Evaluating lower limb tendinopathy with Victorian Institute of Sport Assessment (VISA) questionnaires: a systematic review shows very-low-quality evidence for their content and structural validity—part I

Abstract

Purpose The Victorian Institute of Sport Assessment (Achilles tendon—VISA-A, greater trochanteric pain syndrome—VISA-G, proximal hamstring tendinopathy—VISA-H, patellar tendon—VISA-P) questionnaires are widely used in research and clinical practice; however, no systematic reviews have formally evaluated their content, structural, and cross-cultural validity evidence. The measurement properties referring to content, structural and cross-cultural validity of the VISA questionnaires were appraised and synthesized. Methods The systematic review was conducted according to Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology. PubMed, Cochrane, CINAHL, EMBASE, Web of Science, SportsDiscus, grey literature, and reference lists were searched. Development studies and cross-cultural adaptations (12 languages) assessing content or structural validity of the VISA questionnaires were included and two reviewers assessed their methodological quality. Evidence for content (relevance, comprehensiveness, and comprehensibility), structural, and cross-cultural validity was synthesized. A modified Grading of Recommendations Assessment Development and Evaluation (GRADE) approach was applied to evidence synthesis. Results The VISA-A presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility. VISA-G displayed moderate-quality evidence for sufficient comprehensibility and very-low-quality evidence of sufficient relevance and comprehensiveness. The VISA-P presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility, while VISA-H presented very-low evidence of insufficient content validity. VISA-A displayed low-quality evidence for structural validity concerning unidimensionality and internal structure, while VISA-H presented low-quality evidence of insufficient unidimensionality. The structural validity of VISA-G and VISA-P were indeterminate and inconsistent, respectively. Internal consistency for VISA-G, VISA-H, and VISA-P was indeterminate. No studies evaluated cross-cultural validity, while measurement invariance across sexes was assessed in one study. Conclusions Only very-low-quality evidence exists for the content and structural validity of VISA questionnaires when assessing the severity of symptoms and disability in patients with lower limb tendinopathies. Level of evidence IV. Registration PROSPERO reference—CRD42019126595.

TENDINopathy Severity assessment – Achilles (TENDINS-A): Evaluation of reliability and validity in accordance with COSMIN recommendations

“…The TENDINS-A demonstrated moderate correlations to both the VISA-A and FAOS, which is expected given they are proposed to measure the same overall health domain of disability. 15 We did not expect strong correlations to the VISA-A or FAOS given the limitations of the VISA-A, 10 11 14 which we theorised would extend to the FAOS as it is also lacking content validity. We expected the TENDINS-A was likely to be superior as it adhered to the guidelines set out by COSMIN for the development of an outcome measure.…”

“…7 8 In clinical practice measures of tendon-related disability are not commonly used, 9 in part due to inadequate content validity. 10 11 Thus, despite a consensus of it being an important aspect of health, 6 there remains no measure of tendon-related disability that is validated for research or clinical use.…”

“…15 Existing PROMs, such as the Victorian Institute of Sport Assessment – Achilles (VISA-A), are recommended in the absence of other tools, 16 but do not satisfy the guidelines set out by COSMIN for the assessment of Achilles tendinopathy, largely because of inadequate content and structural validity. 10 11…”

The VISA-A (sedentary) should be used for sedentary patients with Achilles tendinopathy: a modified version of the VISA-A developed and evaluated in accordance with the COSMIN checklist

“…It is felt that internal validity of the VISA-A was not adequately investigated in the original study,9 likely due to the fact that it was developed before the COSMIN guidelines were published. However, recent systematic reviews conclude that while the VISA-A demonstrates insufficient evidence for measurement error there is sufficient evidence for reliability, construct validity and responsiveness 24 25…”

Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties

“…The suitability of two items in the VISA questionnaires for less active populations has come under scrutiny, due to the focus on the performance of sporting activities (item seven and eight) 31–33. For example, in item eight of VISA-G responders are asked to answer one of three sections that corresponds with their ability to perform activities for certain durations, and consider the influence on pain in the performance of the activity 21.…”