Translation, cross-cultural adaptation, reliability and construct validity of the Dutch Oxford Knee Score – Activity and Participation Questionnaire

Abstract Background Patients undergoing total knee arthroplasty (TKA) tend to be younger and tend to receive TKA at an earlier stage compared to 20 years ago. The Oxford Knee Score – Activity and Participation (OKS-APQ) questionnaire evaluates higher levels of activity and participation, reflecting activity patterns of younger or more active people. The purpose of this study was to translate the OKS-APQ questionnaire into Dutch, and to evaluate its measurement properties in pre- and postoperative TKA patients. Methods The OKS-APQ was translated and adapted according to the forward–backward translation multi step approach and tested for clinimetric quality. Floor and ceiling effects, structural validity, construct validity, internal consistency and test–retest reliability were evaluated using COSMIN quality criteria. The OKS-APQ, the Oxford Knee Score (OKS), the Short Form-36 (SF-36), a Visual Analogue Scale (VAS) for pain and the Forgotten Joint Score (FJS) were assessed in 131 patients (72 preoperative and 59 postoperative TKA patients), and the OKS-APQ was administered twice in 50 patients (12 preoperative and 38 postoperative TKA patients), after an interval of minimal 2 weeks. Results Floor effects were observed in preoperative patients. Confirmatory factor analyses (CFA) indicated a good fit of a 1-factor model by the following indices: (Comparative Fit Index (CFI): 0.97, Tucker-Lewis Index (TLI): 0.96 and Standardized Root Mean Square Residual (SRMR): 0.03). Construct validity was supported as > 75% of the hypotheses were confirmed. Internal consistency (Cronbach α’s from 0.81 to 0.95) was good in the pooled and separate pre- and postoperative samples and test–retest reliability (Intraclass Correlation Coefficients (ICCs) from 0.63 – 0.85) were good in postoperative patients and moderate in preoperative patients. The standard Error of Measurements (SEMs) ranged from 8.5 – 12.2 and the Smallest Detectable Changes in individuals (SDCind) ranged from 23.5 – 34.0 (on a scale from 0 to 100). Conclusions Preliminary findings suggest that the Dutch version of the OKS-APQ is reliable and valid for a Dutch postoperative TKA patient sample. However, in a preoperative TKA sample, the OKS-APQ seems less suitable, because of floor effects and lower test–retest reliability. The Dutch version of the OKS-APQ can be used alongside the OKS to discriminate among levels of activity and participation in postoperative patients.

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The Dutch Version of the Oxford Knee Score – Activity and Participation Questionnaire: A Validation Study

10.21203/rs.3.rs-142010/v1 ◽

2021 ◽

Author(s):

Malou te Molder ◽

Johanna Vriezekolk ◽

Menno Bénard ◽

Petra Heesterbeek

Keyword(s):

Construct Validity ◽

Root Mean Square ◽

Internal Consistency ◽

Oxford Knee Score ◽

Reliability And Validity ◽

Mean Square ◽

Knee Score ◽

Retest Reliability ◽

Dutch Translation ◽

Test Retest Reliability

Abstract Background: Patients undergoing total knee arthroplasty (TKA) tend to be younger and tend to receive TKA at an earlier stage compared to 20 years ago. The Oxford Knee Score – Activity and Participation (OKS-APQ) questionnaire evaluates higher levels of activity and participation, reflecting activity patterns of younger or more active people. The purpose of this study was to translate a Dutch-language version of the OKS-APQ questionnaire, and to validate it in pre- an postoperative TKA patients. Methods: We evaluated the Dutch translation of the OKS-APQ for reliability and validity. Internal consistency, test-retest reliability, factor analysis, construct validity and, floor and ceiling effects were evaluated using quality criteria. The OKS-APQ, the Oxford Knee Score (OKS), the Short Form-36 (SF-36), a Visual Analogue Scale (VAS) for pain and the Forgotten Joint Score (FJS) were assessed in 131 patients, and the OKS-APQ was administered twice in 50 patients after an interval of minimal 2 weeks.Results: Internal consistency (Cronbach α‘s from 0.81 to 0.95) and test-retest reliability (Intraclass Correlation Coefficients (ICCs) from 0.63 – 0.88) were satisfactory to good. The standard Error of Measurements (SEMs) ranged from 8.5 – 12.2 and the Smallest Detectable Changes in individuals (SDCind) ranged from 23.5 – 34.0 (on a scale from 0 to 100). Confirmatory factor analyses (CFA) indices indicated a satisfactory fit of a 1-factor model (Comparative Fit Index (CFI): 0.97, Tucker-Lewis Index (TLI): 0.96, Root Mean Square Error of Approximation (RMSEA): 0.1, Standardized Root Mean Square Residual (SRMSR): 0.03). Construct validity was supported as >75% of the hypotheses were confirmed and floor effects were observed in preoperative patients. Conclusions: The Dutch translation of the OKS-APQ showed good reliability and validity in the Dutch population, and can be used alongside the OKS in clinical research and clinical practice to discriminate among levels of activity and participation in postoperative patients.

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Psychometric Evaluation of the Vietnamese Hemodialysis Stressor Scale

Clinical Nursing Research ◽

10.1177/1054773816631724 ◽

2016 ◽

Vol 27 (3) ◽

pp. 364-385

Author(s):

Thi Loan Dang ◽

Fu-Chih Lai ◽

Yen-Kuang Lin ◽

Kuei-Ru Chou ◽

Nae-Fang Miao ◽

...

Keyword(s):

Construct Validity ◽

Psychometric Properties ◽

Internal Consistency ◽

Assessment Tool ◽

Short Form ◽

Psychometric Evaluation ◽

Retest Reliability ◽

Instrument Translation ◽

Test Retest Reliability ◽

Stressor Scale

The lack of a suitable assessment tool may limit optimal stress management and impair the health-related quality of life of patients undergoing hemodialysis. The purpose of the study was to examine latent constructs and psychometric properties of the Vietnamese Hemodialysis Stressor Scale (HSS-V). In total, 180 patients receiving hemodialysis were recruited. Psychometric properties of the HSS-V, including the construct validity, internal consistency, and test–retest reliability, were tested after the instrument translation. The exploratory factor analysis resulted in a 24-item HSS-V with four extracted factors, which explained 58.32% of the total variance. The construct validity was confirmed by significant negative correlations between scores on the HSS-V and Vietnamese-version Short Form-36. The internal consistency (Cronbach’s α = .82-.91) and test–retest reliability (intra-class correlations coefficient = .91-.94) of the 24-item HSS-V were satisfactory. A simple structure and preliminary acceptable psychometric properties of the HSS-V were established and can serve as a basis for further studies.

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FRI0583 VALIDATION OF THE MODIFIED FATIGUE IMPACT SCALE IN DANISH PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.1293 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 895.1-896

Author(s):

C. I. Junker ◽

K. Duch ◽

L. Dreyer ◽

J. W. Gregersen ◽

S. Kristensen

Keyword(s):

Construct Validity ◽

Correlation Coefficient ◽

Internal Consistency ◽

Lupus Erythematosus ◽

Short Form ◽

Retest Reliability ◽

Short Form 36 ◽

Impact Scale ◽

Fatigue Impact Scale ◽

Test Retest Reliability

Background:Patients with systemic lupus erythematosus (SLE) experience significant fatigue, a debilitating symptom associated with reduced quality of life. A simple, reliable multidimensional method for assessing fatigue has not yet been validated for Danish patients with SLE.Objectives:The primary objective was to study the internal consistency, test-retest reliability, and construct validity (convergent and discriminant validity) of the multidimensional Modified Fatigue Impact Scale (MFIS) in patients with SLE. The secondary objective was to investigate the contribution of disease activity and organ damage to fatigue.Methods:Data from the ”Bio and Genome Bank Study in Centre for SLE and Vasculitis” obtained through routine visits were used. Fatigue was assessed using the MFIS and Short Form 36 (SF36). Internal consistency of the MFIS was assessed with Cronbach’s alpha (α). Test-retest reliability was evaluated using the intraclass correlation coefficient (ICC). Construct validity was studied using Spearman’s rank correlation coefficient (rs) and Principal Component Analysis (PCA) between MFIS and SF36 vitality (VT-SF36) and mental health (MH-SF36) subscales. Association between MFIS and disease activity and organ damage was estimated with Spearman’s rank correlation coefficient.Results:The study included 30 patients with SLE. Internal consistency of the MFIS was excellent with Cronbach’s α = 0.97 for the complete scale. Excellent test-retest reliability was found with ICC = 0.95 (95% confidence interval: 0.88-0.98, p < 0.05). Construct validity was confirmed by Spearman’s correlation (VT-SF36: rs= −0.73, p < 0.001 (Fig. 1). MH-SF36: rs= −0.74, p < 0.001 (Fig. 2)) and PCA with explained variance from the first two principal components (PC) (VT-SF36: PC1 = 60.2%, PC2 = 8.5%. MH-SF36: PC1 = 58.5%, PC2 = 7.4%). No significant correlation was found between the MFIS and SLEDAI (rs= 0.04, p = 0.84) or SLICC Damage Index (rs= 0.32, p = 0.08).Figure 1.Scatter plot of the Modified Fatigue Impact Scale (MFIS) and the Short Form 36 vitality (VT-SF36) subscale.Figure 2.Scatter plot of the Modified Fatigue Impact Scale (MFIS) and the Short Form 36 mental health (MH-SF36) subscale.Conclusion:The present study found the multidimensional assessment of fatigue with MFIS to be a reliable and valid instrument in SLE. The MFIS might provide more detailed information about fatigue in future studies. In agreement with some previous studies we found no association between fatigue and SLEDAI or SLICC which raises questions about the cause of this symptom. Further and larger studies are needed to investigate if any association between fatigue and disease components exist.Disclosure of Interests:None declared

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A meta-analysis of measurement properties of the Western Ontario Meniscal Evaluation Tool (WOMET)

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-020-02103-9 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Nikolas Leon Krott ◽

Marcel Betsch ◽

Michael Wild

Keyword(s):

Construct Validity ◽

Internal Consistency ◽

Content Validity ◽

Meta Analysis ◽

Cross Cultural ◽

Measurement Properties ◽

Consistency Test ◽

Retest Reliability ◽

Test Retest Reliability

Abstract Background We provide a meta-analysis for clinicians and researchers regarding the psychometric properties of the WOMET as a patient-reported outcome measure (PROM) for patients with meniscal pathologies. Methods A comprehensive literature search identified 6 eligible papers evaluating WOMET measurement properties in patients with different meniscal injuries and meniscal treatments following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The quality of the included studies was evaluated using the four-point Consensus-based Standard for the selection of health Measurement Instruments (COSMIN) Checklist for good measurement properties. The checklist was specifically developed for studies on health-related PROMs. Results Our meta-analysis suggests that the WOMET can be used to evaluate patients with different meniscal injuries and meniscal treatments, especially acute or chronic meniscal injuries and traumatic or degenerative meniscal injuries treated operatively or conservatively. The WOMET shows satisfactory internal consistency, test-retest reliability, and construct validity. Due to limitations in both sample sizes and methodologies of the included studies, no conclusions can be drawn regarding the WOMET’s content validity, structure validity, cross-cultural validity, measurement error, or responsiveness. A further limitation of the studies included in this meta-analysis is the lack of cross-cultural validation, although recommended by the COSMIN Standards. Conclusions The first meta-analysis on measurement properties of the WOMET demonstrates satisfactory internal consistency, test-retest reliability, and construct validity. Further studies are needed, focusing on the methodological deficiencies highlighted in this meta-analysis. To ensure that the WOMET adequately reflects the symptoms, functions, and quality of life of patients with meniscal tears based on COSMIN criteria, it is necessary to assess the structural validity and content validity of this PROM.

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Validation of the Chinese Version of Family-Professional Partnership Scale in Early Intervention

Journal of Early Intervention ◽

10.1177/1053815120945025 ◽

2020 ◽

Vol 42 (4) ◽

pp. 381-395

Author(s):

Lin-Ju Kang ◽

Yu-Wei Hsu ◽

Ai-Wen Hwang

Keyword(s):

Early Intervention ◽

Construct Validity ◽

Internal Consistency ◽

Intraclass Correlation ◽

Chinese Version ◽

Measurement Properties ◽

Retest Reliability ◽

The Family ◽

Test Retest Reliability ◽

Family Centered

The Chinese version of the Family-Professional Partnership Scale (FPPS-C) measures satisfaction with mutually established parent-professional partnerships. This study aimed to evaluate the measurement properties of the FPPS-C Family and Professional Versions. The participants comprised 167 parents who had a child enrolled in an early intervention program, and 200 early intervention professionals in Taiwan. Structural validity, internal consistency, test–retest reliability, and construct validity were examined. The Family Version denoted a single-dimensional scale with high internal consistency (α = .99) and adequate test–retest reliability (intraclass correlation coefficient [ICC] = 0.54). The Professional Version showed a three-factor structure with moderate to adequate internal consistency (α = .64–.90) and test–retest reliabilities (ICC = 0.60–0.77). Construct validity was evidenced through positive associations between parental and professional perceptions on partnerships and to family-centered service provision. The FPPS-C is a reliable and valid measure, and the study findings can influence research initiatives and practices that aim to ameliorate the provision of family-centered services by early intervention programs.

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Validity and Reliability of the German Quality of Life–Alzheimer’s Disease (QoL-AD) Self-Report Scale

Journal of Alzheimer s Disease ◽

10.3233/jad-200400 ◽

2020 ◽

Vol 77 (2) ◽

pp. 581-590 ◽

Cited By ~ 1

Author(s):

Vanessa Stypa ◽

Peter Haussermann ◽

Tim Fleiner ◽

Sandra Neumann

Keyword(s):

Quality Of Life ◽

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Construct Validity ◽

Internal Consistency ◽

Short Form ◽

Self Report ◽

Retest Reliability ◽

Test Retest Reliability

Background: The Quality of Life–Alzheimer’s Disease (QoL-AD) scale is a widely used measure of quality of life (QoL) in dementia. Although the instrument has been validated in several languages, the psychometric properties of the German self-report version have not yet been analyzed. Objective: This study examines the internal consistency, test-retest reliability, and construct validity of the German QoL-AD self-report scale. Methods: The sample included 30 patients suffering from mild to moderate Alzheimer’s disease or vascular dementia (19 females; mean age 77.3 years; mean Mini-Mental State Examination (MMSE) score 19.7 points). To determine test-retest reliability, the QoL-AD self-report scale was re-administered four to seven days apart. For construct validity analysis, the Dementia Quality of Life instrument (DQoL), Geriatric Depression Scale (GDS), MMSE, and an adapted short form of the Neuropsychiatric Inventory (NPI) were used. Results: The German QoL-AD self-report scale shows an internal consistency of α= 0.79 and a test-retest reliability of r = 0.75 (p < 0.01). Regarding construct validity, there was a significant positive correlation between the total scores of the QoL-AD and DQoL (r = 0.47, p < 0.05). The analysis revealed no significant correlations with the GDS or the adapted NPI. No association could be observed between the QoL-AD and the MMSE (r = 0.01), confirming divergent validity. Conclusion: The results indicate that the German QoL-AD self-report scale is a suitable instrument for assessing QoL in patients suffering from mild to moderate dementia, thus supporting its use in clinical practice and research.

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Cross-cultural adaptation, reliability and validity of the Fremantle Knee Awareness Questionnaire in Italian subjects with painful knee osteoarthritis

Health and Quality of Life Outcomes ◽

10.1186/s12955-021-01754-4 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Marco Monticone ◽

Cristiano Sconza ◽

Igor Portoghese ◽

Tomohiko Nishigami ◽

Benedict M. Wand ◽

...

Keyword(s):

Construct Validity ◽

Knee Osteoarthritis ◽

Pain Intensity ◽

Internal Consistency ◽

Structural Validity ◽

Retest Reliability ◽

Knee Oa ◽

Pain Catastrophising ◽

Test Retest Reliability ◽

Painful Knee

Abstract Background and aim Growing attention is being given to utilising physical function measures to better understand and manage knee osteoarthritis (OA). The Fremantle Knee Awareness Questionnaire (FreKAQ), a self-reported measure of body-perception specific to the knee, has never been validated in Italian patients. The aims of this study were to culturally adapt and validate the Italian version of the FreKAQ (FreKAQ-I), to allow for its use with Italian-speaking patients with painful knee OA. Methods The FreKAQ-I was developed by means of forward–backward translation, a final review by an expert committee and a test of the pre-final version to evaluate its comprehensibility. The psychometric testing included: internal structural validity by Rasch analysis; construct validity by assessing hypotheses of FreKAQ correlations with the knee injury and osteoarthritis outcome score (KOOS), a pain intensity numerical rating scale (PI-NRS), the pain catastrophising scale (PCS), and the Hospital anxiety and depression score (HADS) (Pearson’s correlations); known-group validity by evaluating the ability of FreKAQ scores to discriminate between two groups of participants with different clinical profiles (Mann–Whitney U test); reliability by internal consistency (Cronbach’s alpha) and test–retest reliability (intraclass correlation coefficient, ICC2.1); and measurement error by calculating the minimum detectable change (MDC). Results It took one month to develop a consensus-based version of the FreKAQ-I. The questionnaire was administered to 102 subjects with painful knee OA and was well accepted. Internal structural validity confirmed the substantial unidimensionality of the FreKAQ-I: variance explained was 53.3%, the unexplained variance in the first contrast showed an eigenvalue of 1.8, and no local dependence was detected. Construct validity was good as all of the hypotheses were met; correlations: KOOS (rho = 0.38–0.51), PI-NRS (rho = 0.35–0.37), PCS (rho = 0.47) and HADS (Anxiety rho = 0.36; Depression rho = 0.43). Regarding known-groups validity, FreKAQ scores were significantly different between groups of participants demonstrating high and low levels of pain intensity, pain catastrophising, anxiety, depression and the four KOOS subscales (p ≤ 0.004). Internal consistency was acceptable (α = 0.74) and test–retest reliability was excellent (ICC = 0.92, CI 0.87–0.94). The MDC95 was 5.22 scale points. Conclusion The FreKAQ-I is unidimensional, reliable and valid in Italian patients with painful knee OA. Its use is recommended for clinical and research purposes.

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Validation of the Beliefs of Physical Activity among Clergy (B-PAC) Instrument

American Journal of Health Studies ◽

10.47779/ajhs.2017.91 ◽

2017 ◽

Vol 32 (2) ◽

Author(s):

Shannon Gwin ◽

Paul Branscum ◽

E. Laurette Taylor

Keyword(s):

Physical Activity ◽

Factor Analysis ◽

Construct Validity ◽

Psychometric Properties ◽

Internal Consistency ◽

Internal Consistency Reliability ◽

Retest Reliability ◽

Reliable Instrument ◽

The Stability ◽

Test Retest Reliability

The purpose of this study was to create a valid and reliable instrument to evaluate theory-basedbeliefs towards physical activity among clergy members. Data were collected from 174 clergy that par-ticipated in a 15-item online and paper-based survey. Psychometric properties of the instrument includedconfirmatory factor analysis (construct validity), and cronbach’s alpha (internal consistency reliability).In addition, the stability (test-retest reliability) of each subscale was evaluated with a sub-sample of 30participants. Results show the instrument was both valid and reliable, and will be useful in future studiestargeting this population. Future implications are discussed.

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Psychometric properties of patient reported outcome (PRO) instruments in patients with small cell lung cancer (SCLC) in RESILIENT part 1.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e24027 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e24027-e24027

Author(s):

Jaba Kokhreidze ◽

Veleka Allen ◽

Cristina Ivanescu ◽

Xiaopan Valerie Yao ◽

Bin Zhang ◽

...

Keyword(s):

Lung Cancer ◽

Construct Validity ◽

Psychometric Properties ◽

Internal Consistency ◽

Life Questionnaire ◽

Retest Reliability ◽

Patient Reported ◽

Eortc Qlq ◽

Test Retest Reliability ◽

Pro Instruments

e24027 Background: The ongoing two-part phase 2/3 RESILIENT study (NCT03088813) is investigating the efficacy and safety of liposomal irinotecan monotherapy in patients with SCLC who have progressed on or after first line platinum-based chemotherapy. This exploratory analysis from RESILIENT part 1 was conducted to confirm the psychometric properties of established PRO instruments that had not previously been validated in patients with SCLC. Methods: Patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) Core 30 (C30) and the EORTC QLQ Lung Cancer 13 (LC13) before treatment assignment (baseline), every 6 weeks thereafter, at treatment discontinuation and at the 30-day follow-up visit. Psychometric methods included descriptive statistics (items and scales), correlations (item-to-item and item-to-total), internal consistency (Cronbach’s α), test-retest reliability (intraclass correlation coefficient [ICC], two-way random effects model), construct validity and sensitivity to change. The analysis included patients who received at least one dose of study drug and completed at least one PRO assessment. Results: Thirty patients were enrolled in RESILIENT part 1 and included in the analysis. At baseline, 68% of patients reported ‘not severe’ or ‘mild’ symptoms. Floor effects (i.e. more than 25% of responses of ‘not at all’) were observed for several of the functioning/impact and symptom scales of the EORTC QLQ C30 and LC13. Moderate to strong correlations were found among most questionnaire items within their respective scales. Acceptable evidence for internal consistency and good test-retest reliability were observed. Selected results for the EORTC QLQ LC13, including dyspnea scales, are shown in the Table. The magnitude of correlations among PRO instruments supported evidence for convergent validity in this sample. Conclusions: In RESILIENT part 1, patients experienced low and tolerable symptoms at enrollment, limiting the potential for further improvement. Overall, these PRO instruments had acceptable psychometric properties (e.g. construct validity, reliability and ability to detect change) in this sample. However, these analyses should be repeated in a larger sample using data from RESILIENT part 2. Clinical trial information: NCT03088813. [Table: see text]

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Translation, cross-cultural adaptation and validation of the English Lequesne Algofunctional index in to Bengali

Health and Quality of Life Outcomes ◽

10.1186/s12955-020-01583-x ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Tarek Mahmood ◽

Minhaj Rahim Choudhury ◽

Md Nazrul Islam ◽

Syed Atiqul Haq ◽

Md Abu Shahin ◽

...

Keyword(s):

Construct Validity ◽

Knee Osteoarthritis ◽

Correlation Coefficient ◽

Internal Consistency ◽

Cultural Adaptation ◽

Convergent Validity ◽

Divergent Validity ◽

Retest Reliability ◽

Knee Oa ◽

Test Retest Reliability

Abstract Background This study was focused on translation and cultural adaptation of the English Lequesne Algofunctional index (LAI) into Bengali for patients with primary knee osteoarthritis (OA) and testing reliability and validity of the Bengali version of the LAI. Methods This study was carried out in the Department of Rheumatology, BSM Medical University, Dhaka, Bangladesh. Using the forward–backward method the English LAI was translated into Bengali including cultural adaptation. For pretesting, A sample of 40 patients with primary knee osteoarthritis were screened using the Bengali version of LAI. Following the pretest, 130 consecutive patients with symptomatic knee OA completed the interviewer administered Bengali LAI, the validated Bengali version of SF-36, Visual Analogue Scale for Pain, Distance Walked and Activities of Daily Living. For the retest 60 randomly selected patients from the cohort were administered the Bengali LAI 7 days later. An item by item analysis was performed. Internal consistency was assessed by Cronbach’s alpha, test–retest reliability by intraclass correlation coefficient (ICC) and Kappa coefficient, construct validity was measured using the Spearman rank correlation coefficient. Results It took 3.25 ± 0.71 min to complete the Bengali LAI and the mean score was 9.23 ± 4.58. For the Bengali LAI Cronbach’s alpha score was 0.88, test–retest reliability assessed by ICC was 0.97. For construct validity, excellent convergent validity was achieved (ρ = 0.93) but the divergent validity was moderate (ρ = 0.43). Conclusions The Bengali LAI showed excellent convergent validity, internal consistency and test–retest reliability, only the divergent validity was moderate. So, the Bengali LAI can be applied as a HRQoL assessment tool for primary knee OA patients.

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