1Centre for Occupational Therapy Studies, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Malaysia
2Kids Enhancement Centre (KEC), Johor Bahru, Malaysia
3Special Population Research, Innovation and Knowledge, Faculty of Health Sciences, Universiti Teknologi MARA, Shah Alam, Malaysia
4Department of Health Information Management and Technology, College of Applied Medical Sciences, University of Hafr Albatin, Hafr Albatin, Saudi Arabia
5Public Health Unit, Department of Primary Health Care, Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia (USIM), Nilai, Malaysia
Corresponding Author: Ahmad Zamir Che Daud Centre for Occupational Therapy Studies, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam 42300, Selangor, Malaysia. Tel: +60-3-3258-4568 Fax: +60-3-3258-4000 E-mail: zamir5853@uitm.edu.my
• Received: November 23, 2025 • Revised: May 5, 2026 • Accepted: June 4, 2026
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To translate, culturally adapt, and validate the Roland-Morris Disability Questionnaire (RMDQ) for Malay-speaking individuals with low back pain (LBP) in Malaysia.
Methods
A methodological study was conducted following established international guidelines for cross-cultural adaptation and psychometric validation. The process included forward–backward translation, expert review, content validation, face validation, and psychometric testing among individuals with LBP. Content and face validity indices were evaluated by rehabilitation professionals (n=8) and individuals with LBP (n=9). Psychometric testing was conducted with 102 participants to assess internal consistency, test-retest reliability (n=31), concurrent validity using the Malay Oswestry Disability Index, and known-groups validity.
Results
All items demonstrated excellent content and face validity (I-CVI, I-FVI, S-CVI/Ave, and S-FVI/Ave=1.00). The Malay RMDQ showed high internal consistency (Cronbach’s α=0.932) and excellent test-retest reliability (ICC=0.996). Concurrent validity with the Malay Oswestry Disability Index was moderate (r=0.742, p<0.001). A preliminary known-groups comparison showed a statistically significant difference in the Malay RMDQ scores between participants with LBP and those without LBP (p=0.03).
Conclusion
The Malay RMDQ demonstrated preliminary psychometric support, including evidence of reliability, validity, and cultural appropriateness, for assessing disability in individuals with LBP. Future research should explore its responsiveness and utility in broader populations.
Low back pain (LBP) is among the most common musculoskeletal disorders and is a major contributor to global disability and healthcare burden [1]. It is typically defined as pain or discomfort located between the lower costal margin and the superior gluteal line, with or without radiation to the lower limbs, and is classified as chronic when persisting for more than three months [2]. LBP can stem from various sources, including occupational strain, injury, degenerative changes, or systemic conditions, and affects individuals across all age groups.
Reflecting its global burden, LBP remains highly prevalent and impacts function, well-being, and productivity, especially among healthcare professionals [3]. In Malaysia, studies have reported prevalence rates between 12.4% and 84.6% across various occupational groups, including healthcare professionals, drivers, and office workers [4]. These figures highlight the multifactorial etiology of LBP, often linked to physical strain, prolonged sitting, poor posture, and degenerative changes.
Given the multidimensional burden of LBP, the use of reliable and valid instruments to detect and monitor disability is essential for clinical evaluation, intervention planning, and outcome monitoring. The Roland-Morris Disability Questionnaire (RMDQ), developed from the Sickness Impact Profile, is a widely used 24-item self-report tool designed to measure functional disability in individuals with mild to moderate LBP [5]. To date, the RMDQ has been translated into over 50 languages, enabling cross-cultural comparisons and global dissemination [6].
Despite its broad international usage, a validated Malay version of the RMDQ has not been available. Given that Malay is the national and most commonly spoken language in Malaysia, a linguistically and culturally adapted version is essential. Patients with limited English proficiency may misinterpret items or skip questions, resulting in inaccurate scores and compromised clinical utility [7]. Furthermore, ad hoc translation by clinicians can introduce inconsistencies, reducing measurement reliability. Cross-cultural adaptation ensures that translated instruments retain conceptual equivalence while being linguistically and culturally relevant for the target population [8]. Accordingly, this study aimed to cross-culturally translate and adapt the RMDQ into the Malay language and to evaluate its content validity, face validity, internal consistency, test-retest reliability, and construct validity among Malaysian adults with LBP.
METHODS
Study design
A methodological study of the translation, cultural adaptation, and psychometric validation was conducted in four sequential stages: (1) translation and cross-cultural adaptation; (2) content validity evaluation; (3) face validity evaluation; and (4) psychometric testing. The process adhered to internationally recognized guidelines for adapting health-related instruments across cultures [7,8]. This study was approved by the Research Ethics Committee of Universiti Teknologi MARA (Reference: FERC/FSK/MR/2024/00359). Written informed consent was obtained from all individual participants included in the study. The official RMDQ website states that the questionnaire and its translations are in the public domain and may be used without prior permission (https://www.rmdq.org/). Therefore, formal permission was not required for this translation, cross-cultural adaptation and validation study. The processes involved in this research are illustrated in Fig. 1.
Participants and sampling
A total of 102 participants were recruited using purposive sampling from three Malaysian states: Johor, Melaka, and Selangor. The sample comprised individuals with LBP and a comparison group without current LBP, which was included a priori to provide a preliminary test of known-groups validity. Participants in the LBP group were required to be adults aged 18 to 59 years experiencing mild to moderate LBP for a duration of 6 to 12 weeks. This criterion was selected because the RMDQ has been reported to demonstrate greater sensitivity in individuals with mild to moderate disability than in those with more severe disability [9]. Restricting the sample to this subgroup also helped to minimize floor and ceiling effects and reduce heterogeneity associated with severe or chronic LBP conditions, which often involve more complex clinical presentations. Exclusion criteria included (1) back pain due to specific pathological conditions (e.g., malignancy, infection, or fracture); (2) cognitive or psychiatric impairments affecting comprehension; and (3) a history of spinal surgery. Of the total sample, 31 participants from the LBP group participants completed the test-retest component after a two-week interval.
Stage 1: Translation and cross-cultural adaptation
Forward translation of the original English RMDQ into Malay was independently performed by two bilingual translators, one with a clinical rehabilitation background and the other with linguistic expertise. The two versions were synthesized into a single reconciled draft. Backward translation was then conducted by another two independent translators, both blinded to the original version. An expert committee consisting of researchers and translators reviewed all versions to achieve semantic, idiomatic, experiential, and conceptual equivalence. The pre-final version Malay RMDQ was established following this process.
Stage 2: Content validity
Content Validity Index (CVI) was assessed by a panel of eight experts with clinical experience in rehabilitation, comprising three occupational therapists, three physiotherapists, and two rehabilitation doctors. Each item was evaluated for relevance, clarity, simplicity, and ambiguity using a 4-point Likert scale [10,11]. For the calculation of the CVI, ratings of 3 or 4 were considered indicative of agreement, while ratings of 1 or 2 were considered not acceptable. The Item-level Content Validity Index (I-CVI) was calculated as the proportion of experts who rated each item as acceptable. The Scale-level Content Validity Index was computed using two methods: the universal agreement approach (S-CVI/UA), defined as the proportion of items rated as acceptable by all experts, and the averaging approach (S-CVI/Ave), defined as the average of I-CVI values across all items [11]. An I-CVI value of ≥0.78 was considered acceptable for individual items, while S-CVI/UA ≥0.80 and S-CVI/Ave ≥0.90 indicated adequate content validity [11].
Stage 3: Face validity
Face validity was assessed by nine lay individuals with mild to moderate LBP. Each item was evaluated for clarity and comprehensibility using a 4-point scale [12]. For the calculation of the Face Validity Index (FVI), ratings of 3 or 4 were considered indicative of agreement (clear and understandable). The Item-level Face Validity Index (I-FVI) was calculated as the proportion of participants rating each item as clear and comprehensible, while the Scale-level Face Validity Index (S-FVI/Ave) was computed as the average of I-FVI values across all items [12]. Values ≥0.83 were considered acceptable for face validity. In addition, item impact scores were calculated to assess the perceived importance of each item. For each item, the impact score was obtained by multiplying the frequency of participants rating the item as important (score 4 or 5 on a 5-point scale) by the item's mean importance score. An item impact score of ≥1.5 was considered acceptable [10].
Stage 4: Psychometric evaluation
A target of 100–120 participants was established based on reliability study recommendations [13]. Internal consistency of the Malay RMDQ was assessed using Cronbach’s α. Values between 0.70 and 0.95 were considered acceptable, and values between 0.80 and 0.90 were regarded as good [14]. To evaluate test-retest reliability, a minimum of 30 participants were targeted to complete the Malay RMDQ twice, with a two-week interval between administrations, consistent with recommended intervals for minimizing recall bias and clinical change [15]. The intraclass correlation coefficient (ICC) was calculated using a two-way mixed-effects model, absolute agreement, single measurement (ICC[3,1]), with values ≥0.75 indicating good reliability [16].
Concurrent validity was examined by correlating the Malay RMDQ scores with those from the validated Malay version of the Oswestry Disability Index (ODI) [17]. The ODI is another widely used questionnaire for assessing LBP-related disability, covering 10 functional domains such as pain intensity, lifting, walking, and social life. A validated Malay version of the ODI has shown acceptable reliability and construct validity among Malay-speaking individuals with LBP [17]. Preliminary known-groups validity was examined by comparing the Malay RMDQ scores between participants with LBP and those without LBP. A statistically significant difference (p<0.05) was interpreted as preliminary evidence of discriminative validity [18].
Outcome measures
The primary instrument used was the Malay version of the RMDQ, a 24-item self-report scale that assesses disability due to LBP. Each item is answered using a binary response format (“Yes”=1; “No”=0), with total scores ranging from 0 (no disability) to 24 (maximum disability). The Malay ODI was used to evaluate concurrent validity. A demographic questionnaire collected information on age, sex, occupation, and LBP characteristics. Structured rating forms were used for both expert and lay evaluations during the content and face validity phases.
Data analysis
All data were analysed using the IBM SPSS version 29 (IBM Corp.). Descriptive statistics were used to summarize participant characteristics. Content and face validity indices were computed using established formulas. Internal consistency was examined using Cronbach’s α. Item-level analysis was also performed by calculating Cronbach’s α if item deleted to assess the contribution of each item to the overall scale reliability. Test-retest reliability was evaluated using the ICC. Concurrent validity was assessed using Pearson’s correlation coefficient, with correlation strengths interpreted as: poor (0.00–0.25), fair (0.26–0.50), moderate (0.50–0.75), and strong (0.76–1.00) [19]. Known-groups validity was analysed using independent samples t-tests. A significance level of p<0.05 was considered statistically significant for all inferential analyses.
RESULTS
Translation and cross-cultural adaptation
No major linguistic or conceptual difficulties were encountered during the forward or backward translation processes. The expert committee reached consensus on the linguistic, experiential, and conceptual equivalence of items. Specifically, extensive deliberations were undertaken for two Malay terms to ensure accurate semantic alignment with the original English version. The final version was clear and contextually appropriate for the Malaysian population (Supplementary Material S1).
Content validity
All 24 items demonstrated perfect agreement across relevance, clarity, simplicity, and ambiguity, with each item receiving an I-CVI score of 1.00. The overall S-CVI/UA and S-CVI/Ave values were both 1.00, indicating excellent content validity across all domains (Supplementary Material S2).
Face validity
Nine lay participants with varying degrees and types of LBP assessed the clarity and comprehensibility of the Malay RMDQ items. All items received an I-FVI score of 1.00. Similarly, both the S-FVI/UA and S-FVI/Ave reached a maximum score of 1.00, indicating complete agreement among participants that the items were clear and understandable. Additionally, impact scores were calculated, with the majority of items scoring 5.00 on a 5-point Likert scale. The lowest recorded mean score was 4.63, suggesting high perceived relevance and acceptability of the items (Supplementary Material S3).
Participant characteristics
A total of 102 participants completed the psychometric evaluation procedures. The majority were female (64.7%), and most were aged between 18 and 40 years (76.4%). More than half were employed (54.9%). Of the total sample, 60 participants (58.8%) were classified as having LBP of 6–12 weeks’ duration, while 42 participants (41.2%) were classified as without LBP (Table 1).
Internal consistency
The overall Cronbach’s α was 0.932, indicating excellent reliability (Table 2). The standardized Cronbach’s α was 0.936. Item-level analysis showed that removal of any item would not improve the overall α, with values ranging from 0.927 to 0.933 across all 24 items.
Test-retest reliability
A subset of 31 participants completed the RMDQ twice over a two-week interval. The overall ICC for the total score was 0.996 (95% confidence interval [CI]: 0.991–0.998), indicating excellent test-retest stability. Item-level ICCs ranged from 0.854 to 1.000, with most items demonstrating perfect agreement.
Concurrent validity
The Malay RMDQ demonstrated moderate concurrent validity when compared with the Malay version of the ODI. All 102 participants completed both the RMDQ and the ODI, and the resulting Pearson correlation coefficient was r=0.742, p<0.001, indicating a statistically significant and moderate positive correlation between the two instruments.
Known-groups validity
As a preliminary assessment of discriminative validity, the Malay RMDQ scores were compared between participants with LBP (n=60) and those without LBP (n=42). A statistically significant difference in the Malay RMDQ scores was observed between the two groups, with a mean difference of 3.46 points (95% CI: 0.38–6.54, p=0.03). Table 2 summarizes the preliminary psychometric findings, including internal consistency, test-retest reliability, concurrent validity, and known-groups comparison.
DISCUSSION
This study aimed to culturally translate, adapt, and validate the RMDQ into the Malay language for use among individuals with LBP in Malaysia. Each stage of the translation and validation process followed rigorous guidelines, ensuring both linguistic and conceptual equivalence between the original and translated versions [8]. The absence of major linguistic challenges during the forward and backward translation processes, together with the strong consensus of the expert committee suggests that the final version likely preserved the original intent and meaning of the items and was culturally appropriate for the Malaysian context, as further supported by the subsequent psychometric findings.
The psychometric properties of the Malay RMDQ were consistent with those reported in previous RMDQ adaptations across various languages and populations, such as those in Hindi [20] Yoruba [21], Hausa [22], Arabic [23], Moroccan [24], Spanish (Argentinean) [25], and simplified Chinese [26]. These findings reinforce the robustness and transferability of the RMDQ as a cross-culturally applicable measure of LBP-related disability [5]. Expert panel evaluations demonstrated strong agreement on the relevance, clarity, and simplicity of the items, while feedback from lay individuals confirmed that the instrument was comprehensible and perceived as relevant. These outcomes are comparable to earlier studies that established good content and face validity in translated RMDQ versions [20-26].
The internal consistency results fell within acceptable ranges, with item-level values suggesting that the scale items work together to assess the intended construct. Similar internal consistency values have been documented in earlier translated versions [20-26]. Similarly, test-retest reliability was very high, demonstrating the scale’s temporal stability and confirming its suitability for repeated use in both clinical monitoring and research contexts. In terms of construct validity, the Malay RMDQ showed moderate concurrent validity through its significant correlation with the Malay ODI, aligning with results from earlier studies [20,22,25,26].
A preliminary comparison between participants with and without LBP demonstrated significantly higher Malay RMDQ scores in the LBP group. However, this finding represents only preliminary discriminative evidence and should be interpreted cautiously, as the comparison was based on the presence or absence of LBP rather than clinically distinct severity subgroups. In addition, non-zero scores observed in the group without LBP may reflect nonspecific functional limitations or other musculoskeletal complaints. Future studies should therefore examine known-groups validity using clinically distinct LBP subgroups, such as categories based on pain severity, disability level, or clinical diagnosis.
From a practical perspective, the availability of a culturally adapted and tested Malay version of the RMDQ may assist healthcare professionals in evaluating LBP-related disability using a self-report format that reflects local language and context. It may be used not only for clinical screening and functional status monitoring but also as an outcome measure in rehabilitation research and workplace health surveillance programs, particularly given the high burden of LBP in Malaysia [4].
Nonetheless, this study is not without limitations. First, while the overall sample size of 102 participants met minimum recommendations for psychometric validation, a larger and more diverse sample would further strengthen the generalizability and robustness of the findings across both reliability and validity domains. Second, the sample was limited to selected regions and included predominantly younger adults, which may restrict the generalizability of findings to older populations. Furthermore, no formal assessment of clinical stability (e.g., global rating of change) was conducted during the two-week interval for test-retest reliability. As the sample included individuals with subacute LBP, some degree of clinical change may have occurred over time. Therefore, the very high test-retest reliability observed in this study should be interpreted with caution, as the absence of a formal stability assessment limits certainty that participants’ clinical status remained unchanged during the interval.
The known-groups analysis was also based on comparison between participants with and without LBP rather than clinically distinct LBP subgroups, which limits the strength of the discriminative validity evidence. Lastly, responsiveness to change was not evaluated. Future research could address these gaps by including more diverse population groups, incorporating explicit stability measures for test-retest analysis, examining clinically relevant subgroup differences, and evaluating the tool’s performance in longitudinal or intervention-based studies.
Conclusion
The Malay version of the RMDQ demonstrated preliminary evidence of reliability, validity, and cultural relevance for assessing functional disability in individuals with LBP. Through a rigorous translation and adaptation process, supported by expert and lay evaluations, the instrument showed promising psychometric properties, including high internal consistency, test-retest reliability, and construct validity. Its clarity and acceptability support its use in clinical and research settings within the Malay-speaking population. Future studies involving larger samples should examine floor and ceiling effects, measurement error, responsiveness, and applicability across broader and more diverse patient groups.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
This study was supported by the Ministry of Higher Education Malaysia through the Fundamental Research Grant Scheme Grant: FRGS/1/2023/SS10/UITM/02/1.
AUTHOR CONTRIBUTION
Conceptualization: Che Daud AZ. Methodology: Mohd Yasin NS, Mohd Poot EF, Mohd Nayan NA, Alrashdi M, Che Daud AZ. Investigation: Mohd Yasin NS, Mohd Poot EF, Ainuddin HA. Data curation: Mohd Yasin NS, Mohd Poot EF, Ainuddin HA. Formal analysis: Mohd Yasin NS. Funding acquisition: Che Daud AZ. Resources: Ainuddin HA. Validation: Mohd Nayan NA, Alrashdi M, Baharom N, Che Daud AZ. Visualization: Mohd Yasin NS. Supervision: Che Daud AZ. Project administration: Che Daud AZ. Writing – original draft: Mohd Yasin NS. Writing – review & editing: Mohd Poot EF, Ainuddin HA, Mohd Nayan NA, Alrashdi M, Baharom N, Che Daud AZ. Approval of final manuscript: all authors.
DATA AVAILABILITY STATEMENT
The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request, in accordance with data sharing policies and participant confidentiality agreements.
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, Erna Faryza Mohd Poot, MHSc1
