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Translation, cultural adaptation, validity and reliability of the Turkish ASES

questionnaire

Article in Knee Surgery Sports Traumatology Arthroscopy · August 2012

DOI: 10.1007/s00167-012-2183-3 · Source: PubMed

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Knee Surg Sports Traumatol Arthrosc (2013) 21:2184–2189
DOI 10.1007/s00167-012-2183-3

SHOULDER

Translation, cultural adaptation, validity and reliability

of the Turkish ASES questionnaire
Derya Çelik • Ata Can Atalar • Mehmet Demirhan •

Ahmet Dirican

Received: 30 March 2012 / Accepted: 17 August 2012 / Published online: 30 August 2012
Ó Springer-Verlag 2012

Abstract SPADI and SF-S6 questionnaire, which may also be

Purpose The American Shoulder and Elbow Surgeons defined as ‘construct validity’. The results were analysed
Standardized Shoulder Assessment Form (ASES) is a using Pearson’s correlation test.
standard shoulder assessment form, which is comprised of Results The test–retest reliability of the ASES pain and
objective and subjective sections and prepared by shoulder function subscales and total ASES score were 0.95, 0.86
and elbow surgeons. The purpose of this study was to and 0.94, respectively. Cronbach’s alpha coefficient for the
translate the subjective part of the ASES into Turkish and total ASES was 0.88. The correlation between the total
establish its cultural adaptiveness and validity. ASES and total SPADI score was -0.82; the correlation
Methods The original version of the ASES was translated coefficient between the ASES pain subscale and SPADI
into Turkish in accordance with the stages recommended pain subscale was -0.79 (p \ 0.000); and the correlation
by Guillemin. Sixty-three patients (average age: 48.2 ± between the ASES and SPADI function subscales were
13.4; range: 18–74 years) suffering from different shoulder -0.53 (p \ 0.000). The highest correlation was between
complaints were included in the study. The ASES was ASES and SF-36 bodily pain, as well as ASES and SF-36
completed twice at 3- to 7-day intervals for test–retest mental health (r = 0.64, r = 0.56, p \ 0.000), and the
reliability. The intraclass correlation coefficient was used lowest correlations were between ASES and the SF-36
to calculate the test–retest reliability, and Cronbach’s alpha physical component score and between ASES and SF-36
was used for internal consistency. Patients were asked to social function (r = 0.28, r = 0.33 p \ 0.000).
complete the short form 36 (SF-36) and the Shoulder Pain Conclusion The Turkish version of the ASES is a valid
and Disability Index (SPADI) for correlation. Validity was and reliable shoulder assessment form that can be used for
evaluated by external correlation of the ASES with the numerous shoulder disorders.
Level of evidence III.

D. Çelik (&) Keywords Subjective shoulder scores
ASES

Division of Physiotherapy and Rehabilitation, Turkish validation
Faculty of Health Sciences, Istanbul University,
Millet Street, 34093 Çapa, Istanbul, Turkey
e-mail: ptderya@[Link]
Introduction
A. C. Atalar
Department of Orthopedics and Traumatology,
Shoulder injuries cause pain and reduce articular mobility,
Faculty of Medicine, Istanbul University, Istanbul, Turkey
ultimately adversely affecting the functional abilities, work
M. Demirhan activities and qualities of life of these patients [6]. For
Faculty of Medicine, Koç University, Istanbul, Turkey many years, rating scales and scoring systems have been
used to assess the outcomes of shoulder injuries and
A. Dirican
Department of Biostatistics, Faculty of Medicine, treatment. In general, assessments are categorised in two
Istanbul University, Istanbul, Turkey groups: general health and disease and joint-specific. After

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Knee Surg Sports Traumatol Arthrosc (2013) 21:2184–2189 2185

systematically reviewing the literature, Bot et al. [5] dis- Turkish individuals, with a good command of English,
covered 16 objective questionnaires in English. were responsible for the literary and conceptual translation
Questionnaires were established in order to investigate a of the patient self-report section of the ASES assessment
specific disease or certain part of the body [25]. However, form. The translators were a nurse and an engineer who
the characteristics of the majority of these scores reflect the were familiar with the purpose of the study; translations
language and social culture of the community in which were completed independently. Both translations were
they were established; therefore, it is necessary to translate compared and reviewed by a bilingual person who high-
and culturally adapt these scores for other communities. lighted any conceptual errors or inconsistencies in the
Published in 1994, The American Shoulder and Elbow translations in order to establish the first Turkish transla-
Surgeons Standardized Shoulder Assessment Form (ASES) tion. Once the first Turkish translation was decided upon,
has two sections: the patient self-evaluation section (also two translators who had a good command of Turkish but
known as the patient self-report section) and the physician spoke English as a first language and who were familiar
assessment section (also known as the medical professional with the purpose of the study, translated the finalised
assessment section) [20]. Because the ASES is available in Turkish translation back into English separately; both
English-speaking countries, it is not applicable over a translators were unaware of the purpose of the study and
wider geographical range. In order to broaden its usage, the had no access to the original assessment form.
questionnaire needs to be translated into other languages, Recent versions of the questionnaire were compared to
culturally adapted to other countries and validated against the initial translation. A committee consisting of four
the original questionnaire. The only questionnaires that translators compared the English retranslation with the
have a valid Turkish version are the Shoulder Pain and initial Turkish translation and then approved the Turkish
Disability Index (SPADI), the Western Ontorio Rotator version of the ASES assessment form. Once approved, the
Cuff Index (WORC), Disability of the Arm, Shoulder and assessment form was administered to the patients.
Hand Questionnaire (DASH), the Oxford Shoulder Ques- No issues involving the translation or cultural adaptation
tionnaire (OSQ) and [4, 8, 18, 23]. were experienced during the pilot study conducted on 20
Compared to the other Turkish validated shoulder patients; however, patients had difficulty answering Ques-
scores, ASES has some advantages. DASH has many tion 8, and those that did not engage in regular sporting
detailed questions and takes more time to complete, and activities left Question 10 blank. Question 8 was changed
thus people in Turkey, specifically in the elderly popula- from ‘throw a ball overhand’ to ‘over the head throwing
tion, generally do not fill out these forms. They also have activity’. Question 10 was changed to provide two options:
some difficulties answering the VAS-type questions, such ‘(a) do usual sport, (b) do not do usual sport’; in other
as in SPADI. However, ASES is shorter, so it requires little words, option ‘a’ was similar to the original, and option ‘b’
time for the patient to complete and for the health practi- was comprised of questions such as ‘putting up nails’,
tioner to evaluate. It is also not disease-specific, such as ‘beating carpets’ and ‘using a vacuum cleaner’. In addition
WORC, so it can be used for many shoulder pathologies. to these changes, ‘10 libre’ in question 7 was converted to
Although there is no standard translation and validation ‘5 kg’ because libre is not a Turkish unit of measurement.
of the ASES, it is widely used by physiotherapists and
health practitioners. However, different interpretations of Questionnaires
its meaning may affect clinical outcomes. In order to
eliminate differences in methods and scores and replace The ASES consists of 2 sections: a patient self-evaluation
them with suitable standards, we believe that cultural component and an assessment performed by a physician.
adaptation and its valid use in Turkish is important. The The patient self-evaluation section has 11 items that can be
purpose of this study was to translate the ASES subjective used to generate a score. These items are divided into 2
form into Turkish and investigate its validity and areas: pain (1 item) and function (10 items). The pain
reliability. question was scored on a scale (visual analogue scale) of 0
(no pain) to 10 (worst pain ever). The function questions
ask patients whether they can perform 10 daily life activ-
Materials and methods ities. Additionally, they are asked whether they can do their
usual work and take part in normal sporting activity. The
Translation and cultural adaptation items are rated on a four-point Likert scale. Scores
obtained from the pain and function subsections are
Only the patient self-report section of the ASES was transformed into percentages, where each represents 50 %
translated into Turkish and culturally adapted in accor- of the final score. Scores on the ASES range from 0
dance with stages recommended by Guillemin [9]. Two (absence of function) to 100 (normal function) [4]. The

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four-point Likert scale for the function questions ranges Table 1 Demographics
from 0 (unable to do) to 3 (not difficult). The final score N (%)
(a possible maximum score of 100) is calculated by multi-
plying the pain section score (a possible maximum score of Gender
10) by five (a possible maximum score of 50) and multiplying Female 30 (48.4)
the cumulative activity score (a possible maximum score of Male 33 (51.5)
30) by 5/3 (a possible maximum score of 50). Age
The 13-question SPADI is comprised of two subscales: Mean ± SD 48.2 ± 13.4
pain and disability. The subscale ‘pain’ presents five Education
questions about pain severity, and the patient answers each Primary school 18 (28.5)
question based on a scale (visual analogue scale) from 1 High school 24 (33.3)
(no pain) to 10 (the worst pain imaginable). The subscale University degree 16 (25.3)
‘disability’ poses eight questions about the level of diffi- Doktorate 5 (7.3)
culty experienced when conducting daily living activities Dominant/non-dominant side
that require use of the upper extremities [21]. Right dominant 56 (84.1)
The Short Form Health Survey (SF-36): SF-36 was used Left dominant 7 (11.1)
to establish a health profile that consists of eight scaled Involved right 34 (53.9)
scores, where each scale was directly transformed into a Involved left 26 (41.2)
scale from 0 to 100 in order to identify the patient’s Diagnosis
physical and mental state. These 8 sections include phys- Frozen shoulder phase 2 9 (14.2)
ical functioning (PF), physical role functioning (RP), Frozen shoulder phase 3 10 (15.8)
bodily pain (BP), general health perceptions (GH), vitality Proximal humerus fracture 4 (6.3)
(VH), social role functioning (SF), emotional role func- Bankart surgery 10 (15.8)
tioning (RE) and mental health (MH) [24]. SLAP repair 2 (3.1)
Synovectomy 1 (1.5)
Patients Rotator cuff small tear 11 (17.4)
Rotator cuff medium tear 4 (6.3)
Seventy-five patients suffering from shoulder complaints
Rotator cuff repair 5 (7.3)
were recruited from the Istanbul University Faculty of
Impingement syndrome 6 (9.5)
Medicine, Department of Orthopedics. Eight patients did
Multidirectional instability 1 (1.5)
not return for the retest assessment, two declined to com-
plete the SF-36 and two had received medical treatment
before the retest assessment. In all, sixty-three patients
(30 male and 33 female; mean age: 48.2 ± 13.4; range: Testing protocol
18–74 years) were included in the study. Table 1 presents
the various diagnoses of the patients. Patients were asked to complete the Turkish version of
The patients were clinically examined by two experi- ASES, the previously validated Turkish version of the
enced shoulder surgeons. When necessary, X-ray and MRI SPADI and the SF-36 [4, 14].
(magnetic resonance imaging) were performed. Physical therapy undergraduate students administered the
The inclusion criteria are listed as follows: (1) 18 years listed questionnaires to patients in waiting rooms prior to an
of age or older, (2) the presence of a shoulder problem and appointment with an orthopaedic surgeon. In the event of any
(3) no treatment between test–retest assessments. The difficulties, students took notes on each patient.
exclusion criteria were as follows: (1) inability to complete
the form due to cognitive impairment; (2) illiteracy or lack of
understanding of Turkish; (3) patients whose conditions could Validity
not be stabilized following a second assessment for other
ailments, such as cancer, serious infection or inflammatory Validity is represented by the extend to which a score
disease; (4) the presence of neurological or musculoskeletal retains its intended meaning and interpretation [7]. In this
disorders other than the shoulder condition. study, validity was assessed according to three factors:
Prior to the start of the study, participants were asked to construct, convergent/divergent and content validity. The
read and sign an informed consent form, which had been construct validity of the Turkish ASES was tested by
approved by the ethical committee at Istanbul University correlation with the SPADI and the physical component
(IRB study protocol: 2010/898-268). score of the SF-36.

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Knee Surg Sports Traumatol Arthrosc (2013) 21:2184–2189 2187

SF-36 PF, SF-36 RP and SF-36 PCS domains were used A statistical package for the social sciences (SPSS) 17.5
to asses the convergent validity. Divergent validity was was used to conduct statistical analysis. The agreed level of
evaluated by using SF-36 MH, SF-36 RE and SF-36 MCS significance was p \ 0.05. Floor and ceiling effects and the
domains. It is hypothesized that the physical domains of number of items answered were identical during the test
SF-36 would correlate with disease or joint-specific ques- and retest examination.
tionnaires better than the mental domains.
The content validity was assessed by the distribution and
occurrence of ceiling and floor effects. The ceiling effect Results
occurs when the maximum possible score of 100 is
achieved. The floor effect occurs when the minimum Table 1 illustrates the main demographic and clinical
possible score of 0 is reached. For the maximal score, we characteristics of the patients. The patients were literate,
applied scores of 90 to 100 %, and for the minimum score, but their educations were mostly at the high school level.
we used 0 to 10 % scores. Greater than 15 % of the patients They were of the middle socio-economic class. None were
scored a maximal or minimal score, and we considered this athletes or regularly participated in any sport. The duration
as a floor and ceiling effect. of the symptoms was 4.8 ± 1.2 months. The Turkish
ASES was completed in approximately four minutes. No
Reliability difficulties were noted during the testing protocol. The
Turkish ASES showed high-to-moderate correlation with
The test–retest reliability, which is a measure of stability or the SPADI score and BP domains of the SF-36 (Tables 2,
reproducibility, represents a scale’s capability of giving 3). Contrary to our hypothesis, the Turkish ASES did not
consistent results when administered on separate occasions show strong correlation with SF-36 physical domains, but
[17]. The reliability of scale scores has been estimated there was better correlation with SF-36 mental domains
using the internal consistency method and test–retest (Table 4). Three out of 63 patients (4.7 %) scored between
method across repeated administrations. To determine the 90 and 100, and 2 out of 63 (3.1 %) scored between 0 and
test–retest reliability, 63 patients were asked to complete 10. A total of 8 % of patients ranged maximal and minimal
the ASES 3–7 days after the first assessment. To minimise scores, which were below 15 %. This implies that there are
the risk of short-term clinical change, no treatment was no floor and ceiling effects. A Cronbach’s alpha value of
provided during this period. 0.88 was found. The Turkish ASES domains and total score
showed strong ICC values. The paired t test did not dem-
Statistic analysis onstrate statistically significant differences between the
test–retest means (Table 2).
Construct and convergent/divergent validities were
tested with Pearson’s correlation coefficient, and a
95 % confidence interval was used for all correlation
coefficients. The intraclass correlation coefficient Discussion
(ICC) was used to measure the test–retest reliability of
the ASES assessment form. Correlation values C0.4 In this study, the most important finding is that the Turkish
were considered satisfactory (r C 0.81–1.0 excellent, version of the ASES is reliable, valid and sensitive to
0.61–0.80 very good, 0.41–0.60 good, 0.21–0.40 fair changes over time. The ASES demonstrated acceptable
and 0.00–0.20 poor) [10, 15]. Cronbach’s alpha coeffi- psychometric performance for patients with various
cient was used to determine internal consistency. A shoulder pathologies within the Turkish population. It can
paired t test was used for the comparison of first and be used to assess both individual patients and groups of
second measurements to compare and determine the Turkish patients with confidence.
statistically significant differences between the first and The test–retest indicated excellent reliability with values
second tests. of 0.95 for the pain subscale of the ASES, 0.86 for the

Table 2 Test–retest reliability

ASES Mean ± SD Reliability Standard error means p
and internal consistency of
ASES T1 T2 ICC SEM

Pain 26.5 ± 16.0 28.3 ± 17.2 0.95 1.85 0.000

Function 25.7 ± 10.6 28.1 ± 10.8 0.86 1.63 0.000
Total 52.3 ± 22.0 56.3 ± 24.6 0.94 2.51 0.000
T1 Test 1 and T2 Test 2

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2188 Knee Surg Sports Traumatol Arthrosc (2013) 21:2184–2189

Table 3 The correlation with ASES and SPADI In recent studies, translated versions of the ASES have
SPADI pain SPADI function SPADI total
been correlated using DASH, a visual analogue scale
(VAS) and the OSQ. Correlation coefficients with the
ASES pain -0.79 0.62 0.75 ASES were reported between 0.48 and 0.92. Yahia et al.
p = 0.000 p = 0.000 p = 0.000 [26] correlated the Arabic ASES with the SPADI and they
ASES function 0.59 -0.53 0.73 reported good correlation (ICC = 0.79) between the total
p = 0.000 p = 0.000 p = 0.000 SPADI score and the ASES. In our study, convergent
ASES total 0.86 0.72 -0.82 validity was tested by comparing the ASES with the
p = 0.000 p = 0.00 p = 0.000 SPADI score and the SF-36 questionnaire. The correlation
coefficients between the ASES and the subscale scores of
SPADI were good to excellent (Table 3).
The correlation between the ASES and SF-36 is poor to
Table 4 The correlation with SF-36 and ASES moderate, even though authors report good-to-high corre-
SF-36 ASES ASES ASES ASES total lations between the ASES, SPADI, DASH and OSQ. These
pain function total Mean ± SD results are not surprising and are probably due to the dif-
SF-36 (PF) 0.28 0.30 0.35* 67.6 ± 18.3 ferences in context between condition-specific question-
p 0.02 0.01
naires, such as the DASH, SPADI and ASES, and generic
SF-36 (RP) 0.41* 0.26 0.43* 30.1 ± 40.9
questionnaires such as the SF-36 [2]. The correlation
p 0.03
between the SF-36 score and scores of specific instruments
is poor, which proves that the SF-36 measures additional
SF-36 (BP) 0.61* 0.40* 0.64* 38.2 ± 23.0
aspects of physical health and provides more comprehen-
SF-36 (GH) 0.41* 0.22 0.41* 59.5 ± 21.3
sive information than condition-specific questionnaires [1].
p 0.07
Researchers investigated the correlation between the ASES
SF-36 (VT) 0.43* 0.40* 0.50* 49.7 ± 20.7
and the SF-36 subscales in different settings, and results
SF-36 (SF) 0.32* 0.20 0.33* 65.4 ± 26.3
yielded poor-to-high correlations [16, 17, 26]. The corre-
p 0.11
lation between the Italian ASES and the SF-36 and
SF-36 (RE) 0.34* 0.21 0.35* 46.3 ± 44.1
the German ASES and the SF-36 was poor to moderate
p 0.09
(r = -0.25 to 0.60, r = 0.18 to 0.66). In our study, the
SF-36 (MH) 0.45* 0.48* 0.56* 58.8 ± 18.6
highest correlation was observed with BP and the lowest
SF-36 (PCS) -0.01 0.86 0.02 47.41 ± 44
correlation was observed with PCS (Table 4).
p 0.89 0.50 0.82
The answers to questions in the MCS of the SF-36 can be
SF-36 (MCS) 0.45* 0.43* 0.53* 43.51 ± 10 different from the results reported in the literature owing to the
* p \ 0.000 characteristics of Turkish culture. In general, health problems
in the Turkish community may not be a reason for people not
to visit relatives and friends or alienate them socially.
Therefore, contrary to the literature, a higher correlation of the
function subscale of the ASES subjective form and 0.94 for ASES and SF-36 MCS was observed (Table 4).
the total ASES. The internal consistency was high (Cron- In the literature, the psychometric properties of ASES
bach’s alpha coefficient: 0.88). Michener et al. analysed the were studied for different shoulder pathologies, pre- or
psychometric properties of the ASES in sixty-three patients post-operative surgeries and in- or outpatient settings.
with varied shoulder diagnoses [16]. Compared to our Beaton et al. [3] have shown that the ASES questionnaire is
results, they reported a lower test–retest reliability reproducible, valid and responsive to change in patients
(ICC = 0.84) but a similar internal consistency (Cron- with active disease. Skutek et al. [22] have assessed post-
bach’s alpha = 0.86). operative shoulder patients with ASES. Kocher et al. [13]
There are a limited number of valid ASESs discussed in used selected shoulder pathologies, such as shoulder
the literature; for example, there are German, Brazilian, instability, rotator cuff disease and glenohumeral arthritis,
Italian and Arabic versions [11, 12, 19, 26]. John et al. in their study. In our study, even though we have a small
conducted a validity test for the German ASES and they sample size, our patients varied with respect to their
reported a high coefficient alpha value (Cronbach’s shoulder pathologies and pre- and post-operative condi-
alpha = 0.90) and 0.93 for the test–retest reliability anal- tions. It is short and easy to administer and interpret, with a
ysis of the total ASES [11]. The valid Arabic version had minimal investment of time required for either the clinician
similar results, with a Cronbach’s alpha coefficient of 0.81 or researcher. Therefore, we believe that the Turkish ASES
and an ICC of 0.96, which is similar to our results. is sufficient to evaluate the different states of disease.

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Knee Surg Sports Traumatol Arthrosc (2013) 21:2184–2189 2189

A limitation of our study was the untested statistical Turkish version of the Western Ontario Rotator Cuff Index.
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