Translation, inter-rater reliability, agreement, and internal consistency of the Spanish version of the cumulated ambulation score in patients after hip fracture

Translation, inter-rater reliability, agreement, and internal consistency of the Spanish version of the cumulated ambulation score in patients after hip fracture “This is an original manuscript of an article published by Taylor & Francis in Disability and Rehabilitation on March 2019, available at: doi: 10.1080/09638288.2019.1577499.” 1 Translation, inter-rater reliability, agreement, and internal consistency of the Spanish 1 version of the cumulated ambulation score in patients after hip fracture 2 Authors 3 Patrocinio Ariza-Vega.1,2, PhD, Marta Mora-Traverso.3, MSc, Mariana Ortiz-Piña.4, MSc, 4 Mauren Celeste Ashe.5,6, PhD, Morten Tange Kristensen.7,8, PhD. 5 6 1Rehabilitation and Traumatology Service, University Hospital of Granada, Granada, Spain 7 2Department of Physiotherapy, University of Granada, Granada, Spain. 8 3Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain. 9 4Vista Nevada Nursing Home for older adults, Granada, Spain. 10 5The University of British Columbia, Vancouver, Canada. 11 6Centre for Hip Health and Mobility, Vancouver, Canada. 12 7Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),Copenhagen, 13 Denmark. 14 8Departments of Physiotherapy and Orthopaedic Surgery, Copenhagen University Hospital, 15 Hvidovre, Copenhagen, Denmark. 16 17 18 19 Corresponding Author: Patrocinio Ariza Vega, PhD. Department of Physiotherapy. University 20 of Granada. Rehabilitation and Traumatology Service, University Hospital of Granada. Avenida 21 de la Investigación, s/n . CP 18016. Granada. Spain. Telephone: 0034 958021596, E-mail: 22 [email protected] 23 24 Abstract 25 26 Purpose: To translate the Cumulated Ambulation Score (CAS) into Spanish (CAS-E) and to 27 examine the interrater reliability and agreement of the CAS-E. 28 2 Materials and Methods: Two occupational therapists, independently reviewed 60 patients 29 consecutively admitted to a traumatology service of a public hospital with a hip fracture, and 30 rated the three CAS activities from 0 to 2, within the first post-surgery week. We determined the 31 internal consistency of CAS-E using Cronbach’s α coefficient. To test reliability, we used 32 weighted kappa statistics, the standard error of measurement (SEM) and the smallest real 33 difference (SRD). We determined the systematic between-rater bias using the McNemar–Bowker 34 test. 35 Results: No between-rater bias was seen, and the Cronbach’s α for the CAS-E was 0.89. The 36 weighted kappa was ≥ 0.83 for the three individual activities and the total CAS-E, while the 37 observed agreement was ≥ 0.87. The SEM and the SRD for the total CAS-E (0-6 points) were 38 0.18 and 0.83 points, respectively. 39 Conclusions: We present the CAS for use in Spanish speaking countries and provide evidence 40 for excellent relative and absolute reliability of the CAS-E to assess basic mobility for patients 41 with hip fracture in an acute care hospital. 42 43 Key words: hip fracture, basic mobility, reliability, older adults, psychometric properties 44 45 Introduction 46 The loss of functional independence after hip fracture is widely reported in the literature [1–3], 47 and early mobilization is recommended [4] to reduce the risk for prolonged hospital stay, 48 morbidity [5], and mortality [5,6]. To optimize recovery post-hip fracture, rehabilitation should 49 begin soon after surgery [4,5], and clinicians need valid and reliable measurement instruments 50 (e.g., outcome measures, such as scales or scores) to describe and evaluate changes in patients' 51 3 function to guide rehabilitation. For real-world uptake, outcome measures must also be simple to 52 use and quick to administer within the demands of daily clinical practice. 53 54 Outcome measures frequently used to objectively describe older adults’ function after hip 55 fracture include the Functional Independence Measure (FIM) [7], Barthel Index [8], Timed Up 56 and Go Test (TUG) [9] or the Tinetti Performance Oriented Mobility Assessment (POMA) [10]. 57 However, these scales are most useful for the assessment of all patients in the later phases of 58 rehabilitation (some floor effect is seen in the acute care setting) [9,10]. The FIM is time 59 consuming [7], the POMA cannot be used in patients with cognitive impairment [10], while the 60 TUG prerequisite the ability to rise from a chair and walk, independent of support from another 61 person [9]. Thus, there is a need for an efficient, easily applicable and stable outcome measure to 62 monitor all older adults’ basic function, across the mobility spectrum and continuity of care. 63 64 The Cumulated Ambulation Score (CAS ) [11] is a valid and reliable outcome measure to 65 quantify patients’ ability to perform three basic mobility activities: (i) getting in and out of bed; 66 (ii) sitting and rising from a chair (with armrests); and (iii) indoor walking (with/without walking 67 aid) [11]. Each subcomponent of the CAS is graded out of 2 points and the total CAS score can 68 range from 0 (dependent) to 6 (independent). The simplicity of the CAS makes it an ideal 69 outcome to use in a busy clinical setting. Previous research recognized the CAS as valid for use 70 with patients with hip fracture (including those with cognitive impairment) (5), total knee 71 replacement [12,13] and older adults with an acute medical hospital admission [14,15]. Other 72 literature observed its predictive ability for hospital length of stay and short-term (one month) 73 post-operative mortality in patients hip with fracture [5]. In addition, the CAS can detect 74 4 differences between groups of patients in relation to anemia [16], pain [17], type of fracture [18], 75 age [16] and the pre-fracture functional level [16,18]. Overall, the CAS is an important clinical 76 instrument that overcomes limitations of other outcome measures and is easy to integrate within 77 daily practice [19]. 78 79 The popularity of the CAS is gaining momentum and is adopted for use in many countries [20– 80 23]. In Denmark, the CAS is a mandatory component of the nationwide Danish Multidisciplinary 81 Hip Fracture Database [24]. In this way, the CAS can provide population level data for future 82 evaluation of change scores across settings (acute hospital to community). Such a versatile 83 measure is important for clinical practice and population health. For southern Europe, the cross84 cultural validity and reliability of the CAS is established in Italian [20]. Spanish is the second 85 most common language spoken globally, but the CAS is not available in Spain, where the annual 86 age-adjusted incidence of hip fracture in older adults (65 years and older) is 766 and 325 87 cases/100,000 for women and men respectively [25]. Given the high rate of hip fracture in Spain, 88 it is important to maximize recovery, and reliable and valid outcome measures are essential to 89 evidence-based practice. Therefore, the aim of this study was to translate the English version of 90 the Cumulated Ambulation Score into Spanish (CAS-E), and examine the interrater reliability 91 and agreement of the CAS-E. 92 93 Methods 94 Procedure 95 We enrolled 60 consecutive patients with hip fracture, admitted to the trauma service of the 96 Hospital of (blinded for peer-review), between January 2017 and March 2017. We included all 97 5 older adults aged 65 years and older. For patients with cognitive impairment, the informed 98 consent was signed by their relatives. The study was approved by the ethics committee of the 99 (blinded for peer-review), and all patients, or their proxy, signed a consent form before starting 100 the study. 101 102 We extracted descriptive information from the medical chart, such as, weight and height, type of 103 fracture and surgery. During an in-person interview (conducted between day 2 and 6 post104 surgery) we collected the following sociodemographic and clinical information: age, gender, 105 highest level of education, residence (pre-fracture and discharge), cognitive status [Short 106 Portable Mental State Questionnaire (SPMSQ)] [26], self-perceived health (5 item Likert scale), 107 pre-fracture functional level [Functional Independence Measure (FIM)] [7], and pain (visual 108 analogue scale (VAS)] [27]. 109 110 The Cumulated Ambulation Score (CAS) 111 The CAS describes three basic mobility activities: (i) getting in and out of bed (the sequence of 112 events is as follows: patient is supine on the bed, then moves to sitting, standing or transferring 113 to a chair next to the bed, then returns to sitting, then supine position on the bed); (ii) sit to stand 114 to sit from a chair with armrests (with or without aids), and (iii) walking indoors (with or without 115 walking aids) [11]. All three CAS activities are graded out of two points and they are summed to 116 generate a total 1-day score from 0 (dependent [bed bound]) to 6 (independent). Each activity is 117 scored with two points when verbal or physical assistance is not required (independent), even 118 for safety reasons; 1 point is assigned when human assistance (verbal or physical assistance) is 119 required from one or more persons; and no points are given when the patient is not able to do the 120 6 activity despite human assistance (dependent) [11]. Overall, it takes 5-10 minutes (depending on 121 patients’ mobility level) for the clinician to observe the patient complete the three activities of 122 the CAS in the clinical setting. 123 124 Translation of the CAS 125 We followed the recommendations provided by Ramada-Rodilla and colleagues [28] to translate 126 the comprehensive English version of the CAS manual [29]. Two people (unfamiliar with the 127 CAS) independently translated it from English to Spanish using the expressions of the Spanish 128 culture and language (to preserve the original intent of the test). A third person synthesized the 129 new CAS from the two versions described above. This person had not read the original English 130 version of the test. 131 132 The back translation was conducted by a fourth person who was a native English speaker. This 133 English version was forwarded to and approved by (author, blinded for peer-review), one of the 134 original CAS developers [11]. The objective in this phase was to identify possible differences, 135 difficulties, or errors of the Spanish translation in relation to the official English version. The 136 final version of the Spanish translation of the CAS (CAS-E) is located in supplementary data 137 (Appendix). 138 139 Inter-rater Reliability 140 We followed the guide provided by Kottner and colleagues [30] to exam the inter-rater 141 reliability. One senior dual-educated occupational and physiotherapist (blinded for peer-review) 142 and one novice CAS user (a graduate student and occupational therapist; blinded for peer143 7 review) tested interrater reliability of the CAS-E. For our preliminary work, the raters first met to 144 confirm the procedures for the CAS-E. Following this the senior therapist (blinded for peer145 review) completed the CAS-E with 15 in-patients with hip fracture, while the novice CAS 146 (blinded for peer-review) observed the procedure. The following day, the two raters concurrently 147 evaluated six patients with the CAS-E (not included in the results of this study) and discussed the 148 scores. The senior therapist was previously trained by one of the creators of the CAS. 149 In brief, to assess the inter-rater reliability of the CAS-E, the raters used several procedures to 150 add strength to the procedure. First, they used a random number generator to decide the order of 151 who gave the CAS-E instructions to the patients. In this way, a rather provided the instruction to 152 30 patients and the other rather did the same to the other 30 patients. Second, raters assessed 153 patients in the same session (concurrently), but they did not discuss the ratings and recorded their 154 scores independently (a third person collected rating scores at the end of each day). Third, all 155 testing was completed before patients’ usual daily rehabilitation. 156 157 Sample size 158 We based the sample size for the reliability testing following recommendations of Hopkins WG 159 [31], who suggest precision for reliability estimates require a minimum of 50 study patients. We 160 included 10 additional patients (total n=60) for consistency with the reliability study for the 161 original CAS [11]. 162 163 Statistical analysis 164 We present continuous data as means (standard deviation), medians (q25, q75) or number and 165 percentages depending on the data and its distribution. We used the Shapiro-Wilk Test for 166 8 examination of normal distribution of continuous data, and Chi-square or Fisher's Exact test to 167 explore differences for categorical data. We used Cronbach’s α coefficient [32] to test for 168 internal consistency between raters. To calculate the inter-rater reliability (for individual 169 activities and the total CAS-E) we used a linear weighted kappa and 95% confidence interval 170 [33] for ordinal scales. We calculated the observed (exact) agreement between raters and the 171 prevalence of scores 0–2 for the three activities and assessed systematic between-rater bias using 172 the McNemar-Bowker test. We provide a Bland-Altman plot to illustrate differences between 173 raters’ scores. We use the Standard Error of Measurement (SEM) to report the absolute 174 reliability at group level based on the standard deviation (SD) of patient scores for both raters 175 and the Intraclass Correlation Coefficient (ICC2.1), and calculated as SEM = SD x √(1-ICC) (34). 176 To calculate the smallest real difference (SRD; smallest measurement change that can be 177 interpreted as a real change for an individual person) we used the following equation; SRD = 178 SEM x √2 x 1.96 [35]. We used IBM SPSS Statistics Version 20.0 (IBM Corp., Armonk, New 179 York) and set the level of significance at P<0.05. 180 181 Results 182 We provide sociodemographic and clinical data for all patients in Table 1. 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Spanish version of the Cumulated Ambulation Score (CAS-E). 403 404 Escala de Movilidad Acumulada (CAS-E) Actividad Capaz de hacerlo independientemente (Sin guía verbal ni ayuda física), 2 puntos Capaz de hacerlo con guía verbal o ayuda física de una o varias personas, 1 puntos Incapaz de hacerlo incluso con ayuda de otras personas, 0 puntos Levantarse de la cama y acostarse Levantarse y sentarse en una silla Caminar dentro de casa con o sin ayuda técnica Puntuación Total: 405 406 Levantarse de la cama y acostarse; (De supino en cama a sentarse en el borde de la cama, 407 permanecer sentado o sentarse en una silla junto a la cama, y volver a la posición de supino en 408 cama). 409 20 Se asignan 2 puntos cuando la actividad se desarrolla independientemente. Independientemente 410 significa que no es necesaria guía verbal ni ayuda física de una persona, incluso por razones de 411 seguridad. Los pacientes pueden usar ayudas técnicas. 412 Se asigna 1 punto cuando se requiere ayuda de una persona. La ayuda de otra persona puede ser 413 desde cualquier indicación verbal hasta la ayuda física por parte de una o varias personas. Los 414 pacientes pueden usar ayudas técnicas. 415 Se asignan 0 puntos si los pacientes no son capaces de levantarse de la cama. Esto significa que 416 los pacientes no pueden levantarse de la cama y sentarse en una silla incluso con la ayuda de una 417 o varias personas. Los pacientes pueden usar ayudas técnicas. 418 419 Levantarse y sentarse en una silla con reposabrazos; (Levantarse, permanecer de pie y 420 sentarse). 421 Se asignan 2 puntos cuando la actividad se desarrolla independientemente. Independientemente 422 significa que no es necesaria guía verbal ni ayuda física de una persona, incluso por razones de 423 seguridad. Los pacientes pueden usar ayudas técnicas. 424 Se asigna 1 punto cuando se requiere ayuda de una persona. La ayuda de otra persona puede ser 425 desde cualquier indicación verbal hasta la ayuda física por parte de una o varias personas. Los 426 pacientes pueden usar ayudas técnicas. 427 Se asignan 0 puntos si los pacientes no son capaces de levantarse de la silla. Esto significa que 428 los pacientes no pueden levantarse y sentarse en una silla incluso con la ayuda de una o varias 429 personas. Los pacientes pueden usar ayudas técnicas. 430 431 Caminar dentro de casa 432 21 Se asignan 2 puntos cuando se consigue caminar independientemente usando una ayuda técnica. 433 Independientemente significa que no es necesaria guía verbal ni ayuda física de una persona, 434 incluso por razones de seguridad. Los pacientes pueden usar ayudas técnicas. 435 Se asigna 1 punto cuando se requiere ayuda de una persona. La ayuda de otra persona puede ser 436 desde cualquier indicación verbal hasta la ayuda física por parte de una o varias personas. Los 437 pacientes pueden usar ayudas técnicas. 438 Se asignan 0 puntos a aquellos pacientes que no son capaces de caminar. Esto hace referencia a 439 aquellos pacientes que no son capaces de caminar incluso siendo ayudados por una o varias 440 personas al mismo tiempo que usan una ayuda técnica para caminar. 441 442 La puntuación total es de 0 a 6 puntos. Cada una de las tres actividades tiene una puntuación 443 entre 0 y 2 puntos. 444 445 446 22 Tables 447 448 Table 1. Characteristics of patients (N=60). Values are presented as median (q25-q75); number of patients (%) and mean (standard deviation) [minimum-maximum] depending on the variable. Age, y mean (SD); min-max 81.6 (6.8); 64-96 Gender Women 46 (77) Men 14 (23) Body Mass Index, (BMI) kg/m2 Underweight, BMI < 18.5 1 (2) Normal, BMI =18.5-24.9 18 (30) Overweight, BMI > 25 41 (68) Highest level of Education, n (%) Cannot read and write 16 (27) Can read and write 25 (42) Primary school 13 (22) High School 3 (5) College (University) 3 (5) Type of fracture Intracapsular 40 (67) Extracapsular 20 (33) Type of Surgery 23 Dynamic Hip Screw / Intra Medullar Hip Screw 32 (53) Hemiarthroplasty 28 (47) Cognitive Status No cognitive impairment 27 (45) Mild cognitive impairment 14 (23) Moderate cognitive impairment 10 (17) Severe cognitive impairment 9 (15) Self-perceived health Very good 1 (2) Good 21(35) Average 23 (38) Bad 12 (20) Very bad 3 (5) Pre-fracture Functional Level (measured by FIM) Median (q25-q75) 102 (79-124) Pain during activity (measured by VAS), mean (SD) 5.15 (2.41) Pre-fracture residence Home, lives alone 17 (28) Home, lives with someone 28 (47) Relative´s home 9 (15) Nursing home 6 (10) Discharge destination Home, lives alone 4 (7) 24 Home, lives with someone 30 (50) Relative´s home 18 (30) Nursing home 8 (13) Total CAS-E, mean (SD); min-max novice therapist 3.32 (1.86); 0-6 senior therapist 3.30 (1.91); 0-6 CAS-E. Cumulated Ambulation Score-Spanish version; FIM. Functional Independence Scale; VAS. Visual Analogue Scale 449