Abstract
In our country, outcome measures are needed to evaluate the results of occupational therapy in amputees. This study aimed to cross-culturally adapt the Reintegration to Normal Living Index (RNLI) and to evaluate the reliability and validity of a Turkish version of the RNLI. The Turkish version of the RNLI was applied to 120 amputees. Cronbach’s alpha coefficient and the intraclass correlation coefficient (ICC) were used to determine internal consistency and test–retest reliability, respectively. Criterion validity was assessed using Short Form 36 (SF-36). The Turkish version of the RNLI presented reliable results in repeated assessments (ICC = .88), and the internal consistency of the RNLI was high (Cronbach’s α coefficient = .89). A statistically significant relationship was found between RNLI and SF-36 (p < .05). The Turkish RNLI is a reliable and valid tool to evaluate the level of reintegration to normal living for amputees.
Introduction
Amputation is a major trauma affecting functional status and daily living activities (Dajpratham et al., 2008). After amputation, individuals experience functional impairments that affect their return to preinjury roles and routines. Furthermore, they are likely to experience social and occupational barriers (Dajpratham et al., 2008; Schoppen et al., 2001).
Amputees may experience a wide range of activity limitations and participation restrictions (Kohler et al., 2009). These limitations are related to self-care and mobility. These factors negatively affect the return to work, the maintenance of social relationships, the participation in recreational activities, and engaging in active social life (Kohler et al., 2009; Schoppen et al., 2001; Whyte & Carroll, 2002). The International Classification of Functioning, Disability and Health (ICF) model developed by the World Health Organization (2001) demonstrated that the level of participation is an important component of health and functioning. According to the ICF, the areas representing the multifaceted nature of participation include communication, mobility, personal care, home life, interpersonal interactions and relationships, main living areas and community, and social and civil life. The participation definition of the ICF includes being involved in a life area, being accepted, or having access to needed resources (World Health Organization, 2001, 2002).
The primary objective of amputee rehabilitation is to improve quality of life, reduce functional limitation and disability, and enable a person’s return to work or new employment and former social life. A prosthesis enables amputees to navigate their environment, maintaining daily and social activities by compensating for the loss of mobility (Fernandez et al., 2000). Most amputees can regain the preamputation level of activity and lifestyle with effective rehabilitation and prosthetic fit (Lusardi et al., 2013).
The participation of people with amputation must be assessed to evaluate the long-term results of amputee rehabilitation (Nissen & Newman, 1992). Gunshot wound trauma and diabetic ulcer amputations are common in Turkey (Aygan et al., 1999; Şener et al., 1999; Yesil et al., 2009). Gunshot wounds are common, especially in the eastern border of Turkey. Amputations are also common after burns due to electric shock or falling into ovens for baking bread (Dogan et al., 2008). In our country, there are many prosthetic centers for the building and fitting of prosthetics for amputees. However, observational and subjective assessment methods are used in these centers (Ünver et al., 2016). Standard and objective outcome measures are needed to assess the long-term outcomes of amputee rehabilitation. The Reintegration to Normal Living Index (RNLI) is a practical survey for participation assessment (Andersson et al., 2020; Hitzig et al., 2012; Liu & Ma, 2017). The RNLI evaluates participation after chronic diseases, and it is a useful tool because it can be completed within 5 to 10 min. It consists of concisely phrased and easily understood items (Hitzig et al., 2012; Nissen & Newman, 1992). The RNLI items assess the parameters of mobility, personal care, home life, interpersonal relationships and interactions, involvement in normal roles and responsibilities, and active participation in the community, which are included in the definition of participation (Pang et al., 2011; Wood-Dauphinee et al., 1988).
Evaluation of long-term outcomes is important in terms of planning rehabilitation programs on the basis of these results. Turkey has no valid and reliable instrument that can measure participation in amputees, which is one of the long-term objectives of amputee rehabilitation. The RNLI has been translated into other languages, such as Chinese and Igbo language (Okoye et al., 2019; Pang et al., 2011). This index is also used in other countries. Therefore, the present study aimed to determine whether the Turkish version of the RNLI is reliable and valid in determining the outcome of unilateral limb amputation in a group of Turkish amputees.
Method
Participants
This study was conducted with amputees who applied to “Hacettepe University, Faculty of Physical Therapy and Rehabilitation.” Participants were included if they (a) had a unilateral limb amputation, (b) had been using a prosthesis for at least 1 year, and (c) were between 18 and 50 years of age. Amputees were excluded if they (a) could not read, speak, and write Turkish; (b) had congenital or bilateral amputation; and (c) had a diagnosis with a cognitive or mental illness. Ethical approval was received from the “Hacettepe University Ethics Board.” All participants provided written informed consent.
Translation Into Turkish
After obtaining permission from the developers of the RNLI, the Turkish version of the tool was developed. For the translation process, the guidelines for cross-cultural adaptation were used (Beaton et al., 2000). Two translations from English to Turkish were performed by two independent translators whose mother tongue was Turkish, allowing the detection of errors and divergent interpretations of items with ambiguous meaning in the guidelines for the original instrument. One was a physiotherapist, and the other, a professionally trained translator with no background in medicine or rehabilitation. The two translations were then backtranslated into English blindly and independently by two native English speakers. Each English translation was then compared with the original English RNLI and checked for inconsistencies.
The Turkish version was jointly reviewed by a bilingual team including the translators to assess the necessity of performing cultural adaptation and fine-tuning for use with Turkish patients. The Turkish version was compared again with the original English version to detect errors of interpretation and nuances which might have been missed. The forward and backward translation processes were documented carefully. The final stage of the adaptation process was the testing of the prefinal version. Pretesting of the prefinal Turkish version on 15 randomly selected amputees revealed no further difficulties with the questionnaire. The study was continued because the individuals who completed the questionnaire stated that the questions were clear and concise.
Alternative scoring methods were used for the RNLI (Bourget et al., 2018). In this study, we used a 5-point Likert-type scale (Nissen & Newman, 1992). Each answer was scored from 1 to 5 points (1 = absolutely disagree, 2 = disagree, 3 = undecided, 4 = agree, and 5 = absolutely agree). In this scoring system, the lowest total score is 11 and the highest is 55, with a higher score indicating better reintegration (Davis et al., 1999).
Procedure
Demographic data containing information about the amputation and prosthesis use of the participants were obtained. Each participant was asked to complete the Turkish version of the RNLI twice at an interval of 1 to 3 days. During the first application of the RNLI, Short Form 36 (SF-36) was also applied.
Outcome Measures
RNLI
The RNLI is a generic scale that assesses the perceptions about reintegration to normal living of people with incapacitating disease or injury (Wood-Dauphinee et al., 1988). The RNLI is a multidimensional examination tool evaluating moving around living areas, moving around the community, ability to take trips out of town, comfort with self-care needs, occupation in work activities, participation in recreational activities, participation in social activities, assumption of role in the family, comfort with personal relationships, comfort with self in the company of others, and ability to deal with life events (Davis et al., 1999). The original RNLI comprises 11 items, the first eight of which constitute the daily functioning subscale and the other three items constitute the perception of self-subscale (Wood-Dauphinee et al., 1988).
SF-36
The validity of the Turkish version of the RNLI was evaluated using SF-36. SF-36 is a self-reported survey that includes a multi-item scale that assesses eight health concepts: physical functioning (PF), role limitations due to physical health problems (RP), bodily pain (BP), general health perception (GH), vitality (V), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). The Turkish version of SF-36, a generic quality of the life measurement tool, is a valid and reliable outcome measure. Cronbach’s alpha coefficients of the Turkish version of SF-36 were calculated for each subscale and found to be .7324 to .7612. The correlation coefficients for each subscale were found to be .44 to .65 (Kocyigit, 1999). The total score obtained from each subscale ranged from 0 to 100, with a higher score indicating better health-related quality of life. SF-36 is an examination tool capable of defining physical function and injury-related health changes and is used in the amputee population (Atic & Aydin, 2018).
Statistical Analysis
Data obtained in the study were analyzed statistically using SPSS version 16.0 for Windows. The measured variables are presented as mean ± standard deviation and categorical variables as number (n) and percentage (%). Statistical significance was considered at p < .05.
Reliability
The most frequently used forms of assessment of reliability are test–retest reliability and internal consistency. Test–retest reliability measures the stability of a test over a given period of time. In the present study, retesting occurred within 1 to 3 days. The intraclass correlation coefficient (ICC, range: .00–1.00) was used to determine test–retest reliability. A reliability coefficient between .50 and .75 was deemed moderate, while an ICC > .75 was deemed good reliability (Portney & Watkins, 2009). The internal consistency of a scale relates to its homogeneity. It is a good measure of how homogeneous questions are supposed to measure a given area, regardless of whether the questions measure only the desired concept (Karakoç & Dönmez, 2014). The coefficient of internal consistency is mainly assessed with Cronbach’s alpha (Cronbach, 1951). The value of alpha should be >.80 for acceptance as high internal consistency (Alpar, 2006). Item-total correlation, which is another form of reliability assessment, was also used to assess the contribution of each question to the scale. A high item-total correlation means the item is highly correlated with the overall scale (Ebel, 1951). The item-total correlation coefficient is expected to be >.25 (Alpar, 2006).
Validity
Validity is the degree to which a measuring tool is intended to measure accurately without confusing any other features. Criterion-based validity is a technique which examines the relationship between test scores and one or more external criteria (Karakoç & Dönmez, 2014). Criterion validity requires a correlation between the tested scale and another scale accepted in this field (Bellamy, 1993). The scale used as a criterion must be valid, reliable, and standard. In this study, the standard, valid, and reliable scale SF-36 was used to examine criterion validity in amputees (Atic & Aydin, 2018). Previous studies also used SF-36 to demonstrate RNLI validity (Daneski et al., 2003). The Spearman’s rank correlation coefficient was used in the criterion validity analysis.
Results
Participants
The mean age of the 120 amputees was 34.52 ± 6.91 years (minimum: 18 years, maximum: 50 years). Average time since amputation was 13.32 ± 8.05 years (minimum: 2 years, maximum: 44 years). Demographic data and amputation-related data are shown in Table 1. A greater proportion of participants (54.16%) was below knee amputees.
Demographic and Amputation-Related Information of Participants.
Scale Scores
The mean RNLI score was 46.93 ± 6.92. When the mean values of each RNLI item were examined, the highest mean value (4.40 ± 0.69) was determined for Item 8, which questioned the role taken in the family. The lowest mean value was determined for Item 5 (4.12 ± 0.99), which questioned job activity (Table 2). The mean scores of the SF-36 are shown in the Table 3.
RNLI Items Scores.
Note. RNLI = Reintegration to Normal Living Index.
Short Form 36 Scores.
Cross-Cultural Adaptation
In the cross-cultural adaptation of the RNLI, some changes were made for clarification. “Reintegration” in the title was changed to more the commonly used “Yeniden katılım” (Reparticipation) in Turkish for easy understanding. Expressions in brackets were removed from items 1 to 3 (wheelchairs, other equipment or resources may be used) and from items 4, 5, 6, 7, and 8 (adaptive equipment, supervision, and/or assistance may be used). All participants in this study were mobile and could perform daily activities with their prosthesis and reported that the above-mentioned statements had led to confusion. Item 4 “I am comfortable with how my self-care needs are met” was translated as “Kendime bakım ile ilgili ihtiyaçlarımın karşılanmasıyla ilgili sıkıntım yok” (I have no discomfort about with how my self-care needs are met.). Item 6 “I am able to participate in recreational activities as I want to” was translated as “Boş zaman aktivitelerine istediğim şekilde katılabilirim” (I am able to participate in leisure activities as I want to.). Patients understood these expressions easily.
Reliability
Cronbach’s alpha coefficient was determined as .85 for the daily functioning subscale, .87 for the perception of self-subscale, and .89 for the total score. Therefore, the internal consistency was deemed good. The Cronbach’s alpha value was greater than .80, which indicated high internal consistency (Alpar, 2006). Item-total correlation coefficients were between .53 and .71, and a strong relationship with the total score was determined for each item. The ICC values are shown in Table 4. The test–retest reliability of the scale was deemed good because the ICC coefficient was greater than .75 (Portney & Watkins, 2009).
Data-Related RNLI Test–Retest Reliability, Correlation of Subheadings—Total Score and Cronbach’s Alpha.
Note. RNLI = Reintegration to Normal Living Index; ICC = intraclass correlation coefficient; CI = confidence interval; r = Spearman’s correlation coefficient, correlation of subheadings and total score.
p < .001.
Validity
A statistically significant correlation was found among the daily functioning subscale score, the perception of self-subscale score, the total RNLI score, and SF-36 subdivisions (p < .05; Table 5).
Correlation Between SF-36 and RNLI Scores.
Note. RNLI = Reintegration to Normal Living Index; PF = physical function; RP = physical role; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = emotional role; MH = mental health. Bold values indicate p<.001.
Discussion
The results of this study indicate that the Turkish version of the RNLI is a reliable and valid instrument to measure participation in Turkish-speaking amputees.
Individuals with different amputation levels were included in this study. Wood-Dauphinee et al. (1988) applied the RNLI to patients with various chronic diseases in their studies. Stark et al. (2005) and Miller et al. (2011) also demonstrated the validity and reliability of the RNLI in different groups of patients, including those who suffered stroke and spinal cord injury. In this current study, the inclusion of individuals with amputation for various reasons and at different levels demonstrated that the RNLI could be used in amputees with different characteristics.
In a study by Nissen and Newman (1992) of amputees, the lowest score of the RNLI was found to be for Item 6, which questioned participation in recreational activities. In this study, the average age of the participants was 68 ± 1.5 years. Thus, participation in recreational activities is important for these individuals. Gretschel et al. (2017) reported the lowest score in individuals with a disability to be for Item 5, which questioned participation in work activities. A similar finding was observed in our study because the participants were of working age but had limited access to work. The total RNLI score in the current study was higher than that for other disability groups (Gretschel et al., 2017; Merz et al., 2017; Stark et al., 2005). This result shows that amputees who can perform daily activities using prostheses are better able to participate in normal life.
As noted in literature, the RNLI is a valid and reliable tool which evaluates reintegration to normal living after an incapacitating illness or trauma (Bourget et al., 2018). In a study examining reintegration to normal living in acute care and rehabilitation patients including amputees, Wood-Dauphinee et al. (1988) found that the RNLI has internal consistency and criterion validity. Test–retest reliability, internal consistency, and construct validity were the most investigated parameters in studies which examined the psychometric properties of the RNLI (Bourget et al., 2018). We evaluated similar parameters of the Turkish version of the RNLI in our study.
Different scoring systems of the RNLI are available. Likert-type scoring is highly preferred for the RNLI (Hitzig et al., 2012; Liu & Ma, 2017; Pang et al., 2011; Stark et al., 2005). In the present study, 5-level Likert-type scoring was used because it is easy to understand and practical for the participants.
The items of the RNLI allow a general assessment of participation. This index is suitable for various disease groups and cultures. It is practiced in various cultures, such as Europe, Asia, Africa, and Australia (Bourget et al., 2018; Hitzig et al., 2012; Liu & Ma, 2017; Okoye et al., 2019; Pang et al., 2011; Stark et al., 2005). Assessments such as mobility, self-care activities, work or leisure activities, and social roles are also available and necessary for the Turkish community. In the Turkish version of the RNLI, only two items were used with different expressions for easier understanding. In the current study, the Turkish version of the RNLI was deemed an appropriate and useful scale for assessing the ability of people with limb loss to reintegrate to normal social activities with their prostheses.
The ICC value was between .71 and .87 in previous studies which examined the test–retest reliability of the RNLI (Bourget et al., 2018; Liu & Ma, 2017; Miller et al., 2011; Pang et al., 2011). In those studies, the intervals between test and retest were 2 weeks and 1 month. In the current study, ICC values were .85 for the daily functioning subscale, .83 for the perception of self-subscale, and .88 for the total RNLI score. These results show that the RNLI has high test–retest reliability in the examination of participation to daily living after amputation. This result was similar to that of studies evaluating RNLI reliability in disease groups with mobility limitations (Liu & Ma, 2017; Miller et al., 2011; Pang et al., 2011).
Cronbach’s alpha value was between .73 and .97 in studies which examined the internal consistency of the RNLI. Similarly, in this current study, the internal consistency of the RNLI (Cronbach’s α = .89) was good. Most previous studies have indicated that the RNLI subscales and RNLI have internal consistency (Bourget et al., 2018; Daneski et al., 2003; Hitzig et al., 2012; Liu & Ma, 2017; Pang et al., 2011; Stark et al., 2005; Wood-Dauphinee et al., 1988). Similar to the findings of Wood-Dauphinee et al. (1988), the item-total correlation was high in our study. This result showed that each item of the RNLI has high power in the measurement of participation to daily living.
Statistically significant correlations were found between the RNLI scores and the SF-36 subdivisions scores, showing that the RNLI has criterion validity. Daneski et al. (2003) also found strong correlations between the RNLI scores and the SF-36 subdivisions scores. Previous studies indicated that the RNLI has criterion validity (Daneski et al., 2003; Hitzig et al., 2012; Liu & Ma, 2017; Merz et al., 2017; Pang et al., 2011). In studies investigating the validity of the RNLI, Pearson’s or Spearman’s correlation coefficients were found in the range of .25 to .77 (Bourget et al., 2018). In our study, Spearman’s correlation coefficients were found in this range.
The number of studies examining the level of participation in amputees in Turkey is limited. Participation in sports activities in Turkish amputees has a positive effect on body image, balance, physical fitness, and quality of life (Bayramlar & Ergun, 2009; Guchan et al., 2017; Tatar, 2010; Yazicioglu et al., 2007). Community participation is associated with education, employment, and satisfaction from leisure activities in people with disabilities in Turkey (Akyurek et al., 2020). The RNLI includes these parameters which affect social participation in our country. In our country, tools to evaluate participation in amputees are limited. We believe that the validity and reliability of the RNLI are important in terms of allowing the evaluation of participation in Turkish amputees. In consideration that the RNLI allows a multifaceted assessment, it can allow the evaluation of different aspects of participation in the amputees and occupational therapy organized accordingly the findings of the assessment. Multidimensional evaluation of participation to daily living after amputee rehabilitation can guide Turkish professionals working on this issue.
Limitations
One limitation of this study was the low number of participants with upper extremity amputation. Lower extremity amputations are more common in Turkey (Aygan et al., 1999; Şener et al., 1999). Rejection of prosthesis after unilateral upper extremity amputation is also common because the amputees can manage to perform daily activities with an intact upper extremity (Østlie et al., 2012). Another limitation of this study is that different reliability and validity methods were not analyzed. Further studies should be conducted with different statistical methods.
Conclusion
The RNLI is a practical survey which can be used routinely in clinical environments for amputees. It is administered in a short time and allows multidimensional evaluation of participation in the context of daily functions and perceptions of self. The Turkish version of the RNLI can be used to assess the long-term occupational therapy results after amputation.
Footnotes
Acknowledgements
The authors wish to thank Sharon Wood-Dauphinee for granting permission to use the Reintegration to Normal Living Index (RNLI).
Ethical Approval
The study was approved by the Ethics Committee of Hacettepe University (Decision no.: HEK 11/87).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
