Victorian Institute of Sport Assessment (VISA) Questionnaire, Patellar Tendon

Link to instrument: VISA-P PDF Form

Acronym:

VISA-P

Purpose:

Symptoms of jumper's knee (patellar tendinosis) are not easily quantified and this may explain why there are no evidence-based guidelines for managing the condition. A simple, practical questionnaire-based index of severity would facilitate jumper's knee research and subsequently, clinical management.

Description:

A questionnaire containing 8 questions about patellar tendinosis

• Assesses symptoms, simple tests of function, and ability to play sports
• 6 of 8 questions are scored on a VAS from 0-10 (10 is optimal health)
• Question 7 has 4 categories that can be scored at 0, 4, 7 or 10
• Question 8 is dependent on patient's current pain level and scored based on how long they can train
• Max score for asymptomatic individual is 100; theoretical minimum is 0

Area of Assessment: Functional Mobility, Life Participation, Pain

Body Part: Lower Extremity

ICF Domain: Body Function, Activity, Participation

Domain: ADL, Motor

Assessment Type: Patient Reported Outcomes

Length of Test: 05 Minutes or Less

Time to Administer:

3 minutes

Number of Items: 8 questions

Equipment Required: Writing utensil

Training Required: None

Type of training required: no training

Cost: Free

Actual Cost: Printing costs for form.

Age Range: Adult: 18-64 years

Administration Mode: Paper/Pencil

Diagnosis: Knee Dysfunction, Pain

Populations Tested:

Visentini et al (1998)

• Asymptomatic University students
• Sports medicine clinic patients with symptoms unrelated to knees
• Sports medicine clinic patients who presented with jumper's knee
• Elite basketball players who competed in the national league(current or past history of jumper's knee were not exclusion criteria)
• Patients before and after surgery for chronic jumper's knee.

Frohm et al (2004)

• Healthy students
• Members of Swedish male national basketball team (at-risk population)
• Non-surgically treated patients with clinically diagnosed patellar tendinopathy

Zwerver et al (2009)

• Healthy students
• Competitive volleyball players (at-risk population)
• Patients with patellar tendinopathy
• Patients who had surgery for patellar tendinopathy
• Patients with knee injuries other than patellar tendinopathy
• Patients with symptoms unrelated to their knees
• * Participants completed the Dutch VISA-P

Hernandez-Sanchez (2011)

• Healthy students
• Athletes who participated in sports such as volleyball, basketball, and handball (at-risk population for patellar tendinopathy)
• Athletes diagnosed with patellar tendinopathy who played for professional sports clubs in Spain
• Patients with knee injuries other than patellar tendinopathy

Wilgen et al (2011)

• Asymptomatic male and female volleyball players
• Athletes with symptomatic patellar tendinopathy who specifically had activity-related anterior knee pain and palpation tenderness
• * Participants completed the Dutch VISA-P

Hernandez-Sanchez et al (2012)

• Athletes with patellar tendinopathy from 10 sports physiotherapy clinics across Spain

Maffulli et al (2008)

• 25 male athletes with diagnosis of classic patellar tendinopathy between ages 18-32
• * Participants completed the Italian VISA-P

Standard Error of Measurement (SEM):

Visentini et al (1998)

• 90% MDC for test-retest
  • All subjects = 1.39
  • Only tendons with VISA <80 = 1.49
  • Inter-tester all subjects tested = 1.49
  • Inter-tester for only tendons with VISA <80 = 3.33
  • Stability = 3.94

Hernandez-Sanchez et al (2012)

• SEM = 4.0

Minimal Detectable Change (MDC):

Hernandez-Sanchez et al (2012)

• MDC using a 95% CI= 11.1

Minimally Clinically Important Difference (MCID):

Hernandez-Sanchez et al (2012)

• > 13 point on the VISA-P score or 15.4-27% of relative change achieved MCID
• Probability of clinical change 98% when threshold was achieved
• Probability of clinical change 45% when MCID not achieved

Cut-Off Scores:

Hernandez-Sanchez (2012)

• Cut-off score of ≥3 on the Global Rating of Change scale (GROC) to define MCID level

Normative Data:

Visentini et al (1998)

• The maximal VISA-P score for an asymptomatic, fully-performing individual is 100 points

Frohm et al (2004)

• Scores of these populations:
  • Patients had a mean score of 47.76 (SD=20.26)
  • Healthy Students had a mean score of 79.00 (SD=24.18)
  • Basketball players had a mean score of 83.06 (SD=12.60)

Wilgen et al (2011)

("Athletes without knee complaints score the maximal score of 100, whereas athletes with PT usually score 50-75")

• 54 athletes with patellar tendinopathy: mean 60 (SD=13.1)
• 48 athletes with patellar tendinopathy: mean 58 (SD=17.1)

Zwerver et al (2009)

	VISA-P Score
Healthy Students	95.3 (SD = 8.8)
At-risk population	88.6 (SD = 11.1)
Injury other than knee	76.6 (SD = 24.3)
Knee Injury	61.9 (SD = 24.1)
Patellar Tendinopathy	58.2 (SD = 18.9)
Surgery for patellar tendinopathy	56.0 (SD = 20.9)

Hernandez-Sanchez et al (2011)

• First VISA-P-Spanish (0-100)--at baseline
  • Healthy Population: Mean 95.4 (SD=2.5)
  • At Risk: Mean 90.0 (SD=9.7)
  • Patellar Tendinopathy: Mean 54.8 (SD=13.2)
  • Other Knee Injuries: Mean 56.4 (SD=11.3)
• Second VISA-P-Spanish (0-100)--1 week after baseline
  • Healthy Population: Mean 95.8 (SD=2.4)
  • At Risk: Mean 89.8 (SD=9.4)
  • Patellar Tendinopathy: Mean 56.3 (SD=12.9)
  • Other Knee Injuries: Mean 56.3 (SD=11.4)

Maffulli et al (2008)

• First mean VISA-P-I score = 44.3 (range of 33-61)
• Second mean VISA-P-I score taken 30 min later = 45.2 (range of 31-61)
• No significant difference between test-retest assessments

Test-retest Reliability:

Visentini et al (1998)

• Excellent test-retest reliability (r > 0.95)

Frohm et al (2004)

• Excellent test-retest reliability (ICC = 0.97)

Zwerver et al (2009)

• Adequate to excellent test-retest reliability (ICC = 0.74, p < 0.001)

Wilgen et al (2011)

• Adequate to excellent test-retest reliability (ICC = 0.74)

Hernandez-Sanchez et al (2011)

• Excellent test-retest reliability ICC = 0.994

Interrater/Intrarater Reliability:

Visentini et al (1998)

Interrater Reliability (same as Test-retest Reliability)

• Excellent interrater reliability (r > 0.95)

Internal Consistency:

Frohm et al (2004)

• 1st assessment:
  • Excellent internal consistency (Cronbach's alpha = 0.83)
• 2nd assessment
  • Excellent internal consistency (Cronbach's alpha = 0.82)

Zwerver et al (2009)

• 1st assessment
  • Adequate internal consistency (Cronbach's alpha = 0.73)
• 2nd assessment
  • Adequate internal consistency (Cronbach's alpha = 0.71)

Hernandez-Sanchez et al (2011)

• 1st assessment
  • Excellent internal consistency (Cronbach's alpha = 0.885)
• 2nd assessment
  • Excellent internal consistency (Cronbach's alpha = 0.880)

Maffulli et al (2008)

• Adequate internal consistency (Kappa = 0.78, range of 0.7 - 0.86 with p < 0.05)

Criterion Validity (Predictive/Concurrent):

Not Established

Construct Validity (Convergent/Discriminant):

Frohm et al (2004)

• Differences between scores of the patients, healthy students, and basketball players were statistically significant: p<0.001

Wilgen et al (2011)

• Significant difference between PPT results of "symptomatic group" (with scores less than 80) and participants classified as "normal group" (scores above 80)--symptomatic group's PPTs were lower: x² p< 0.001

Hernandez-Sanchez et al (2011)

• Differences between the healthy and the at-risk groups were statistically significant with respect to the participants with tendinopathy (37.9 points, P<.01) and other knee injuries (36.3 points, P<.01)
• However, no differences were found between scores of participants in the tendinopathy group and those in the other knee injury group (1.6 points, P>.05) or between the healthy and the at-risk groups (5.45 points, P>0.05)

Zwerver et al (2009)

• ANOVA revealed a significant difference between the six groups (F = 10.7, p < 0.001). See normative data for the six groups.

Content Validity:

Not Established

Face Validity:

Not Established

Floor/Ceiling Effects:

Hernandez-Sanchez et al (2011)

• Ceiling and floor effects were not observed in this study further supporting the validity of the VISA-P

Responsiveness:

Hernandez-Sanchez et al (2012)

• We combined anchor-based (MCS and ROC curve) and distribution-based approaches (SEM and MDC) to study responsiveness
• AUC represents responsiveness, AUC between 0.7 and 0.8 were considered acceptable discrimination. Values higher than 0.8 have excellent discrimination
• To interpret the VISA-P changes, alternative methods of studying responsiveness are required alongside further studies

Hernandez-Sanchez et al (2011)

• In athletes with tendinopathy, VISA-P (spanish) score changes were observed in those who were able to return to sports participation. The mean SD change in scores for this group was 15.23 +/- 13.01 points between the first and third applications of the questionnaire
• The effect size (less than 0.8) provides evidence that the VISA-P (spanish) can detect changes in symptom severity at 2 different time points in the clinical course of tendinopathy

Considerations:

Time, mental status, fatigue. The VISA-P is not a diagnostic test. The test is inappropriate for individuals who cannot perform functional tests due to other limitations.

 

Frohm et al (2004)

• The VISA-P score has not been validated for pathological knee conditions other than patellar tendinopathy
• The VISA-P score could be abbreviated to two or three items without losing significant clinical information

Zwerver et al (2009)

• A limitation of this study is that the test-retest reliability was investigated in asymptomatic students. One could argue that testing reliability in athletes with patellar tendinopathy would have been more appropriate

Hernandez-Sanchez et al (2012)

• The estimated MCID for the VISA-P is dependant on baseline scores and the interpretation of the relevant change on GROC
• The MCID values vary depending on intervention type therefore further studies are needed to assess whether these values differ after surgical treatment

Hernandez-Sanchez et al (2011)

• The sample in this study consisted primarily of male participants, which may limit the generalization for the results. Further research is necessary to better establish the responsiveness of the scale
• The VISA-P should not be considered a diagnostic tool, because there were no significant differences between the scores of athletes with tendinopathy and those of patients with other knee injuries

Maffulli et al (2008)

• The VISA-P-I was only validated for classic patellar tendinopathy as it is more common than tendinopathy of the main body of the patellar tendon
• The VISA-P-I was not administered to any patients scheduled for surgery

Bibliography:

Frohm A, Saartok T, Edman G, Renström P. Psychometric properties of a Swedish translation of the VISA-P outcome score for patellar tendinopathy. BMC Musculoskelet Disord. 2004;5:49.

Hernandez-Sanchez S, Hildalgo MD, Gomez A. Cross-cultural adaptation of VISA-P score for patellar tendinopathy in Spanish population. Journal of Orthopaedic and Sports Physical Therapy. 2011; 41(8):581-91.

Hernandez-Sanchez, S., Hidalgo, M., & Gomez, A. (2012). Responsiveness of the VISA-P scale for patellar tendinopathy in athletes. British Journal of Sports Medicine Br J Sports Med, 453-457.

Maffulli N, Longo UG, Testa V, Oliva F, Capasso G, Denaro V. VISA-P score for patellar tendinopathy in males: Adaptation to Italian. Disability and Rehabilitation. 2008;30(20-22):1621-1624.

Van wilgen P, Van der noord R, Zwerver J. Feasibility and reliability of pain pressure threshold measurements in patellar tendinopathy. J Sci Med Sport. 2011;14(6):477-81.

Visentini PJ, Khan KM, Cook JL, Kiss ZS, Harcourt PR, Wark JD. The VISA score: an index of severity of symptoms in patients with jumper's knee (patellar tendinosis). Victorian Institute of Sport Tendon Study Group. J Sci Med Sport. 1998;1(1):22-8.

Zwerver J, Kramer T, Van den akker-scheek I. Validity and reliability of the Dutch translation of the VISA-P questionnaire for patellar tendinopathy. BMC Musculoskelet Disord. 2009;10:102.

Year published: 1998

Instrument in PDF Format: Yes

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