VISA-A scale: Difference between revisions

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{{subst:Outcome Measure
<div class="editorbox">
'''Original Editor '''- [[User:Liselotte Vandenbergen|Liselotte Vandenbergen]].


}}<u>1.Objective:<br></u>Sportspeople for sure and also those having an active lifestyle with lots of walking and hiking suffer from prolonged pain and disability with Achilles tendinopathy as the major cause.&nbsp;&nbsp; <br>Evaluating the clinical severity for patients with chronic Achilles tendinopathy was the goal of this test.&nbsp;
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>  
== Objective ==


The VISA-A is an easily self-administered questionnaire that evaluates symptoms and their effect on physical activity. It can be used to compare different populations with chronic achilles tendinopathy, and facilitate comparisons between studies.&nbsp; It can be used to determine the patient’s clinical severity and provide a guideline for treatments as well as for monitoring the effect of treatment.(2)
The Victorian Institute of Sport Assessment-Achilles (VISA-A) Scale aims to evaluate the clinical severity for patients with chronic Achilles tendinopathy. It is an easily self-administered questionnaire that evaluates symptoms and their effect on physical activity. It can be used to compare different populations with chronic achilles tendinopathy, and facilitate comparisons between studies. It can be used to determine the patient’s clinical severity and provide a guideline for treatments as well as for monitoring the effect of treatment<ref name="Silbernagel">Silbernagel KG, Thomeé 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 Mar 6;6:12.</ref> 


The test as such is very user friendly, as it takes in general less than five minutes to complete , this being also the case for patients with chronic and severe symptoms.  
The VISA-A is very user friendly, as it generally takes less than five minutes to complete, even for patients with chronic and severe symptoms. The questionnaire represents a valid, reliable and disease-specific questionnaire to measure the condition of the achilles tendon, but it is not a diagnostic tool. 


The VISA-A questionnaire represents a&nbsp; valid, reliable and disease specific questionnaire to measure the condition of the Achilles Tendon. <br>The VISA-A questionnaire is for certain not a diagnostic tool. <br>The final version of the questionnaire was called the Victorian Institute of Sport Assessment-Achilles Questionnaire.
== Intended Population  ==


<br><u>2 Intended Population</u>
*Patients with achilles tendinopathy.
*Patients who are able to give written informed consent.
*Exclusions: pregnant or nursing women, individuals who have sustained a total rupture of the achilles tendon.


Patients with Achilles Tendinopathy.<br>Patients must be able to give written informed consent.&nbsp;&nbsp;&nbsp;&nbsp; <br>Exclusions were made for pregnant or nursing women and for those suffering from a total rupture of the Achilles Tendon.
== Method of Use  ==


<u>3 Method of Use</u>
The questionnaire contains eight questions, covering three necessary domains: 1) pain, 2) functional status, and 3) activity (= three significant domains of dysfunction):


The questionnaire contains 8 questions, covering 3 necessary domains being pain, functional status and activity. (=three significant domains of dysfunction)<br> The first 3 questions are related to pain. (in this questionnaire, the term pain refers specially to pain in the Achilles’ tendon region). <br>Question 4-6 are related to&nbsp; function, question 7-8 to activity. <br>Question 8 contains actually two questions, one about pain with activity and one about duration of activity. <br>The first seven questions have a score out of 10, and question 8 scores a&nbsp; maximum of 30. <br>The first six questions use a VAS so that the patient may report magnitude of a continuum of subjective symptoms. The final two questions used a categorical rating scale. (1)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br> <br>Answering to question 8 is limited to A,B or C and this related to the reality of the patient.&nbsp; The patient loses automatically at least 10 of 20 points when he had pain during sports activity.  
*Questions 1-3 are related to pain. (in this questionnaire, the term "pain" refers specifically to pain in the Achilles tendon region).  
*Questions 4-6 are related to function.
*Questions 7-8 are related to activity.  
*Question 8 actually contains two questions: a) pain with activity, and b) duration of activity.  
*The first seven questions have a score out of 10, and question 8 scores a maximum of 30.  
*The first six questions use a VAS so that the patient may report the magnitude of a continuum of subjective symptoms. The final two questions used a categorical rating scale<ref name="Robinson">J M Robinson, J L Cook, C Purdam, P J Visentini, J Ross, N Maffulli, J E Taunton, K M Khan, for the Victorian Institute of Sport Tendon Study Group. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335-341.</ref>


Maximum result of the questionnaire is score&nbsp; 100.&nbsp; This score would be the score of an asymptomatic person. A lower score indicates more symptoms and greater limitation of physical activity. <br>The recreational person who has achilles tendinopathy couldn’t score higher than 70 on the VISA-A scale.  
Answering question 8 is limited to A,B or C and relates to the reality of the patient. The patient automatically loses at least 10 of 20 points if he or she has pain during sports activity.  


<br><u>4. Reference</u>
The maximum score that can be achieved on the question is 100, and would be the score of person who is completely asymptomatic. A lower score indicates more symptoms and greater limitation of physical activity.  


<u>5 Evidence</u>
A recreational person who has achilles tendinopathy will not score higher than 70 on the VISA-A scale.


<u>5.1 Reliability</u>
== Evidence  ==


The VISA-A questionnaire had good test-retest (r=0.93), intrarater (thee tests, r = 0.90), and interrater ( r=0.90) reliability as well as good stability when compared one week apart (R=0.81)<br>There were no difference in scores whether the test-retest questionnaires were completed at the first visit or at the second visit (p=0.58) . Reliability data were analyzed by Pearson ‘r, as these date were normally disturbed. (1)
=== Reliability  ===


It is noted that the VISA-A score does not indicate whether surgery is decided upon, even though&nbsp; for non-surgical and surgical patients there was a statistically significant difference between population mean VISA-A scores.  
The VISA-A questionnaire has good test-retest (r=0.93), intrarater (thee tests, r = 0.90), and interrater (r=0.90) reliability as well as good stability when compared one week apart (R=0.81).  


To internationally compare results, to perform multinational studies or to minimize bias originating from subpopulations speaking different languages within one country a unique protocol of forward and back translations and cultural adaptations as well as ‘‘verification of the scaling requirements and validation of and establishing normative values of the new version’’ are required . <br>This procedure has already been performed and in published for the Swedish,Italian and Turkish version of the VISA-A questionnaire. Cross-cultural adaptions to Spanish,Portuguese,and Flemish language have been done but were not reported in journals available in Medline/Pubmed (2) (3) (4) (6) (7)
There are no difference in scores whether the test-retest questionnaires is completed at the first visit or at the second visit (p=0.58). Reliability data were analyzed by Pearson ‘r, as these data were normally distributed.<ref name="Robinson" />


<br><u>5.2 Validity</u>
It is noted that the VISA-A score does not indicate whether surgery is decided upon, even though it has been shown that there are statistically significant differences between population mean VISA-A scores in&nbsp;non-surgical vs surgical patients.  
=== Validity ===


The VISA-A score correlated significantly with both Percy and Conochie’s grade of severity (Spearman’s r =0.58; p&lt;0.01) and that of Curwin and Stanish (Spearman’s r=-0.57; p&lt;0.001) (1)<br>The factor analysis gave the two factors strongly confirming that the questionnaire is valid for evaluating the patient’s symptoms and its effect on physical activity. The factor analysis and an internal consistency of 0.77 as measured by Cronbach’s alpha indicate that no question should be excluded. (1)<br>The VISA-A questionnaire displayed construct validity when used in two populations of patients with Achilles tendinopathy and control subjects. The mean (95% confidence interval)&nbsp; score in the non-surgical patients was 64 (59-69), in presurgical patients 44 (28-60) and with asymptomatic persons 96 (94-99). The VISA-A score was higher in non-surgical than presurgical patients (p=0.02) en higher in asymptomatic persons than in presurgical or non-surgical patients (p&lt;0.001).&nbsp; (1)
The VISA-A score correlates significantly with both Percy and Conochie’s grade of severity (Spearman’s r =0.58; p&lt;0.01) and that of Curwin and Stanish (Spearman’s r=-0.57; p&lt;0.001).<ref name="Robinson" />  


<u>5.3 Responsiveness</u>  
Factor analysis has provided two factors strongly confirming that the questionnaire is valid for evaluating the patient’s symptoms and its effect on physical activity. An internal consistency of 0.77 as measured by Cronbach’s alpha indicates that no question should be excluded.<ref name="Robinson" />  


The VISA-A questionnaire shows good responsiveness; it is sensitive for clinically important changes over time with treatment, easy for patients to fill out, and the data is easily handled. (8)  
The VISA-A questionnaire displays construct validity when used in two populations of patients with Achilles tendinopathy and control subjects. The mean (95% confidence interval)&nbsp; score in non-surgical patients has been shown to be 64 (59-69), in presurgical patients 44 (28-60), and with asymptomatic persons 96 (94-99). VISA-A scores are higher in non-surgical vs presurgical patients (p=0.02) and higher in asymptomatic persons vs presurgical or non-surgical patients (p&lt;0.001).<ref name="Robinson" />


<br><u>5.4 Miscellaneous</u>
=== Responsiveness  ===


As there is for this questionnaire a minimum of investigator assistance and thus it can be self administered , risks for potential observer bias are very limited.  
The VISA-A questionnaire shows good responsiveness; it is sensitive for clinically important changes over time with treatment, easy for patients to fill out, and the data is easily handled.<ref>Karin Grävare Silbernagel, Roland ThomeéfckLRBengt I. Eriksson, and Jon Karlsson.  Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy.  Am J Sports Med. 2007 Jun;35(6):897-906.</ref><br>


The VISA-A questionnaire is in its actual form&nbsp; for certain not a diagnostic tool, the score will be reduced or influenced in case of e.g. lower limb function . Limitations of function limits the subject’s ability to score well in question 8, even though the Achilles tendon may be uninjured.
== Other Languages and Cross-cultural Adaptations  ==


The continuous numerical result of the VISA-A questionnaire is ideal for comparing patients’ progress in the clinical setting. Continuous numerical result has the potential to provide utility in both the clinical setting and research.<br>Further studies are needed to determine whether the VISA-A score predicts prognosis. (1)  
The French version of this questionnaire (VISA-AF) is also available. It has been recently shown to have satisfactory levels of construct validity, excellent test–retest reliability, good internal consistency and discriminatory validity, as well as an absence of floor and ceiling effects. <ref name="Kaux et al 2016">Kaux JF, Delvaux F, Oppong-Kyei J, Dardenne N, Beaudart C, Buckinx F, Croisier JL, Forthomme B, Crielaard JM, Bruyère O. Validity and reliability of the French translation of the VISA-A questionnaire for Achilles tendinopathy. Disability and rehabilitation. 2016 Dec 17;38(26):2593-9.</ref>


A lower score indicates more symptoms and bigger limitation of physical activity, but there is no evidence that indicates for ex that a patient with a score of 70 is cured.  
To internationally compare results, perform multinational studies, or minimize bias originating from subpopulations speaking different languages within one country, a unique protocol of forward and back translations and cultural adaptations as well as ‘‘verification of the scaling requirements and validation of and establishing normative values of the new version’’ are required .


<br>  
This procedure has been performed and published for the Swedish, Italian, and Turkish versions of the VISA-A questionnaire. Cross-cultural adaptions to Spanish, Portuguese, and Flemish languages have been done but are not reported in journals available in Medline/Pubmed.<ref name="Silbernagel" /><ref name="Lohrer">Lohrer H, Nauck T. Cross-cutrural adaption and validation of the VISA-A questionnaire for German-speaking Achilles tendinopathy patients. BMC Musculoskelet Disord. 2009 Oct 30;10:134.</ref><ref name="Silbernagel et al">Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011 Mar;39(3):607-13.</ref><ref name="Dogramaci">Dogramaci Y, Kalaci A, Kücükkübas N, Inandi T, Esen E, Yanat AN. Validation of the VISA-A questionnaire for Turkish language: the VISA-A-Tr study. Br J Sports Med. 2011 Apr;45(5):453-5</ref><ref name="Maffulli">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. Disabil Rehabil. 2008;30(20-22):1635-9.</ref>
== Miscellaneous  ==


<br><u>6 Links</u>
Since minimal investigator assistance is required, the VISA-A can be self-administered and risks for potential observer bias are very limited.


Link to the questionnaire&nbsp;: <br>http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf
The VISA-A questionnaire is not a diagnostic tool, and the score can be reduced or influenced, e.g. lower limb function. Limitations of function limits the subject’s ability to score well in question 8, even though the Achilles tendon may be uninjured.  


<br>  
The continuous numerical result of the VISA-A questionnaire is ideal for comparing patients’ progress in the clinical setting. Continuous numerical result has the potential to provide utility in both the clinical setting and research.<br>Further studies are needed to determine whether the VISA-A score predicts prognosis<ref name="Robinson" /><br>  


<u>7 Recent Related Research (from Pubmed)</u>
A lower score indicates more symptoms and a larger limitation of physical activity, but there is no evidence that indicates, for example, that a patient with a score of 70 is "cured".


4. Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011 Mar;39(3):607-13.
== Resources  ==
*[https://www.londonorthopaedicsurgery.co.uk/media/1476/VISA-A-Questionnaire.pdf VISA-A Questionnaire]


<br>
== References  ==
 
<references />  
<u>8 References</u>  
[[Category:Outcome_Measures]]
 
[[Category:Tendons]]
1. J M Robinson, J L Cook, C Purdam, P J Visentini, J Ross, N Maffulli, J E Taunton,<br>K M Khan, for the Victorian Institute of Sport Tendon Study Group. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335-341.<br>Level of evidence: A1
[[Category:Musculoskeletal/Orthopaedics]]
 
[[Category:Sports Medicine]]
2. Silbernagel KG, Thomeé 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 Mar 6;6:12. <br>Level of evidence: A1
[[Category:Sports Injuries]]
 
3. Lohrer H, Nauck T. Cross-cutrural adaption and validation of the VISA-A questionnaire for German-speaking Achilles tendinopathy patients. BMC Musculoskelet Disord. 2009 Oct 30;10:134. <br>Level of evidence: A2
 
4. Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011 Mar;39(3):607-13. <br>Level of evidence: 4
 
5. Richards PJ, McCall IW, Day C, Belcher J, Maffulli N. Longitudinal microvascularity in Achilles tendinopathy (power Doppler ultrasound, magnetic resonance imaging time-intensity curves and the Victorian Institute of Sport Assessment-Achilles questionnaire): a pilot study. Skeletal Radiol. 2010 Jun;39(6):509-21&nbsp; <br>Level of evidence: A1<br>6. Dogramaci Y, Kalaci A, Kücükkübas N, Inandi T, Esen E, Yanat AN. Validation of the VISA-A questionnaire for Turkish language: the VISA-A-Tr study. Br J Sports Med. 2011 Apr;45(5):453-5 <br>Level of evidence: A2
 
7. 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. Disabil Rehabil. 2008;30(20-22):1635-9. <br>Level of evidence: A2
 
<br>8. Karin Grävare Silbernagel,*†‡ PT, ATC, PhD, Roland Thomeé,†‡ PT, PhD,<br>Bengt I. Eriksson,† MD, PhD, and Jon Karlsson,† MD, PhD. Continued Sports Activity, Using a Pain-<br>Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy.&nbsp; Am J Sports Med. 2007 Jun;35(6):897-906.<br>Level of evidence: A1
 
<br>
 
<br>
 
<br>

Latest revision as of 04:49, 25 January 2024

Original Editor - Liselotte Vandenbergen.

Top Contributors - Evan Thomas, Admin, Wanda van Niekerk, Carina Therese Magtibay, 127.0.0.1, Liselotte Vandenbergen, WikiSysop and Habibu Salisu Badamasi

Objective[edit | edit source]

The Victorian Institute of Sport Assessment-Achilles (VISA-A) Scale aims to evaluate the clinical severity for patients with chronic Achilles tendinopathy. It is an easily self-administered questionnaire that evaluates symptoms and their effect on physical activity. It can be used to compare different populations with chronic achilles tendinopathy, and facilitate comparisons between studies. It can be used to determine the patient’s clinical severity and provide a guideline for treatments as well as for monitoring the effect of treatment[1]

The VISA-A is very user friendly, as it generally takes less than five minutes to complete, even for patients with chronic and severe symptoms. The questionnaire represents a valid, reliable and disease-specific questionnaire to measure the condition of the achilles tendon, but it is not a diagnostic tool.

Intended Population[edit | edit source]

  • Patients with achilles tendinopathy.
  • Patients who are able to give written informed consent.
  • Exclusions: pregnant or nursing women, individuals who have sustained a total rupture of the achilles tendon.

Method of Use[edit | edit source]

The questionnaire contains eight questions, covering three necessary domains: 1) pain, 2) functional status, and 3) activity (= three significant domains of dysfunction):

  • Questions 1-3 are related to pain. (in this questionnaire, the term "pain" refers specifically to pain in the Achilles tendon region).
  • Questions 4-6 are related to function.
  • Questions 7-8 are related to activity.
  • Question 8 actually contains two questions: a) pain with activity, and b) duration of activity.
  • The first seven questions have a score out of 10, and question 8 scores a maximum of 30.
  • The first six questions use a VAS so that the patient may report the magnitude of a continuum of subjective symptoms. The final two questions used a categorical rating scale[2]

Answering question 8 is limited to A,B or C and relates to the reality of the patient. The patient automatically loses at least 10 of 20 points if he or she has pain during sports activity.

The maximum score that can be achieved on the question is 100, and would be the score of person who is completely asymptomatic. A lower score indicates more symptoms and greater limitation of physical activity.

A recreational person who has achilles tendinopathy will not score higher than 70 on the VISA-A scale.

Evidence[edit | edit source]

Reliability[edit | edit source]

The VISA-A questionnaire has good test-retest (r=0.93), intrarater (thee tests, r = 0.90), and interrater (r=0.90) reliability as well as good stability when compared one week apart (R=0.81).

There are no difference in scores whether the test-retest questionnaires is completed at the first visit or at the second visit (p=0.58). Reliability data were analyzed by Pearson ‘r, as these data were normally distributed.[2]

It is noted that the VISA-A score does not indicate whether surgery is decided upon, even though it has been shown that there are statistically significant differences between population mean VISA-A scores in non-surgical vs surgical patients.

Validity[edit | edit source]

The VISA-A score correlates significantly with both Percy and Conochie’s grade of severity (Spearman’s r =0.58; p<0.01) and that of Curwin and Stanish (Spearman’s r=-0.57; p<0.001).[2]

Factor analysis has provided two factors strongly confirming that the questionnaire is valid for evaluating the patient’s symptoms and its effect on physical activity. An internal consistency of 0.77 as measured by Cronbach’s alpha indicates that no question should be excluded.[2]

The VISA-A questionnaire displays construct validity when used in two populations of patients with Achilles tendinopathy and control subjects. The mean (95% confidence interval)  score in non-surgical patients has been shown to be 64 (59-69), in presurgical patients 44 (28-60), and with asymptomatic persons 96 (94-99). VISA-A scores are higher in non-surgical vs presurgical patients (p=0.02) and higher in asymptomatic persons vs presurgical or non-surgical patients (p<0.001).[2]

Responsiveness[edit | edit source]

The VISA-A questionnaire shows good responsiveness; it is sensitive for clinically important changes over time with treatment, easy for patients to fill out, and the data is easily handled.[3]

Other Languages and Cross-cultural Adaptations[edit | edit source]

The French version of this questionnaire (VISA-AF) is also available. It has been recently shown to have satisfactory levels of construct validity, excellent test–retest reliability, good internal consistency and discriminatory validity, as well as an absence of floor and ceiling effects. [4]

To internationally compare results, perform multinational studies, or minimize bias originating from subpopulations speaking different languages within one country, a unique protocol of forward and back translations and cultural adaptations as well as ‘‘verification of the scaling requirements and validation of and establishing normative values of the new version’’ are required .

This procedure has been performed and published for the Swedish, Italian, and Turkish versions of the VISA-A questionnaire. Cross-cultural adaptions to Spanish, Portuguese, and Flemish languages have been done but are not reported in journals available in Medline/Pubmed.[1][5][6][7][8]

Miscellaneous[edit | edit source]

Since minimal investigator assistance is required, the VISA-A can be self-administered and risks for potential observer bias are very limited.

The VISA-A questionnaire is not a diagnostic tool, and the score can be reduced or influenced, e.g. lower limb function. Limitations of function limits the subject’s ability to score well in question 8, even though the Achilles tendon may be uninjured.

The continuous numerical result of the VISA-A questionnaire is ideal for comparing patients’ progress in the clinical setting. Continuous numerical result has the potential to provide utility in both the clinical setting and research.
Further studies are needed to determine whether the VISA-A score predicts prognosis[2]

A lower score indicates more symptoms and a larger limitation of physical activity, but there is no evidence that indicates, for example, that a patient with a score of 70 is "cured".

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Silbernagel KG, Thomeé 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 Mar 6;6:12.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 J M Robinson, J L Cook, C Purdam, P J Visentini, J Ross, N Maffulli, J E Taunton, K M Khan, for the Victorian Institute of Sport Tendon Study Group. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335-341.
  3. ↑ Karin Grävare Silbernagel, Roland ThomeéfckLRBengt I. Eriksson, and Jon Karlsson. Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy. Am J Sports Med. 2007 Jun;35(6):897-906.
  4. ↑ Kaux JF, Delvaux F, Oppong-Kyei J, Dardenne N, Beaudart C, Buckinx F, Croisier JL, Forthomme B, Crielaard JM, Bruyère O. Validity and reliability of the French translation of the VISA-A questionnaire for Achilles tendinopathy. Disability and rehabilitation. 2016 Dec 17;38(26):2593-9.
  5. ↑ Lohrer H, Nauck T. Cross-cutrural adaption and validation of the VISA-A questionnaire for German-speaking Achilles tendinopathy patients. BMC Musculoskelet Disord. 2009 Oct 30;10:134.
  6. ↑ Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011 Mar;39(3):607-13.
  7. ↑ Dogramaci Y, Kalaci A, Kücükkübas N, Inandi T, Esen E, Yanat AN. Validation of the VISA-A questionnaire for Turkish language: the VISA-A-Tr study. Br J Sports Med. 2011 Apr;45(5):453-5
  8. ↑ 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. Disabil Rehabil. 2008;30(20-22):1635-9.
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