552010... verified that the Brazilian version of the SRS-22r questionnaire has satisfactory concurrent validity. This was determined by correlating the Brazilian tool with the Brazilian SF-36 questionnaire. However, the cross-cultural adaptation steps were not described. Additionally, the questionnaire's reliability, which is an important psychometric property, was not reported.

Thus, the aim of this study was to describe the cultural adaptation of the SRS-22r questionnaire for the Brazilian Portuguese language and to determine its reliability. This report will provide more complete information about the questionnaire.

Method

Forty-four volunteers, 40 females and 4 males, participated in this study. Participants were recruited by convenience from orthopedic private practices, public orthopedic clinics in the region and the school hospital of the Ribeirão Preto Medical School. Patients were contacted by three of the authors, who also administered the questionnaires. Clinical diagnostics were assessed by orthopedic surgeons. In addition, posterior-anterior standing radiographic images were used to measure each patient's Cobb angle. The mean age of the participants was 18.93 years (ranged from 12 to 36 years) and their average magnitude of scoliosis curve was 54.6° Cobb angle (ranged to 10 to 92° Cobb angle). Four female patients underwent surgery and reached 20.5° Cobb of correction in average. The postoperative curves of these four patients were used in the calculation of the average magnitude of the scoliotic curve. Illiterate patients and patients under 12 years old were excluded due to their limited ability to properly understand or read the questionnaire²⁶26. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine (Phila Pa 1976). 2000;25:3186-91. PMid:11124735. http://dx.doi.org/10.1097/00007632-200012150-00014
http://dx.doi.org/10.1097/00007632-20001... . Individuals with any other musculoskeletal impairments or neurologic pathologies were excluded.

This study protocol was approved by the Ethics Committee for Research Involving Humans Beings of the Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil (approval number 9853/2005). The volunteers signed an Informed Consent prior to study participation. For those individuals under 18 years old, parents or legal guardians signed this document to consent to participation.

Cultural adaptation

The SRS-22r questionnaire was subjected to the cultural adaptation process proposed by Beaton et al.²⁶26. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine (Phila Pa 1976). 2000;25:3186-91. PMid:11124735. http://dx.doi.org/10.1097/00007632-200012150-00014
http://dx.doi.org/10.1097/00007632-20001... and recommended by the American Academy of Orthopedic Surgeons (AAOS).

Two independent translations, T1 and T2, were initially performed by two native Brazilian bilingual translators. Next, a synthesis of these two translations, the T-12 version, was produced. Afterwards, the synthesis was translated back into the English language independently by two American translators living in Brazil, resulting in the back-translations BT1 and BT2. This process is used to determine if the translated version reflects the original content of the questionnaire. Next, an expert committee composed of two orthopedic physicians, two physical therapists and one English Language teacher (non-native) revised the T-12 version, the back-translations and the original questionnaire. The committee examined the discrepancies with the aim of resolving them through a consensus and producing a pre-final version of the Brazilian questionnaire. The group's decisions were made with the goal of achieving semantic, idiomatic, experimental and conceptual equivalence with the original instrument. Some alterations were needed to adjust the tool to assess Brazilian patients with idiopathic scoliosis.

The pre-final version was administered to 44 volunteers with idiopathic scoliosis. Patients were instructed to not answer questions that they did not understand or questions that did not apply to themselves. The expert committee could have been required to meet once more to judge and propose changes for answer items or whole questions that were not answered by more than 15% of participants (6 or more volunteers). Proposed changes would maintain the original concept and a new pretesting would be repeated until all questions have good level of understanding¹⁶16. Campos CC, Manzano GM, Andrade LB, Castelo A Fº, Nóbrega JAM. Tradução e Validação do Questionário de Avaliação de Gravidade dos Sintomas e do Estado Funcional na Síndrome do Túnel do Carpo. Arq Neuropsiquiatr. 2003;61:51-55. PMid:12715019. http://dx.doi.org/10.1590/S0004-282X2003000100009
http://dx.doi.org/10.1590/S0004-282X2003... . The Brazilian Scoliosis Research Society Revised Questionnaire (SRS-22r) can be seen in ^{Appendix 1} Appendix A . The score sheet is presented in ^{Appendix 2} Appendix B .

Data analysis

Reliability measures included statistics measuring internal consistency and test/retest reproducibility. Internal consistency was assessed with Cronbach's alpha statistic and test/retest reliability was determined using the Intraclass Correlation Coefficient (ICC 2.1).

Floor effects were not seen in any domain of the questionnaire. Ceiling effects were observed in the Pain and Treatment Satisfaction domains.

Results

Test of the pre-final version

After administering it to forty-four individuals with idiopathic scoliosis, the questionnaire was analyzed for its level of comprehension. Campos et al.¹⁶16. Campos CC, Manzano GM, Andrade LB, Castelo A Fº, Nóbrega JAM. Tradução e Validação do Questionário de Avaliação de Gravidade dos Sintomas e do Estado Funcional na Síndrome do Túnel do Carpo. Arq Neuropsiquiatr. 2003;61:51-55. PMid:12715019. http://dx.doi.org/10.1590/S0004-282X2003000100009
http://dx.doi.org/10.1590/S0004-282X2003... posit that the misunderstood questions or those that did not apply for more than 15% of the studied sample should be changed to preserve their cultural equivalence. In this study, a question would be changed if at least 6 participants did not answer it. The pre-final version of the Portuguese SRS-22r did not require alterations because no question was left unanswered by more than 15% of the participants in the studied sample.

However, during this phase, a deficiency was noted by the interviewer in the Brazilian version of question 11, as follows:

"Which one of the following best describes your pain medication use for back pain?"

None

Non-narcotics weekly or less (e.g.: aspirin, diclofenac, dipyrone)

Non-narcotics daily (e.g.: aspirin, diclofenac, dipyrone)

Narcotics weekly or less (e.g.: amitriptyline)

Others

Medication: ___________________________________

Use (the whole week or less or everyday): _______________

Of the ten volunteers who affirmed consuming medication for back pain, four chose the last answer "others", but the blank space was used to indicate infrequent drug intake, or drug intake only when pain was present. This item, however, holds the lowest score in the question, representing the worst option. The committee assumed that these patients chose this item because they did not understand the previous higher-score items indicating less frequent medication usage. Based on the Spanish version proposed by Bago et al.²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... , the items in this question were changed as follows:

"Which one of the following best describes your pain medication use for back pain?"

None

Non-narcotics weekly or less (e.g.: aspirin, diclofenac, dipyrone or others)

Non-narcotics daily (e.g.: aspirin, diclofenac, dipyrone or others)

Narcotics weekly or less

Narcotics daily

Table 1 presents the average scores for the 44 volunteers for each domain. The minimum and maximum average scores for each domain and the score distributions are also shown.

Reliability

The test/retest reliability calculation was carried out using data from thirty of the forty-four volunteers enrolled in the pre-final test. The ICC (2.1) values are presented in Table 2. All domains had excellent ICC values, above 0.90.

The internal consistency values are presented in Table 3. The domains Pain (0.80), Self-image (0.82), and Mental Health (0.85) had very good internal consistency. Internal consistency values were good for the Function (0.77) and Management Satisfaction domains (0.70).

Unlike in the original and Spanish versions, question 15 had little influence on the internal consistency values in the Function domain. Without this question, Cronbach's alpha decreases from 0.77 to 0.75.

Discussion

The important characteristics of a questionnaire are its score distribution and its psychometric properties, specifically reliability, validity and responsiveness¹⁵15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030... . A previous study published by Rosanova et al.³⁰30. Rosanova GC, Gabriel BS, Camarini PM, Gianini PE, Coelho DM, Oliveira AS. Concurrent Validity of the Brazilian Version of SRS-22r with Br-Sf-36. Rev Bras Fisioter. 2010;14(2):121-6. PMid:20464160. http://dx.doi.org/10.1590/S1413-35552010005000012
http://dx.doi.org/10.1590/S1413-35552010... determined the concurrent validity of the Brazilian version of the SRS-22r questionnaire by correlating it to the Brazilian version of the SF-36 questionnaire. The authors verified that the instrument has satisfactory concurrent validity; therefore, this tool is able to measure what it intends to measure.

The current study complements the previous work by Rosanova et al.³⁰30. Rosanova GC, Gabriel BS, Camarini PM, Gianini PE, Coelho DM, Oliveira AS. Concurrent Validity of the Brazilian Version of SRS-22r with Br-Sf-36. Rev Bras Fisioter. 2010;14(2):121-6. PMid:20464160. http://dx.doi.org/10.1590/S1413-35552010005000012
http://dx.doi.org/10.1590/S1413-35552010... with two important additions. One novel addition is the description of the cross-cultural adaptation process used to translate the instrument to the Brazilian Portuguese language. This process is important for adjusting the new version to target the local population. Beaton et al.²⁶26. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine (Phila Pa 1976). 2000;25:3186-91. PMid:11124735. http://dx.doi.org/10.1097/00007632-200012150-00014
http://dx.doi.org/10.1097/00007632-20001... state that the cultural adaptation process maintains the content validity of the questionnaire, preserving the same concepts across various cultures. For this reason, the Brazilian version of the SRS-22r questionnaire was subjected to the cultural adjustment process proposed by these authors and the steps of this process are presented in this study.

The original version of SRS-22 was culturally adapted to Spanish²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... ^{, 31}31. Climent JM, Bago J, Ey A, Perez-Grueso FJ, Izquierdo E. Validity of the Spanish Version of the Scoliosis Research Society-22 (SRS-22) Patient Questionnaire. Spine (Phila Pa 1976). 2005;30:705-709. PMid:15770189. http://dx.doi.org/10.1097/01.brs.0000155408.76606.8f
http://dx.doi.org/10.1097/01.brs.0000155... , Turkish³²32. Alanay A, Cil A, Berk H, Acaroglu RE, Yazici M, Akcali O, et al. Reliability and Validity of Adapted Turkish Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Spine (Phila Pa 1976). 2005;30:2464-8. PMid:16261127. http://dx.doi.org/10.1097/01.brs.0000184366.71761.84
http://dx.doi.org/10.1097/01.brs.0000184... , Japanese³³33. Hashimoto H, Sase T, Arai Y, Maruyama T, Isobe K, Shouno Y. Validation of a Japanese Version of the Scoliosis Research Society-22 Patient Questionnaire Among Idiopathic Scoliosis Patient in Japan. Spine (Phila Pa 1976). 2007;32:E141-6. PMid:17304124. http://dx.doi.org/10.1097/01.brs.0000255220.47077.33
http://dx.doi.org/10.1097/01.brs.0000255... , Chinese³⁴34. Cheung KC, Senkoylu A, Alanay A, Genc Y, Lau S, Luk KD. Reliability and Concurrent Validity of the Adapted Chinese Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Spine (Phila Pa 1976). 2007;32:1141-5. PMid:17471100. http://dx.doi.org/10.1097/01.brs.0000261562.48888.e3
http://dx.doi.org/10.1097/01.brs.0000261... ^{, 35}35. Zhao L, Zhang Y, Sun X, Du Q, Shang L. The Scoliosis Research Society-22 Questionnaire Adapted for Adolescent Idiopathic Scoliosis in China: Reliability and Validity Analysis. J Child Orthop. 2007;1:351-355. PMid:19308531 PMCid:PMC2656752. http://dx.doi.org/10.1007/s11832-007-0061-1
http://dx.doi.org/10.1007/s11832-007-006... , French Canadian³⁶36. Beauséjour M, Joncas J, Goulet L, Roy-Beaudry M, Parent S, Grimard G, et al. Reliability and Validity of Adapted French Canadian Version of Scoliosis Research Society Outcomes Questionnaire (SRS-22) in Quebec. Spine (Phila Pa 1976). 2009;34:623-8. PMid:19282743. http://dx.doi.org/10.1097/BRS.0b013e3181973e58
http://dx.doi.org/10.1097/BRS.0b013e3181... , German⁹9. Niemeyer T, Schubert C, Halm HF, Herberts T, Leichtle C, Gesicki M. Validity and Reliability of an Adapted German Version of Scoliosis Research Society-22 Questionnaire. Spine (Phila Pa 1976). 2009;34:818-21. PMid:19365251. http://dx.doi.org/10.1097/BRS.0b013e31819b33be
http://dx.doi.org/10.1097/BRS.0b013e3181... and Greek³⁷37. Antonarakos PD, Katranitsa L, Angelis L, Paganas A, Koen EM, Christodoulou EA, et al. Reliability and Valididy of the Adapted Greek Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Scoliosis. 2009;4:1-7. PMid:19607720 PMCid:PMC2720382. http://dx.doi.org/10.1186/1748-7161-4-14
http://dx.doi.org/10.1186/1748-7161-4-14... .

No domain in the Portuguese Language (Brazil)-adapted questionnaire demonstrated a floor effect, as found to German and Canadian versions. However, previous studies that have produced versions of the SRS-22 questionnaire, including the original version, reported low floor effect values. Such studies enrolled larger samples, resulting in more opportunities for a floor effect to occur.

The Brazilian questionnaire exhibited ceiling effects in the Pain and Management Satisfaction domains. This effect was also noted in the original version and in most of the SRS-22 questionnaires adapted for other countries. The original, Spanish, Turkish and German versions also presented a high percentage of ceiling effects for these domains. This indicates that in such domains there is limited ability to distinguish different levels of scoliosis severity. Significative percentage of the sample showing a ceiling effect in the Pain domain can be explained by the absence of pain in idiopathic scoliosis during adolescence and early adulthood. The high ceiling effect in the Treatment Satisfaction domain may reflect patients' confidence in the recruitment hospital, where most patients in this study are treated⁹9. Niemeyer T, Schubert C, Halm HF, Herberts T, Leichtle C, Gesicki M. Validity and Reliability of an Adapted German Version of Scoliosis Research Society-22 Questionnaire. Spine (Phila Pa 1976). 2009;34:818-21. PMid:19365251. http://dx.doi.org/10.1097/BRS.0b013e31819b33be
http://dx.doi.org/10.1097/BRS.0b013e3181... ^{, 32}32. Alanay A, Cil A, Berk H, Acaroglu RE, Yazici M, Akcali O, et al. Reliability and Validity of Adapted Turkish Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Spine (Phila Pa 1976). 2005;30:2464-8. PMid:16261127. http://dx.doi.org/10.1097/01.brs.0000184366.71761.84
http://dx.doi.org/10.1097/01.brs.0000184... ^{, 34}34. Cheung KC, Senkoylu A, Alanay A, Genc Y, Lau S, Luk KD. Reliability and Concurrent Validity of the Adapted Chinese Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Spine (Phila Pa 1976). 2007;32:1141-5. PMid:17471100. http://dx.doi.org/10.1097/01.brs.0000261562.48888.e3
http://dx.doi.org/10.1097/01.brs.0000261... . However, unlike the original version, the Brazilian questionnaire was not administered by the operating orthopedic surgeon, but rather by three physical therapy students who were not involved with patients' treatment. This decreases the potential for response bias in the Treatment Satisfaction domain¹⁵15. Asher MA, Lai SM, Burton D, Manna B. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis. Spine (Phila Pa 1976). 2003;28:63-9. PMid:12544958. http://dx.doi.org/10.1097/00007632-200301010-00015
http://dx.doi.org/10.1097/00007632-20030... .

The second important addition that complements the work of Rosanova et al.³⁰30. Rosanova GC, Gabriel BS, Camarini PM, Gianini PE, Coelho DM, Oliveira AS. Concurrent Validity of the Brazilian Version of SRS-22r with Br-Sf-36. Rev Bras Fisioter. 2010;14(2):121-6. PMid:20464160. http://dx.doi.org/10.1590/S1413-35552010005000012
http://dx.doi.org/10.1590/S1413-35552010... is the Brazilian instrument's reliability. Test/retest reliability values were considered excellent. All domains had ICC values above 0.90, which was also true of the original, Spanish and Chinese versions¹³13. Parent EC, Hill D, Moreau M, Mahood J, Raso J, Lou E. Score Distribution of the Scoliosis Quality of Life Index Questionnaire in Different Subgroups of Patients With Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976). 2007;32:1767-77. PMid:17632398. http://dx.doi.org/10.1097/BRS.0b013e3180b9f7a5
http://dx.doi.org/10.1097/BRS.0b013e3180... ^{, 37}37. Antonarakos PD, Katranitsa L, Angelis L, Paganas A, Koen EM, Christodoulou EA, et al. Reliability and Valididy of the Adapted Greek Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Scoliosis. 2009;4:1-7. PMid:19607720 PMCid:PMC2720382. http://dx.doi.org/10.1186/1748-7161-4-14
http://dx.doi.org/10.1186/1748-7161-4-14... .

Cronbach's alpha values for all domains are above 0.70 and thus considered satisfactory. However, the original SRS-22 has better internal consistency values. According to Bago et al.²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... , it is typical for culturally adapted questionnaires to have slightly inferior internal consistency than the original tool.

Asher et al.²⁵25. Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS-22 Health-Related Quality of Life Questionnaire Function Domain. Spine (Phila Pa 1976). 2006;31:593-7. PMid:16508558. http://dx.doi.org/10.1097/01.brs.0000201331.50597.ea
http://dx.doi.org/10.1097/01.brs.0000201... observed that questions 15 and 18 decreased the internal consistency of the Function domain in the original SRS-22 when applied to individuals younger than 18 years old. A similar phenomenon occurred using the Spanish²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... and Turkish³²32. Alanay A, Cil A, Berk H, Acaroglu RE, Yazici M, Akcali O, et al. Reliability and Validity of Adapted Turkish Version of Scoliosis Research Society-22 (SRS-22) Questionnaire. Spine (Phila Pa 1976). 2005;30:2464-8. PMid:16261127. http://dx.doi.org/10.1097/01.brs.0000184366.71761.84
http://dx.doi.org/10.1097/01.brs.0000184... versions. Despite this, the authors maintained question 15 unaltered because it assesses the important concept of financial difficulties related to scoliosis, and altered question 18. Hence, the SRS-22 was then named the SRS-22 revised version (SRS-22r). In the Brazilian version, question 15 had a slight influence on the internal consistency value of the Function domain. Without this question, Cronbach's alpha decreased from 0.77 to 0.75. Question 18 was translated and adjusted according to the revised version of the SRS-22r questionnaire during the adaptation process for the Brazilian version.

Question 11 in the Brazilian version decreased the internal consistency of the Pain domain. Cronbach's alpha increased from 0.80 to 0.85 after removing question 11. This is consistent with the observation that some volunteers experienced difficulty with this question during the pre-final test. Of the ten patients who reported medication usage, four answered the question incorrectly. Hence, the authors believe that if most of the volunteers consumed medications for back pain, or if the study sample were larger, there would be more participants with problems with that question. The problems occurred because these items are presented as a consumption frequency scale for medication, increasing from the first to the last item. The last item, "others", receives the worst score. However, three patients chose this item as their answer and reported that they use common medication "sometimes" or "when in pain". This way, they have a lower score than they would have if they were answering the question correctly. As mentioned in the Results section, question 11 has been updated in a similar manner to that recommended by Bago et al.²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... In the latest validation studies of the English version of the SRS-22r questionnaire²⁵25. Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS-22 Health-Related Quality of Life Questionnaire Function Domain. Spine (Phila Pa 1976). 2006;31:593-7. PMid:16508558. http://dx.doi.org/10.1097/01.brs.0000201331.50597.ea
http://dx.doi.org/10.1097/01.brs.0000201... ^{, 38}38. Glattes RC, Burton DC, Lai SM, Frasier E, Asher MA. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire Compared With the Child Health Questionnaire-CF87 Patient Questionnaire for Adolescent Spinal Deformity. Spine (Phila Pa 1976). 2007;16:1778-84. PMid:17632399. http://dx.doi.org/10.1097/BRS.0b013e3180dc9bb2
http://dx.doi.org/10.1097/BRS.0b013e3180... , question 11 reflects this change. For the sake of completeness it would be desirable to test the Brazilian version once again. However, we believe that published results using the updated question #11²2. Bago J, Climent JM, Ey A, Pere-Grueso FJ, Izquierdo E. The Spanish Version of the SRS-22 Patient Questionnaire for Idiopathic Scoliosis: Transcultural Adaptation and Reliability Analysis. Spine (Phila Pa 1976). 2004;29:1676-80. PMid:15284516. http://dx.doi.org/10.1097/01.BRS.0000132306.53942.10
http://dx.doi.org/10.1097/01.BRS.0000132... ^{, 25}25. Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS-22 Health-Related Quality of Life Questionnaire Function Domain. Spine (Phila Pa 1976). 2006;31:593-7. PMid:16508558. http://dx.doi.org/10.1097/01.brs.0000201331.50597.ea
http://dx.doi.org/10.1097/01.brs.0000201... ^{, 38}38. Glattes RC, Burton DC, Lai SM, Frasier E, Asher MA. The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire Compared With the Child Health Questionnaire-CF87 Patient Questionnaire for Adolescent Spinal Deformity. Spine (Phila Pa 1976). 2007;16:1778-84. PMid:17632399. http://dx.doi.org/10.1097/BRS.0b013e3180dc9bb2
http://dx.doi.org/10.1097/BRS.0b013e3180... and our experience detailed here make this unnecessary.

Finally, the questionnaire seemed simple and practical, and its psychometric characteristics were similar to those of the original questionnaire. All questions were answered by more than 15% of patients. These results suggest that the tool is properly adjusted for use in the population of Brazilian patients with idiopathic scoliosis.

The authors would like to thank Mr. A. Asher, from the Department of Orthopedic Surgery of the Kansas University Medical Center, for his valuable comments during manuscript preparation. The authors also would like to thank the Fundação de Amparo à Pesquisa do Estado de São Paulo – FAPESP (2005/56130-3).

References

Appendix A

Appendix B

Publication Dates

History