VISA-A scale

Objective[edit | edit source]

The VISA-A 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. The final version of the questionnaire was named the Victorian Institute of Sport Assessment-Achilles Questionnaire.

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.

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][3][4][5][6]

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.[7]

Other Languages[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. [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. 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.
  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.
  5. 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
  6. 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.
  7. 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.
  8. 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.fckLRDisability & Rehabilitation. 2016, 38(26): 2593-9.