Psychometric Properties of the Arabic Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Ar-HSS-Pedi-FABS) Among Saudi Children and Adolescents: A Validation Study

Abstract

Background:

Children and adolescents’ participation in organized sports is widespread, resulting in significant sports-related injuries. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) assesses activity levels in children and adolescents involved in sports. Current Arabic-language pediatric orthopaedic rating scales often overlook active children or are lengthy and culturally biased, limiting their effectiveness.

Purpose:

To translate, culturally adapt, and validate the HSS Pedi-FABS for Arabic-speaking populations.

Study design:

Cohort study (Diagnosis); Level of evidence 3.

Methods:

This study was conducted from March to June 2024 at King Saud University Medical City in Riyadh, Saudi Arabia, and included participants aged 8 to 21 years who were fluent in Arabic and participated in organized sports and physical activity. The HSS Pedi-FABS was translated and validated through a multistep process involving forward and backward translations by certified translators, expert review, and face and content validity testing with content experts. Participants completed a survey with demographic questions, the Arabic-adapted HSS Pedi-FABS, and the Pediatric Activity Questionnaire for Older Children (PAQ-C). Reliability was assessed by internal consistency and test-retest reliability assessments and validity through both convergent and discriminant validity analyses.

Results:

A total of 150 participants aged 8 to 21 years were included. The Arabic HSS Pedi-FABS (Ar-Pedi-FABS) demonstrated acceptable internal consistency (Cronbach alpha, .79) and substantial agreement on test-retest reliability (intraclass correlation coefficient, 0.78). Convergent validity with the PAQ-C demonstrated moderate positive correlation (r = 0.60; P < .001), with Bland-Altman analysis indicating mean differences close to zero. Discriminant validity testing revealed that age demonstrated a clinically insignificant negative correlation with Ar-Pedi-FABS and sex was not significantly associated with Ar-Pedi-FABS.

Conclusion:

This study translated, cross-culturally adapted, and validated an Arabic version of the HSS Pedi-FABS, which demonstrated acceptable reliability and validity for assessing activity levels in Arabic-speaking children and adolescents. This development facilitates the assessment of physical activity in a way that respects cultural relevance for Arabic-speaking populations, supporting better communication, tailored interventions, and improved health outcomes.

The engagement of children and adolescents in organized sports programs is ubiquitous in many societies, including the United States, with >30 million young individuals actively participating in sports.^1,14,18 As a result, injuries related to these activities are increasing, with over 3.5 million children annually aged 14 and younger seeking medical attention for sports-related injuries.^16,18 However, within the speciality of pediatric orthopaedic surgery, current rating scales primarily focus on children with significant disabilities, thereby lacking comprehensive measurement tools for children involved in sports with varying activity levels.^17,18

In pediatric and adolescent orthopaedic sports medicine, clinical outcome research often guides treatment algorithms for young individuals sustaining musculoskeletal injuries. ¹¹ Understanding the effect of interventions on recovery from injury is crucial, with activity level recognized as a pivotal prognostic variable, particularly for active pediatric and adolescent patients. Existing scales that measure functional activity in children are often lengthy, time-consuming, and sometimes specific to particular activities, sports, or joints. ¹¹ To address the lack of a concise yet comprehensive scale for assessing activity levels in children and adolescents, the Hospital for Special Surgery Pediatric Functional Brief Scale (HSS Pedi-FABS) was developed in 2013 as a validated tool for evaluating activity in children and adolescents aged 10 to 18. ⁶

Because of the need for similar instruments in other languages, the HSS Pedi-FABS has also been translated and cross-culturally adaptated into Japanese, ⁹ Dutch, ⁴ Italian, ¹⁵ Spanish, ¹² and French, ³ demonstrating its global applicability and the widespread recognition of its importance in pediatric orthopaedic surgery and sports medicine. These international adaptations underscore the necessity and value of creating culturally and linguistically appropriate tools that can accurately measure and track the activity levels and rehabilitation progress of young athletes worldwide. Each version undergoes specific modifications to ensure cultural relevance and maintain the integrity of the instrument's psychometric properties, making the HSS Pedi-FABS a versatile and essential tool in pediatric sports medicine.

The HSS Pedi-FABS has not yet been translated and adapted for Arabic-speaking populations. Presently, there needs to be more comprehensive information regarding the psychometric properties of the HSS Pedi-FABS tool when applied to Arabic-speaking children and adolescents. Therefore, this study aims to translate, validate, and culturally adapt the HSS Pedi-FABS tool into Arabic, ensuring its cultural appropriateness by assessing its psychometric properties in an Arabic-speaking population of children and adolescents. It is hypothesized that the culturally adapted Arabic-translated version will exhibit robust psychometric properties, including validity and reliability, and will be culturally appropriate for use within Arab populations.

Methods

Study Design, Participants, Setting

This prospective cohort study was conducted primarily at King Saud University Medical City in Riyadh, Saudi Arabia, with participants recruited from a variety of settings—including schools, youth sports clubs, and similar institutions—to enhance the diversity of the sample, between March 2024 and June 2024. We enrolled fluent Arabic-speaking participants between 8 and 21 years of age who reported participation in ≥1 athletic activity from various clinics in the hospital, mainly the general pediatric and orthopaedic clinics. To maximize generalizability of the results, there were no additional exclusion criteria applied.

Translation and Cultural Adaptation of HSS Pedi-FABS Instrument to the Arabic HSS Pedi-FABS

The HSS Pedi-FABS consists of 8 items that evaluate running, cutting, decelerating, pivoting, duration, endurance, competition, and supervision. It is scored from 0 to 30 (0 being least active and 30 being most active). For questions regarding running, cutting, decelerating, pivoting, duration, and endurance, each question is worth 0, 1, 2, 3, or 4 points. For the questions about competition and supervision, each question is worth 0, 1, 2, or 3 points (Figure 1). ⁶

Figure 1.

Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Scoring is performed by adding points from each question for total possible score range from 0 to 30 (0 being least active and 30 being most active). For questions regarding running, cutting, decelerating, pivoting, duration, and endurance, each question is worth 0, 1, 2, 3, or 4 points. For the questions about competition and supervision, each question is worth 0, 1, 2, or 3 points.^6,7

Cross-cultural adaptation of the HSS Pedi-FABS to the Arabic HSS Pedi-FABS (Ar-Pedi-FABS) was performed using an established methodology, as recommended by Sousa and Rojjanasrirat. ¹⁹ Two certified professional translators were assigned to independently translate the tool from English to Arabic. The first translation, done by a bilingual physician, was labeled TL-1, and the second, done by a professional translator not in the medical field, was labeled TL-2.

After the forward translations were completed, 2 authors (N.M.A. and A.Addar) carefully reviewed and compared both versions to ensure they converted the same meaning. They subsequently merged the 2 translations into 1 document, referred to as Preliminary Initial - Target Language (PI-TL). This version was then given to a third certified independent translator (R.A.) who was not involved in the forward translation, who performed a backward translation to English. This version is labeled Backwards - Target Language version 1 (B-TL 1), which was then reviewed by the original developer (P.D.F) to confirm it accurately reflected the original content. This ensured that the Ar-Pedi-FABS was an appropriate translation and cross-cultural adaptation of the original English version.

Content Validity

Content validity assessment was performed by a panel of 13 subject matter experts comprising 5 general orthopaedic surgeons, 4 pediatric orthopaedic surgeons, 2 family physicians, 1 psychiatrist, and 1 clinical epidemiologist. Each expert evaluated all items in the scale based on 4 criteria: simplicity, relevance (measured through item-level Content Validity Index), importance, and clarity. They used a 4-point Likert scale for their ratings: 1 = strongly disagree; 2 = maybe; 3 = somewhat agree; and 4 = strongly agree. To calculate the item-level Content Validity Index (I-CVI), we counted how many experts rated an item as either “somewhat agree” or “strongly agree” (scores of 3 or 4), and divided that number by the total number of experts. This produced a score between 0 and 1, where a higher score indicated stronger agreement among experts that the item was valid. The same method was used to calculate the individual simplicity index, individual importance index, and individual clarity index for each item. Based on the panel's feedback, revisions were made to improve clarity and content, resulting in the finalized version of the Ar-Pedi-FABS, which included the same 8 items and follows the original scoring method used in the HSS Pedi-FABS (Figure 2).

Figure 2.

The Arabic version of Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Ar-Pedi-FABS). Scoring is performed by adding points from each question for total possible score range from 0 to 30 points. For questions regarding running, cutting, decelerating, pivoting, duration, and endurance, each question is worth 0, 1, 2, 3, or 4 points. For the questions about competition and supervision, each question is worth 0, 1, 2, or 3 points. A scoring legend is shown in Supplemental Material S1 (available online).

Questionnaire Distribution and Psychometric Analysis for Validity and Reliability

Study participants were recruited and completed an electronic survey consisting of 3 different sections: (1) demographic data, (2) Ar-Pedi-FABS, and (3) Pediatric Activity Questionnaire for Older Children (PAQ-C). ¹⁵ Demographic data included age, sex, and sports participation. The HSS Pedi-FABS specified how often they performed each activity, which included running, cutting, decelerating, pivoting, duration, and endurance. PAQ-C section asked participants about their exercise patterns, including the day of the week and specific times they exercised.

Convergent validity was assessed by analyzing scores on the Arabic version of the PAQ-C, Ar-Pedi-FABS. Discriminant validity was assessed through assessment of Ar-Pedi-FABS scores by age and sex. Reliability was tested using internal consistency and the test-retest method, where participants completed the Ar-Pedi-FABS again 2 to 3 weeks after their initial responses to evaluate stability in the absence of any clinical change over time.

Ethical Considerations

Ethical approval was granted by the host institutional review board at the College of Medicine, King Saud University, Riyadh, Saudi Arabia. Consent was obtained electronically following an explanation of the study's content, goal, and purpose. The principal investigator's (A.Addar) contact details were included for any questions. No financial incentives or rewards were offered, and participation did not affect the care of participants in any way. No potential participant declined participation in the study. As the study involved minors, informed consent was obtained from their parents or legal guardians.

Statistical Analysis

Statistical analyses were conducted using RStudio software (Version 4.3.1). Reliability was assessed using Cronbach alpha (for internal consistency) and intraclass correlation coefficient (ICC) (for test-retest reliability). ICC values <0.50 were considered poor, 0.50-0.74 moderate, 0.75-0.90 good, and >0.90 excellent reliability. Convergent validity was evaluated by assessing the correlation between the total score of the Ar-Pedi-FABS and the Parent Adult-Child Relationship Questionnaire (PACQ) summary score. Pearson correlation coefficients were used to evaluate the strength of the relationship between the 2 scales, and Bland-Altman plots were generated to assess agreement and systematic bias. Discriminant validity was assessed by assessing for correlation between age and Ar-Pedi-FABS and by comparing mean Ar-Pedi-FABS scores between male and female participants. All comparisons were 2-tailed, and P≤ .05 was used as threshold for statistical significance.

Results

The study included 150 participants aged 8 to 21 years, with a mean age of 14.9 ± 2.9 years. The majority of participants were aged 13 to 17 years (60.7%), followed by those aged 8 to 12 years (26.7%), and 18 to 21 years (12.7%). Of the total participants, 54% were male and 46% were female. A total of 30 participants completed the Ar-Pedi-FABS a second time and were included in the test-retest reliability analysis.

The content validity of the Ar-Pedi-FABS tool in our study was evaluated across 4 key domains: importance (II), simplicity (SI), Item-level Content Validity Index (I-CVI), and clarity (CI). Subject matter experts in the field reviewed the tool's items and rated these indices. The II had a mean score of 0.77 ± 0.16, indicating that the items were considered highly relevant to the construct of interest by the experts. The SI showed a mean score of 0.67 ± 0.16, suggesting that the items were generally straightforward and understandable. The I-CVI achieved a mean score of 0.66 ± 0.20, demonstrating that the items were deemed relevant to the construct under study. Last, the CI shared the same mean score as the SI (0.67 ± 0.16), reflecting that the items evaluated were sufficiently clear.

The mean Ar-Pedi-FABS score for the entire cohort was 14.1 ± 5.8 at first administration (N = 150). The mean for the test-retest subgroup was 15.9 ± 4.9 at first administration and 16.4 ± 4.4 at second administration (n = 30). The mean PAQ-C summary was 21.6 ± 6.8 and mean PAQ-C was 2.4 ± 0.8 (n = 130).

Internal consistency of the Ar-Pedi-FABS was evaluated using Cronbach alpha, which was 0.79 (95% CI, 0.74-0.84), which was unaffected by removing individual questionnaire items. Test-retest reliability was assessed using the ICC, which was 0.78 (95% CI, 0.60-0.89), indicating substantial agreement (Figures 3 and 4). ¹³

Figure 3.

Scatterplot of the Arabic HSS Pedi-FABS (Ar-Pedi-FABS) scores at baseline and after 3 weeks. Notably, there were no floor or ceiling effects observed in the data set. A total of 30 participants completed Ar-Pedi-FABS’ first and second administrations (ICC = 0.78; 95% CI, 0.60-0.89; r = 0.79). HSS Ar-Pedi-FABS, Arabic version of Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Figure 4.

Bland-Altman plot for measurement agreement between Arabic HSS Pedi-FABS (Ar-Pedi-FABS) scores at first and second administrations. The blue line denotes the mean difference between first and second administration; the red lines denote the limits for agreement. HSS Ar-Pedi-FABS, Arabic version of Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Convergent validity was assessed by correlating the Ar-Pedi-FABS total score with the PACQ summary score. The Pearson correlation (Figure 5) was r = 0.60 (95% CI, 0.47-0.70; P < .001), indicating a moderate positive correlation between the 2 scales. Discriminant validity testing revealed that age was very weakly (and clinically insignificantly) negatively correlated with Ar-Pedi-FABS (r = −0.179; P = .03) and that male participants did not have significantly different scores from their female counterparts (14.3 ± 5.4 vs 13.9 ± 6.3; P = .70).

Figure 5.

Scatterplot of Arabic HSS Pedi-FABS (Ar-Pedi-FABS) total score and Parent Adult-Child Relationship Questionnaire (PACQ) summary score. Notably, no floor or ceiling effects were found for either scale, as the minimal score was observed once (0.8%) in both versions, and the maximal score was not observed in either. A total of 130 participants completed Ar-Pedi-FABS and PACQ instruments (r = 0.60; 95% CI, 0.47-0.70; P < .001). HSS Ar-Pedi-FABS, Arabic version of Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Discussion

The main results of the current study demonstrated acceptable internal consistency reliability (Cronbach alpha = .79) and test-retest reliability (ICC = 0.78) of the Ar-Pedi-FABS instrument. The Ar-Pedi-FABS demonstrated acceptable convergent validity with a moderate positive correlation with the PACQ (r = 0.60). It demonstrated discriminant validity with a weak negative correlation with age (r = −0.179) and no significant difference based on sex (P = .70). While the original English HSS Pedi-FABS has undergone extensive reliability and validity testing^{2,5-8,10,21,22} and although it has been translated into several languages,^3,4,9,12,15 the current study provides the newly developed Ar-Pedi-FABS. The Ar-Pedi-FABS is a reliable and valid tool that can be used to assess activity levels in Arabic-speaking children and adolescents.

The Ar-Pedi-FABS instrument demonstrated acceptable reliability. Internal consistency was evaluated using Cronbach alpha, which yielded a coefficient of 0.79, indicating acceptable internal consistency. This shows that the individual items on the questionnaire properly measure the individual's activity level. Although the value of Cronbach alpha observed in the current study (0.79) is seemingly slightly lower than that of other studies—original development/validation study by Fabricant et al ⁶ (0.91), Japanese (0.9), ⁹ Dutch (0.82), ⁴ Italian (0.93), ¹⁵ and French (0.87) ³ versions)—it remains within the acceptable range for internal consistency reliability (between 0.70 and 0.95 ²⁰ ). Although impossible to directly compare with the original data of previous studies, this slight apparent difference is unlikely to be statistically significant or clinically relevant and at best may represent slight differences in sample heterogeneity among study populations. Test-retest reliability was determined using ICC, which assessed the ability of the tool to produce consistent results over time. We administered the survey to the same participants twice, spaced 2 to 3 weeks apart. The ICC for the total HSS Pedi-FABS score was 0.78, indicating substantial agreement. Although this value was seemingly slightly lower than the Japanese (0.90) ⁹ and Italian (0.94) ¹⁵ translations, and similar to the Dutch version (0.76), ⁴ this apparent minor difference may reflect subtle changes in participants’ activity levels between the 2 administrations. In such a situation, the actual test-retest reliability would in fact be even better than that demonstrated in the current study. Nevertheless, the Ar-Pedi-FABS demonstrated acceptable test-retest reliability consistent with previous translations in various languages, which are now widely used in pediatric orthopaedics and sports medicine. To ensure that Arabic-speaking children and adolescents are not excluded from biomedical research—and to provide them with access to the same validated clinical tools as their peers around the world—this adaptation holds the potential for broad and meaningful impact.

The Ar-Pedi-FABS instrument demonstrated acceptable convergent and discriminant validity. To assess convergent validity, Ar-Pedi-FABS scores were compared with scores on the established Arabic-language PAQ-C. The PAQ-C was chosen as it is well-established in Arabic language and was also used for convergent validity in the original HSS Pedi-FABS validation study. ⁶ The Pearson correlation between the 2 scores was 0.59 (P < .001), indicating a moderate positive correlation between the 2 measures. In convergent validity testing, moderate positive correlations are ideal as they demonstrate agreement (positive correlation) between the 2 scores being tested, and moderate-strength agreement indicates they are testing distinct constructs and that the new scale is therefore not redundant with an existing scale. Discriminant validity revealed a statistically significant, however very weak, negative correlation between age and Ar-Pedi-FABS score and showed that sex was not associated with Ar-Pedi-FABS. Although the negative correlation between age and Ar-Pedi-FABS was statistically significant, the weak magnitude indicates the lack of a clinically relevant effect of age on Ar-Pedi-FABS score, as expected. Taken together with the reliability analyses, the Ar-Pedi-FABS demonstrated acceptable psychometric properties for quantifying activity levels in Arabic-speaking pediatric and adolescent athletes.

Limitations

The current study has limitations. First, we did not specifically quantify any objective changes in activity level between the 2 administrations of the Ar-Pedi-FABS. Without guaranteeing the absence of change in true activity level, test-retest reliability can be subject to bias. However, any undetected changes in activity between test administrations would underestimate test-retest reliability, meaning actual reliability is, if anything, greater than reported here. Second, participants were recruited from one region of Saudi Arabia, so results may not be entirely generalizable to Arabic speakers in other countries. However, we recruited children and adolescents from a variety of different settings (schools, youth sports clubs, etc), which help construct a heterogeneous participant population from which we were able to validate the Ar-Pedi-FABS among Arabic-speaking youth. Finally, the current study assessed participants aged 8 to 21 years, which is a larger age range than the original English HSS-Pedi-FABS. The original English HSS-Pedi-FABS validation study used participants aged 10 to 18 years as a target population to assess young athletes participating in youth sports up to but not including the college and university level, as there can be substantial shifts in activity level (both increases and decreases) among American youth as they enter college and university and either further specialize in competitive sports, move to a more recreational level, or focus entirely on other pursuits. Conversely, in Saudi Arabia, youth engagement in sports and physical activities varies due to cultural, environmental, and infrastructural factors. Structured athletic programs and recreational opportunities are not universally accessible. In the Arab world, soccer remains the most popular sport, and while other sports are increasing in popularity, their prevalence remains limited. Sex-based differences in sports participation are also more pronounced, potentially influencing activity patterns across age groups. These disparities can lead to varying levels of physical activity, with some adolescents having limited access to organized sports. Societal expectations and school-based physical education policies further shape activity levels among different age groups. In Saudi Arabia, the presence of Little League baseball is still expanding, which can affect the baseline characteristics of youth engagement in sports and physical activities over time. Therefore, participants ≤21 were included in the current study population, which strengthens the generalizability of the study and may partly explain the statistically significant but not clinically meaningful negative correlation observed between age and Ar-Pedi-FABS score in discriminant validity testing.

Conclusion

The current study adapted and validated an Arabic-translated version of the HSS Pedi-FABS (Ar-Pedi-FABS), which demonstrated acceptable reliability and validity for assessing activity levels in Arabic-speaking children and adolescents. This development facilitates the assessment of physical activity in a way that respects cultural relevance for Arabic-speaking populations, supporting better communication, tailored interventions, and improved health outcomes.

Supplemental Material

sj-pdf-1-ojs-10.1177_23259671251376536 – Supplemental material for Psychometric Properties of the Arabic Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Ar-HSS-Pedi-FABS) Among Saudi Children and Adolescents: A Validation Study

Supplemental material, sj-pdf-1-ojs-10.1177_23259671251376536 for Psychometric Properties of the Arabic Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Ar-HSS-Pedi-FABS) Among Saudi Children and Adolescents: A Validation Study by Abdullah Addar, Nasser M. AbuDujain, Fayez A. Alhabib, Abdullah Alhumimidi, Hani A. Alghamdi, Rahaf Alsemairi, Yasir Alabdulkarim, Ruth H. Jones and Peter D. Fabricant in Orthopaedic Journal of Sports Medicine

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