Angle Labor Pain Questionnaire Turkish Version: Validity and Reliability Study and Evaluation of Efficacy With a Non-pharmacological Method
Phase: NA
Conditions: Labor Pain
Sponsor: Eskisehir Osmangazi University

Angle Labor Pain Questionnaire Turkish Version: Validity and Reliability Study and 
Evaluation of Efficacy With a Non-pharmacological Method 
04 February 2021 
ID: ALPQT_NONFARMA 
NCT number: Not available 
 
 

STUDY PROTOCOL 
Study design and participants 
 
The randomized experimental study was conducted with two parallel groups consisting of 
60 pregnant women (administration group n:30; control group n:30) who met the inclusion criteria 
(Figure 2). The inclusion criteria of the study were similar to the first stage; in addition, pregnant 
women who had any contraindications for applying a back massage were excluded from the study. 
The sample size in the study group and control group was determined by power analysis in the 
PASS 11 package program. The sample calculation was made as per the pain score averages of the 
experimental and control groups in the study conducted by Karami et al. (2007) evaluating the 
effectiveness of massage practice in managing labor pain (Karami, Safarzadeh, & Fathizadeh, 
2007). The calculation set forth that at least 28 pregnant women should be available for each group 
with a power level of 0.80 and a confidence level of 95% (Type 1 margin of error 0.05). 
 -Randomization and blinding 
For the assignment of the participants to the groups, two separate number sequences were 
formed by defining the range of numbers 1—80 in the "Research Randomizer" in the computer 
environment, despite possible data loss. Considering their order of participation in the study, the 
pregnant women were assigned to the groups (study group and control) in accordance with the 
randomization sequence. Pregnant women assigned to the study group were also informed about 
the lower back massage application.  

Assignment of the participants to the groups, applications, pain evaluations, and data 
analysis were performed by the researchers because of the nature of the study (thesis). Therefore, 
blinding was not performed in the study.  
-Instruments and Interventions 
“Pregnant Information Form,” “Labor Follow-up Form,” and “VAS” were used in the first 
stage, and the Turkish version of the A-LPQ. Basic information for the pregnant women was 
obtained from patient files. The "Pregnant Identification Form" and "Labor Follow-up Form" 
(Angle et al., 2017; Hamlacı & Yazıcı, 2017), which were prepared based on the literature, were 
used for the collection of the study data. The Visual Analog questionnaire and A-LPQ Turkish 
draft were used for the evaluation of the labor pain.  
-Pregnant Identification Form: This form was composed of 23 questions regarding socio-
demographic characteristics (age, education, occupation, social security, and family type) of the 
pregnant women and their obstetric history and characteristics (number of births, delivery method, 
complaints about current pregnancy, receiving antenatal care, etc.) (Angle et al., 2017, 2016; I. M. 
Gönenç & Terzioǧlu, 2020; Hamlacı & Yazıcı, 2017).  
-Labor Follow-Up Form: This form consisted of information about the week of pregnancy, 
the onset of labor and interventions performed in the first stage of labor (amniotomy, showering, 
oral feeding, etc.), maternal health, and the progression of labor (blood pressure, arterial pulse, 
body temperature, cervical dilation and effusion, condition of membranes, fetal head level, and 
heart rate) (Angle et al., 2017; Hamlacı & Yazıcı, 2017; Türkmen, 2017).  

-Visual analog scale (VAS): VAS is a one-dimensional questionnaire used to evaluate 
perceived pain. VAS was first developed by Price et al. (1983) (Price et al., 1983). Cline et al. 
(1992) stated that the vertical use of the VAS was better understood by the patients in their study 
to ensure standardization in the VAS (Cline et al., 1992). VAS was used in the vertical form in the 
present study. 
-Angle Labor Pain Questionnaire (A-LPQ): It is the first measurement tool developed 
by Angle et al. to measure labor pain. The original questionnaire consists of 22 items and five sub-
dimensions (Angle, 2013; Angle et al., 2017, 2016). Each item in the questionnaire is scored 
between 0 and 10. Two of the sub-dimensions of the questionnaire are scored 0-50 and the other 
three sub-dimensions are scored 0-40. A total of 220 points is obtained from the questionnaire, and 
an increase in the total score is interpreted as an increase in labor pain with no cut-off point. A-
LPQ was used in this study with its Turkish translation and cultural adaptation. Language and 
content validity was performed to obtain the Turkish draft version of the A-LPQ. Relevant 
permissions were obtained from the authors who developed the questionnaire via e-mail on 
02.05.2017, and a contract was signed with Mapi Thrust, the research company holding the 
copyright of the questionnaire, on 22.01.2018. Turkish translation and cultural adaptation of the A-
LPQ was performed in six stages (Figure 1); (1) The questionnaire was translated from English, its 
original language, to Turkish by an obstetrician, who was an expert in the field, and another person 
who was not a healthcare professional, both native Turkish speakers. (2) The Turkish draft version 
of the questionnaire was formed by analyzing the two different Turkish translations. (3) The 
Turkish draft version of the questionnaire was translated back into English by another independent 
translator whose native language was Turkish, who had a good command of English, and did not 

know the original version of the A-LPQ. Certain language and grammar revisions were made at 
this stage (5). The final Turkish version of the questionnaire was evaluated for content validity by 
nine experts in the field, in accordance with the Davis method. Experts rated each item in 
accordance with the Davis method as follows: a: "Appropriate," b: "Should be slightly revised," c: 
"Should be substantially reviewed," and d: "Not appropriate." Intraclass correlation coefficient 
(ICC) analysis was performed with the data obtained from the nine experts to evaluate the 
consistency between the expert opinions given for each item of the A-LPQ. The “Coverage Validity 
Rate” was obtained for each item and the “Coverage Validity Index'” was obtained for the total 
questionnaire, and 0.80 was taken as a reference (F. Y. Karakoç & Dönmez, 2014; Yurdugül, 
2005). (6) A pre-application was made with 20 pregnant women in order to eliminate spelling, 
expression, and grammar problems of the Turkish version of the questionnaire, and the Turkish 
form was finalized.  
Interventions group: The VAS and A-LPQ forms were administered to evaluate the perceived pain 
levels of the pregnant women before the application after they were informed about the study and 
their consent was obtained (First measurement). The application was initiated immediately after 
the pain evaluation (max. 1 min later). 
Lower back massage performance: In the study, Linda Kimber's massage protocol was used 
(Kimber, 1999). The researcher applied the lower region circular hip massage, sacral pressure 
massage, and lateral lower region circular back massage to the pregnant women in the treatment 
group as per the Linda Kimber massage protocol (Figure 1). First, the researcher ensured that the 
patient was holding the bed, squatting, or bent over on the bed, which is suitable for the massage, 
between two contractions. The pregnant woman was instructed to breathe deeply and exhale 

audibly when her contractions began. Gloves were worn during the massage and liquid Vaseline, 
which does not contain any active substance, was used to provide lubricity. The circular hip 
massage was applied at the beginning of the contraction, and lower lateral area and sacral pressure 
massage was applied towards the end of the contraction as per the massage protocol, and 
simultaneously with the inhaling sound of the pregnant woman (Figure 3). The massage application 
was continued for an average of 20-25 minutes for at least three contractions. No massage was 
applied between contractions. After the massage application was finished, the vital signs and fetal 
heart sounds were checked and the VAS and A-LPQ were administered to the pregnant woman 
(Second Measurement). Measurements were made between contractions to evaluate the changes in 
pain level caused by massage application.  
Control group: Pregnant women in the control group received standard care in their room 
and their VAS and A-LPQ score was also evaluated during the same phases (Test 1 and Test 2). 
-Data analysis  
Data were evaluated in the statistical package program IBM SPSS Statistics Standard Concurrent 
User V 26 (IBM Corp., Armonk, New York, USA). Shapiro-Wilk test of normality and Q-Q graphs 
were used to evaluate the distribution of the data. Chi-square test, Mann-Whitney U, and t-test were 
used in the comparison of groups for socio-demographic, obstetric, and clinical findings. Two-way 
analysis of covariance was used for repeated measurements in the comparison of VAS score and 
A-LPQ scores between and within groups in proportion to the measurement times. The partial eta-
square calculation was used to evaluate the influence quantity in the comparison of the VAS and 
A-LPQ scores between the groups. Spearman correlation analysis was used to assess differences 
between the VAS score of the study group and the total and sub-dimension scores of the A-LPQ to 

determine the influence of A-LPQ in the measurement of the perceived pain change. The 
“Intention-to-Treat” method was not used in the analyses. Statistical significance level was 
recorded at p<0.05. 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1. CONSORT flow chart of the randomized controlled experimental study (Grant et al., 2018) 
 
Pregnant Women Evaluated for 
Suitability (n: 165) 
Excluded from study: 
 Did not meet the inclusion 
criteria (n: 73) 
 Did not agree to participate 
(n: 23) 
Randomization (n: 69) 
Control group (n: 35) 
Provided routine care 
Study group (n: 34) 
Application of lower back 
massage 
Analyzed (n: 30) 
Analyzed (n: 30) 
Determining groups  
Pregnant women who met the inclusion 
criteria (n: 69) 
Registration 
Obtaining Informed Consent From 
Pregnant Women, Completing the 
“Pregnant Women Introduction 
Form” and the “Labor Observation 
Form” 
First 
observation  
Pain evaluation 
 ALPQ-1 (n: 31) 
 VAS-1 (n: 31) 
Pain evaluation 
 ALPQ-1 (n: 33) 
 VAS-1 (n: 33) 
Second 
observation  
Analysis   
Intervention    
Withdrew from study: 
received a 
pharmacological method 
to reduce pain (n: 2) 
Withdrew from study: 
did not want massage (n: 3) 
Application of lower back 
massage for approximately 
20-25 min 
Routine follow-up and care 
(20-25 min) 
Pain evaluation 
 ALPQ-2 (n: 30) 
 VAS-2 (n: 30) 
Pain evaluation 
 ALPQ-2 (n: 30) 
 VAS-2 (n: 30) 
Withdrew from study: 
(n: 1) 
Withdrew from study: 
(n: 3) 
First Evaluation