Advancing global orthopedic research through culturally adapted outcome measures

Abstract

Patient-reported outcome measures (PROMs) are essential in orthopedic research and clinical practice, promoting standardized assessments of treatment efficacy and patient well-being. However, their validity across diverse populations depends on rigorous processes of translation, cultural adaptation, and validation. AlMousa et al successfully validated the Arabic version of the American Academy of Orthopedic Surgeons Foot and Ankle Outcomes Questionnaire, demonstrating strong reliability and clinical applicability for Arabic-speaking patients with traumatic foot and ankle injuries. This article highlights the vital role of culturally adapted PROMs in expanding the global scope of orthopedic research, enhancing patient-centered care, and promoting international collaboration. By addressing linguistic and cultural barriers, such adaptations support a more comprehensive and inclusive approach to evidence-based medicine. Future research should aim to optimize the integration of adapted PROMs into clinical practice, evaluate their influences on treatment decision-making, and investigate their functions in large-scale multicenter studies to further globally advance orthopedic research.

Key Words: Patient-reported outcome measures; Cultural adaptation; Orthopedic research; Foot and ankle injuries; Evidence-based medicine

Core Tip: The validation of the Arabic version of the American Academy of Orthopedic Surgeons Foot and Ankle Outcomes Questionnaire addresses a critical gap in the orthopedic research, advancing inclusivity and enhancing the generalizability of patient-reported data. Integrating culturally adapted patient-reported outcome measures into clinical practice allows for more accurate assessment of outcomes, thereby supporting global progress in evidence-based orthopedic care.

INTRODUCTION

Patient-reported outcome measures (PROMs) are indispensable in the orthopedic research and clinical practice, promoting standardized evaluations of treatment efficacy, functional recovery, and patient well-being[1]. However, their applicability across diverse populations necessitates rigorous linguistic and cultural adaptation[2]. A PROM validated in one context may not be directly transferable to another owing to differences in language, health perceptions, and sociocultural norms, recognizing as factors that may result in inaccurate data and contribute to disparities in care[3,4]. AlMousa et al[5], who validated the Arabic version of the American Academy of Orthopedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire in Gulf-raised Arabic speakers at a single Saudi center, exemplified the transformative potential of culturally adapted PROMs. Their research addressed a critical gap for Arabic-speaking populations and revealed the importance of global inclusivity in the orthopedic research.

NECESSITY OF CULTURAL ADAPTATION IN PROMS

Although PROMs are designed to standardize patient assessments, their validity diminishes when applied across cultures without appropriate adaptation. Relying on direct translation alone can lead to misinterpretation; for instance, terms, such as “disability” or “pain severity” may not have precise linguistic equivalents, and cultural norms, such as a tendency toward stoicism in reporting symptoms, can skew responses[6,7]. A notable example of this is the Mandarin adaptation of the Oswestry Disability Index, which replaced “lifting heavy objects” with “carrying water buckets” to reflect rural Chinese labor practices, an essential cultural nuance often overlooked in generic instruments[8].

The study by AlMousa et al[5] adheres to established adaptation protocols, utilizing forward–backward translation, cognitive interviews, and psychometric validation. The Arabic version of the AAOS questionnaire demonstrated acceptable-to-excellent internal consistency (Cronbach’s α, 0.7-0.9) and moderate test-retest reliability (intraclass correlation coefficient 0.69 for the Global Foot and Ankle Scale; 0.66 for the Shoe Comfort Scale). Responsiveness and minimal clinically important difference were not assessed. This meticulous adaptation process preserves conceptual equivalence while incorporating cultural relevance, providing a model for future research. Table 1 summarizes representative PROMs that have undergone cross-cultural adaptation globally.

Table 1 Examples of culturally adapted patient-reported outcome measures in musculoskeletal and orthopedic research.

Instrument	Target population	Adapted language(s)	Ref.
ODI	Low back pain	Mandarin, Arabic, Spanish, etc.	[8,13]
SF-36 health survey	General health	> 40 languages worldwide	[2,12]
KOOS/HOOS	Knee/hip disorders	Japanese, Turkish, Arabic, etc.	[20,21]
COMI	Low back pain	Arabic, German, Italian, etc.	[13]
PROMIS measures	Various conditions	Multiple languages through ICHOM	[22,23]

ODI: Oswestry disability index; SF-36: 36-Item Short Form Health Survey; KOOS: Knee injury and Osteoarthritis Outcome Score; HOOS: Hip disability and Osteoarthritis Outcome Score; COMI: Core Outcome Measures Index; PROMIS: Patient-Reported Outcomes Measurement Information System; ICHOM: International Consortium for Health Outcomes Measurement.

ENHANCING INCLUSIVITY AND ENSURING THE GENERALIZABILITY OF RESEARCH OUTCOMES

Musculoskeletal disorders disproportionately impact low- and middle-income countries, where culturally adapted PROMs are often limited. This scarcity contributes to underrepresentation in research, constraining the generalizability of findings and impeding evidence-based policymaking[9,10]. Socioeconomic factors, such as limited literacy level, language diversity, lack of familiarity with self-administered surveys, and restricted access to healthcare facilities can further compromise the implementation and accuracy of PROMs in these settings. Limited digital infrastructure and high patient volumes also reduce the feasibility of routine PROM collection. Strategies, including interviewer-administered formats, pictorial or simplified versions of PROMs for patients with low literacy, and integration into community health programs may help overcome these barriers and ensure equitable participation. Without tools that accurately capture patient-reported outcomes within their native linguistic and cultural contexts, several populations continue to be excluded from high-quality clinical research. This lack of inclusive data perpetuates healthcare inequities and obstructs the development of universally applicable treatment guidelines[11,12].

By validating the Arabic version of the AAOS questionnaire, AlMousa et al[5] enable clinicians and researchers working with Gulf-raised Arabic speakers to generate data reflective of their patient demographics. Further validation is required across Levantine, Egyptian, and Maghrebi dialects before broader applicability can be claimed. This contribution broadens the scope of musculoskeletal research and promotes meaningful cross-population comparisons. PROMs adapted to specific linguistic and cultural contexts ensure an accurate representation of patient experiences, thereby promoting the development of more effective treatment strategies and health policies[13,14]. These efforts align with the World Health Organization’s call for “health equity through contextualized care” and promote multicenter collaborations that enhance the global orthopedic evidence base[15].

CRITICAL APPRAISAL OF ALMOUSA ET AL’S RESEARCH

The single-center design of the study with Gulf-raised Arabic speakers could enhance internal cultural alignment, while might limit generalizability to other Arabic dialect groups. Recruitment included a heterogeneous integration of trauma and non-trauma patients. Minor inconsistencies in sample size reporting (n = 100 in text vs n = 105) highlight the need for transparent data reconciliation. Psychometrically, Cronbach’s α ranged from 0.7 to 0.9, and intraclass correlation coefficient s were 0.69 for the Global scale and 0.66 for the Shoe Comfort scale, which necessitated non-parametric analysis. Future research should concentrate on establishing responsiveness, the minimal clinically important difference, and measurement invariance across dialects to promote multi-center data pooling.

CLINICAL AND RESEARCH IMPLICATIONS

Culturally adapted PROMs may directly impact patient-centered care. They provide clinicians with tools to individualize rehabilitation protocols, establish realistic recovery expectations, and engage patients in shared decision-making. For instance, a validated Arabic PROM can illuminate patient priorities and preferences relevant to shared decision-making, encouraging surgeons to adopt more conservative approaches when appropriate[16,17]. Beyond individual care, these instruments enable health systems to benchmark outcomes, identify disparities, and allocate resources more effectively[18], thereby contributing to health equity frameworks.

In the orthopedic research, validating and implementing culturally adapted PROMs may enhance the generalizability of study findings[19,20]. Studies employing culturally appropriate PROMs generate comparable data across diverse populations, thereby increasing the external validity of research outcomes[21]. Moreover, standardized PROMs facilitate multicenter and cross-cultural studies, accelerating international collaborations and contributing to a more comprehensive understanding of orthopedic conditions and treatment responses[22].

From a health policy perspective, culturally adapted PROMs support improved resource allocation by enabling policymakers to identify healthcare disparities and to better understand patients’ needs. Reliable patient-reported data allow health systems to design targeted interventions and rehabilitation programs for specific populations, advancing more effective public health strategies[23-25]. Furthermore, integrating adapted PROMs into routine clinical practice supports the pursuit of universal health coverage by ensuring that all patients, regardless of their linguistic or cultural background, receive appropriate assessments and care.

FUTURE DIRECTIONS: FROM VALIDATION TO IMPLEMENTATION

While AlMousa et al’s study[5] represents significant progress, several challenges persist. Firstly, integrating adapted PROMs into routine clinical workflows remains inconsistent, often hindered by limited digital infrastructure and insufficient clinician training[26,27]. Practical solutions involve adopting hybrid paper-digital data collection methods where appropriate, integrating PROM data into electronic health record systems to alleviate administrative burdens, developing standardized training modules for clinicians and staff to enhance adoption and interpretation, and appointing institutional champions or interdisciplinary teams to ensure long-term sustainability. Secondly, longitudinal studies must evaluate whether culturally sensitive tools improve long-term outcomes, such as patient adherence, satisfaction[28,29], and functional recovery. Finally, global orthopedic consortia should prioritize the development of multilingual PROM libraries to minimize redundant adaptation efforts and accelerate the pace of cross-cultural research.

The development of digital and artificial intelligence-driven adaptations of PROMs provides a promising direction for the future research. Practical applications include mobile apps for real-time PROM data collection, chatbot-assisted questionnaire administration, and artificial intelligence-driven adaptive testing algorithms that dynamically adjust items based on prior responses to reduce patient burden. These approaches can enhance accessibility and responsiveness by delivering timely feedback and integrating PROM data into electronic health records[30,31]. However, these innovations face potential limitations. Data privacy and cybersecurity risks must be addressed through robust encryption and governance frameworks. Low digital literacy and limited access to devices or the internet in resource-limited settings may exacerbate disparities. Future programs should include offline-compatible solutions, user training, and context-specific implementation strategies to maximize equity and effectiveness. Utilizing these technologies may help bridge linguistic and cultural gaps, ensuring that PROMs remain adaptable to evolving healthcare systems and patient needs. The cross-cultural adaptation and validation of PROMs are illustrated in Figure 1.

Figure 1 Conceptual flowchart of cross-cultural adaptation and validation of patient-reported outcome measures.

Longitudinal studies are also essential to evaluate the sustained impact of culturally adapted PROMs on patient recovery trajectories and clinical decision-making[32,33]. Understanding how these tools impact outcomes over time may guide best practices for their integration into orthopedic care. Additionally, incorporating culturally adapted PROMs into large-scale multicenter trials may produce robust, globally relevant evidence, strengthening international collaboration and advancing the field of evidence-based orthopedic medicine.

CONCLUSION

The validation of the Arabic AAOS Foot and Ankle Outcomes Questionnaire highlights the transformative impact of culturally adapted PROMs. As orthopedic research increasingly embraces globalization, such initiatives ensure that no population is excluded from pursuing equitable, evidence-based care. By dismantling linguistic and cultural barriers, an inclusive paradigm can be established where the voices of all patients, regardless of language, are integral to develop orthopedic research and clinical care. The objective is to promote the integration of culturally adapted PROMs into research and clinical practice, while concurrently emphasizing to policymakers the critical value of these measures in advancing health equity on a global scale. Promoting inclusivity in clinical research and amplifying diverse patient perspectives will ultimately improve outcomes and globally advance musculoskeletal health.