Korean J Pain.  2021 Oct;34(4):501-508. 10.3344/kjp.2021.34.4.501.

Cross-cultural adaptation and validation of the Turkish Yellow Flag Questionnaire in patients with chronic musculoskeletal pain

• Koç M
• Bazancir Z
• Apaydın H
• Talu B
• Bayar K

• KMID: 2520758
• DOI: http://doi.org/10.3344/kjp.2021.34.4.501

Abstract

Background
Yellow flags are psychosocial factors shown to be indicative of longterm chronicity and disability. The purpose of the study was to evaluate the psychometric properties of the Turkish Yellow Flag Questionnaire (YFQ) in patients with chronic musculoskeletal pain (CMP).
Methods
The cross-cultural adaptation was conducted with translation and backtranslation of the original version. Reliability (internal consistency and test-retest) was examined for 231 patients with CMP. Construct validity was assessed by correlating the YFQ with the Hospital Anxiety and Depression Scale (HADS), Orebro Musculoskeletal Pain Questionnaire (OMPQ), and Tampa Kinesiophobia Scale (TKS). Factorial validity was examined with both exploratory and confirmatory factorial analysis.
Results
The YFQ showed excellent test/retest reliability with an Intraclass correlation coefficient of 0.82. The internal consistency was moderate (Cronbach’s alpha of 0.797). As a result of the exploratory factor analysis, there were 7 domains compatible with the original version. As a result of confirmatory factor analysis, the seven-factor structure of YFQ was confirmed. There was a statistically significant correlation between YFQ-total score and OMPQ (r = 0.57, P < 0.001), HADS-anxiety (r = 0.32, P < 0.001), HADS-depression (r = 0.44, P < 0.001), and TKS (r = 0.37, P < 0.001).
Conclusions
This study’s results provide considerable evidence that the Turkish version of the YFQ has appropriate psychometric properties, including test-retest reliability, internal consistency, construct validity and factorial validity. It can be used for evaluating psychosocial impact in patients with CMP.

Keyword

Anxiety; Chronic Pain; Cross-Cultural Comparison; Depression; Factor Analysis; Statistical; Musculoskeletal Pain; Patient Reported Outcome Measures; Psychometrics; Reproducibility of Results; Surveys and Questionnaires; Validation Study

Reference

1. Kendall N. 1997. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. January 1997 ed. Accident Rehabilitation and Compensation Insurance Corporation, The National Health Committee;Wellington: https://natlib.govt.nz/records/22224916?search%5Bpath%5D=items&search%5Btext%5D=Guide+to+assessing+psychosocial+yellow+flags+in+acute+low+back+pain.

2. Kovacs FM, Abraira V, Zamora J, Fernández C. 2005; The transition from acute to subacute and chronic low back pain: a study based on determinants of quality of life and prediction of chronic disability. Spine (Phila Pa 1976). 30:1786–92. DOI: 10.1097/01.brs.0000172159.47152.dc. PMID: 16094282.

3. Main CJ, Kendall NAS, Hasenbring MI. Hasenbring MI, Rusu AC, Turk DC, editors. 2012. Screening of psychosocial risk factors (yellow flags) for chronic back pain and disability. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford University Press;Oxford: https://books.google.co.kr/books?hl=ko&lr=&id=sXTZCLGjQ0cC&oi=fnd&pg=PA203&ots=SLgUvIRwlU&sig=hTCW80Rk3uQsHEZK5yOfpv222pY&redir_esc=y#v=onepage&q&f=false.

4. Salathé CR, Trippolini MA, Terribilini LC, Oliveri M, Elfering A. 2018; Assessing psycho-social barriers to rehabilitation in injured workers with chronic musculoskeletal pain: development and item properties of the Yellow Flag Questionnaire (YFQ). J Occup Rehabil. 28:365–76. DOI: 10.1007/s10926-017-9728-8. PMID: 28887786.

5. Mannion AF, Mariaux F, Reitmeir R, Fekete TF, Haschtmann D, Loibl M, et al. 2020; Development of the "Core Yellow Flags Index" (CYFI) as a brief instrument for the assessment of key psychological factors in patients undergoing spine surgery. Eur Spine J. 29:1935–52. DOI: 10.1007/s00586-020-06462-z. PMID: 32556625.

6. Butera KA, George SZ, Lentz TA. 2020; Psychometric evaluation of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool: factor structure, reliability, and validity. J Pain. 21:557–69. DOI: 10.1016/j.jpain.2019.09.003. PMID: 31541719. PMCID: PMC7078059.

7. Grotle M, Vøllestad NK, Brox JI. 2006; Screening for yellow flags in first-time acute low back pain: reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire. Clin J Pain. 22:458–67. DOI: 10.1097/01.ajp.0000208243.33498.cb. PMID: 16772801.

8. Tsang S, Royse CF, Terkawi AS. 2017; Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth. 11(Suppl 1):S80–9. DOI: 10.4103/sja.SJA_203_17. PMID: 28616007. PMCID: PMC5463570.

9. Danielsen AK, Pommergaard HC, Burcharth J, Angenete E, Rosenberg J. 2015; Translation of questionnaires measuring health related quality of life is not standardized: a literature based research study. PLoS One. 10:e0127050. DOI: 10.1371/journal.pone.0127050. PMID: 25965447. PMCID: PMC4428794.

10. Aydemir Ö, Güvenir T, Küey L, Kültür S. 1997; Validity and reliability of Turkish version of Hospital Anxiety and Depression Scale. Türk Psikiyatr Derg. 8:280–7. Turkish. https://www.researchgate.net/publication/301778685_Hastane_Anksiyete_ve_Depresyon_Olcegi_Turkce_Formunun_Gecerlilik_ve_Guvenilirlik_Calismasi_Reliability_and_Validity_of_the_Turkish_version_of_Hospital_Anxiety_and_Depression_Scale.

11. Öncü J, Ilişer R, Kuran B. 2016; Cross-cultural adaptation of the Orebro Musculoskeletal Pain Questionnaire among Turkish workers with low back pain. J Back Musculoskelet Rehabil. 29:135–43. DOI: 10.3233/BMR-150609. PMID: 26406190.

12. Tunca Yılmaz Ö, Yakut Y, Uygur F, Uluğ N. 2011; Turkish version of the Tampa Scale for Kinesiophobia and its test-retest reliability. Fizyoterapi Rehabil. 22:44–9. Turkish. https://dergipark.org.tr/en/pub/tfrd/issue/12959/156532.

13. Linton SJ, Boersma K. 2003; Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Örebro Musculoskeletal Pain Questionnaire. Clin J Pain. 19:80–6. DOI: 10.1097/00002508-200303000-00002. PMID: 12616177.

14. Zigmond AS, Snaith RP. 1983; The hospital anxiety and depression scale. Acta Psychiatr Scand. 67:361–70. DOI: 10.1111/j.1600-0447.1983.tb09716.x. PMID: 6880820. PMCID: PMC5420371.

15. Lundberg MK, Styf J, Carlsson SG. 2004; A psychometric evaluation of the Tampa Scale for Kinesiophobia - from a physiotherapeutic perspective. Physiother Theory Pract. 20:121–33. https://doi.org/10.1080/09593980490453002. DOI: 10.1080/09593980490453002.

16. Andresen EM. 2000; Criteria for assessing the tools of disability outcomes research. Arch Phys Med Rehabil. 81(12 Suppl 2):S15–20. DOI: 10.1053/apmr.2000.20619. PMID: 11128900.

17. Marx RG, Menezes A, Horovitz L, Jones EC, Warren RF. 2003; A comparison of two time intervals for test-retest reliability of health status instruments. J Clin Epidemiol. 56:730–5. DOI: 10.1016/S0895-4356(03)00084-2. PMID: 12954464.

18. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. 2007; Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 60:34–42. DOI: 10.1016/j.jclinepi.2006.03.012. PMID: 17161752.

19. Gaskin CJ, Happell B. 2014; On exploratory factor analysis: a review of recent evidence, an assessment of current practice, and recommendations for future use. Int J Nurs Stud. 51:511–21. DOI: 10.1016/j.ijnurstu.2013.10.005. PMID: 24183474.

20. Lee HJ, Choi EJ, Nahm FS, Yoon IY, Lee PB. 2018; Prevalence of unrecognized depression in patients with chronic pain without a history of psychiatric diseases. Korean J Pain. 31:116–24. DOI: 10.3344/kjp.2018.31.2.116. PMID: 29686810. PMCID: PMC5904346.