ORIGINAL ARTICLE Development of a Language-Independent Functional Evaluation Andrew J. Haig, MD, Senthil Jayarajan, MD, Eric Maslowski, BA, Karen S. Yamakawa, MS, Melissa Tinney, MD, Klaus P. Beier, PhD, Derek Juang, MD, Lilliene Chan, BS, Tony Boggess, DO, Jesse Loar, BS, Bertha Owusu-Ansah, BS, Claire Kalpakjian, PhD ABSTRACT. Haig AJ, Jayarajan S, Maslowski E, Yamakawa KS, Tinney M, Beier KP, Juang D, Chan L, Boggess T, Loar J, Owusu-Ansah B, Kalpakjian C. Development of a language-indepen- dent functional evaluation. Arch Phys Med Rehabil 2009;90:2074-80. Objective: To design, validate, and critique a tool for self- report of physical functioning that is independent of language and literacy. Design: Software design and 2 prospective trials followed by redesign. Setting: United States and African university hospitals. Participants: Outpatient and inpatient competent adults with diverse physical impairments. Interventions: (1) Software design process leading to a Preliminary Language-Independent Functional Evaluation (Pre-L.I.F.E.); (2) patient surveys using a printed Pre-L.I.F.E. and a computer-animated Pre-L.I.F.E. tested in random order, followed by a questionnaire version of the standard Barthel Index; and (3) software redesign based on objective and qual- itative experiences with Pre-L.I.F.E. Main Outcome Measures: Validation of the general con- cept that written and spoken language can be eliminated in assessment of function. Development of a refined Language- Independent Functional Evaluation (L.I.F.E.). Results: A viable Pre-L.I.F.E. software was built based on design parameters of the clinical team. Fifty Americans and 51 Africans demonstrated excellent (Cronbach 0.8 Americans) and good (.425 Africans) reliability. In general, the rela- tions between Pre-L.I.F.E. and Barthel scores were excellent in the United States (interclass correlation coefficient for stair climbing, .959) but somewhat less good in Africa, with elim- ination functions very poorly related. The computer-animated Pre-L.I.F.E. was faster and trended to be more reliable than the printed Pre-L.I.F.E. in both the United States and Africa. Redesign meetings corrected statistical and qualitative chal- lenges, resulting in a new tool, the L.I.F.E. Conclusions: Literacy and language translation can be elim- inated from some aspects of functional assessment. The new L.I.F.E., based on solid empirical evidence and design princi- ples, may be a practical solution to assessment of function in the global culture. Key Words: Africa; Disability evaluation; Epidemiology; Language; Educational status; Outcome assessment (health care) Rehabilitation. © 2009 by the American Congress of Rehabilitation Medicine F UNCTION IS THE CORNERSTONE of rehabilitation. The ICF, for instance, has been acknowledged as the key framework for scientific and social policy issues related to disability and rehabilitation. 1 The measurement of function is critical if society is to understand the cost of disability and the impact of rehabilita- tion. Functional measures are necessary in epidemiologic stud- ies of disability, in quality improvement for rehabilitation pro- grams, and as critical outcome measures in medical research. Tools used to measure function vary widely depending on the need. They range from multiday physical and cognitive assess- ments with high-tech devices to simple questionnaires. Be- cause questionnaires are easy to use and inexpensive, they may be the most common tool for measurement of function. There are substantial problems in using questionnaires. Written questionnaires require literacy. Spoken questionnaires depend on translation into the language of the user. Even where there is translation, meaning may be lost, or meaning may change with local dialects. 2 It is extremely rare for a translated functional assessment to meet stringent requirements of back-translation and validation in a second language. When one understands that there are more than 7000 languages in the world, 3 and the Barthel Index, 4 arguably the most translated functional assessment, has only been translated into 17 languages according to our literature searches, one might conclude that the issue of functional assess- ment, when viewed from a global perspective, is hopelessly con- fused—literally a Tower of Babel problem. Most function is motion, not words. Especially with the advent of advanced computer graphics, it is possible that func- tional assessment can take the form of moving pictures that From the Department of Physical Medicine and Rehabilitation (Haig, Yamakawa, Boggess, Kalpakjian), 3-D Lab (Maslowski, Beier, Chan), Medical School (Juang, Loar), University of Michigan, Ann Arbor, MI; Department of General Surgery, Temple University Health System, Philadelphia, PA (Jayarajan); Veterans Hospital of Huntington, Huntington, WV (Tinney); and School of Allied Health Sciences, Uni- versity of Ghana, Accra, Ghana (Owusu-Ansah). Presented in part at the Ted Cole Research Day, University of Michigan, November 5, 2005, Ann Arbor, MI; The Kathy Kelb Memorial Lectureship, 2006, University of Michigan, Ann Arbor, MI; and as a poster at the American Academy of Physical Medicine and Rehabilitation, November 9 –12, 2006, Honolulu, HI. Supported by The Summer Biomedical Research Program, University of Michigan Medical School; The Blue Cross Blue Shield of Michigan Foundation McDevitt Excellence in Research Award; and The Michigan Rehabilitation Research and Training Grant (grant no. H133P090008). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Correspondence to Andrew J. Haig, MD, University of Michigan Spine Program, 325 E Eisenhower Pkwy, Ann Arbor, MI 48108, e-mail: andyhaig@umich.edu. Reprints are not available from the author. 0003-9993/09/9012-00923$36.00/0 doi:10.1016/j.apmr.2009.05.025 List of Abbreviations ICF International Classification of Functioning, Disability and Health L.I.F.E. Language-Independent Functional Evaluation Pre-L.I.F.E. Preliminary Language-Independent Functional Evaluation 2074 Arch Phys Med Rehabil Vol 90, December 2009