Maribo et al.

BMC Neurology (2016) 16:205

DOI 10.1186/s12883-016-0728-7

RESEARCH ARTICLE Open Access

Assessment of primary rehabilitation needs

in neurological rehabilitation: translation,
adaptation and face validity of the Danish
version of Rehabilitation Complexity
Scale-Extended
Thomas Maribo1,2* , Asger R. Pedersen3, Jim Jensen3 and Jørgen F. Nielsen3

Abstract
Background: Assessing primary rehabilitation needs in patients with acquired brain injury is a challenge due to
case complexity and the heterogeneity of symptoms after brain injury. The Rehabilitation Complexity Scale-Extended
(RCS-E) is an instrument used in assessment of rehabilitation complexity in patients with severe brain injury. The aim of
the present study was to translate and test the face validity of the RCS-E as a referral tool for primary rehabilitation.
Face validity was tested in a sample of patients with acquired brain injury.
Methods: Ten clinicians and records from 299 patients with acquired brain injury were used in the translation,
cross-cultural adaptation and face validation study of the RCS-E. RCS-E was translated into Danish by a standardized
forward-backward translation by experts in the field. Face validity was assessed by a multi-professional team assessing
299 patients. The team was asked their opinion on whether the RCS-E presents a sufficient description of the patients.
Results: The RCS-E was translated according to international guidelines and tested by health professionals; some
adaptations were required due to linguistic problems and differences in the national health system structures.
The patients in the study had a mean age of 63.9 years (SD 14.7); 61 % were male.
We found an excellent face validity with a mean score of 8.2 (SD 0.34) assessed on a 0–10 scale.
Conclusions: The RCS-E demonstrated to be a valid assessment of primary rehabilitation needs in patients with
acquired brain injury. Excellent face validity indicates that the RCS-E is feasible for assessing primary rehabilitation
needs and the present study suggests its applicability to the Danish health care system.
Keywords: Assessment of rehabilitation needs, Translation and adaption, Validation, Complexity of rehabilitation
needs, Neurological rehabilitation, Acquired brain injury, Needs assessment, Psychometric properties,
Rehabilitation Complexity Scale-Extended

* Correspondence: Thomas.maribo@rm.dk
1
Department of Public Health, Section of clinical social medicine and
rehabilitation, Aarhus University, Aarhus, Denmark
2
DEFACTUM, Central Denmark Region, Aarhus, Denmark
Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Maribo et al. BMC Neurology (2016) 16:205 Page 2 of 6

Background RCS-E would have a high face validity of >7 scored on a

After acute treatment, most patients with acquired brain 0–10 point scale.
injury will continue rehabilitation according to the com-
plexity of their injury [1]. Assessing primary rehabilitation Methods
needs, i.e., for the rehabilitation starting immediately after Outcome measure
acute treatment, is a challenge due to case complexity and The RCS-E consists of six domains shown in Table 1 [8].
the heterogeneity of symptoms after brain injury [2]. The first two domains are usually scored as care or risk,
Complexity relates to the number of different factors that leaving a scale with five domains.
affect the course of rehabilitation, which has traditionally
been evaluated in terms of comorbidity or physical de- Translation and cross-cultural adaptation
pendency [3, 4]. The integrative biopsychosocial model The translation and cross-cultural adaptation of the
(ICF) places function between health and contextual fac- RCS-E to create a Danish version was done according to
tors, making complexity much more important than co- internationally accepted guidelines [13] and with permis-
morbidity [5]. Physical dependency does not capture sion from the developers of the RCS-E. The group re-
needs for specialist medical care, specialist nursing care, sponsible for the translation consisted of seven persons.
or the need for cognitive, behavioural or other psycho- The five forward translators (native Danish speakers) in-
logical interventions. Frequently used outcome measures cluded a physiotherapist (PT), an occupational therapist
in neurological rehabilitation such as the Barthel Index (OT), a medical doctor (MD), and two nurses (RN). The
and the Functional Independence Measure evaluate inde- two first authors (PT and OT) translated the entire RCS-
pendence and physical dependency, making them unfit for E, the MD translated “medical needs” and “risk”; two
assessing complexity and as referral tools [3]. RNs translated “basic care” and “skilled nursing needs”.
In rehabilitation, variables from different domains usu- The different versions were synthesized into a forward
ally interact in a non-linear way, with complicated inter- version. The forward translation was discussed by three
relationships that impede assessment of rehabilitation groups of health care professionals (MD, RN and OT/
needs and call for multi-professional assessment [3]. PT) working with specialized neurorehabilitation. Each
Assessing the complexity of primary rehabilitation group discussed only the domains they were to score:
needs in order to refer patients to the appropriate “medical needs” and “risk” were discussed by a group of
care setting is a worldwide challenge [3, 6]; only few MDs, “basic care” and “skilled nursing needs” were
tools are concerned with rehabilitation complexity; all discussed by a group of RNs, and the required number
have their limitations. An editorial review from 2011 of different therapy disciplines, therapy intensity, and
gave examples of four tools [3]. One of the recom- equipment needs were discussed by a group of OTs/PTs.
mended tools was the Rehabilitation Complexity Scale Comments from this process were incorporated in the
(RCS) [3]. The RCS was introduced in 2007 as a final forward translation. The backward translations
measure of case-load complexity in rehabilitation [7], were done by two English native speakers, one with a
developed to detect the clinical need for higher-level background in rehabilitation, the other a non-medical
services instead of local services; differentiating be- professional translator. The two backward translations
tween ‘complex specialized’ and ‘district specialist’ re- were synthesized by the first author and sent to the de-
habilitation services is found to be valid [7]. Since the veloper of the RCS-E for approval.
editorial review in 2011, the RCS has undergone fur- To check acceptability and comprehension a pilot-test
ther development [8]. The earlier versions of the RCS was carried out with 25 patients.
had problems with ceiling effects, and no information
on the need for special equipment was collected. Fur- Table 1 The domains in the Rehabilitation Complexity Scale-
thermore, the earlier versions did not capture the Extended
“Risk” or needs for supervision of patients who were Abbreviation Domain Range
mobile, but confused; e.g., in cognitive behavioural re- C Basic care (support needs) 0–4
habilitation settings [8]. The Rehabilitation Complex-
R Risk (cognitive or behavioural needs) 0–4
ity Scale-Extended (RCS-E) was developed to address
these problems [8]. The RCS-E has proved reliable [9, 10] N Skilled nursing needs 0–4
and is used as a measure of complexity within the M Medical needs 0–4
rehabilitation process, especially in neurological re- Therapy needs
habilitation [3, 11, 12]. TD Required number of different therapy disciplines 0–4
The aim of this study was to formally translate and TI Therapy intensity 0–4
cross-culturally adapt the RCS-E into Danish and to test
E Equipment needs 0–2
its face validity. It was hypothesized that the translated
Maribo et al. BMC Neurology (2016) 16:205 Page 3 of 6

Study design for face validity RCS-E. The experts’ scoring on face validity was pre-
Data from 300 consecutive patients with acquired brain sented as mean, standard deviation (SD) and range.
injury aged 18 or more and admitted to Hammel Neuror- The COSMIN checklist suggests >100 as the number
ehabilitation and Research Centre, Denmark, between required for assessment of structural validity [16]. As we
February and August 2014, was used in the test for face were to test 300 cases for another study (Pedersen AR,
validity. Nielsen JF, Jensen J, Maribo T. Referral decision support
The RCS-E was scored by an expert team comprising a in patients with subacute brain injury: evaluation of the
MC, a RN and an OT not involved in the translation Rehabilitation Complexity Scale - Extended. Disabil
process. Each domain was scored by a single team mem- Rehabil. 2016. Jul 6:1-7. Epub ahead of print), this num-
ber; the MD scored “medical needs” and “risk”, the RN ber was chosen as the sample size.
scored “basic care” and “skilled nursing needs”, and the There were no missing data: all data were collected
OT scored “required number of different therapy disci- electronically, and respondents were not given the possi-
plines”, “therapy intensity”, and “equipment needs”. After bility of continuing if an answer was missing.
a pilot phase where the team used 10 medical records to
jointly score the RCS-E, each team member scored their Results
own domains. In cases of doubt, the relevant records Translation and cross-cultural adaptation
would be discussed in the team. The forward translation from English into Danish re-
Face validity is one of the basic psychometric requisites vealed certain cross-cultural and linguistic issues. The
for an assessment tool and addresses whether the scale ap- domains “risk” and “therapy needs” in particular gave
pears to actually cover the concept it intends to measure rise to questions. This became evident through the pilot
[14]. It considers the relevance of a test as it appears to tes- test, prompting the need to reword several items. A
ters: a test can be said to have face validity if it “looks like” number of MDs, RNs, nursing assistants, OTs, and PTs
it will in fact measure what it is supposed to measure [15]. participated in the pilot test, which included 25 patients.
Face validity is desirable as tools that are perceived as The English word “therapy” changes meaning when
irrelevant may be answered with less care, making them translated as the Danish “terapi”: the Danish term refers
less reliable. Face validity is evaluated by a subjective almost exclusively to physiotherapy or occupational ther-
judgment of experts [14]. apy. In sections TD and TI Therapy needs are translated
After every 10 patients, each team member was asked as interdisciplinary interventions, and therapy disciplines
two questions: 1) “Did you have any problems scoring one translated as professions.
of the 10 latest patients? – If yes, indicate which patient(s)”, The risk section refers to Mental Health Act (R2 and
and 2) “On average over the last 10 patients, does the RCS- R3). There is no such act in Denmark and thus no add-
E present a sufficient description of the patient in the areas itional paperwork. The reference was removed.
you have been asked to assess? Please indicate on a scale In the therapy section, a reference is made to The
from 0 to 10, where 0 is not at all sufficient and 10 is suffi- Northwick Park Therapy Dependency Assessment
cient.” Case material was collected from medical records. (NPTDA). NPTDA is not translated into Danish, and
Hammel Neurorehabilitation and Research Centre is a the reference was removed.
rehabilitation hospital, treating patients with acquired The adjusted version was then back translated, and
brain injury, and has a background population of 2.9 this version was approved by Lynne Turner-Stokes. The
million individuals. Patients with severe acquired brain procedure only gave rise to minor changes; for example,
injury are referred for inpatient rehabilitation after treat- the translation of Environmental control (E2) was chan-
ment at intensive care units or departments of neurology ged. Figure 1 shows the translation and adaptation
or neurosurgery. process. The Danish version of RCS-E is available as
Depending on the patient’s clinical severity at admis- Additional files 1 and 2 give directions to the English
sion, two multidisciplinary rehabilitation options were Version of RCS-E.
available: 1) complex specialized service: High-intensity Three hundred records were included, but due to a
rehabilitation and therapy during all waking hours; car- mistake one record appeared in duplicate, leaving 299
ried out by staff experienced in neurorehabilitation of se- included patients. Demographic details and clinical char-
verely affected patients, and 2) district specialist service: acteristics are presented in Table 2.
Moderate-intensity rehabilitation and therapy carried There were no missing items in the baseline informa-
out only during daytime hours (until 6 pm). tion data included in the analysis of face validity.
A summary of the distribution of RSC-E scores within
Statistical analysis each domain, and the total scores are presented in Table 3.
Descriptive statistics were used for age, gender, diagnosis The team members had difficulties scoring 11 records
and whether experts observed problems scoring the (3.7 %). The MD and the RN had problems scoring one
Maribo et al. BMC Neurology (2016) 16:205 Page 4 of 6

Table 3 (n = 299)
Translation from English Domain Median [IQR] (range)
into Danish by independent
translators Basic care (support needs) 1 [1; 2] (0; 4)
First Danish Risk (cognitive or behavioural needs) 1 [1; 2] (0; 3)
consensus Skilled nursing needs 2 [2; 3] (0; 4)
version
Medical needs 1 [1; 2] (0; 3)
Face validity test among
doctors, nurses, nursing Required number of different therapy disciplines 2 [2; 3] (2; 4)
assistants, occupational
therapists and Therapy intensity 2 [2; 2] (1; 4)
physiotherapists Equipment needs 1 [1; 1] (0; 2)
Total RCS-E 10 [9; 12] (5; 21)
Second Danish
consensus

Back translation from The translation from English into Danish and back
Danish into English by two was carried out according to international guidelines
independent translators
[13]. In this process, small adaptations to the original
English English version were made, such as excluding the
consensus version Mental Health Act referenced in the original.
Approval/comment from the
The team carried out preliminary training by discuss-
developer ing the RCS-E and scoring 10 patients together in the
team. This pilot test and discussion process took five
Adjustment hours, and after this initial trial the team felt ready to
use the RCS-E; no further training was needed.
Final Danish version of The RCS-E proved to be applicable to almost all the re-
Rehabilitation Complexity cords examined: the team only found difficulties in assessing
Scale - Extended
11 (3.7 %) of the records. This confirmed our hypothesis
Fig. 1 Translation of the Rehabilitation Complexity Scale - extended
that <10 % of the cases would be difficult to score.
After a short discussion on the records that were diffi-
cult to score, the team was able to score these cases.
patient each, while the OT had problems scoring 9 re- Typically, the problems concerned therapy intensity as
cords. These records were discussed by the team. the medical records lacked information on whether the
Overall the team members were pleased with the RCS- presence of an assistant was necessary, making it diffi-
E. The team gave a mean score of 8.2 SD 0.34 in their cult to distinguish between TI2 and TI3. Another prob-
answers to the question “On average over the last 10 pa- lem was to determine the required number of disciplines
tients, does the RCS-E present a sufficient description of in cases where it was difficult to distinguish between
the patient?” See Table 4. TD2 and TD3. Almost all patients needed occupational
therapy and physiotherapy, but in the acute state it was
Discussion in some cases difficult to determine whether an add-
The RCS-E was successfully translated and adapted into itional one or two disciplines were needed. The discus-
Danish. High face validity was indicated by all team sion on these records showed that the problems were
members; only few records (3.7 %) needed discussion in due to missing information in the records, meaning that
the team.
Table 4 Face validity for the Rehabilitation Complexity Scale-
Table 2 Demographics and clinical characteristics at admission
Extended
Age [years] 63.88 (14.7)
Team member Medical doctor Nurse Therapist
Sex, male/female 181 (61 %)/118 (39 %)
Domains scored (M and R) (C and N) (TD, TI and E)
Diagnosis
Mean (SD) 8.4 (0.49) 7.8 (0.38) 8.3 (0.91)
Acquired brain injury
Range [8, 9] [7, 8] [6, 10]
Vascular (stroke, SAH) 246 (82 %)
C basic care (support needs), R risk (cognitive or behavioural needs), N skilled
Traumatic 24 (8 %) nursing needs, M medical needs, TD required number of different therapy
disciplines, TI therapy intensity, E equipment needs. After assessing every 10
Other (e.g., Hypoxic/inflammatory) 24 (8 %) patients, each team member answered the question: “On average over the last 10
patients, does the RCS-E present a sufficient description of the patient in the areas
Guillain-Barré and other peripheral neuropathies 5 (2 %)
you have been asked to assess? Please indicate on a scale from 0 to 10, where 0
Values are mean (SD) or n (percentage); n = 299 is not at all sufficient and 10 is sufficient”
Maribo et al. BMC Neurology (2016) 16:205 Page 5 of 6

the problem did not reside with the RCS-E as such, but different domains is important [3] and the RCS-E is
with the records. an easy and quick tool to use in the process.
The inclusion of 299 cases in the face validity test ex- Further studies should test other psychometric proper-
ceeds the sample size suggested by the COSMIN group ties of the RCS-E, primarily whether it can distinguish
and Terwee et al. [16, 17]. between patients’ needs for primary rehabilitation.
The present study has some limitations as the team
consisted only of persons from a single rehabilitation in- Additional files
stitution. Involving more teams and other sites using the
RCS-E could have strengthened the result. Additional file 1: The Danish version of RCS-E. (PDF 68 kb)
There is no consensus on how to interpret results Additional file 2: How to assess the English version of RCS-E. (PDF 100 kb)
from tests of face validity on a 0–10 point scale. Thus, Additional file 3: Data from face validity study. The dataset has 10
variables: Variable a: Case_no refers to the case numbers; Variables b, e, h:
we chose a score of >7 to indicate high validity. We be-
*_problems answers to question “Did you have any problems scoring one
lieve a mean score of 8.2 with a narrow SD is satisfying of the 10 latest patients?”; Variables c, f, i: *_problem_ID gives the ID of
and indicates high face validity. the case with a problem; Variables d, g, j: * _score answers to question
“On average over the last 10 patients, does the RCS-E present a sufficient
As we did not aim for a full evaluation of content val-
description of the patient in the areas you have been asked to assess?
idity it is not possible to fulfil all criteria in the COSMIN Please indicate on a scale from 0 to 10, where 0 is not at all sufficient
group checklist “Content validity (including face valid- and 10 is sufficient”. (CSV 1 kb)
ity)” [18], but more than 10 different health professionals
were involved in the translation process (primarily dur- Abbreviations
ing the pilot testing) and the test of face validity, and all MD: Medical doctor; OT: Occupational therapist; PT: Physiotherapist;
RCS: Rehabilitation Complexity Scale; RCS-E: The Rehabilitation Complexity
indicated that the RCS-E was useful as a tool for assess- Scale-Extended; RN: Nurse; SD: Standard deviation
ment of primary rehabilitation needs. This supports the
good face validity found in this study. The developer of Acknowledgements
The authors are grateful to Tove Kilde and Simone Kellenberger for
the RCS-E and an Italian group carrying out similar their forward translation of the nurses’ part, Clea Petreman and René
work also report no problems in scoring RCS-E, sup- Lauritsen for the back translation of the RCS-E, and to Karen Marie
porting the case for good face validity [8–10, 19]. Rahbech Mørk, Karina Lausten, Iben Bendixen Juul and Karen Jette
Jensen for their great teamwork.
It has been suggested that care or risk should be
assessed [8]. As the RCS-E is a multi-professional assess- Funding
ment, assessing both care and risk might be worth con- Dr. Maribo reports grants from Management Forum for Collaboration
between Aarhus University and the Central Denmark Region, during the
sidering. In this study, care was assessed by the RN and conduct of the study. The other authors received no specific funding for
risk by the MD. The expert team found that assessing this work.
both aspects was a rational move, as this provided a
Availability of data and materials
more comprehensive picture of the patient.
The dataset supporting the conclusions of this article is included within the
Our aim was to test whether a referral support tool article and its Additional files 1, 2 and 3.
used for referral for primary rehabilitation in patients
needing ‘complex specialized’ or ‘district specialist’ re- Authors’ contributions
All authors made substantial contributions to conception and design; TM,
habilitation services in the UK could be used in other JFN and JJ participated in data collection; TM and ARP performed analysis
countries; this aim was met. and interpretation of data; TM and ARP drafted the manuscript; JFN and KK
participated in critically revision; and all authors read and approved the final
manuscript.
Conclusions
We have successfully translated and adapted the RCS- Competing interests
E into Danish, and the Danish version demonstrates The authors declare that they have no competing interests.
excellent face validity. Moreover, the face validity pre-
Consent for publication
sented provide more credibility to the use of RCS-E, Not applicable.
as a tool for assessing complexity and as decision aid
in the referral process. Assessing primary rehabilita- Ethics approval and consent to participate
In Denmark, studies based on anonymized cases do not require approval
tion needs and better referral is crucial as intensive from Central Denmark Region Committees on Biomedical Research Ethics,
neurological rehabilitation is expensive. Compared to but the board were notified on the study (273/2015). Data were available in
the regular clinical approach a systematic assessment an anonymized format so that individuals could not be identified. Data were
stored in accordance with the rules of the Danish Data Protection Agency.
of the elements in the RCS-E in combination with
evaluation of the personal and contextual factors of Author details
1
the patient could lead to improvement in the referral Department of Public Health, Section of clinical social medicine and
rehabilitation, Aarhus University, Aarhus, Denmark. 2DEFACTUM, Central
process. Recognizing the complexity in assessment of Denmark Region, Aarhus, Denmark. 3Hammel Neurorehabilitation and
primary rehabilitation needs and using variables from Research Centre, Aarhus University, Hammel, Denmark.
Maribo et al. BMC Neurology (2016) 16:205 Page 6 of 6

Received: 19 April 2016 Accepted: 15 October 2016

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