Victorian Institute of Sports Assessment - Achilles

Link to instrument: PDF Form

Acronym:

VISA-A

Purpose:

VISA-A serves as a disease-specific questionnaire for measurement of Achilles tendinopathy severity. The questionnaire is meant to be self-administered, uncomplicated, and relatively quick for both subjects and healthcare professionals.

Description:

• Self-reported questionnaire based instrument
• Provides an index of achilles tendinopathy
• Consists of eight questions that address the following domains:
  • pain, function in daily living, and sporting activity
• Scores range from 0 - 100, with 0 being the worst

Area of Assessment: Activities of Daily Living, Functional Mobility, Gait, Life Participation, Pain

Body Part: Lower Extremity

ICF Domain: Body Structure, Body Function, Activity, Participation, Environment

Domain: ADL

Assessment Type: Patient Reported Outcomes

Length of Test: 05 Minutes or Less

Time to Administer:

< 5 Minutes

Number of Items: 8 questions

Equipment Required: None

Training Required: None

Type of training required: no training

Cost: Free

Actual Cost: Free

Age Range: Adolescent: 13-17 years, Adult: 18-64 years

Administration Mode: Paper/Pencil

Diagnosis: Movement Disorders, Pain

Populations Tested:

Maffulli, et al (2008)

• 50 male athletes with unilateral tendinopathy of the main body of the Achilles (average age 26.4, range 18-49 years)
  • Sports participation of the athletes included soccer, track and field, volleyball, basketball, rugby, martial arts, and ballet

JM Robinson, et al (2001)
4 populations were tested:

• Group 1: 45 non-surgical patients in a primary care sports medicine clinic, with a diagnosis of Achilles tendinosis, paratendinitis, or partial rupture
• Group 2: 14 pre-surgical patients referred to a sports orthopaedist for tendon surgery, with a diagnosis of Achilles tendinosis, paratendinitis, or partial rupture
• Group 3: 63 university students ("young normally active people")
• Group 4: 24 active, non-injured members of a running club

Silbernagel, et al (2005)

• 15 healthy individuals, 20-40 years old
• 51 patients with achilles tendinopathy, 39-47 years old

Lohrer, et al (2009)

• All native German speakers, >18 y.o, unilateral involvement
• Excluded: complete ruptures, pregnant/nursing subjects, insertional Achilles tendinopathy, previous surgeries on involved LE, Haglund's disease, LE radicular symptoms
• Total n = 109, divided into 4 groups:
  • Group 1: 15 preoperative achilles tendinopathy patients
  • Group 2: 15 achilles tendinopathy patients conservatively treated
  • Group 3: 48 Frankfort University students with no tendinopathy
  • Group 4: 31 members of local running group without tendinopathy

Standard Error of Measurement (SEM):

Silbernagel, et al (2005):

• SEM = 7.96 (Calculated with available statistics)

Minimal Detectable Change (MDC):

Silbernagel, et al (2005):

• 18.5 (90% MDC)
• 22.1 (95% MDC)

Minimally Clinically Important Difference (MCID):

Not Established

Cut-Off Scores:

Not Established

Normative Data:

Maffulli, et al (2008)

• At first examination:
  • Mean = 51.8; SD = 18.2
• 30 minutes after examination:
  • Mean = 51.1; SD = 19

JM Robinson, et al (2001)

• Group 1, non-surgical patients
  • Mean = 64; SD = 17; 95% CI 59 to 69
• Group 2, pre-surgical patients
  • Mean = 44; SD = 28; 95% CI 28 to 60
• Group 3, university students
  • Mean =96; SD = 7; 95% CI 94 to 98
• Group 4, running club ○ Mean = 98; SD = 3; 95% CI 97 to 99

Silbernagel, et al (2005)

• Mean = 50
• SD = 24 (reliability group) and 23 (validity group)

Lohrer, et al (2009)

• Group 1, preoperative Achilles tendinopathy patients
  • Mean = 44.9; SD = 14.2; 95% CI
• Group 2, Achilles tendinopathy patients conservative treatment
  • Mean= 73.1; SD = 13.5; 95% CI
• Group 3, Frankfort University students with no tendinopathy
  • Mean= 98.0; SD= 7.1; 95% CI
• Group 4, members of local running group without tendinopathy
  • Mean= 99.2 ; SD= 2.0; 95% CI

Test-retest Reliability:

Maffulli, et al (2008)

• Questionnaire completed at first examination and 30 minutes after examination for test-retest evaluation
• Excellent test-retest reliability (Kappa = 0.80, p < 0.05)

JM Robinson, et al (2001)

• Group 1, non-surgical patients
  • Excellent test-retest reliability (r = 0.93)
  • Excellent short term (one week) reliability (r = 0.81)
• Group 4, running club
  • Excellent test-retest reliability (r = 0.98)
  • Excellent short term (one week) reliability (r = 0.98)

Silbernagel, et al (2005)

• Excellent test-retest reliability (r = 0.89)

Lohrer, et al (2009)

• Group 1, not established
• Group 2
  • Excellent test-retest reliability (Spearman's rho = 0.66, p < 0.05)
  • Excellent test-retest reliability (ICC = 0.87, p < 0.05)
• Group 3
  • Excellent to adequate test-retest reliability (Spearman's rho = 0.60, p < 0.05)
  • Excellent test-retest reliability (ICC = 0.97, p < 0.05)
• Group 4
  • Excellent test-retest reliability (Spearman's rho = 0.70, p < 0.05)
  • Adequate test-retest reliability (ICC = 0.60, p < 0.05)

Interrater/Intrarater Reliability:

JM Robinson, et al (2001)

• Group 1, non-surgical patients
  • Excellent Intrarater Reliability [3 trials] (r = 0.90)
  • Excellent Interrater Reliability (r = 0.90)
• Group 4, running club
  • Excellent Interrater Reliability (r = 0.97)

Internal Consistency:

Silbernagel, et al (2005)

• Adequate internal consistency (Cronbach's Alpha=0.77)

Lohrer, et al (2009)

• Adequate internal consistency (Cronbach's Alpha=0.74)

Criterion Validity (Predictive/Concurrent):

Not Established

Construct Validity (Convergent/Discriminant):

Maffulli, et al (2008)

• Construct validity of the VISA-A Italian version was tested according to the original article on the VISA-A English version (see Robinson, et al 2001)

JM Robinson, et al (2001)

• Group 1 completed the VISA-A and 2 other generic tendon grading systems at one visit:
  • Percy and Conochie's grade of severity: Adequate construct validity (r = 0.58; p<0.01)
  • Curwin and Stanish: Adequate construct validity (r = -0.57; p<0.001)
• VISA-A scale was tested in both Group 2 who are generally considered to have the most significant degree of disease and the two control populations (groups 3 and 4)
  • Patients with Achilles tendinopathy (both groups 1 and 2) had significantly lower (p<0.001) scores than those of the control groups (groups 3 and 4)
  • Patients in group 1 also had a significantly higher mean VISA-A score than those in group 2 (p = 0.02)

Silbernagel, et al (2005)

• Construct validity of the Swedish version of VISA-A (VISA-A-S) was tested according to the original article on the VISA-A English version (see Robinson, et al 2001)
• Results from the 51 patients who completed the VISA-A-S were compared with the results from a tendon grading system by Stanish et al. (1984)
• Results from patients with Achilles tendinopathy were compared to results from healthy individuals in the VISA-A-S

Lohrer, et al  (2009)

• VISA-A-G compared to  Percy and Conchoie tendon classification
  • Excellent construct validity (Spearman's rho=.95, p<.05)
• VISA-A-G compared  to classification system  for the Effect of pain on Athletic performance
  • Excellent construct validity (Spearman's rho = -.95  p<.05)

Content Validity:

Maffulli, et al (2008)

"To establish good face validity and content validity, the translation and cultural adaptation of the VISA-A questionnaire into Italian was performed in several steps. The English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The authors of this article compared the original version with the back translation."

 

JM Robinson, et al (2001)

First, a focus group consisting of the principal questionnaire developer, a primary care sports medicine doctor, and two physiotherapists reviewed the items generated. Then, a group of 15 clinicians (including 8 physiotherapists, 4 primary care doctors, 1 orthopaedic surgeon, and 1 rehabilitation specialist) were asked to identify questions they felt were important in assessing the severity of Achilles tendon disorders. They were then shown the VISA-A to evaluate the questionnaire and asked if there were any questions they would add, delete, or modify. 14 had no questions to add, and none wanted any questions deleted or modified.

 

Silbernagel, et al (2005)

The English version of VISA-A was translated by three people (all of whom worked in the medical field and had English as their second language) into the Swedish version. Next, those three translations were "synthesized into one Swedish version" by a panel of four physical therapists who specialized in musculoskeletal disorders. Finally, a pre-final version of the Swedish VISA-A (VISA-A-S) was pilot tested on five patients and five healthy subjects.

 

Lohrer, et al (2009)

To establish content validity of the VISA-A-G based on the VISA-A questionnaire there were six steps followed: translation involving three translators and an orthopedic surgeon, synthesis of the translations, back translation into English, committee review with health and language professionals, pre-testing, final review.

Face Validity:

Maffulli, et al (2008)

"To establish good face validity and content validity, the translation and cultural adaptation of the VISA-A questionnaire into Italian was performed in several steps. The English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The authors of this article compared the original version with the back translation."

Floor/Ceiling Effects:

Not Established

Responsiveness:

Not Established

Considerations:

Pros: Being that there is a need for a quantitative index of pain and function in patients with Achilles tendinopathy, the VISA-A questionnaire scale can be easily administered in clinical practice & quantitative research to gain insight into the severity of Achilles Tendinopathy.

Cons: The test is not designed to be diagnostic. Further studies needed to determine whether the VISA-A score actually predicts prognosis.

Bibliography:

Maffulli N, Longo UG, Testa V, Oliva F, Capasso G, Denaro V. Italian translation of the VISA-A score for tendinopathy of the main body of the Achilles tendon. Disability and Rehabilitation. 2008; 30(20-22):1635.

Robinson JM, Cook JL, Purdam C, et al. The VISA-A questionnaire : a valid and reliable index of the clinical severity of Achilles tendinopathy. 2001:335-341.

Silbernagel KG, Thomee R, Karlsson J. Cross-cultural adaptation of the VISA-A questionnaire, an index of clinical severity for patients with Achilles tendinopathy, with reliability, validity, and structure evaluations. BMC Musculoskelet Disord. 2005; 6:12

Lohrer H, Nauck T. Cross-cultural adaptation and validation of the VISA-A questionnaire for German-speaking Achilles tendinopathy patients. 2009;9:1-9. doi:10.1186/1471-2474-10-134.

Year published: 2001

Instrument in PDF Format: Yes

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