Summary
The English KNEES-ACL for patients with ACL injuries has undergone appropriate translation and cultural adaption using established dual panel and cognitive interviewing methods in the population of interest.
Abstract
Introduction
The Knee Numeric-Entity Evaluation Score (KNEES-ACL) is a 41-item condition-specific questionnaire developed in Denmark for patients following ACL injury and/or reconstruction. The KNEES-ACL is one of the only ACL specific PROMs whose content was developed appropriately through an extensive literature search, unique item bank generation, focus groups and individual interviews with ACL patients themselves. The KNEES-ACL has demonstrated face and content validity, and superior responsiveness compared to other PROMs commonly used with patients following ACL injury. However, this outcome measure was developed in Danish and has not been appropriately translated into English.
Purpose
Translate and culturally adapt the KNEES-ACL patient reported outcome measure from Danish to English using rigorous methodology including feedback from the target population.
Methods
The KNEES-ACL PROM was translated according to the dual panel method. Firstly, the Danish KNEES-ACL was translated by a bilingual panel, providing multiple English wording options for each item. Secondly, a lay panel focus group was conducted to determine the wording for each item that best reflected everyday spoken language. Finally, individual think-aloud cognitive interviews with patients following ACL injury were conducted to evaluate content relevance, comprehensiveness, and comprehensibility according to COSMIN guidelines. Repeated modification and testing were performed with patient feedback until a final English version of the KNEES-ACL was constructed. Participants’ think aloud responses to the KNEES-ACL were recorded and scores for each dimension were calculated, summed and scaled to values out of 100 for ease of comparison.
Results
Participants in the lay panel focus group were able to reach unanimous decisions for each of the 41 questionnaire items. Further changes to 17 items were made following eight think-aloud interviews to ensure items were being interpreted consistently amongst different types of patients. The final English KNEES-ACL Score consists of six domains: Problems with Daily Activities, Mental Impact, Stability, Strength and Control, and Sport and Physical Activity. Patients who had ACL injuries reported that the KNEES-ACL questionnaire was clear, feasible to complete independently, and relevant to their situation. Participants appreciated the addition of specific questions that they felt were particularly relevant to their experiences within the Mental Impact, Strength and Control, and Sport and Physical Activity domains. The range in participant scores appropriately reflected their stage of recovery (pre-operative to 2 years post-operative): problems with daily activities: 13 to 67; mental impact: 0 to 75; stability: 0 to 58; strength & control: 0 to 67; pain: 0 to 71; sport & physical activity: 5 to 100.
Conclusions
The English KNEES-ACL for patients with ACL injuries has undergone appropriate translation and cultural adaption using established dual panel and cognitive interviewing methods in the population of interest. The newly developed English version can be used for to evaluate mental and physical domains in patients after ACL injury. The psychometric properties of the English KNEES-ACL will likely mirror those established with the Danish version. However, direct validation of psychometric properties of the English version would be beneficial prior to widespread use.