We need more empirical research on translation methodologies. Several points emerge from this review. First, producing high-quality translations is labor-intensive. Second, the availability of standardized guidelines and centralized review procedures improves the efficiency of the production of translations. Although we did not find evidence in favor of one method, we strongly advise researchers to adopt a multistep approach. In line with the recent Food and Drug Administration recommendations, we developed a checklist summarizing the steps used for translations, which can be used to evaluate the rigor of the applied methodologies.

Background and Purpose-The modified Rankin Scale (mRS) is widely used to assess global outcome after stroke. The aim of the study was to examine rater variability in assessing functional outcomes using the conventional mRS, and to investigate whether use of a structured interview (mRS-SI) reduced this variability. Methods-Inter-rater agreement was studied among raters from 3 stroke centers. Fifteen raters were recruited who were experienced in stroke care but came from a variety of professional backgrounds. Patients at least 6 months after stroke were first assessed using conventional mRS definitions. After completion of initial mRS assessments, raters underwent training in the use of a structured interview, and patients were re-assessed. In a separate component of the study, intrarater variability was studied using 2 raters who performed repeat assessments using the mRS and the mRS-SI. The design of the latter part of the study also allowed investigation of possible improvement in rater agreement caused by repetition of the assessments. Agreement was measured using the statistic (unweighted and weighted using quadratic weights). Results-Inter-rater reliability: Pairs of raters assessed a total of 113 patients on the mRS and mRS-SI. For the mRS, overall agreement between raters was 43% (ϭ0.25, w ϭ0.71), and for the structured interview overall agreement was 81% (ϭ0.74, w ϭ0.91). Agreement between raters was significantly greater on the mRS-SI than the mRS (PϽ0.001).Intrarater reliability: Repeatability of both the mRS and mRS-SI was excellent (ϭ0.81, w Ն0.94). Conclusions-Although individual raters are consistent in their use of the mRS, inter-rater variability is nonetheless substantial. Rater variability on the mRS is thus particularly problematic for studies involving multiple raters. There was no evidence that improvement in inter-rater agreement occurred simply with repetition of the assessment. Use of a structured interview improves agreement between raters in the assessment of global outcome after stroke.

Background and Purpose-The modified Rankin Scale is widely used to assess changes in activity and lifestyle after stroke, but it has been criticized for its subjectivity. The purpose of the present study was to compare conventional assessment on the modified Rankin Scale with assessment through a structured interview. Methods-Sixty-three patients with stroke 6 to 24 months previously were interviewed and graded independently on the modified Rankin Scale by 2 observers. These observers then underwent training in use of a structured interview for the scale that covered 5 areas of everyday function. Eight weeks after the first assessment, the same observers reassessed 58 of these patients using the structured interview. Results-Interrater reliability was measured with the statistic (weighted with quadratic weights). For the scale applied conventionally, overall agreement between the 2 raters was 57% ( w ϭ0.78); 1 rater assigned significantly lower grades than the other (Pϭ0.048). On the structured interview, the overall agreement between raters was 78% ( w ϭ0.93), and there was no overall difference between raters in grades assigned (Pϭ0.17). Rankin grades from the conventional assessment and the structured interview were highly correlated, but there was significantly less disagreement between raters when the structured interview was used (Pϭ0.004). Conclusions-Variability and bias between raters in assigning patients to Rankin grades may be reduced by use of a structured interview. Use of a structured interview for the scale could potentially improve the quality of results from clinical studies in stroke.