Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

European Portuguese version of the functional

disability inventory: translation and cultural
adaptation, validity, and reliability in adolescents
with chronic spinal pain

Rosa Andias, Joana Monteiro, Beatriz Santos & Anabela G. Silva

To cite this article: Rosa Andias, Joana Monteiro, Beatriz Santos & Anabela G. Silva (2019):
European Portuguese version of the functional disability inventory: translation and cultural
adaptation, validity, and reliability in adolescents with chronic spinal pain, Disability and
Rehabilitation, DOI: 10.1080/09638288.2019.1672110

To link to this article: https://doi.org/10.1080/09638288.2019.1672110

Published online: 10 Oct 2019.

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2019.1672110

ORIGINAL ARTICLE

European Portuguese version of the functional disability inventory: translation

and cultural adaptation, validity, and reliability in adolescents with chronic
spinal pain
Rosa Andiasa,b , Joana Monteiroa, Beatriz Santosa and Anabela G. Silvaa,b
a
School of Health Sciences (ESSUA), University of Aveiro, Campus Universit
ario de Santiago, Aveiro, Portugal; bCenter for Health Technology
and Services Research (CINTESIS.UA), University of Aveiro, Portugal

ABSTRACT ARTICLE HISTORY

Background: Functional disability affects a large percentage of adolescents with chronic pain. The func- Received 5 May 2019
tional disability inventory (FDI) has been widely described in the literature to assess functional disability, Revised 20 September 2019
with good psychometric properties. Accepted 21 September 2019
Purpose: To translate and adapt the FDI to European Portuguese language and assess the validity, reli-
KEYWORDS
ability, and measurement error of this version in adolescents with chronic musculoskeletal pain and, spe- Functional disability
cifically, with neck and low back pain. inventory; chronic pain;
Method: The translation and cross-cultural adaptation of the FDI was conducted according to inter- cross-cultural adaptation;
national guidelines. After that, 1730 adolescents completed the following scales and questionnaires: FDI, validity; reliability;
Nordic Musculoskeletal Questionnaire, Numeric Pain Rating Scale, Pain Catastrophizing Scale, Depression, adolescents
Anxiety and Stress Scale, Tampa Scale of Kinesiophobia, and Basic Scale on Insomnia complaints and
Quality of Sleep. Sixty-three of these adolescents, with at least one painful body site, completed the ques-
tionnaire twice to assess reliability and measurement error. Exploratory factor analysis and hypothesis
testing was used to assess construct validity.
Results: Cronbach’s alpha ranged from 0.81 and 0.88, ICC was 0.86 (95%CI:0.77; 0.92), the SEM and the
SDC were 2.50 and 6.93 (total score of 60 points), respectively. Fair to moderate correlations were
obtained between FDI and pain intensity (rs ¼ 0.33 to 0.43), catastrophizing (rs ¼ 0.41 to 0.44) depression,
anxiety, and stress (rs ¼ 0.48 to 0.53), fear of movement (rs ¼ 0.32 to 0.42), and sleep impairments (rs ¼
0.34 to 0.38). The factor analysis suggested a two-factor solution.
Conclusion: The European Portuguese version of the FDI has very good internal consistency, good tes-
t–retest reliability, and construct validity when used in a sample of community adolescents with
chronic pain.

ä IMPLICATIONS FOR REHABILITATION

 One of the most widely instruments used to assess functional disability is the Functional Disability
Inventory (FDI), which in its original version has good psychometric properties and is recommended
by the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials;
 However, the FDI has not been translated yet into European Portuguese language and its psychomet-
ric properties have not been assessed in adolescents with chronic spinal pain;
 This study suggests that the European Portuguese version of the FDI has very good internal consist-
ency, good test–retest reliability as well as construct validity when used in a sample of community
adolescents with chronic spinal pain;
 Therefore, these findings suggest the use of the European Portuguese version of the FDI to assess
the functional disability in adolescents with chronic spinal pain.

Introduction impairment of relationships and delay of social abilities develop-

Non-disease associated chronic pain is very common in childhood
and adolescence, but there is large variability in prevalence rates
across studies [1]. Musculoskeletal pain has been documented as
the main complaint, being present in 40% of adolescents [2].
Among the body regions identified as painful, the neck and the
low back are the most frequently reported with percentages as
high as 24.4 and 25.1%, respectively [3].
Chronic pain may result in significant losses in quality of life,
being associated with mood changes, sleep disturbance,
ment, which in turn seem to help perpetuate pain [4]. Therefore,
functional disability, defined as a set of limitations of an individual
relative to their ability to perform important daily life activities
including social, physical and personal activities [5], is one of the
consequences of chronic pain and affects 79.7% of adolescents
with chronic pain [6]. Therefore, pain and pain-related functional
disability are key elements to consider when assessing
adolescents with chronic pain and should be part of routine
assessment [7].

CONTACT Rosa Andias rosaandias@ua.pt School of Health Sciences, University of Aveiro, Campus Universit
ario de Santiago, Aveiro 3810-193, Portugal
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 R. ANDIAS ET AL.
There are several instruments that can be used to assess func-
tional disability in adolescents with chronic pain [5]. One of the
most widely used is the Functional Disability Inventory (FDI) [8],
which in its original version has good psychometric properties [9]
and is recommended by the Pediatric Initiative on Methods,
Measurement, and Pain Assessment in Clinical Trials [5]. It was ori-
ginally developed to assess disability in children and adolescents
with chronic abdominal pain [9], but has been used to assess
health-related activity limitations reported by children and adoles-
cents between 8 and 17 years old in both community and several
clinical populations [10]. The questionnaire consists of 15 items
assessing the individual perception on the limitations in daily life
activities for the past 2 weeks, which are measured in a five-point
Likert scale. Total score ranges from 0 to 60 points and higher
scores indicate greater disability [11]. The original version of the
FDI showed high test–retest reliability (r ¼ 0.74) and excellent
internal consistency (a ¼ 0.86 to 0.91) in 596 children (mean age
of 11.59 ± 2.45 years) with chronic abdominal pain [9]. Further
studies reported positive correlations between FDI and pain inten-
sity [12], catastrophizing [12], depression [13] anxiety [14], fear of
movement [15] and sleep problems [16]. An exploratory factor
analysis yielded a two-factor solution in a sample of 1300 children
and adolescents (mean age of 14.20 ± 2.40 years) with chronic
pain [10]. Although the FDI has demonstrated good psychometric
characteristics in several chronic painful syndromes [17–20], it has
not been validated for European Portuguese language and culture
neither for adolescents with chronic neck pain (NP) or low back
pain (LBP). Therefore, this study aimed to translate and adapt the
FDI to European Portuguese language and culture and assess the
validity, reliability, and measurement error of this version in ado-
lescents with chronic musculoskeletal pain and in a subgroup of
adolescents with chronic NP and LBP as the main musculoskel-
etal complaint.
Methods
This study was divided in two phases: (i) the translation and
cross-cultural adaptation of the FDI into European Portuguese and
(ii) the validity and reliability study to determine the psychometric
characteristics of the European Portuguese version of the FDI.
Cross-cultural adaptation process
The translation and cross-cultural adaptation of the FDI into
European Portuguese was conducted in line with the World
Health Organization [21] and Sousa and Rojjanasrirat [22] recom-
mendations. Permission to translate the FDI was obtained from
the authors via email. After that, the original version of FDI was
independently translated from English to European Portuguese by
two native European Portuguese physiotherapists, who were flu-
ent in English. These two versions were merged into one version,
resulting from a reconciliation process. This process was per-
formed by a third bilingual physiotherapist who holds a Doctoral
degree and is also a University lecturer together with the original
translators. The two versions of the FDI were compared against
each other and against the original version and discrepancies
were discussed until consensus was reached. This version was
back translated to English by two independent bilingual transla-
tors with no knowledge of the original version of the FDI (a med-
ical imaging researcher leaving in the UK and a University English
lecturer), and the back translated version was compared against
the original. In the translation process, emphasis was on concep-
tual and cultural equivalence and not linguistic equivalence. Both
the Portuguese European version and the back-translation were
sent to the author of the original version for comment. After
reaching an agreement on the pre-final version, it was tested in a
small sample of 10 Portuguese adolescents, five girls and five
boys, from the 10th grade (mean age of 15 years) with chronic
pain to assess clarity, comprehensibility and acceptability of the
European Portuguese version of the FDI. This pre-testing was
performed by a physiotherapist with a Master’s degree in
Musculoskeletal Physiotherapy.
Validity and reliability of the European Portuguese FDI
Procedures
For this part of the study the ethical approval was obtained from
the Ethics and Deontology Council of the University of Aveiro.
The final version of the European Portuguese FDI was applied in
four high schools, in Portugal, where all adolescents who
attended the 10th, 11th, and 12th grades were invited to partici-
pate. Both adolescents and legal guardians gave their written
informed consent before adolescents could enter the study if they
were 17-years old or younger. For those aged 18-years old, only
the adolescent’s written consent was required.
Adolescents were asked to complete an online questionnaire
containing sociodemographic information and the following
instruments (in addition to the FDI): Nordic Musculoskeletal
Questionnaire, Numeric Pain Rating Scale, Pain Catastrophizing
Scale (PCS), Depression, Anxiety and Stress Scale for Children
(DASS-C), Tampa Scale of Kinesiophobia (TSK) and the Basic Scale
on Insomnia complaints and Quality of Sleep (BaSIQS).
Adolescents with pathology of the nervous system were excluded.
The FDI was completed twice in a subsample of 63 adolescents
with at least one painful body site to assess the reliability and
standard error of measurement. According to the Consensus-
based Standards for the Selection of Health Measurement
Instruments guidelines [23], a minimum sample size of 50 partici-
pants is needed for reliability studies.
Instruments
Nordic musculoskeletal questionnaire. Adolescents completed the
Portuguese version of the Nordic Musculoskeletal Questionnaire
[24]. It consists of three questions (“Had some troubles or pain in
the last 12 months?”, “In the last 12 months felt some limitation
caused by work in the daily activities?”, “Had some troubles or
pain in the last 7 days?”) applied to nine anatomic regions, specif-
ically, neck, shoulders, wrists/hands, thoracic region, lumbar
region, hips/thighs, knees and ankles/feet. A total of 27 questions
could be marked as “Yes” or “No” [24]. In our study, we used the
3 months and the 7 days recall periods.
Numeric pain rating scale. Adolescents were asked about pain
intensity “now” for each painful body site where pain in the last 3
months and 7 days was reported using a numeric pain scale rang-
ing from 0 (no pain) to 10 (worst imaginable pain). A recent sys-
tematic review reported high levels of test–retest reliability [limits
of agreement of 0.9 and 1.2], and moderate correlations with the
FDI (r ¼ 0.35 to 0.43) [25].
Pain catastrophizing scale (PCS). The PCS consists of 13 items
that describe different thoughts and feelings that may be associ-
ated with pain. Each item can be classified in a scale of five
points, ranging from 0 ¼ “never” to 4 ¼ “always”. Total score
ranges from 0 to 52 points and higher scores indicate higher lev-
els of catastrophizing [26]. The European Portuguese version

showed construct validity and high internal consistency (cron-
bach’s alpha – a ¼ 0.91) [27]. It has already been used in children
and adolescents [28].
Depression, anxiety, and stress scale for children (DASS-C). The
DASS-C is a self-report instrument composed of 21 items distrib-
uted in three subscales: (i) depression, (ii) anxiety, and (iii) stress
[29,30]. Each item is classified in a scale of four points, ranging
from 0 ¼ “Did not apply to me at all” and 3 ¼ “Applied to me
very much, or most of the time”. Total score ranges from 0 to 21
points for each subscale, and higher scores indicate more nega-
tive affective conditions [29,30]. The DASS-C European Portuguese
version was developed by Pais-Ribeiro et al. [29] and its adapta-
tion for children and adolescents was performed by Leal
et al. [30].
Tampa scale of kinesiophobia (TSK). The TSK consists of 13 items
to assess fear of movement and the degree of comfort, security
and preparation for movement. Each item can be classified in a
scale of four points, ranging from 1 ¼ “strongly disagree” and 4
¼ “strong agree”. Total score ranges from 13 to 52 points and
higher scores indicate increased levels of fear of movement [31].
TSK Portuguese version showed good internal consistency
(a ¼ 0.82), and excellent test–retest reliability (Internal Correlation
Coefficient – ICC ¼ 0.99) [31].
Basic scale on insomnia complaints and quality of sleep (BaSIQS).
The BaSIQS was developed from the Sleep–Wake Questionnaire
by Allen Gomes et al. [32]. Its consists of seven items that assess
the difficulties in starting and maintaining sleep, and quality and
depth of sleep during the last month and considering a normal
week of classes. Total score ranges from 0 to 28 points and higher
scores are associated with poor quality of sleep. Reliability and
validity were tested in 1654 Portuguese adolescents and accept-
able internal consistency (a > 0.70) and good test–retest reliability
was reported (ICC  0.80) [32].
Data analysis
In line with the recommendations of the Consensus-based
Standards for the Selection of Health Measurement Instruments
guidelines [23] the following was assessed for the European
Portuguese version of the FDI: reliability (test–retest reliability and
internal consistency), measurement error (standard error of meas-
urement – SEM and smallest detectable change – SDC) and con-
struct validity (structural validity and hypothesis testing to assess
both convergent and divergent validity). Validity was assessed
separately for adolescents who reported at least 1 painful body
site and those who reported NP and LBP as their chief complaint.
Statistical analyses were conducted using the Statistical
Package for the Social Sciences (SPSS) version 25. Descriptive sta-
tistics (mean/median, standard deviation/interquartile range, per-
centage) were used to characterize the sample.
Cronbach’s alpha and item-total correlations were used to
examine the internal consistency of the FDI [33]. Values between
0.60 and 0.70 were considered acceptable and between 0.80 and
0.95 were considered very good [34,35]. Test–retest reliability was
assessed by means of an ICC (3,1) [36], with an interval of 4 weeks
between assessments. For this, a subsample of 63 adolescents
was randomly selected by class. Inside an opaque envelope, 35
papers were placed identifying each class of the last school
assessed. Sequentially and randomly, the papers were removed
until the required sample was reached.
EUROPEAN PORTUGUESE VERSION OF THE FDI 3
Excellent reliability was considered when the ICC >0.90, good
reliability when 0.75< ICC 0.90, moderate reliability when 0.50
ICC 0.75 and poor reliability when ICC <0.50 [36]. The SEM and
SDC were calculated using the formula SEM ¼ sd  冑1-ICC and
SDC¼ 1.96 冑2 X SEM, where sd is the standard deviation of the
sample [35].
Construct validity was assessed with an exploratory factor ana-
lysis, using a principal axis factor analysis, and hypothesis testing.
Exploratory factor analysis was performed in line with Kashikar-
Zuck et al. [10] who also assessed the validity of the FDI. This
method was chosen since there is no previous version of this
instrument in European Portuguese language and therefore its
structural validity has not been tested [37]. Preliminary analysis
was conducted to ensure that all requirements, and factorability
criteria were met (inter-item correlation, Kaiser-meyer-olkin meas-
urement of sampling adequacy, and Bartlett’s test of sphericity).
The FDI items were allocated into a principal axis factor analysis
with an oblique rotation. In line with previous publications where
two factors were found [10,38], a two-factor model was forced in
the analysis. Items were accepted within a factor if they had a pri-
mary factor loading of 0.40 and a secondary factor loading of
0.30. Items that did not clearly load on 1 factor were called
complex items and a sequential exploratory factor analysis was
used to remove these items one at a time to assess if the model
could be improved [10].
Hypothesis for construct validity were developed based on
existing evidence, assessed using a Spearman’s correlation coeffi-
cient (rs) and the strength of the correlation was interpreted as lit-
tle or no correlation (<0.25), fair (0.25–0.50), moderate to good
(0.50–0.75) and good to excellent (0.75–1) [39]. It was hypothe-
sized that: (i) pain intensity [12,40], catastrophizing (PCS) [12,41],
anxiety [14,40,41], stress (subscale DASS-C), and fear of movement
(TSK) [15], would show a positive and fair correlation with FDI
scores; (ii) sleep (BaSIQS) [16], depression (subscale DASS-C) as
well as the total score of the DASS-C [13,14] would show a posi-
tive and moderate to good correlation with FDI scores. In add-
ition, it was hypothesized that the European Portuguese version
of the FDI would be able to discriminate between adolescents
with and without pain (discriminant validity), what was assessed
using a Mann-Whitney U test. Significance was set at alpha
¼ 0.05.
Results
Sample characteristics
A total of 1730 adolescents entered the study, of whom 1435
(82.9%) reported at least one painful body site. Adolescents with
pain reported a mean (±sd) of 3.03 (±1.67) painful body sites
(range 1–9) and a mean(±sd) FDI score of 5.36 (±6.16).
Among those with pain, 123 (8.6%) reported that NP was their
chief complaint and 230 (16.0%) reported LBP as their chief com-
plaint. In the group of adolescents with NP and LBP, the
mean(±sd) of painful body sites was 3.63 (±1.53) and 3.59 (±1.44),
respectively; mean(±sd) pain intensity was 4.20 (±2.27) and 4.99
(±2.36), respectively, and mean(±sd) FDI score was 5.75 (±5.85)
and 7.47 (±7.35), respectively. A detailed characterization of the
sample is presented in Table 1.
Cross-cultural validation
After the pre-testing of the final European Portuguese version of
the FDI, no changes were suggested. The European Portuguese
FDI was considered clear, with a comprehensive and appropriate
4 R. ANDIAS ET AL.

Table 1. Sample characteristics.

Without pain With paina With NPb With LBPc
N 295 (17.1%) 1435 (82.9%) 123 (8.6%) 230 (16.0%)
Gender
Girls 103 (34.9%) 919 (64.0%) 90 (73.2%) 164 (71.3%)
Boys 192 (65.1%) 516 (36.0%) 33 (26.8%) 66 (28.7%)
Age (years) 16.47 ± 1.19 16.30 ± 1.17 16.25 ± 1.08 16.42 ± 1.21
Scholar level
10 94 (31.9%) 522 (36.4%) 42 (34.2%) 72 (31.3%)
11 91 (30.8%) 442 (30.8%) 41 (33.3%) 68 (29.6%)
12 110 (37.3%) 471 (32.8%) 40 (32.5%) 90 (39.1%)
Family situation (lives with … )
Father and mother 210 (71.2%) 964 (67.2%) 79 (64.3%) 149 (64.8%)
Mother 58 (19.6%) 287 (20.0%) 32 (26.0%) 53 (23.0%)
Father 7 (2.4%) 34 (2.4%) 1 (0.8%) 6 (2.6%)
Other 20 (6.8%) 150 (10.4%) 11 (8.9%) 22 (9.6%)
d
Pain intensity (0–10) 4.20 ± 2.27 4.99 ± 2.36
Number of pain sites
1 295 (20.6%) 6 (4.9%) 5 (2.2%)
2 350 (24.4%) 27 (21.9%) 54 (23.5%)
3 292 (20.3%) 31 (25.2%) 67 (29.1%)
4 210 (14.6%) 20 (16.3%) 44 (19.1%)
5 or more 288 (20.1%) 39 (31.7%) 60 (26.1%)
Number of pain sites (mean ± sd) 3.03 ± 1.67 3.63 ± 1.53 3.59 ± 1.44
FDI (0–60) 1.27 ± 2.94 5.36 ± 6.16 5.75 ± 5.85 7.47 ± 7.35
DASS-C (0–63)
Total score 3.84 ± 5.92 10.96 ± 11.40 14.02 ± 13.23 14.99 ± 13.21
Anxiety (subscale score DASS-C) 0.84 ± 1.68 2.78 ± 3.63 3.92 ± 4.43 3.85 ± 4.40
Depression (subscale score DASS-C) 1.54 ± 2.68 4.10 ± 4.59 5.31 ± 5.26 5.40 ± 5.09
Stress (subscale score DASS-C) 1.46 ± 2.33 4.08 ± 4.27 4.80 ± 4.56 5.74 ± 4.94
BaSIQS (0–28) 6.49 ± 3.74 8.83 ± 4.70 8.87 ± 5.27 9.72 ± 4.51
PCS (0–52)
Total score 5.85 ± 7.96 10.98 ± 10.62 10.33 ± 9.67 13.70 ± 11.90
Rumination 2.23 ± 3.29 4.03 ± 4.13 4.07 ± 4.14 5.04 ± 4.60
Magnification 1.26 ± 1.95 2.49 ± 2.69 2.00 ± 2.37 3.07 ± 2.99
Helplessness 2.36 ± 3.36 4.47 ± 4.69 4.26 ± 4.22 5.59 ± 5.30
TSK (13–52) 20.53 ± 7.59 23.69 ± 7.14 22.94 ± 7.07 24.41 ± 6.90
NP: neck pain; LBP: low back pain; FDI: functional disability inventory; DASS-C: depression, anxiety and stress scale for children; BaSIQS: basic
scale on insomnia complaints and quality of sleep; PCS: pain catastrophizing scale; TSK: tampa scale of kinesiophobia; sd: standard deviation.
a
Adolescents with at least 1 painful body site.
b
Adolescents with NP.
c
Adolescents with LBP.
d
It was not possible to determine the intensity of pain for this group, since in the questionnaire the pain intensity was only assessed by pain-
ful body area and not in general.

language for application in Portuguese adolescents with p ¼ 0.36). ICC was 0.86 (95% CI: 0.77; 0.92) indicating good reliabil-
chronic pain. ity. SEM and SDC were 2.50 and 6.93, respectively, considering
the total score of 60 points.
Reliability
Internal consistency Validity
Cronbach’s alpha was calculated both with data from the whole Hypotheses testing
sample and with data from the subsample used for test–retest The scores of the European Portuguese FDI showed positive and
reliability. The European Portuguese version of the FDI showed
fair to moderate correlations with pain intensity, catastrophizing,
very good internal consistency in the group with at least one
depression, anxiety and stress, fear of movement and sleep
painful body site (a ¼ 0.84), in the subgroup with NP (a ¼ 0.81)
impairments (Table 3) in both the group with at least one painful
and LBP (a ¼ 0.87) and in the subsample used for test–retest reli-
body site and the subgroup with NP as the chief complaint. In
ability (moment 1: a ¼ 0.82 and moment 2: a ¼ 0.88). Cronbach’s
the subgroup of adolescents with LBP as their chief complaint
alpha for each FDI item, in both moments, was also performed
correlations were fair.
and is shown in Table 2.

Test–retest reliability, standard error of measurement, and Discriminant validity

smallest detectable change
These indicators were calculated for the subsample of 63 adoles-
cents that filled the FDI twice. Mean(±sd) FDI scores were 7.06
(±6.67) in the first assessment and 6.87 (±7.31) in the second
assessment and no significant differences were found (Z ¼ 0.92;
The European Portuguese version of the FDI was able to discrim-
inate between the group of adolescents without pain and adoles-
cents (i) with at least one painful body site (Z ¼ 14.55; p ¼ 0.00),
(ii) with NP as chief complaint (Z ¼ 10.33; p ¼ 0.00) and (iii) with
LBP as chief complaint (Z ¼ 13.86; p ¼ 0.00).
 EUROPEAN PORTUGUESE VERSION OF THE FDI 5

Table 2. Internal consistency.

At least 1 Subsample moment Subsample
painful body sitea NPa LBPa 1a moment 2a
FDI item (n ¼ 1435) (n ¼ 123) (n ¼ 230) (n ¼ 63) (n ¼ 63)
1. Walking to the bathroom. 0.84 0.82 0.87 0.82 0.88
2. Walking up stairs. 0.83 0.80 0.86 0.80 0.87
3. Doing something with a friend (e.g., playing a game). 0.83 0.80 0.86 0.81 0.87
4. Doing chores at home. 0.83 0.80 0.86 0.80 0.87
5. Eating regular meals. 0.84 0.81 0.86 0.80 0.87
6. Being up all day without a nap or rest. 0.84 0.81 0.87 0.82 0.88
7. Riding the school bus or traveling in the car. 0.84 0.81 0.86 0.80 0.89
8. Being at school all day. 0.84 0.79 0.86 0.80 0.87
9. Doing the activities in gym class (or playing sports). 0.83 0.79 0.85 0.79 0.87
10. Reading or doing homework. 0.84 0.80 0.86 0.79 0.88
11. Watching TV. 0.84 0.81 0.86 0.81 0.87
12. Walking the length of a football field. 0.83 0.81 0.86 0.81 0.87
13. Running the length of a football field. 0.82 0.79 0.86 0.80 0.87
14. Going shopping. 0.83 0.81 0.86 0.81 0.87
15. Getting to sleep at night and staying asleep. 0.84 0.82 0.87 0.82 0.88
a Total 0.84 0.81 0.87 0.82 0.88
NP: neck pain; LBP: low back pain; a: Cronbach’s alpha.
a
a if the item is excluded.

Table 3. Correlations between FDI and intensity of pain, catastrophizing, 14 (combined R2 ¼ 36.2%), 5 (combined R2 ¼ 37.2%), and 15
depression, anxiety, stress, fear of movement and sleep for the groups with at (combined R2 ¼ 37.1%) (Table 4). Therefore, these items were
least 1 painful body site, neck and low back pain. kept in the model.
Functional disability
(high scores ¼ higher levels of disability) Group with NP
At least 1 As in the group of adolescents with at least 1 painful body site,
painful body NP LBP the distribution patterns were clear in the items 2, 3, 4, 9, 12, 13
Scales site (n ¼ 1435) (n ¼ 123) (n ¼ 230) (factor 1) and 7, 8, 10 and 11 (factor 2), but not in the items 1, 5,
1. Pain intensity – 0.33 0.43 6, 14 and 15 (complex items). It was considered that the strength
2. PCS 0.41 0.44 0.44
3. DASS-C 0.53 0.56 0.48
of the model did not change considerably after removing items 1
4. Depression (subscale score DASS-C) 0.46 0.56 0.40 (combined R2 ¼ 36.9%), 5 (combined R2 ¼ 36.9%), 6 (combined
5. Anxiety (subscale score DASS-C) 0.51 0.52 0.48 R2 ¼ 36.0%), 14 (combined R2 ¼ 35.8%) and 15 (combined R2 ¼
6. Stress (subscale score DASS-C) 0.48 0.50 0.44 36.5%) (Table 4). Thus, these items were kept in the initial model.
7. TSK 0.42 0.39 0.32
8. BaSIQS 0.34 0.35 0.38
Group with LBP
NP: neck pain; LBP: low back pain; PCS: pain catastrophizing scale; DASS-C:
depression, anxiety and stress scale for children; TSK: Tampa scale of kinesiopho- In this group the distribution pattern was clear for all items with
bia; BaSIQS: basic scale on insomnia complaints and quality of sleep a primary factor loading 0.40 and a secondary factor loading
Correlation is significant at the 0.01 level (two-tailed).
0.30. Items 1, 2, 3, 4, 5, 9, 12, 13 and 14 loaded in factor 1 and
items 6, 7, 8, 10, 11 and 15 loaded on factor 2 (see Table 4).

Explanatory factor analysis

The Kaiser-meyer-olkin measurement of sampling adequacy was
0.89, 0.74, and 0.87 in the group with at least one painful body
site, NP and LBP, respectively, i.e., showed a good recommenda-
tion for the factorial analysis for the first and last group and a
medium recommendation for the group with NP [42]. Globally,
nine items were equally loaded into the three groups
representing a division into activities that require physical effort
(factor 1: items 2,3,9,12,13) and activities that require little or no
physical effort (factor 2: items 7,8,10,11). The remaining 6 items
loaded differently in both factors between the three groups. The
two factors explained 35.9% of variance in the group of at least
one painful body site, 34.7% in the group with NP and 42.6% in
the group with LBP.
Group of adolescents with at least one painful body site
The distribution patterns were clear for most items, with a pri-
mary factor loading 0.40 and a secondary factor loading 0.30,
except for items 4, 5, 14 and 15 where the primary factor load
was <0.40. These items were considered complex items and were
sequentially removed, one at a time; the strength of the model
remained similar for all four items: item 4 (combined R2 ¼ 36.1%),
Discussion
This study aimed to translate and culturally adapt the original ver-
sion of the FDI to European Portuguese and to explore the valid-
ity and reliability of this version in a sample of adolescents with
at least one painful body site and in subgroups with NP and LBP
as their chief complaint. Results suggest that the European
Portuguese version of the FDI is both reliable and valid.
FDI and pain
FDI scores in this study sample were lower than those previously
reported. A recent study with adolescents (14.2 ± 2.1 years), with
musculoskeletal chronic pain, from a school community found an
FDI of 12.1 ± 10.5 [43]. These authors used a definition of chronic
pain that is similar to the definition used in the present study,
but they included body areas not included in the present study,
such as head, abdomen and chest, which might have influenced
the final levels of disability. Guite et al. [12] and Kashikar-Zuck
et al. [10] recruited adolescents from pain clinics and reported
higher FDI scores (23.75 ± 10.76 and 21.1 ± 11.4, respectively). The
fact that the total FDI score was lower in our study that used and
 6 R. ANDIAS ET AL.

non-clinical population further reinforces the validity of the

Factor 2
E ¼ 1.10
0.28
0.12
0.02
0.19
0.03
0.58
0.43
0.51
0.13
0.67
0.52
0.05
0.05
0.19
0.48
European Portuguese version of the FDI.
The prevalence of chronic pain for at least one body site
(82.9%) in our study is higher than that found in previous studies
in other countries [1,6], but closer to previous values reported in
LBP (n ¼ 230)
Factor 1
E ¼ 5.29
0.85
0.56
0.75
0.47
0.58
0.06
0.23
0.15
0.65
0.04
0.19
0.78
0.69
0.57
0.01
our country [44]. Hoftun et al. [6] reported a prevalence of 33.4%
and King et al. [1] reported a prevalence ranging from 4 to 40%.
Differences in the measurement instruments used to identify the
painful body sites and in the definition of NP and LBP may have
impacted the results. In contrast, the prevalence of neck (8.6%)
(0.38)
(0.84)
(0.80)
(0.84)
(0.55)
(1.02)
(0.73)
(0.90)
(1.03)
(0.81)
(0.64)
(0.63)
(1.08)
(0.66)
(1.11)
Mean (sd)

and low back (16%) chronic pain as main complaint found in the
0.08
0.66
0.40
0.55
0.16
0.68
0.33
0.69
0.96
0.47
0.24
0.30
0.83
0.27
0.83
present study are similar or lower than that reported in previous
studies [3,6]. Hoftun et al. [6], reported a prevalence of 14.3% for
NP and of 10.9% for LBP in the age group of 13- to 15-years old
and of 20.9 and 17.5%, respectively, in the age group of 16- to
Factor 2
E ¼ 1.35
0.05
0.09
0.07
0.17
0.04
0.09
0.63
0.41
0.12
0.73
0.86
0.18
0.18
0.26
0.18
18-years old. The fact that we included in these groups only those
adolescents who reported NP and LBP as main complaints may
explain the slightly lower prevalence values found in the pre-
sent study.
NP (n ¼ 123)
Factor 1
E ¼ 3.85
0.19
0.60
0.61
0.44
0.34
0.37
0.01
0.30
0.65
0.09
0.14
0.66
0.88
0.26
0.19

Reliability and measurement error

The European Portuguese version of the FDI, showed very good
internal consistency (a ¼ 0.82–0.88) and good reliability (ICC ¼
(0.22)
(0.73)
(0.62)
(0.72)
(0.44)
(0.98)
(0.64)
(0.88)
(0.87)
(0.73)
(0.67)
(0.52)
(1.00)
(0.50)
(1.06)
Mean (sd)
Table 4. Factor loadings based on explanatory factor analysis for the groups with at least 1 painful body site, neck and low back pain.

0.86; 95% CI ¼ 0.77;0.92), in agreement with previous studies

[8,9,38]. Claar and Walker [9] in a sample of 596 children and ado-
0.03
0.52
0.27
0.40
0.15
0.58
0.24
0.54
0.71
0.40
0.24
0.17
0.67
0.18
0.65

lescents (8–17 years) with chronic abdominal pain reported an

internal consistency ranging from a ¼ 0.86 to 0.91 and good tes-
t–retest reliability (r ¼ 0.74). Similar results were also obtained in
adolescents with chronic pain from a school community with the
Factor 2
E ¼ 0.97

0.003
0.05
0.07

0.30
0.31
0.43
0.42
0.53
0.02
0.69
0.62
0.07
0.04
0.31
0.35

Catalan version of the FDI (a ¼ 0.89) [43]. The values of SEM and
SDC found in the present study were 2.50 and 6.93, respectively.
At least 1 painful body site (n ¼ 1435)

No other studies in the literature assessing these psychometric

characteristics of the FDI were found.
Factor 1
E ¼ 4.41
0.49
0.61
0.65
0.37
0.18
0.07
0.18
0.06
0.75
0.11
0.13
0.77
0.79
0.34
0.15

Validity
The results for convergent validity confirmed the a priori hypoth-
esis of the positive and significant correlation between the FDI
and catastrophizing, depression, anxiety, stress, fear of movement
and sleep impairments, in the three groups assessed. Our results
(0.33)
(0.82)
(0.73)
(0.70)
(0.44)
(0.91)
(0.54)
(0.84)
(0.99)
(0.62)
(0.47)
(0.63)
(1.03)
(0.49)
(0.99)
Mean (sd)

support the findings reported in the literature and showed similar

magnitudes of correlation between the FDI and pain intensity
0.06
0.55
0.32
0.35
0.11
0.51
0.18
0.46
0.77
0.25
0.13
0.25
0.67
0.15
0.59

[12], catastrophizing [12,41], anxiety [40,41], fear of movement

[15] and depression [9,13] and the FDI. Contrary to what we had
hypothesized, we found a fair correlation between sleep impair-
ments and the FDI. Evans et al. [16] reported a correlation of 0.61
NP: neck pain; LBP: low back pain; sd: standard deviation.
3. Doing something with a friend (e.g., playing a game).

between the Pittsburg Sleep Quality Index and FDI, in a clinical

9. Doing the activities in gym class (or playing sports).

sample of 213 adolescents (14.5 ± 2.4 years) with chronic pain,

15. Getting to sleep at night and staying asleep.

including head and abdominal pain. Differences in the characteris-

7. Riding the school bus or traveling in the car.

tics of the sample and the type of measurement instrument may

13. Running the length of a football field.
6. Being up all day without a nap or rest.

12. Walking the length of a football field.

help explain this difference in the results.

As reported by Kashikar-Zuck et al. [10] and Offenbacher et al.
[38], we found two factors and in line with the definition previ-
10. Reading or doing homework.

ously used by the referred authors, we defined these factors as

1. Walking to the bathroom.

activities requiring physical effort and less strenuous physical

8. Being at school all day.
4. Doing chores at home.
5. Eating regular meals.

activities. However, the percentage of variance explained by the

2. Walking up stairs.

14. Going shopping.

two factors was 35.9% (group with at least 1 painful body site),
11. Watching TV.

34.7% (group with NP) and 42.6% (group with LBP), which is
FDI item (0–4)

lower than that previously reported [10,38]. It is possible that

these results may have been influenced by differences in sample
characteristics and by the different complex items found in the
final models between the studies. In our samples of adolescents

with at least one painful body site and with NP, we found four
and five complex items, respectively, but its exclusion from the
model did not strengthen it. Thus, we decided to keep these
items in the model. Kashikar-Zuck et al. [10] only found two com-
plex items, the 4 and 15 items, which were kept in the model for
the same reason.
Limitations and future research
There are a few limitations that should be considered. Although
we have one main group of adolescents with chronic pain and
two sub-groups, these subgroups are included in the main group.
However, considering that this was the first validation study of
the version of the European Portuguese FDI we considered it
important to perform the analysis of the instrument only on ado-
lescents with NP and with LBP, to better characterize and perceive
the applicability of the FDI to different conditions. Additionally,
although the Nordic Musculoskeletal Questionnaire body-chart
illustrating the different body regions was used, there may have
been some errors in the identification and distinction of body
regions by the adolescents. For example, between NP and shoul-
der pain, or between thoracic, hip and LBP.
The reliability study was performed at a 4-week interval and
the literature has reported shorter periods for this assessment
[23]. However, this did not seem to significantly impact test–retest
reliability.
The FDI scores were low and it was not possible to establish
cutoffs for different levels of disability as reported by Kashikar-
Zuck et al. [10]. Furthermore, this limits the generalizability of the
findings to clinical samples of adolescents with chronic pain.
Conclusion
The findings of this study suggest that the European Portuguese
version of the FDI has very good internal consistency, good tes-
t–retest reliability, SEM and SDC values of 2.50 and 6.93, respect-
ively, as well as construct validity when used in a sample of
community adolescents with chronic pain. Further investigation of
the properties of this instrument is necessary in clinical samples
of adolescents with chronic pain.
Ethical approval
Ethical approval was obtained from the Ethics and Deontology
Council of the University of Aveiro.
Disclosure statement
Although there are no conflicts of interest, we would like to
inform you that one of the authors of this original article is the
author of 1 article referenced in this study and other is the author
of 3 articles referenced in this study.
Funding
This work is part of a PhD scholarship from the Foundation for
Science and Technology (SFRH/BD/119528/2016), Portugal.
ORCID
Rosa Andias http://orcid.org/0000-0003-2419-5642
EUROPEAN PORTUGUESE VERSION OF THE FDI 7
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