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Reliability of the Scoliosis Research Society-22 Patient
Questionnaire (Italian version)
in mild adolescent vertebral deformities
M. MONTICONE 1, R. CARABALONA 2, S. NEGRINI 1 2 Aim. The reliability evaluation of the Italian version of
1ISICO (Italian Scientific Spine Institute), Milan, Italy the Scoliosis Research Society-22 Patient Questionnaire
2Unit of Functional Rehabilitation (SRS-22-I), administered to adolescents with mild verte-
Don Gnocchi Foundation, Milan, Italy bral deformities, is evaluated.
Study design: forward-backward translation,
pretest, final version according to a focus-group evalu-
ation, and 1 week test/retest. Population: pretest: 35
subjects (22 females), age range 8.5-19 years, 28 idiopath-
ic scoliosis (17°±7°), 7 hyperkyphosis (54°±4°); test/retest:

ent type. Lack of reliability for questions 12 and 21
20 subjects (11 females), age range 12-17.5 years, 15
should be better understood. Until now the psychomet-
idiopathic scoliosis (16°±8°), 5 hyperkyphosis (55°±5°).
ric properties of SRS-22 questionnaire have been evalu-
Statistical analysis: Spearman rank test, percent of agree-
ated only in USA populations, and in idiopathic scolio-
ment. Statistical significance: 0.05. Software: Statgraphics
sis. Moreover, only one study has been proposed includ-
3.0. We calculated the results of the questionnaire and
ing patients with mild idiopathic scoliosis. This, togeth-
performed the statistical analysis using non parametric
er with the non-parametric statistical analysis used,
test because of the charcteristics of the data: this differ
could explain the high ceiling and floor effects we found
from previously published results.
in our data.
Results. Response rate was 100%. Total score: median 4
Key words: Scoliosis - Rehabilitation - Questionnaires.
(range 3-5); results for different domains (median,
range): function/activity 4 (3-5), pain 5 (3-5), self image/
appearance 3 (2-5), mental health 4 (3-5), satisfaction
with management 4 (2-5). Time required to answer the

Once diagnosed, idiopathic scoliosis can develop during adolescence in more than 85% of cases 1, 2 questionnaire ranged from 5 to 20’; for 12 to 17.5 years
old subjects from 5 to 10’. pretest showed difficulties

and requires treatment to be stopped. Both surgical with questions on pain; the questionnaire was changed
and conservative treatments cause, respectively, per- accordingly. Spearman’s rho ranged from 0.42 to 1, not
manent and transient disability, having a high psy- significantly different from null value for questions 12
chological impact, often underestimated by health and 21. Percent of agreement (evaluated only for ques-
professions, even if they are relevant for patients and tion 11a) was 100%. The ceiling and floor effects have
been found high.
To entirely understand the scoliosis problem we Conclusion. The SRS-22-I was found to be reliable for
young patients with mild vertebral deformities of differ-

have to go beyond its biological aspects, consideringthe adolescent’s point of view, that is the most impor- Submitted for publication July 20, 2004.
tant to obtain a good compliance to the treatment.
Patients’ perceptions of several aspects of their healthcondition and the outcome of its management are cru- Address reprint requests to: S. Negrini, ISICO (Istituto Scientifico cial for final results.4 Anyway, these results go beyond Italiano Colonna Vertebrale), Via Carlo Crivelli 20, 20122 Milano. the simple clinical and, above all, strictly radiological RELIABILITY OF THE SCOLIOSIS RESEARCH SOCIETY-22 PATIENT QUESTIONNAIRE (ITALIAN VERSION) evaluation.5 These results can be assessed by health from 5 (best) to 1 (worst).14 The SRS-22 patient ques- related quality of life (HRQL) questionnaires: much tionnaire gained good score distribution, internal con- remains to be discovered about population health in sistency, reproducibility, concurrent and discriminant comprehensive terms of functional health and well- validity,14, 15 being shorter and more focused on the being, regarding the relative burden of disease, and the health issues related to adolescent idiopathic scolio- specific benefits of selected treatments.5 sis (AIS) than SF-36. The SRS-22 patient questionnaire Advances and in-depth research have been large- obtained a satisfying level of acceptance to be used ly conducted over these last few years for finding sat- and safely developed in pre/post surgical AIS English- isfying methods able to describe patients’ subjective speaking patients, for both clinical and research deci- health status perceptions: today several valid and reli- able patient-based tools are available. The most The aim of this study was to develop an Italian ver- famous and world-known is the SF-36,6 which has sion of the Scoliosis Research Society-22 Patient been employed in more than 1 000 indexed studies, Questionnaire (SRS-22-I), and to verify its reliability and adopted because of its brevity and of its com- and applicability in Italian adolescents with mild ver- prehensiveness.7 The usefulness of the SF-36 in esti- tebral deformities in everyday clinical practice.
mating disease burden is illustrated in many articlesdescribing more than 130 diseases and conditions:among the most frequent, with more than 20 SF-36 Materials and methods
English-speaking publications each, are arthritis, backpain, depression, hypertension and diabetes.7 Trans- We performed a forward-backward translation of lation, subsequent validation and reliability studies the English version of the questionnaire, made both by gave rise to many other indexed and not-indexed arti- an expert of scoliosis and a mother-tongue translator: a focus-group evaluation (group composed by sen- The SF-36 is a generic HRQL questionnaire, but in ior and junior researchers, translator and statistician) specific diseases the usefulness of specific HRQL eval-uations has been shown. In the field of scoliosis treat- produced the first version of the questionnaire. A ment, many efforts in this direction have been made pretest assessment was performed on the pretest group by the Scoliosis Research Society.11 The original (PTG): self-compiled the questionnaire in presence of Scoliosis Research Society HRQL questionnaire has one researcher, which was there to receive his sugges- been first produced by Haher et al. in 1999 12 to pro- tions and identify his difficulties with any single ques- vide a simple, direct, disease-specific, patient-based tions. Consequently, the actual version of the question- assessment for patients with idiopathic scoliosis. This naire (named SRS-22-I, Appendix A) was produced first HRQL questionnaire demonstrated satisfactory after a second focus group evaluation (group now internal consistency for all 7 domains and reproducibil- composed by senior and junior researchers, and sta- ity for 3 of the domains in which it was divided.12 tistician): its reliability was finally evaluated through Anyway, this HRQL scoliosis questionnaire needed test-retest in a second sample of patients, the test/- important improvements and modifications in the fol- retest group (TTG). In this phase, according to the original instructions, the questionnaire was self-com- The results of these changes led to the Scoliosis piled by the patients together with their parents in the Research Society-22 Patient Questionnaire (SRS-22), waiting room, immediately after medical evaluation.
published in the past year by Asher et al.14-16 This Patients were asked to answer with no more instruc- new questionnaire, named SRS-22 Patient Question- tions then those written on top of the questionnaire.
naire, includes 5 domains. The domains and the num- The help of a researcher was available, but never ber of the questions (reported in parenthesis) in each required. Retest was performed at home after 7 days.
domain are the following: function/activity (5), pain The complete characteristics of PTG and TTG are (5), self-image/appearance (5), mental health (5) and satisfaction with management (2). The combination of Due to the nominal or ordinal nature of our data,17 the first 4 domains is labelled subtotal. The mental we choose to perform the statistical analysis according health questions were adapted with permission from to a nonparametric approach using Spearman rank SF-36. For each question, the scoring scale ranged test (percent of agreement for question 11A and 11B).
RELIABILITY OF THE SCOLIOSIS RESEARCH SOCIETY-22 PATIENT QUESTIONNAIRE (ITALIAN VERSION) TABLE I.—Characteristics of the population. TABLE III.—Statistical results of test/retest evaluation. TABLE II.—Question 11: comparison of the English and Italian 11. Which one of the following 11. A) Utilizzi farmaci per la tua — Non-narcotics weekly or less 11. B) Se hai risposto sì, quali? fore the instructions for compilation and the ques- tions 1, 2, 7, 12, 13, 19, and 20 were slightly changed,while the questions 5, 6, 10 and 11 were completely Statistical significance was set at 0.05. Software used changed to produce the final version. All these vari- included Excel 7.0 and Statgraphics 3.0.
ations were related only to the translation of the ques-tionnaire and did not change its general structure,with only one possible exception: in fact, the wayquestion 11 was asked in English could not be pro- posed in Italian without medical explanations andwe changed it slightly from the original (Table II). The response rate was 100% in both populations The subjects required no explanations during the and time required to answer the questionnaire ranged test phase. In the TTG, Spearman’s rho ranged from from 5 to 20 s in the PTG (which included also young- 0.42 to 1, and it was not significantly different from null er subjects) and from 5 to 10 s in the TTG. value for questions 12 and 21, belonging, respective- During the pretest phase, patients gave some sug- ly, to function/activity and satisfaction with manage- gestions on the way questions had been written: there- ment domains (Table III): it must be considered that RELIABILITY OF THE SCOLIOSIS RESEARCH SOCIETY-22 PATIENT QUESTIONNAIRE (ITALIAN VERSION) the p-value for question 12 was 0.06. Percent of agree- changed accordingly. May be this could depend on the ment was evaluated only for question 11a, where all fact that our target was strictly mild idiopathic scoli- subjects answered “no”, and was 100%. The floor/ceil- osis: in this phase, pain is not as frequent as in the pre- ing effect we found are reported in Table IV, compared surgical (or postsurgical) phase can be. with those of the original USA version (the last one The questionnaire showed to be repeatable, with the have been obtained using the average to calculate exceptions of question 12 and 21. As happened in the the domains, while in our results we used the medi- original SRS-22 version,14 the SRS-22-I demonstrated to an, coherently with the data analyzed).
be easily understandable and answerable in time (also Looking at the results from a clinical point of view, for younger patients), repeatable, and reliable.
the total score (median, range) was 4 (3-5), while the Asher et al. too found difficulties in the assessment results for the 5 different domains were, respectively: of satisfaction with treatment 15 (question 21) but there function/activity 4 (range 3-5), pain 5 (3-5), self are differences with the previous study: all our patients image/appearance 3 (2-5), mental health 4 (3-5), sat- underwent conservative treatment (only exercise or exercise and brace treatment) and not also surgery;moreover, the questionnaires were self-compiled andnot administered through interviews made by the sur- Discussion and conclusions
geons. Anyway, in our study we had a change of set-ting (compilation at home vs in the waiting room of Scoliosis treatment cannot longer be considered the Scoliosis Centre) that could drive to variations (as) only a mere radiographic treatment: there are when asking about satisfaction with treatment (ques- core aspects such as patients’ satisfaction, psycholog- tion 21), but also when looking at interference with ical problems, quality of life etc.,4 that all need to be everyday home activities (question 12). In this last case, it is also possible that the questionnaire pro- The well-known SF-36 is a useful instrument for duced attention to changes not even discovered studying general population, individuating the relative before, or that the results of the visit drove to chang- burden of diseases, differentiating the health benefits es in everyday life not understood immediately after produced by a wide range of different treatments, the medical evaluation. Nevertheless, even if the ten- and screening different patients.7 However, the SF- dency toward significance of question 12 was clear, 36 is a multipurpose, generic health survey, that yields our results in this case should be deepened in future an 8-scale profile of scores as well as physical and studies, while the answers to question 21 should be mental health summary evaluation, opposed to ques- tionnaires that target a specific age, disease, and treat- When compared to Asher’s results,14 we have found satisfying clinical results in the self-image/appear- The latest version of the American SRS-22 patient ance, pain and mental health domains: these results questionnaire has been strongly advocated to go may depend upon the fact that mild idiopathic scoli- beyond this limits:13 this questionnaire proved to be osis produces a lower perception of the spinal defor- highly tailored to this particular kind of patients and mities than presurgical conditions can determine. The age, to their physical changes according to treatment self-image/appearance domain of SRS-22 patient ques- (both surgical and conservative), to their psycholog- tionnaire is not found in SF-36 HRQL questionnaire, ical problems, and above all to their quality of life being of greatest importance in scoliotic patients.14 We must underline the ceiling effect we verified in our This study has been developed with clear intents.
population, were the lowest answer was 2, and only It may compare the Italian results with the results in 2 domains (self image/appearance and satisfaction existing in the original version in the effort of verify- with management), while in the others it was 3. This ing the reliability of this HRQL questionnaire for mild is likely due to the low-medium degree of scoliosis AIS Italian patients. We did not find problems during considered in our sample: in future studies in this the forward-backward translation phase, reaching the kind of population this result should be taken in final Italian version according to an expert group eval- account, even if changing the scale could drive to uation. Patients in the PTG demonstrated some diffi- difficulties comparing the data internationally.
culties, and the Italian version of the questionnaire was Another difference between our study and the pre- RELIABILITY OF THE SCOLIOSIS RESEARCH SOCIETY-22 PATIENT QUESTIONNAIRE (ITALIAN VERSION) vious one can be found for the age: Asher’s results References
ranged from 10 to 16 years old subjects,14-16 while we 1. Weinstein SL. Natural history. Spine 1999;24:2592-600.
selected 8.5 to 19 years old subjects, proving the SRS- 2. Weinstein SL, Ponseti IV. Curve progression in idiopathic scolio- 22-I reliability also in these 2 extremes of childhood sis. J Bone Joint Surg Am 1983;65:447-55.
and adolescence, respectively. Moreover, we includ- 3. Weinstein SL, Anderson BJ, Dickson RA, Lonstein JE, Nachem- son A, Weinstein JN et al. Spine Focus Issue. Spine 1999;24: The information gathered through this type of ques- 4. Negrini S, Monticone M, Brambilla C, Carabalona R. Treatments of tionnaire can be of great importance, particularly adolescents idiopathic scoliosis: the problem of acceptability.
Proceedings of International Research Society for Spinal Deformities when critical therapeutic decisions are advocated, (IRSSD) Annual Meeting, 2004, June 10-12, Vancouver (Canada).
dealing with the adolescent’s perceptions, which in 5. Hudak PL, Wright JG. The characteristics of patient satisfaction most cases are not easily understood during the few 6. Ware JE. SF-36 Health Survey: Manual and Interpretation Guide.
minutes of the visit. Asher concluded that SRS-22 2nd ed. Boston: The Health Institute, New England Medical Center; patient questionnaire may become important in deci- 7. Ware JE. SF-36 Health Survey Update. Spine 2000;25:3130-9.
sion making for or against surgery.16 We agree with 8. Apolone G, Mosconi P. The Italian SF-36 Survey: translation, val- him, but we also foresee this questionnaire decisive idation and norming. J Clin Epidemiol 1998;51:1025-36.
9. Gandek B, Ware JE. Methods for validating and norming transla- for all other therapeutic decisions, including the tions of health status questionnaires: the IQOLA project approach.
patient’s own aesthetic decisions.
In conclusion, the SRS-22-I was found to be reliable 10. Ware JE, Gandek B. Methods for testing data quality, scaling assumptions, and reliability: the IQOLA project approach. J Clin for young Italian patients with mild vertebral defor- mities of different type, although the ceiling effect and 11. Climent JM, Reig A, Sanchez J, Roda C. Construction and valida- not all questions proved to be without any problem.
tion of a specific quality of life instrument for adolescents with spinedeformities. Spine 1995;20:2006-11.
This is the first reliability study for a translated version 12. Haher TR, Homel P, Merola AA, Grogan DP. Results of the Scoliosis of the original questionnaire in a non-English language: Research Society instrument for evaluation of surgical outcome inadolescent idiopathic scoliosis: a multi-center study of 244 patients.
till now the SRS-22 questionnaire has been studied and applied only in USA populations, and particular- 13. Asher M, Min Lai S, Burton DC. Further developments and valida- ly in pre/post surgical idiopathic scoliosis; moreover, tion of the Scoliosis Research Society (SRS) Outcomes Instruments.
Spine 2000;25:2381-6.
only one study has been proposed including patients 14. Asher M, Lai SM, Burton D, Manna B. The reliability and concur- with mild idiopathic scoliosis.16 The SRS-22-I proved to rent validity of the Scoliosis Research Society-22 patient question- be suitable for self-administration, while computer- naire for idiopathic scoliosis. Spine 2003;28:63-9.
15. Asher M, Lai SM, Burton D, Manna B. Scoliosis Research Society- ized administration or administration by trained inter- 22 patient Questionnaire. Responsiveness to change associated viewers (in person or by telephone) to person aged 10 with surgical treatment. Spine 2003;28:70-3.
16. Asher M, Lai SM, Burton D, Manna B. Discrimination validity of the years and older should be evaluated in the future. We scoliosis research society-22 patient Questionnaire. Relationship to strongly recommend the everyday use of this ques- idiopathic scoliosis curve pattern and curve size. Spine 2003;28: tionnaire, which could bring many interesting informa- 17. Fisher WP Jr. Objectivity in psychosocial measurement: what, tion in research, but also in everyday clinics. why, how. J Outcome Meas 2000;4(2):527-63.
Questionario SRS-22 - Versione Italiana Istruzioni: stiamo valutando le condizioni di salute della tua schiena ed è perciò importante che tu risponda a ognuna di queste domande da solo.
Per favore, segna per ogni domanda la risposta che ritieni più adeguata 1. Quale termine descrive meglio il dolore di cui hai 6. Qual è il tuo aspetto quando sei vestito/a? 7. Negli ultimi 6 mesi sei stato/a così depresso/a da 2. Quale termine descrive meglio il dolore di cui hai 3. Durante gli ultimi 6 mesi sei stato/a molto ner- 4. Se l’aspetto estetico della tua schiena dovesse 9. Qual è il tuo attuale livello di attività lavorativa/ restare quello attuale per il resto della tua vita, 10. Quale di questi termini meglio descrive l'aspetto 5. Riesci a fare normalmente le tue attività quoti- del tuo tronco (ossia del tuo corpo, esclusi la tes- ❏ faccio qualunque cosa senza limitazioni RELIABILITY OF THE SCOLIOSIS RESEARCH SOCIETY-22 PATIENT QUESTIONNAIRE (ITALIAN VERSION) 11. A. Utilizzi farmaci per la tua schiena? 17. Negli ultimi 3 mesi ti sei mai assentato/a dal lavoro/scuola per il mal di schiena e se così è sta- 11. C. Se hai risposto sì, con che frequenza? 12. La tua schiena limita in qualche modo le tue atti- 18. Esci di più o di meno rispetto ai tuoi amici? 13. Ti sei sentito/a calmo/a e tranquillo/a negli ultimi 19. Data la condizione attuale della tua schiena ti sen- 14. Pensi che la condizione della tua schiena inter- 20. Sei stato/a felice negli ultimi 6 mesi? 15. Tu e/o la tua famiglia state vivendo delle diffi- 21. Sei soddisfatto dei risultati del trattamento della tua coltà economiche a causa della tua schiena? 16. Negli ultimi 6 mesi ti sei mai sentito/a disperato/a 22. Ti sottoporresti ancora allo stesso trattamento se


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CHLAMYDIA (Revised April 29, 2005) A. Diagnosis Clinical: Found in 20-35% of patients with NGU, PID, gonorrhea, mucopurulent cervicitis, and up to 10% of asymptomatic STD clinic patients. Laboratory: Definitive diagnosis requires isolation of CT by cell culture or identification by nucleic acid amplification test (NAAT), including strand displacement assay (SDA) and polymerase cha

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