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Cognitive Testing of the Spinal Appearance Questionnaire With Typically Developing Youth and Youth With Idiopathic Scoliosis

Mulcahey, Mary Jane PhD; Chafetz, Ross S. DPT; Santangelo, Anna Marie RN; Costello, Kimberly RN; Merenda, Lisa A. MSN; Calhoun, Christina MSPT; Samdani, Amer F. MD; Betz, Randal R. MD

Journal of Pediatric Orthopaedics: September 2011 - Volume 31 - Issue 6 - p 661–667
doi: 10.1097/BPO.0b013e318221ea8b

Background The Spinal Appearance Questionnaire (SAQ) underwent initial psychometric studies, which suggested good reliability and discriminative ability. Although the SAQ is used as a self report of appearance, our center was concerned about its use with youth owing to complex words and vague questions. We conducted this cross-sectional study to evaluate the readability, comprehension, and interpretation of items on the SAQ.

Methods Cognitive interview methodology of 76 youths (8 to 16 y; average age 13) included 31 with scoliosis and 45 typically developing. Subjects were required to read each SAQ item and think aloud to capture cognitive processes about the items and responses. Interviews were audiotaped and transcribed verbatim. Problems were categorized and frequencies for each category were calculated.

Results There were reading and comprehension problems and problems understanding the illustration with every written and pictorial SAQ item, respectively. The percent of subjects who encountered at least one problem ranged from 16% to 96%. Subjects had difficulty with understanding the intent of every SAQ item and with understanding the meaning of specific words such as “prominence” and “flank.” The pictorial illustrations for items 2 and 3 were problematic for 58% and 49% of subjects, respectively. The illustrations of the lungs (item 4) and hips (items 4 and 5) were problematic for 42% and 27% of subjects, respectively. These results were consistent regardless of age or diagnoses.

Conclusion This study does not support the use of the SAQ as currently used with youth owing to use of complex medical words, vague questions, difficult illustrations, and various interpretations of the intent of many of the items.

Level of Evidence Not applicable (not an intervention study).

Shriners Hospitals for Children—Philadelphia, Philadelphia, PA

The study was funded by the Shriners Hospitals for Children—Philadelphia, the Harms Study Group, and a clinical research grant from DePuy Spine, Inc.

The authors have no conflict of interest.

Reprints: Mary Jane Mulcahey, PhD, Shriners Hospitals for Children—Philadelphia, 3551 North Broad Street, Philadelphia, PA 19140. e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.