INTRODUCTION
Stroke is a global health issue that is the second or third cause of death in many countries, and it is one of the most common causes of disability for adults worldwide (Langhorne et al., 2011). Globally, there are over 80 million stroke survivors, and each year, there are an estimated 13.7 million new cases, with 5.5 million people dying due to stroke. The brain continuously requires 25% of the heart’s output, and any decrease in blood supply to the brain will cause the death of brain tissue, which affects brain function (Flynn et al., 2008). A stroke is caused when the function of the brain is lost rapidly as a result of disruption of the blood supply to a specific area of the brain. Strokes can be categorized according to the cause of the blood supply disruption into one of two main types: ischemic stroke (about two-thirds of all strokes) or hemorrhagic stroke (Doyle et al., 2008). The level of deterioration in brain function depends on the size and area of the brain ischemia (Flynn et al., 2008). Risk factors for stroke include hypertension, a high body mass index, smoking, diabetes, and aging.
Balance problems are a very common issue after stroke, and there is an inverse relationship of balance problems with the recovery of mobility and activities of daily living (Tyson et al., 2006). Moreover, balance dysfunction increases the risk of falling for patients who have suffered a stroke (Hyndman et al., 2002). Balance refers to the ability to maintain an upright position within the base of support and to restore physical stability after external perturbation (Juras et al., 2008). Balance control is a multifaceted process, because it requires many systems within the body to work and act together, including the motor cortex and the motor, vestibular, auditory, sensory, and visual systems (Mancini and Horak, 2010). Balance disorders affect social aspects of individuals’ lives (e.g. due to fears of falling) as much as they affect physical performance (Mancini and Horak, 2010). For those reasons, physical therapists assess balance problems to apply appropriate interventions (Horak et al., 2009).
Many assessment tools are used to identify balance disorders and evaluate the risk of falls for older persons (Horak et al., 2009), including the Berg Balance Scale (Berg et al., 1992), Activities-specific Balance Confidence scale (Powell and Myers, 1995), and Postural Assessment Scale for Stroke Patients (PASS) (Benaim et al., 1999). The PASS is a 12-item outcome measure that assesses many aspects of balance, including maintaining position and changing position in stroke patients. Each item on this scale is scored from 0 to 3, where 0 means that the patient cannot perform the task and 3 indicates that the patient achieved performance of the item (Benaim et al., 1999). The PASS has high levels of reliability (Benaim et al., 1999), internal consistency (Mao et al., 2002), and concurrent validity (Wang et al., 2004). Stroke is a major health concern in Saudi Arabia, yet there is a lack of an Arabic version of the widely used PASS. Despite the high incidence of stroke and the need for effective rehabilitation tools in the Arabic-speaking population, there is a gap in validated assessment instruments to accurately measure postural control among Arabic-speaking stroke survivors. This gap hinders healthcare providers in Saudi Arabia from delivering optimal care and rehabilitation services, as they lack a culturally and linguistically appropriate tool to assess and track the progress of stroke patients’ recovery.
The purpose of this study was to translate and culturally adapt the English version of the PASS into Arabic language [Arabic version of PASS (PASS-Arabic)]. This adaptation is critical to addressing the unique needs of Arabic-speaking stroke survivors, providing healthcare professionals with a reliable and valid tool for assessing postural control. By bridging this gap, the PASS-Arabic will ease access for stroke survivors to one of the most widely used tools for assessing postural control. This will enhance the quality of care and rehabilitation outcomes for stroke survivors, support improved stroke management, and reduce disability in Saudi Arabia. Facilitating more accurate assessments will enable targeted interventions, ultimately contributing to better recovery rates and quality of life for stroke patients.
MATERIALS AND METHODS
This cross-sectional study was carried out between February 2022 and January 2023 in Saudi Arabia. The new PASS-Arabic was reviewed by 40 Arabic-speaking physical therapists to verify the comprehensibility of each item. The translation and cross-cultural adaptation of the PASS was performed according to international guidelines for the translation and cultural adaptation of self-reported measures proposed by Beaton et al. (2000).
Initially, the first step was the forward translation of the English PASS, which was performed independently by two translators who were native Arabic speakers and also fluent in English. One translator was a physical therapist and the other translator did not have a medical background. The forward translation resulted in two Arabic versions of the PASS. In the second step, the two forward translators along with the authors worked together to combine the two Arabic translations into one Arabic refined version of the PASS, where the differences between the two versions were reviewed and resolved by consensus. The third step was translating the combined PASS-Arabic back into English (backward translation), performed independently by two translators who were blinded to the original PASS. The two translators of the backward translation were native English speakers and also fluent in Arabic. The backward translation resulted in two English versions of the PASS.
The fourth step was to develop the pre-final Arabic version by holding a meeting that included the two forward translators, the two backward translators, and the authors. Developing the pre-final Arabic version was accomplished in this meeting by comparing the two English backward translation versions with the original English version, identifying and discussing any differences between them, and implementing any modification needed to the Arabic version.
The last step was pre-testing the translated PASS-Arabic using a group of Arabic-speaking physical therapists and recording their feedback on the PASS-Arabic. After reading the PASS-Arabic, the physical therapists provided feedback by answering three questions for each of the assessment’s sections. The questions were as follows:
Did you face any difficulties reading the PASS-Arabic?
Did you understand all parts of the PASS-Arabic?
Were all questions related to postural assessment?
After receiving the responses of the physical therapists, authors discussed the feedback of physical therapists to make any modifications needed to the final PASS-Arabic version.
RESULTS
The PASS was translated and culturally adopted according to the translation guideline from English into Arabic language. A pre-final Arabic version was produced and presented to physical therapists to express their feedback about the ease of reading the scale, understanding the scale, and the extent to which the questions relate to assessing balance. The two backward translations to English are shown in Table 1.
The original Postural Assessment Scale for Stroke (PASS) and the Arabic version (PASS-Arabic) with the backward translations.
| Item | Original PASS | PASS-Arabic | Backward translation 1 | Backward translation 2 |
|---|---|---|---|---|
| Introduction | Give the subject instructions for each item as written below. When scoring the item, record the lowest response category that applies for each item. | أعطِ المريض تعليمات لكل الفقرات التالية. قم بتسجيل أقل درجة تنطبق على أداء المريض. تأكد من فهم المريض للتعليمات. | Give the patient instructions for all the following paragraphs. Record the lowest score applicable to the patient’s performance. Make sure the patient understands the instructions. | Give the patient instructions for each of the following sections Track the lowest score applicable to the patient’s performance. Make sure the patient understands the instructions. |
| 1 | Have the subject sit on a bench/mat without back support and with feet flat on the floor. 3. Can sit for 5 minutes without support 2. Can sit for more than 10 seconds without support 1. Can sit with slight support (for example, by 1 hand) 0. Cannot sit | اطلب من المريض ان يجلس على مقعد / سرير بدون دعامة للظهر والقدم مسطحة على الأرض ٣. يمكنه الجلوس لمدة ٥ دقائق بدون مساعدة ٢. يمكنه الجلوس لأكثر من ١٠ ثوانٍ بدون مساعدة ١. يمكنه الجلوس مع مساعدة طفيفة (مثلا: مساعدة بيد واحدة) ٠. لا يمكنه الجلوس | Ask the patient to sit on a seat/bed without back support, feet flat on the floor 3. He can sit for 5 minutes without help 2. He can sit for more than 10 seconds without assistance 1. He can sit with slight assistance (example: one-handed assistance) 0. He can’t sit down | Ask the patient to sit on a chair/bed without back support with the feet flat on the floor. 3. The patient sat for five minutes unassisted 2. The patient sat for more than 10 seconds unassisted 1. The patient sat with a slight assistance (e.g. one hand support) 0. The patient couldn’t sit down |
| 2 | Have the subject stand, providing support as needed. Evaluate only the ability to stand with or without support. Do not consider the quality of the stance. 3. Can stand with support of only 1 hand 2. Can stand with moderate support of 1 person 1. Can stand with strong support of 2 people 0. Cannot stand, even with support | اطلب من المريض ان يقف مع تقديم المساعدة عند الحاجة. قيّم القدرة على الوقوف فقط مع المساعدة أو بدونها. لا تأخذ بعين الاعتبار جودة الوقوف. ٣. يمكنه أن يقف مع مساعدة من يد واحدة فقط ٢. يمكنه أن يقف مع مساعدة متوسطة من شخص واحد ١. يمكنه أن يقف مع مساعدة قوية من شخصين ٠. لا يمكنه أن يقف حتى مع المساعدة | Ask the patient to stand with assistance when needed. Assess the ability to stand only with or without assistance. Do not take into account the quality of the stand. 3. He can stand for 5 minutes without help 2. He can stand for more than 10 seconds without assistance 1. He can stand with slight assistance (example: one-handed assistance) 0. He can’t stand up | Ask the patient to stand with assistance if needed. Assess the ability to stand with or with no assistance. Regardless of the posture of the stand 3. The patient stood with one hand assistance 2. The patient stood with average assistance from another person 1. The patient stood with strong assistance from two people 0. The patient couldn’t stand even with assistance |
| 3 | Have the subject stand without support. Evaluate only the ability to stand with or without support. Do not consider the quality of the stance. 3. Can stand without support for more than 1 minute and simultaneously perform arm movement at about shoulder level. 2. Can stand without support for 1 minute or stands slightly asymmetrically. 1. Can stand unassisted for 10 seconds or rely heavily on one leg. 0. Cannot stand without support | اطلب من المريض أن يقف بدون مساعدة. قيّم القدرة على الوقوف فقط مع مساعدة أو بدونها. لا تأخذ بعين الاعتبار جودة الوقوف. ٣. يمكنه أن يقف دون مساعدة لأكثر من دقيقة واحدة والقيام في الوقت نفسه بإستخدام الذراع عند مستوى الكتف تقريبًا ٢. يمكنه أن يقف بدون مساعدة لمدة دقيقة واحدة أو الوقوف بشكل غير متناسق نوعًا ما ١. يمكنه أن يقف دون مساعدة لمدة ١٠ ثوانٍ أو أن يعتمد بشدة على رِجلٍ واحدة ٠. لا يمكنه أن يقف بدون مساعدة | Ask the patient to stand unassisted when needed. Assess the ability to stand only with or without assistance. Do not take into account the quality of the stand. 3. He can stand unassisted for more than one minute and at the same time use the arm at shoulder level approximately 2. He can stand unassisted for one minute or stand somewhat disproportionately. 1. He can stand unassisted for 10 seconds or rely heavily on one leg. 0. He cannot stand without assistance | Ask the patient to stand unassisted. Assess the ability to stand with or with no assistance. Regardless of the posture of the stand 3. The patient stood unassisted for more than one minute, while simultaneously using the arm at about shoulder level 2. The patient stood unassisted for one minute or stood up disproportionately 1. The patient stood unassisted for 10 seconds or relied heavily on one leg 0. The patient couldn’t stand unassisted |
| 4 | Have the subject stand on the nonparetic leg. Evaluate only the ability to bear weight entirely on the nonparetic leg. Do not consider how the subject accomplishes the task. 3. Can stand on nonparetic leg for more than 10 seconds 2. Can stand on nonparetic leg for more than 5 seconds 1. Can stand on nonparetic leg for a few seconds 0. Cannot stand on nonparetic leg | اطلب من المريض الوقوف على رِجلهِ السليمة. قيِّم القدرة على تحميل الوزن كاملًا على الرِجلِ السليمة دون الاعتبار بكيفية تنفيذ المريض للمهمة. ٣. يمكنه أن يقف على الرِجلِ السليمة لأكثر من ١٠ ثوانٍ ٢. يمكنه أن يقف على الرِجلِ السليمة لأكثر من ٥ ثوانٍ ١. يمكنه أن يقف على الرِجلِ السليمة لثوانٍ معدودة ٠. لا يمكنه أن يقف على الرِجلِ السليمة | Ask the patient to stand on his good leg. Assess the ability to bear the full weight on the good leg, regardless of how the patient performs the task. 3. He can stand on the good leg for more than 10 seconds 2. He can stand on the good leg for more than 5 seconds 1. He can stand on the good leg for a few seconds 0. He cannot stand on the good leg | Ask the patient to stand on the intact foot. Assess the ability to endure full weight on the intact foot regardless of the posture of the stand 3. The patient stood on the intact foot for more than 10 seconds 2. The patient stood on the intact foot for more than five seconds 1. The patient stood on the intact foot for a few seconds 0. The patient couldn’t stand on the intact foot |
| 5 | Have the subject stand on the paretic leg. Evaluate only the ability to bear weight entirely on the paretic leg. Do not consider how the subject accomplishes the task. 3. Can stand on paretic leg for more than 10 seconds 2. Can stand on paretic leg for more than 5 seconds 1. Can stand on paretic leg for a few seconds 0. Cannot stand on paretic leg | اطلب من المريض الوقوف على رِجلهِ المصابة. قيِّم القدرة على تحميل الوزن كاملًا على الرِجلِ المصابة دون الاعتبار بكيفية تنفيذ المريض للمهمة. ٣. يمكنه أن يقف على الرِجلِ المصابة لأكثر من ١٠ ثوانٍ ٢. يمكنه أن يقف على الرِجلِ المصابة لأكثر من ٥ ثوانٍ ١. يمكنه أن يقف على الرِجلِ المصابة لثوانٍ معدودة ٠. لا يمكنه أن يقف على الرِجلِ المصابة | Ask the patient to stand on the affected leg. Assess the ability to bear the full weight on the affected leg, regardless of how the patient performs the task. 3. He can stand on the affected leg for more than 10 seconds 2. He can stand on the affected leg for more than 5 seconds 1. He can stand on the affected leg for a few seconds 0. He cannot stand on the affected leg | Ask the patient to stand on the injured foot. Assess the ability to endure full weight on the injured foot regardless of the posture of the stand 3. The patient stood on the injured foot for more than 10 seconds 2. The patient stood on the injured foot for more than five seconds 1. The patient stood on the injured foot for a few seconds 0. The patient couldn’t stand on the injured foot |
| 6 | Begin with the subject in supine on a treatment mat. Instruct the subject to roll to the paretic side (lateral movement). Assist as necessary. | ابدأ مع المريض المستلقي على ظهره على المرتبة العلاجية. اطلب منه الانقلاب على الجهة المصابة، وساعده حسب الحاجة. | Start with the patient lying on his back on the treatment mattress. Ask him to roll over on the affected side, and help him as needed. | Start with the patient lying on his back on the mattress. Ask him to roll over on the injured side, assist if needed. |
| 7 | Begin with the subject in supine on a treatment mat. Instruct the subject to roll to the nonparetic side (lateral movement). Assist as necessary. | ابدأ مع المريض المستلقي على ظهره على المرتبة العلاجية. اطلب منه الانقلاب على الجهة السليمة، وساعده حسب الحاجة. | Start with the patient lying on his back on the treatment mattress. Ask him to turn on the good side, and help him as needed. | Start with the patient lying on his back on the mattress. Ask him to roll over on the intact side, assist if needed. |
| 8 | Begin with the subject in supine on a treatment mat. Instruct the subject to come to sitting on the edge of the mat. Assist as necessary. | ابدأ مع المريض المستلقي على ظهره على المرتبة العلاجية. اطلب منه الجلوس على طرف المرتبة العلاجية، وساعده حسب الحاجة. | Start with the patient lying on his back on the treatment mattress. Ask him to sit on the edge of the treatment mattress, and help him as needed. | Start with the patient lying on his back on the mattress. Ask him to sit on the edge the mattress, assist if needed. |
| 9 | Begin with the subject sitting on the edge of a treatment mat. Instruct the subject to return to supine. Assist as necessary. | ابدأ مع المريض الجالس على طرف المرتبة العلاجية. اطلب منه العودة للاستلقاء على ظهره، وساعده حسب الحاجة. | Start with the patient on the edge of the treatment mattress. Ask him to lie on his back, and help him as needed. | Start with the patient sitting on the edge of the mattress. Ask him to lay on the back again, assist if needed. |
| 10 | Begin with the subject sitting on the edge of a treatment mat. Instruct the subject to stand up without support. Assist if necessary. | ابدأ مع المريض الجالس على طرف المرتبة العلاجية. اطلب منه الوقوف دون أن يستند على شيء، وساعده حسب الحاجة. | Start with the patient sitting on the edge of the treatment mattress. Ask him to stand without resting on anything, and help him as needed. | Start with the patient sitting on the edge of the mattress. Ask him to stand still, assist if needed. |
| 11 | Begin with the subject standing by the edge of a treatment mat. Instruct the subject to sit on edge of mat without support. Assist if necessary. | ابدأ مع المريض الواقف بجانب المرتبة العلاجية. اطلب منه الجلوس على طرف المرتبة العلاجية دون أن يستند على شيء، وساعده حسب الحاجة. | Start with the patient standing next to the treatment mattress. Ask him to sit on the edge of the treatment mattress without resting on anything, and help him as needed. | Start with the patient standing next to the edge of the mattress. Ask him to sit on the edge of the mattress without resting on anything, assist if needed. |
| 12 | Begin with the subject standing. Instruct the subject to pick up a pencil from the floor without support. Assist if necessary. | ابدأ مع المريض واقفًا. اطلب منه التقاط قلمٍ من الأرض دون أن يستند على شيء، وساعده حسب الحاجة. | Start with the patient standing. Ask him to pick up a pen from the ground without resting on anything, and help him as needed. | Start with the patient standing. Ask him to pick up a pen from the ground without resting on anything, assist if needed. |
| Scoring instruction | Evaluate the subject’s performance on the amount of help required. Do not consider the quality of performance. | قيِّم الأداء حسب مقدار المساعدة المقدمة دون الاعتبار بجودة التنفيذ. | Evaluate performance by the amount of assistance provided without regard to the quality of implementation. | Assess the performance based on the assistance provided regardless of how it was performed. |
| Can perform without help | يمكنه أداؤها دون مساعدة | He can perform it without assistance | The patient did it unassisted | |
| Can perform with little help | يمكنه أداؤها مع القليل من المساعدة | He can perform it with a little help | The patient needed little assistance | |
| Can perform with much help | يمكنه أداؤها مع الكثير من المساعدة | He can perform it with a lot of help | The patient needed a lot of assistance | |
| Cannot perform | لا يمكنه أداؤها | He can’t do it | The patient couldn’t do it |
A total of 40 physical therapists [26 males and 14 females; mean (M) age = 33.85 years, standard deviation (SD) = 6.63 years] participated in the study and provided their feedback on the PASS-Arabic. The participants were currently practicing physical therapists with a mean of 8.95 years of experience (SD = 6.71 years). A total of 85% of participants stated that they were specialists in the following areas of physical therapy: neurological [47.5% (n = 19)], musculoskeletal [27.5% (n = 11)], sports [5% (n = 2)], and cardio or geriatric [5% (n = 2)]. The 40 physical therapists were asked the following three questions: (1) Did you face any difficulties reading the PASS-Arabic? (2) Did you understand all parts of the PASS-Arabic? (3) Were all questions related to postural assessment?
The first question of the scale was difficult to read or answer for two participants (5%). One participant (2.5%) found questions 6 and 7, as well as the scoring instructions, challenging to read or answer. None of the remaining items were deemed difficult to read or answer by any participant. The responses of physical therapists are presented in Table 2.
Physical therapists’ feedback for each item of the scale.
| Item | Q1 (reading difficulties) N (%) | Q2 (understandable) N (%) | Q3 (balance related) N (%) |
|---|---|---|---|
| Introduction | 40 (100) | 40 (100) | 40 (100) |
| 1 | 38 (95) | 40 (100) | 40 (100) |
| 2 | 40 (100) | 40 (100) | 40 (100) |
| 3 | 40 (100) | 40 (100) | 40 (100) |
| 4 | 40 (100) | 40 (100) | 40 (100) |
| 5 | 40 (100) | 40 (100) | 40 (100) |
| 6 | 39 (97.5) | 40 (100) | 37 (92.5) |
| 7 | 39 (97.5) | 40 (100) | 37 (92.5) |
| 8 | 40 (100) | 40 (100) | 39 (97.5) |
| 9 | 40 (100) | 40 (100) | 39 (97.5) |
| 10 | 40 (100) | 40 (100) | 39 (97.5) |
| 11 | 40 (100) | 40 (100) | 39 (97.5) |
| 12 | 40 (100) | 40 (100) | 39 (97.5) |
| Scoring instructions | 39 (97.5) | 40 (100) | 40 (100) |
Q1: Did you face any difficulties reading PASS-Arabic? Q2: Did you understand all parts of PASS-Arabic? Q3: Were all questions related to postural assessment?
All of the participants were able to comprehend each scale item. However, three respondents (7.5%) felt that questions 6 and 7 did not pertain to the assessment of balance. In addition, one therapist (2.5% of the sample) deemed questions 8 through 12 irrelevant to balance assessment. All participants deemed the remaining scale items relevant to balance assessment (Appendix 1).
DISCUSSION
The present study aimed to translate and culturally adapt the PASS from English into Arabic. Because stroke is a major cause of disability worldwide and has a high level of prevalence in Saudi Arabia, the PASS-Arabic is an important outcome measure for assessing balance control in stroke patients. The translation process followed Beaton’s guidelines, and the comprehensibility of the translated PASS-Arabic was reviewed by 40 Arabic-speaking physical therapists (Beaton et al., 2000). The physical therapists’ feedback indicated that the PASS-Arabic was clear and comprehensible in general. A high percentage of physical therapists (≥95%) reported that the PASS-Arabic items were easy to read and fill out. Moreover, all physical therapists indicated that all items of the PASS-Arabic were easy to understand. A previous study conducted by Benaim et al. (1999) revealed that PASS has a high reliability when comparing the results of different raters with each other (interrater reliability) and comparing the results of the same rater on two different occasions (intrarater reliability). The high reliability scores of the PASS found in Benaim’s study support and explain the clarity of the PASS-Arabic among the physical therapists participating in this study.
A significant number of physical therapists (≥93%) found the PASS-Arabic items directly relevant to posture and balance assessment. This result is consistent with the results of the study by Benaim et al. (1999), which indicated a high concurrent validity of the PASS. The results of previous studies that examined the reliability and validity of the PASS in its English version and the results of this study indicate that there are no noticeable challenges facing physical therapists when applying the scale (Benaim et al., 1999; Mao et al., 2002; Wang et al., 2004; Estrada-Barranco et al., 2022).
The translation and cultural adaptation of the PASS-Arabic is an important step toward improving the assessment and management of balance impairments in stroke patients in Saudi Arabia and other Arabic-speaking countries. The high comprehensibility and relevance of the PASS-Arabic among physical therapists imply that the tool can be effectively integrated into clinical practice, facilitating better assessment and targeted interventions for stroke patients. This adaptation addresses the critical need for culturally and linguistically appropriate assessment tools, which can enhance the quality of care and rehabilitation outcomes for stroke survivors in Arabic-speaking communities.
A notable strength of this study is the rigorous translation and cultural adaptation process, which followed established guidelines and involved comprehensive feedback from a large sample of physical therapists. However, the study acknowledged one limitation: the lack of assessment on the tool’s validity and reliability in stroke patients. To address this limitation, future research recommendations include the importance of conducting validation studies to assess validity in Arabic-speaking stroke patients, evaluation of reliability through test–retest and interrater reliability, and studies to assess the tool’s ability to track balance changes during rehabilitation. Overall, the present study highlights the importance of cross-cultural adaptation and translation of assessment tools in diverse populations to enhance clinical practice and patient care.
CONCLUSION
This study successfully translated and culturally adapted the English version of the PASS into an Arabic version called the PASS-Arabic. Arabic-speaking physical therapists provided feedback that confirmed the comprehensibility and relevance of the translated PASS-Arabic. Although the majority of therapists found the PASS-Arabic to be clear and comprehensible, a few suggested modifications to address the possibility of patient confusion. Future studies should address the validation and reliability assessment of the tool in stroke patients. Recommendations for future research include conducting validation studies to assess the tool’s validity in Arabic-speaking stroke patients, evaluating reliability through test–retest and interrater reliability, and assessing the tool’s ability to track balance changes during rehabilitation. Overall, the present study underscores the importance of cross-cultural adaptation and translation of assessment tools in diverse populations to enhance clinical practice and patient care. The translation and cultural adaptation of the PASS-Arabic is a significant step toward enhancing the assessment of balance in stroke patients in Arabic-speaking communities.
