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PM R XXX (2018) 1-12
6 www.pmrjournal.org 86
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8 Original Research 88
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Validity, Reliability, and Responsiveness of the Spanish Version of 91
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the OPTIMAL Instrument 93
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17 Q4 Arrate Pinto-Carral, PhD, Tania Fernández-Villa, PhD, Andrew A. Guccione, PhD, 97
18 a 98
19 Federico Montero Cuadrado, PhD, José M Cancela, PhD, Antonio José Molina, PhD 99
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24 104
25 Abstract 105
26 106
27 Background: The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a self-report instrument 107
28 108
29
developed to measure the ability to perform mobility actions. 109
30 Objective: To validate a Spanish version of the OPTIMAL instrument. 110
31 Design: Cross-cultural adaptation and validation study. 111
32 112
Setting: Primary and specialized outpatient care settings.
33 113
34 Participants: Three hundred seven patients beginning physical therapy treatment and 30 subjects from the general population. 114
35 Methods: A 2-part study was designed based on guidelines for cultural adaptation of patient-reported outcome measures. 115
36 Outcomes: Reliability was estimated by internal consistency (Cronbach a), SE of measurement, and test-retest reliability 116
37 117
38 (intraclass correlation coefficient) at 2 weeks. Confirmatory factor analysis was performed to examine structural validity. The 118
39 association with the Physical Functioning Subscale was assessed with Spearman correlation coefficients. OPTIMAL scores across 119
40 different groups were compared with Mann-Whitney U and Kruskal-Wallis tests. Effect size, standardized response mean, and 120
41 121
42
minimal detectable change were determined for responsiveness. 122
43 Results: The Spanish version of the OPTIMAL instrument showed a similar structure to the original English questionnaire. Cronbach 123
44 a was 0.95 for the difficulty and confidence scales. Intraclass correlation coefficient was 0.91 (95% CI 0.87-0.94) for the difficulty 124
45 scale and 0.90 (95% CI 0.85-0.93) for the confidence scale. The SE of measurement was 5.11 for the difficulty scale and 6.54 for the 125
46 126
47 confidence scale. The association with the Physical Functioning Subscale was strong and significant (P < .001). The 2 scales 127
48 showed significantly different scores for each of the established patient groups. The effect size was 0.61 (95% CI 0.48-0.74) for the 128
49 difficulty scale and 0.53 (95% CI 0.38-0.69) for the confidence scale. The standardized response mean was 0.97 (95% CI 0.78-1.13) 129
50 130
51
for the difficulty scale and 0.76 (95% CI 0.48-1.01) for the confidence scale. The minimal detectable change, of a possible score of 131
52 100, was 14.2 for the difficulty scale and 18.1 for the confidence scale. 132
53 Conclusion: The Spanish version of the OPTIMAL has appropriate reliability, validity, and responsiveness and it is an adequate self- 133
54 134
report instrument for the assessment of mobility actions.
55 135
56 Level of Evidence: III 136
57 137
58 138
59 139
60 140
61 141
62 Introduction mobility. Cronbach a coefficients were 0.85-0.95 in 142
63 143
64 these subscales [1]. Each scale consists of 22 items 144
65 The Outpatient Physical Therapy Improvement in related to the mobility domain within the activities and 145
66 146
67
Movement Assessment Log (OPTIMAL) is a self-report participation component of the International Classifi- 147
68 instrument developed to measure the ability to cation of Functioning, Disability and Health [2]. Two 148
69 perform mobility actions in the adult physical therapy more questions ask the patient to indicate which 3 ac- 149
70 150
71 population [1]. It consists of 2 scales, difficulty and tivities the patient would like to be able to do without 151
72 confidence, that respectively assess difficulty and con- any difficulty and to mark which of those 3 the patient 152
73 153
74 fidence in performing movements. The original study of considers the most important. These 2 questions allow 154
75 the OPTIMAL identified 3 factors in the 2 scales: trunk the formulation of patient-centered functional goals as 155
76 156
77
mobility, lower extremity mobility, and upper extremity currently demanded in rehabilitation [3-6]. 157
78 158
79 1934-1482/$ - see front matter ª 2018 by the American Academy of Physical Medicine and Rehabilitation 159
80 https://doi.org/10.1016/j.pmrj.2018.05.021 160

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 2 Spanish Version of the OPTIMAL Instrument Q1

161 The OPTIMAL instrument also incorporates 2 novel 241

162 242
163 characteristics. First, it permits patient selection of 243
164 those movements patients wish to improve, thereby of- 244
165 245
166
fering some very valuable information for setting ob- 246
167 jectives and offering patient-centered care. Few health 247
168 care measures permit such individualization, most 248
169 249
170 notably the Patient-Specific Functional Scale [7] and the 250
171 Patient-Generated Index [8]. Second, this instrument 251
172 252
173
allows for the assessment of the ability to make move- 253
174 ments from not only a physical perspective (difficulty) 254
175 but also from an affective one (confidence) [1]. The 255
176 256
177 difficulty in performing actions is a concept that is 257
178 included in many functional status questionnaires [9-15]. 258
179 259
180 However, the confidence needed to carry out these 260
181 movements is not as frequently analyzed. It is based on 261
182 262
183
the self-efficacy concept by Bandura [16] and is impor- 263
184 tant inasmuch as it acknowledges the individual’s beliefs 264
185 and sense of control in performing specific movements. 265
186 266
187 Diverse generic [17,18] and specific [19-22] question- 267
188 naires exist to measure this dimension of the patient’s 268
189 269
190
experience, but in the specific scope of physical therapy, 270
191 only the Functional Abilities Confidence Scale [23] and 271
192 the OPTIMAL instrument are available. 272
193 273
194 The OPTIMAL instrument, being a patient-reported 274
195 outcome measure, permits the collection of informa- 275
196 276
197
tion that comes directly from the patient. Patient- 277
Figure 1. Validation process of the Outpatient Physical Therapy
198 reported outcome measures, more and more 278
199
Improvement in Movement Assessment Log (OPTIMAL) instrument into 279
frequently used and valued in physical therapy and Spanish.
200 280
201 rehabilitation [6,24], include health aspects that cannot 281
202 always be collected with objective measures [25]. 282
203 283
204 Indeed, the OPTIMAL instrument was developed with the Pharmacoeconomics and Outcomes Research Task Force 284
205 intent of assessing patient movement ability according for Translation and Cultural Adaptation [31] were used: 285
206 286
to the patient’s perspective and environment [1].
207 287
208 The OPTIMAL instrument is available in English
Preparation. A thorough bibliographic search was 288
209 [1,26,27] and Italian [28] versions, with good psycho- conducted to ensure the relevance of the cultural 289
210 290
211 metric properties. Given the growing implementation of adaptation process of the OPTIMAL instrument to the 291
212 international research projects and the need to consider Spanish language, and all relevant authorizations 292
213 293
214
immigrant populations in health care assistance services were obtained. 294
215 and populations from noneEnglish-speaking countries
Forward translation. Two native Spanish speakers 295
216 [29,30], the aim of this study was to obtain a Spanish- provided 2 simultaneous and independent trans- 296
217 297
218 adapted version of the OPTIMAL instrument with appro- lations of the questionnaire to the Spanish language. 298
219 priate levels of reliability, validity, and responsiveness to
Reconciliation. The 2 translated versions were 299
220 300
221
measure the ability to perform mobility actions. compared and combined by a different native Spanish 301
222 speaker (the linguistic coordinator). 302
223
Back-translation. The unified Spanish version result- 303
224 Methods 304
225 ing from the previous step was translated into English 305
226 by a native English speaker. 306
227 A 2-part study was designed based on guidelines for 307
228
Back-translation review. The linguistic coordinator 308
cultural adaptation of patient-reported outcome and
229 compared the back-translation with the original 309
230 health-related quality-of-life measures (Figure 1) 310
231
version and identified all existing discrepancies. 311
[30-32]. Ethical approval was obtained from the corre-
232
Harmonization. A group of experts evaluated the 312
233
sponding research ethics committees. 313
different versions and selected the best option of the
234 314
235 translation for any doubtful items. 315
236 Phase 1: Adaptation Process
Cognitive debriefing. The Spanish version resulting 316
237 317
238
from harmonization was used in a pilot test in which 318
239 For adaptation into Spanish, the following 10 15 individuals who met the same inclusion criteria as 319
240 steps established by the International Society for for the psychometric phase participated. We used a 320

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321 cognitive methodology that combined the think- be converted to a percentage, which allows for com- 401
322 402
323 aloud technique with the semistructured interview. parisons across subjects [37]. Scores approaching 403
324
Review of cognitive debriefing results and finaliza- 0 represent good mobility and scores approaching 100 404
325 405
326
tion. The results of the pilot test were pooled with indicate poor mobility (greater physical disability). 406
327 those of the translation group and the main author of 407
328 the original version of the questionnaire. 408
329
Data Collection 409
330
Proofreading. With the resolution of any doubts and For data collection, a physiotherapy coordinator was 410
331 conflicts detected during the pilot test, the final appointed at each of the 7 participating centers. All 411
332 412
333
questionnaire was drafted. patients completed the data collection form on at least 413
334
Final report. 1 occasion during their first or second physical therapy 414
335 415
336 session. For test-retest reliability, in addition to the 30 416
337 individuals from the general population, a subsample of 417
338 Phase 2: Psychometric Testing 418
339
patients completed the questionnaires on 2 occasions 419
340 separated by a 1-week interval. The 2 data collections 420
341 After adapting the instrument, its measurement were conducted by the same physical therapist and 421
342 422
343
properties were analyzed according to the Consensus- under the same conditions. Subjects did not undergo 423
344 based Standards for the Selection of Health Measure- any treatment between the 2 measurements. A 424
345 ment Instruments checklist [33] and the criteria of the 425
346
different subsample of patients participated in data 426
347 Scientific Advisory Committee of the Medical Outcomes collection for responsiveness analyses. The baseline 427
348 Trust [34,35]. measurement was taken at the first or second physical 428
349 429
350 therapy session and the final measurement was taken 430
351 Subjects after 4 weeks or at discharge (if sooner than 4 weeks) 431
352 Three hundred twenty-two patients who were 432
353
from physical therapy into the clinical setting. This 433
354 beginning physical therapy at 7 public rehabilitation 4-week period was used in accordance with the results 434
355 centers in the northwestern region of Spain were invited cited in the original validation of the English version [1]. 435
356 436
357
to participate in the study. One was a specialized care 437
358 center and the others were primary care centers. As Analyses 438
359 inclusion criteria, individuals had to be outpatients 439
360 Patients’ diagnoses were classified according to 4 440
361 older than 18 years and able to read Spanish. A conve- groups: upper limb, lower limb, trunk and spine, and 441
362 nience sample of 30 individuals from the general pop- 442
363 general (cardiopulmonary, neurologic, or systemic con- 443
364 ulation was used for the analysis of test-retest reliability ditions). The scales and subscales of the OPTIMAL 444
365 and known-groups validity. questionnaire were scored up to value of 100, with 445
366 446
367 higher scores indicating greater disability, according to 447
368 Instruments the following formula [37]: 448
369 After providing written informed consent, each 449
370 450
371 participant completed some sociodemographic and ftotal score  total number of items scoredg  100 451
372 health questions, the Spanish version of the Physical 452
373 ftotal possible score  total number of items scoredg 453
374
Functioning Subscale (PF-10) [36], and the Spanish- 454
375 adapted version of the OPTIMAL instrument. 455
376 The PF-10 scale contains 10 items and offers 3 The Shapiro-Wilk test and quantiles of normal distri- 456
377 457
378 response options for each item. It is scored from 0 to bution plots were applied to examine the normality of 458
379 100, with a higher score indicating higher functionality. OPTIMAL and PF-10 scores [38]. Mean  SD and median 459
380 460
381
The Spanish version of this scale yielded an intraclass and first and third quartiles were calculated for each 461
382 correlation coefficient of 0.83 and a Cronbach a coef- measure. Missing data and those recorded as “not 462
383 ficient of 0.84 in the study by Alonso et al [36]. applicable” were scored as 0 and were weighted in 463
384 464
385 The OPTIMAL instrument, as described in the Intro- accordance with the formula used to score the OPTIMAL 465
386 duction, includes 2 scales, difficulty and confidence, instrument. 466
387 467
388 each of which contains 22 items. The response options To determine the structural validity, a confirmatory 468
389 of the items include 5-point Likert scales plus a “not factor analysis was carried out for the difficulty scale 469
390 470
391
applicable” option. The total score for each scale can and for the confidence scale. The starting model was 471
392 be calculated by summing all applicable responses, with the one proposed in the original validation of the English 472
393 a result of 22-110 when the respondent completes all version [1]. Given the ordinal nature of the data and the 473
394 474
395 items. If 1 activity included in the OPTIMAL is marked lack of normal distribution of the items, we used the 475
396 “not applicable,” then it is completely deleted from the robust weighted least squares mean and variance- 476
397 477
398
total score and the maximum possible score is lower. adjusted estimation [39]. The root mean square error 478
399 However, this total score can be expressed as a pro- of approximation (RMSEA) and its CI of 90%, comparative 479
400 portion based on the number of answered items that can fit index (CFI), and Tucker-Lewis index (TLI) were 480

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 4 Spanish Version of the OPTIMAL Instrument

481 Table 1 561

482 Spanish version of the OPTIMAL instrument* 562
483 563
484 OPTIMAL dificultad 564
485 565
486 Instrucciones: Por favor 566
487 marque con una “X” 567
488 el nivel de dificultad que tiene Puedo realizarla Puedo realizarla Puedo realizarla Puedo realizarla 568
489 para realizar cada actividad, sin ninguna con un poco de con dificultad con mucha No puedo 569
490 a dı́a de hoy. dificultad dificultad moderada dificultad realizarla No aplicable 570
491 571
492 1. Tumbarse ,1 ,2 ,3 ,4 ,5 ,9 572
493 2. Darse la vuelta tumbado ,1 ,2 ,3 ,4 ,5 ,9 573
494 3. Pasar de tumbado a sentado ,1 ,2 ,3 ,4 ,5 ,9 574
495 575
496
4. Sentarse ,1 ,2 ,3 ,4 ,5 ,9 576
497 5. Ponerse en cuclillas ,1 ,2 ,3 ,4 ,5 ,9 577
498 6. Inclinarse/doblarse ,1 ,2 ,3 ,4 ,5 ,9 578
499 7. Mantener el equilibrio ,1 ,2 ,3 ,4 ,5 ,9 579
500 8. Arrodillarse ,1 ,2 ,3 ,4 ,5 ,9 580
501 581
9. Estar de pie ,1 ,2 ,3 ,4 ,5 ,9
502 582
503 10. Caminarddistancias cortas ,1 ,2 ,3 ,4 ,5 ,9 583
504 11. Caminarddistancias largas ,1 ,2 ,3 ,4 ,5 ,9 584
505 12. Caminardal aire libre ,1 ,2 ,3 ,4 ,5 ,9 585
506 13. Subir escaleras ,1 ,2 ,3 ,4 ,5 ,9 586
507 14. Saltar a la pata coja ,1 ,2 ,3 ,4 ,5 ,9 587
508 588
15. Saltar con las dos piernas ,1 ,2 ,3 ,4 ,5 ,9
509 589
510 16. Correr ,1 ,2 ,3 ,4 ,5 ,9 590
511 17. Empujar ,1 ,2 ,3 ,4 ,5 ,9 591
512 18. Tirar (de algo hacia uno) ,1 ,2 ,3 ,4 ,5 ,9 592
513 19. Alcanzar algo (estirándose) ,1 ,2 ,3 ,4 ,5 ,9 593
514 20. Agarrar ,1 ,2 ,3 ,4 ,5 ,9 594
515 595
516
21. Levantar objetos ,1 ,2 ,3 ,4 ,5 ,9 596
517 22. Llevar objetos ,1 ,2 ,3 ,4 ,5 ,9 597
518 23. De la lista anterior, elija las tres actividades que más le gustarı́a poder de realizar sin ninguna dificultad (por ejemplo, si le gustarı́a poder 598
519 subir escaleras, arrodillarse y saltar sin ninguna dificultad, usted elegirı́a 13, 8, 14): 1.____________; 2.____________; 3.____________ 599
520 24. De las tres actividades de la lista anterior, elija la actividad principal que le gustarı́a poder realizar sin ninguna dificultad. Meta 600
521 601
principal: _____________
522 602
523 OPTIMAL confianza 603
524 604
525 Instrucciones: Por favor marque 605
526 con una “X” el nivel de confianza Confı́o plenamente No confı́o en mi 606
527 que tiene en su capacidad para en mi capacidad Muy Con confianza Con poca capacidad para 607
528 realizar cada actividad, a dı́a de hoy. para realizarla confiado moderada confianza realizarla No aplicable 608
529 609
530 1. Tumbarse ,1 ,2 ,3 ,4 ,5 ,9 610
531 2. Darse la vuelta tumbado ,1 ,2 ,3 ,4 ,5 ,9 611
532 612
3. Pasar de tumbado a sentado ,1 ,2 ,3 ,4 ,5 ,9
533 613
534 4. Sentarse ,1 ,2 ,3 ,4 ,5 ,9 614
535 5. Ponerse en cuclillas ,1 ,2 ,3 ,4 ,5 ,9 615
536 6. Inclinarse/doblarse ,1 ,2 ,3 ,4 ,5 ,9 616
537 7. Mantener el equilibrio ,1 ,2 ,3 ,4 ,5 ,9 617
538 8. Arrodillarse ,1 ,2 ,3 ,4 ,5 ,9 618
539 619
9. Estar de pie ,1 ,2 ,3 ,4 ,5 ,9
540 620
541 10. Caminarddistancias cortas ,1 ,2 ,3 ,4 ,5 ,9 621
542 11. Caminarddistancias largas ,1 ,2 ,3 ,4 ,5 ,9 622
543 12. Caminardal aire libre ,1 ,2 ,3 ,4 ,5 ,9 623
544 13. Subir escaleras ,1 ,2 ,3 ,4 ,5 ,9 624
545 14. Saltar a la pata coja ,1 ,2 ,3 ,4 ,5 ,9 625
546 626
547
15. Saltar con las dos piernas ,1 ,2 ,3 ,4 ,5 ,9 627
548 16. Correr ,1 ,2 ,3 ,4 ,5 ,9 628
549 17. Empujar ,1 ,2 ,3 ,4 ,5 ,9 629
550 18. Tirar (de algo hacia uno) ,1 ,2 ,3 ,4 ,5 ,9 630
551 19. Alcanzar algo (estirándose) ,1 ,2 ,3 ,4 ,5 ,9 631
552 632
20. Agarrar ,1 ,2 ,3 ,4 ,5 ,9
553 633
554 21. Levantar objetos ,1 ,2 ,3 ,4 ,5 ,9 634
555 22. Llevar objetos ,1 ,2 ,3 ,4 ,5 ,9 635
556 636
OPTIMAL ¼ Outpatient Physical Therapy Improvement in Movement Assessment Log.
557 637
558 * Used by permission from the American Physical Therapy Association. 638
559 639
560 640

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641 Table 2 721

642 Participant characteristics 722
643 723
644 Test-retest General 724
645 Entire sample subsample Responsiveness community 725
646 Characteristic (N ¼ 307) (n ¼ 84) subsample (n ¼ 92) (n ¼ 30) 726
647 727
648 Age (y), mean  SD 54.2  15.4 47.5  11.3 55.7  15.4 43.8  8.2 728
649 Age distribution, n (%) 729
650 18-34 33 (10.8) 9 (10.7) 8 (8.7) 2 (6.7) 730
651 731
652
35-54 120 (39.2) 51 (60.7) 35 (38.0) 24 (80.0) 732
653 55-74 119 (38.9) 23 (27.4) 37 (40.2) 4 (13.3) 733
654 75-94 34 (11.1) 1 (1.2) 12 (13.0) 0 734
655 Gender, n (%) 735
656 Men 107 (34.9) 32 (38.1) 31 (33.7) 16 (53.3) 736
657 737
Women 200 (65.1) 52 (61.9) 61 (66.3) 14 (46.7)
658 738
659 Marital status, n (%) 739
660 Single 64 (20.9) 22 (26.2) 16 (17.4) 12 (40.0) 740
661 Married 186 (60.8) 47 (56.0) 60 (65.2) 16 (53.3) 741
662 Widowed 30 (9.8) 6 (7.1) 8 (8.7) 1 (3.3) 742
663 Separated or divorced 26 (8.5) 9 (10.7) 8 (8.7) 1 (3.3) 743
664 744
Education, n (%)
665 745
666 Less than elementary 47 (15.4) 6 (7.1) 15 (16.3) 0 746
667 Elementary 138 (45.1) 33 (39.3) 37 (40.2) 6 (20.0) 747
668 High school 80 (26.1) 25 (29.8) 23 (25.0) 11 (36.7) 748
669 Postgraduate 41 (13.4) 20 (23.8) 17 (18.5) 13 (43.3) 749
670 Employment, n (%) 750
671 751
672
Working 115 (37.8) 43 (51.2) 43 (47.3) 27 (90.0) 752
673 Not working 189 (62.2) 41 (48.8) 48 (52.7) 3 (10.0) 753
674 Use of walking aid, n (%) 754
675 No 234 (76.7) 81 (96.4) 73 (80.2) 30 (100) 755
676 Yes 71 (23.3) 3 (3.6) 18 (19.8) 0 756
677 757
Chronicity, n (%)
678 758
679 No 149 (49.0) 53 (63.1) 47 (51.7) 27 (90.0) 759
680 Yes 155 (51.0) 31 (36.9) 44 (48.3) 3 (10.0) 760
681 Mobility problems in past week, n (%) 761
682 None 49 (16.1) 37 (44.0) 11 (12.1) 23 (76.7) 762
683 Mild 91 (29.8) 22 (26.2) 31 (34.1) 6 (7.0) 763
684 764
Moderate 124 (40.7) 21 (25.0) 34 (37.3) 0
685 765
686 Severe 41 (13.4) 4 (4.8) 15 (16.5) 1 (3.3) 766
687 Setting, n (%) 767
688 Specialized care 103 (33.6) 0 18 (19.6) 0 768
689 Primary care 204 (66.4) 54 (64.3) 74 (80.4) 0 769
690 Others 0 30 (35.7) 0 30 (100) 770
691 771
692 772
693 773
694 774
695 estimated. We considered the following criteria to status and worse perceived mobility would score 775
696 determine a good model fit: RMSEA less than 0.10, CFI at significantly higher than the other groups. 776
697 777
698 least 0.95, and TLI at least 0.95 [40,41]. We compared The Cronbach a coefficient was determined for in- 778
699 the different models with the weighted root mean ternal consistency and the 1-way random effect intra- 779
700 780
701
square residual and considered the one with the lower class correlation coefficient (with 95% CI) was 781
702 value. calculated for test-retest reliability [42]. Reliability 782
703 The Spearman correlation coefficient (r) was used to coefficients greater than 0.70 were considered satis- 783
704 784
705 assess convergent validity. The research hypothesis was factory [43]. SE of measurement was estimated with the 785
706 that the OPTIMAL and the PF-10 would yield a strong equation SD{1  intraclass correlation coefficient} .
½ Q2 786
707 787
708 (>0.70) and inverse correlation [12]. To establish Internal responsiveness was determined by 788
709 known-groups construct validity, OPTIMAL scores were comparing baseline scores with 4-week follow-up scores 789
710 790
711
compared between patients and the general population using the Wilcoxon signed-rank test. We also calculated 791
712 using the Mann-Whitney U-test. OPTIMAL scores also effect size (ES; and 95% CI) as the difference between 792
713 were compared across known groups of patients ac- the mean baseline and follow-up scores divided by the 793
714 794
715 cording to their state of health and perceived mobility SD of baseline scores [44]. The threshold for a large ES 795
716 using the Mann-Whitney U and Kruskal-Wallis tests, was considered at least 0.8 [45]. The standardized 796
717 797
718
respectively. We worked under the research hypotheses response mean (and 95% CI) was analyzed by dividing 798
719 that patients would score significantly higher than the the difference between the mean baseline and follow- 799
720 general population and that patients with worse health up scores by the SD of the mean change score [44]. 800

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 6 Spanish Version of the OPTIMAL Instrument

801 Table 3 881

802 OPTIMAL and PF-10 scores at baseline 882
803 883
804 Patients (N ¼ 307) General community (n ¼ 30) 884
805 885
806 Instrument Mean (SD) Median (IQR) Mean (SD) Median (IQR) 886
807 PF-10* 57  28.7 65 (35-80) 95.8  6.6 100 (95-100) 887
808 888
OPTIMAL difficulty†
809 889
810 Total 30.1  21.5 26.25 (11.4-46.6) 5.4  9.3 2.3 (0.0-6.8) 890
811 Trunk subscale 17.9  20.2 12.5 (0.0-31.3) 2.5  6.5 0.0 (0.0-0.0) 891
812 Lower extremity subscale 33.8  26.9 31.3 (8.3-58.3) 5.8  8.4 3.1 (0.0-8.3) 892
813 Upper extremity subscale 31.4  25.5 25 (12.5-50) 6.7  15.7 0.0 (0.0-4.2) 893
814 OPTIMAL confidence† 894
815 895
816
Total 34.5  23.3 31.8 (15.9-52.3) 8.0  12.0 2.8 (0.0-11.4) 896
817 Trunk subscale 32.1  27.0 20.8 (8.3-50.0) 10.7  13.0 4.2 (4.2-12.5) 897
818 Lower extremity subscale 42.1  29.7 44.1 (16.7-63.9) 10.6  13.0 5.6 (0.0-16.7) 898
819 Upper extremity subscale 36.0  28.3 33.3 (8.3-58.3) 7.1  16.4 0.0 (0.0-8.3) 899
820 900
821 OPTIMAL ¼ Outpatient Physical Therapy Improvement in Movement Assessment Log; PF-10 ¼ Physical Functioning Subscale; IQR ¼ interquartile 901
822 range. 902
823 * Score 0-100, with higher scores related to lesser disability. 903
824 †
Score 0-100, with higher scores related to greater disability. 904
825 905
826 906
827 907
828 The minimal detectable change (MDC) was determined samples. Of the total study sample of 307 patients, 107 908
829 according to the equation 1.96  {SE of measurement} (34.9%) were men and 200 (65.1%) were women with a 909
830 910
831
Q3 2½ [46]. The MDC proportion (percentage of patients mean age  SD of 54.2  15.4 years. Of these subjects, 911
832 exceeding the MDC) also was estimated. For external 34.3% were recipients of physical therapy because of 912
833 913
834
responsiveness, the correlation between the difference neuromusculoskeletal disorders located in the spine or 914
835 measured with the OPTIMAL and the difference trunk (36.2% low back pain, 33.3% neck pain, 20.9% 915
836 measured with the PF-10 was determined by the general back pain, 4.8% upper back pain, 1.9% surgery, 916
837 917
838 Spearman coefficient (r). 2.9% others), 32% for neuromusculoskeletal disorders of 918
839 Data were analyzed using STATA/SE 14 (StataCorp, the lower limb (26.5% knee disorders, 24.5% surgery, 919
840 920
841
College Station, TX) and MPLUS 7.3 [39]. Statistical 22.4% ankle/knee disorders, 9.2% fractures, 8.2% hip 921
842 significance was set at a P value less than .05. disorders, 2.1% amputation, 7.1% others), 27.1% for 922
843 neuromusculoskeletal disorders of the upper limb 923
844 924
845 Results (40.9% shoulder disorders, 16.9% wrist or hand disorders, 925
846 16.9% fractures, 15.7% surgery, 4.8% elbow disorders, 926
847 927
848 Results of Adaptation Process 4.8% others), and 6.6% for systemic diseases (65% dis- 928
849 eases of the nervous system, 30% rheumatic diseases, 5% 929
850 930
851
The adaptation process was carried out according to others). 931
852 the 10 steps listed earlier, resulting in the Spanish 932
853 version of the OPTIMAL instrument (Table 1). Any dis- 933
854 Structural Validity 934
855 crepancies were resolved using the terminology 935
856
The model that yielded the best adjustment for the 936
collected in the Spanish version of the International
857 difficulty scale consisted of 3 factors and 22 items 937
858 Classification of Functioning, Disability and Health [2]. 938
(Figure 2) and its fit indices were 0.093 (90% CI 0.085-
859 Participants in the pilot test consisted of 8 women 939
860 0.101) for RMSEA, 0.980 for CFI, 0.977 for TLI, and 940
861
(53%) and 7 men (47%) with a mean age  SD of 53.9  941
1.352 for weighted root mean square residual. For the
862 15.6 years. All these participants showed a good un- 942
863
confidence scale, the model having the best adjust- 943
derstanding of the concepts assessed in the
864 ment consisted of 3 factors and 22 items (Figure 3) 944
865 questionnaire. 945
and its fit indices were 0.100 (90% CI 0.092-0.107) for
866 946
867 RMSEA, 0.975 for CFI, 0.972 for TLI, and 1.435 for 947
868 Results of Psychometric Testing 948
weighted root mean square residual. Fit indices
869 949
870 for the different models proposed are presented in 950
Three hundred eleven patients (96.6%) agreed to
871 Table 4. 951
872 participate in this phase, but 4 records were eliminated 952
873 because more than 25% of their data were missing. 953
874 954
875 Thus, the total analyzed sample consisted of 307 pa- Convergent Validity 955
876 tients for whom 53 missing items were recorded. The The association with the PF-10 yielded a r value of 956
877 957
878
characteristics for this sample and for the general 0.87 (P < .001) for the OPTIMAL difficulty scale and a r 958
879 population sample are presented in Table 2. Table 3 value of 0.73 (P < .001) for the OPTIMAL confidence 959
880 presents the OPTIMAL and PF-10 scores for the 2 scale. 960

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961 1041
962 1042
963 1043
964 1044
965 1045
966 1046
967 1047
968 1048
969 1049
970 1050
971 1051
972 1052
973 1053
974 1054
975 1055
976 1056
977 1057
978 1058
979 1059
980 1060
981 1061
982 1062
983 1063
984 1064
985 1065
986 1066
987 1067
988 1068
989 1069
990 1070
991 1071
992 1072
993 1073
994 1074
995 1075
996 1076
997 1077
998 1078
999 1079
1000 1080
1001 1081
1002 1082
1003 1083
1004 1084
1005 1085
1006 1086
1007 1087
1008 1088
1009 1089
1010 1090
1011 1091
1012 1092
1013 1093
1014 1094
1015 1095
1016 1096
1017 1097
1018 1098
1019 Figure 2. Results of confirmatory factor analysis for the difficulty scale. Covariates between items 5-8 and items 14-15 were found. OPTIMAL ¼ 1099
1020 Outpatient Physical Therapy Improvement in Movement Assessment Log. 1100
1021 1101
1022 1102
1023 1103
1024 1104
1025 Known-Groups Validity patients plus the 30 individuals from the general popu- 1105
1026 As expected, the general population group obtained lation), of which 38.1% were men and 61.9% were 1106
1027 1107
1028 significantly lower results on the OPTIMAL instrument women with a mean age  SD of 47.5  11.3 years. 1108
1029 than the patient group (P < .001; Table 3). Patients with However, 3 subjects had missing data on the confidence 1109
1030 1110
1031
chronic health problems and those with mobility prob- scale at retest. Table 6 presents internal consistency, 1111
1032 lems during the past week obtained higher scores than test-retest reliability, and SE of measurement values. 1112
1033 the other groups, with significant differences for these 2 1113
1034 1114
1035 groups (P < .001; Table 5). Responsiveness 1115
1036 In the analysis of responsiveness, a subsample of 92 1116
1037 1117
1038
Reliability patients consisted of 33.7% men and 66.3% women with 1118
1039 In the analysis of test-retest reliability, the data from a mean age  SD of 55.7  15.4 years. The mean time 1119
1040 84 individuals were analyzed (a subsample of 54 between the 2 data collections was 27.6  1.7 days. 1120

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1121 1201
1122 1202
1123 1203
1124 1204
1125 1205
1126 1206
1127 1207
1128 1208
1129 1209
1130 1210
1131 1211
1132 1212
1133 1213
1134 1214
1135 1215
1136 1216
1137 1217
1138 1218
1139 1219
1140 1220
1141 1221
1142 1222
1143 1223
1144 1224
1145 1225
1146 1226
1147 1227
1148 1228
1149 1229
1150 1230
1151 1231
1152 1232
1153 1233
1154 1234
1155 1235
1156 1236
1157 1237
1158 1238
1159 1239
1160 1240
1161 1241
1162 1242
1163 1243
1164 1244
1165 1245
1166 1246
1167 1247
1168 1248
1169 1249
1170 1250
1171 1251
1172 1252
1173 1253
1174 1254
1175 1255
1176 1256
1177 1257
1178 1258
1179 Figure 3. Results of confirmatory factor analysis for the confidence scale. Covariates between items 5-8, 14-15, and 21-22 were found. OPTIMAL ¼ 1259
1180 1260
Outpatient Physical Therapy Improvement in Movement Assessment Log.
1181 1261
1182 1262
1183 Data were missing from 3 subjects at follow-up. The improvement of 15.9 points in the total raw would be 1263
1184 1264
1185 differences between baseline and 4-week follow-up necessary to determine a real change in mobility. The 1265
1186 scores were significant (P < .001) for the OPTIMAL and proportion of MDC was 37% in the difficulty scale and 1266
1187 1267
1188
the PF-10 (Table 7). The ES was 0.61 (95% CI 0.48-0.74) 32.6% in the confidence scale. The correlation between 1268
1189 for the OPTIMAL difficulty scale and 0.53 (95% CI 0.38- the change measured for the OPTIMAL instrument and 1269
1190 0.69) for the OPTIMAL confidence scale. The standard- that measured with the PF-10 was 0.78 for difficulty 1270
1191 1271
1192 ized response mean was 0.97 (95% CI 0.78-1.13) for the and 0.64 for confidence (P < .001). 1272
1193 difficulty scale and 0.76 (95% CI 0.48-1.01) for the con- 1273
1194 1274
1195 fidence scale. The MDC for the difficulty scale was 14.2 Discussion 1275
1196 of 100, indicating an improvement of 12.5 points in the 1276
1197 1277
1198
total raw score of the scale (22-110) would be necessary The OPTIMAL instrument measures the difficulty and 1278
1199 to determine a real change in mobility. For the confi- confidence in performing movements. According to 1279
1200 dence scale, the MDC was 18.1 of 100, indicating an Riddle et al [26], the 2 scales overlap with each other, 1280

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1281 Table 4 1361

1282 Fit indices of different models proposed for difficulty and confidence scales 1362
1283 1363
1284 Model Items Factors RMSEA (90% CI) CFI TLI WRMR 1364
1285 1365
1286 OPTIMAL difficulty 1366
1287 1. Original model [1] 21 3 0.111 (0.103-0.118) 0.974 0.970 1.573 1367
1288 2. Original model with item 9 (standing) associated with lower 22 3 0.107 (0.099-0.114) 0.973 0.970 1.560 1368
1289 extremity mobility factor [37] 1369
1290 3. Original model with item 9 (standing) associated with trunk 22 3 0.111 (0.104-0.119) 0.971 0.967 1.625 1370
1291 1371
1292
mobility factor [37] 1372
1293 4. Original model with item 9 (standing) associated with lower 22 3 0.093 (0.085-0.101) 0.980 0.977 1.352 1373
1294 extremity mobility factor, with 2 covariates (5-8; 14-15) 1374
1295 OPTIMAL confidence 1375
1296 1. Original model [1] 21 3 0.125 (0.118-0.133) 0.964 0.959 1.775 1376
1297 1377
2. Original model with item 9 (standing) associated with lower 22 3 0.124 (0.117-0.132) 0.961 0.956 1.804
1298 1378
1299 extremity mobility factor [37] 1379
1300 3. Original model with item 9 (standing) associated with trunk 22 3 0.124 (0.117-0.131) 0.961 0.957 1.800 1380
1301 mobility factor [37] 1381
1302 4. Original model with items 6, 7, and 9 (standing) associated 22 3 0.100 (0.092-0.107) 0.975 0.972 1.435 1382
1303 with lower extremity mobility factor, with 3 covariates (5-8; 1383
1304 1384
14-15; 21-22)
1305 1385
1306 RMSEA ¼ root mean square error of approximation; CFI ¼ comparative fit index; TLI ¼ Tucker-Lewis Index; WRMR ¼ weighted root mean square 1386
1307 residual; OPTIMAL ¼ Outpatient Physical Therapy Improvement in Movement Assessment Log. 1387
1308 1388
1309 1389
1310 1390
1311 but according to Guccione and Mielenz [47], they are 2 self-efficacy and future perspectives, whereas the 1391
1312 1392
1313 different constructs related to movement and therefore difficulty dimension is related more to physical func- 1393
1314 should be scored separately. In our analysis, we found tioning. According to Luszczynska et al [48], self- 1394
1315 1395
1316
significant differences (P < .001) between the scores efficacy has a prospective nature and is related to the 1396
1317 obtained from these 2 scales (by Wilcoxon signed-rank beliefs of each individual regarding that individual’s 1397
1318 test). The OPTIMAL confidence score showed higher ability to take on certain demands. According to these 1398
1319 1399
1320 values than the OPTIMAL difficulty score, as in studies investigators, individuals having a high level of self- 1400
1321 carried out with the English version [1,26]. The fact that efficacy tend to select more challenging objectives. 1401
1322 1402
1323
the OPTIMAL confidence scale measured significantly According to Lackner et al [49], for patients with lower 1403
1324 higher levels of disability than the OPTIMAL difficulty back pain, self-efficacy is of greater predictive value 1404
1325 scale offers evidence regarding content validity sup- than pain with regard to functioning. 1405
1326 1406
1327 porting the idea that they are measuring 2 distinct di- The results of confirmatory factor analysis showed a 1407
1328 mensions related to movement. slightly different structure for the confidence scale with 1408
1329 1409
1330
In the convergent validity analyses conducted in this respect to the trunk factor. Confidence in the ability to 1410
1331 study, the intensity of the association with the PF-10 perform movements of the trunk can be strongly 1411
1332 1412
was greater for the difficulty scale than for the confi- conditioned by psychological factors, such as fear of
1333 1413
1334 dence scale. In these 2 cases, it was strong (>0.70) and pain. Self-efficacy has been related to lower levels of 1414
1335 significant (P < .001), providing further evidence for disability caused by lumbar pain [50,51]. Also, the fear 1415
1336 1416
1337 content validity. The OPTIMAL confidence scale of making movements and catastrophizing have been 1417
1338 measures a construct that is more closely related to directly related to cervical [52,53] and lumbar [54-56] 1418
1339 1419
1340 1420
1341 1421
1342 Table 5 1422
1343 Known-groups validity of the Spanish version of the OPTIMAL instrument 1423
1344 1424
1345 OPTIMAL difficulty OPTIMAL confidence 1425
1346 Patients (N ¼ 307) Median (IQR) P value Median (IQR) P value 1426
1347 1427
1348 Chronicity 1428
1349 No (n ¼ 149) 18.2 (9.1-34.1) <.001* 25.0 (11.8-42.6) <.001* 1429
1350 Yes (n ¼ 155) 33.8 (17.0-50.0) 38.6 (19.3-55.7) 1430
1351 1431
Mobility problems in past week
1352 1432
1353 None (n ¼ 49) 9.1 (3.4-15.9) <.001† 10.2 (3.4-21.6) <.001† 1433
1354 Mild (n ¼ 91) 17.5 (9.1-28.4) 25.0 (11.8-37.5) 1434
1355 Moderate (n ¼ 124) 35.2 (20.5-51.7) 41.5 (25.6-56.8) 1435
1356 Severe (n ¼ 41) 54.5 (42.0-69.3) 57.9 (35.2-77.3) 1436
1357 1437
1358 OPTIMAL ¼ Outpatient Physical Therapy Improvement in Movement Assessment Log; IQR ¼ interquartile range. 1438
1359 * By Mann-Whitney U-test. 1439
1360 †
By Kruskal-Wallis test. 1440

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 10 Spanish Version of the OPTIMAL Instrument

1441 Table 6 increases [62]. In our study, we also calculated the MDC, 1521
1442 Reliability of the Spanish version of the OPTIMAL instrument (n ¼ 84) 1522
1443 a datum that had not been calculated in previous 1523
1444 Cronbach a ICC (95% CI) SEM studies regarding the OPTIMAL questionnaire and that is 1524
1445 1525
1446 OPTIMAL difficulty of great interest in physical therapy [46]. 1526
1447 Total 0.95 0.91 (0.87-0.94) 5.11 1527
1448 Trunk subscale 0.89 0.83 (0.76-0.89) Limitations 1528
1449 Lower extremity 0.95 0.92 (0,88-0.95) 1529
1450 subscale 1530
1451 The main limitation of our study is the lower 1531
1452
Upper extremity 0.91 0.87 (0.80-0.91) 1532
1453 subscale adjustment obtained in most analyses for the confi- 1533
1454 OPTIMAL confidence dence scale. To calculate convergent validity and 1534
1455 Total 0.95 0.90 (0.85-0.93) 6.54 1535
1456
external responsiveness, the PF-10 was used in our study 1536
Trunk subscale 0.91 0.83 (0.74-0.88)
1457
Lower extremity 0.94 0.91 (0.88-0.94)
for the comparison of the difficulty scale and the con- 1537
1458 fidence scale. This instrument was chosen because it 1538
1459 subscale 1539
1460 Upper extremity 0.94 0.89 (0.83-0.93) had been used as a comparison instrument to determine 1540
1461 subscale the convergent validity of several instruments [63,64], 1541
1462 1542
1463 OPTIMAL ¼ Outpatient Physical Therapy Improvement in Movement including the English version of the OPTIMAL [1]. It 1543
1464 Assessment Log; ICC ¼ intraclass correlation coefficient; SEM ¼ SE of would have been interesting to use another instrument 1544
1465 measurement. to specifically measure the construct of confidence or 1545
1466 1546
1467 self-efficacy. Another limitation is the fact that no 1547
1468 pain. This could explain in part why the dimension of external criteria were used on the improvement (or not) 1548
1469 1549
1470 trunk mobility has a greater weight in the confidence of the patients; therefore, the clinically meaningful 1550
1471 scale. change was not determined [62]. Future studies should 1551
1472 consider these 2 aspects with regard to the OPTIMAL 1552
1473
In our study, the estimated reliability was appro- 1553
1474 priate for the difficulty and confidence scales, given instrument. 1554
1475 reliability coefficients of at least 0.90 [43], similar to 1555
1476 1556
1477 those from Vanti et al [28] in the Italian version of the Conclusion 1557
1478 OPTIMAL. 1558
1479 1559
1480
The Spanish adaptation of the OPTIMAL instrument is This study of cultural adaptation and psychometric 1560
1481 sensitive to change over time, but with a moderate ES validation indicates that the Spanish version of the 1561
1482 (<0.80). However, this ES is larger than the one cited in OPTIMAL instrument has a functional equivalence with 1562
1483 1563
1484 the original validation of the English version [1]. Diverse its original English version and that it is a reliable, valid, 1564
1485 studies have granted more responsiveness to specific and responsive instrument for the assessment of 1565
1486 1566
1487 instruments compared with generic ones [57,58], mobility. 1567
1488 whereas others [59-61] have suggested that the 2 in- 1568
1489 1569
1490
strument types can measure change over time in a Acknowledgments 1570
1491 similar manner. Furthermore, it is necessary to take into 1571
1492 account that ES is a statistic that depends on the SD of We greatly appreciate the work done by the physio- 1572
1493 1573
1494 the sample and, hence, that ES decreases as SD therapists who collaborated in this study. The 1574
1495 1575
1496 1576
1497 Table 7 1577
1498 Responsiveness of the Spanish version of the OPTIMAL instrument (n ¼ 92) 1578
1499 1579
1500
Change scores 1580
1501 Mean  SD Median (IQR) P value* ES (95% CI) SRM (95% CI) MDC† 1581
1502 1582
1503 OPTIMAL difficulty 1583
1504 Total 13.7  14.1 10.2 (5.1-18.8) <.001 0.61 (0.48-0.74) 0.97 (0.78-1.13) 14.2 1584
1505 Trunk subscale 10.0  16.6 6.26 (0-18.75) <.001 1585
1506 1586
Lower extremity subscale 14.1  14.9 9.4 (4.2-24.8) <.001
1507 1587
1508 Upper extremity subscale 16.1  19.3 12.5 (0-25) <.001 1588
1509 OPTIMAL confidence 1589
1510 Total 13.1  17.3 12.5 (2.3-21.2) <.001 0.53 (0.38-0.69) 0.76 (0.48-1.01) 18.1 1590
1511 Trunk subscale 13.6  20.6 8.3 (0-25) <.001 1591
1512 Lower extremity subscale 16.6  19.6 11.1 (1.4-22.2) <.001 1592
1513 1593
1514
Upper extremity subscale 14.6  23.3 8.3 (0-33.3) <.001 1594
1515 PF-10 20.3  22.0 15 (0-35) <.001 1595
1516 1596
OPTIMAL ¼ Outpatient Physical Therapy Improvement in Movement Assessment Log; ES ¼ effect size; SRM ¼ standardized response mean; MDC ¼
1517 1597
1518 minimal detectable change; IQR ¼ interquartile range; PF-10 ¼ Physical Functioning Subscale. 1598
1519 * By Wilcoxon signed rank test. 1599
†
1520 Score 0-100. 1600

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 12 Spanish Version of the OPTIMAL Instrument

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1820 pain patients. Eur J Pain 2007;11:711-718. 813-817. 1905
1821 1906
1822 1907
1823 1908
1824 1909
1825
Disclosure 1910
1826 1911
1827 1912
A.P.-C. SALBIS Research Group, School of Health Science, Universidad de León, F.M.C. Pain Unit, Rı́o Hortega University Hospital, Valladolid, Spain
1828 1913
1829 Av Astorga s/n 24401, Ponferrada, León, Spain. Address correspondence to: Disclosures: none 1914
1830 A.P.-C.; e-mail: apinc@unileon.es 1915
1831 Disclosures: none J.M.C. Galicia Sur Health Research Institute (IIS Galicia Sur), Sergas-UVIGO, 1916
1832 HealthyFit Research Group; Faculty of Education and Sport Sciences, University 1917
1833 T.F.-V. Research Group on Gene-Environment Interactions and Health (GIIGAS), of Vigo, Pontevedra, Spain 1918
1834 Institute of Biomedicine (IBIOMED), Universidad de León, León Spain Disclosures: none 1919
1835 1920
Disclosures: none
1836 1921
1837 A.J.M. Research Group on Gene-Environment Interactions and Health (GIIGAS), 1922
1838 A.A.G. Department of Rehabilitation Science, George Mason University, Fairfax, Institute of Biomedicine (IBIOMED), Universidad de León, León, Spain 1923
1839 VA Disclosures: none 1924
1840 Disclosures: none 1925
1841 Submitted for publication March 20, 2018; accepted May 26, 2018. 1926
1842 1927
1843 1928
1844 1929
1845 1930

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