breast cancer is the most prevalent cancer amongst women but it has the highest survival 
 rate of all cancers1 . breast cancer treatments may damage the 
 lymph vessels and nodes , resulting in impaired lymph transport capacity and the accumulation 
 of protein - rich interstitial fluid in the torso or upper extremity3 . lymphedema causes limb and shoulder pain , heaviness , tightness , and decreased range of 
 motion . anxiety , depression , and emotional distress are more common among patients with 
 breast cancer - related lymphedema ( bcrl)4 , 5 . this condition may lead to difficulty with 
 activities of daily living ranging from overhead reaching , lifting , carrying objects , to 
 caring for family and returning to work . after breast cancer treatment , women who develop 
 lymphedema have greater restrictions in activities of daily living , and report poorer 
 quality of life than women without lymphedema6 , 7 . quality of life instruments are used to describe and evaluate functioning in clinical 
 practice . because it is a complex term that involves different contexts , the world health 
 organization ( who ) developed the international classification of functioning , disability and 
 health ( icf)8 . since quality of life 
 questionnaires and the icf represent two different perspectives regarding functionality and 
 health , they are used simultaneously in clinical practice9 . carvalho et al.10 studied patients who had breast cancer surgery and reported that 
 long - term follow - up is necessary to better define the disability of this population . the lymphoedema functioning , disability and health questionnaire ( lymph - icf ) assesses 
 impairments in function , activity limitations , and participation restrictions related to 
 lymphedema developed after axillary dissection for breast cancer , and it is based on the 
 terminology of the icf11 . a study showed that the original lymph - icf had high internal consistency , excellent 
 test - retest reliability , good convergent validity with the short form-36 ( sf-36 ) 
 questionnaire , and good responsiveness12 . the aims of this study were to cross - culturally adapt the lymph - icf for turkish - speaking 
 patients , and to determine the clinimetric properties of its reliability , criterion 
 validity , internal consistency , and measurement error for patients with bcrl . the lymph - icf was translated into turkish and culturally adapted in accordance with the 
 method recommended by beaton et al12 . the study group consisted of 
 patients diagnosed with lymphedema with complaints after breast cancer surgery . the 
 inclusion criteria were as follows : unilateral mild or moderate lymphedema following breast 
 cancer surgery lasting for at least three months , and an age between 25 and 75  years , and 
 the ability to reply to visual or verbal instructions . a difference in circumference of up 
 to 2 cm indicated mild lymphedema , and a difference of 25  cm was classified as moderate 
 lymphedema . the affected 
 side of the patients was 15 ( 50% ) for the right upper extremity and 15 ( 50% ) for the left 
 upper extremity . the clinical assessment revealed 7 ( 23.3% ) patients had mild lymphedema and 
 23 ( 76.7% ) patients had moderate lymphedema . each question is answered using a 
 visual analog scale ( vas ) ranging from 0 to 100  mm . the anchors for the impairments in 
 function ( e.g.  does your arm hurt ?  ) are  not at all  and  very much ,  and those for the 
 activity limitations and participation restrictions ( e.g.  are you able to carry heavy 
 weights ?  ) are  very well  and  not at all . the lymph - icf has 5 domains : physical function , 
 mental function , household activities , mobility activities , and life and social activities . 
 the total score of the lymph - icf is equal to the sum of the scores of the questions divided 
 by the total number of answered questions . the lymph - icf takes about 5 minutes to 
 complete . the 36 item short - form ( sf-36 ) the sf-36 was designed for use in clinical practice and research , health 
 policy evaluations , and general population surveys . the sf-36 includes one multi - item scale 
 that assesses eight health concepts : 1 ) limitations of physical activities because of health 
 problems ; 2 ) limitations of social activities because of physical or emotional problems ; 3 ) 
 limitations of usual role activities because of physical health problems ; 4 ) bodily pain ; 5 ) 
 general mental health ( psychological distress and well - being ) ; 6 ) limitations of usual role 
 activities because of emotional problems ; 7 ) vitality ( energy and fatigue ) ; and 8) general 
 health perceptions . the survey was constructed for self - administration by persons 14  years 
 of age or older , and for administration by a trained interviewer in person or by telephone . this study was approved by the institutional ethical board of medipol university and was 
 conducted in accordance with the declaration of helsinki . the english version of the lymph - icf was adapted for turkish use according to the 
 established guidelines for cross - cultural adaptation of self - reported questionnaires . the 
 guideline has 5 steps : ( 1 ) translation , ( 2 ) synthesis , ( 3 ) back translation , ( 4 ) evaluation 
 by a team of experts , and ( 5 ) pretests . in step one , the english version of the lymph - icf 
 was translated into turkish by two independent native turkish speakers ( two 
 physiotherapists ) who were fluent in english . both translations were assembled by two translators and a team of 
 experts . in step three , the turkish translation of the lymph - icf was translated back into 
 english by two persons , who were bilingual native english speakers and did not receive any 
 information about the lymph - icf . in step four , all the translations were reviewed by an 
 expert committee consisting of the forward and back translators , one physiotherapist 
 specialized in lymphedema disorders and one other physician . consensus was achieved on 
 semantic , idiomatic , experiential and conceptual features and the prefinal version of the 
 turkish lymph - icf was consolidated . in step five , the prefinal versions of turkish lymph - icf 
 were tested using ten patients with lymphedema to determine the accuracy of the wording and 
 understanding of the test items at an outpatient physiotherapy department . the interviewer 
 ( one physiotherapist ) defined and recorded any problems occurring during the filling out of 
 the prefinal turkish lymph - icf questionnaire . after consideration of these issues , a final 
 turkish version of the turkish lymph - icf was established . the questions were understood by 
 all of the patients and there were no ambiguities . the reliability and validity of the final turkish versions of the turkish lymph - icf was 
 tested using 30 patients with lymphedema . all patients completed the turkish version of the 
 lymph - icf and the turkish version of the sf-36 in a first examination under supervision of 
 one of the authors ( ak ) at the outpatient physiotherapy department . on the second visit 7 
 days later , the patients completed the same questionnaires again under supervision of the 
 same assessor ( ak ) and another assessor ( zh ) to determine the test - retest and inter - tester 
 reliability , respectively . the statistical package for social science ( spss ) software version 21.0 ( spss inc . , the normality of the distribution was 
 assessed using the kolmogorov - smirnov test , which found they were normally distributed . for 
 categorical variables , the data are presented as descriptive statistics ( means and standard 
 deviations , frequencies and percentages ) were reported . the reliability of the lymph - icf scale was assessed using the reproducibility ( test - retest 
 reliability ) of scores , and the internal consistency of the scale . test - retest and 
 inter - tester reliability were determined using the interclass correlation coefficient 
 ( icc(2,1 ) ) and the icc(2,k ) , respectively . the internal consistency of the lymph - icf was 
 assessed using cronbach s alpha . the validity of the construct was analyzed by examining correlations between the lymph - icf 
 scores and the sf-36 scores . pearson correlation coefficients were used to evaluate 
 construct validity because lymph - icf and sf-36 scores were continuous variables and were 
 normally distributed . correlation coefficients were rated as follows : strong correlation 
 > 0.6 ; moderate 0.6 and > 0.3 ; and poor 0.3 . the questionnaires were given to 30 patients and all of the patients completed the 
 questionnaires in full . the mean age of the patients was 53.8  5.8  years and their mean 
 lymphedema complaint duration was 18.2  7.7 months ( table 1table 1.demographic and clinical characteristics of the patientscharacteristicsmean  sd , nrangeage ( years ) 53.8  5.8(396)bmi ( kg / m)30.4  4.1(24.339.8)mean duration of lymphedema ( month ) 18.2  7.7(63)mean duration of operation ( month)28.5  9.6(104)severity lymphedema ( patients ) mild7 ( % 23.3)moderate23 ( % 76.7)dominant side ( r / l)26/4affected side ( r / l ) 15/15bmi : body mass index , r : right , l : left ) . bmi : body mass index , r : right , l : left investigation of the test - retest stability over the 7-day interval found that the 
 difference between the two measurements was not statistically significant ( p>0.05 ) . the 
 results of the reliability analyses and the mean scores of the subscales are presented in 
 table 2table 2.test-retest and inter - tester reliability of the turkish versions of the 
 lymph - icfself - reported outcome measurementsassessor i first assessment assessor i second assessmentassessor iiassessor i first - second assesment assessor i first - assessor ii icccronbach s alphaicccronbach s alphalymph - icf total 46.53  19.1146.90  17.94 46.53  17.560.900.990.980.99physical function ( heavy , stiff , swollen , lost 
 strength , tingle , hurt , tensed skin)43.33  24.59 43.53  24.39 43.43  23.590.990.990.990.99mental function ( feel sad , feel discouraged , lack of 
 self confidence , feel stressed)41.90  30.53 42.73  30.10 43.06  29.670.990.990.990.99household activities ( clean , cook , iron , garden)54.13  38.2652.00  28.1253.36  30.280.800.890.730.85mobility activities ( tasks with elevated arm , lift 
 heavy objects , sleep on effected side , work on computer , sunbathe , drive a car , 
 walk more than 2 km , cycle ) 57.16  35.65 53.46  26.83 55.00  27.600.850.920.830.90life and social activities ( go on vacation , perform 
 hobbies , practice sports , wear clothes of choice , do a job , do social 
 activities)47.13  25.95 48.53  27.75 47.60  25.580.980.990.990.99icc : intraclass correlation coefficent . the test - retest reliability ( icc range , 0.800.99 , cronbach s alpha range , 
 0.890.99 ) and inter - tester reliability ( icc range , 0.730.99 , cronbach s alpha range , 
 0.850.99 ) of the lymph - icf total score , physical function score , mental function score , 
 household activities score , mobility activities score , and the life and social activities 
 score were excellent . icc : intraclass correlation coefficent table 3table 3.construct validity : correlation analysis of the turkish versions of the lymph - icf 
 and sf-36lymph icfsf-36 domainphysical functionmental functionhousehold activitiesmobility activitieslife and social activitiesphysical functioning0.498**0.0750.0260.1360.088role - physical0.1390.0710.0560.1820.337bodily pain0.2660.0760.0660.2230.393*general health0.1850.3490.3570.416*0.323vitality0.1500.3550.1840.2870.203social functioning0.463**0.0870.0300.2080.262role - emotional0.2740.0560.0770.0710.156mental health0.0300.2150.1330.1710.371**moderate correlation , * * strongest correlation shows the results of the validity analyses . there were significant 
 correlations between the lymph - icf total score , physical function score , mental function 
 score , household activities score , mobility activities score , life and social activities 
 score and the sf-36 subscales ( physical functioning , role - physical , bodily pain , general 
 health , vitality , social functioning , role - emotional , mental health ) ( range , 0.030.49 ) . the 
 correlations between the lymph - icf physical function and sf-36 physical functioning total 
 ( r=0.49 p=0.005 ) , and the lymph - icf physical function and sf-36 social functioning 
 ( r=0.463 p=0.010 ) , were strong . the correlations between the lymph - icf mobility activities 
 and sf-36 general health ( r=0.41 p=0.020 ) , the lymph - icf life and social activities and 
 sf-36 bodily pain ( r=0.39 p=0.032 ) , and the lymph - icf life and social activities and sf-36 
 mental health ( r=0.37 p=0.044 ) were moderate . the present study , demonstrated that the lymph - icf is a valid and reliable tool for 
 assessing the impairments in function , activity limitations , and participation restrictions 
 of patients with bcrl patients . the original dutch and english versions of the lymph - icf 
 have been found to be valid and reliable instruments for women with arm lymphedema . since 
 all of the patients found the questions understandable , it was nt necessary to change any 
 item . the test - retest indicated the subscales had adequate to excellent reliability and the 
 lymph - icf questionnaire as a whole had very good reliability . in the literature , test - retest 
 reliabilities of the total score and of the physical function and household activities 
 scores were reported as very strong ( icc>0.90 ) , those of the mental function and mobility 
 activity scores strong ( icc>0.75 ) , and that of the life and social activities score 
 moderate ( icc=0.65 ) for the original version of the lymph - icf11 . in our study , the test - retest reliabilities of the physical 
 function , mental function , and life and social activity scores were very strong 
 ( icc>0.90 ) , and those of the lymph - icf total , household activities and mobility 
 activities were strong ( icc>0.75 ) , the same as for the original version of the lymph - icf . the icc results in our study were higher than those reported for the original version of the 
 lymph - icf11 . this may be because the 
 first and second lymph - icf were conducted at different times . the time interval between 
 repeated measurements is an important factor in the determination of test - retest 
 reliability . the reliability tends to be higher when an interval of 7 days or less is used , 
 because short test - retest intervals can elicit similar responses12 . therefore , 7 days was chosen for the retest assessment 
 interval to decrease the possibility of participants remembering the questions . it is our 
 opinion that the conditions of the bcrl patients would nt be expected to change over this 
 period13 . in this study , the well - established questionnaire sf-36 was chosen because it is a widely 
 used generic health related quality of life instrument both in turkey and worldwide , and it 
 has with demonstrated validity and reliability for cancer patients14 . for the concurrent validity , pearson correlation coefficients of the subscales of the 
 lymph - icf and sf-36 were computed . the physical functioning domain of the lymph - icf showed 
 strong correlations with the physical and social functioning domains of the sf-36 ; the 
 mobility activities domain of the lymph - icf showed a moderate correlation with the general 
 health domain of the sf-36 ; the social activities domain of the lymph - icf showed a moderate 
 correlation with the body pain domain of the sf-36 . this confirms that the sf-36 measures additional aspects of physical health and provides 
 more comprehensive , but less specific , information about a patient s overall health than 
 condition - specific questionnaires . the lymph - icf showed stronger correlations with was more 
 strongly related to concurrent measures of physical and social functions than to concurrent 
 measures of general health . in the literature , klernas et al . used sf-36 and lymphedema 
 quality of life inventory ( lyqli ) in their validation study15 . they demonstrated there were correlations between the scores of 
 the domains of the lyqli and the physical and mental scores of the sf-36 , as also found by 
 our present study . as expected , sf-36 and the lymph - icf have similar items due to the sf-36 
 being a generic quality of life scale . the internal consistency analysis using cronbach s alpha showed all the questions to be 
 within the recommended range of values ( 0.700.95)16 . the cronbach alpha values or the present study are higher than 
 0.70 and similar to the values reported by viehoff et al.17 who tested the ull-27 . reported cronbach s alpha 
 values of 0.720.92 which are similar to the values of our present study . limitations of this study include the lack of comparison between patients with bcrl and 
 healthy women . in the recent literature there was no other report of validation and cultural 
 adaptation of lymph - icf to other languages . in conclusion , based on the results of this study , the turkish version of the lymph - icf is 
 reliable and may be applicable in clinical research and practice for bcrl patients .
[ purpose ] the purpose of this study was to adapt the lymphoedema functioning , disability 
 and health questionnaire into the turkish language , and to evaluate the psychometric 
 properties of the turkish version in patients with breast cancer - related lymphedema . 
 [ subjects and methods ] after the translation , inter - rater and test - retest reliability were 
 assessed between patients and physiotherapists using the intra - class correlation 
 coefficient . 
 thirty patients with breast cancer - related lymphedema were asked to fill out 
 the turkish version of the lymphoedema functioning , disability and health questionnaire 
 two times , one week apart . 
 internal consistency was tested using cronbach s alpha , and the 
 test - retest reliability was assessed by calculating the intra - class correlation 
 coefficient . 
 construct validity was investigated by comparing the results of the 
 lymphoedema functioning , disability and health and short form-36 questionnaires . 
 [ results ] 
 the test - retest reliability and inter - tester reliability of the lymphedema functioning , 
 disability and health questionnaire total score , physical function score , mental function 
 score , household activities score , mobility activities score , life and social activities 
 score were excellent . 
 [ conclusion ] the turkish version of the lymphoedema functioning , 
 disability and health questionnaire was found to be valid and reliable for patients with 
 breast cancer related lymphedema .