900
of the disease activity and progression, as well as the
response to therapies. However, especially in the case of
clinical trials, the very low and diverging incidence be-
tween populations might reveal biases. Larger studies are
needed to confirm these issues.
Fabrizio Conti, MD
Fulvia Ceccarelli, MD
Carlo Perricone, MD
Laura Massaro, MD
Francesca Romana Spinelli, MD
Guido Valesini, MD, Professor
Sapienza Università di Roma
Rome, Italy
1. Nikpour M, Urowitz MB, Ibanez D, Gladman DD. Frequency
and determinants of flare and persistently active disease in
systemic lupus erythematosus. Arthritis Rheum 2009;61:
1152– 8.
2. Gladman DD, Ibanez D, Urowitz MB. Systemic Lupus Erythem-
atosus Disease Activity Index 2000. J Rheumatol 2002;29:288 –
91.
3. Mosca M, Bencivelli W, Vitali C, Carrai P, Neri R, Bombardieri
S. The validity of the ECLAM index for the retrospective eval-
uation of disease activity in systemic lupus erythematosus.
Lupus 2000;9:445–50.
4. Gladman DD, Urowitz MB, Goldsmith CH, Fortin P, Ginzler E,
Gordon C, et al. The reliability of the Systemic Lupus Interna-
tional Collaborating Clinics/American College of Rheumatol-
ogy Damage Index in patients with systemic lupus erythema-
tosus. Arthritis Rheum 1997;40:809 –13.
DOI 10.1002/acr.20157
Reply
To the Editors:
We thank Conti et al for reporting their experience with
the concept of flare and PAD, as well as for suggesting that
these may be useful outcomes in evaluating patients with
SLE. As suggested by Dr. Conti and colleagues, the differ-
ences noted between our study and theirs may be ex-
plained by their smaller cohort, shorter period of observa-
tion, or by ethnic differences.
Mandana Nikpour, MBBS, FRACP, FRCPA
Murray B. Urowitz, MD, FRCPC
Dominique Ibañez, MSc
Dafna D. Gladman, MD, FRCPC
University of Toronto Lupus Clinic and Toronto Western
Hospital
Toronto, Ontario, Canada
DOI 10.1002/acr.20113
Systematic review of shoulder function
questionnaires: comment on the article by
Roy et al
To the Editors:
We read with great interest the systematic review of four
shoulder function questionnaires by Roy et al, recently
Letters
published in Arthritis Care & Research (1). We appreciated
the effective study design and the simple and clear expo-
sure. We would like to comment on the use of question-
naires in clinical research. The “ideal” questionnaire, as
described by Roy et al, must be validated by an extensive
process, which includes tests for reliability, sensitivity,
and responsiveness (2,3). However, there are 2 other char-
acteristics that are fundamental for using questionnaires in
clinical research. First, the questionnaire must be submit-
ted to a cross-cultural validation process in order to have a
version that fits the language and culture of the studied
population. To use a questionnaire from different language
groups and in different cultural settings, the questionnaire
must not only be translated into the new language, but also
be adapted to the local culture. The cross-cultural adapta-
tion guidelines described by Guillemin et al are widely
accepted and used for the translation and adaptation of
questionnaires (2,4 – 6). We used these guidelines for the
cross-cultural adaptation and validation of the Italian ver-
sion of some questionnaires (6 –9). In their study, Roy et al
report that the Disabilities of the Arm, Shoulder, and Hand
(DASH) questionnaire has been translated into 16 different
languages. This characteristic must be emphasized so cli-
nicians can choose the correct questionnaire for their own
clinical research.
Second, the questionnaire should be widely used in the
literature. If, in scientific literature, the researchers use
only 1 questionnaire, the data extraction for secondary
publication may be possible. This fact, in our opinion, is
very important for providing potentially useful informa-
tion for therapeutic recommendations.
Roberto Padua, MD
Don Gnocchi Foundation and GLOBE, Evidence-Based
Orthopedics Working Group of Italian Society of
Orthopedics and Traumatology
Rome, Italy
Nicola’s Foundation
Arezzo, Italy
Alex Castagna, MD
GLOBE, Evidence-Based Orthopedics Working Group of
Italian Society of Orthopedics and Traumatology
Rome, Italy
Instituto Clinico Humanitas
Milan, Italy
Federica Alviti, MD
GLOBE, Evidence-Based Orthopedics Working Group of
Italian Society of Orthopedics and Traumatology and
Sapienza University of Rome
Rome, Italy
Luca Padua, MD
Don Gnocchi Foundation and Neurology Institute,
Catholic University
Rome, Italy
1. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder
function: a systematic review of four questionnaires. Arthritis
Rheum 2009;61:623–32.
2. Guillemin F, Bombardier C, Beaton D. Cross-cultural adapta-
tion of health-related quality of life measures: literature review
and proposed guidelines. J Clin Epidemiol 1993;46:1417–32.
Letters
3. Pynsent PB. Choosing an outcome measure. J Bone Joint Surg
Br 2001;83:792– 4.
4. Atroshi I, Gummersson C, Andersson B, Dahlgren E, Johansson
A. The Disabilities of Arm, Shoulder, and Hand outcome
questionnaire: reliability and validity of the Swedish version
evaluated in 176 patients. Acta Orthop Scand 2000;71:613– 8.
5. Germann G, Wind G, Harth A. The DASH (Disability of Arm-
Shoulder-Hand) questionnaire: a new instrument for evaluat-
ing upper extremity treatment outcome. Handchir Mikrochir
Plast Chir 1999;31:149 –52. In German.
6. Padua L, Evoli A, Aprile I, Caliandro P, Mazza S, Padua R, et al.
Health-related quality of life in patients with myasthenia gravis
and the relationship between patient-oriented assessment and
conventional measurements. Neurol Sci 2001;22:363–9.
7. Padua R, Zanoli G, Ceccarelli E, Romanini E, Bondi R, Campi
A. The Italian version of the Oxford 12-item Knee Ques-
tionnaire: cross-cultural adaptation and validation. Int Orthop
2003;27:214 – 6.
8. Padua R, Padua L, Ceccarelli E, Romanini E, Zanoli G, Amadio
PC, et al. Italian version of the Disability of the Arm, Shoulder
and Hand (DASH) questionnaire: cross-cultural adaptation and
validation. J Hand Surg Br 2003;28:179 – 86.
9. Padua R, Padua L, Ceccarelli E, Romanini E, Zanoli G, Bondi R,
et al. Italian version of the Roland Disability Questionnaire,
specific for low back pain: cross-cultural adaptation and vali-
dation. Eur Spine J 2002;11:126 –9.
DOI 10.1002/acr.20121
Reply
To the Editors:
We thank Dr. Padua and colleagues for their interest in
our systematic review. We strongly agree that cross-cul-
tural validation of any translated self-report measure, in
addition to excellent linguistic translation, is essential
since measuring the patient perspective should not be
restrictive. Translated questionnaires must be culturally
adapted to insure content validity at a conceptual level,
before they are used across different cultures (Beaton DE,
Bombardier C, Guillemin F, Ferraz MB. Guidelines for the
process of cross-cultural adaptation of self-report mea-
sures. Spine 2000;25:3186 –91).
In our opinion, the translation/cross-cultural validation
process is a reason to favor the DASH over other region- or
shoulder-specific scales for use in clinical practice and
research. Of the 4 questionnaires reviewed (the American
Shoulder and Elbow Surgeons score, DASH, the Shoulder
Pain and Disability Index, and the Simple Shoulder Test),
only the DASH has an established, standardized process
for translation/cross-cultural validation that requires writ-
ten permission to proceed with the translation and use of
specific translation guidelines to perform a translation/
cross-cultural adaptation of the scale. These guidelines
have been published by Beaton et al and are available on
the Web site for the DASH outcome measure (URL: www.
dash.iwh.on.ca).
Six specific stages (1) are recommended when perform-
ing a translation/cross-cultural adaptation of the DASH: 1)
initial translation: 2 bilingual translators of different pro-
fessional backgrounds, whose mother tongue is the target
language, produce independent translations; 2) synthesis
901
of the translation: the translators and a recording observer
sit down to synthesize the results of the translations in
order to reach consensus; 3) back translation: 2 translators,
working from the target language version of the question-
naire and totally blind to the original version, translate the
questionnaire back into the original language; 4) expert
committee: the expert committee consolidates all the ver-
sions of the questionnaire and develops what would be
considered the prefinal version of the questionnaire for
field testing; 5) test of the prefinal version: 30 – 40 subjects
complete the questionnaire and are interviewed about
what they thought was meant by each questionnaire item
and the chosen response; and 6) submission of documen-
tation to the developers: submission of all the reports and
forms are submitted to the Institute of Work & Health to
verify that the recommended stages were followed.
The DASH is already widely used in the literature. As of
December 2009, approved versions of the DASH were
freely available in 27 languages (and 6 versions were in
progress) on the Web site of the DASH outcome measure.
Making the validated versions of the questionnaire freely
available facilitates their use, which will ultimately lead to
better benchmarking between studies. We consider that
the process used by the DASH developers might serve as
an exemplar for other tool developers whose scales may
contribute to health measurement, including those who
have developed shoulder-specific scales.
Jean-Sébastien Roy, PT, PhD
McMaster University
Hamilton, Ontario, Canada
Joy C. MacDermid, PT, PhD
McMaster University
Hamilton, Ontario, Canada
St. Joseph’s Health Centre
London, Ontario, Canada
Linda J. Woodhouse, PT, PhD
McMaster University and Hamilton Health Sciences
Hamilton, Ontario, Canada
Holland Orthopaedic & Arthritic Hospital of Sunnybrook
Health Sciences Centre
Toronto, Ontario, Canada
DOI 10.1002/acr.20120
Antidepressants as an often overlooked
therapeutic option for the treatment and
management of arthritis pain: comment on
the article by Wolfe and Michaud
To the Editors:
I read with great interest the article by Wolfe and
Michaud recently published in Arthritis Care & Research
(1). The authors have clearly illustrated the value and need
for assessing pain and depression in the treatment of rheu-
matoid arthritis. Not surprisingly, one aspect of arthritis
pain management that is often overlooked is the clinical
use of the analgesic effects of antidepressants (2).