Key words
spine - knee - Osteoarthritis - sports performance - cardiovascular physiology - exercise - anabolic steroids - ischemic preconditioning - sport recovery - copy editing - Ger > Eng translation - Medicine - Knee - Pain - Hib - Validation - sportsmedicine - international open - journal
Introduction
Osteoarthritis is mainly characterized as joint pain that interferes with a
patient’s life [1]. The knee, hip, and
hand joints can be affected, and the knee is the most common [2]. Osteoarthritis is one of the most common
forms of arthritis [3]. This disease has
multifactorial causes, such as aging, the female gender, being overweight, and
previous injury [4]
[5]
[6]
[7].
There are many approaches to diagnose osteoarthritis and determine the severity of
the disease. The disease can be diagnosed clinically based on the presence of
certain symptoms (pain, joint stiffness in the morning, and a decrease in the joint
function), the above-mentioned risk factors, or radiographic images [8].
The extent of joint pain can be assessed by several questionnaires, and one of the
most accurate is the Intermittent and Constant Osteoarthritis Pain (ICOAP)
questionnaire, which was developed in focus groups to evaluate the severity of pain
and its impact on the quality of life of patients with knee/hip
osteoarthritis. Furthermore, it is the only scale that can evaluate the constant and
intermittent pain that may present itself in patients with osteoarthritis. It can
also be used to follow the progression of the disease, treatment responsiveness, and
the need for joint replacements [13].
As the ICOAP questionnaire shows a high level of reliability for evaluating the
patient’s condition [9], it has been
translated into several languages and is used in many studies within different
populations [10]
[11]. This study aims to translate the scale
into Arabic and validate it within the Saudi population.
Methods
The study was conducted in the orthopedic surgery clinic covering the period from
March 2018 to August 2018. The study included any adult males or females who could
speak, read, and write Arabic. Patients needed to be diagnosed with knee or hip
osteoarthritis based on the clinical and radiographic criteria of the American
College of Rheumatology (grade 2 or above according to the Kellgren-Lawrence
classification system).
The study was conducted in two stages. The first stage was the translation of the
scale into Arabic, and the second stage was data collection.
The scale was translated into Arabic following clear and user-friendly guidelines by
an independent orthopedic resident and an English teacher whose native language was
Arabic. Both were fluent in English and Arabic, well-experienced in the cultures of
the two languages, and had background knowledge of medical terms. We then compared
and reviewed the two translated versions, after which the final version was adopted.
Two backward translations of the new Arabic version to English were done by another
two translators, who were native English speakers and were fluent in both languages.
Sufficient knowledge of both cultures and languages and experience in translating
medical studies were important criteria for selecting the translators. Finally, we
compared and reviewed the two backward translations and then compared them again
with the original instrument, obtaining the final ICOAP scale that was to be used in
the study. After that, a pilot study was conducted with 30 participants who met the
inclusion criteria to identify any difficulties in understanding the scale. Any
notes or suggestions were taken into account prior to proceeding with the data
collection.
After the validation process, here is the Intermittent and Constant Osteoarthritis
Pain in Arabic (ICOAP-AR) questionnaire.
Knee ICOAP questionnaire:
Hip ICOAP questionnaire:
The second part of the study involved collecting data from the participants by
distributing paper ICOAP questionnaires over two time intervals to ensure the
reliability of the questionnaire. In the first round, we obtained the
participants’ approval by asking them to sign the consent form. During the
second round, the participants answered two questionnaires. The first one was the
ICOAP and the second questionnaire was the Knee injury and Osteoarthritis Outcome
Score (KOOS) for constructive validity.
This study was conducted according to the ethical standards of the International
Journal of Sports Medicine and was approved by the University ethics committee. A
consent form was distributed and signed by each participant recruited in this study
[18].
Statistical analysis
The data were analyzed using the Statistical Package for Social Studies (IBM SPSS
Statistics for Windows, Version 22.0; IBM Corp., Armonk, NY, USA). The
categorical variables were expressed as percentages. The continuous variables
were expressed as mean ± standard deviation.
Cronbach’s alpha was used to assess the internal consistency of the
ICOAP. The subscales to total and the inter-subscale correlations were used to
assess the internal consistency with Pearson’s correlation analysis. The
test-retest values of the subscales and total scores were compared with the
Wilcoxon signed-rank test. The test-retest reliability was calculated using the
intraclass correlation coefficient (ICC). A p-value of < 0.05 was
considered statistically significant.
Results
A total of 90 subjects were included in this study, of which 29 participants were
re-evaluated for reliability testing. The participants filled in all the sections of
the ICOAP and the KOOS subscale. The demographic data is shown in [Table 1].
Table 1 Demographic characteristics.
|
|
Number
|
%
|
|
Gender
|
Male
|
44
|
48.9
|
|
Female
|
46
|
51.1
|
|
Monthly Income
|
<1333.4 USD
|
44
|
48.9
|
|
1333.4–2666.6 USD
|
23
|
25.6
|
|
2666.6–4000 USD
|
8
|
8.9
|
|
4000–5333.3 USD
|
8
|
8.9
|
|
> 5333.3 USD
|
7
|
7.8
|
|
Level of Education
|
Primary
|
38
|
42.2
|
|
Intermediate or Secondary
|
29
|
32.2
|
|
Bachelor
|
15
|
16.7
|
|
Diploma
|
5
|
5.6
|
|
Postgraduate
|
3
|
3.3
|
|
Marital Status
|
Single
|
2
|
2.2
|
|
Married
|
77
|
85.6
|
|
Divorced
|
2
|
2.2
|
|
Widowed
|
9
|
10.0
|
Based on the participants’ feedback, it was found that the translated
definitions of both the terms ‘Constant’ and
‘Intermittent’ pain were clear, and the participants reported no
difficulties in understanding the meaning of these two terms. Moreover, all the
questions and answers were comprehensible.
As shown in [Table 2], the test-retest values
of the subsample with 29 participants revealed no difference regarding the constant
and transient knee pain and the constant and transient hip pain (p-value >
0.05).
Table 2 The reliability and validity of the intermittent and
constant osteoarthritis pain scale (ICOAP).
|
Reliability
|
|
Test (n=90)
|
Retest (n=29)
|
ICC
(95% confidence interval)
|
Alpha
coefficient
|
|
Mean
|
SD
|
Mean
|
SD
|
|
ICOAP
|
|
|
|
|
|
|
|
Knee
|
|
|
|
|
|
|
|
Total score
|
27.98
|
21.68
|
23.82
|
13.51
|
0.881 (0.841–0.914)
|
0.881
|
|
Constant pain subscale
|
28.17
|
29.79
|
32.76
|
31.81
|
0.944 (0.923–0.960)
|
0.944
|
|
Intermittent pain subscale
|
27.82
|
27.21
|
16.38
|
22.82
|
0.934 (0.911–0.953)
|
0.934
|
|
Hip
|
|
Total score
|
9.97
|
21.97
|
3.45
|
9.16
|
0.977 (0.969–0.983)
|
0.977
|
|
Constant pain subscale
|
9.94
|
23.97
|
3.10
|
9.95
|
0.985 (0.980–0.989)
|
0.985
|
|
Intermittent pain subscale
|
10.00
|
22.22
|
3.74
|
11.04
|
0.963 (0.950–0.974)
|
0.963
|
|
KOOS
|
48.40
|
28.11
|
|
|
|
|
|
Validity
|
|
Constant pain subscale
|
Intermittent pain subscale
|
Total score
|
|
r
|
P-value
|
r
|
P-value
|
r
|
P-value
|
|
KOOS
|
0.324
|
0.086
|
0.025
|
0.896
|
0.235
|
0.221
|
SD, standard deviation; ICC, intraclass correlation coefficient; r,
correlation coefficient.
The ICC was used to assess test-retest reliability. The ICC of the total score of the
knee ICOAP was 0.841, and the score was 0.911 for the intermittent knee pain
subscale and 0.923 for the constant knee pain subscale. Moreover, the ICC for the
total score of the hip ICOAP was 0.923, and the score was 0.950 for the intermittent
hip pain subscale and 0.980 for the constant hip pain subscale.
Cronbach’s alpha was 0.88, 0.93, and 0.94 for the total score, intermittent
knee pain, and constant knee pain, respectively. Additionally, Cronbach’s
alpha of the hip ICOAP was 0.977, 0.963, and 0.985 for the total score, intermittent
hip pain, and constant hip pain, respectively.
The correlation between the total score of the ICOAP and the KOOS pain subscale was
assessed using the criterion validity, and the results revealed that r=0.235
(P < 0.05). Thus, based on the criterion validity, there is a correlation
between the ICOAP and the KOOS pain subscale.
Discussion
Pain severity varies depending on the progression of the specific case [12]. Constant pain is less intense and is
persistent all the time, whereas intermittent pain is more intense and transient.
The ICOAP scale can measure the frequency and severity of the pain and its effect on
mood, sleep, and the quality of life [9].
The results of this study revealed that the ICOAP-AR is valid and reliable for
diagnosing patients with knee or hip osteoarthritis. No additional adjustments were
made to the ICOAP items, which indicates the clarity of the scale when translated
into Arabic.
Regarding the translation procedure and the cross-cultural adaptation, the
translators faced no difficulties in translating and adapting the items and answers
of the ICOAP into Arabic, which resulted in a comprehensible Arabic scale. This is
also similar to other adaptation studies [13].
Furthermore, the majority of the participants faced no difficulty in answering the
questionnaire, which mirrors other cross-cultural translations and adaptation
studies [10]
[11].
The ICOAP-AR scale was evaluated using the internal consistency and the test-retest
reliability to identify the validity of this scale.
Cronbach’s alpha of the total score for the Arabic knee ICOAP-AR was 0.88,
which is close to the Persian study (0.89), the Portuguese study (0.92), and the
original study that developed the ICOAP (0.93). Additionally, Cronbach’s
alpha of the total score for the hip ICOAP-AR was 0.97, which is similar to the 0.93
value in the original study [9]
[14]
[15].
The test and retest reliability was evaluated by giving the 29 participants the ICOAP
scale two times, with a one-week period in between. The results were evaluated using
the ICC, which was 0.841. The ICC of the original scale was 0.93, whereas the ICC of
the Portuguese scale was 0.88–0.92, and the Persian result was 0.91 [14]
[15]
[16].
The construct validity of the ICOAP-AR scale and the KOOS pain subscale of
r=0.24 (P < 0.05) represents a good correlation between the knee
ICOAP-AR and the KOOS, while the correlation in the original study was
r=0.6. The modest correlation between the two scales is due to the nature of
the ICOAP scale, which evaluates the patient’s condition based on the
severity of the pain. On the other hand, the KOOS questionnaire identifies the
participant’s physical symptoms, such as swelling, stiffness, and pain in
the knee joint [13]
[17].
Conclusion
The psychometric evidence supports the Arabic version of the ICOAP as a reliable and
valid cross-sectional measure of the impact of intermittent and constant pain in
patients diagnosed with knee or hip osteoarthritis.
