Cross-cultural adaptation of the pain understanding and confidence questionnaire into Japanese

Abstract

[Purpose] This study aimed to develop a culturally adapted Japanese version of the Pain Understanding and Confidence Questionnaire (PUnCQ). The first-factor structure describes management from 12 perspectives for a case vignette of chronic pain and determines whether the management is based on a biomedical or biopsychosocial perspective. The second-factor structure evaluates the confidence level in management skills for the same case from 21 perspectives. [Participants and Methods] We conducted a cross-cultural adaptation based on five stages according to Beaton’s guidelines (two forward translations, creation of an integrated forward translation version, two backward translations, creation of a provisional Japanese version, and a pilot test). In the pilot test, we asked 40 Japanese physical therapists to rate their understanding of the PUnCQ descriptions on a five-point Likert scale (1, not at all understandable; 5, completely understandable) and provide comments when they rated 1 to 3. We repeated revisions and pilot tests until less than 10% of the respondents rated 1 for all descriptions. [Results] By conducting two rounds of the pilot test, all items of descriptions satisfied the preestablished criteria. [Conclusion] A Japanese version of the PUnCQ was developed.

INTRODUCTION

It is recommended that musculoskeletal physiotherapy be used to make the shift from a biomedical approach (the belief that pain is the result of tissue damage) to a biopsychosocial approach (the belief that pain can also be caused or exacerbated by factors other than tissue damage and that psychosocial aspects of assessment and intervention are important)^1,2,3). This transition is known to be influenced not by the therapist’s gender, years of experience, or level of education but by their neurophysiological understanding of pain⁴⁾. Additionally, it is believed that the therapist’s perspective on pain influences patient outcomes^5,6,7). Particularly, therapists who use a biomedical approach tend to view all painful aspects of assessment and treatment as negative, have a fear-avoidance and pain bias, delay patients’ return to work and activities and encourage them to take sick leave, and adhere poorly to practice guidelines^8,9,10,11). Furthermore, the therapist’s fear-avoidance and fear of pain correlate with those of their assigned patients^{12, 13)}.

Patient-reported outcome measures (PROMs) that assess knowledge of the neurophysiology of pain have been developed^{14, 15)}. In addition, a PROM that also assesses the knowledge of physiotherapy students has been recently developed¹⁶⁾, and its Japanese version is currently available¹⁷⁾. However, these PROMs only assess knowledge of the neurophysiology of pain, not the ability to actually manage it.

Based on the core curriculum of the International Association for the Study of Pain¹⁸⁾ and the British Pain Society¹⁹⁾, the Pain Understanding and Confidence Questionnaire (PUnCQ) was recently developed to assess the level of knowledge and confidence in pain management²⁰⁾. The PUnCQ has a two-factor structure. The first-factor structure describes management from 12 perspectives for a case vignette of chronic pain and determines whether the management is based on a biomedical or biopsychosocial perspective. The second-factor structure evaluates the confidence level in management skills for the same case from 21 perspectives. The confidence section of the PUnCQ is a particularly promising psychometric property for assessing the relationship between therapists’ confidence in their ability to manage pain and patient outcomes, which has not previously been verified. It is also expected to be used for determining the effectiveness of practical education and lectures on pain in pre- and post-graduation. Therefore, this study aimed to undertake cultural adaptation of the PUnCQ to Japanese.

PARTICIPANTS AND METHODS

According to Beaton’s guidelines for cross-cultural adaptation²¹⁾, this study was conducted in five stages for cross-cultural adaptation: (1) forward translation, (2) creation of an integrated forward translation version, (3) backward translation, (4) creation of a provisional Japanese version, and (5) a pilot test. The participants in the pilot test were kept anonymous, and prior approval (22831) was obtained from the ethics committee of Saitama Prefectural University.

Regarding procedures, before creating the provisional Japanese version, we first obtained permission from the developer (SG) of the PUnCQ to translate it into Japanese. Then two translators, both bilingual (native Japanese and English), independently performed the forward translation of the PUnCQ from English to Japanese: one was a physiotherapist who had read the PUnCQ development articles^{20, 22)}, and the other was a university English teacher who maintained the confidentiality of the PUnCQ concept and development articles^{20, 22)}. For the backward translation, two nonmedical professional English–Japanese translators (native English speakers) independently translated the integrated Japanese version into English, who also maintained confidentiality of the PUnCQ concept and development articles^{20, 22)}. The two backward translations were then discussed by five individuals (two forward translators, two backward translators, and an author [RT]). Finally, the two backward translations were shown to the developer (SG), and consistency with the original was inspected. Consequently, a provisional Japanese version was developed.

For the pilot test, since cross-cultural adaptation guidelines²¹⁾ require data from 30–40 individuals, convenience sampling of 40 licensed physical therapists working at the authors’ three medical facilities in Chiba and Sapporo was undertaken. Data were collected from December 2022 to February 2023 through an anonymous paper survey.

The primary outcome was the degree to which the meaning of each phrase was understood in Japanese, measured using a 2-label 5-point numerical rating scale (1, not at all understandable; 5, completely understandable)^{17, 23, 24)}. When the rates were 1 to 3, free comments were obtained on specific concerns. The comments were used for discussion by the five members who prepared the tentative Japanese version. Based on the comments, revisions were made as necessary with clarifications from the developer. The revisions and pilot test were repeated until less than 10% of the respondents rated 1 for all descriptions.

The secondary outcomes were gender, age, highest academic degree (career college or junior college, college, master degree, doctoral degree), and years of experience as a physical therapist. Data were calculated as means, standard deviations, or percentages using descriptive statistics.

RESULTS

Discussions to develop the translation-integrated version are presented in Supplementary Table 1. In both pilot tests, 20 volunteers from a hospital in Chiba Prefecture and 10 volunteers each from another hospital in Chiba Prefecture and a hospital in Hokkaido participated.

The initial pilot test results, comments, discussions, and modifications are presented in Supplementary Table 2. Out of the 41 items, including the instructions, nine received comments from more than 20% of the respondents in the first pilot test. As a result, a revised version was developed, and a second pilot test was conducted as all items did not meet the predetermined criteria.

Participants for the second pilot test were recruited regardless of their participation in the first pilot test. The results of the second pilot test, comments, discussions, and modifications are presented in Supplementary Table 3. In the second pilot test, no items received comments from more than 20% of the respondents. All items met the predetermined criteria; hence, only minor modifications were made in the final version.

In Table 1, the characteristics of the participants in the two pilot tests are summarized. The final Japanese version of the PUnCQ is presented in Supplementary material 1.

Table 1. Characteristics of the participants in the two pilot tests.

Variable	First pilot test (n=40)	Second pilot test (n=40)
Age (years)	33.2 ± 6.1	31.7 ± 6.5
Gender (males: females)	30 [75.0%]: 10 [25.0%]	36 [90.0%]: 4 [10.0%]
Years of experience as a physical therapist (years)	10.7 ± 5.2	9.1 ± 5.6
Highest academic degree	20 [50.0%]: 17 [42.5%]: 3 [7.5%]: 0 [0%]	19 [47.5%]: 17 [42.5%]: 4 [10.0%]: 0 [0%]
(career college or junior college: college: master degrees: doctoral degrees)

Values are presented with mean ± standard deviations or number [%].

DISCUSSION

In this study, a Japanese version of the PUnCQ was developed according to Beaton’s cross-cultural adaptation guidelines²¹⁾. This guideline does not describe the criteria for conducting another pilot test. This study adopted a quantitative evaluation based on previous studies^{17, 23, 24)}. Some studies have set the criteria for retests at 5%–20% of those who cannot understand the meaning of an item or sentence^{23, 25, 26)}. For missing values, more than 15% are considered unacceptable²⁷⁾; therefore, in this study, revisions through retesting were repeated until the percentage of those who could not understand the text was less than 10%.

The attitude of therapists toward pain influences patient outcomes^5,6,7). When the confidence level in pain management is low, highly effective musculoskeletal physical therapy interventions cannot be expected. Because a high level of knowledge of pain physiology does not necessarily translate into confidence in pain management, future educational methods for increasing therapists’ confidence need to be explored; the second-factor structure of the PUnCQ is a promising measure for this. The PUnCQ is only partially assured of content validity (i.e., expert comprehensiveness), and only internal consistency has been conformed²⁰⁾, which is part of the next most important psychometric properties of the internal structure. Therefore, further evaluation of the internal structure is warranted in the future; for example, the Knowledge and Attitude of Pain^{16, 17)} and the Pain Attitudes and Beliefs Scale for Physiotherapists^{28, 29)} could be used to verify the convergent validity of the first-factor structure.

This study has two potential limitations. The first limitation is the use of convenience sampling. The second limitation is that, although the PUnCQ can be used by other healthcare professionals²⁰⁾, only physical therapists were included in this study. However, this study includes the first author, a physical therapist student, on the member panel for cross-cultural adaptation, and we believe that the Japanese version of the PUnCQ will be understood by other healthcare professionals.

Funding and Conflict of interest

None.