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Clin Rheumatol

DOI 10.1007/s10067-013-2347-7

ORIGINAL ARTICLE

Validation of the Arabic version of the revised Fibromyalgia


Impact Questionnaire (FIQR_A) on Jordanian
females with fibromyalgia
Sana Abu-Dahab & Salah M. AbuRuz & Khader Mustafa &
Yusef Sarhan

Received: 14 March 2013 / Revised: 1 July 2013 / Accepted: 16 July 2013


# Clinical Rheumatology 2013

Abstract The aim of this study was to translate and validate


the Arabic version of the Revised Fibromyalgia Impact
Questionnaire (FIQR_A). Translation of the FIQR followed
a worldwide-recognized approach to ensure the accuracy and
equivalency of the translation from the English version of the
FIQR. Following the translation of the FIQR, 92 women with
fibromyalgia completed the FIQR_A, the Arabic Research
ANd Development Short Form Health Survey (RAND SF36), and the Arabic Hospital Anxiety and Depression Scales
(HADS). The FIQR_A significantly correlated with RAND
SF-36 domains and HADS. The correlations ranged from fair
to moderate. For selected outcomes, BlandAltman plots were
consistent with Spearmans correlations. Testretest intraclass
correlation coefficients were all significant and ranged from
moderate to excellent. Internal consistency was found to be
excellent. These observations suggest that the FIQR_A is a
valid and reliable tool for both clinical practice and research
purposes with Arabic speakers globally.

S. Abu-Dahab (*)
Department of Occupational Therapy, Faculty of Rehabilitation
Sciences, The University of Jordan, Amman 11942, Jordan
e-mail: s.abudahab@ju.edu.jo
S. M. AbuRuz
Department of Clinical Pharmacy, The University of Jordan,
Amman 11942, Jordan
e-mail: aburuz@ju.edu.jo
K. Mustafa
Section of Rheumatology, Department of Internal Medicine,
Jordan University Hospital, Amman 11942, Jordan
e-mail: kmustafa@ju.edu.jo
Y. Sarhan
Ibn Al-Haytham Hospital, Amman, Jordan
e-mail: ysarhan@yahoo.com

Keywords Arabic . Fibromyalgia . Quality of life .


Reliability . Revised Fibromyalgia Impact Questionnaire .
Validity

Introduction
Fibromyalgia (FM) is a chronic pain syndrome affecting 2
5 % of the general population, and presents with a greater
prevalence among women [13]. Patients with FM report
symptoms of widespread pain, fatigue, sleep disturbances
and stiffness, along with anxiety and depression [4]. In addition, cognitive dysfunctions have been reported in patients
with FM [5]. The etiology of these symptoms is as of yet,
unclear. As such, the diagnosis of FM is multifaceted and is
still clinically based, due largely to the absence of any single
or multiple diagnostic laboratory work to support the clinical
manifestations. Currently, the classification of FM is based on
the 1990 American College of Rheumatology (ACR) criteria
[6]. Likewise, the diagnosis of FM is solely based on the 2010
ACR criteria [7].
The impact of FM on various aspects of patients lives has
been widely documented, including personal relationships, careers, mental health, and social support [810]. One of the major
elements that increase the health burden of FM is that FM is
generally considered an invisible disability with a very subjective
nature [11, 12]. This ambiguity of a defined disease state limits
the objectivity of assessing FM-related effects on patients.
Validated, self-reported questionnaires measuring patients perceptions of their own health status and the effect of FM on their
daily functioning is a fundamental element in the meaningful
assessment of FM patients and intervention efficacy.
The original Fibromyalgia Impact Questionnaire (FIQ) was
first published in 1991 [13] with minor revisions in 1997 and

Clin Rheumatol

2002 [14], and has since become the most frequently used tool
in the evaluation of patients with FM [1416]. The Revised
Fibromyalgia Impact Questionnaire (FIQR) was developed in
response to problems found in the FIQ with regard to content
and scoring. The FIQR consists of 21 items organized into
three domains: (a) function, (b) overall impact, and (c) symptoms. Each item within these domains is rated on an 11-point
scale of 010, with 10 being worst, and is meant to be
answered in the context of the past 7 days. The scoring of the
FIQR is quite simple, wherein the summed score of the
function domain (ranging from 090) is divided by 3, the
summed score for overall impact domain (ranging from 0
20) is left unchanged, and the summed score for symptoms
domain (ranging from 0100) is divided by 2. The total FIQR
score consists of the sum of the three modified domain scores
[25]. The FIQR is being increasingly used in research studies
as an outcome variable to evaluate the effectiveness of different interventions [1719] and to examine differences between
patients with FM and patients with other diseases/disorders
such as systematic lupus erythematosus and rheumatoid arthritis [20].
Prevalence studies of FM have not been conducted in the
Arab world in general, in part, due to a lack of awareness as
well as the limitation of validated Arabic-language assessment
tools specific for FM. In Jordan, the Jordanian Fibromyalgia
Association was established in 2010 by both patients with FM
and physicians and health paraprofessionals. Its primary purpose has been aimed at increasing the awareness of FM both
in the community in general as well as in medical and rehabilitation communities, and support and encourage research
related to FM. Therefore, the aim of this study was to translate
and validate the Arabic version of FIQR in the hopes that the
availability of this critical assessment and evaluative tool will
aid in the development and implementation of intervention
strategies.

Methods
Overall study design
The FIQR was first translated into Arabic following a worldwide recognized approach for translation and adaption of
instruments. The multiple forward/backward translational
steps yielded a final Arabic-language FIQR, (FIQR_A).
After the translation process, a booklet consisting of the
FIQR_A, the Arabic Research ANd Development Short
Form Health Survey (RAND SF-36) short form, and the
Arabic Hospital Anxiety and Depression Questionnaire
(HADS), was distributed by a research assistant to a convenient sample of patients with FM visiting the Rheumatology
diseases clinic at the University of Jordan Hospital (JUH). The
study participants completed the questionnaires while waiting

for their appointments. Data were collected over a period of


12 months. Thirty patients were randomly selected to fill out
the questionnaire a second time for the purposes of testretest
reliability within a period of 710 days. All questionnaires
were kept in locked cabinets following data entry. Data was
entered and analyzed using SPSS version 17.
Participants
The target participants of the study were women who have
been diagnosed with FM. Men were excluded from the study
due to the limited availability of male subjects (during the
12 months of data collection, only two men visiting the clinic
were diagnosed with FM). Participants were recruited from
the Rheumatology diseases clinic at JUH. Criteria for study
inclusion was the following: age over 18 years old, an
established diagnosis of FM by a licensed rheumatologist
(per ACR 1990 criteria), and a tender point count (TPC) of
11 or higher at the time of the study. Participants were excluded from the study if they had a diagnosis of major depression,
were pregnant, or were unable to read and write Arabic.
Operational qualities such as time needed to complete the
questionnaire were not collected; however, all patients were
able to complete the questionnaire by themselves in a reasonable period of time. The study was approved by the IRB
committee at the University of Jordan and informed consent
was obtained from all patients.

Measures
Arabic translation of the FIQR
The translation of the FIQR to Arabic followed the linguistic
validation guidelines provided by the MAPI Research
Institute, after receiving an approval for translation from the
author of the original FIQR. In phase one, two independent
translators who are fluent in both Arabic and English language
conducted the forward translation of the FIQR. The pooled
version of the two translations (version 1) was discussed in an
expert panel meeting of the translators and a medical professional in which all disagreements were resolved. Version 1 of
the FIQR_A was then sent to a native English speaker of
Arabic descent who was also fluent in Arabic for translation
back into English in order to ensure semantic fidelity and
coherence of the FIQR_A. The backward translator had no
prior knowledge of or access to the original survey. All discrepancies between forward and backward translations were
resolved in a second panel meeting, resulting in version 2 of
the FIQR_A. In phase 3, version 2 of the FIQR_A was piloted
on five patients with FM through face-to-face interviews. The
final version of the FIQR_A (version 3) was thus approved for
data collection.

Clin Rheumatol

RAND SF-36 short form

Results

The RAND SF-36 is a measure of quality of life that has been


widely used in FM studies to assess health burden. The
RAND SF-36 is a self-administered questionnaire consisting
of eight different scales: physical functioning (PF), role functioning difficulties caused by physical problems (PR), bodily
pain (BP), general health (GH), vitality (VT), social functioning (SF), role functioning difficulties caused by emotional
problems (RE), and mental health (MH). There are also two
main domains: physical component score (PCS) and mental
component score (MCS). Scores are calculated for each scale
and domain, with higher scores reflecting better functioning.
The Arabic translation of the RAND SF-36 has been previously validated [21].

Arabic translation of the FIQR

Hospital Anxiety and depression scale


HADS is a 14-item self-administered questionnaire that is
designed to screen for the existence of depression and anxiety
symptoms in patients with physical illnesses. The 14 items are
divided into two groups of 7 items for depression and anxiety
symptoms. Each item is rated on a 4-point Likert Scale with
higher scores reflecting heightened depression or anxiety
levels. The Arabic version of the HADS has been previously
validated [22, 23].
Tender point count
TPC was carried out by a licensed rheumatologist who applied
a uniform amount of pressure over the 18 designated points by
the ACR. TPC was carried out by the same licensed rheumatologist for all patients in our study by means of digit palpation. A valid tender point was considered if the patient verbally
or non-verbally expressed pain. Number of valid points were
summed and reported as mean SD.
Statistical analysis
Data was entered and analyzed using SPSS version 17.
Descriptive statistics of patients demographic and clinical characteristics were conducted. Spearmans rho correlation coefficients were calculated for the purposes of establishing construct
validity with the SF-36 and HADS. BlandAltman plots were
also produced for two selected main outcomes to verify the
Spearmans rho correlation coefficients. Testretest reliability
was measured with intraclass correlation coefficients (ICC,
3 k). Correlations were considered as little or no relationship
(0.00<r<0.25), fair (0.25<r<0.50), or good (0.50<r<0.75),
and good to excellent (r 0.75) [24]. Internal consistency was
examined by Cronbachs alpha coefficients.

Differences in backward translation were minor and were


mainly related to synonyms in the English language. Three
items needed elaborate discussion by the expert panel and
subsequent modifications. In these three items, there were no

Table 1 Participants demographics (N=92)


Age, years
Mean (SD)
Range
Academic level
Primary school (%)
High school (%)
2 years diploma (%)
Bachelors (%)
High diploma (%)
Masters (%)
Doctor of philosophy (%)
Yearly income
Less than 12,000 JOD (%)
12,00024,000 JOD (%)

48.66 (9.9)
2572
24 (26.1)
27 (29.3)
18 (19.6)
17 (18.5)
4 (4.3)
1 (1.1)
1 (1.1)
75 (81.5)
11 (12.0)

24,00036,000 JOD (%)


Greater than 36,000 JOD (%)
Not indicated
Marital status
Single (%)
Married (%)
Divorced (%)
Widowed (%)
Number of children
No children (%)
1 to 3 children (%)
4 to 6 children (%)
More than 6 children (%)
Not indicated (%)
Syndrome duration (months)
Mean (SD)
Range
Symptoms duration (months)

4 (4.3)
1 (1.1)
1 (1.1)

Mean (SD)
Range
Visual analog scale
Mean (SD)
Range
Tender point count
Mean (SD)
Range

77.6 (69.32)
1.0360.0

11 (12.0)
71 (77.2)
3 (3.3)
7 (7.6)
5 (5.4)
24 (26.2)
32 (34.8)
19 (20.6)
12 (13.0)
48.7 (59.3)
0.0240.0

7.0 (2.0)
1.910.0
15.9 (2.2)
1118

Clin Rheumatol

depression/anxiety (HADS). Spearmans rho correlation coefficients between FIQR_A scores (total as well as individual
domains (function, overall, and symptoms)) and SF-36 domains were all significant and ranged from fair to moderate,
except the correlation between FIQR symptom score and PR
(weak) (Table 2). The strongest correlation was between FIQR
total score and the physical component score of the SF-36.
The inverse relationship between the scores is related to the
opposite direction of scores in each questionnaire.
Likewise, Spearmans rho correlations between the FIQR_A
total, function, overall, and symptoms scores and the HADS
domains were all significant and ranged from fair to moderate
(Table 2). The strongest correlation was between FIQR_A total
and symptoms score with the anxiety domain of the HADS.
Results from BlandAltman plots (Fig. 1) were consistent
with Spearmans rho correlations. The moderate relationship
between the FIQR_A total score with the SF-36 PCS and
MCS scores were evident in the plots as the majority of data
points fell in between 95 % confidence interval lines.

equivalent words in the standard Arabic to reflect certain


English words; the word flight in item Climb one flight
of stairs, the word overwhelming in the item I was
completely overwhelmed by my fibromyalgia symptoms,
and the word tenderness in the item Please rate your level
of tenderness to touch. It was agreed by the expert panel to
substitute each word with word(s) from standard Arabic to
better reflect the meaning. Thus, flight was substituted with
10 steps which is the average of a flight of stairs, overwhelming was substituted with two words that reflect its
meaning, and tenderness was substituted with its definition
pain due to touch or pressure.
To ensure cultural validity, patients were asked, in both
pilot and data collection phases, to point out any items that
were difficult for them to understand or they were unable to
relate to. None of the patients referred to an item as not
understood or not applicable.
Participants
The characteristics of the total sample for the study (N=92) are
displayed in Table 1. FM patients were all women between 25
and 72 years of age. Most of the participants (75 %) had
achieved an academic level of less than a Bachelors degree.
In addition, most of the participants (77.2 %) were married and
had at least one child (81.6 %). The mean syndrome duration
(since diagnosis) was 48.7 months. On the other hand, the mean
of symptom duration (the duration since patients had FM
symptoms) was 77.6 months. TPC ranged from 11 to 18 with
an average of 15.9.

Reliability
Testretest ICCs all reached significance, and ranged from
moderate to excellent (Table 3). The strongest stability of the
FIQR_A occurred in the total and symptoms scores. Internal
consistency of the FIQR_A was excellent with a Cronbachs
alpha of 0.91.

Discussion
In this study, the FIQR_A was found to be a valid, reliable, and
culturally acceptable measure for assessing the impact of FM
on female patients. The aim of translating the FIQR was to
produce an accurate and linguistically equivalent Arabic version of the FIQR that is culturally valid, and this aim was
achieved. The translation and adaptation of the FIQR did not
require any cross-cultural adaptations, and literal equivalent
translation was possible with the exception of three items

Construct validity
FIQR_A, SF-36, and HADS
In order to validate the FIQR_A, we compared the responses
on the FIQR_A to responses given on two previously validated Arabic language measures of quality of life (SF-36) and of

Table 2 Spearmans rho rank correlation coefficients between the FIQR_A total, function, overall, and symptom score, and RAND SF-36 domains and
scales, and HADS*

FIQR_A total score


FIQR_A function
FIQR_A overall
FIQR_A symptom

PCS

MCS

PF

PR

BP

GH

VT

SF

RE

MH

HADS dep

HADS anx

0.65
0.54
0.54
0.57

0.61
0.46
0.47
0.61

0.57
0.50
0.42
0.49

0.31
0.33
0.30
0.19

0.54
0.42
0.45
0.54

0.33
0.20
0.30
0.32

0.54
0.45
0.46
0.43

0.52
0.41
0.41
0.49

0.48
0.39
0.38
0.45

0.43
0.26
0.30
0.47

0.49
0.35
0.33
0.51

0.57
0.40
0.40
0.57

*All correlations were significant at .01 level (two tailed)


FIQR_A Arabic version of the Revised Fibromyalgia Impact Questionnaire, HADS Hospital Anxiety and Depression Scale, PCS physical component
score, MCS mental component score, PF physical functioning, PR role functioning difficulties caused by physical problems, BP bodily pain, GH general
health, VT vitality, SF social functioning, RE role functioning difficulties caused by emotional problems, MH mental health, Dep depression, Anx anxiety

Clin Rheumatol
Fig. 1 Construct validity of the
FIQR_A using BlandAltman
plots. FIQR_A Arabic version of
the Revised Fibromyalgia Impact
Questionnaire, PCS Physical
component score of SF-36, MCS
mental component score of SF-36

which required only minor modifications. The items of the


FIQR_A reflected activities or behaviors typical of Jordanian
women, and thus, patients in the study were able to relate to all
items presented in the questionnaires. It is important to note as
well that the FIQR was translated into standard Arabic and
does not conform to any specific dialect. Standard Arabic is
used by Arabic speakers worldwide, increasing the potential
of feasibly administering of the FIQR_A to a larger geographical population.
Construct validity of the FIQR_A was examined by correlating all its domains with the Arabic versions of the RAND
SF-36 and the HADS. Significance was reached for correlations between the FIQR_A total and domain scores (function,
overall, and symptom) and RAND SF-36 component or scale
scores which was further confirmed with the BlandAltman
plots for component scores. Indeed, all but one of these
relationships ranged from good to moderate, with stronger
correlations between the FIQR_A total score and the RAND
SF-36 component scores. Furthermore, many of the individual
domains of the FIQR_A correlated most closely with the
corresponding subscales in the SF-36. For example, the
FIQR total and function scores correlated most closely with
the physical component and physical functioning scores of the
RAND SF-36, supporting observations made in an earlier
English language study [25].
FIQR_A correlations with HADS were all significant, ranging from moderate to good, and were all stronger than a similar
study validating a Turkish translation of the FIQR [26]. The
strongest correlation (0.57) observed was between the FIQR_A
total and symptoms score and the HADS anxiety subscale.
The strength of this correlation draws attention to the effect of
FM on patient anxiety levels. As previously suggested, anxiety
Table 3 Testretest intraclass
correlation coefficients (ICCs) of
the FIQR_A total, function, overall, and symptom scores
FIQR_A Arabic version of the
Revised Fibromyalgia Impact
Questionnaire, T1 first visit, T2
second visit

Number

FIQR_A Total
FIQR_A Function
FIQR_A Overall
FIQR_A Symptom

19
19
19
19

levels may contribute to the functional impairments evident in


FM patients [27].
Stability of the FIQR_A, as measured by testretest reliability, was also found to be moderate to excellent. The strongest
stability was observed for the FIQR_A total (ICC=0.93) and
symptom (ICC=0.95) scores. The strength of the stability of the
FIQR_A may enable its use not only for assessment but for reevaluation purposes as well. Importantly, these results indicate
that the FIQR_A can be used as an outcome measure for
intervention studies. Currently, responsiveness of assessment
tools for measuring clinical improvements or change in FM
patients due to a specified treatment or management is difficult
to attain. Most existing assessment criteria prior to the development of the FIQR were insensitive to change and relied on a
general subjective examination by physicians. While this study
suggests that the FIQR_A could be a highly useful assessment
tool for intervention studies, further studies need to be conducted to more thoroughly assess the sensitivity of the FIQR_A
in the context of intervention outcome studies.
As an initial validation report, our study indicates that
further extensive analysis of the FIQR_A is merited. Our
sample was a convenience sample from the Rheumatology
disease clinic at JUH. A multi-center random sample would be
a logical next step to increase the validity of our study results.
For example, patients who visit the rheumatology clinic at
JUH, although very variable in demographics, tend to be more
severely affected than patients who visit private clinics and
community clinics. This possible selection artifact of FM
severity may affect the generalizability of the study results.
In future studies stemming from a larger population pool, we
intend to apply the more current 2010 ACR criteria. In the
current study, we chose to apply the ACR 1990 criteria, as our
T1

T2

Mean (SD)

Mean (SD)

52.62 (20.67)
13.06 (6.50)
11.74 (5.38)
27.32 (11.12)

48.74 (22.30)
11.01 (7.27)
11.44 (5.82)
27.32 (11.16)

ICCs

p Value

0.93
0.83
0.57
0.95

<0.001
<0.001
0.04
<0.001

Clin Rheumatol

sample pool was limited and included patients who were


diagnosed prior to 2010. Larger sample sizes will also allow
for factor analyses and stronger conclusions. We will also
document the percentage of patients unable to complete the
measures without assistance and the time taken to complete all
measures. Due to the small sample size, non-parametric testing was the most appropriate method for the analyses of our
data. Our confidence with the results increased with the agreement between Spearmans rho correlations and the Bland
Altman plots.
In conclusion, we found that the FIQR_A is a valid and
reliable tool for use with Arabic speakers. The application of
the FIQR_A is plausible for both clinical practices and research purposes.
Acknowledgments This research was fully funded by the Deanship of
Research at The University of Jordan (Grant # 1401). We would like to
thank R. Anne Stetler, PhD for editorial assistance and Margo B. Holm,
PhD, OTR/L for statistical consultation.
Disclosures None

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