Abstract
Background
The foot and ankle ability measure (FAAM) scale is a patient-reported outcome measure used to assess lower extremity functional status in a variety of musculoskeletal disorders. It was first created in English (E-FAAM) to gauge its applicability across several languages, and other translations are accessible in different languages.
Objectives
This study aimed to translate the English version of the FAAM into Hindi (H-FAAM), evaluate its content validity, conduct cross-cultural adaptation, and assess its test-retest reliability.
Method
Following Beaton guidelines, the translation process involved forward and backward translations by two bilingual translators and a pain specialist, with approval from the original developers. Content validation was conducted using the Delphi method, involving 10 experts with over five years of experience. Cross-cultural adaptation was assessed with 30 outpatient participants who provided feedback on the clarity and relevance of the H-FAAM items. Test-retest reliability was evaluated using Cronbach’s alpha and intraclass correlation coefficient (ICC) in 51 patients, with responses collected at two time points.
Results
Of the 21 items in the H-FAAM, 19 achieved universal agreement (100% consensus), while two items received 80% agreement, indicating strong content validity overall. Cross-cultural adaptation was well-received, with 28 out of 30 patients providing positive feedback on the clarity and understanding of the scale. Test-retest reliability was excellent, with Cronbach’s alpha and ICC values of 0.94
Conclusion
The Hindi version of the FAAM (H-FAAM) demonstrated excellent content validity and test-retest reliability, making it a reliable tool for assessing in native Hindi-speaking populations.
1
Introduction
Chronic ankle instability (CAI) is characterized by recurrent episodes of ankle giving way, persistent pain, and functional impairments following an initial ankle sprain . It is a common sequela of lateral ankle sprain, affecting up to 70% of individuals who experience acute ankle injuries, which can significantly impair mobility, balance, and overall physical function . Patients with CAI often struggle with reduced proprioception, muscular weakness, and altered movement patterns, leading to long-term instability and an increased risk of re-injury .
Pain, swelling, weakness, instability, and repeated instances of the ankle ”giving way” are key indicators of chronic ankle instability, which involves both mechanical and functional instability . These persistent symptoms can interfere with physical activity in young individuals , potentially harming their overall health and well-being by increasing the likelihood of obesity and other related health concerns . While declines in physical activity have been documented in adults, their impact on adolescents’ activity levels remains unclear .
The fundamental Patho-mechanics of chronic ankle instability involves inversion at the subtalar joint, accompanied by either the presence or absence of plantar flexion and forefoot adduction . After suffering an acute ankle injury, the prevalence of CAI varies from 9% to 76% It is a residual symptom from an initial lateral ankle sprain (CAI). Ankle sprains in children have been linked to this syndrome in 18–71% of cases .
The proper assessment of chronic ankle instability is crucial for appropriate clinical therapy. The Foot and Ankle Ability Measure questionnaire (FAAM) was created as a comprehensive tool to identify and evaluate the characteristics of chronic ankle instability . It is an outcome measure that patients use to assess their lower extremities functional state and perform their everyday activities and to evaluate a person’s quality of life (QOL) . The scale was primarily developed by Martin et.al. in 2005 in the English language (E-FAAM) . It is quite effective in identifying any ankle pathologies related to trauma or unidentified pathologies. This is an ordinal scale with 21 items. The highest score is 100, with 0 denoting the greatest difficulty and 4 denoting no difficulty. The score illustrates the difficulty the patient currently finds in the task stipulated on the questionnaire .
The test-retest reliability for sports subscales was 0.89 and 0.87, respectively. For the ADL and sports subscales, the least detectable change, as determined by a 95% confidence interval, was ±5.7 and ±12.3 points, respectively . The validity of an item or scale is determined by how closely an outcome measure matches what it is meant to evaluate . Additionally, it assures by presenting the true picture. A crucial stage in translating is ensuring the scale’s validity so that the public can use it without worrying about incorrect interpretation and maintaining the new version’s authenticity concerning the original .
2
Methods
The study fully adheres to the World Medical Association’s Declaration of Helsinki and the International Ethical Guidelines for Health-Related Research Involving Humans (revised 2017) established by the Council for International Organizations of Medical Sciences. It was conducted under the guidelines outlined by Beaton et al .
2.1
Ethical consideration
The study was initiated following ethical approval, granted under reference number IEC-2999 by the Institutional Ethics Committee of a tertiary care teaching hospital located in northern India. Additionally, the study was registered with the Clinical Trials Registry of India (CTRI) under reference number CTRI/2024/09/074477. The translation and validation process for the scale commenced after obtaining formal permission from the original developer, confirmed through email correspondence.
2.2
Procedure of translation
This process consists of five stages (see Fig. 1 ) ( Fig. 2 ) ( Fig. 3 ) ( Fig. 4 ).
Process of translation of the scale.
Content validity with Universal agreement.
Scatter plot for test-retest reliability.
Bland Altman plot.
2.2.1
STAGE-1 Permission from the author
Before proceeding with the study, a permission request letter was sent to the corresponding authors and the developer of the original FAAM, seeking their approval for the translation of the scale.
2.2.2
STAGE-2 Preparation of the scale draft
A panel consisting of two individuals—one physiotherapist and one native Hindi speaker—was selected to create an initial draft by translating the English version of the FAAM into Hindi. The draft was then reviewed by individuals proficient in both English and Hindi, ensuring that it was clearly understood. As a result, a preliminary version of the H-FAAM was developed.
2.2.3
STAGE-3 Forward translation
The preliminary draft was submitted to two independent language experts for review and necessary revisions. Both experts held master’s degrees (MA) in Hindi and had over 10 years of experience, with strong proficiency in both English and Hindi. They were asked to verify the translation of the original FAAM, ensuring that the language and meaning of the questions were preserved. Their feedback was carefully considered and valued, and all recommended corrections were implemented accordingly.
2.2.4
Compilation
Once the revised drafts from both experts were received, they were compared with each other. Common items from both versions were combined into a single draft. Discrepancies between the drafts were analysed, and the most appropriate corrections were selected. After incorporating all the suggestions provided by the experts, the pre-final version of the H-FAAM was finalized.
2.2.5
Backward translation
The pre-final draft was sent to two independent English language experts, both holders of master’s degrees (MA). They reviewed the draft to ensure that the translation accurately reflected the original meaning and that the content of the scale remained unchanged. After translating the pre-final H-FAAM back into English, the translation was compared with the original version to confirm that the items retained their original meaning. Following this process, a verified version of the H-FAAM was finalized.
Thus, the final version of the H-FAAM was completed and subsequently sent for content validation.
2.2.6
Content validation
The content of the final version of the scale was validated using the Delphi method . For the validation of the H-FAAM, 10 experts with at least 5 years of experience in the field were invited, all of whom were blinded to the study’s purpose. A Google form ( https://forms.gle/dzezuPuHbJapT5LQ6 ) was created, containing each item of the scale. The experts were asked to respond with ‘Agree,’ ‘Disagree,’ or ‘Neutral’ for each item. If any expert considered an item to be ‘invalid,’ they were requested to suggest any necessary changes. An item was considered ‘Validated’ if it received 80% or more valid responses, at which point the subsequent steps of the process would be carried out.
The content validity was assessed in five stages, as outlined below.
2.2.6.1
Individual– level content validity index (I-CVI)
It is calculated by dividing the number of evaluators who validated an item by the total number of evaluators. Each item on the scale has its validity, which is calculated separately , .
2.2.6.2
Content validity ratio (CVR)
It is defined by the proportion that each item on the scale represents, indicating the validity of each item concerning the others. The calculation is done using the formula: CVR = (Ne– N/2) ÷ N/2, where N is the total number of experts, and Ne is the number of evaluators who agreed with the item. This ratio is calculated separately for each item .
2.2.6.3
Scale- level content validity index (S-CVI)
It is calculated in two ways: one by summing the average value, and the other by counting the total agreement among all evaluators .
2.2.6.4
Averaging value (SCI/Ave)
It is defined as the average of all the individual item content validity indices (I-CVIs). It is calculated by summing the I-CVIs of all items and dividing the total by the number of items in the scale .
2.2.6.5
Universal agreement calculation (S-CVI/UA)
It is defined as the proportion of items on an instrument that receive a significant rating from the experts, meaning all experts must agree on the items. If even one expert disagrees with an item, it is considered not universally agreed upon. This is calculated using the formula: the sum of all UA scores divided by the total number of items in the questionnaire.
2.2.7
Cross cultural adaptation
In this process, pilot testing was conducted to evaluate the suitability of the H-FAAM scale among native individuals with chronic ankle instability, who visited the outpatient department (OPD) of tertiary hospitals. A total of 30 patients, aged between 20 and 40 years, were selected through convenience sampling. The inclusion criteria were individuals diagnosed with chronic ankle instability, as per the Foot and Ankle Ability Measure Questionnaire (FAAM), and those patients with no Ankle instability were included for comparison. Exclusion criteria included patients with cognitive or psychological impairments, any previous history of foot and ankle surgery, or those who are uncooperative.
Before starting the process, patients provided informed consent. They then completed an assessment form to document their problem list in respect to ankle instability, followed by filling out the translated version of the FAAM scale (H-FAAM) based on their current condition and experiences during the listed activities. After completing the scale, they were given a form to provide feedback, including their responses (positive or negative) and any suggestions for modifying the items to improve understanding. This feedback was essential for refining the scale for future use.
2.2.8
Test-retest reliability
Convenience sampling was used to select 51 patients to evaluate the test-retest reliability of the scale’s translated Hindi version. The scale was given to the participants twice, on occasions A1 and A2, separated by 48 h, by a single, impartial assessor, Evaluator A. The participants had no idea that their answers from the two sessions would be compared to assess consistency over time, and they were blinded to the study’s goal.
2.3
Data analysis
The collected data was analysed using SPSS version 26 (Statistical Package for the Social Sciences). The analysis encompassed content validation, cross-cultural adaptation, and the test-retest reliability assessment of the translated scale, H-FAAM.
The normality of the data was assessed using the Shapiro-Wilk test. Content validity was evaluated through the I-CVI and S-CVI/Average methods. The scale’s internal consistency was measured using Cronbach’s alpha, and test-retest reliability was determined using the Intra-Class Correlation Coefficient (ICC).
3
Result
For Cross-cultural Adaptation, it was observed that all the patients understood the translated items well. No item was left unfilled/ unanswered, and no modifications were suggested by the patients. Therefore, the scale showed a high cross-cultural adaptation among the local Hindi-speaking population. 19 questions out of 21 scored 100% with all the positive responses.
Total percentage of the responses given by patients to examine the adaptability of each domain of FAAM
Abbreviations: FAAM- Foot and Ankle Ability Measure
Interpretation: This table shows that the responses of the patients towards the intelligibility of each domain and overall scale is 100% (minimum acceptance 80%) indicating excellent adaptability of FAAM ( Table 1 ) ( Table 2 ).
Table 1
Demographic details of patients participated in reliability testing (n = 51).
| Demographic characteristics | Mean±SD | Standard Error Mean (SEM) | P value |
|---|---|---|---|
| Age | 29.33 ± 6.28 | 0.88 | .004 |
| Height | 165.26 ± 4.22 | 0.59 | .047 |
| Weight | 62.53 ± 8.69 | 1.21 | .200 |
| BMI | 23.02 ± 4.03 | 0.56 | .004 |
Table 2
Responses of the patients for cross-culture adaptation II.
| S.No. | Domains of FAAM | Positive Response | Negative Response | % |
|---|---|---|---|---|
| 30 | 0 | Total | ||
| 1. | खडा है | 30 | 0 | 100% |
| 2. | समतल भूमि पर चलना | 30 | 0 | 100% |
| 3. | बिना जूतों के समतल जमीन पर चलना | 30 | 0 | 100% |
| 4. | ऊंचाई पर चलना | 30 | 0 | 100% |
| 5. | नीचाई पर चलना | 30 | 0 | 100% |
| 6. | सीढ़ियाँ चढ़ना | 30 | 0 | 100% |
| 7. | नीचे (सीढ़ी) उतरना | 30 | 0 | 100% |
| 8. | उबड़– खाबड़ (ऊँची-नीची) भूमि पर चलना | 30 | 0 | 100% |
| 9. | ऊपर– नीचे कदम रखना | 30 | 0 | 100% |
| 10. | स्क़ुआत्तिन्ग (बैठना) | 28 | 2 | 93.3% |
| 11. | पांव की अंगुलिओं पर उठना/ खड़े होना | 30 | 0 | 100% |
| 12. | प्रारहम्भ में चलना | 30 | 0 | 100% |
| 13. | पाँच मिनट या उससे कम चलना | 30 | 0 | 100% |
| 14. | लगभग दस मिनट चलना | 30 | 0 | 100% |
| 15. | पंद्रह मिनट या अधिक चलना | 30 | 0 | 100% |
| 16. | घर की जिम्मेदारियां | 30 | 0 | 100% |
| 17. | दैनिक जीवन की गतिविधियां | 30 | 0 | 100% |
| 18. | व्यक्तिगत देखभाल | 30 | 0 | 100% |
| 19. | हल्के से मध्यम कार्य (खड़े होना, चलने में) | 30 | 0 | 100% |
| 20. |
भारी काम (धकेलना/ खींचना,
आरोहण, भार उठाना) |
30 | 0 | 100% |
| 21. | मनोरंजन गतिविधियाँ | 29 | 1 | 96.6% |
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