Cross-cultural adaptation, validity, and reliability of the Arabic version of the shoulder disability questionnaire

Background: Following low back and knee discomfort, shoulder pain (SP) is the third most common musculoskeletal problem, with an estimated global prevalence of 1.0% – 4.8%. The (Shoulder Disability Questionnaire (SDQ)) is used to investigate pain in patients with shoulder-related disabilities, and it represents a promising psychometric property but has no Arabic version. Aim: To implement a cross-cultural approach to create an Arabic version of the SDQ and evaluate its psychometric properties in patients with nonspecific SP. Methods: 231 people were diagnosed with nonspecific SP. They completed the SDQ-Arabic, which was translated using global standards. The structural validity (Exploratory Factor Analysis (EFA)), reliability (internal consistency (Cronbach alpha)), and (intraclass correlation coefficients (ICC)) were assessed. Results: Using EFA, the involvement psychosocial component and activity subscale were also identified. The existence of internal consistency was supported by the results of subscales 1 and 2 (α=0.960 and 0.950), respectively, with (α= 0.977) as a total score. The construct validity was satisfactory, and the test was applicable (EFA>0.4). Conclusions: This study provides clinicians with an Arabic version of the SDQ that has been successfully adapted. The SDQ-Arabic tool is valid for patients with shoulder-related disabilities with non-specific SP assessment.

. This tends to be higher in women than men and higher in high-income nations than in upper-middle-income, lower-middle-income, and low-income countries (Lucas et al., 2022).Moreover, many physical factors, such as heavy lifting loads, tedious movements in challenging positions, and vibrations, affect the range of symptoms and disabilities (Charles et al., 2018).The etiology of SP includes pathologies from many origins, such as the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues near the shoulder girdle (Linaker and Walker-Bone, 2015).The rotator cuff is the most common source of SP, accounting for more than two-thirds of all cases (Naunton et al., 2020).Patients are diagnosed with nonspecific SP when they experience pain of unknown cause or are not consequent to a clear structural, pathoanatomic, or pathophysiological origin (Liu et al., 2022).If the symptoms of SP and its complications persist for > six months, the patient can be diagnosed with chronic SP (Thapa et al., 2016).
Shoulder pain can obstruct the quality of life owing to functional disabilities.Which complicates daily work, social activities, sleep, and autonomy.Consequently, it may contribute to the development of psychological problems such as depression, anxiety, and pain catastrophizing, which are known to influence pain experiences and disability levels (Den-Boer et al., 2022; Oh and Lee, 2022).Many questionnaires were developed to investigate the disabilities of patients with SP, including the (Shoulder Disability Questionnaire (SDQ)) (Croft et al., 1994).The SDQ evaluates functional limitations and contains 22 items taken from the Sickness Impact Profile, classified into 14 categories used to measure disabilities in patients with SP.The SDQ items related to activities are essential for patients, physiotherapists, physicians, and psychologists (Hall et al., 2019;Monticone et al., 2019).The SDQ categories describe activity and participation impairments and the range of shoulder limitations.
The SDQ is a practical measure, as it is easy to administer and score and is widely used in primary care (Thoomes-de-Graaf et al., 2016).The SDQ is designed to cover many conditions, including SP, adhesive capsulitis, variously sized rotator cuff tears, and chronic nonspecific SP patients (Hall et  is no Arabic version available.Because psychometric properties are influenced by social, environmental, and clinical aspects, they must be evaluated prior to utilizing the SDQ in Arabian patients (Monticone et al., 2019).Thus, this study aimed to design an Arabic version of the SDQ cross-culturally and examine its psychometric properties in patients with nonspecific SP.

Study Settings and Participants
The questionnaire was sent to 231 patients with nonspecific SP from different regions of Saudi Arabia using an electronic method (WhatsApp).Individuals diagnosed with nonspecific SP who were 18 years of age or older included in the study.On the other hand, participants were excluded if they were diagnosed with specific SP, frozen shoulder, shoulder instability, and SP because of cervical problems or cognitive impairment.An informed consent form was created and signed by the participants.

Shoulder Disability Questionnaire
The 22 items of the SDQ inquire about symptoms related to SP during the last 24 hours and evaluate restrictions in daily activities, including physical, emotional, and social aspects.The final score is calculated by summating the 22 items and lies in the range (0-22).
As the final score increases, the level of disability increases and vice versa (Thoomes-de-Graaf et al., 2018).

Translation and Cross-Cultural Adaptation
According to international guidelines, the SDQ was cross-culturally adapted into Arabic to confirm content consistency and ensure validity between the original and Saudi Arabian versions.The SDQ was forward-translated from English into Arabic, considering the meaning of the original questionnaire.Two translators independently translated the original questionnaire.The first translator was a linguistics professor unfamiliar with the scale, and the second was a physical therapist in private practice.The translators tried to utilize language that was suitable for the patient's reading level, culture, and age.The two translators worked together to settle complex terms.Two multilingual, fluent English speakers completed a reverse translation of the original questionnaire to ensure that

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the Arabic version was compatible with the original design.To avoid information bias, the two translators had different medical backgrounds and were aware of the explored concepts.
A bilingual group of four translators reviewed both the forward and backward versions.The committee addressed potential questions and answers.They also took into account the conceptual equivalents of the two versions.The completed questionnaire was randomly distributed to a subset of patients who met the inclusion and exclusion criteria to ensure that it appropriately reflected each item's intended meaning and potential replies.Patients were requested to complete the survey via WhatsApp before each subsequent therapy session, with the exception of the initial visit.Each and every patient marked items whose meaning was unclear or confused.
The committee of experts revised and re-evaluated all items.At the end of this step, the version was named the SDQ-Arabic.

Statistical Analysis
Descriptive statistics comprised the mean, median, and standard deviation (SD) for interval variables.When we discuss the survey's acceptability, we mean the amount of time required to complete it.Parallel Analysis (PA) was conducted using Factor software (Version 10.9.02 for Windows, Tarragona) prior to doing exploratory factor analysis (EFA) using Mplus program (version 6.0).This was done to estimate the approximate number of questionnaire subscales that needed to be collected.The relative importance of each item on the aforementioned subscales was assessed using the ordinal data from Muthen & Muthen (Los Angeles, CA; 1998-2010).Next, the structural validity was evaluated.

Reliability Assessment
A measure of a questionnaire's internal consistency can be found by evaluating its reliability or how effectively each question covers various elements of an overall concept.As per Vanti et al., (2013), we assess the questionnaire using Cronbach alpha (α).Reliability analyses were done on each subscale following the factor analysis identification of them.

Construct Validity Assessment
Using hypothesis testing, the concept validity was assessed.Different hypotheses were developed for each subscale.A factor analysis was performed to assess the internal structure of the scale.With this approach, we may see if we can narrow down on a few variables that best capture the connections between the original components.If only one element accurately summarizes every item, the overall score-which is the sum of all item scores-may represent satisfaction.If, conversely, more elements are needed, each relating to a distinct aspect of the satisfaction itself (e.g., satisfaction with the therapy itself vs. satisfaction with the environment in which the therapy is obtained), then it can be assumed that satisfaction is a complicated concept.The total score was divided into more detailed components (subtotals) (Vanti et al., 2013).

Participants Characteristics
In total, 231 participants completed the SDQ-Arabic.The mean age of the participants was 29.53±8.846.Of them, 198 were male (85.7%) and 33 were female (14.3%) (Figure 1).Among the participants, 41.99% were from Central Saudi Arabia.38.1 Of the participants, 38.1% experienced pain between three and six months of age.A summary of the participants' characteristics is presented in (Table 1 and Figure 1).

Translation and Cross-Cultural Adaptation of the SDQ
The SDQ was translated from English into Arabic.Back-translation of the questionnaire was also performed without major linguistic or grammatical problems.The results of the pretest phase showed that the SDQ-Arabic items regarding language and cultural concepts were understandable.

Construct Validity Assessment
Structural validity was measured by performing [exploratory factor analysis (EFA) to determine the factor structure of the SDQ-Arabi.
Principal component analysis with varimax rotation revealed that the test was functional (EFA >0.4) (Table 3).

DISCUSSION
The results of this study showed a significant cross-cultural adaptation of the SDQ into Arabic and proved the effectiveness of the translation by offering considerable insight into the psychometric aspects of the Arabic version of the SDQ in patients with nonspecific SP.The Arabic SDQ is divided into two sections and has excellent construct validity and reliability.Furthermore, the validation of the internal consistency and interclass correlation of the two subscales of the questionnaire was conducted.Subscale 1 appeared to measure activity, whereas Subscale 2 evaluated involvement and psychological characteristics.The SDQ-Arabic has shown to be a useful, effective, and easy-to-understand instrument because of its precise terminology and unambiguous reporting of partial responses.
According to a set of recommendations for selecting health measurement instruments based on general agreement (COSMIN) checklist, overall internal consistency should be assessed after the factorial structures of the instruments, in addition to calculating internal consistency for each subscale.Which was created to assess the merit of each research methodologies investigating property measurements of (Patient-Reported Outcome Measures (PROMs)) (Taber, 2018).In the current study, the internal consistency was verified for subscales 1 and 2 (α=0.960 and 0.950), respectively, with (α= 0.977) as a total score.Thus, the internal consistency results in al., 2019; Monticone et al., 2019; Thoomes-de-Graaf et al., 2016).The responsiveness of the SDQ has been previously described in a comparatively homogeneous population of patients (Desai et al., 2010; Monticone et al., 2019).Based on previous literature, many international versions of the SDQ are available and have been validated, including the Turkish Ozsahin et al., (2008), Korean Choi et al., (2015), Spanish Alvarez-Nemegyei et al., (2005), and Italian Monticone et al., (2019) versions.Currently, there

Figure 1
Figure 1 Participants characteristics; gender and education level.

Table 2
Item descriptive statistics and internal consistency of the Arabic version of the Shoulder Disability Questionnaire (SDQ)

Table 3
Exploratory Factor Analysis of the Arabic version of the Shoulder Disability Questionnaire (N=231)