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RehabMeasures Instrument

Victorian Institute of Sports Assessment - Achilles

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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.

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Instrument Details

Acronym VISA-A

Area of Assessment

Activities of Daily Living
Functional Mobility
Gait
Life Participation
Pain

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Pain Management

Key Descriptions

  • The VISA-A is a self-reported questionnaire-based instrument that provides an index of achilles tendinopathy pain and function.
  • Consists of eight questions that address the following domains:
    1) Pain
    2) Function in daily living
    3) Sporting activity
  • Scores range from 0 - 100, with 0 being the worst.

Number of Items

8

Time to Administer

Less than 5 minutes

Required Training

No Training

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Instrument Reviewers

Initially reviewed by Terra Osmon, SPT, Melody Tran, SPT, Megan Schilter, SPT, Dan Steele, SPT, Meredith Smythe, SPT, and Elizabeth Lynch, SPT.

Body Part

Lower Extremity

ICF Domain

Body Structure
Body Function
Activity
Participation
Environment

Measurement Domain

Activities of Daily Living

Professional Association Recommendation

Recommendations for use of the instrument from a clinical practice guideline for achilles tendinopathy by the Orthopaedic Section of the American Physical Therapy Association (APTA) and the Journal of Orthopaedic Sports Physical Therapy (JOSPT).

For further detail on Achilles tendinopathy clinical practice guidelines, please visit: http://www.jospt.org/doi/pdf/10.2519/jospt.2010.0305 

 

Clinicians should incorporate validated functional outcome measures, such as the Victorian Institute of Sport Assessment and the Foot and Ankle Ability Measure [VISA-A]. These should be utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with Achilles tendinopathy.

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.

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Mixed Populations

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Standard Error of Measurement (SEM)

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

Silbernagel, et al (2005): 

  • SEM = 7.96 (Calculated with available statistics)

Minimal Detectable Change (MDC)

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

Silbernagel, et al (2005): 

  • 18.5 (90% MDC)
  • 22.1 (95% MDC)

Normative Data

50 male athletes with unilateral tendinopathy of the main body of the Achilles (average age 26.4, range 18-49 years)

Maffulli, et al (2008)

  • At first examination:

    • Mean = 51.8; SD = 18.2

  • 30 minutes after examination:

    • Mean = 51.1; SD = 19

 

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

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

 

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

Silbernagel, et al (2005)

  • Mean = 50

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

 

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.

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

50 male athletes with unilateral tendinopathy of the main body of the Achilles (average age 26.4, range 18-49 years)

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)

 

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

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)

 

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

Silbernagel, et al (2005)

  • Excellent test-retest reliability (r = 0.89)

 

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.

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

 

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

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

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

Silbernagel, et al (2005)

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

 

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.

Lohrer, et al (2009)

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

Construct Validity

50 male athletes with unilateral tendinopathy of the main body of the Achilles (average age 26.4, range 18-49 years)

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)

 

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

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)

 

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

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

 

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.

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

50 male athletes with unilateral tendinopathy of the main body of the Achilles (average age 26.4, range 18-49 years)

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.”

 

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

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.

 

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

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.

 

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.

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

50 male athletes with unilateral tendinopathy of the main body of the Achilles (average age 26.4, range 18-49 years)

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.”

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.