Journal of Clinical Orthopaedics and Trauma 10 (2019) S189eS192

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Journal of Clinical Orthopaedics and Trauma

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Reliability and validity of Kannada version of Victorian Institute of

Sports Assessment for patellar tendinopathy (VISA-P-K) questionnaire
Gayatri Upasana Acharya a, Ajay Kumar a, Sannasi Rajasekar a, Asir John Samuel b, *
a
College of Physiotherapy, Srinivas University, Mangalore, 575001, Karnataka, India
b
Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi
Markandeshwar Deemed to be University, Mullana, 133207, Haryana, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: In sporting activities, patellar tendon is commonly subjected to overuse and it influences
Received 11 December 2017 the athletes' career especially in elite basketball and volleyball players. A condition specific and self-
Accepted 16 August 2018 administrated questionnaire is required for clinical and research purpose to rate disability. The Victo-
Available online 18 August 2018
rian Institute of Sports Assessment for patellar tendinopathy (VISA-P) questionnaire is widely accepted
and a valid tool to assess pain and athletes, suffering from PT, ability to participate in sports. So, the
Keywords:
objective of this study is to develop and validate Kannada version of VISA-P questionnaire among
Cross cultural adaptation
Kannada speaking population athletes.
Patellar tendinopathy
VISA-P
Objective: To translate VISA-P questionnaire into Kannada and to study reliability and validity of Kannada
Reliability version.
Validity Methodology: Translation and cross-culture adaptation were performed according to the guidelines
followed internationally. Those are: translation, synthesis, back-translation, revision by expert commit-
tee, pretesting and appraisal by advisory committee. The psychometric properties were tested by
administering the questionnaire to 70 subjects (35 symptomatic and 35 asymptomatic). For test-retest
reliability, athletes with patellar tendinopathy were tested twice within a week and test-retest reli-
ability was assessed by Intra-class correlation coefficient (ICC). The validity was tested by comparing the
VISA-P-Kannada questionnaire (VISA-P-K) against Blazina classification of patellar tendinopathy (BCPT)
using Spearman correlation coefficient.
Result: The test-retest reliability was excellent (ICC 0.97). Internal consistency was found to be good
(Cronbach's alpha ¼ 0.98). The VISA-PK showed significant correlation by comparing against Blazina and
Spearman's score (r ¼ 0.72, p < 0.01).
Conclusion: The VISA-P-K translation and adaptation processes were successful. The adapted instrument
demonstrated good psychometric properties. The VISA-P-K has proven to be reliable and valid tool and
can be used in the Kannada speaking patients with patellar tendinopathy.
© 2018

1. Introduction repetitive micro trauma which leads to inflammatory changes in

In sporting activities, patellar tendon is commonly subject to
overuse which is characterized by load dependent pain especially
eccentric loading at inferior pole of patella.1 It influences the ath-
letes' career especially in elite basketball and volleyball players for a
prevalence rates of 31.9% and 44.6% respectively.2 Overuse causes
* Corresponding author. Maharishi Markandeshwar Institute of Physiotherapy
and Rehabilitation, Maharishi Markandeshwar Deemed to be University, Mullana,
133207, Haryana, India.
E-mail address: asirjohnsamuel@mmumullana.org (A.J. Samuel).
the tendon due to chronic collagen fiber degeneration.3
Both intrinsic and extrinsic risk factors contribute to patellar
tendinopathy. Intrinsic factors like strength imbalance, improper
posture, foot malalignment, reduced ankle dorsiflexion and lack of
flexibility. Extrinsic factor includes improper training surfaces,
insufficient footwear and high intensity training.4,5
To assess pain, and athletes, suffering from PT, ability to
participate in sports, various instruments had been used but none
of them regarded as ideal. So, VISA Patellar tendinopathy ques-
tionnaire was developed by a group of experts from Victorian
institute of sport assessment.6 VISA-P has been widely accepted

https://doi.org/10.1016/j.jcot.2018.08.017
0976-5662/© 2018
S190 G.U. Acharya et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S189eS192
and valid tool and can be administered in various groups of athletes
suffering from patellar tendinopathy.2 Disability questionnaires are
subjective and to be duly filled by patient, availability and consis-
tent use of established questionnaires in the other language can
facilitate the collection of reliable data. Articles considered for
meta-analysis, permits valid comparison of the attribute in ques-
tion between various culture and reduce the number of patients
who will have to be ruled out from the study because they are not
well versed in foreign languages.7 Currently, VISA-P questionnaire
has been translated, adopted and validated for Swedish Italian,
Dutch and German populations.8,9 As Karnataka is one of the major
states in India, it is ranked 9th in terms of population. As per 2016
census, population of Karnataka was approximately 66, 076, 021.
Kannada is the official language of Karnataka (a state in Southern
India). Till now no version of VISA-P in Kannada language is
available. The objective of this study was to develop Kannada
version of VISA-P and its reliability and validity for the patients
with the patellar tendinopathy. For the usage of Kannda version of
VISA- P questionnaire in clinical practice and research, cultural
adaptation and validation of the questionnaire is paramount. So,
simple translation of the questionnaire alone doesn't ensure its
validity. validation process requires to compare translated version
against some gold standard questionnaire for patellar tendinop-
athy. Since there has been no more questionnaires available in
Kannada version to measure PT symptoms and functions, VISA-P-K
can be compared against Blazina grading classification for patellar
tendinopathy.
2. Methodology
The study protocol was approved by the university research and
ethics committee and the study was done strictly in accordance
with the guidelines of Helsinki declaration, revised 2013.10 The
study conducted between September 2015 and March 2017. Before
commencing the study, Dr Karim Khan, one of the co-developers of
the VISA-P questionnaire, was emailed to sought consent for the
usage of VISA-P questionnaire for translation. Various sports clubs
and university sports clubs and recreational clubs in and around
Mangalore were approached. A total of 70 athletes, 35 symptomatic
and 35 asymptomatic, were included in the study. Written
Informed consent were obtained from the athletes, after getting
permission from the clubs. Athletes who fulfilled the inclusion
criteria were included in the study. The inclusion criteria for the
symptomatic group were age between 18 and 35 years, knee pain in
the patellar tendon or its insertion, tenderness at patellar tendon
and positive single leg decline squat test. The inclusion criteria for
asymptomatic group were age between 18 and 35 years, no h/o
previous knee pain since 1 year and at risk for patellar tendinop-
athy. The exclusion criteria for symptomatic group were other
conditions causing anterior knee pain like fat pad syndrome, PFPS,
signs and symptoms of knee pathologies, any knee surgery or in-
jection therapy in the past one year, and athletes consuming
NSAIDs and analgesics. To test the reliability of the questionnaire,
the subjects were asked to fill the questionnaire twice at one week
interval. To validate the questionnaire, the VISA-P-K was compared
against Blazina scale.
3. Cross-cultural adaptation
To obtain cross-cultural adaptation, the following essential steps
are recommended:
3.1. Step-1
Initial translation to Kannada language/forward translation:
Initial translation of VISA-P questionnaire has been done into
Kannada language from original English version of VISA-P. Two
bilingual individuals whose native language is Kannada had
translated the VISA-P into Kannada. One of them was an Ortho-
paedic surgeon by profession and another one was a physiothera-
pist with sound knowledge and experience in musculoskeletal
conditions.
3.2. Step 2
Synthesis:
A meeting was conducted between the two translators in order
to attain a consensus on the translated VISA-P, without disrupting
original VISA-P.
3.3. Step 3
Back translation:
Back translation of preliminary VISA-P was conducted by two
translators who were fluent in both English and Kannada. But they
were from non-medical profession and were unaware of original
VISA-P.
3.4. Step-4
Reviewers committee:
The Pre final version of the VISA-P-K was developed by both
backward and forward translators, a health care professional and a
linguistic professional. They would develop pre final version of
VISA-P-K emphasizing on semantic, idiomatic, experimental and
conceptual equivalence in relation to original back translated VISA-
P versions.
3.5. Step 5
Pretesting:
The pre final version of questionnaire was given away to seven
patients diagnosed with patellar tendinopathy. The interviewer
reported on each respondents understanding the questionnaire
items and making decision on them. As no more adaptation was
indicated, the pre final and final VISA-P-K would be identical. The
main objective was to test whether the translated questionnaire
was understandable, the vocabulary and the expression were
relevant for Kannada culture.
3.6. Step 6
Validation study:
Criterion validity has been demonstrated by correlation of one
measure with another at the same time. In this study, the validity
was done by finding the correlation between Blazina classification
of patellar tendinopathy and VISA-P-K questionnaire scores. Test-
retest reliability was done, questionnaire was given twice within
a week.
4. Data analysis
Descriptive statistics were done by using the mean values of age,
weight, height, BMI. Demographic characteristics of the subject
(age, weight, height, BMI) follow the normal distribution and hence
it is reported in mean ± standard deviation. Internal consistency
was reported in terms of cronbachs a. Cronbachs a coefficient was
calculated for item-scale correlation. It was calculated from first
and second administration of VISA-P-K. Test-retest reliability was
tested by using the ICC(2,1). Normality of collected data was
 G.U. Acharya et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S189eS192
Table 1
Demographic characteristics of athletes with and without patellar tendinopathy recruited.
Demographic characteristic Athlete with Patellar tendinopathy
Age (Years) 18.9 ± 2.2
Height (cm) 170.5 ± 7.7
Weight (kg) 58.4 ± 7.1
BMI (kg/m2) 20.1 ± 5.1
Abbreviations: cm e centimeter; kg e kilogram; BMI e Body mass index.
established by Shapiro wilk test. As the data doesn't follow the
normal distribution. Spearman rank correlation was used to find
the validity of Kannada version of VISA-PK with gold standard
Blazina classification of patellar tendinopathy (BCPT). For all the
statistical analysis, the level of significance was set at p < 0.05.
5. Results
The Demographic characteristics of athletes recruited with and
without patellar tendinopathy were displayed in Table 1. There
exists no significance difference between the athletes. Internal
consistency and test-retest reliability of VISA-P-K questionnaire
was elaborated in Table 2. The validity VISA-P-K with Blazina
classification of patellar tendinopathy (BCPT) was tabulated in
Table 3.
6. Discussion
Authors of this study assert that the English version of VISA-P
questionnaire is successfully adapted to a Kannada version. In Pre-
vious studies, test-retest reliability of the German version of VISA-P
was excellent and it was tested twice within a week for athletes with
Patellar tendinopathy and asymptomatic group (ICC ¼ 0.88, 0.87;
p < 0.001) and concurrent validity was perfect.6 In Swedish version,
the test-retest showed good reliability and it was significant
(ICC ¼ 0.97,p < 0.001).8 In Korean version, the test-retest showed
good reliability and it was significant (ICC ¼ 0.96,p < 0.001).11 In this
study, VISA-P-K questionnaire was administered twice within a
week for athletes with PT and asymptomatic group and the results
were excellent (ICC ¼ 0.97 and 0.96; p < 0.001). Criterion validity
was done by comparing Blazina with VISA-P test. It showed signifi-
cant correlation with spearman's score rho (r ¼ 0.42), p ¼ 0.01 it was
almost perfect.
In Dutch version, the test-retest showed satisfactory reliability
which was slightly lower as compared to German, Swedish and
Korean. The reason for lower reliability was attributed to 2.5 week
Table 2
Internal consistency and test-retest reliability of Kannada version of Victorian
Institute of Sports Assessment for patellar tendinopathy (VISA-P-K) questionnaire.
Individuals Cronbach's a Intrarater reliability
Symptomatic 0.99 0.97 (0.95e0.98)
Asymptomatic 0.98 0.96 (0.94e0.98)
Note: Internal consistency is expressed in terms of cronbach's alpha (a); Test-retest
reliability is expressed as intra-class correlation coefficient (ICC).
Table 3
Validity of Victorian Institute of Sports Assessment for patellar tendinopathy (VISA-
P-K) questionnaire.
VISA-P-K Spearman's rho (r) p-value
BCPT 0.72 <0.001
Note: Kannada version of Victorian Institute of Sports Assessment for patellar ten-
dinopathy e VISA-P-K; Blazina classification of patellar tendinopathy (BCPT).
S191
Athlete without Patellar tendinopathy p- value
19.0 ± 1.1 0.94
171.1 ± 8.1 0.91
63.6 ± 8.2 0.63
21.9 ± 3.6 0.42
interval period between administering the questionnaire. However,
the limitation of the study was that test-retest was done on
asymptomatic subjects.12
On the other hand, the test-retest reliability of Greek version of
VISA questionnaire was good despite being fifteen to seventeen
days interval period (ICC ¼ 0.818, p < 0.001; CI-95%) and internal
consistency was a ¼ 0.785 to 0.784. Concurrent validity showed
high level of association between VISA-P-GR and Blazina classifi-
cation (r ¼ 0.839, p < 0.001).13
In the sample configuration, we did not include individuals who
had undergone knee surgery or in the surgical waiting list, as in
other studies. Similar to previous studies, we also decided to take
longer time interval, i.e. 1 week or more to avoid participants from
recalling their response to the questionnaire. None of the athletes,
suffering from PT, had undergone any kind of treatment during the
study period. So, the change in symptom response could be
excluded in one week study period otherwise medications could
have influenced the test results.
As we didn't find any other questionnaire in Kannada language
to compare with VISA-P-K for criterion validity, we used Blazina
scale to test it against VISA-P-K questionnaire. Blazina scale grades
the patellar tendinopathy signs and symptoms into 4 grades and it's
the only grading system available for patellar tendinopathy.14
For question number 4, an adapted translation of the term
“weight-bearing lunge,” was done as there is no literal translation
for the term in Kannada language. Differences in opinion were
found out between the translators for this question. Hence, we
consulted various athletes and other professionals to find common
term and accepted by everyone. Eventually, we adopted a similar
term which was understandable by athletes. It was found that the
items of VISA-P-K were equivalent to those in the original version,
as established by the bilingual and clinical experts involved in the
study.
We have found limitation of this study that athletes suffering
from patellar tendinopathy had not undergone Doppler ultrasound
or MRI investigations for further confirmation of patellar tendin-
opathy. Instead, we were solely dependent on clinical examination
findings. Nevertheless, The VISA-P-K questionnaire demonstrated
to be highly acceptable, easily understood and self-administrable.
The results of this study showed that functional status question-
naire could be translated into other languages without affecting the
psychometric properties of the original English version. This
questionnaire will be useful for both researchers and clinicians to
measure outcomes in clinical evaluations and research in Kannada
speaking patients.
7. Conclusion
The VISA-P-K was cross-culturally adapted and validated for use
in Kannada-speaking populations. The psychometric properties of
the VISA-P-K were as good as to those of the original English
version, so, the VISA-P-K can be recommended for assessing
symptoms, function and ability to play sport in Kannada -speaking
patients with patellar tendinopathy.
S192 G.U. Acharya et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S189eS192

Conflicts of interest
None of the authors have competing interest declared.
Funding
No funding.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jcot.2018.08.017.
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