Abstract
Objective
The purpose of this study was to measure the reliability, internal consistency, construct validity, and floor and ceiling effects of the Brazilian version of the Self-Estimated Functional Inability because of Pain (SEFIP-dance) instrument.
Methods
This was a questionnaire validation study. Both professional dancers and those who use dance as a recreational activity were included in the study. For test–retest reliability, SEFIP-dance was administered to the same dancer at 2 different times, with an interval of 7 days between the moments. For construct validity, Spearman's correlation coefficient (rs) was used to determine the magnitude of the correlations between SEFIP-dance and the Numerical Rating Scale, the 36-Item Short-Form Health Survey, the Roland–Morris Disability Questionnaire for general pain, and the Örebro Musculoskeletal Pain Questionnaire.
Results
A total of 111 dancers were recruited and included in the study. From this total sample, a subsample of 31 was used for the calculations of test–retest reliability: when considering each item of SEFIP-dance, we observed adequate κ values (κ ≥ 0.52); considering the total score, we observed excellent reliability (intraclass correlation coefficient = 0.94). In addition, we identified adequate values for internal consistency (Cronbach's α ≥ 0.80). We observed significant correlations of the SEFIP-dance total score with the Numerical Rating Scale, 36-Item Short-Form Health Survey, the Roland–Morris questionnaire, and the Örebro Musculoskeletal Pain Questionnaire (rs varying between 0.248 and 0.489). Ceiling and floor effects were not observed.
Conclusion
This study found that the Brazilian Portuguese version of SEFIP-dance has psychometric properties suitable for its use in dancers.
Key Indexing Terms: Musculoskeletal Pain, Surveys and Questionnaires, Reproducibility of Results
Introduction
Dance can be understood in several dimensions in an individual's life: its artistic aspect, leisure, rehabilitation, a means of knowledge, and communication.1 Over the years, there has been an increase in the number of dance practitioners, and several contemporary elements have been incorporated into it. Currently, the dance modalities with a considerable number of practitioners worldwide are ballet, ballroom dancing, folk rhythms, street dance, and jazz.2,3 In Brazil, samba is a modality that is still commonly practiced.4
Musculoskeletal pain or discomfort is a common clinical finding in both professional and nonprofessional dancers, and may interfere in the execution of certain movements in dance as well as in activities of daily and professional life.3,5,6 Depending on the intensity and repetition of movements during the dance, there is a predisposition to the development of injuries, especially in the lower limbs,2 most prevalently chronic inflammation, muscle strains, and sprains.7
Tools that can track injuries in dancers are important and should include the location and the degree of disability. The literature presents a series of instruments used in dancers to assess injury and pain, such as the numerical rating scale, the Brief Pain Inventory, and the Pain Sensitivity Questionnaire.3,5
Specifically, the Self-Estimated Functional Inability because of Pain questionnaire for dancers (SEFIP-dance) is an instrument that was developed in the English language with the objective of measuring musculoskeletal pain or discomfort in dancers, created and developed from the Nordic Musculoskeletal Questionnaire.6 It has been used in relevant studies8,9 and has already been translated and validated into the Turkish language.10 It has the differential of allowing a dancer to describe in which region of the body the pain or discomfort is located and how much this affects the ability to dance.
In Brazil, only the translation and cross-cultural adaptation of SEFIP-dance has been carried out,11 with proper validation still needed to measure pain and track musculoskeletal injuries in a specific way in dancers, thus justifying this study. Therefore, the objective of this study is to measure the reliability, internal consistency, construct validity, and floor and ceiling effects of the Brazilian version of SEFIP-dance. The hypothesis of this study is that the questionnaire has adequate psychometric properties.
Methods
Study design
This was a questionnaire validation study carried out based on the Consensus-based Standards for the Selection of Health Measurement Instruments.12 Data were collected from dance schools in the cities of São Luís and São Paulo, Brazil. The study was carried out with 2 sample sizes: the complete sample was used to assess the construct validity and measure the floor and ceiling effects, and a subsample was used for internal consistency and test–retest reliability (SEFIP-dance was administered to the same dancer at 2 different times by a single examiner, with an interval of 7 days between).
Ethics
The study procedures were approved by the research ethics committee of the Universidade Federal do Maranhão (opinion number 02273718.5.0000.5087). All participants signed an informed consent form.
Participants
Both professional dancers and those who used dance as a recreational activity at least twice a week for at least 3 months were included in the study. In addition, participants were able to read and write in Brazilian Portuguese, were literate, did not cognitive impairments, and were over 18 years old.
The exclusion criteria were a history of cancer; recent acute infections; systemic, rheumatological, neurologic, or degenerative diseases; and other previously diagnosed chronic pain. In addition, participants in drug or physical therapy treatment were excluded.
Self-Estimated Functional Inability Because of Pain (SEFIP-dance)
SEFIP-dance is an instrument that is mainly intended for professional dancers but can also be used by students, dance teachers, and other individuals who dance regularly and with relative intensity. Its main objective is to allow the tracking of musculoskeletal injuries (before and after training, competitions, artistic presentations, or similar) in a regionalized way by considering 14 regions of the body: neck, shoulders, elbows, wrists/hands, upper back, lower back, hips, thighs (front), thighs (back), knees, shins, calves, ankles/feet, and toes. For each region of the body, it is possible to indicate the degree of disability in relation to the practice of the dance on a 5-point Likert scale. The instrument has a total score ranging from 0 to 56 points,6 but we also suggest using the score from 0 (no pain and disability) to 4 (maximum pain and disability) for each region of the body. It has recently been translated and cross-culturally adapted to Brazilian Portuguese, and is available in the appendices of the study by Reis-Júnior et al.11
Other Questionnaires
To determine construct validity, other questionnaires already validated for Brazilian Portuguese were used in this study for proper correlations. The Numerical Rating Scale was used to measure the highest pain intensity in any region of the body affected. It is an instrument consisting of a sequence of numbers from 0 to 10, with 0 representing “no pain” and 10 representing “the worst pain imaginable,” and has been validated for Portuguese by Ferreira-Valente et al.13 In this way, the study participants graded their pain based on these parameters.
The 36-Item Short-Form Health Survey (SF-36) is an instrument for assessing quality of life that is easy to administer and understand and has been validated for Brazil by Ciconelli et al.14 It is a questionnaire consisting of 36 items divided into 8 domains: functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, and mental health. It presents a total score from 0 to 100 for each domain: the higher the value, the better the individual's quality of life.
The Roland–Morris Disability Questionnaire for general pain (RMDQ-general) measures functional disability related to pain, validated for Brazil by Sardá Júnior et al.15 This tool consists of 24 items, with a binary response for each item equivalent to a score of 0 or 1. The total score therefore varies between 0 and 24, with higher values indicating more disability.
The short version of the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) is a tool used in individuals with musculoskeletal pain and dysfunction to assess the risk of a worse prognosis in relation to psychosocial factors, validated for Brazil by Fagundes et al.16 It consists of 10 items with a numerical classification from 0 to 10, except for item 1, which is scored from 1 to 10. Thus, the total score varies between 1 and 100. Higher scores represent a worse pain prognosis.
Statistical Analysis
We assessed the test–retest reliability by means of the κ coefficient for each questionnaire item and the intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimum detectable change (MDC) for the total questionnaire score. Interpretation of κ was based on the study by Sim and Wright17: <0, poor; 0.01–0.20, slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, substantial; and 0.81–1, almost perfect. Interpretation of the ICC was based on the study by Fleiss18: <0.40, low reliability; 0.40–0.75, moderate reliability; 0.75–0.90, substantial reliability; and >0.90, excellent reliability. Interpretation of the SEM was based on the study by Ostelo et al19: ≤5%, very good; >5% and ≤10%, good; >10% and ≤20%, doubtful; and >20%, negative. Adequate Cronbach's α values20 vary between 0.70 and 0.95.
To determine construct validity, Spearman's correlation coefficient (rs) was used to determine the magnitude of the correlations between SEFIP-dance and the SF-36, RMDQ-general, and ÖMPQ. Interpretation of the coefficients followed the COSMIN recommendations:12 correlations with instruments measuring similar constructs should be ≥0.50; correlations with instruments measuring related but dissimilar constructs should be 0.30 to 0.50; and correlations with instruments measuring unrelated constructs should be <0.30.
Ceiling and floor effects were evaluated. These effects occur when a number of study participants (over 15%) reach the minimum or maximum values of the total score of the questionnaire.
Results
A total of 111 dancers were recruited and included in the study. From this total sample, a subsample of 31 was used for the internal consistency and test–retest reliability calculations. Table 1 presents the characteristics of the sample. We observe that the majority of the participants were women, single, and not overweight, and danced more than 3 times/wk.
Table 1.
Participant Sociodemographic and Clinical Characteristics Related to Dance
| Variable | Reliability phase (n = 31) | Validity phase (n = 111) |
|---|---|---|
| Age, y | 22.67± 3.40 | 24.32 ± 8.14 |
| Sex (female/male) | 20/11 (64.5/35.5) | 87/24 (78.4/21.6) |
| Marital status | ||
| Single | 31 (100) | 106 (95.5) |
| Married | 0 (0) | 3 (2.7) |
| Divorced | 0 (0) | 1 (0.9) |
| Widowed | 0 (0) | 1 (0.9) |
| Weight, kg | 64.52 ± 12.62 | 45.98 ± 28.77 |
| Height, m | 1.66 ± 0.08 | 1.65 ± 0.08 |
| BMI, kg/m2 | 23.17 ± 3.54 | 23.85 ± 3.53 |
| Education | ||
| Basic education | 2 (6.5) | 3 (2.7) |
| High school | 27 (87.1) | 87 (78.4) |
| Higher education | 2 (6.5) | 21 (18.9) |
| Dance modality | ||
| Ballet | 5 (16.1) | 52 (46.8) |
| Hip-hop | 12 (38.8) | 14 (12.6) |
| Jazz | 5 (16.1) | 14 (12.6) |
| Zumba | 0 (0) | 10 (9) |
| Ballroom | 4 (12.9) | 8 (7.2) |
| Urban | 1 (3.2) | 7 (6.4) |
| Rhythms | 3 (9.7) | 4 (3.6) |
| Aerobic | 1 (3.2) | 1 (0.9) |
| Stiletto | 0 (0) | 1 (0.9) |
| Frequency, times/wk | 4.29 ± 1.61 | 3.71 ± 1.61 |
| Amount, min/wk | 399.67 ± 309.77 | 362.57 ± 272.82 |
| Length of regular dancing, mo | 61.29 ± 43.93 | 86.31 ± 102.41 |
| NRS score | 3.19 ± 2.72 | 2.85 ± 2.55 |
| SF-36 score | ||
| Functional capacity | 79.54 ± 21.92 | 86.81 ± 16.04 |
| Physical aspects | 65.93 ± 32.19 | 81.01 ± 27.79 |
| Pain | 51.19 ± 19.80 | 68.46 ± 20.80 |
| General health status | 61.83 ± 20.24 | 64.57 ± 17.34 |
| Vitality | 59.51 ± 17.04 | 55.84 ± 16.05 |
| Social aspects | 66.06 ± 25.93 | 73.37 ± 19.53 |
| Emotional aspects | 65.56 ± 32.76 | 74.75 ± 30.23 |
| Mental health | 68.77 ± 19.41 | 61.61 ± 19.47 |
| RMDQ-general score | 3.16 ± 3.82 | 2.41 ± 3.07 |
| ÖMPQ score | 32.29 ± 16.03 | 34.70 ± 17.93 |
| SEFIP-dance score | 7.20 ± 5.82 | 4.85 ± 4.49 |
Values are presented as mean ± SD or number (percentage).
BMI, body mass index; NRS, Numerical Rating Scale; ÖMPQ, Örebro Musculoskeletal Pain Questionnaire; RMDQ-general, Roland–Morris Disability Questionnaire for general pain; SEFIP-dance, Self-Estimated Functional Inability because of Pain for dancers; SF-36, 36-Item Short-Form Health Survey.
Regarding reliability (Table 2), when considering each item of SEFIP-dance we observed adequate κ values (≥0.52). The item “elbows” was the most reliable (κ = 1.00) and the item “shins” was the least reliable (κ = 0.52). Considering the total score, we observed excellent reliability: ICC = 0.94, SEM = 1.81, SEM% = 19.79, MDC = 3.91, and MDC% = 54.85. In addition, we identified adequate values for internal consistency (Cronbach's α ≥ 0.80).
Table 2.
Reliability and Internal Consistency of the Self-Estimated Functional Inability Because of Pain Instrument
| Mean ± SD |
||||
|---|---|---|---|---|
| SEFIP-dance item | Test | Retest | Reliability: k (95% CI) | Cronbach's α if item excluded |
| Neck | 0.56 ± 0.72 | 0.60 ± 0.77 | 0.68 (0.48–0.89) | 0.81 |
| Shoulders | 0.60 ± 0.72 | 0.50 ± 0.77 | 0.67 (0.45–0.89) | 0.81 |
| Elbows | 0.13 ± 0.43 | 0.13 ± 0.43 | 1.00 (1.00–1.00) | 0.83 |
| Wrists/hands | 0.36 ± 0.76 | 0.26 ± 0.69 | 0.69 (0.40–0.98) | 0.80 |
| Upper back | 0.80 ± 0.96 | 0.80 ± 0.88 | 0.72 (0.52–0.91) | 0.80 |
| Lower back | 1.23 ± 1.04 | 1.23 ± 1.07 | 0.55 (0.28–0.81) | 0.81 |
| Hips | 0.53 ± 0.86 | 0.63 ± 0.96 | 0.56 (0.29–0.84) | 0.83 |
| Thighs (front) | 0.33 ± 0.60 | 0.33 ± 0.60 | 0.61 (0.37–0.85) | 0.83 |
| Thighs (back) | 0.20 ± 0.40 | 0.26 ± 0.58 | 0.65 (0.42–0.88) | 0.83 |
| Knees | 1.03 ± 0.99 | 0.90 ± 0.88 | 0.54 (0.29–0.76) | 0.83 |
| Shins | 0.36 ± 0.66 | 0.30 ± 0.59 | 0.52 (0.20–0.84) | 0.82 |
| Calves | 0.33 ± 0.60 | 0.26 ± 0.52 | 0.71 (0.40–1.00) | 0.81 |
| Ankles/feet | 0.36 ± 0.55 | 0.50 ± 0.62 | 0.76 (0.56–0.97) | 0.82 |
| Toes | 0.33 ± 0.66 | 0.33 ± 0.66 | 0.62 (0.31–0.93) | 0.83 |
| Total score | 7.20 ± 5.82 | 7.06 ± 5.70 | 0.94a (0.87–0.97) | 0.83b |
CI, confidence interval; ICC, intraclass correlation coefficient; SEFIP-dance, Self-Estimated Functional Inability because of Pain for dancers.
ICC.
Cronbach's α.
For assessment of construct validity through correlation with validated questionnaires (Table 3), we observed significant correlations of the SEFIP-dance total score with: the Numerical Rating Scale (rs = 0.460); the SF-36 domains of functional capacity (rs = −0.422), physical aspects (rs = −0.404), pain (rs = −0.489), social aspects (rs = −0.289), and emotional aspects (rs = −0.318); the RMDQ-general (rs = 0.458); and the ÖMPQ (rs = 0.248). Eight participants (7.2%) achieved a total SEFIP-dance minimum score of 0. No participant reached the maximum score of 56 points; therefore ceiling and floor effects were not observed.
Table 3.
Correlations Between Self-Estimated Functional Inability Because of Pain Total Score and Other Questionnaires (n = 111)
| Questionnaire | SEFIP-dance rs (P) |
|---|---|
| NRS | 0.460 (<0.001) a |
| SF-36 | |
| Functional capacity | −0.422 (<0.001)a |
| Physical aspects | −0.404 (<0.001)a |
| Pain | −0.489 (<0.001)a |
| General health status | −0.156 (0.103) |
| Vitality | −0.074 (0.427) |
| Social aspects | −0.289 (0.002)a |
| Emotional aspects | −0.318 (0.001)a |
| Mental health | −0.030 (0.753) |
| RMDQ-general | 0.458 (<0.001)a |
| ÖMPQ | 0.248 (0.009)a |
NRS, Numerical Rating Scale; ÖMPQ, Örebro Musculoskeletal Pain Questionnaire; RMDQ-general, Roland–Morris Disability Questionnaire for general pain; SEFIP-dance, Self-Estimated Functional Inability because of Pain for dancers; SF-36, 36-Item Short-Form Health Survey.
Statistically significant correlation.
Discussion
In this study, we observed that the Brazilian Portuguese version of SEFIP-dance presents adequate values of reliability (κ ≥ 0.52, ICC = 0.94), internal consistency (Cronbach's α ≥ 0.80), and construct validity through correlations with other questionnaires (rs varying between 0.248 and 0.489), and we did not observe ceiling or floor effects.
A study of the creation and validation of SEFIP-dance in English was conducted in 28 dancers.6 For item reliability, those authors observed κ values ranging from 0.48 to 0.92. This variation was similar to the results of the present study, in which κ values varied from 0.52 to 1.00. The initial publication of SEFIP-dance did not measure the reliability of the total score using the ICC, nor did it correlate with other instruments. However, its authors conducted an accuracy analysis by considering a battery of tests as the gold standard, observing a sensitivity of 78% and a specificity of 89%.
The scientific literature presents the translation, cross-cultural adaptation, and validation of SEFIP-dance for only 1 language (Turkish).10 That study was carried out with 64 dancers and observed a test–retest ICC for the total questionnaire score of 0.807 and a correlation of 0.672 with the Visual Analogue Scale. The results of the Turkish study are acceptable from a psychometric point of view, as are the results of the present study (ICC = 0.94, correlations ranging from 0.248 to 0.489).
However, our study has greater methodological robustness because it presents the following differentials over the 2 studies just mentioned6,10: larger sample size; measurement of internal consistency using Cronbach's α; measurement of SEM and MDC for the SEFIP-dance total score; correlation with a greater number of questionnaires (Numerical Rating Scale, 8 SF-36 domains, RMDQ-general, and ÖMPQ); and identification of ceiling and floor effects.
In Brazil, the translation and cross-cultural adaptation of SEFIP-dance was carried out according to the best international guidelines.12,21 In the initial validation conducted by Reis-Júnior et al,11 100% understanding of the dancers was verified in relation to the statement, items, and responses to the items. However, analysis of psychometric properties is necessary to scientifically support the use of the Brazilian version, a gap that is filled by the present study.
Our study shows a correlation coefficient below 0.50, although the values found here are acceptable according to COSMIN.12 We emphasize that this is due to the fact that the SEFIP-dance total score does not represent disability completely well. For example, if a dancer marks the score 4 (“Can not work in the production because of pain”) for “knees” and 0 (“Very well”) for the remaining 13 items, this already signals a total inability to dance. In contrast, if a dancer marks the score 1 (“Some pain but not much problem”) for all 14 items of the questionnaire, this will result in a total score of 14, but the dancer can continue to dance despite this discomfort throughout the body. In this example, the total score of 4 represents greater disability than the total score of 14. In this way, we suggest that total score be used only complementarily and point out that SEFIP-dance has a better capacity to track disability in a regionalized way—that is, for each body part.
Limitations
The study has limitations that should be highlighted here. Our sample is predominantly female, since women in Brazil are more involved in activities related to dance. Furthermore, there was a large variation in weekly frequency and duration of dancing.
Conclusion
This study found that the Brazilian Portuguese version of SEFIP-dance has psychometric properties suitable for its use in dancers.
Funding Sources and Conflicts of Interest
This study was supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (PIBIC/CNPq and PIBITI/CNPq) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, finance code 001). No conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): F.O.P., C.A.F.-P.-G., C.S.S, D.B.-D., A.V.D.-F.
Design (planned the methods to generate the results): F.O.P., C.A.F.-P.-G., C.S.S., D.B.-D., A.V.D.-F.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): F.O.P., C.A.F.-P.-G., C.S.S., D.B.-D., A.V.D.-F.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): A.M.M.-C., J.S.P., M.E.C.C., C.A.B.P., L.N.G., C.I.A.-S.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): A.M.M.-C., J.S.P., M.E.C.C., C.A.B.P., L.N.G., C.I.A.-S.
Literature search (performed the literature search): A.M.M.-C., J.S.P., M.E.C.C., C.A.B.P., L.N.G., C.I.A.-S.
Writing (responsible for writing a substantive part of the manuscript): A.M.M.C., J.S.P., M.E.C.C., C.A.B.P., L.N.G., C.I.A.-S.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): F.O.P., C.A.F.-P.-G., C.S.S., D.B.-D., A.V.D.-F.
Practical Applications.
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•
SEFIP-dance is a questionnaire that tracks musculoskeletal injuries and disability in dancers.
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•
SEFIP-dance has adequate measurement properties (reliability, internal consistency, and construct validity).
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•
This study found that the Brazilian version of SEFIP-dance can be used in the clinical field and in research.
Alt-text: Unlabelled box
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