Objectives To evaluate the validity and reliability of the Turkish version of the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire for patients with Achilles tendinopathy.
Design Fifty-five patients with a diagnosis of Achilles tendinopathy and 55 healthy subjects were included in the study. VISA-A questionnaires were translated and culturally adapted into Turkish. The final Turkish version (VISA-A-Tr) was tested for reliability on healthy individuals and patients. Tests for internal consistency, validity and structure were performed on 55 patients.
Results The VISA-A-Tr showed good test–retest reliability (Pearson's r=0.99, p<0.001). The patients with Achilles tendinopathy had a significantly lower score (p<0.001) than the healthy individuals. The VISA-A-Tr score correlated significantly with the Stanish tendon grading system (Spearman's r=−0.86; p<0.001).
Conclusion The VISA-A-Tr is a valid and reliable tool for evaluating the severity of Achilles tendinopathy.
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Achilles tendinopathy (AT) is well-recognised as an important clinical entity with significant patient burden.1,–,5 A uniform score is essential to document, compare and combine data among different investigations. The Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire was designed by Robinson et al, as a region-specific functional questionnaire, to assess the severity of AT.6 It contains eight questions that cover the three domains of pain (questions 1–3), function (questions 5–7) and activity (questions 7 and 8). Scores are summed to give a total out of 100. An asymptomatic person would score 100.
The aim of this study was to test the reliability and validity of the Turkish version of the VISA-A questionnaire (VISA-A-Tr).
Materials and methods
This study was approved by the Ethics committee of the Faculty of Medicine of the University of Mustafa Kemal. Fifty-five patients (39 male, 16 female) with a diagnosis of AT were included in the study. The patients had to be older than 18 years and can read and speak Turkish language. Pain at the Achilles tendon at rest or at exercise associated with tenderness and swelling were the main diagnostic criteria.
Exclusion criteria were: previous surgery on the Achilles tendon, clinical diagnosis of autoimmune or inflammatory conditions, endocrine disorders, total rupture of the Achilles tendon, nerve entrapment around the ankle joint, pregnancy and lactation.
For control purpose, 55 healthy active individual (39 male, 16 female), who engaged in sportive activities like running, long distance marching and playing ball games whose age matched the patient groups, were included in the study.
The guidelines proposed by Beaton et al were used for cross-cultural adaptation.10 The original English version of the VISA-A was translated into Turkish by two bilingual orthopedic surgeon. The back translation of the Turkish version into English was performed by two bilingual translators who didn't know the purpose of study and was totally blind to the original version of the index. The original and back-translated forms were then compared by a team of bilingual persons (three orthopaedic surgeons, a bilingual teaching staff member in the sport school, one translator, one physiotherapist and one physician).
Pretesting of the intermediate Turkish version
The purpose of pre-testing was to obtain data on the acceptability, appropriateness and comprehensibility of the instrument. Pre-testing was done with 10 randomly selected patients with AT. The research team reviewed and corrected the items reported to be incomprehensible or lacking content. Following this phase, the final Turkish version of the VISA-A-Tr was printed and used in the present study.
VISA-A-Tr was tested on both healthy individuals (n=55) and patients (n=55) with a diagnosis of AT. Additionally, questionnaires regarding the physical activity,11 tendon injury according to Stanish et al,12 and the Turkish version of the World Health Organization Quality of Life (WHOQOL-BREF) generic tool were also applied consequently to the same patients for the purpose of demonstrating convergent validity.13
The WHOQOL-BREF is a quality of life assessment tool which has been validated in Turkish.14 It is a 26-item self reporting instrument which assesses four domains assumed to represent the quality of life construct: physical domain, psychological domain, social relations domain and environment domain; plus two facets for assessing overall quality of life and general health.
For test–retest evaluation, 26 patients and 26 healthy persons to whom the VISA-A-Tr was administered were asked to complete the questionnaire at first visit, 60 min following the end of this examination and after 1 week. Construct validity of the VISA-A-Tr was tested according to the original article on the VISA-A English version.6 The results from the VISA-A-Tr questionnaire for patients with AT were also compared with the results of healthy individuals.
Data were analysed using the SPSS for Windows version 11.0 (Statistical Package for Social Sciences, Chicago, Illinois, USA). Comparison of VISA-A-Tr with Stanish et al12 tendon grading system was performed by calculating the Spearman's rank correlation coefficient for non-parametric data. VISA-A-Tr scores for the healthy group and the patient group were compared using the Mann–Whitney U test. Test–retest data were analysed by Pearson's r, as in the VISA-A English version. Internal consistency was assessed by calculation of Cronbach's α and split-half reliability coefficient. The level of significance was set at p=0.05.
The mean age of the patients group was 40.9±6.2 years; for the control group, this was 38.5±7.2 years (table 1).
The VISA-A-Tr showed good test–retest reliability (Pearson's r=0.99, p<0.001). There was no statistically significant difference between the scores of the first, second and third tests.
The VISA-A-Tr score correlated significantly with the tendon grading system described by Stanish et al12 (Spearman's r=−0.86; p<0.001), the physical activity grading system described by Grimby et al11 (Spearman's r=+0.74; p<0.001) and the physical domain of the WHOQOL-BREF (Spearman's r=+0.37; p<0.01). No significant correlation was found between the VISA and social domain of the WHOQOL-BREF (Spearman's r=+0.13; p<0.15).
In evaluating the reliability of the eight questions in the VISA-A-Tr, an internal consistency analysis was conducted and the Cronbach's α-coefficient score was 0.66. The split-half reliability coefficient was 0.70.
The patients with AT had a significantly lower score (p<0.001) compared with the healthy individuals. The mean VISA-A-Tr score was 52.8±13.9 (range 24–72) for the patients and 97.1±1.5 (range 95–100) for the healthy individuals (table 1).
In the practice of evidence-based medicine, the clinical evaluation alone is not sufficient to describe and document the severity of the disease. A questionnaire that assesses the severity of the disease will be useful to measure the outcome in treatment studies.
In general, this study revealed that the Turkish version of VISA, as the original version, was a reliable and valid tool which can measure the severity of the AT.
The questionnaire was found to be appropriate to evaluate the severity of the disease and transform it into numerical data. Moreover, the questionnaire was determined to be easily understandable by all of the participants and easy to administer.
The internal consistency of the Turkish version of VISA-A was acceptable. In this study, the Cronbach's α internal consistency coefficient was 0.66 for the patients group, while the Cronbach's α internal consistency coefficient for the patients group in the Swedish version of the scale was 0.77.7
The test–retest reliability coefficient of 0.99 indicated that VISA-A-Tr didn't show variability in the course of time and remained fixed. These findings were in accordance with that of the original, the Swedish and the Italian version of the questionnaire.6 7
Like other studies, we did find a relationship between the VISA and another tendon injury grading systems.12 We also found that there is a relation between the AT and the physical aspects of the patients' quality of life measured by WHOQOL-BREF.13 14 We also recognised that AT has a greater impact on the physical aspects rather than the social aspects of the of a patient's life. The Turkish and the English versions of the VISA-A questionnaire evaluate the same aspects of clinical severity in patients with AT.
A limitation of this study is that we had not compared the VISA scores in this study with the VISA scores in the original study.
In conclusion, the Turkish version of VISA-A is a valid and reliable measure for Turkish patients with AT.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Mustafa Kemal University,Ethical committee.
Provenance and peer review Not commissioned; externally peer reviewed.