ABSTRACT:
OBJECTIVE To translate and culturally adapt the Long Head of Biceps Tendon (LHB) score
into Brazilian Portuguese.
METHODS The process involved translations by professionals fluent in the target
language, followed by independent back translations. Next, a committee
compared the original and translated versions, pretested the final version,
and concluded it.
RESULTS We translated and adapted the questionnaire according to the proposed
methodology. In the first version in Portuguese (VP1) there was divergence
regarding the translation of twelve terms. Compared to the original version,
the back translation of VP1 presented eight diverging terms. A committee
prepared a second version in Portuguese (VP2) and applied it to a pretest
group consisting of 30 participants. Finally, we conceived the third version
in Portuguese, called LHB-pt.
CONCLUSION The translation and cultural adaptation into Brazilian Portuguese of the LBH
score was successfully accomplished.
Keywords: LHB score; tenodesis; tenotomy; long head biceps tendon.
RESUMO:
OBJETIVO Realizar a tradução e adaptação cultural à língua portuguesa do Long Head of
Biceps Tendon (LHB).
MÉTODOS O processo envolveu a produção de traduções por indivíduos com domínio da
língua-alvo, retrotraduções de maneira independente, criação de um comitê
para comparar as versões original e traduzida, realização de pré-teste com a
versão final, e elaboração da versão final.
RESULTADOS O questionário foi traduzido e adaptado conforme a metodologia proposta. Na
primeira versão em português (VP1), houve divergências na tradução de doze
termos. A retrotradução da VP1 apresentou, quando comparada à versão
original, divergência em oito termos. A segunda versão em português (VP2),
elaborada por um comitê, foi aplicada a um grupo pré-teste constituído por
30 participantes, e ao final chegou-se à terceira versão em português,
denominada LHB-pt.
CONCLUSÃO A tradução e adaptação do LHB foram concluídas com sucesso.
Palavras-chave: LHB score; tenodese; tenotomia; tendão da cabeça longa do bíceps.
FIGURES
| Citation: Godinho AC, Almeida FS, Ayres JCZ, Godinho PC, Godinho GG, Sugawara MJT. Translation and Cultural Adaptation to Portuguese of the Long Head of Biceps Tendon Score*. 58(3):471. doi:10.1055/s-0042-1750825 |
| Financial Support: The authors declare that they have received no financial support from public, commercial, or non-profit sources. |
|
Conflict of interests: The authors have no conflict of interests to declare. |
|
*
Study developed at the Shoulder Surgery Service of Hospital Ortopédico BH (Belo Horizonte, Minas Gerais, Brazil) and the Department of Orthopedics and Traumatology of Universidade Federal de São Paulo (São Paulo, São Paulo, Brazil). |
| Received: January 06 2022; Accepted: April 28 2022 |
INTRODUCTION
Injuries to the tendon of the long head of the biceps are a significant cause of shoulder pain,1 especially on the anterior surface, with potential irradiation along its course through the arm.2 The symptoms usually result from instability, inflammation, or local trauma.3 The incidence of pain ranges from 36% to 83%, and it is higher according to the severity of associated rotator cuff injuries.4,5
Several clinical tests aid in the diagnosis. The Speed test,6 which is widely accepted and used in the academic environment, has high sensitivity (90%) and low specificity (13.8%).7
Complete rupture of the LHB fibers causes a cosmetic deformity known as Popeye sign, which is an increase in the volume of the distal region of the arm, on the anterior surface, resulting from the distal migration of the muscle belly. In a systematic review8 of 699 tenotomies, the authors reported that this deformity occurs in 43% of the cases. According to the Brazilian literature,9,10,11,12 its incidence ranges from 8.3% to 59.1%. Several factors influence the identification of this sign, including age, the experience of the evaluator, and obesity (especially when the patient has a body mass index [BMI] > 30 kg/m2).9,10,13 The Popeye sign is a critical outcome in studies assessing the treatment of biceps injuries.
The biceps brachii acts in forearm supination and elbow flexion; in addition, it makes a small contribution to shoulder flexion.14 Electroneuromyographic studies15 have shown that the muscle belly of the long head of the biceps contributes to the dynamic stabilization of the glenohumeral joint, especially during flexion and abduction. A retrospective isokinetic evaluation study16 involving tenotomized patients with a 7-year follow-up showed 7% of loss in maximal forearm flexion strength and 9.1% of loss in maximal forearm supination strength. Other authors17 have observed a higher loss of supination strength due to complete tendon rupture. The Brazilian literature has also reported these changes; however, the loss of strength was not higher in patients with more evident Popeye sign.18
The wide variety of outcomes associated with this structure has led to the development of the Long Head of Biceps Tendon (LHB) score,19 which is a functional, specific questionnaire applied by an examiner comparing both shoulders. The LHB score consists of three large domains with different scores: the first one refers to signs and symptoms, the second, to the identification of the Popeye sign, and the third, to the assessment of elbow flexion strength.
In the present study, we describe the process of translation and cultural adaptation of the LHB score into Brazilian Portuguese.
MATERIALS AND METHODS
The institutional ethics committee analyzed and approved the study. We informed the developers of the score about our intention to translate it, and they consented to it.
Translation and cultural adaptation
The translation into Portuguese and cultural adaptation of the LHB score followed the guidelines proposed by Guillemin.20 The process included five steps: 1) translation by professionals fluent in the target language; 2) independent back translations; 3) creation of a committee to compare the original and translated versions; 4) pretest of the final version to determine its equivalence with the original test; and 5) adaptation of the weight of the scores per the cultural context.
The translation was made by two translators, native Portuguese speakers and fluent in English. Then, the researchers compared these two versions to generate a consensual first version in Portuguese (VP1). The terms patient name, date of examination, and date of birth” were excluded from the translation as they are not part of the score.
The back translation started following the completion of the VP1. After choosing the terms for the VP1, the researchers designed the LHB form using the same graphic and image standards as those of the original score. A third translator, a native English speaker fluent in Portuguese, also blinded to the study, evaluated the VP1 and made the back translation.
The professionals who prepared the VP1 and the one who did the back translation were unaware of the purpose of the study.
The third step was the creation of a committee, consisting of three translators, three researchers, and three orthopedists who specialized in shoulder surgery, which compared the original version, the VP1, and the back translation. Based on this analysis, the terminology used in the second Portuguese version (VP2) was determined by consensus. The committee assessed semantic (word meaning), idiomatic (idioms and colloquialisms), and conceptual (concept validity) equivalences through practical experience.
The pretest stage began after the completion of the first three steps. Then, the principal investigator recruited 30 male and female Brazilian subjects, aged 18 to 80 years, who presented partial or subtotal rupture of the long head of the biceps tendon, superior labrum anterior to posterior (SLAP) injuries, or bicipital tendon instability with pulley or rotator cuff injury. They underwent arthroscopic surgical treatment and were followed up for at least one year. We excluded patients with calcified tendinitis, glenohumeral arthrosis, or associated neurological injury. The exclusion criteria were patients with deafness, aphasia, or any cognitive deficit that directly limited their understanding of the test.
The selected patients filled out an informed consent form (ICF) before the pretest. Then, the principal investigator read VP2 aloud. If any of the terms were not understood by the participant, the researcher could explain the meaning in their own words. Then, the participant could suggest a new word which, in their opinion, provided a clearer definition in Brazilian Portuguese. We reformulated items with a non-understanding rate of 15% or more using the definitions proposed by the participants to develop the third Portuguese version (VP3).
RESULTS
►Table 1 shows the terms presented by translators A and B, as well as the VP1. In the first step of the process, twelve cases of divergence were observed.
| Item | Original | Translator A | Translator B | VP1 |
|---|---|---|---|---|
| Pain/Cramps* | Pain/Cramps (max. 50 points) | Dor/Cãibras (máx. 50 pontos) | Dor/Cólica (Máximo 50 pontos) | Dor/Cãibras (máx. 50 pontos) |
| Severe* | Severe | Severa | Severa | Grave |
| None | None | Nenhuma | Nenhuma | Nenhuma |
| LHB – pain | LHB – pain | Dor LHB | Dor LHB | Dor na cabeça longa do bíceps |
| Right side | Right side | Lado direito | Lado direito | Lado direito |
| Left side | Left side | Lado esquerdo | Lado esquerdo | Lado esquerdo |
| Tenderness* | Tenderness over the bicipital grove | Maciez ao redor do sulco bicipital | Sensibilidade no sulco bicipital | Sensibilidade no sulco bicipital |
| Speed-test* | Speed-test | Teste de velocidade | Teste rápido | Teste de Speed |
| Cramps* | Cramps | Cãibras | Cólicas | Cãibras |
| At rest* | At rest | Em repouso | Sem esforço | Em repouso |
| On exertion* | On exertion | Em esforço | Com esforço | Em esforço |
| None | None | Nenhuma | Nenhuma | Nenhuma |
| Cosmesis* | Cosmesis (max. 30 points) | Cosmética (máx.30 pontos) | Cosmese (máximo 30 pontos) | Estética |
| Patient-dependent deformity* | Patient-dependent deformity | Percepção do paciente em relação à deformidade | Deformidade do paciente dependente | Percepção do paciente em relação à deformidade |
| None | None | Nenhuma | Nenhuma | Nenhuma |
| Mild* | Mild | Fraca | Suave | Leve |
| Moderate | Moderate | Moderada | Moderada | Moderada |
| Severe* | Severe | Severa | Severa | Grave |
| Examiner-dependent deformity* | Examiner-dependent deformity | Percepção do examinador em relação à deformidade | Deformidade do examinador dependente | Percepção do examinador em relação à deformidade |
| Elbow flexion strength | Elbow flexion strength (max. 20 points) | Força de flexão do cotovelo (máx. 20 pontos) | Força de flexão do cotovelo (máximo 20 pontos) | Força de flexão do cotovelo (máx. 20 pontos) |
| Affected side | Affected side | Lado afetado | Lado afetado | Lado afetado |
| Opposite side | Opposite side | Lado oposto | Lado oposto | Lado oposto |
| Total | Total | Total | Total | Total |
Abbreviations: LHB, long head of the biceps; max., maximum; máx., máximo.
Notw* Terms in which divergences were observed between the translators, and/or divergences with the VP1 developed by the researchers.
►Table 2 shows the back translation, in which eight cases of divergence in the translation were observed regarding the original version. This table also describes the terms chosen by the committee for the VP2.
| Original version | VP1 | Back translation | VP2 |
|---|---|---|---|
| Pain/Cramps (max. 50 points)* | Dor/Cãibras (máx. 50 pontos) | Pain/Cramps (max. 50 points) | Dor/Desconforto muscular (máx. 50 pontos) |
| Severe* | Grave | Severe | Intensa |
| None | Nenhuma | No pain** | Nenhuma |
| LHB – pain | Dor na cabeça longa do bíceps | Pain on the biceps brachii long head** | Dor na cabeça longa do bíceps |
| Right side | Lado direito | Right side | Lado direito |
| Left side | Lado esquerdo | Left side | Lado esquerdo |
| Tenderness over the bicipital grove* | Sensibilidade no sulco bicipital | Sensitivity in the bicipital groove** | Dolorimento no sulco bicipital |
| Speed-test | Teste de Speed | Speed-test | Teste de Speed |
| Cramps* | Cãibras | Cramps | Desconforto muscular |
| At rest | Em repouso | At rest | Em repouso |
| On exertion* | Em esforço | With effort** | Ao esforço |
| None | Nenhuma | None | Nenhuma |
| Cosmesis (max. 30 points)* | Estética (máx. 30 pontos) | Aesthetics (max. 30 points)** | Aspecto estético (máx. 30 pontos) |
| Patient-dependent deformity* | Percepção do paciente em relação à deformidade | Perception of the patient in relation to the deformity** | Percepção da deformidade pelo paciente |
| None | Nenhuma | None | Nenhuma |
| Mild* | Leve | Slight** | Discreta |
| Moderate | Moderada | Moderate | Moderada |
| Severe | Grave | Severe | Grave |
| Examiner-dependent deformity* | Percepção do examinador em relação à deformidade | Perception of the examiner in relation to the deformity** | Percepção da deformidade pelo examinador |
| Elbow flexion strength (max. 20 points) | Força de flexão do cotovelo (máx. 20 pontos) | Elbow flexion strength (max. 20 points) | Força de flexão do cotovelo (máx. 20 pontos) |
| Affected side | Lado afetado | Affected side | Lado afetado |
| Opposite side | Lado oposto | Opposite side | Lado oposto |
| Total | Total | Total | Total |
Abbreviations: LHB, long head of the biceps; max., maximum; máx., máximo; VP1, first version in Portuguese.
Notes:* Terms modified by the committee. ** Terms in which divergences were observed between the original version and the back translation.
►Table 3 presents the descriptive analysis of the group submitted to the pre-test. The sample was mainly composed of female patients with an average age of 62.3 years; the right side was the most affected. The postoperative follow-up ranged from 1 to 6 years.
| Gender | n |
|---|---|
| Male | 12 |
| Female | 18 |
| Age (years) | |
| Minimum | 45 |
| Maximum | 79 |
| Dominant side | |
| Right | 29 |
| Left | 01 |
| Laterality | |
| Right | 16 |
| Left | 14 |
| Shoulder procedure | |
| Arthroscopic repair of the rotator cuff | 30 |
| Biceps procedure | |
| Tenotomy | 19 |
| Tenodesis | 11 |
At the end of this stage, the final version of the Brazilian Portuguese translation of the LHB score, called LHB-pt was concluded (►Fig. 1).
DISCUSSION
The most significant result of the present work is that the LHB-pt score will be made available for public use. This score is a practical tool with great potential in studies involving the long head of the biceps tendon.
Several authors have demonstrated that general scores to assess shoulder function, such as the Constant-Murley score, are not helpful in the follow-up of patients with conditions affecting the long head of the biceps tendon. In addition, these scores do not enable the detection of differences between bicipital tenotomy and tenodesis.21,22,23,24 In a comparative functional assessment using the LHB score, Schiebel et al.25 could observe differences among patients undergoing distinct bicipital tenodesis techniques.
The LHB score is more specific for this type of assessment because it includes outcomes that several authors deem fundamental.8,9,10,21,22,23,24,26,27,28 However, its accuracy is limited because there may be an overlap with symptoms from rotator cuff injury. Therefore, the LHB score is not useful to screen for lesions before surgery.19
In a study regarding the translation and cultural adaptation of the LHB score into Turkish, the authors29 assessed its reproducibility, validity, and reliability. They29 concluded that the questionnaire was reproducible (interclass coefficient: 0.940; p < 0.001), valid (Cronbach alpha: 0.640), and reliable, as it remained stable throughout the testing and retesting processes. Although we did not evaluate the properties of the test, we believe that we may extrapolate these findings to the LHB-pt.
Some modifications occurred after the analysis of the VP1 and the back translation by the expert committee. The committee changed the term dor/cãibra (pain/cramp) to dor/desconforto muscular (pain/muscle discomfort) due to the belief that cãibra defines a very intense muscle discomfort in the Brazilian sociocultural context. As the score intends to identify the intensity of muscle discomfort, it would not be proper to use a term that culturally already defines it as intense. However, during the pretest, 14 patients (46%) suggested replacing desconforto muscular with cãibra. Thus, researchers decided to use cãibra in the final version of the score.
We changed the term grave (severe) to intensa (intense). The latter is better associated with the degree of muscle pain and discomfort, whereas grave can indicate a subjective worsening of the patient’s condition, with no quantitative evaluation.
In addition, we changed sensibilidade no sulco bicipital (bicipital sulcus tenderness) to dolorimento no sulco bicipital (bicipital sulcus soreness). This change occurred because sensibilidade (tenderness), in the Brazilian context, is more related to a sensory ability, be it tactile, thermal, or related to pain. The committee believes the score does not intend to identify the sensory capacity of the bicipital sulcus but rather the sensation of pain on local palpation. Therefore, we opted for the term dolorimento (soreness).
We suggested some modifications to adapt to the syntactic context of Brazilian Portuguese. Therefore, em esforço (on exertion) was altered to ao esforço. Likewise, the terms percepção do paciente em relação à deformidade (patient-dependent deformity) and percepção do examinador em relação à deformidade (examiner-dependent deformity) were respectively altered to percepção da deformidade pelo paciente and percepção da deformidade pelo examinador.
The term estética (cosmesis) was altered to aspecto estético, a more didactic way for the patient to understand that this item evaluates the physical features of the affected site. The committee chose to use the terms nenhuma (none), discreta (mild), moderada (moderate), and grave (severe) to assess the degree of deformity perceived by the patient. Among these terms, only discreta was not included in the VP1 and was chosen for the VP2. This occurred because the committee believed that a potential change in cosmesis would be better graded as discreta instead of leve (the usual translation for mild).
It is worth mentioning that the first question of the tool refers to pain in the long head of the biceps. While applying the test, evaluators may have doubts on how to measure pain. Scheibel et al.25 say that this parameter should be assessed as the perception of spontaneous pain in the anterior aspect of the shoulder. There was no change in this methodology when we adapted and translated the score. It is also important to clarify that, according to the developers of the score,19 a dynamometer must determine elbow flexion strength, and this measurement must be repeated three times. The mean flexion strength of the affected limb is compared with that of the healthy contralateral limb. The percentage results are scored from 0 to 20 points. Strength higher than 91% results in 20 points; from 90% to 81%, 16 points; from 80% to 71%, 12 points; from 70% to 61%, 8 points; and from 60% to 51%, 4 points. Strength below 50% receives no points.
We believe that the objective nature of the answers associated with direct questions facilitates the use of the LHB score in the clinical practice. Despite the great diversity of regionalisms and barbarisms in Brazil, the questionnaire is easy to understand. Moreover, it has great applicability in studies that assess the long head of the biceps tendon.
The limitations of the present study include the lack of assessment of the reproducibility and reliability of the test. We believe that future publications may identify these properties.
CONCLUSION
The translation and cultural adaptation of the LHB score into Brazilian Portuguese, which generated the LHB-pt, were successfully accomplished.
