Brazilian Journal of Medical and Biological Research (2001) 34: 203-210 203

Brazil Roland-Morris questionnaire

ISSN 0100-879X

Translation, adaptation and validation

of the Roland-Morris questionnaire -
Brazil Roland-Morris

L. Nusbaum, J. Natour, Disciplina de Reumatologia, Escola Paulista de Medicina,

M.B. Ferraz and J. Goldenberg Universidade Federal de São Paulo, São Paulo, SP, Brasil

Abstract

Correspondence The purpose of the present study was to translate the Roland-Morris Key words
J. Natour (RM) questionnaire into Brazilian-Portuguese and adapt and validate · Low back pain
Disciplina de Reumatologia it. First 3 English teachers independently translated the original ques- · Disability
EPM, UNIFESP Roland-Morris questionnaire
tionnaire into Brazilian-Portuguese and a consensus version was ·
Rua Botucatu, 740 Spine
04023-900 São Paulo, SP
generated. Later, 3 other translators, blind to the original question- ·

Brasil naire, performed a back translation. This version was then compared
Fax: +55-11-5576-4239 with the original English questionnaire. Discrepancies were discussed
E-mail: [email protected] and solved by a panel of 3 rheumatologists and the final Brazilian
version was established (Brazil-RM). This version was then pretested
Publication supported by FAPESP. on 30 chronic low back pain patients consecutively selected from the
spine disorders outpatient clinic. In addition to the traditional clinical
outcome measures, the Brazil-RM, a 6-point pain scale (from no pain
Received May 24, 2000
to unbearable pain), and its numerical pain rating scale (PS) (0 to 5)
Accepted December 12, 2000 and a visual analog scale (VAS) (0 to 10) were administered twice by
one interviewer (1 week apart) and once by one independent inter-
viewer. Spearman’s correlation coefficient (SCC) and intraclass cor-
relation coefficient (ICC) were computed to assess test-retest and
interobserver reliability. Cross-sectional construct validity was evalu-
ated using the SCC. In the pretesting session, all questions were well
understood by the patients. The mean time of questionnaire adminis-
tration was 4 min and 53 s. The SCC and ICC were 0.88 (P<0.01) and
0.94, respectively, for the test-retest reliability and 0.86 (P<0.01) and
0.95, respectively, for interobserver reliability. The correlation coeffi-
cient was 0.80 (P<0.01) between the PS and Brazil-RM score and 0.79
(P<0.01) between the VAS and Brazil-RM score. We conclude that
the Brazil-RM was successfully translated and adapted for application
to Brazilian patients, with satisfactory reliability and cross-sectional
construct validity.

Introduction physical disability, which may be either tem-

porary or permanent.
The incidence of low back pain and its Several clinical parameters have been de-
socioeconomic implications have led to the veloped in order to evaluate different dis-
search for improved methods of diagnosis eases and their varied consequences. In 1983,
and treatment and especially assessment of Roland and Morris (1) selected 24 state-

Braz J Med Biol Res 34(2) 2001

204 L. Nusbaum et al.

ments from the complete (136 questions) Cultural equivalence

Sickness Impact Profile (SIP) (2) according
to their ability to evaluate disability as a Version V1 was administered by an in-
result of low back pain, in addition to the terviewer to 30 patients admitted at the Spine
phrase “because of my back”, thus develop- Disorders Outpatient Clinic (Division of
ing and validating a specific questionnaire Rheumatology, Federal University of São
for patients suffering from low back pain. Paulo, São Paulo, SP, Brazil). In this group
The questionnaire is quick and easy to ad- the female/male ratio was 27/3, mean age
minister, takes five minutes on average, and was 54.3 years, 10 patients were totally illit-
can be readily scored. This questionnaire erate and 7 patients had not completed el-
proved to be valid when Deyo and Centor (3) ementary school. All of these patients had
compared it to the complete SIP in 1986. Its been suffering from low back pain for at
quick and easy handling, besides its wide least 3 months, none of them had deficient
use in different studies carried out world- neurological signs or any other disability,
wide, have convinced us of the need to de- and none was seeking monetary compensa-
velop a version to be used in Brazil. tion. All patients agreed to participate in the
study. The main purpose of this study phase
Material and Methods was to assess the general comprehension of
the questions.
Translation The only change in relation to the origi-
nal was the format of the questionnaire. The
The recommendations made by Guillemin original English version was designed as
et al. (4,5) were followed in order to estab- self-applicable, whereas it was decided that
lish the cultural equivalence of the original the best option for the Brazilian-Portuguese
English version of the Roland-Morris (RM) version would be reading the questionnaire
questionnaire (1). out loud to the patient during a personal
Three teachers of the English language interview due to the rate of illiteracy among
(all native English speakers) who worked our patients. Thus, the phrase “when you
independently from one another initially read these statements” was changed to “when
translated the questionnaire. This resulted in you listen to these statements”, followed by
three different versions, which were later the instruction to answer yes or no.
compared to produce the final consensual The statements could be understood and
version in the Brazilian-Portuguese language answered by at least 80% of the patients,
(V1). This version was then given to three thus proving to be easy to understand and
other translators, all fluent in English, who culturally appropriate. The time required for
did not know of the existence of the original the application of the questionnaire was
questionnaire, and were asked to translate measured in minutes and seconds with a
V1 back into English. These three new ver- digital chronometer.
sions were compared to each other and used
to construct a consensual English version Reliability and convergent validity
from the translation of the Brazilian ques-
tionnaire (back translation - V2). This new Once the cultural equivalence had been
English version (V2) when compared to the established, the questionnaire was adminis-
original English version proved to be gram- tered by the interviewer to a new group of 30
matically and semantically equivalent, thus patients at the same outpatient clinic on three
allowing V1 to be accepted as the final ver- occasions. This new group also had chronic
sion in the Brazilian-Portuguese language. low back pain. There were 26 female and 4

Braz J Med Biol Res 34(2) 2001

Brazil Roland-Morris questionnaire 205

male patients, with a mean age of 51.4 years. numerical values.

Eleven patients were totally illiterate. On the Table 1 shows the clinical and demo-
first occasion (visit 1: baseline visit), in addi- graphic data resulting from the survey con-
tion to the RM questionnaire which gener- ducted with the first patient group during the
ated score 1 (0 to 24), the patient was intro- translation and cultural equivalence phase.
duced to a quantitative scale for pain - the This group was predominantly composed of
visual analog scale (VAS 1) ranging from 0 females, with an average score of 13.9 for
to 10, and a qualitative scale for pain - pain the questionnaire. Table 1 also shows the
scale (PS 1), ranging from no pain at all to clinical and demographic data obtained from
the pain is almost unbearable, also used for the second patient group during the reliabil-
validation purposes by the authors of the ity and validation phase. In this second group,
original questionnaire. The PS 1 scale was the average score was 14.5 for the question-
later assigned numerical values: 0 for no naire and the group was also predominantly
pain, and 5 for almost unbearable pain (Ap- composed of females, the data being ob-
pendix) for calculation purposes. The pa- tained by the first and second interviewers
tients were also requested to bend forward, during the patient’s return visit 7 days later.
without bending their knees while in the During this phase, even though no treatment
upright position, and the distance between was suggested, the average score was 14.6
their fingertips and the floor was measured for the first interviewer and 14.3 for the
in centimeters (index 1). The patient was second. Tables 2 and 3 show the numerical
then instructed to return 7 days after the first variables obtained by Spearman’s correla-
interview in order to be re-assessed by the tion coefficient. We obtained r = 0.88 for
same interviewer (visit 2: 1-week visit with intra-observer reliability and r = 0.86 for
the same interviewer) originating score 2, interobserver reliability. The following cor-
VAS 2, PS 2, index 2, and by a second relations were also calculated: 0.54 between
interviewer (visit 3: 1-week visit with a dif- score 1 and VAS 1, 0.79 between score 2 and
ferent interviewer), originating score 3. We VAS 2, 0.65 between score 3 and VAS 2,
decided to use this time interval because we 0.76 between score 1 and PS 1, 0.76 between
assumed that patient clinical status will not score 2 and PS 2, and 0.60 between score 3
change over a period of 7 days in the absence and PS 2. All of these correlations were
of a specific intervention. statistically significant (P<0.01). Only the
Descriptive statistics were used to estab-
lish the demographic and clinical character- Table 1 - Demographic and clinical data of patients included in the translation and
istics of the patients assessed. Spearman’s validation process of the Roland-Morris (RM) questionnaire.
correlation coefficient was used to evaluate
Finger to floor: Fingertip to floor distance; visit 1: baseline visit; visit 2: visit scheduled
the reliability and validity of the test. Values 1 week later with the same interviewer; visit 3: visit scheduled 1 week later with a
above 0.478 were considered statistically different interviewer. VAS: Visual analog scale. *Data are reported as means ± SD for
significant (P<0.01). The intraclass correla- 30 patients per group.
tion coefficient (ICC) was also used to as-
Patient data Translation stage Visit 1 Visit 2 Visit 3
sess intra- and interobserver reliability.
Females/males 27/3 26/4 26/4 26/4
Results Average age 54.3 ± 9.47 51.4 ± 14.5 51.4 ± 14.5 51.4 ± 14.5
RM score* 13.9 ± 5.44 14.5 ± 6.79 14.6 ± 7.52 14.3 ± 7.47

Appendices 1 and 2 show the final Bra- Pain VAS 6.6 ± 2.81 6.9 ± 3.25 6.4 ± 3.34 -
Time* 4’53" ± 1’5" 4’03" ± 31" 3’51" ± 27" 3’27" ± 27"
zilian-Portuguese version and the original
Pain scale* - 2.5 ± 1.33 2.27 ± 1.36 -
English version of the RM questionnaire and
Finger to floor* - 10.21 ± 12.0 10.63 ± 12.0 -
the scale for pain with its corresponding

Braz J Med Biol Res 34(2) 2001

206 L. Nusbaum et al.

Discussion
Table 2 - Validity of the Brazilian-Portuguese version of the Roland-Morris (RM) scale:
Spearman’s correlation coefficient between measures applied for group validation at
baseline and during the 1-week visit. Lack of data concerning the characteris-
tics of the measurements most frequently
For abbreviations, see legend to Table 1.
used for the assessment of clinical param-
RM score Pain VAS Pain scale Finger to floor eters in studies with patients suffering from
low back pain has made it difficult to inter-
Visit 1
pret and evaluate therapeutical interventions,
Visit 1 RM score -
Pain VAS 0.54 -
as well as prognosis. For a more reliable
Pain scale 0.76 0.64 - overall assessment of patients suffering from
Finger to floor 0.24 0.23 0.37 - back pain, new questionnaires are being pro-
posed for the evaluation of different param-
Visit 2
eters concerning physical disability and its
Visit 2 RM score -
Pain VAS 0.79 -
consequences on quality of life.
Pain scale 0.76 0.94 - In 1983, Roland and Morris (1) pointed
Finger to floor 0.10 -0.14 0.26 - out the conflicting results obtained from clini-
cal trials evaluating the efficacy of therapeu-
tic measures when identical procedures were
Table 3 - Reliability of the Brazilian-Portuguese version of the Roland-Morris (RM) scale: used. Among the difficulties encountered in
intra- and interobserver Spearman’s correlation coefficient and intraclass correlation the assessment of therapeutic intervention
coefficients between measures applied for group validation.
on low back pain there is the possibility of
For abbreviations, see legend to Table 1. spontaneous improvement of pain, the diffi-
culty in forming homogeneous groups of
Visit 2 Visit 3 patients, in making an accurate diagnosis
RM score Pain VAS Pain scale Finger to RM score based on the reported symptoms and the
floor traditional factors of evolution, such as pres-
ence or absence of physical signs and symp-
Spearman correlation
Visit 1 RM score 0.88 0.68
toms, healing or death. In their original pa-
Pain VAS 0.50 per the authors found a mean score of 11.4
Pain scale 0.54 and they considered scores over 14 to indi-
Finger to floor 0.90
cate significant disability. The reproducibil-
Visit 2 RM Score 0.86
ity between the two sets of scores was 0.91.
Intraclass correlation
Our choice of the RM questionnaire was
Visit 1 RM score 0.94
Pain VAS 0.63 based on its simple presentation and scoring
Pain scale 0.69 system, and its use in the various studies
Finger to floor 0.97 reported in the medical literature concerning
Visit 2 RM score 0.95
patients suffering from low back pain. Other
questionnaires such as the Oswestry one (6),
although widely used, are more difficult to
correlations referring to fingertip-floor meas- apply and take more time to complete. For a
urements and other indices were not statisti- successful transcultural translation, care
cally significant. The ICC was 0.94 for the should be taken to use terms and expressions
intra-observer score and 0.95 for interob- that make sense in the new language. Fortu-
server score in the second visit. The ICC was nately, in our study we did not need any
0.63 between VAS 1 and VAS 2, 0.69 be- adaptation because the original question-
tween PS 1 and PS 2 and 0.97 between index naire only explores day to day actions and
1 and index 2. needs, except that we changed the form of

Braz J Med Biol Res 34(2) 2001

Brazil Roland-Morris questionnaire 207

presentation of the questions. eter was 0.51. In our study this coefficient
In 1986, Deyo (7) compared the RM was 0.76.
questionnaire to the complete SIP and con- In 1986, Deyo (7) applied the RM di-
sidered the RM to be more sensitive to change rectly to the patients and compared the re-
throughout patient follow-up and to be more sults to the questions appearing in the SIP,
reliable when compared to the physical as- and the two measurements were found to be
pects of SIP. correlated. In that study, the average score
The option of altering the presentation of obtained was 10.1 while in our survey the
the questionnaire (the patients having the average score was 14.3.
questionnaire read to them instead of the In 1988, Lanier and Stockton (12) com-
questionnaire being self-applicable) was due pared short-term (work days lost) and long-
to the considerable number of illiterate pa- term (still disabled after 6 weeks of treat-
tients seen at our spine disorders unit. The ment) prognosis results in patients with acute
statements used in the Brazilian question- mechanical low back pain using the RM and
naire proved to be easy to understand since concluded that a three-point increase in ques-
no question was left unanswered by 94% of tionnaire scores implied a worse prognosis
the patients. Therefore, no modifications were for the resolution of the condition. During
necessary concerning question formulation - the first visit the mean score for the sympto-
as was the case in the studies by Deyo (8) and matic patients was 11.8 and during the sec-
Ferraz et al. (9) in 1984 and 1990, respec- ond visit, the mean score fell to 2.7 among
tively. The French version of the RM (10) the patients who had improved.
also did not require further adaptations. In Hadler et al. (13) in 1987 and Klein and
the French study the mean score of the French Eek (14) in 1990 used the RM to evaluate
version was 12.1, and the ICC between the groups of patients undergoing manipulation
two scores was 0.89, with a 7-day interval and laser therapy, respectively. In the latter
between interviews. study the RM score was also correlated with
As regards to reliability and validity of the visual analog scale, and the mean score
the RM used and other parameters of clinical was 5.4, perhaps because the patients had no
evaluation, the data obtained in the present acute exacerbation of the chronic pain.
study were compatible with the results of In 1991, Frymoyer et al. (15) published
previous studies in which the RM was used. the consensus of several authors suggesting
In 1986, Weinstein et al. (11) studied pa- the use of the RM in therapeutic trials, among
tients who had undergone chemonucleolysis other measures, such as data obtained by
and discectomy, and who were interviewed physical examination and additional exams
10 years after the event for comparison of for the evaluation of physical disability and
the RM to other parameters such as visual prognostic evolution of patients with chronic
scale for pain (scores 0 to 100), and “pain low back pain, and highlighted the need for
thermometer” ranging from “absence of pain” reliable parameters particularly in multicen-
to “almost unbearable pain”, also taken from ter studies.
the original RM, and obtained correlated In 1994, Stratford et al. (16) compared
rates when the end-point was the analysis of the RM scoring to other questionnaires like
improvement of pain and return to a normal the Oswestry and Jan Van Breener Institute
work routine. The mean score was 8.19 for ones (17), finding the latter to be more sensi-
patients who were satisfied with the treat- tive to change through time. In that study the
ment applied and 14.01 for patients who mean score was 11.8.
were not satisfied. The correlation coeffi- In conclusion, the original version of the
cient between the score and pain thermom- RM questionnaire proved to be reliable and

Braz J Med Biol Res 34(2) 2001

208 L. Nusbaum et al.

valid in studies involving patients with lum- being evaluated.

bago. The Brazilian-Portuguese language ver- The Brazil-RM is the first and so far the
sion of this questionnaire also proved to be only available specific low back pain ques-
reproducible and valid when applied to a tionnaire in Brazil, representing an impor-
universe of Brazilians suffering from low tant tool for low back pain patient evalua-
back pain. The sensitivity to change of the tion, especially in clinical studies.
Brazilian-Portuguese version is currently

References

1. Roland M & Morris R (1983). Study of 7. Deyo RA (1986). Comparative validity of predictor of outcome of acute episodes
natural history of low back pain. Part II: Sickness Impact Profile and shorter scales of low back pain. Journal of Family Prac-
development of guidelines for trials of for functional assessment in low back tice, 27: 483-487.
treatment in primary care. Spine, 8: 145- pain. Spine, 11: 951-954. 13. Hadler NM, Curts P, Gillips DB & Sinnett
150. 8. Deyo RA (1984). Pitfalls in measuring the S (1987). Benefit of spinal manipulation
2. Bergner M, Bobbitt RA, Carter WB & health status of Mexican Americans: as adjunctive therapy for acute low back
Gilson BS (1981). The Sickness Impact Comparative validity of the English and pain: stratified controlled trial. Spine, 12:
Profile: development and final revision of Spanish Sickness Impact Profile. Ameri- 703-706.
a health status measure. Medical Care, can Journal of Public Health, 74: 569-573. 14. Klein RG & Eek BJ (1990). Low energy
19: 787-805. 9. Ferraz MB, Oliveira LM, Araujo PMP, Atra laser treatment and exercise for chronic
3. Deyo RA & Centor RM (1986). Assessing E & Tugwell P (1990). Cross-cultural reli- low back pain: Double blind controlled
the responsiveness of functional scales ability of the physical ability dimension of trial. Archives of Physical Medicine and
to clinical change: analogy to diagnostic the Health Assessment Questionnaire. Rehabilitation, 71: 34-37.
test performance. Journal of Chronic Dis- Journal of Rheumatology, 17: 813-817. 15. Frymoyer JW, Nelson RM, Spangfort E &
eases, 39: 897-906. 10. Coste J, Parc JM, Leberge E, Delecoevil- Waddell G (1991). Clinical tests applicable
4. Guillemin F (1995). Measuring health sta- lerie G & Paolaggi JB (1993). Validation to the study of chronic low back disability.
tus across cultures. Rheumatology in Eu- Française d’une échelle d’incapacité fonc- Spine, 16: 681-682.
rope, 24 (Suppl 2): 102-103. tionalle pour l’évaluation des lombalgies 16. Stratford PW, Binkley J, Solomon P, Gill C
5. Guillemin F, Bombardier C & Beaton D (EIFEL). Revue du Rhumatisme. Edition & Finch E (1994). Assessing change over-
(1993). Cross-cultural adaptation of health- Française, 60: 335-341. time in patients with low back pain. Physi-
related quality of life measures: literature 11. Weinstein J, Sprattik E, Lehman T, cal Therapy, 74: 528-533.
review and proposed guidelines. Journal McNeill T & Hena W (1986). Lumbar disc 17. Lankahorst GJ, Van de Stadt RJ &
of Clinical Epidemiology, 46: 1417-1432. herniation - A comparison of the results of Voglelaar TW (1982). Objectivity and re-
6. Fairbank JCT, Couper J & Davies JB chemonucleolysis ND open discectomy peatability of measurements in low back
(1980). The Oswestry low back disability after ten years. Journal of Bone and Joint pain. Scandinavian Journal of Rehabilita-
questionnaire. Physiotherapy, 66: 271- Surgery, 68-A: 43-54. tion Medicine, 14: 21-26.
273. 12. Lanier DC & Stockton PAS (1988). Clinical

Braz J Med Biol Res 34(2) 2001

Brazil Roland-Morris questionnaire 209

Appendix 1 - Original and Brazilian-Portuguese version of the Roland-Morris questionnaire.

Instructions:

Quando suas costas doem (When your back hurts), você pode encontrar dificuldade em
fazer algumas coisas que normalmente faz (you may find it difficult to do some of the things
you normally do).
Esta lista possui algumas frases que as pessoas tem utilizado para se descreverem quando
sentem dores nas costas (This list contains some sentences that people have used to describe
themselves when they have back pain). Quando você ouvir estas frases pode notar que
algumas se destacam por descrever você hoje (When you hear them, you may find that some
stand out because they describe you today). Ao ouvir a lista pense em você hoje (As you hear
the list, think of yourself today). Quando você ouvir uma frase que descreve você hoje,
responda sim (When you hear a sentence that describes you today, answer yes). Se a frase
não descreve você, então responda não e siga para a próxima frase (If the sentence does not
describe you, than answer no and go on to the next one). Lembre-se, responda sim apenas à
frase que tiver certeza que descreve você hoje (Remember, answer yes only to the sentence
if you are sure that it describes you today).

Phrases:

1. [ ] Fico em casa a maior parte do tempo por causa de minhas costas.

I stay at home most of the time because of my back.
2. [ ] Mudo de posição freqüentemente tentando deixar minhas costas confortáveis.
I change position frequently to try and get my back comfortable.
3. [ ] Ando mais devagar que o habitual por causa de minhas costas.
I walk more slowly than usual because of my back.
4. [ ] Por causa de minhas costas eu não estou fazendo nenhum dos meus trabalhos que
geralmente faço em casa.
Because of my back I am not doing any of the jobs that I usually do around the house.
5. [ ] Por causa de minhas costas, eu uso o corrimão para subir escadas.
Because of my back, I use a handrail to get upstairs.
6. [ ] Por causa de minhas costas, eu me deito para descansar mais freqüentemente.
Because of my back, I lie down to rest more often.
7. [ ] Por causa de minhas costas, eu tenho que me apoiar em alguma coisa para me levantar
de uma cadeira normal.
Because of my back, I have to hold on to something to get out of an easy chair.
8. [ ] Por causa de minhas costas, tento conseguir com que outras pessoas façam as coisas
por mim.
Because of my back, I try to get other people to do things for me.
9. [ ] Eu me visto mais lentamente que o habitual por causa de minhas costas.
I get dressed more slowly because of my back.
10. [ ] Eu somente fico em pé por períodos curtos de tempo por causa de minhas costas.
I only stand up for short periods of time because of my back.
11. [ ] Por causa de minhas costas evito me abaixar ou me ajoelhar.
Because of my back, I try not to bend or kneel down.
12. [ ] Encontro dificuldades em me levantar de uma cadeira por causa de minhas costas.

Braz J Med Biol Res 34(2) 2001

210 L. Nusbaum et al.

I find it difficult to get out of a chair because of my back.

13. [ ] As minhas costas doem quase que o tempo todo.
My back is painful almost all the time.
14. [ ] Tenho dificuldade em me virar na cama por causa das minhas costas.
I find it difficult to turn over in bed because of my back.
15. [ ] Meu apetite não é muito bom por causa das dores em minhas costas.
My appetite is not very good because of my back pain.
16. [ ] Tenho problemas para colocar minhas meias (ou meia calça) por causa das dores em
minhas costas.
I have trouble putting on my socks (or stockings) because of the pain in my back.
17. [ ] Caminho apenas curtas distâncias por causa de minhas dores nas costas.
I only walk short distances because of my back pain.
18. [ ] Não durmo tão bem por causa de minhas costas.
I sleep less well because of my back.
19. [ ] Por causa de minhas dores nas costas, eu me visto com ajuda de outras pessoas.
Because of my back pain, I get dressed with help from someone else.
20. [ ] Fico sentado a maior parte do dia por causa de minhas costas.
I sit down for most of the day because of my back.
21. [ ] Evito trabalhos pesados em casa por causa de minhas costas.
I avoid heavy jobs around the house because of my back.
22. [ ] Por causa das dores em minhas costas, fico mais irritado e mal humorado com as
pessoas do que o habitual.
Because of my back pain, I am more irritable and bad tempered with people than
usual.
23. [ ] Por causa de minhas costas, eu subo escadas mais vagarosamente do que o habitual.
Because of my back, I go upstairs more slowly than usual.
24. [ ] Fico na cama a maior parte do tempo por causa de minhas costas.
I stay in bed most of the time because of my back.

Appendix 2 - Qualitative pain scale.

Escala de dor (pain rating scale) Numerical pain rating scale

Dor quase insuportável (the pain is almost unbearable) 5

Dor muito forte (very strong pain) 4
Dor forte (quite strong pain) 3
Dor moderada (moderate pain) 2
Dor leve (mild pain) 1
Sem dor (no pain at all) 0

Braz J Med Biol Res 34(2) 2001