CULTURAL adaptation and validation of the Indonesian version of the Roland-Morris disability questionnaire: A psychometric analysis

Abstract

Background

Epidemiological evidence underscores low back pain (LBP) as a prevalent and consequential musculoskeletal disorder, posing a significant public health challenge. Patient-reported outcome measures (PROMs) play a crucial role in the diagnostic process for LBP, with the Roland-Morris Disability Questionnaire (RMDQ) being a commonly utilized tool in evaluating LBP.

Objective

This cross-sectional study aimed to cross-culturally adapt and validate the Indonesian version of the 24-item-RMDQ among nonspecific LBP (NSLBP) patients.

Methods

The RMDQ scales underwent forward-backwards translation, readability, and content validity assessments with NSLBP patients (n = 137), with a mean age of 38.6 ± 11.8 years (59% female). Psychometric testing included assessments of internal consistency and 1-week test-retest reliability, convergent validity with pain numeric rating scale (PNRS), and the Physical Component Summary (PCS) and Mental Component Summary (MCS) of quality of life (Short Form 12). The construct validity using confirmatory factor analyses (CFA).

Results

The findings of this study indicated a good internal consistency (Cronbach α = 0.80) of the translated instrument. Moderate to good repeatability estimates of all RMDQ items were demonstrated with the total ICC of the total RMDQ score of 0.90 [95%CI (0.85–0.94)]. The instrument correlations with PNRS, PCS, and MCS were 0.54, 0.60, and 0.23, respectively. The goodness-of-fit test further affirmed an acceptable fit of the data, although low factor loadings were found in several RMDQ items.

Conclusion

Although the factor structure of the RMDQ scale warrants further investigation, the overall findings support its suitability for clinical application in Indonesian NSLBP patients.

Keywords

Low back pain psychometric reliability translation validity

1. Introduction

Low back pain (LBP) is a significant global public health concern that affects the quality of life and work absenteeism of individuals across all age groups [1]. While healthcare utilisation for addressing LBP shows regional variations, globally, LBP is one of the most prominent causes of primary care visits and has a higher impact on the workforce and finances [2], thus, imposes substantial disability and financial burdens [3]. As a leading cause of disability globally [4, 5], LBP also ranks fourth in disability-adjusted life years (DALYs), with over half a billion people worldwide affected by this condition [6]. The burden of LBP is projected to increase, particularly in low-income and middle-income countries, including Indonesia. Recent studies in Indonesia indicate a 12-month prevalence of 44% among middle-aged adults [7], while the estimated overall prevalence is between 7.6% and 37% [8]. The exact prevalence of LBP in Indonesia, however, remains uncertain, partly due to diagnosis limitations in clinical settings.

The LBP diagnosis often uses Patient Reported Outcome Measures (PROMs), with the Roland-Morris Disability Questionnaire (RMDQ) being a prevalent choice for assessing, monitoring, and evaluating LBP [9]. The RMDQ is widely used in clinical and research settings for quantifying disability, monitoring changes over time, assessing treatment effectiveness, and comparing the impact of LBP across different groups. The RMDQ comes in various versions, varying in the number of questions assessing LBP’s impact on daily functioning [10]. The 24-item version offers the most comprehensive assessment, covering a wide range of activities, allowing the most detailed examination [11]. The shorter version, such as the 15- and 16-item versions, however, provides a time-efficient alternative. Nevertheless, all versions capture diverse dimensions of disability, including personal care, lifting, walking, sitting, standing, sleeping, and social interactions. The 24-item RMDQ version, however, is currently the recommended RMDQ version.

The RMDQ is known for its ease of understanding and has been validated in various settings, including in a Hindi version [12, 13]. The Urdu version of the RMDQ has also been found to be a valid and reliable instrument for evaluating disability associated with chronic nonspecific LBP [14]. The Amharic version of the RMDQ was found to have good reliability and validity in assessing disability related to LBP in the Ethiopian population [15], as well as the Hausa [16], and Igbo [17] version in Nigerian LBP patients. Despite evidence supporting the RMDQ’s validity in assessing disability in LBP patients across various populations and cultures, it has yet to undergo cross-cultural adaptation to ensure its validity and reliability in Indonesia. This adaptation is crucial for facilitating direct comparisons with global research and improving generalizability and our understanding of LBP’s worldwide impact. Given that most LBP cases fall under nonspecific LBP (NSLBP), where the LBP cause is not definite [18], this study focuses on cross-culturally adapting and evaluating the validity and reliability of the 24-item RMDQ among individuals experiencing NSLBP in Indonesia.

2. Methods

2.1. Study design, participants, and ethical clearance

This cross-sectional study focuses on individuals in Indonesia experiencing nonspecific low back pain (NSLBP). Participants for the readability test were recruited from a health clinic, while those for psychometric analysis were recruited online through social media platforms, relying on the networks of the authors and research assistants. Inclusion criteria involved individuals with NSLBP who could understand Indonesian. Additionally, participants were questioned about symptoms related to specific LBP and provided their physician’s diagnosis, if available, to exclude specific LBP diagnoses. Those participating in the readability assessment underwent physical examinations to rule out specific causes of LBP. The study encompassed individuals with acute, sub-acute, and chronic nonspecific LBP, covering a range of symptom durations. The required sample size for assessing the instrument’s validity was determined by the ratio of cases to parameters, set at 5 : 1 for confirmatory factor analysis [19, 20]. Thus, the minimum sample required for the analysis was 120 participants. A subsample of participants who completed the initial assessment responded to the questionnaire one week later for a 1-week test and retest reliability assessment.

This study conformed with the Declaration of Helsinki. All participants provided written informed consent embedded in the online form. The procedure received approval from the Ethics Committee at the Directorate of Research and Community Service, Universitas Negeri Yogyakarta, under protocol No. T/17/UN34.9/KP.06.07/2023.

2.2. Measures

The instrument subjected to cross-cultural adaptation in this study was the RMDQ, developed by Martin Roland and Chris Morris in 1983 to assess the impact of LBP on an individual’s daily functioning [21]. Consisting of 24 items, the questionnaire explores a diverse range of activities, encompassing fundamental movements such as walking, standing, and sitting, as well as more intricate tasks like lifting and bending. Respondents provided ‘yes’ or ‘no’ responses to each item [22]. A score of 1 was allocated for every “yes” response, indicating the extent of disability experienced [23]. The scoring process involved summing up the scores across all 24 items, resulting in a total score that ranged from 0 to 24, with the higher score representing a higher disability [24].

Participants were also asked to respond to the 11-point numeric pain rating scale (NPRS) and quality of life using the Short Form (SF-12) with its component scores and subscales. The SF-12 comprises 12 items within eight subscales [25, 26]. Six items from four subscales generated a physical component summary score (PCS). These subscales assess various aspects, including general health perception (GH), physical functioning (PF), role limitation due to physical health (RP), and bodily pain (BP) [27]. A mental component summary score (MCS) was also derived from six items across four other subscales. These encompassed measurements of role limitations due to emotional problems (RE), vitality (VT), mental health (MH), and social functioning (SF). Higher scores on these subdomains indicate a higher quality of life [28].

Additional measures in this study were demographic characteristics, including age, sex and questions regarding the onset of the LBP and symptoms associated with specific LBP.

2.3. Procedures

This study adhered to a standardised instrument cross-cultural adaptation protocol, encompassing the essential steps of forward and backward translation for all five scales, transitioning from the source language (English) to the target language (Indonesian/Bahasa) [29]. The process also included readability and content validity evaluations, followed by comprehensive psychometric testing [21]. This study engaged six independent translators in both forward and backward translations. The readability study was conducted in 10 LBP patients. They were provided with paper copies of the translated scales and were required to review each item, responding to those they comprehended while identifying items with unclear wording. Adhering to established norms, in instances where less than 80% of participants understood all scale items, the translators undertook revisions until the specified criterion was met [21].

A panel of five experts, consisting of three general practitioners, a physiotherapist, and a public health specialist recruited from the researchers ‘network, independently assessed content validity for each item, considering its relevance to the local culture and clarity using a 4-point Likert scale. The item content validity index was calculated from the proportion of experts rating 3 or 4. An item was deemed acceptable if the index was 0.78 or higher. Items below this threshold underwent expert revision and were re-evaluated for readability and content validity to ensure cultural appropriateness and linguistic precision within the examined scales.

To evaluate convergent and construct validity, the translated scales were disseminated online for participants to complete independently. The minimal sample size for confirmatory factor analysis for validity testing was determined by maintaining a ratio of 5 cases to 1 parameter, as required for statistical estimation in confirmatory factor analysis [17, 18]. Therefore, a minimum of 120 participants was required for the analysis. The number of participants enlisted in this study exceeded this requirement. A subset of individuals participating in the initial assessment were contacted later for a second evaluation, completing the scales once more to assess the reliability through a 1-week test and retest.

2.4. Statistical analysis for psychometric testing

To evaluate the internal consistency reliability, Cronbach’s α was calculated. A commonly adopted criterion for acceptable reliability was set at alpha ≥0.70, and a corrected item-total correlation exceeding 0.30 was considered indicative of effective discrimination for an item [22]. To assess the 1-week test-retest reliability, Cohen Kappa was measured for each item while intraclass correlation coefficients (ICCs) were computed for the total score. The ICC and Cohen Kappa values below 0.50 were deemed poor, those in the range of 0.50–0.75 were considered moderate, scores between 0.75–0.90 were regarded as good, and values exceeding 0.90 were classified as excellent [23]. For convergent validity assessment, Spearman correlations were computed between RMQD and an 11-point numeric pain rating scale (PNRS) and quality of life using the Short Form (SF-12) with its component scores and subscales.

In the final step, a confirmatory factor analysis (CFA) was carried out to assess the construct validity of the Indonesian version of RMDQ. The model fit of the data was appraised based on the theoretical structure proposed by the original developers of each scale, utilising the maximum likelihood method. Several goodness-of-fit indices were considered for determining acceptable model fit. The first criterion involved the χ2/degree of freedom (df) ratio, where a value below 3 signified a good fit. The second criterion was the root mean square error of approximation (RMSEA), with a value below 0.08 indicating good fit, a value ranging from 0.08 to 0.10 indicating moderate fit, and a value exceeding 0.10 indicating poor fit [24]. Additionally computed were the comparative fit index (CFI), Tucker–Lewis index (TLI), and the standardised root mean square residual (SRMR) [24]. Adequate fit between the hypothesised model and the observed data was indicated by CFI and TLI values exceeding 0.90 and SRMR values below 0.08 [24].

The statistical analysis of data was conducted with SPSS^® v29.0 (IBM, Chicago, IL, US), with the exception of the CFA analyses, which utilised STATA v14 (College Station, TX, US). Statistical significance was considered at a p-value below 0.05.

3. Results

3.1. Participant characteristics

The readability assessment involved the participation of ten NS LBP patients with a mean age of 37,2 ± 10,6 years. Additionally, 137 individuals with NSLBP, with a mean age of 38.6 ± 11.8 years (59% female), completed the online version of the Indonesian-RMDQ for the psychometric testing. Among these, 62 participants, with a mean age of 39.1 ± 12.6 years (56% female), also completed the test and retest reliability assessment a week later. Most participants across both samples reported experiencing chronic LBP, constituting 37% in the total sample and 42% in the test-retest sample. Notably, no differences in characteristics were identified between participants who completed the test and retest reliability assessment and those who did not.

3.2. Translation, readability, and content validity assessments

No modification beyond linguistic translation by panel translators was made. All the translated scales fulfilled the criterion of at least 80% of participants comprehending each item. All experts assigned ratings of 3 or 4 for equivalency and relevance to all items, affirming their acceptable content validity. As a result, no additional modifications were deemed necessary.

3.3. Psychometric testing

As shown in Table 1, the internal consistency of the Indonesian-translated version of RMDQ was good (Cronbach’s α = 0.80). The item-total correlation of several items were below 0.3. However, all items were retained to achieve comparability with the original item. The repeatability coefficients of each item were moderate to good (ICCs = 0.90 [[95%CI (0.85–0.94)).

Table 1.

Correlation matrix of the Rolland-Morris disability questionnaire with numeric pain rating scale and quality of life.

Items	% of Yes response	Corrected item-item correlation	Kappa or ICC
1. I stay at home most of the time because of my back	95 (69.3)	0.38	0.90[95%CI (0.77–1.00)]
2. I change position frequently to try and get my back comfortable	83 (60.6)	0.52	0.76[95%CI (0.59–0.92)]
3. I walk more slowly than usual because of my back	61 (44.5)	0.33	0.81[95%CI (0.66–0.95)]
4. Because of my back, I am not doing any of the jobs that I usually do around the house	73 (53.3)	0.25	0.81[95%CI (0.63–0.97)]
5. Because of my back, I use a handrail to get upstairs	90 (65.7)	0.47	0.80[95%CI (0.63–0.97)]
6. Because of my back, I lie down to rest more often	77 (56.2)	0.20	0.93[95%CI (0.85–1.02)]
7. Because of my back, I have to hold onto something to get out of an easy chair	92 (67.2)	0.51	0.79[95%CI (0.62–0.94)]
8. Because of my back, I try to get other people to do things for me	76 (55.5)	0.45	0.87[95%CI (0.74–0.99)]
9. I get dressed more slowly than usual because of my back	81 (59.1)	0.23	0.87[95%CI (0.73–0.99)]
10. I only stand up for short periods of time because of my back	91 (66.4)	0.34	0.77[95%CI (0.59–0.94)]
11. Because of my back, I try not to bend or kneel down	95 (69.3)	0.62	0.77[95%CI (0.60–0.94)]
12. I find it difficult to get out of a chair because of my back	81 (59.1)	0.33	0.76[95%CI (0.59–0.93)]
13. My back is painful almost all the time	84 (61.3)	0.31	0.87[95%CI (0.75–0.99)]
14. I find it difficult to turn over in bed because of my back	90 (65.7)	0.26	0.84[95%CI (0.69–0.99)]
15. My appetite is not very good because of my back pain	84 (61.3)	0.31	0.85[95%CI (0.71–0.99)]
16. I have trouble putting on my socks (or stockings) because of the pain in my back	78 (56.9)	0.26	0.81[95%CI (0.66–0.95)]
17. I only walk short distances because of my back pain	96 (70.1)	0.39	0.84[95%CI (0.69–0.99)]
18. I sleep less well because of my back	85 (62.0)	0.30	0.90[95%CI (0.79–1.01)]
19. Because of my back pain, I get dressed with help from someone else*	87 (63.5)	0.28	0.82[95%CI (0.67–0.97)]
20. I sit down for most of the day because of my back	79 (57.7)	0.30	0.76[95%CI (0.59–0.93)]
21. I avoid heavy jobs around the house because of my back	77 (56.5)	0.43	0.93[95%CI (0.84–1.03)]
22. Because of my back pain, I am more irritable and bad tempered with people than usual	62 (59.9)	0.54	0.86[95%CI (0.73–0.99)]
23. Because of my back, I go upstairs more slowly than usual	68 (49.6)	0.34	0.97[95%CI (0.90–1.03)]
24. I stay in bed most of the time because of my back	81 (59.1)	0.48	0.93[95%CI (0.83–1.03)]
Total		0.80	0.90[95%CI (0.85–0.94)]

3.4. Convergent validity test

Figure 1 shows the Spearman correlation test between the RMDQ and PNRS was 0.54, while the RMDQ with PCS and MCS were 0.6 and 0.23, respectively. Moderate correlations were found between RMDQ and ‘bodily pain’ (r = 0.63) and ‘role physical’ (r = 0.56) subscales.

Fig. 1.

Correlation matrix of the Rolland Morris disability questionnaire with numeric pain rating scale and quality of life. Notes: RMDQ: Rolland Morris Disability Questionnaire, PNRS; Pain Numeric Rating Scale (Pain), GH: General Health, PH: Physical Health, RP: Role Physical, BP: Bodily Pain, RP: Role Physical, MH: Mental Health, V: Vitality, SF: Social Functioning, PCS: Physical Component Health, MCS: Mental Component Summary.

3.5. Construct validity test

Figure 2 further illustrates the unidimensional factor structure of the 24 RMDQ items.

Fig. 2.

Confirmatory factor analysis of the Rolland Morris disability questionnaire.

The goodness and fitness assessments of the unidimensional hypothetical factor structure of the Indonesian RMSQ revealed an RMSEA of 0.098 and a chi-square to degrees of freedom ratio (χ2/df) of 2.85. Additionally, the CFI was 0.86, the TLI was 0.90, and the SMSR was 0.081. The goodness and fitness assessments, thus, imply a moderate level of fit between the model and the observed data.

4. Discussion

This study is the first study that culturally adapts and analyses the psychometrics of the Indonesian version of the RMDQ. Findings from the readability test emphasise the clarity and accessibility of the translated version, while the content validity assessment confirms an acceptable content validity index for both instruments, affirming their linguistic integrity. Additional psychometric analyses of the translated instrument’s internal consistency, test-retest reliability, and convergent validity reveal satisfactory results. The goodness-of-fit test further affirmed an acceptable fit of the data, although low factor loadings were found in several RMDQ items. While the factor structure of the RMDQ scale warrants further investigation, the overall findings support its suitability for application in Indonesian NSLBP patients.

The comparative analysis explores studies on the cross-cultural adaptation and validation of the RMDQ across various linguistic and cultural contexts. The adapted Indonesian version of RMDQ displayed satisfactory internal consistency reliability and test and retest in this current study, as evidenced by a Cronbach’s α of 0.80 and an ICC of 0.90. Similar findings were reported in a study adapting the RMDQ in the Hindi population, demonstrating excellent psychometric indices with Cronbach’s α of 0.99 and ICC of 0.98 [11]. Significant correlations were also observed between the Hindi RMDQ scores and pain numeric rating scale (PNRS) ratings, indicative of its convergent validity within the Indian cultural setting [11]. Similarly, the Urdu adaptation exhibited commendable psychometric properties [25, 26], including strong internal consistency (Cronbach’s α = 0.860) and test-retest reliability (ICC = 0.846) [26]. These findings were further substantiated by significant associations with pain measures, affirming their reliability and validity within the Pakistani NSLBP population.

The Nigerian adaptations, encompassing both Igbo [15] and Hausa [14] versions, also showcased excellent psychometric properties, rendering them valuable tools for assessing disability in Nigerian NSLBP patients. The Igbo adaptation demonstrated excellent internal consistency (Cronbach’s α = 0.91) and test-retest reliability (ICC = 0.84) [15], while the Hausa version exhibited adequate internal consistency (Cronbach’s α = 0.70) and test-retest reliability (ICC = 0.79) [14]. Moreover, significant correlations with pain measures underscored the convergent validity of both adaptations, further supporting their applicability in assessing disability within the Nigerian cultural setting. Lastly, the Ethiopian adaptation of the RMDQ in Amharic also demonstrated good internal consistency (Cronbach’s α = 0.88) and excellent test-retest reliability (ICC = 0.91) [13]. Furthermore, significant correlations with quality of life measures underscored its convergent validity, endorsing its efficacy in capturing disability experiences within Ethiopian NSLBP patients [13].

While each adaptation of the RMDQ exhibited commendable psychometric properties reflective of its reliability and validity within specific cultural and linguistic contexts, nuanced discrepancies in factorial structure and levels of reliability underscore the necessity for tailored adaptations and validation processes. The findings collectively underscore the imperative for meticulous cross-cultural adaptation to ensure the validity and reliability of the RMDQ across diverse populations with NSLBP. Further research to refine the utility of the RMDQ as a comprehensive tool for assessing disability and informing clinical interventions in the global population, particularly in Indonesia, is warranted.

Furthermore, factor analyses to confirm the underlying structure of the Indonesian RMDQ are recommended, as the CFA in this study revealed discrepancies in item loadings. This is also crucial because there is a lack of studies incorporating factor analysis. Additionally, most studies have relied on the exploratory factor analysis (EFA) [13, 25], rather than CFA, while the EFA is not designed to confirm whether the hypothetical unidimensional structural factor in the RMDQ is retained in the translated version. Moreover, the RMDQ cross-cultural adaptation studies that demonstrated the translation versions’ uni-dimensionality were reported in the shorter RMDQ versions, such as the 15-item Brazilian RMDQ for general pain [27] and a 15 item Brazilian RMDQ for NSLBP [27]. Moreover, the bidimensional factor structure was also reported in the 16-item Brazilian RMDQ [27] and the bidimensional 16-item English RMDQ in older adults NSLBP [12]. The findings from these studies also suggest the necessity for further exploration of the factor structure in the 24-item Indonesian RMDQ. In line with the approaches employed in these studies, future research should consider exploring the selection of items from the original 24-item Indonesian RMDQ version to create alternative shorter RMDQ versions.

This research supports previous findings in various cultural contexts, emphasising the importance of linguistic and cultural adjustments to clarify translated assessment tools and ensure that the original RMDQ’s psychometric properties are retained in the translated version. Notably, the study rigorously evaluates RMDQ’s suitability for assessing disabilities among the NSLBP in the Indonesian population, contributing valuable insights for clinical practice. However, the study has several limitations that should be acknowledged. Firstly, the exclusive focus on NSLBP may limit the generalizability of its findings to other musculoskeletal disorders. Thus, caution is advised when applying these findings to different clinical contexts or populations. Secondly, this study’s cross-sectional design may overlook longitudinal changes in patients’ conditions, potentially impacting the assessment of the measures’ responsiveness over time. Therefore, exploring the RMDQ responsiveness to changing health conditions is recommended. Thirdly, although the ratio of participants to number of items/parameters in this study was 5 : 1, which was an acceptable sample size for CFA analysis, as suggested by Kline [28], the ratio was below the sample size for CFA of at least 200 participants that is recommended by Myers, Ahn [29]. Expanding the sample, including various age groups, and incorporating patient perspectives through qualitative methods may offer valuable insights for improving the cross-cultural adaptation of the instruments.

5. Conclusion

The Indonesian RMDQ translation demonstrated acceptable content validity and was readable for NSLBP patients. Further psychometric testing revealed good internal consistency and test-retest reliability. The instrument also demonstrated convergent validity with pain and quality of life measures. However, while the construct validity showed an acceptable fit, some RMDQ items had low factor loadings, indicating a need for further exploration of the underlying factor structure and potential selective item retentions for alternative shorter RMDQ versions. Nevertheless, the overall findings support the suitability of the Indonesian version of the RMDQ for clinical use among NSLBP patients in Indonesia. This adaptation offers a valuable tool for assessing disability and functioning in Indonesian NSLBP patients. It also has the potential to contribute to global health initiatives and cross-cultural disability research in diverse populations.

Footnotes

Author contributions

NIA, RY, JK, and HH conceived and planned the study. NIA, JK, and HH administered the survey. NIA, RY, and HH performed the statistical analysis and interpreted the data. NIA and JK drafted the manuscript. All authors reviewed and approved the final version of the manuscript.

Acknowledgments

This study was funded by the Universitas Negeri Yogyakarta Research Assignment Grant Number 01-08/UN.34/SPK/KU/2023.

Conflict of interest

No conflict of interest is declared.

References

Franchini

Salvatori

Denoth

Molinaro

Pieroni

. Participation in low back pain management: it is time for the to-be scenarios in digital public health. Int J Environ Res Public Health 2022;19:7805. doi:10.3390/ijerph19137805.

March

Zheng

Huang

Wang

Zhao

, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med 2020;8:299. doi:10.21037/atm.2020.02.175.

Chen

Lin

Tao

Cao

, et al. Global, regional and national burden of low back pain 1990-2019: A systematic analysis of the Global Burden of Disease study 2019. J Orthop Translat 2022;32:49–58. doi:10.1016/j.jot.2021.07.005.

Ferreira

de Luca

Haile

Steinmetz

Culbreth

Cross

, et al. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2023;5:e316–e29. doi:10.1016/S2665-9913(23)00098-X.

Hurwitz

Randhawa

Cote

Haldeman

. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. EuR Spine J 2018;27:796–801. doi:10.1007/s00586-017-5432-9.

Makkiyah

Sinaga

Khairunnisa

. A Study from a Highly Populated Country: Risk Factors Associated with Lower Back Pain in Middle-Aged Adults. J Korean Neurosurg Soc 2023;66:190–8. doi:10.3340/jkns.2021.0278.

Novy

Fonda

Suwadi

. Cases, Prevalence and Treatment of Low Back Pain at Bandung Pain Rehab. IndoJPMR. 2023;12:52–60.

Roland

Morris

. A study of the natural history of low-back pain. Part II: development of guidelines for trials of treatment in primary care. Spine (Phila Pa 1976) 1983;8:145–50. doi:10.1097/00007632-198303000-00005.

Yamato

Maher

Saragiotto

Catley

McAuley

. The Roland-Morris Disability Questionnaire: one or more dimensions? EuR Spine J 2017;26:301–8. doi:10.1007/s00586-016-4890-9.

10.

Frota

Fidelis-de-Paula-Gomes

Pontes-Silva

Pinheiro

de Jesus

SFC

Apahaza

GHS

, et al. 15-item Roland-Morris Disability Questionnaire (RMDQ-15): structural and criterion validity on patients with chronic low back pain. BMC Musculoskelet Disord 2022;23:978. doi:10.1186/s12891-022-05953-y.

11.

Mohan

Sharma

Ghai

Kumar

Makkar

Jain

. Cross-cultural Adaptation and Validation of Hindi Version of Roland Morris Disability Questionnaire for Chronic Low Back Pain in Indian Population. Spine (Phila Pa 1976) 2023;48:364–70. doi:10.1097/BRS.0000000000004472.

12.

Takara

Alamino Pereira de Viveiro

Moura

Marques Pasqual

Pompeu

. Roland-Morris disability questionnaire is bidimensional and has 16 items when applied to community-dwelling older adults with low back pain. Disabil Rehabil 2023;45:2526–32. doi:10.1080/09638288.2022.2096127.

13.

Chala

Donnelly

Wondie

Ghahari

Miller

. Cross-cultural adaptation and validation of the Amharic version of Roland Morris Disability Questionnaire in people with low back pain in Ethiopia. Disabil Rehabil 2022;44:5638–48. doi:10.1080/09638288.2021.1939798.

14.

Raheem

Ibrahim

Ganiyu

Faruk

Akindele

. Translation, Cross-cultural Adaptation and Psychometric Evaluation of the Hausa Roland-Morris Disability Questionnaire in Mixed Rural and Urban Nigerian Populations with Low Back Pain. Spine (Phila Pa 1976) 2021;46:E639–47. doi:10.1097/BRS.0000000000003867.

15.

Igwesi-Chidobe

Obiekwe

Sorinola

Godfrey

. Assessing self-reported disability in a low-literate population with chronic low back pain: cross-cultural adaptation and psychometric testing of Igbo Roland Morris disability questionnaire. Disabil Rehabil 2019;41:948–57. doi: 10.1080/09638288.2017.1416185.

16.

Oliveira

Maher

Pinto

Traeger

Lin

Chenot

, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. EuR Spine J 2018;27:2791–803. doi:10.1007/s00586-018-5673-2.

17.

Bentler

Chou

C-P

. Practical issues in structural modeling. Sociological Methods & Research 1987;16:78–117.

18.

Bentler

Yuan

K-H

. Structural equation modeling with small samples: Test statistics. Multivariate Behavioral Research 1999;34:181–97.

19.

Ware

Keller

Kosinski

. SF-12: How to score the SF-12 physical and mental health summary scales: Health Institute, New England Medical Center; 1995 [Available from: https://www.researchgate.net/publication/291994160_How_to_score_SF-12_items

20.

Ware

Jr Kosinski

Keller

. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical care 1996:220–33. doi: 10.1097/00005650-199603000-00003.

21.

Sousa

Rojjanasrirat

. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract 2011;17:268–74. doi:10.1111/j.1365-2753.2010.01434.x.

22.

Gliem

. Calculating, interpreting, and reporting Cronbach’s alpha reliability coefficient for Likert-type scales: Midwest Research-to-Practice Conference in Adult, Continuing, and Community Education; 2003.

23.

Koo

. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. Journal of Chiropractic Medicine 2016;15:155–63.

24.

Bentler

. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal 1999;6:1–55.

25.

Shabbir

Imran

Kamran

Wassi

Amin

Balqees

, et al. Linguistic Reliability & Validity of Urdu Version of Roland-Morris Disability Questionnaire in Patients with Chronic Non-Specific Low Back Pain: Roland-Morris Disability Questionnaire in Patients with Chronic Non-Specific Low Back Pain. Pak J Med Sci 2022;79–84. doi: 10.54393/pbmj.v5i7.627.

26.

Sohail

Ahmad

Arslan

Munawar

Amjad

Asjad

. Translation, Cultural Adaptation and Validation of the Urdu Version of Ronald Morris Low Back Pain and Disability Questionnaire in Pakistani Population. 2022. doi:10.21203/rs.3.rs-1333642/v1.

27.

da Silva Júnior

Dibai-Filho

Pinheiro

CAB

Fidelis-de-Paula-Gomes

Pinheiro

Girasol

, et al. 15-item Roland-Morris disability questionnaire for general pain (RMDQ-g): Structural validity and criterion validity on Brazilian patients with chronic pain. Musculoskelet Sci Pract 2023;66:102823. doi:10.1016/j.msks2023.102823.

28.

Kline

. Principles and practice of structural equation modeling: Guilford publications; 2015. 427p.

29.

Myers

Ahn

Jin

. Sample size and power estimates for a confirmatory factor analytic model in exercise and sport: A Monte Carlo approach. Research Quarterly for Exercise and Sport 2011;82:412–23.