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ORIGINAL ARTICLE
Neurogenic bowel dysfunction (NBD) translation and linguistic validation to classical Arabic
Traduction et validation linguistique en Arabe classique du questionnaire Neurogenic Bowel Dysfunction (NBD)
A. Mallek
a,b, M.H. Elleuch
a,∗,b, S. Ghroubi
a,baServicedemédecinephysique,rééducationetréadaptationfonctionnelle,CHUHabib Bourguiba,routeL’AinKm1.5,3000Sfax,Tunisia
bUnitéderecherchedel’évaluationdespathologiesdel’appareillocomoteurUR12ES18, 3000Sfax,Tunisia
Received29February2016;accepted17June2016 Availableonline20July2016
KEYWORDS
Neurologicalpatient;
Anorectal;
Evaluation;
Questionnaire;
Translation
Summary
Objective.—TotranslateandlinguisticallyvalidateinclassicalArabic;theFrenchversionof theneurogenicboweldysfunction(NBD).
Patientsandmethods.—ArabictranslationoftheNBDscore wasobtained bythe‘‘forward translation/backword translation’’method. Patients withmultiple sclerosis(MS) and spinal cordinjurywereincluded.Evaluationofintestinalandanorectaldisorderswasconductedby theself-administeredquestionnaireNBD,whichwasfilledtwicetwoweeksapart.Anitem-by- itemanalysis wasmade.Thefeasibility,acceptability,internalconsistency usingCronbach’s alpha,andtest—retestrepeatabilitybynon-parametricSpearmancorrelationwerestudied.
Results.—Twenty-threepatients withcolorectaldisorderssecondarytoneurologicaldisease wereincluded,theaverageagewas40.79±9.16yearsandthesex-ratiowas1.85.Theques- tionnairewasfeasibleandacceptable,noitemswereexcluded.Thespearmancorrelationwas of0.842.InternalconsistencywasjudgedgoodthroughtheCronbach’salphawasof0.896.
∗Correspondingauthor.
E-mailaddress:habib.eleuch@rns.tn(M.H.Elleuch).
http://dx.doi.org/10.1016/j.purol.2016.06.008
1166-7087/©2016ElsevierMassonSAS.Allrightsreserved.
Conclusion.—TheArabicversionofNBDwasreproducibleandconstructvaliditywassatisfac- tory.Thestudyofitsresponsivenesstochangewithalargernumber ofpatientswillbethe subjectoffurtherwork.
Levelofevidence.— 4.
©2016ElsevierMassonSAS.Allrightsreserved.
MOTSCLÉS Patient neurologique; Anorectal; Évaluation; Questionnaire; Traduction
Résumé
But.—TraduirelequestionnaireNeurogenicBowelDysfunction(NBD)etétudiersavalidation linguistiqueenarabeclassiqueàpartirdelaversionfranc¸aise.
Patientsetméthode.—Latraduction aétéobtenueparlaméthode de« traduction/contre traduction ». Des patients ayant une sclérose en plaque (SEP) et des blessés médullaires ont été inclus. L’évaluation des troubles intestinaux et anorectaux a été réalisée par l’autoquestionnaireNBD,quiaétérempliàdeuxreprisesespacéparunepériodede15jours.
Uneanalyseitemparitemaétéfaite.Lafaisabilité,l’acceptabilité,lacohérenceinterneen utilisantlecoefficientalphadecronbachetlarépétabilitétest—retestparlacorrélationnon paramétriquedeSpearmanontétéétudiées.
Résultat.—Vingt-troispatientsprésentantdestroublescolorectauxsecondairesàunepatholo- gieneurologiqueontétéinclus,l’âgemoyenétaitde40,79±9,16ans,etlesex-ratioétaitde 1,85.Lequestionnaireétaitfaisableetacceptable,aucunitemn’aétéexclu.Lecoefficient alphadeCronbachétaitbonà0,896,ainsiquelacorrélationdeSpearmanquiaétéà0,842.
Conclusion.—LaversionarabeduNBDétaitreproductibleetsacohérenceinterneétaitsatis- faisante.L’étudedesasensibilitéauchangementavecunnombredepatientplusimportant feral’objetd’untravailultérieur.
Niveaudepreuve.— 4.
©2016ElsevierMassonSAS.Tousdroitsr´eserv´es.
Introduction
Colorectal disorders arecommon in neurological diseases [1].Severalstudieshave beenconcernedwiththeevalua- tionofthesedisordersandtheirimpactonthepsychological condition[2]andthequalityoflife[3].Amongtheseevalu- ationmeans,differentscoreswereusedfortheevaluation of constipation[4,5] or incontinence[6,7] though a large proportionofpatients aresuffering fromtheneurological combinationofthesetwoproblems.However,noneofthese meansof evaluationarecurrently available inArabic lan- guage.
Thedevelopmentofobjectivetoolevaluationisanabso- lutenecessityfacetodifficultiesofquantifyingsymptoms.
Two optionsfor developinga scale: eithertranslate an alreadyexistingscaleordevelopandvalidateanewscale.
The first one has the advantage of allowing comparison betweenstudiesindifferentcountries.
Inthiscontext,Kroghetal.[8]developedastandardized scalefortheanalysisofconstipationandfaecalincontinence inspinal cordinjury (SCI) patients:the NeurogenicBowel DysfunctionScore(NBD).ThisNBDscorewasusedtoassess symptomsaswellastheeffectivenessofneurogenicbowel managementinindividuals livingwitha spinalcordinjury foratleasttenyears[9,10].
NBDhasbeentranslatedintoseverallanguages(Danish, German,Italian,Swedish...).Thisworkaimedattranslating
andlinguisticallyvalidatingtheNBDscoretoclassicalArabic andclosedtoourdialectfromitsFrenchversion.
Patients and methods
The index: the Neurogenic Bowel Dysfunction (NBD) score
NeurogenicBowelDysfunction(NBD)scoreisascoredevel- opedbyaDanishteamtoassesstheneurologicaldysfunction intestineandtoidentifychangesinthestateofthepatient undertreatment[8].Itincludestenitems.
Totalscoreisfrom0to47.Thehigherscoreis,themore importantthegeneis:
• from0to6:veryminordysfunction;
• from7to9:minordysfunction;
• from10to13:moderatedysfunction;
• over14:severedysfunction.
Translation
The translation to Arabic was conducted according to the ‘‘forward translation/backward translation’’ method [11,12]andwascarriedoutindependentlybythreebilingual translators.ThesetranslatorsdidnotknowtheNBDanddid notuseitintheirdailypractices.The instructiongivento
eachtranslatorwastotrytopreservethemeaningofques- tionsandavoidverbatimtranslations.Theintermediateand definiteversionsweresubmittedtoanexpert’scommittee madeofthreedoctorsofphysicalmedicineandrehabilita- tiontobringthenecessaryadaptationsonalinguistic and culturallevel.
Thesynthesisofvarioustranslationshasresultedinafinal Arabicversionveryclosetotheoriginalwritteninasimple literarylanguage.Thefinalversionwasre-translatedfrom ArabicintoFrenchbytwoothertranslatorswhowereunin- formedaboutthesoughtpropertiesoftheinstrument.These translationswereconfrontedwiththeoriginalversion.
Translation difficulties, cultural differences, concep- tualequivalenceandlanguagedifferenceshave beenwell detectedbythismethodology.
Study of the series
Patients
The NBD validation was conducted with a sample of 23 patients(onepatientwasEgyptian,oneotherwasMoroccan andtherestwereTunisians).Theyhadcolorectaldysfunc- tionsecondarytopathologiesofthecentralnervoussystem.
Themaininclusioncriteriawere:
• adultsagedfrom20to60yearsinbothsexes;
• patients referred to our consultation, recruited for in FebruaryandMarch2015;
• patients with spinal cord injuries (traumatic or non- traumaticorigin),outsidethespinalshockphase;
• patientswithmultiplesclerosisinremission.
Themainexclusioncriteriawere:
• cognitiveandpsychiatricdisorders;
• poorknowledgeoftheArabiclanguage;
• the alterationoftheintestinalor colorectalcontinuity:
Ostomy.
Methods
Weevaluatedthecomprehensionofeachitemby:notunder- standable;doubtinunderstanding;understandable.
Thefeasibilityandacceptabilityofourscalewerestudied bythenumberofmissinganswersandalsobythecompre- hensionandthetimerequiredtorespondtothescale.
Patientswereaskedtorespondtoaquestionnairetwice withina15-dayinterval.
At T1: at the firstmeeting, we collected demographic dataandclinicalpatientdata.NBDwasfilledbythepatient withoutassistance,andanoralinterviewbythesameinves- tigator was done to note the level of understanding and acceptanceforeachitem.
At T2: after fifteen days, this self-questionnaire was administered a second time to patients who considered themselvesclinicallystable.Thechoiceofthisintervalwas basedon theneed for a stableclinical status onthe one handandpatientsnotmemorizingtheanswersontheother hand.
Statistical analysis
We used the SPSS software for Windows (version 20) to conductthestatisticalanalysiswithasignificantthreshold
setatP<0.05.Thesociodemographiccharacteristicsofthe patientsweredescribedwithaveragesandstandarddevia- tions.
Consistency and test—retest reliability were analyzed respectivelywith:
• Cranach’salpha:evaluatesthecontentvalidity(internal consistency);
• the non-parametric correlation coefficient of spearman wasusedtostudytheFidelitytest—retest.
Results Translation
The ‘‘forward translation/backward translation’’ method led to linguistic adaptations, focusing on promoting the meaningoftheitemratherthanachievinga literaltrans- lation.Thetranslation difficultiesweremainly duetothe needtotranslateintoaneasyliteraryArabicclosetothe Tunisiandialect.
The synthesis of the three translators versions has resultedinauniquetranslation.Thetwo-backwardtransla- tionsofthisversionwerecomparabletotheoriginalscale.
TheCommitteeofthreedoctorshadagreedwiththefinal versionscale.
Validation of the Arabic translation of the score NBD
Demographic and clinical data of patients
Thisself-questionnairewasadministeredto23middle-aged patients40.79±9.16years,witha sex-ratioreaching1.85 andhavingcolorectaldisorderssecondarytoaneurological pathology.
Table1summarizedtheclinicalandpatientdemograph- icscharacters.
Metrological properties of the items, feasibility
Wehavenoticedthatalltheanswersofitemnumber4were
‘‘theirregularuseoftabletsagainstconstipation’’excluding twopatients.
Allitemswereconsideredunderstandableexcept:
• for item 6: therewasa doubt to understanding with7 patientsandnotunderstandablewith2patients;
• for item 7: therewasa doubt to understanding with4 patients
These twoitems werenotunderstandable becausethe twowords‘‘stool’’and‘‘anus’’wereusedinFrenchforthe majority of the Tunisian population, against the Egyptian patientwhoreportedthatallwaswellunderstood.
Fortheitem8:3patientshadadoubttounderstanding sinceclassicalArabictranslationleadedtoconfusion.There- fore,itsmeaninghasbeen addedin bracketstofacilitate understanding.
NoitemswereexcludedfromthefinalArabicversion.The averagetimerequiredtocompletewas4.05±1.92minutes.
There were missing responses in 1.7% of patients and no doubleanswers.
Table1 Clinicalanddemographicdataforpatients.
Number(%) Natureofdisease
Spinalcordinjury
(traumatic/non-traumatic)
15(65.3%)
Multiplesclerosis 8(34.7%)
Clinicalpresentation
Nodeficitmotor 3(13%)
Paraparesis 18(78.26%)
Tetraparesia 2(8%)
Urinarysymptom
Clinicaloveractivebladder 10(43.47%)
Obstructivesyndrome 5(21.17%)
Theassociationofbothsyndromes 8(34.7%) Colorectaldisorders
Constipation 15(65.21%)
Fecalincontinence 3(13.04%)
Occasionalconstipationandfecal leakage
5(21.17%) Professionalactivity
Workstopping 7(30.43%)
Training 1(4.3%)
Regularoccupation 15(65.21%)
Psychometric properties
The NBD self-administered questionnaire was filled twice withafifteen-dayintervalby23patients.AtT1,theaver- agetotalNBDscorewas9.47±4.9and9.58±5.9atT2.The Spearmancorrelationshowsgoodrepeatabilitywith0.842.
Theinternal consistencyofthisself-administeredques- tionnaire was considered as good through the Cronbach alphacoefficient,whichreached0.896.
Discussion
Inourstudy,wefoundthattheNBDscoreArabicversionhas hadreproducibilityanditsconstructvaliditywassatisfac- tory.
Withoutaconsensusaboutthetranslationmethodology [13],wehaveadoptedthe‘‘forwardtranslation/backward translation’’madebythreeindependenttranslators.
Wehavechosentotranslatetoasimpleliterarylanguage becauseliteraryArabicremainsthelinkbetweenthevarious dialectsinTunisiaandinotherArabcountries.
Theliterarytranslationofsometermswasdifferentfrom thetermusedinthelocaldialect.Inthiscase,thesynonym used in the dialect can be added while these dialectical synonymsmaydifferfromoneArabcountrytoanotheror fromoneregiontoanotherinthe samecountry.We have exceededthisproblemwithanexplanationofthetwowords
‘‘stool’’and‘‘anus’’whenthequestionnairewasfirstfilled.
Therepeatabilityoftheresponsestothisquestionnaire wasgood.This canhardlybeexplainedbythe smalltime intervalbetween the administration of the twoquestion- naires,andthustoamemorizationofthepatients’answers.
Ifpatientscouldrecallquestions,theywouldhardlyremem- bertheirpreviousanswers.
Wehave noticedthatalltheanswersofitemnumber4 were ‘‘the irregularuse of tablets against constipation’’, exceptfor an Egyptianpatientandanotheronewhoused irregularly plant extract tablets. This is due to the fact that in Tunisia constipation treatment is available in the form of syrup or sachet and a herbal therapy product in the form of tablets that is not within the reach of all patients.
NBDscorewasvalidatedfor SCIpatients[8]whereasin the study conducted by Fourtassi et al. [14], the effec- tiveness of transanals irrigation for bowel and anorectal disorders,inshort-andlong-term,usingNBDscorewitha population of SCI and multiple sclerosis(MS) patients has beenevaluated.Inaddition,inanotherstudyconductedin 2009byKroghandChristensen,announcedthattheNBDwas used toevaluate the intestinaland anorectal dysfunction secondarytotheimpairmentofthecentralnervoussystem andnotapplicableforpatientswithParkinson’sdiseaseor myelomeningocele.Inourstudy,weincludedMSandspinal cordinjurypatients.
Theresultsofthisstudyshouldbeconsideredintermsof severallimitations.
The sample was reduced to 23 patients compared to 258patientsinthestudyof Adriaansenetal.whostudied theoutcomesofneurogenicbowelmanagementinindivid- uals living with a SCI patients for at least ten years [9], whichcouldrequirethecontinuationofthisworkwiththe recruitmentofagreaternumberofpatientstocompletethe validationofthisscale.
We cannot use the NBD for all Tunisian SCI and MS patientsbecausethereareilliteratepatientswhospeakonly Tunisiandialect.Infact,theTunisianpeoplearetheresult of amosaic ofcultures(Arab,African,Mediterranean and French)andtheirdialectisveryrichandvaried.Peoplewho haveneverbeentoschoolandwhoknowonlythatdialect cantotallyignorethenameofcertainobjects,verbsoreven toolsusedindailylifeinliteraryArabic.
Fecalincontinenceandconstipationremainataboosub- jectformanyneurologicalpatients.Theytrynottoevoke theirproblems,notonlybydecencybutalsobecausetheir dysfunctionisnotimportant.Infact,morethanhalfofour populationhasminimalandmoderatedysfunction.Thisself- administeredquestionnaireallowedustobetterunderstand theanorectaldysfunctionofourpatients.
The combination of vesico-sphincter disorders and anorectaldysfunctionarefrequentlyencounteredduetothe centralneurologicaldisease.Allourpatientshadassociated vesico-sphincterdisorders.An evaluationby theUSP[15], whichhasalreadyundergoneatranslationintoArabic,and theNBDwillallowabettermanagementofthesepatients andeventuallyimprovetheirqualityoflife.
Conclusion
Thiswork,neverrealizeduntilnow,hasallowedustoobtain areproducibleArabicversionofNBD scorewithgoodout- come of constructvaliditydespite languagedifficulties of themulticulturalismoftargetpopulation.
Thesimplicityofthisindexalloweditsuseindailyclinical practiceandforscientificstudiesofourTunisianpopulation.
ThisarticleproposedatranslatedversionofNBDandwillbe
followedbyasecondwork,whichwillsuggestthestudyofits responsivenesstochangewithalargernumberofpatients.
Disclosure of interest
Theauthorsdeclarethattheyhavenocompetinginterest.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.purol.
2016.06.008.
References
[1]Higgins P, Johanson J. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 2004;99(4):750—9.
[2]CooperZr,RoseS.Fecalincontinence:aclinicalapproach.Mt SinaiJMed2000;67:96—105.
[3]DeLoozeD,VanLaereM,DeMuynckM,BekeR, ElewautA.
Constipation and other chronic gastrointestinal problems in spinalcordinjurypatients.SpinalCord1998;36:63—6.
[4]AgachanF,ChenT,PfeifferJ,ReismanP,WexnerSD.Aconsti- pationscoringsystemtosimplifyevaluationandmanagement ofconstipatedpatients.DiscolonRectum1996;39:681—5.
[5]KnowlesCH,EccersleyAJ,ScottSM,WalkerSM,ReevesB,Lun- nissPJ.Lineardiscriminantanalysisofsymptomsinpatients withchronicconstipation.DiscolonRectum2000;43:1419—26.
[6]Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut 1999;1(44):77—80.
[7]RockwoodTH,ChurchJM,FleshmanJW,KaneRL,Mavrantonis C,ThorsonAG,etal.Faecalincontinencequalityoflifescale.
DisColonRectum2000;43:9—17.
[8]Krogh k, Christensen P, Saboroe S, Laurberg S. Neurogenic boweldysfunctionscore.Spinalcord2006;44:625—31.
[9]AdriaansenJJ,VanAbesbeckFW,VanKuppeveltD,SnoekGJ, PostMW.Outcomesofneurogenicbowelmanagementinindi- vidualslivingwithaspinalcordinjuryfor atleast10years.
ArchPhysMedRehabil2015;96:905—12.
[10]LiuCW,HuangCC,ChenCH,YangYH,ChenTW,HuangMH.
Predictionofsevereneurogenicboweldysfunctioninpersons withspinalcordinjury.SpinalCord2010;48:554—9.
[11]PrenegerT,LeplègeA,EtterJF.Cross-culturaladaptationofa psychometricinstrument:twomethodscompared.JClinEpi- demiol1999;52:1037—46.
[12]HendricsonWD,RusselIJ,PrihodaTJ,JacobsonJM,RoganA, BishopG,etal.Developpementandintialvalidationofadual languageEnglish-Spanishformatforthearthritisimpactmea- surementscales.ArthritisRheum1989;9:1153—9.
[13]GuilleminF,BombardierC,BeatonD.Cross-culturaladaptation ofhealthrelatedqualityoflifemeasures:literaturereviewand proposedguidelines.JClinEpidemiol1993;12:1417—32.
[14]FourtassiM,CharvierK,HajjaouiA,HavéL,RodeG.Intérêtdes irrigations transanalesdans lagestion des troublesintestin- aux et ano-rectaux chez les blessés médullaires.Prog Urol 2012;22:467—74.
[15]ArabiH,BendeddoucheI,KhalfaouiS,LouardiN,AmeurA,Le BretonF,etal.Traductionetvalidationlinguistiqueenarabe classiqueduquestionnairedel’UrinarySymptomProfile(USP).
ProgUrol2013;23:244—8.
