Arabic-Translated Versions of Patient-Reported Outcome Measures Utilized in Spine Research: A Review of Validated Studies

Patient-reported outcome measures (PROMs) are standardized tools commonly applied in research and healthcare appraisal. Most were developed in English and the cross-cultural adaptation (CCA) and validation of their translated versions remain topics of contemporary research appeal. This review aimed to identify the Arabic-translated PROMs that were utilized in spine research and to assess the methodological qualities of their studies. The PubMed database was searched, and all relevant publications were identified. The CCA and measurement properties were assessed using the guidelines described by Oliveria and Terwee respectively. Thirty studies that validated the Arabic versions of 26 PROMs were found suitable. The tools that had the highest total citation numbers were Neck Disability Index, Ronald-Morris Disability Questionnaire, Oswestry Disability Index, Fear Avoidance Beliefs Questionnaire, Scoliosis Research Society-22, Back Beliefs Questionnaire, Quebec Back Pain Disability Scale, and McGill Pain Questionnaire-Short Form. The Arabic versions of Short Form-36 (SF-36), Visual Analogue Scale (VAS), and EuroQol-5D (EQ-5D) were not included due to lack of validation in spine research. All the articles were published from 2007 to 2023 (median 2019) and their journal’s impact factor and citation numbers were relatively modest (mean 2 and 6.5 respectively). Most patients had low back pain (19 articles), were recruited from physiotherapy and rehabilitation departments (18 articles) and came from the Kingdom of Saudi Arabia (12 articles). The quality of the CCA of the Arabic versions was rated good in forward translation, synthesis, back translation, and expert committee review but less so in pretesting and submission. The measurement properties of the studies were considered good quality in internal consistency, reliability, structural validity and cross-cultural validity but less so in content validity, error measurement, responsiveness and floor/ceiling effect. In conclusion, with a few exceptions, most of the widely utilized PROMs in spine research have validated Arabic versions. The methodological quality of the studies was good apart from a few shortages that could be improved upon by further research. Work should be done to address the validation of Arabic versions of SF-36, VAS and EQ-5D in spine research. PROMs are valuable in systematizing subjective outcomes. Their usage in research and clinical settings in any validated language should be highly encouraged.


Introduction And Background
Patient-reported outcome measures (PROMs) are validated questionnaires that assess patients' health status and are completed by the patients themselves without interpretation by clinicians or anyone else.The term covers an extensive range of instruments that measure quality of life, well-being, satisfaction, symptoms, and functioning [1][2][3].PROMs are widely accepted as valuable tools in research, clinical decision-making, patient-centred care, health policy and more recently compensation rulings.They are designed to be generic, disease-specific, or treatment-specific [4][5][6].For the tools to be useful, they must possess several quality properties and pass stringent methodological appraisals that include validity, reliability, responsiveness, and interpretability [6,7].The utilization of PROMs in spine research is well documented.The nature and number of instruments used vary according to the breadth of the search criteria.Guzman et al. [5], identified 206 tools that were used in studies that were published in five spine journals from 2004 to 2013.Beighley et al. [8] named 37 spine-specific PROMs that were utilized the spine disease and deformity literature.Ramasamy et al. [9] found 176 PROMs that were employed in chronic back pain research during 2011 and 2015.Jamjoom et al. [4] reported 33 PROMs that were reported in high-impact publications in the neurospine surgical literature.Most PROMs were developed in the English language and the literature is rich with research initiatives that focused on translating them to other languages.It is accepted that for a translated version to be acknowledged as having similar properties to the original tool it must meet rigorous assessments of its cross-cultural adaptation (CCA) and validation [1][2][3].This matter has been a topic of significant research interest in recent years.In fact, 19 out of the 50 most cited publications that utilized PROMs in the neurospine surgical literature focused on validating translated versions of PROMs to other languages [4].
Arabic is one of the most commonly spoken languages in the world.It is the official language in 25 countries and is articulated by more than 300 million people [1,10].Arab countries' contribution to the neurospine surgical literature may be judged modest.Their researchers published 434 articles in the spine literature over a 15-year period (2000-2015) [11] and accounted for only 0.53% of the total neurosurgery research from 2005 to 2019 [12].Most Arab countries are considered developing countries and many of them are counted as low-and middle-income on the economic scale [12].Lack of resources, absence of research infrastructure and deficiency of state-of-the-art technology were identified as the reasons why the Arab world lagged behind in biomedical research [12].Nevertheless, an increase in academic productivity in Arab countries has been observed in the spine [11,13], and neurosurgical research in recent years [12].The Arabic language has many different dialects, however, modern standard Arabic is widely understood and accepted in formal communication and the media in all Arab countries.In the last two years, three studies reviewed the quality of the Arabic translations of PROMs that were utilized in a wide range of diseases [1,2] or related to a specific anatomical location [10].To our knowledge, an evaluation of the Arabic versions of spine-related PROMs has not been addressed in the literature.This review aimed at identifying and assessing the methodological quality of the Arabic-translated, cross-culturally adapted, and validated PROMs that were utilized in spine research.

Review Methods
This study was carried out at King Saud bin Abdulaziz University for Health Science (KSAU-HS), Jeddah, Kingdom of Saudi Arabia (KSA).No ethical approval was necessary by our institution as the study was based on data obtained from open-access sources.The PubMed database was searched in June 2023 for studies that validated Arabic translations of PROMs utilized in spine literature.The search was performed using the keywords alone or in combination: "Arabic," "Arab," "Spine," "Spinal," "Scoliosis," "Back," "Neck," "Validation," "Validity," "Reliability," "Cross-Cultural," "Cervical," "Lumbar, and "Dorsal."Using full articles, the following data was collected for each study: year of publication, publishing journal, its impact factor (IF), number of authors, number of centres, citation number, PROM name and number of items, number of participating patients, their country, the diagnoses for which the PROMs were used and the setting where the recruitment was done.The journal IF data was obtained from an online source [14].The statistical analysis was carried out using Social Sciences Statistics [15].In view of the regular changes in the citation numbers, the search findings on a single day (1st August 2023) were documented and used for analysis.
The CCA was assessed using the guidelines described by Oliveria et al. [2,16,17].The guidelines comprise the following six items: initial translation, synthesis, back translation, expert committee review, pretesting and submission.For every study, each of the items was rated as good, fair, or not assessed.A positive rating based on the Oliveria et al. criteria [2,16,17] was given a good rating while doubtful and negative ratings were allocated a fair rating.The measurement properties were evaluated using the guidelines described by Terwee et al. [2,17,18].The parameters consisted of the following eight items: internal consistency, reliability, structural validity, content validity, cross-cultural validity, error measurement, responsiveness, and floor/ceiling effect.For every study, each of the items was rated as good, fair, or not assessed.A positive rating based on the Terwee et al. criteria [2,17,18] was given a good rating while doubtful and negative ratings were allocated a fair rating.The collection of data, CCA and measurement properties assessments were performed by two of the authors independently and any discrepancies were resolved by consensus.

Results
The search yielded a total of 613 articles.After removing duplicates, title and abstract screening, and fulltext review, 583 articles were excluded.A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram showing the flow of the review phases is presented in Figure 1.
Fourteen (47%) of the articles reviewed here were published during 2020 to 2023 [35][36][37][38][39][40][41][42][43][44][45][46][47][48], an indication that validation of Arabic versions of spine-related PROMs is an ongoing topic in the literature.Article citation numbers are known to positively correlate with journal IF and publication's age [4,13].The relatively short duration from publication for most articles (median age four years) and low journal IF (median 2) explain the modest citation numbers (median 6.5) for the selected studies.Nineteen (63%) of the articles used the Arabic-translated tools to assess LBP.This is not surprising as LBP is one of the most common spine pathologies that command the use of PROMs [6,9,49,50].Most patients (60%) were recruited from physiotherapy and rehabilitation services while most studies (57%) were published in spine, orthopaedic and neurosurgery journals.KSA ranked first in the participant's country (40%) with Egypt second (17%).Previous publications had put Egypt as the Arab country with the highest contribution to spine and neurosurgical research [11,12].

Limitations
There are several limitations to this study.The study was reliant on the precision of PubMed.It is possible that some Arabic-translated PROMs may have been missed.The exclusion of studies that were not published in English may have caused some bias.The grading of the CCA and management properties of the translated PROMs require a subjective judgement which we strived to reduce by having two of the authors review the studies independently.The guidelines do not provide information on how to assign numeric values to the grading.Also, many of the studies did not provide all the necessary quality-related information.The citation numbers were taken at a certain point which was likely to change relatively quickly.The review did not necessarily provide a specific solution to which Arabic-translated PROMs to be used in specific spine diseases.

Conclusions
Most of the widely utilized PROMs in spine research, except a few, have Arabic-translated cross-culturally adapted validated versions.The majority of studies were published in recent years and have modest citation numbers.Most participants had low back pain and were recruited from physiotherapy and rehabilitation services.The methodological quality of the studies was good apart from a few shortages that could be improved upon by further research.Work should be done to address the validation of Arabic versions of SF-36, VAS and EQ-5D in spine research.PROMs are valuable in systematizing subjective outcomes.Their usage in research and clinical settings in any validated language should be highly encouraged.

TABLE 2 : List of the 26 validated cross-culturally adapted translated Arabic versions of patient- reported outcome measures (PROMs) that were utilized in spine literature.
Morocco.The participants' diseases were low back pain (LBP) (19 articles), neck pain and cervical spondylotic myelopathy (four articles), scoliosis (four articles), spinal cord injury (SCI) (two articles) and mixed spinal pain (one article).The participants' settings were the services of physiotherapy and rehabilitation medicine (18 articles), spine, orthopaedics and neurosurgery (eight articles) and others (four articles).

TABLE 3 : Summary of the cross-cultural adaptation (CCA) overall assessment for the reviewed 30 articles according to the guidelines described by Oliveria et al.
[2,16,17]e CCA rating meets Oliveria et al.[2,16,17]assessment for a positive rating **Fair: The CCA rating meets Oliveria et al.[2,16,17]assessment for doubtful and negative ratings

TABLE 4 : Summary of the measurement properties overall assessment for the reviewed 30 articles according to the guidelines described by Terwee et al.
[2,17,18]e measurement property rating meets Terwee et al.[2,17,18]assessment for a positive rating **Fair: The measurement property rating meets Terwee et al.[2,17,18]assessment for doubtful and negative ratings