© 2013 John Wiley & Sons A/S.
Scand J Med Sci Sports 2013: ••: ••–•• doi: 10.1111/sms.12157
Published by John Wiley & Sons Ltd
Swedish translation and validation of a web-based questionnaire for registration of overuse problems E. Ekman1, A. Frohm1,2, P. Ek1, J. Hagberg1, C. Wirén1, A. Heijne1 1
Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden, Swedish Sports Confederation Center, Bosön SportsClinic, Lidingö, Sweden Corresponding author: Annette Heijne, Division of Physiotherapy, NVS, Karolinska Institutet, Alfred Nobels Allé 23, SE-141 83 Huddinge, Sweden. Tel: +46-8-524 88837, Fax: +46-8-524 88813, E-mail: [email protected] 2
Accepted for publication 1 November 2013
The main aim of this study was to translate the Oslo Sport Trauma Research Center (OSTRC) Overuse Injury Questionnaire into Swedish. The validity and applicability of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering top athletes were also examined. The backtranslation method was used for translation. An expert committee further developed it for use in a study of injuries in handball, orienteering, tennis, and volleyball. A 10-week pretest was then conducted on 43 athletes, average age 21 (18–31) from these sports, during which time the athletes completed the modified OSTRC questionnaire on a weekly basis. In the 10th week, four addi-
tional questions were added in order to examine the questionnaire’s content validity. No major disagreement was found in the translation. The athletes perceived the web-based questionnaire to be smooth and easy to complete, accurately capturing overuse injuries. However, suggestions were made to add questions relating to the hip for orienteerers and to the hand/fingers for handball players. The average prevalence of overuse injuries for all athletes, in any anatomical area was 22% (95% confidence interval 20–25). Construct validity appeared to be high, and we therefore suggest that the questionnaire may be used when studying overuse injuries in different sports.
In epidemiological studies of sports injuries, it is common that a broad classification of injury type is made, based on the mechanism of injury (Van Mechelen et al., 1992). Those that can be associated with a single, identifiable event are referred to as acute (or traumatic) injuries, with those that cannot be linked to a specific event often referred to as overuse injuries (Fuller et al., 2006). While a universally accepted definition of overuse injury is currently lacking, an implicit assumption is that their mechanism is a process of cumulative tissue microtrauma. Attention has been drawn to the challenges of recording the magnitude of overuse injuries using established injury surveillance methods (Bahr, 2009). Central issues include that athletes often continue to train and compete despite the existence of overuse problems and that their exact point of occurrence is difficult to define, as they normally occur gradually. An alternative approach to recording overuse injuries has therefore recently been proposed (Clarsen et al., 2013a). The method involves the regular administration of an overuse injury questionnaire to all subjects throughout the course of a surveillance study and employs a broad injury definition, recording all physical complaints in predefined anatomical areas, including their consequence on sports participation and performance.
The questionnaire was developed in Norway and validated for several sports, including volleyball and handball; however, its validity for use among tennis players and orienteerers is unknown and needs to be established. In general, orienteerers most frequently incur injuries in the lower leg and hip (Sutker et al., 1985; Linde, 1986; Ekstrand et al., 1990). In tennis, a highly technical sport with unilateral repetitive loading, overuse injuries, especially in the shoulders, are reportedly more frequent than acute injuries (Pluim et al., 2006; van der Hoeven & Kibler, 2006; Ljungqvist et al., 2009; Hjelm et al., 2010). Previous studies have shown a correlation between earlier and present pain and severe injury (Bahr & Holme, 2003; Bahr, 2009), a correlation that strengthens and highlights the necessity of preventing pain and overuse problems. A first step to design successful prevention strategies is to map out the prevalence and severity of overuse injuries. Sweden lacks uniform and validated systems for the registration of overuse sports injuries. The main aim of this study was to translate the Oslo Sports Trauma Research Center (OSTRC) Overuse Injury Questionnaire into Swedish. The validity and applicability of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering athletes were also examined.
1
Ekman et al. Material and methods Methods The questionnaire The questionnaire used in the present study was developed in Norway at the Oslo Sports Trauma Research Center (Clarsen et al., 2013a). Approval to translate into Swedish, develop, and use the questionnaire, was obtained from the head of the research group. The OSTRC questionnaire (Clarsen et al., 2013a) consisted of 12 questions because three body areas were used; however, the decision to include three areas was arbitrary. Their definition of injury as “all physical complaints” and for overuse injuries as “all injuries that were not associated with a specific, identifiable injury event” was used in the present study.
Translation The Norwegian version of the OSTRC Overuse Injury Questionnaire, developed in parallel to the published English version, was used for the Swedish translation. The translation of the questionnaire was conducted according to the back-translation method presented by Werner and Campbell (1970). This process consists of four steps: (a) back-translation; (b) testing of the original and the translated questionnaire by bilingual individuals; (c) discussion in expert committees; and (d) a pretest. Steps 1 and 2: Back-translation and testing. Translation from Norwegian to Swedish was independently carried out by four Swedish physiotherapists, resulting in four different translations. The back-translation was done with a supplemented target check, as recommended by Brislin (1970). In this way, errors or ambiguities in the original translation could be corrected. Backtranslation (translation back into the original language) was performed by two independent translators, educated in sports medicine, whose native language was Norwegian. The four translated versions were then compared. Two words identified as having been differently translated were discussed until everyone agreed. Step 3: Discussion by an expert committee. The content of the questionnaire was then discussed by an expert committee (Werner & Campbell, 1970) of the four physiotherapists (with 4–5 years of experience in rehabilitation and sports medicine) involved in the translation, plus two additional physiotherapists with PhDs in sports medicine. Based on previous research on injury location in sport (Linde, 1986; Pommering et al., 2005; Bahr, 2009; Jonasson et al., 2011), the expert committee agreed to add a cluster of questions regarding the foot. Two open background questions, on time of exposure during training and on exposure during competition, were included in the present questionnaire. A further, three questions were added to gather weekly background data: (a) Have you sustained an acute injury for example, a sprain, strain, or fall during the past seven days? (b) Are there any reasons other than injury or pain for not being able to train/compete during the past seven days? and (c) On what surface have you mainly been training during the past seven days? The first question regarding acute injury did not interfere with the data collection from the athletes, who were asked to continue to register every week even if an acute injury had occurred. The final Swedish version of the questionnaire therefore contained four multiple-choice questions for the shoulder, knee, lower back, and foot, and the five additional questions, 21 questions in total. The questionnaire was then distributed via a survey tool to the athletes (v. 9.9, Questback AS, Oslo, Norway). The time needed to complete the questionnaire, which was done online, was estimated at 4–6 min (for the Swedish version, please see Supporting Information File S1).
2
Step 4: Pretest. The next step was to pretest (Werner & Campbell, 1970) the questionnaire on a target population (see Athletes and recruitment later) in order to determine its content validity and to evaluate the online technique.
Athletes and recruitment Coaches from one orienteering club, one tennis club, one handball club, and one volleyball club in the Stockholm area were contacted for the recruitment of athletes. Eight orienteerers, 14 tennis players, 15 handball players, and 6 volleyball players accepted the invitation, giving 43 athletes (32 men and 11 women), all competing at elite level. The average age was 21 years (18–31) and the average self-reported years of competition and training was 14.5 years (6–25). The inclusion criteria were: age over 18 years, membership in the club’s elite program, competing at sub-elite or elite level and ability to speak and understand the Swedish language. Athletes were included regardless of whether they had present or previous overuse injuries. An introductory meeting was scheduled with the coaches and the athletes to present the purpose of the study and the registration process. The athletes were informed that participation was voluntary and that they could terminate the registration without further notice at any time during the study. An informed consent form was signed by all the athletes included.
Data collection The participants were asked to complete the web-based questionnaire once a week for 10 weeks. The questionnaire was e-mailed to them through QuestBack (v. 9.9, Questback AS, Oslo, Norway) every Sunday. If no response had been registered by the following Tuesday, an automatic reminder was sent. If an acute injury had occurred within the previous 7 days, the athlete was asked to register that and to send an encrypted e-mail to the data collector responsible for that specific sport. After decryption, the injured athlete was contacted by telephone for assistance with further medical treatment from a physiotherapist or a physician. Overuse and acute injury data were not separated in the database. This study was approved by the Regional Ethical Committee in Stockholm, no. 2011/74931/3.
Content validity The content validity was recorded in two steps: first, determining the frequency of overuse injuries over 10 weeks of web-based, self-reported registration, and second, by adding the following four dichotomous (yes/no) questions to the questionnaire at the 10th week of registration (Dahmström, 2011): (a) Do you consider the questionnaire to contain relevant questions regarding the sport you are participating in? (b) Was the questionnaire difficult to complete? (c) Would you like to exchange or add any question to the questionnaire? If so, please specify; and (4) Do you think that the web-based technique works well? After each question the athletes were offered space for any of their own comments.
Data analysis Background data are presented in median (Mdn) and range. Response rate appears in numbers and percentages for all athletes, irrespectively of sport. The rate and severity of overuse injuries was reported for each anatomical area once a week according to the OSTRC methodology (Clarsen et al., 2013a). Each week the prevalence of overuse problems was calculated for each anatomical area by dividing the number of athletes reporting any problem in that area by the number of questionnaire respondents (Clarsen
Swedish translation of OSTRCs questionnaire et al., 2013a). All data were compiled and analyzed in Microsoft Excel software (Microsoft Excel 2007, Microsoft Corporation, Redmond, WA, USA).
Results Translation Two words were discussed by all four translators because of differences in the translations. These words were instability (Swedish instabilitet) and hyperflexibility (Swedish överrörlighet).
the sub-questions regarding that specific anatomical area. Further, some athletes wanted to add pictures of different body parts that could help define which body parts were in focus. Some sport-specific comments were expressed. The orienteerers noted that the questions regarding the shoulder were not relevant for their sport and could be changed to questions related to the hip. Similarly, two handball players proposed that the questionnaire should include a set of questions relating to finger/hand problems. Discussion
Content validity The average prevalence of overuse injuries for all athletes, in any anatomical area, was 22% [95% confidence interval (CI) 20–25]. The average prevalence of substantial overuse injuries, problems causing moderate/severe reductions in training volume or sports performance, or complete inability to participate in training or competition, was 8% (95% CI 7–9; Fig. 1). The prevalence of all overuse injuries, by sports and anatomical areas, is shown in Fig. 2. At the end of the 10th week of data collection, 35 of the 43 (81%) participants were still reporting data. The average response rate to the questionnaire distributed every week, throughout the 10 weeks course of the study, was 85%. Thirty-five athletes reported data on the 10th week of registration and were therefore eligible for the four additional questions. All these athletes except two (33/35), agreed that the questions in the form were relevant to their sport. Some athletes expressed comments related to the simplicity of filling out the questionnaire and to the relevance and usefulness of the web-based methodology. However, suggestions were given regarding the technique, such as developing an application for smart phones and to save time, that if no pain was present in a specific body region (and the initial question was therefore answered in the negative), the system should skip
The primary aim of this study was to translate the OSTRC’s questionnaire designed to register overuse injuries in sport into Swedish. The applicability and the validity of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering top athletes were also examined. No major disagreement was found in terms of translation. The response rate can be considered high and the athletes responded positively to the web-based technique. However, the orienteerers commented that questions regarding the shoulder were not relevant for orienteering and should be changed to questions regarding the hip. Two handball players suggested that a set of questions covering finger/hand problems should be included. This may be particularly useful suggestions if these methods are used to collect data on acute as well as overuse injuries in handball, as a majority of hand injuries are the results of trauma. The athletes’ comments on anatomical areas are in accordance with expert opinions as well as with earlier research (Andersen et al., 2013; Clarsen et al., 2013a,b). This questionnaire has not yet been tested for reliability in either Norway or Sweden, but the method and the questionnaire have been tested earlier for some aspects of validity (Clarsen et al., 2013a,b). The present expert committee agreed on adding a set of supplementary
40 35
Prevalence (%)
30 25
20 Prevalence (all problems) 15
Prevalence (substantial problems)
10 5 0 1
2
3
4
5 6 Weeks
7
8
9
10
Fig. 1. Prevalence of acute and overuse injuries over 10 weeks of registration for all included athletes (n = 43). Substantial problem is defined as acute and overuse problem causing moderate/severe reductions in training volume or sports performance, or complete inability to participate in training or competition.
3
Ekman et al.
Fig. 2. Prevalence, presented in percentage, of all injuries for the four anatomic areas in handball, orienteering, tennis and volleyball over 10 weeks registration. Knee, diamonds; shoulders, squares; feet, triangles; lumbar, crosses.
questions regarding pain and function in the foot and lower leg. These questions were structured in exactly the same order as those for the knee, back, and shoulder (Clarsen et al., 2013a). Adding clusters of questions to the questionnaire is in accordance with the original authors’ conclusion that body regions for inclusion in the questionnaire should be based on previous research, expert opinion and/or thorough pilot testing for the sport in question. It can therefore be assumed that the established content validity of the original questionnaire has not decreased, instead it may have increased. Content validity was further investigated from the respondents’
4
perspective through the four questions suggested by Dahmström (2011) at the 10th week of registration. The athletes found the questions in the questionnaire well formulated, easy to understand and relevant. However, they did make suggestions, such as to add pictures of different body parts that could help define which body parts were in focus. The web-based method was appreciated and described as “smooth,” “easy,” and “fast”. Athletes appreciated the automatic reminder after 2 days. The use of web technique with automatic reminders is therefore suggested to keep the response rate high over time. Weekly reports of injuries decrease
Swedish translation of OSTRCs questionnaire the risk of recall bias (van Mechelen et al., 1992; Fuller et al., 2006; Junge et al., 2006; Streiner & Norman, 2008; Bahr, 2009), and further, it has been suggested that web-based methods result in higher response rates compared with surface mail or manual distribution. However, a limitation of self-reporting registration is the risk that the athlete might under- as well as overestimate a present injury or overuse problem. It was not possible to investigate criterion-related validity in the present study because of the lack of consensus regarding the definition of overuse; nor is other correlated methods presented in the literature. The questionnaire aims to capture the construct or attribute of participation, pain and performance. It may be discussed whether this form is comprehensive enough to reach sufficient construct validity. However, to strengthen construct validity, all questions are followed by graded possible answers, continuously organized from zero pain or no problems to participate to the highest level of pain or no possibility to participate in sport. Together with the satisfactory content validity, this strengthens the construct validity of the questionnaire (Streiner & Norman, 2008). The form’s psychometric characteristic was recently analyzed with satisfactory results, showing a Chronbach’s alpha of 0.91 (Clarsen et al., 2013b). This method provides information regarding the prevalence of overuse injuries, not their incidence. It provides no indication of whether an injury is new or old; however, such questions can be included in future studies. It is therefore problematic to obtain supporting evidence regarding, e.g., risk factors for injury, an important further step when performing injury registration studies. A strength of the method used, however, is that it supplies important information on whether the problems increase or decrease with respect to, among other things, training dosage or intensity. In the present study, no prior power analysis was conducted, as the purpose was not to make generalizable conclusions from the register data: this pretest was performed to determine whether the questionnaire actually captures overuse injuries in this population. The present
methodological study shows that overuse injuries were successfully recorded among the athletes. We found that several athletes participated in sports despite pain and decreased function. However, it can be hypothesized that the prevalence of overuse injuries in the present population would have appeared even higher with an additional set of questions – for the hip for the orienteerers and for the hand/fingers for the handball players. The conclusions from injury registration studies may be affected by the definition of overuse injuries used (van Mechelen et al., 1992). The definition varies in the literature, and a standardized definition is missing. There are ongoing discussions, but no consensus, regarding whether overuse injuries should be judged by body function or consequences (Bahr, 2009). Further discussion and decisions are needed in order to arrive at a clear consensus and definition of overuse injuries. The model used for translation is well established (Brislin, 1970; Werner & Campbell, 1970). Other methods are available for translating questionnaires (Beaton et al., 2000); however, we chose the backtranslation method for the present study as the Norwegian and Swedish languages and cultures are quite similar. We therefore do not consider the translation method a limitation in the present study. Perspective In conclusion, the web-based questionnaire was easy to use and appeared to capture the construct of overuse injuries. Its use is therefore recommended, in accordance with recent research, to record prevalence of overuse injuries in sport. While the main purpose was not to study the prevalence of overuse injuries, we found that several athletes trained or competed with moderate pain despite full sports participation. Studies of larger populations of athletes from these sports are therefore highly desirable. Key words: Content validity, orienteering, sports, tennis, web-based technique.
References Andersen CA, Clarsen B, Johansen TV, Engebretsen L. High prevalence of overuse injury among iron-distance triathletes. Br J Sports Med 2013: 47: 857–861. doi:10.1136/bjsports -2013-092397. Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J Sports Med 2009: 43: 966–972. Bahr R, Holme I. Risk factors for sports injuries—a methodological approach. Br J Sports Med 2003: 37: 384–392.
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000: 25: 3186–3191. Brislin R. Back-translation for cross-cultural research. J Cross Cult Psychol 1970: 1: 185–216. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology. Br J Sports Med 2013a: 47: 495–502.
Clarsen B, Rønsen O, Myklebust G, Flørenes TW, Bahr R. The Oslo Sports Trauma Research Center Questionnaire on Health Problems: a new approach to prospective monitoring of illness and injury in elite athletes. Br J Sports Med 2013b: doi :10.1136/bjsports-2012 -092087. Dahmström K. Konstruktion av ett frågeformulär. In: Dahmström K, ed. Från datainsamling till rapport: att göra en statistisk undersökning. Lund: Studentlitteratur, 2011: 147–172.
5
Ekman et al. Ekstrand J, Roos H, Tropp H. The incidence of ankle sprains in orienteering. Sci J Orienteering 1990: 6: 3–9. Fuller CW, Ekstrand J, Junge A, Andersen TE, Bahr R, Dvorak J Hägglund M, McCrory P, Meeuwisse WH. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Br J Sports Med 2006: 40: 193–201. Hjelm N, Werner S, Renstrom P. Injury profile in junior tennis players: a prospective two year study. Knee Surg Sports Traumatol Arthrosc 2010: 18: 845–850. Jonasson P, Halldin K, Karlsson J, Thoreson O, Hvannberg J, Swärd L, Baranto A. Prevalence of joint-related pain in the extremities and spine in five groups of top athletes. Knee Surg Sports Traum Arthrosc 2011: 19: 1540–1546. Junge A, Langevoort G, Pipe A, Peytavin A, Wong F, Mountjoy M, Beltrami G, Terrell R, Holzgraefe M, Charles R, Dvorak J. Injuries in team sport tournaments during the 2004 Olympic Games. Am J Sports Med 2006: 34: 565–576.
6
Linde F. Injuries in orienteering. Br J Sports Med 1986: 20: 125–127. Ljungqvist A, Jenoure PJ, Engebretsen L, Alonso JM, Bahr R, Clough AF, de Bondt G, Dvorak J, Maloley R, Matheson G, Meeuwisse W, Meijboom EJ, Mountjoy M, Pelliccia A, Schwellnus M, Sprumont D, Schamasch P, Gauthier JB, Dubi C. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes. Clin J Sport Med 2009: 19: 347–365. Pluim BM, Staal JB, Windler GE, Jayanthi N. Tennis injuries: occurrence, aetiology, and prevention. Br J Sports Med 2006: 40: 415–423. Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric and adult athletes. Prim Care 2005: 32: 133–161. Streiner D, Norman G. Methods of administration. In: Streiner D, ed. Health measurement scales: a practical guide to their development and use. Oxford: Oxford University Press, 2008: 331–364. Sutker A, Barber A, Jackson D, Pagliano J. Iliotibial band syndrome in
distance runners. Sports Med 1985: 2: 447–451. Van der Hoeven H, Kibler WB. Shoulder injuries in tennis players. Br J Sports Med 2006: 40: 435–440. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992: 14: 82–99. Werner O, Campbell DT. Translating, wording through interpreters, and the problem of decentering. In: Naroll R, Cohen R, eds. A handbook of method in cultural anthropology. New York: American Museum of Natural History, National History Press, 1970: 974–989.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: File S1. The Swedish version of a questionnaire for registration of overuse injuries.
Scand J Med Sci Sports 2013: ••: ••–•• doi: 10.1111/sms.12157
Published by John Wiley & Sons Ltd
Swedish translation and validation of a web-based questionnaire for registration of overuse problems E. Ekman1, A. Frohm1,2, P. Ek1, J. Hagberg1, C. Wirén1, A. Heijne1 1
Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden, Swedish Sports Confederation Center, Bosön SportsClinic, Lidingö, Sweden Corresponding author: Annette Heijne, Division of Physiotherapy, NVS, Karolinska Institutet, Alfred Nobels Allé 23, SE-141 83 Huddinge, Sweden. Tel: +46-8-524 88837, Fax: +46-8-524 88813, E-mail: [email protected] 2
Accepted for publication 1 November 2013
The main aim of this study was to translate the Oslo Sport Trauma Research Center (OSTRC) Overuse Injury Questionnaire into Swedish. The validity and applicability of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering top athletes were also examined. The backtranslation method was used for translation. An expert committee further developed it for use in a study of injuries in handball, orienteering, tennis, and volleyball. A 10-week pretest was then conducted on 43 athletes, average age 21 (18–31) from these sports, during which time the athletes completed the modified OSTRC questionnaire on a weekly basis. In the 10th week, four addi-
tional questions were added in order to examine the questionnaire’s content validity. No major disagreement was found in the translation. The athletes perceived the web-based questionnaire to be smooth and easy to complete, accurately capturing overuse injuries. However, suggestions were made to add questions relating to the hip for orienteerers and to the hand/fingers for handball players. The average prevalence of overuse injuries for all athletes, in any anatomical area was 22% (95% confidence interval 20–25). Construct validity appeared to be high, and we therefore suggest that the questionnaire may be used when studying overuse injuries in different sports.
In epidemiological studies of sports injuries, it is common that a broad classification of injury type is made, based on the mechanism of injury (Van Mechelen et al., 1992). Those that can be associated with a single, identifiable event are referred to as acute (or traumatic) injuries, with those that cannot be linked to a specific event often referred to as overuse injuries (Fuller et al., 2006). While a universally accepted definition of overuse injury is currently lacking, an implicit assumption is that their mechanism is a process of cumulative tissue microtrauma. Attention has been drawn to the challenges of recording the magnitude of overuse injuries using established injury surveillance methods (Bahr, 2009). Central issues include that athletes often continue to train and compete despite the existence of overuse problems and that their exact point of occurrence is difficult to define, as they normally occur gradually. An alternative approach to recording overuse injuries has therefore recently been proposed (Clarsen et al., 2013a). The method involves the regular administration of an overuse injury questionnaire to all subjects throughout the course of a surveillance study and employs a broad injury definition, recording all physical complaints in predefined anatomical areas, including their consequence on sports participation and performance.
The questionnaire was developed in Norway and validated for several sports, including volleyball and handball; however, its validity for use among tennis players and orienteerers is unknown and needs to be established. In general, orienteerers most frequently incur injuries in the lower leg and hip (Sutker et al., 1985; Linde, 1986; Ekstrand et al., 1990). In tennis, a highly technical sport with unilateral repetitive loading, overuse injuries, especially in the shoulders, are reportedly more frequent than acute injuries (Pluim et al., 2006; van der Hoeven & Kibler, 2006; Ljungqvist et al., 2009; Hjelm et al., 2010). Previous studies have shown a correlation between earlier and present pain and severe injury (Bahr & Holme, 2003; Bahr, 2009), a correlation that strengthens and highlights the necessity of preventing pain and overuse problems. A first step to design successful prevention strategies is to map out the prevalence and severity of overuse injuries. Sweden lacks uniform and validated systems for the registration of overuse sports injuries. The main aim of this study was to translate the Oslo Sports Trauma Research Center (OSTRC) Overuse Injury Questionnaire into Swedish. The validity and applicability of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering athletes were also examined.
1
Ekman et al. Material and methods Methods The questionnaire The questionnaire used in the present study was developed in Norway at the Oslo Sports Trauma Research Center (Clarsen et al., 2013a). Approval to translate into Swedish, develop, and use the questionnaire, was obtained from the head of the research group. The OSTRC questionnaire (Clarsen et al., 2013a) consisted of 12 questions because three body areas were used; however, the decision to include three areas was arbitrary. Their definition of injury as “all physical complaints” and for overuse injuries as “all injuries that were not associated with a specific, identifiable injury event” was used in the present study.
Translation The Norwegian version of the OSTRC Overuse Injury Questionnaire, developed in parallel to the published English version, was used for the Swedish translation. The translation of the questionnaire was conducted according to the back-translation method presented by Werner and Campbell (1970). This process consists of four steps: (a) back-translation; (b) testing of the original and the translated questionnaire by bilingual individuals; (c) discussion in expert committees; and (d) a pretest. Steps 1 and 2: Back-translation and testing. Translation from Norwegian to Swedish was independently carried out by four Swedish physiotherapists, resulting in four different translations. The back-translation was done with a supplemented target check, as recommended by Brislin (1970). In this way, errors or ambiguities in the original translation could be corrected. Backtranslation (translation back into the original language) was performed by two independent translators, educated in sports medicine, whose native language was Norwegian. The four translated versions were then compared. Two words identified as having been differently translated were discussed until everyone agreed. Step 3: Discussion by an expert committee. The content of the questionnaire was then discussed by an expert committee (Werner & Campbell, 1970) of the four physiotherapists (with 4–5 years of experience in rehabilitation and sports medicine) involved in the translation, plus two additional physiotherapists with PhDs in sports medicine. Based on previous research on injury location in sport (Linde, 1986; Pommering et al., 2005; Bahr, 2009; Jonasson et al., 2011), the expert committee agreed to add a cluster of questions regarding the foot. Two open background questions, on time of exposure during training and on exposure during competition, were included in the present questionnaire. A further, three questions were added to gather weekly background data: (a) Have you sustained an acute injury for example, a sprain, strain, or fall during the past seven days? (b) Are there any reasons other than injury or pain for not being able to train/compete during the past seven days? and (c) On what surface have you mainly been training during the past seven days? The first question regarding acute injury did not interfere with the data collection from the athletes, who were asked to continue to register every week even if an acute injury had occurred. The final Swedish version of the questionnaire therefore contained four multiple-choice questions for the shoulder, knee, lower back, and foot, and the five additional questions, 21 questions in total. The questionnaire was then distributed via a survey tool to the athletes (v. 9.9, Questback AS, Oslo, Norway). The time needed to complete the questionnaire, which was done online, was estimated at 4–6 min (for the Swedish version, please see Supporting Information File S1).
2
Step 4: Pretest. The next step was to pretest (Werner & Campbell, 1970) the questionnaire on a target population (see Athletes and recruitment later) in order to determine its content validity and to evaluate the online technique.
Athletes and recruitment Coaches from one orienteering club, one tennis club, one handball club, and one volleyball club in the Stockholm area were contacted for the recruitment of athletes. Eight orienteerers, 14 tennis players, 15 handball players, and 6 volleyball players accepted the invitation, giving 43 athletes (32 men and 11 women), all competing at elite level. The average age was 21 years (18–31) and the average self-reported years of competition and training was 14.5 years (6–25). The inclusion criteria were: age over 18 years, membership in the club’s elite program, competing at sub-elite or elite level and ability to speak and understand the Swedish language. Athletes were included regardless of whether they had present or previous overuse injuries. An introductory meeting was scheduled with the coaches and the athletes to present the purpose of the study and the registration process. The athletes were informed that participation was voluntary and that they could terminate the registration without further notice at any time during the study. An informed consent form was signed by all the athletes included.
Data collection The participants were asked to complete the web-based questionnaire once a week for 10 weeks. The questionnaire was e-mailed to them through QuestBack (v. 9.9, Questback AS, Oslo, Norway) every Sunday. If no response had been registered by the following Tuesday, an automatic reminder was sent. If an acute injury had occurred within the previous 7 days, the athlete was asked to register that and to send an encrypted e-mail to the data collector responsible for that specific sport. After decryption, the injured athlete was contacted by telephone for assistance with further medical treatment from a physiotherapist or a physician. Overuse and acute injury data were not separated in the database. This study was approved by the Regional Ethical Committee in Stockholm, no. 2011/74931/3.
Content validity The content validity was recorded in two steps: first, determining the frequency of overuse injuries over 10 weeks of web-based, self-reported registration, and second, by adding the following four dichotomous (yes/no) questions to the questionnaire at the 10th week of registration (Dahmström, 2011): (a) Do you consider the questionnaire to contain relevant questions regarding the sport you are participating in? (b) Was the questionnaire difficult to complete? (c) Would you like to exchange or add any question to the questionnaire? If so, please specify; and (4) Do you think that the web-based technique works well? After each question the athletes were offered space for any of their own comments.
Data analysis Background data are presented in median (Mdn) and range. Response rate appears in numbers and percentages for all athletes, irrespectively of sport. The rate and severity of overuse injuries was reported for each anatomical area once a week according to the OSTRC methodology (Clarsen et al., 2013a). Each week the prevalence of overuse problems was calculated for each anatomical area by dividing the number of athletes reporting any problem in that area by the number of questionnaire respondents (Clarsen
Swedish translation of OSTRCs questionnaire et al., 2013a). All data were compiled and analyzed in Microsoft Excel software (Microsoft Excel 2007, Microsoft Corporation, Redmond, WA, USA).
Results Translation Two words were discussed by all four translators because of differences in the translations. These words were instability (Swedish instabilitet) and hyperflexibility (Swedish överrörlighet).
the sub-questions regarding that specific anatomical area. Further, some athletes wanted to add pictures of different body parts that could help define which body parts were in focus. Some sport-specific comments were expressed. The orienteerers noted that the questions regarding the shoulder were not relevant for their sport and could be changed to questions related to the hip. Similarly, two handball players proposed that the questionnaire should include a set of questions relating to finger/hand problems. Discussion
Content validity The average prevalence of overuse injuries for all athletes, in any anatomical area, was 22% [95% confidence interval (CI) 20–25]. The average prevalence of substantial overuse injuries, problems causing moderate/severe reductions in training volume or sports performance, or complete inability to participate in training or competition, was 8% (95% CI 7–9; Fig. 1). The prevalence of all overuse injuries, by sports and anatomical areas, is shown in Fig. 2. At the end of the 10th week of data collection, 35 of the 43 (81%) participants were still reporting data. The average response rate to the questionnaire distributed every week, throughout the 10 weeks course of the study, was 85%. Thirty-five athletes reported data on the 10th week of registration and were therefore eligible for the four additional questions. All these athletes except two (33/35), agreed that the questions in the form were relevant to their sport. Some athletes expressed comments related to the simplicity of filling out the questionnaire and to the relevance and usefulness of the web-based methodology. However, suggestions were given regarding the technique, such as developing an application for smart phones and to save time, that if no pain was present in a specific body region (and the initial question was therefore answered in the negative), the system should skip
The primary aim of this study was to translate the OSTRC’s questionnaire designed to register overuse injuries in sport into Swedish. The applicability and the validity of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering top athletes were also examined. No major disagreement was found in terms of translation. The response rate can be considered high and the athletes responded positively to the web-based technique. However, the orienteerers commented that questions regarding the shoulder were not relevant for orienteering and should be changed to questions regarding the hip. Two handball players suggested that a set of questions covering finger/hand problems should be included. This may be particularly useful suggestions if these methods are used to collect data on acute as well as overuse injuries in handball, as a majority of hand injuries are the results of trauma. The athletes’ comments on anatomical areas are in accordance with expert opinions as well as with earlier research (Andersen et al., 2013; Clarsen et al., 2013a,b). This questionnaire has not yet been tested for reliability in either Norway or Sweden, but the method and the questionnaire have been tested earlier for some aspects of validity (Clarsen et al., 2013a,b). The present expert committee agreed on adding a set of supplementary
40 35
Prevalence (%)
30 25
20 Prevalence (all problems) 15
Prevalence (substantial problems)
10 5 0 1
2
3
4
5 6 Weeks
7
8
9
10
Fig. 1. Prevalence of acute and overuse injuries over 10 weeks of registration for all included athletes (n = 43). Substantial problem is defined as acute and overuse problem causing moderate/severe reductions in training volume or sports performance, or complete inability to participate in training or competition.
3
Ekman et al.
Fig. 2. Prevalence, presented in percentage, of all injuries for the four anatomic areas in handball, orienteering, tennis and volleyball over 10 weeks registration. Knee, diamonds; shoulders, squares; feet, triangles; lumbar, crosses.
questions regarding pain and function in the foot and lower leg. These questions were structured in exactly the same order as those for the knee, back, and shoulder (Clarsen et al., 2013a). Adding clusters of questions to the questionnaire is in accordance with the original authors’ conclusion that body regions for inclusion in the questionnaire should be based on previous research, expert opinion and/or thorough pilot testing for the sport in question. It can therefore be assumed that the established content validity of the original questionnaire has not decreased, instead it may have increased. Content validity was further investigated from the respondents’
4
perspective through the four questions suggested by Dahmström (2011) at the 10th week of registration. The athletes found the questions in the questionnaire well formulated, easy to understand and relevant. However, they did make suggestions, such as to add pictures of different body parts that could help define which body parts were in focus. The web-based method was appreciated and described as “smooth,” “easy,” and “fast”. Athletes appreciated the automatic reminder after 2 days. The use of web technique with automatic reminders is therefore suggested to keep the response rate high over time. Weekly reports of injuries decrease
Swedish translation of OSTRCs questionnaire the risk of recall bias (van Mechelen et al., 1992; Fuller et al., 2006; Junge et al., 2006; Streiner & Norman, 2008; Bahr, 2009), and further, it has been suggested that web-based methods result in higher response rates compared with surface mail or manual distribution. However, a limitation of self-reporting registration is the risk that the athlete might under- as well as overestimate a present injury or overuse problem. It was not possible to investigate criterion-related validity in the present study because of the lack of consensus regarding the definition of overuse; nor is other correlated methods presented in the literature. The questionnaire aims to capture the construct or attribute of participation, pain and performance. It may be discussed whether this form is comprehensive enough to reach sufficient construct validity. However, to strengthen construct validity, all questions are followed by graded possible answers, continuously organized from zero pain or no problems to participate to the highest level of pain or no possibility to participate in sport. Together with the satisfactory content validity, this strengthens the construct validity of the questionnaire (Streiner & Norman, 2008). The form’s psychometric characteristic was recently analyzed with satisfactory results, showing a Chronbach’s alpha of 0.91 (Clarsen et al., 2013b). This method provides information regarding the prevalence of overuse injuries, not their incidence. It provides no indication of whether an injury is new or old; however, such questions can be included in future studies. It is therefore problematic to obtain supporting evidence regarding, e.g., risk factors for injury, an important further step when performing injury registration studies. A strength of the method used, however, is that it supplies important information on whether the problems increase or decrease with respect to, among other things, training dosage or intensity. In the present study, no prior power analysis was conducted, as the purpose was not to make generalizable conclusions from the register data: this pretest was performed to determine whether the questionnaire actually captures overuse injuries in this population. The present
methodological study shows that overuse injuries were successfully recorded among the athletes. We found that several athletes participated in sports despite pain and decreased function. However, it can be hypothesized that the prevalence of overuse injuries in the present population would have appeared even higher with an additional set of questions – for the hip for the orienteerers and for the hand/fingers for the handball players. The conclusions from injury registration studies may be affected by the definition of overuse injuries used (van Mechelen et al., 1992). The definition varies in the literature, and a standardized definition is missing. There are ongoing discussions, but no consensus, regarding whether overuse injuries should be judged by body function or consequences (Bahr, 2009). Further discussion and decisions are needed in order to arrive at a clear consensus and definition of overuse injuries. The model used for translation is well established (Brislin, 1970; Werner & Campbell, 1970). Other methods are available for translating questionnaires (Beaton et al., 2000); however, we chose the backtranslation method for the present study as the Norwegian and Swedish languages and cultures are quite similar. We therefore do not consider the translation method a limitation in the present study. Perspective In conclusion, the web-based questionnaire was easy to use and appeared to capture the construct of overuse injuries. Its use is therefore recommended, in accordance with recent research, to record prevalence of overuse injuries in sport. While the main purpose was not to study the prevalence of overuse injuries, we found that several athletes trained or competed with moderate pain despite full sports participation. Studies of larger populations of athletes from these sports are therefore highly desirable. Key words: Content validity, orienteering, sports, tennis, web-based technique.
References Andersen CA, Clarsen B, Johansen TV, Engebretsen L. High prevalence of overuse injury among iron-distance triathletes. Br J Sports Med 2013: 47: 857–861. doi:10.1136/bjsports -2013-092397. Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J Sports Med 2009: 43: 966–972. Bahr R, Holme I. Risk factors for sports injuries—a methodological approach. Br J Sports Med 2003: 37: 384–392.
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000: 25: 3186–3191. Brislin R. Back-translation for cross-cultural research. J Cross Cult Psychol 1970: 1: 185–216. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology. Br J Sports Med 2013a: 47: 495–502.
Clarsen B, Rønsen O, Myklebust G, Flørenes TW, Bahr R. The Oslo Sports Trauma Research Center Questionnaire on Health Problems: a new approach to prospective monitoring of illness and injury in elite athletes. Br J Sports Med 2013b: doi :10.1136/bjsports-2012 -092087. Dahmström K. Konstruktion av ett frågeformulär. In: Dahmström K, ed. Från datainsamling till rapport: att göra en statistisk undersökning. Lund: Studentlitteratur, 2011: 147–172.
5
Ekman et al. Ekstrand J, Roos H, Tropp H. The incidence of ankle sprains in orienteering. Sci J Orienteering 1990: 6: 3–9. Fuller CW, Ekstrand J, Junge A, Andersen TE, Bahr R, Dvorak J Hägglund M, McCrory P, Meeuwisse WH. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Br J Sports Med 2006: 40: 193–201. Hjelm N, Werner S, Renstrom P. Injury profile in junior tennis players: a prospective two year study. Knee Surg Sports Traumatol Arthrosc 2010: 18: 845–850. Jonasson P, Halldin K, Karlsson J, Thoreson O, Hvannberg J, Swärd L, Baranto A. Prevalence of joint-related pain in the extremities and spine in five groups of top athletes. Knee Surg Sports Traum Arthrosc 2011: 19: 1540–1546. Junge A, Langevoort G, Pipe A, Peytavin A, Wong F, Mountjoy M, Beltrami G, Terrell R, Holzgraefe M, Charles R, Dvorak J. Injuries in team sport tournaments during the 2004 Olympic Games. Am J Sports Med 2006: 34: 565–576.
6
Linde F. Injuries in orienteering. Br J Sports Med 1986: 20: 125–127. Ljungqvist A, Jenoure PJ, Engebretsen L, Alonso JM, Bahr R, Clough AF, de Bondt G, Dvorak J, Maloley R, Matheson G, Meeuwisse W, Meijboom EJ, Mountjoy M, Pelliccia A, Schwellnus M, Sprumont D, Schamasch P, Gauthier JB, Dubi C. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes. Clin J Sport Med 2009: 19: 347–365. Pluim BM, Staal JB, Windler GE, Jayanthi N. Tennis injuries: occurrence, aetiology, and prevention. Br J Sports Med 2006: 40: 415–423. Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric and adult athletes. Prim Care 2005: 32: 133–161. Streiner D, Norman G. Methods of administration. In: Streiner D, ed. Health measurement scales: a practical guide to their development and use. Oxford: Oxford University Press, 2008: 331–364. Sutker A, Barber A, Jackson D, Pagliano J. Iliotibial band syndrome in
distance runners. Sports Med 1985: 2: 447–451. Van der Hoeven H, Kibler WB. Shoulder injuries in tennis players. Br J Sports Med 2006: 40: 435–440. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992: 14: 82–99. Werner O, Campbell DT. Translating, wording through interpreters, and the problem of decentering. In: Naroll R, Cohen R, eds. A handbook of method in cultural anthropology. New York: American Museum of Natural History, National History Press, 1970: 974–989.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: File S1. The Swedish version of a questionnaire for registration of overuse injuries.
