Translation & Linguistic Validation of Knee and Osteoarthritis Outcome Score (KOOS) Questionnaire in Marathi Language
Condition: Health-Related Quality Of Life
MeSH terms: Osteoarthritis
Study type: Observational

Summary: 
      Background:

      KOOS is a self -administered instrument which assesses the patient's opinion about the Knee
      associated problems. For now it is available in English & various other languages & is a
      complete instrument in itself.

      In India it has been translated in Hindi so far. However, each province in this country has a
      unique language. Maharashtra is the second largest state in India and Marathi is the regional
      language of the communication. Since KOOS is a self-report measure, its translation in this
      local language was thought to be necessary. This disease specific measure which is originally
      designed for English speaking region when employed to non-English population needed to be
      translated with unique method to achieve a normative equivalence and linguistic validation.

      Methods: After taking permission from KOOS web manager T1, T2, T12, B1 & B2 versions were
      formatted according to the guidelines laid down by AAOS for cross cultural adaptation of
      health status measure. T12 version was sent for the field testing. Total 32 subjects who met
      the eligibility criteria were Included in this study.

      Results:

      Statistical analysis for reliability with test re-test method suggested Perfect correlation
      (r =1) between day 1 & 2. A range of 0.83-0.54 co-relation co-efficient (r) demonstrated the
      validity of KOOS and its subscales when compared against the 8 different domains of SF-36.
      All this correlations were statistically highly significant. Sport and recreation subscale
      had many missing responses since many items in this subscale were not appropriate for the
      Maharashtrian cultural set-up. Participants additionally provided the information about other
      functional activities which were difficult to execute due to knee associated pain and
      disability.

      Conclusion: Marathi version of KOOS is proved to be a reliable & valid measure. Future scope:
      this study demonstrate a need to undertake the cross cultural adaptation since a constant
      pattern of impairment revealed in the execution of daily activities such as sitting on the
      floor and attending certain yoga postures etc.

      Key words: linguistic validation, disease specific self-report, KOOS, Marathi translation,
      quality of life.
    

Detailed description: 
      Disability index is used as the Outcome measures and is a diagnostic tools and prognostic
      tool. This index allows a healthcare professional to measure impact of psycho-social and
      physical factors on the functional performance, ability of the patient. The people suffering
      from osteoarthritis is determined by the interplay of psychosocial, physical and
      physiological neuromuscular factors such as Quadriceps strength, knee pain, and age . These
      components have shown to be more important determinants of functional impairment in elderly
      subjects than the severity of knee osteoarthritis as assessed radiographically.Disability
      index which are designed to measure the influence of this factors on functional outcome are
      hence used clinically to justify the treatment and capture the meaningful recovery.

      The disease specific measures which are designed to assess the specific diagnostic group or
      specific population with a goal to detect a clinical change with the intervention of known
      efficacy should have good reliability, validity, responsiveness, and low burden of
      administration to be clinically useful. Such measures should be standardized and patient-
      centered that can be administered at a low cost. Hence a questionnaire was developed to
      assess short- and long-term patient-relevant outcomes following knee injury in form of Knee
      Injury and Osteoarthritis Outcome Score (KOOS). This is self-administered and assesses five
      outcomes: Pain, Symptoms, Activities of Daily Living, Sport and Recreation Function, and
      Knee-Related Quality Of Life.

      The KOOS meets basic criteria of outcome measures and can be used to evaluate the course of
      knee injury and treatment outcome. KOOS has been used as a reliable and valid measure when
      used to evaluate the effectiveness of an intervention in knee osteoarthritis, total knee
      replacement anterior cruciate ligament and cartilage injury. It has been converted in various
      regional languages. KOOS has been translated in national language of India ie. Hindi.
      However, in many provinces of India the primary language of communication varies. In this
      multi-linguistic country the language shift happens in every province concordant with
      diversified culture. Maharashtra is second largest state in India with estimated population
      is over 117 million appx. the primary language of communication is Marathi and over 70 % of
      population communicate in this regional language. A need for the translational and cross
      cultural adaptation has been emphasized for the effective and reasonable measurement of
      responses to any self-report measure whenever and wherever applicable. This is true
      especially if the self-report measure which was originally designed for English speaking
      region is being employed to non-English population. It is difficult to achieve normative
      equivalence which is dependent on openness with strangers, political opinions, tendency to
      conform or assert oneself , since cultures differ on how willing they are to share personal
      information. On the other hand information relevant to semantic and conceptual equivalence of
      demographic questions across languages, can be extracted with less difficulty since the words
      and ideas are more general and commonly used. This emphasizes a need to translate a health
      status self-administered measure for use in a new country. It is now recognized that a unique
      method should be used to achieve a linguistic validation to reach equivalence between the
      original source and target language of the measure or instrument. A published report by ISPOR
      suggests the consensus on following Principles of Good Practice in translation and cultural
      adaptation of any self-report questionnaire. A guidelines has been evolved for the adaptation
      process and is available in form of a template. Adaptation process is designed to attain
      semantic, idiomatic, experiential, and conceptual equivalence between the source and target
      questionnaires Since KOOS is the self-administered instrument, its translation in this local
      language was thought to be necessary as the majority of population attending physiotherapy
      clinics communicates in Marathi. Unavailability of the Marathi versions of KOOS hence, poses
      a difficulty in functional evaluation in this population on day to day basis before and after
      the treatment. Hence, there exists a need to provide valid and reliable Marathi version of
      KOOS, so as to facilitate the better understanding of functional evaluation findings in
      population suffering from knee osteoarthritis. This study aims to translate and check the
      psychometric properties of the translated version of the KOOS as per the guidelines laid down
      by AAOS. Objective of this study is to provide a valid and reliable instrument in the
      regional language which intends to evaluate disease specific functional problems in Marathi
      speaking population.

      Methods:

      Study design: cross section survey design- a validation study. Permission was obtained from
      Institutional local ethic committee. This study was carried out in 2 phases.

      Phase I consisted of translation of the English version of KOOS into the Marathi version.
      Second phase consisted of the field testing of the translated version to check test-retest
      reliability and validity.
    

Intervention name(s): disability index administration -self report form
Intervention type(s): Other
Intervention description(s): Final T12 version of KOOS was given to the participants by an assistant who was not involved with any prior procedure. At the same time SF- 36 v2[32] generic health measure was also handed over. Filled forms were collected by the same assistant. Next day participants were given another blank copy of Marathi KOOS T12 versions. Hence each participant filled three forms.
Observational model: Other
Time perspective: Cross-Sectional
Sampling method: Probability Sample
Study population: 
        Eligible subjects who the fulfilled the inclusion criteria were register for the study.
      
Keywords: linguistic validation; KOOS; Marathi translation