[ research report ]

SERGIO HERNANDEZ-SANCHEZ, PT1 • MARIA DOLORES HIDALGO, PhD2 • ANTONIA GOMEZ, PT, PhD3

Cross-cultural Adaptation of VISA-P

Score for Patellar Tendinopathy
in Spanish Population

P
atellar tendinopathy is a common overuse injury in sports, clinical symptoms.8
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particularly in athletes who participate in sports such as In 1998, the Victorian Institute of
Sport Assessment (Australia) developed
basketball, athletics, and volleyball, with a prevalence in male
a brief self-administered questionnaire
indoor volleyball players of approximately 50%.26 In severe called the VISA-P, to assess the severity
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

cases it may limit or even prevent participation in sports.22 Patellar of symptoms in athletes with patellar ten-
tendinopathy is a noninflammatory condition. Histologically, pa- dinopathy.37 Currently, it is the only spe-
cific scale for patellar tendinopathy and
tellar tendon biopsies from affected tissue lesions can be demonstrated using ultra- has been adapted for Swedish,12 Italian,29
reveal collagen degeneration and fibrotic sound20; but there is a rather poor cor- Dutch,39 and German28 populations. The
scarring of the tendon.19 These tendon relation between imaging results and psychometric properties of these versions
are summarized in TABLE 1.
Since its publication in 1998, the in-
TTSTUDY DESIGN: Clinical measurement. which consisted of rest, ice, eccentric exercise,
strument has been increasingly used
TTOBJECTIVES: To adapt the VISA-P question- electrotherapy, and manual therapy.
Journal of Orthopaedic & Sports Physical Therapy®

to assess changes in the severity of

naire into Spanish and to assess its psychometric
properties.
TTBACKGROUND: Health status questionnaires
and scales to report outcomes are increasingly
used in medical research and clinical practice.
Validated versions of these tools are necessary to
avoid bias during use in different languages and
cultures.
TTMETHODS: We followed international recommen-
dations to perform cross-cultural adaptation. The
Spanish VISA-P (VISA-P-Sp) questionnaire and the
Short Form (36) Health Survey (SF-36) were admin-
istered to 150 individuals: 40 healthy students, 40
professional players in sports requiring jumping, 40
athletes with patellar tendinopathy, and 30 athletes
with knee injuries other than patellar tendinopathy.
Participants were assessed at baseline and after 1
week. Athletes with tendinopathy also completed
questionnaires and other knee measures (the
Kujala Scoring Questionnaire and the Cincinnati
Knee Rating Scale) after physiotherapy treatment,
TTRESULTS: The VISA-P-Sp showed high reliability
for both temporal stability (intraclass correlation
coefficient [ICC] = 0.994; 95% CI: 0.992, 0.996)
and internal consistency (Cronbach α = 0.885).
Based on a factor analysis, a 2-factor solution
explained 76.1% of the variance. The VISA-P-Sp
score in the tendinopathy group was significantly
correlated with scores on other knee scales (Kujala
score [Spearman rho = 0.897; P<.001] and Cincin-
nati scale [Spearman rho = 0.782, P<.001]) and
with SF-36 physical components score (Spearman
rho>0.6, P<.001). The standardized size effect was
1.14, and the standardized response mean was 1.17.
TTCONCLUSION: The VISA-P-Sp questionnaire
proved to be a valid and reliable instrument,
sensitive to clinical changes and comparable to the
original English-language version. J Orthop Sports
Phys Ther 2011;41(8):581-591, Epub 12 July 2011.
doi:10.2519/jospt.2011.3613
TTKEY WORDS: jumper’s knee, outcome measure,
tendon, validation
symptoms in athletes with patellar ten-
dinopathy after therapeutic interven-
tion.7,9,15,18,21,38,40 Important advances in
the understanding of tendon pathology
and clinical trials conducted by several
research groups have made the VISA-P
a widely accepted and valuable tool of
reference for the assessment of patellar
tendinopathy.22
Data obtained with appropriate out-
come measures allow an assessment of
the clinical evolution of tendinopathy
and the effectiveness of clinical inter-
ventions.17 However, the validity of the
conclusions drawn from such data de-
pends on the outcome measures used.
Therefore, valid and reliable tools are
essential.3,4
Clinical and research implementa-

Professor, Department of Pathology and Surgery, Physiotherapy Area, University Miguel Hernandez, Sant Joan, Alicante, Spain. 2Professor, Department of Basic Psychology
1

and Methodology, University of Murcia, Murcia, Spain. 3Professor, Department of Physical Therapy, University of Murcia, Murcia, Spain. The protocol for this study was approved
by The Ethics and Experimental Research Committee of Miguel Hernandez University. Address correspondence to Sergio Hernandez-Sanchez, Department of Pathology and
Surgery, Physiotherapy Area, University Miguel Hernandez, Ctra. Valencia, s/n. 03550 Sant Joan (Alicante), Spain. E-mail: sehesa@umh.es

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 [ research report
TABLE 1 Psychometric Properties of Various Versions of the VISA-P Scale
Reliability
Version Internal Consistency
English Pearson r, 0.87
Swedish Cronbach α, 0.83
Dutch Cronbach α, 0.73
Italian Cohen κ, 0.78
German Cronbach α, 0.83
Spanish Cronbach α, 0.83
Abbreviation: ICC, intraclass correlation coefficient.
*P<.001
†
The time interval between successive administration of the questionnaire was 30 minutes.
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tion of the VISA-P scale for the Span-
ish-speaking population requires a
systematic process of cultural adapta-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tion and validation. Simple translation
of the questionnaire does not ensure its
validity in another language or culture.30
Spanish is the second most common lan-
guage in the world. The growing num-
ber of research papers on the treatment
of patellar tendinopathy with Spanish-
speaking athletes33,34 justifies the need for
an adapted version of the VISA-P scale.
Journal of Orthopaedic & Sports Physical Therapy®
In recent years, other scales have been
adapted into Spanish for the assessment
of musculoskeletal conditions.23 There-
fore, it is essential to provide clinicians
and researchers with an unbiased tool to
communicate the results of their work.
The aim of this study was to adapt the
VISA-P questionnaire cross-culturally
and assess its psychometric properties for
Spanish-speaking individuals with patel-
lar tendinopathy.
METHODS
Cross-cultural Adaptation
B
efore beginning this work, we
informed the authors of the origi-
nal questionnaire of our intent, and
they gave their approval for a Spanish ad-
aptation (personal communication with
Dr K.M. Khan, 2007).
Cross-cultural adaptation includes
cultural and linguistic adaptation of a
questionnaire, as well as examination of
582 | august 2011 | volume 41 | number 8 | journal of orthopaedic & sports physical therapy
41-08 Hernandez-Sanchez.indd 582
Test-Retest* Interval, d
… 7
ICC = 0.97 4-7
ICC = 0.74 18-19
… 0†
ICC = 0.88 7 …
ICC = 0.99; 95% CI: .992, .996 7-10
its psychometric properties of reliability
and validity.35 The process was performed
according to the international recom-
mendations published by Beaton et al3
and consists of the 6 following steps: (1)
translation, (2) synthesis, (3) back-trans-
lation, (4) expert committee review, (5)
pretesting, and (6) validation.
(1) Translation (From English to Span-
ish) and (2) Synthesis These steps were
performed by 2 independent bilingual
individuals whose native language was
Spanish. One was a physical therapist
with extensive clinical experience in mus-
culoskeletal disorders and knowledge of
the English culture and language. The
other had a degree in translation and in-
terpretation, and familiarity with English
but no connection to the health sciences.
It was emphasized that the translations
should be semantic, not literal, with a
focus on conceptual equivalence. The
process yielded 2 Spanish-translated
versions of the original VISA-P scale. A
meeting was subsequently held between
the 2 translators and the research team
to obtain a consensus on the translated
version.
(3) Back-Translation Back-translation
was completed independently by 2 na-
tive English speakers fluent in Span-
ish and blinded to the original VISA-P
questionnaire. One was a sport physi-
cal therapist and the other was a native
English teacher without a medical back-
ground. A consensus back-translated
]
Validity
Factor Structure Percent Variance Explained
… …
3-factor solution 85.0%
2-factor solution 64.5%
… …
…
2-factor solution 76.1%
version was obtained from independent
back-translations.
(IV) Expert Committee Review An ex-
pert committee, consisting of all involved
translators, research team members, a
psychosocial science expert, an epide-
miologist, and a sports medicine physi-
cian, drafted the final version. The final
back-translated version was sent to 1 of
the original authors, who participated in
the discussion.
(V) Pretesting A cognitive pretest with
the consensus-translated prefinal version
was performed with a sample of 12 ath-
letes diagnosed with patellar tendinopa-
thy. The objective was to assess whether
the translated questionnaire was under-
standable, the vocabulary appropriate,
and expressions relevant in the Spanish
culture.
(VI) Validation Study The details and re-
sults of the validation study of the Span-
ish version of the VISA-P questionnaire
are provided below
Participants
A convenience sample of 150 athletes
was divided into 4 groups: 40 healthy
students of sport sciences at Miguel Her-
nandez University (39 men and 1 woman;
mean  SD age, 21.3  3.1 years); 40
athletes who participated in sports such
as volleyball, basketball, and handball,
thus were at high risk for patellar ten-
dinopathy (31 men and 8 women; mean
 SD age, 24.5  4.5 years); 40 athletes
7/20/2011 2:09:17 PM
 mittee of Miguel Hernandez University
Descriptive Characteristics and VISA-P-Sp
TABLE 2 (DPC-SHS-08). All of the participants
Scores in the Study Population*
were informed of the study objectives
and signed an informed consent form for
Healthy At Risk Tendinopathy Other Knee Injuries
voluntary participation.
Age, y 21.0  3.1 24.5  4.5 24.4  5.1 24.1  4.0
In the healthy and risk groups, the
BMI, kg/m2 23.1  1.6 23.5  1.8 23.7  2.4 23.2  1.2
principal investigator (S.H.) was respon-
Training, d/wk 3.9  0.6 4.3  1.1 5.0  0.9 3.1  0.8
sible for administration of the question-
Training, h/d 2.0  0.4 2.8  0.9 3.1  0.9 1.6  0.5
naires. Participants in the tendinopathy
SF-36 PCS 55.0  3.8 53.1  4.8 45.0  7.5 44.1  6.3
and other knee injury groups were re-
SF-36 MCS 52.9  6.5 51.9  6.5 51.6  8.2 55.7  6.1
cruited from physiotherapy clinics that
First VISA-P-Sp (0-100) 95.4  2.5 90.0  9.7 54.8  13.2 56.4  11.3
serve 12 professional sports teams in
Second VISA-P-Sp (0-100) 95.8  2.4 89.8  9.4 56.3  12.9 56.3  11.4
Spain (3 handball, 6 volleyball, 2 basket-
Abbreviations: SF-36 PCS, standardized physical component scale of the Short Form (36) Health Sur-
vey; SF-36 MCS, standardized mental component scale of the Short Form (36) Health Survey; First
ball, and 1 soccer). The principal inves-
tigator coordinated the instructions and
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VISA-P-Sp, application of Spanish version of VISA-P scale at baseline; Second VISA-P-Sp, Spanish
VISA-P score at 1 week after baseline assessment. education of the physical therapists to en-
*Data are presented as mean  SD for first application of VISA-P-Sp in all participants.
sure that the procedures were conducted
in a standard manner. The physical ther-
diagnosed with patellar tendinopathy The maximum score possible, which cor- apists provided patient information over
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

who played for professional sport clubs
in Spain (volleyball, basketball, hand-
ball, and soccer; 36 men and 4 women;
mean  SD age, 24.4  5.1 years), and
30 patients with knee injuries other than
patellar tendinopathy (chondropathy,
meniscal tears, and knee ligament inju-
ries; 23 men and 7 women; mean  SD
age, 24.1  4.2 years).
Journal of Orthopaedic & Sports Physical Therapy®
responds to an asymptomatic athlete, is
100 points. The theoretical minimum is
0 points.
Other tools that were used in the ex-
amination of patients with knee disor-
ders were the Cincinnati Knee Rating
Scale (Cincinnati scale), and the Kujala
Scoring Questionnaire (Kujala score).
The Short Form (36) Health Survey
a 2-season period from September 2008
to April 2010.
Reliability of the VISA-P-Sp question-
naire was studied for internal consistency
and temporal stability (test-retest) in all
participants. For test-retest evaluation,
the VISA-P-Sp and the SF-36 were re-
administered 7 to 10 days after the first
assessment.

Inclusion criteria for the tendinopathy
group were as follows: age greater than 18
years and ability to give written informed
consent, clinical diagnosis of patellar ten-
dinopathy with tendinosis verified on ul-
trasound or magnetic resonance imaging,
history of pain symptoms at the inferior
pole of patella that had persisted for at
least 3 months or had been recurrent for
at least 6 months.20
We excluded patients with other si-
multaneous knee injuries, such as quad-
riceps tendinopathy, clinical diagnosis of
total or partial tendon rupture, Osgood-
Schlatter disease, inflammatory condi-
tions, and previous surgery.
Instruments
The VISA-P scale consists of 8 items.
Six items rate pain level during daily ac-
tivities and functional tests on a numeric
pain-rating scale (from 0 to 10), and 2
items provide information on sports par-
ticipation (categorical response options).
(SF-36) was used as a quality-of-life out-
come measure. The Cincinnati scale in-
cludes a functional assessment based on
6 important abilities for participation in
sports. This assessment can help evalu-
ate change after surgery or other clinical
intervention. The maximum score is 420
and the minimum is 120, with higher
scores indicating better function.31 The
Kujala score24 is a 13-item questionnaire
that includes different items that address
pain-related functioning and activities.
Its score ranges from 0 to 100 (no dis-
ability). The SF-36 is a generic measure
of health-related quality of life, with 36
questions. It yields an 8-scale profile of
functional health and well-being scores
that range from 0 to 100 (higher scores
indicating better health status) and has
been validated in Spanish.2
Procedure
The study protocol was approved by The
Ethics and Experimental Research Com-
Internal validity (factorial validity)
was studied through an analysis of the
factor structure of the questionnaire.
External validity was tested by compar-
ing scores between groups. The results of
the VISA-P-Sp were also compared with
results from individuals who completed
the original and other adapted versions.
From the results of other similar stud-
ies and considering the theoretical basis,
we expected to find 2 components in the
factor analysis: one related to “pain dur-
ing activities” and the other related to
“sports participation.”
For convergent validity, we also hy-
pothesized a priori that correlations
among the VISA-P-Sp and other scales
related to the knee (Cincinnati scale and
Kujala score) and the 4 physical dimen-
sions of the SF-36 (physical functioning,
physical role, bodily pain, and standard-
ized physical component) would be high.
In the external validity study, correlation
of the VISA-P-Sp with other dimen-

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 [ research report
sions of the SF-36 scale (vitality, mental
health, emotional, and social role) was
calculated.
To assess responsiveness, we only
included the participants from the ten-
dinopathy group. The physiotherapists
working with the sports teams followed
the clinical course of the athletes and
monitored therapeutic processes and
clinical changes. In addition to initial
and second assessments for test-retest
reliability, the VISA-P-Sp, Kujala score,
Cincinnati scale, and SF-36 were com-
pleted a third time by each athlete with
tendinopathy at the end of physiother-
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apy treatment (or within 3 months of
the first assessment, whichever occurred
first). The results of this third application
were compared with those of the initial
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
assessment.
Treatment provided to the athletes
with tendinopathy included rest, ice,
eccentric exercises, anti-inflammatory
pain medications, electrotherapy, manual
therapy, and activity modifications.
Finally, to assess acceptability and
feasibility, we recorded the percentage
of unanswered questions and amount
Journal of Orthopaedic & Sports Physical Therapy®
of time the participants spent filling out
the VISA-P-Sp questionnaire. In addi-
tion, ceiling and floor effects were mea-
sured. Ceiling and floor effects for the
total score on the VISA-P-Sp question-
naire were considered to have occurred
if 15% of the participants in the samples
had the theoretical maximum or mini-
mum total scores. For each item on the
scale, a ceiling effect was considered to
have occurred when at least 75% of the
participants assigned the maximum score
to that item, and the floor effect to have
occurred when at least 75% of the par-
ticipants assigned the minimum score.11
Statistical Analyses
Sample size calculation indicated that a
sample of 120 subjects was required for
an alpha of .05, a statistical power of
0.80, a lower limit of ρ0 = 0.7, an upper
limit of ρ1 = 0.9, and an estimated rho of
0.85. In addition, we used a 20% replace-
ment rate to prevent dropouts. The nec-
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41-08 Hernandez-Sanchez.indd 584
20
Mean Difference (Second – First Assessment)
10
6.05
0
0.39
Mean
difference
–6.83
–10
–20
20
FIGURE 1. Agreement for test-retest measurements visualized by Bland-Altman plot, with limits of agreement as
mean difference  2 SD (dotted lines) in points for a 100-point scale.
essary sample was 144, thus we elected to
enroll 150 individuals in the study. The
characteristics of the participants are
shown in mean and standard deviation
values. The Kolmogorov-Smirnov test
was applied to assess the normal distri-
bution of VISA-P-Sp scores in the sample
with a level of significance of P<.05.
For internal consistency, the Cronbach
α was determined. Test-retest reliability
was determined using intraclass corre-
lation coefficients (ICCs) and related
95% confidence intervals (CIs). A Bland-
Altman plot was constructed to show
agreement for individual participants.
It includes a scatter plot of the differ-
ences between VISA-P-Sp applications
(the second score minus the first score)
against their mean, with 95% limits of
agreement (mean difference  2 SDdiff ).
A bar chart of error distribution was also
constructed to provide information about
agreement and bias.
Dimensionality was assessed using
]
Upper limit of
agreement
Lower limit of
agreement
40 60 80 100
Mean (First and Second Assessment)
exploratory factorial analysis to extract
main components with varimax rotation.
Eigen values over 1 were extracted, and
the continuation of an item in the factor
was considered if the factor loading was
greater than 0.4.1 Items with a loading of
higher than 0.40 on both factors (cross-
loading factors) were assigned to the fac-
tor with a higher correlation, provided
that the difference between the factor
loadings of the components was greater
than 0.2.13
Differences between groups were
analyzed using the Kruskal-Wallis test,
with a post hoc Dunn’s test for multiple
comparisons. Significance level was set at
P<.05. Correlation of VISA-P-Sp scores
with SF-36 components and other knee
scores was calculated using Spearman
rho. To compare VISA-P-Sp scores with
scores of the original and other adapted
versions, we used a 2-sample t test, with
mean and SD only. A paired student t
test, using scores from the first and third
7/20/2011 2:09:20 PM
 (FIGURE 1) showed that the differences
16 1.3%
between 2 assessments were inside the
12 1.3%
limits of agreement. These differences
were plotted around the zero line (homo-
7 0.7%
geneous), with the exception of few out-
6 0.7%
liers. The zero line was within the 95%
Difference (Second – First Assessment)

5 1.3%
CI of the mean difference between the
3 2.7%
second and first assessments, indicating
2 9.3%
no systematic bias. A bar chart (FIGURE 2)
1 20%
reflected the magnitude of the differenc-
0 37.3%
es between the 2 measurement times. In
–1 13.3%
87.9% of the cases, the difference was –2
–2 5.3% and 2 points around zero and showed no
–3 3.3% significant difference between the mea-
–4 1.3% surement times.
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–6 0.7%
–11 0.7% Validity
–15 0.7% In the questionnaire dimensionality
analysis, the sample adequacy rates of the
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

0% 10% 20% 30% 40% Kaiser-Meyer-Olkin measure (0.877) and

Bartlett’s sphericity test (C2 = 892.052,
Frequency P<.001) show values that allow the use of
factor analysis.
FIGURE 2. Bar chart illustrating the percent of observations corresponding to each level of difference (in points for In the exploratory analysis, we ob-
a 100-point scale) between the second and the first VISA-P-Sp applications.
tained a matrix with 2 factors (TABLE 3).
The first, pain/symptoms, comprised
applications of the VISA-P-Sp, was calcu- 7, we exchanged “” for “and/or,” after 6 items (1-6). This solution explained
lated to assess responsiveness. Standard- consulting one of the original authors 63.5% of the total variance. Item factor
Journal of Orthopaedic & Sports Physical Therapy®

ized effect size and standardized response (APPENDIX).
mean statistics16 were also calculated
and interpreted using thresholds estab- Demographics
lished by Cohen.6 All statistical analyses The characteristics of the participants are
were performed using SPSS Version 17.0 presented in TABLE 2. In the tendinopathy
(SPSS Inc, Chicago, IL) and G-Stat 2.0 group, the mean  SD duration of symp-
software. toms was 17.7  17.1 months, and the
right knee was affected in 57.5% of the
RESULTS cases. Patellar tendinosis was confirmed
with ultrasound in 70% of the partici-
Translation pants and with magnetic resonance im-
loadings were greater than 0.6 in all the
cases. The second factor, physical partici-
pation, includes items 7 and 8, and this
factor resulted in a 12.6% additional in-
crease in the explanation of the variance
(76.1%).
Mean VISA-P-Sp scores for the groups
are shown in TABLE 4. VISA-P-Sp scores
had asymmetric distribution (Kolmogo-
rov-Smirnov statistic, 0.19; P<.001)
when all samples were considered. Dif-

A
fter the first formal review, aging in the remaining 30%. ferences between the healthy and the at-
the research team made some risk groups were statistically significant
changes in the questionnaire to Reliability with respect to the participants with
improve understanding. First, as Frohm The Cronbach α was 0.885 for the first tendinopathy (37.9 points, P<.01) and
et al12 suggested, the number of minutes assessment and 0.880 for the second as- other knee injuries (36.3 points, P<.01)
were introduced in the response scale sessment. The ICC was 0.994 (P<.001; (FIGURE 3). However, no differences were
in question 1. Second, to improve the 95% CI: 0.992, 0.996). In individual found between the scores of participants
ease of self-administration, we intro- item analysis, all calculated ICCs ranked in the tendinopathy group and those in
duced pain scale numbers in each box, between 0.992 and 0.998. The average the other knee injury group (1.6 points,
referring to gradual pain level. Scores on difference between repeated measures P>.05) or between the healthy and the at-
each item are presented outside of the for the VISA-P-Sp was 0.39 points, with risk groups (5.45 points, P>.05). For all
boxes by using a smaller size and lighter limits of agreement ranging from 6.83 items on the scale, the athletes with ten-
color to avoid confusion. Finally, in item to –6.05 points. A Bland-Altman plot dinopathy scored significantly lower than

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 [ research report ]
Principal Component Analysis Feasibility
The questionnaire was easily understood
TABLE 3 With 2-Factor Solution and Factor
by the participants in the study, who re-
Loadings for the VISA-P-Sp Scale
quired less than 5 minutes to complete
it independently. All of the participants
Component
completed the full VISA-P-Sp, resulting
Corresponding Questions on VISA-P Scale (English Version) 1 2 in a maximum response rate. Approxi-
1. For how many minutes can you sit pain free? 0.724* 0.059 mately 6.7% of the participants achieved
2. Do you have pain walking downstairs with normal gait cycle? 0.718* 0.460 the highest possible score on the scale,
3. Do you have pain at the knee with full active non–weight-bearing knee extension? 0.837* 0.059 whereas none had a theoretical mini-
4. Do you have pain when doing a full weight-bearing lunge? 0.788* 0.430 mum score. For the individual items on
5. Do you have problems squatting? 0.729* 0.523 the scale, no item received a maximum
6. Do you have pain during or immediately after doing 10 single-leg hops? 0.811* 0.414 or minimum score by more than 75% of
7. Are you currently undertaking sport or other physical activity? 0.037 0.938† the population.
8. For how long can you manage being trained or physically active? 0.508 0.743†
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*Item is in the first factor.

†
Item is in the second factor.
DISCUSSION

A
fter following the adaptation
process described by Beaton et al,3
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Scores for the Original and Adapted we found that the VISA-P-Sp items
TABLE 4
Versions of the Visa-P Questionnaire* were equivalent to those in the original
version, as determined by the bilingual
Healthy At Risk Tendinopathy Other Knee Injuries and clinical experts involved in the study.
n VISA-P Score n VISA-P Score n VISA-P Score n VISA-P Score This adaptation showed good psychomet-
Spanish 40 95.4  2.5 40 90.0  9.7 40 54.8  13.3 30 56.4  11.3 ric properties in Spanish athletes, and
German 57 94.8  6.3 ... ... 23 62.3  14.3 ... ... that the scores of the groups were very
Swedish 17 83.1  12.6 17 79.0  24.2 17 47.7  20.2 ... ... similar to those obtained from subjects
Italian ... ... ... ... 25 44.3  NA ... ... using other versions12,28,29,37,39 of the same
Journal of Orthopaedic & Sports Physical Therapy®

Dutch 18 95.3  8.8 15
English 26 95.0  8.0 100
Abbreviations: NA, not available.
*Data are mean  SD.
did participants in the healthy and at-risk
groups (P<.05). No differences in group
scores were found between the original
or other adapted versions and the VISA-
P-Sp (P>.05) (TABLE 4).
A high correlation between the first
VISA-P-Sp score and the following SF-36
components was found: physical function
(Spearman rho = 0.65, P<.001), physical
role (Spearman rho = 0.57, P<.001), bodi-
ly pain (Spearman rho = 0.60, P<.001),
and standardized physical component
(Spearman rho = 0.58, P<.001).
VISA-P-Sp scores showed low cor-
relations that were not statistically sig-
nificant for social (Spearman rho = 0.21,
P>.05), emotional (Spearman rho =
–0.05, P>.05), general health (Spearman
rho = 0.11, P>.05), vitality (Spearman rho
88.6  11.1 14 58.2  18.9 17
93.0  11.0 14 55.0  12.0 ...
= 0.23, P>.05), and mental health (Spear-
man rho = 0.32, P>.05) dimensions and
standardized mental components (Spear-
man rho = 0.03, P>.05) of the SF-36. A
very high and significant correlation of
VISA-P-Sp scores with the Kujala score
(Spearman rho = 0.897, P<.001) and the
Cincinnati scale (Spearman rho = 0.782,
P<.001) was found.
During the assessment of responsive-
ness, significant changes were detected
between the first and last VISA-P-Sp
scores for the tendinopathy group (t =
7.39, P<.001). The mean change in the
VISA-P-Sp score was 15.23  13.01
points between the first and third ap-
plications. Standardized effect size was
1.148, and standardized response mean
was 1.17.
76.6  24.3 scale supports our findings.
...
Translation Process
For item 4, we tried to achieve an adapted
translation of the term “weight-bearing
lunge,” because there is no literal trans-
lation for this in Spanish. There were
differences in opinion between the
translators for this question; therefore,
we consulted 14 athletes from different
sports (football, fencing, athletics, bas-
ketball, volleyball, and handball) and 15
sport science professionals to find a ge-
neric, representative term. We adopted
the term “zancada” (stride) and attached
a representative image in the margin of
the item. We think this generic term is
understandable by athletes of any prac-
tice level and discipline.
For items 1 and 8, we adopted the
scoring system and times of the original
version, which have also been retained
in the Swedish version. In the Dutch
version, however, different scoring and

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41-08 Hernandez-Sanchez.indd 586 7/20/2011 2:09:23 PM

 time updates have been used. We include
these updates in the VISA-P-Sp version
(APPENDIX).
One important formal change was
the placement of the numeric pain scale
within the response boxes and the score
item points below the boxes in a lighter
color. The original presentation for items
2, 3, 4, and 6 of the questionnaire shows a
numeric pain-rating scale with 2 ends (0-
10) and its corresponding points, which
are inversely proportional to pain level.
During pretesting of the scale, athletes
had difficulties answering these items,
because, on the scale, “no pain” cor-
Downloaded from www.jospt.org at on June 2, 2020. For personal use only. No other uses without permission.
responded to the number 10, which is
cognitively contradictory. Therefore, we
decided to change the presentation.
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Psychometric Properties
To assess the psychometric properties of
the VISA-P-Sp questionnaire, we consid-
ered the criteria described by Terwee et
al.36
Reliability Adequate reliability values
were obtained, both in terms of internal
consistency and temporal stability, in
which we considered ICC values of 0.7 as
Journal of Orthopaedic & Sports Physical Therapy®
a minimum standard.27 These results are
similar to those of other versions.12,28,39
To assess test-retest reliability, we used a
large sample and a time interval of 7 to
10 days between applications. This time
interval was sufficient for participants
to forget their initial responses and for
symptoms not to vary substantially.5
In the sample configuration, we did
not include individuals treated surgically
or on the surgical waiting list, as in the
original study. During data collection,
we found that surgery was performed
only in exceptional cases. As Maffulli et
al29 reported, research and development
in nonsurgical therapies (eccentric exer-
cise, sclerosing therapy, and shockwave
therapy) have led to a marked reduction
in the number of athletes who expect or
receive surgical treatment for patellar
tendinopathy.
Validity Mean VISA-P-Sp scores for each
group were similar to those of the origi-
nal version, and no statistically signifi-
journal of orthopaedic & sports physical therapy | volume 41 | number 8 | august 2011 |
41-08 Hernandez-Sanchez.indd 587
Other knee injuries
Tendinopathy
At risk
Healthy
20
FIGURE 3. Box plot of the mean scores of the VISA-P-Sp* and other data as median (vertical black line in the box),
first and third quartile (blue box), and range (black T lines) for each group at baseline. Differences were found
between the tendinopathy group and the other knee injury group compared with the healthy and the at-risk groups
(P<.05).
cant differences were found. With respect
to the factor structure of the VISA-P-Sp,
a unique solution explains 63.5% of the
total variance. Consideration of a sec-
ond factor increases the explanation of
variance to 76.1% and is better suited to
the theoretical basis. In our adaptation,
we considered 2 dimensions: symptom
of pain during activity and functional
tests, and sports participation. Accord-
ing to the principles of parsimony and
interpretability in factorial analysis, the
number of factors must be as small as
possible and should be subject to sub-
stantive interpretation.13 For these rea-
sons, and considering the theoretical
framework, we interpreted the solution
with 2 factors and this item-factor dis-
tribution. Zwerver et al39 also obtained a
similar structure, although we considered
the first item of the scale within the first
factor (pain during activity). Frohm et al12
obtained an initial solution with 2 factors
and afterward forced a third factor; but
the distribution of items in each factor
*
56.4
*
54.8
*
90
*
95.5
40 60 80 100
VISA-P-Sp Scores at Baseline, Points
does not match ours. As stated in their
work, the item “sit pain free” might be an
artifact to be considered in the first factor
(pain during activity). A 2-factor arrange-
ment seems to be a more evidenced and
appropriate solution.
Responsiveness of scale is not a prop-
erty that has been previously evaluated.
In the athletes with tendinopathy, VISA-
P-Sp score changes were observed in
those who were able to return to sports
participation. The mean  SD change in
VISA-P-Sp score for this group was 15.23
 13.01 points between the first and third
applications of the questionnaire. The
magnitude of effect size (less than 0.8)
in the present study provides evidence
that the VISA-P-Sp can detect changes
in symptom severity at 2 different time
points in the clinical course of the ten-
dinopathy. This finding is important be-
cause it allows researchers and clinicians,
in using the questionnaire, to assess the
impact of therapies that are currently ap-
plied over time.23
587
7/20/2011 2:09:24 PM
 [ research report
Ceiling and floor effects were not ob-
served in our study, further supporting
the validity of the VISA-P-Sp question-
naire. It should be noted that 47.5% of
the athletes in the tendinopathy group se-
lected the maximum response for item 7
(sports participation). This suggests that
many of the injured athletes continue to
fully participate in sports, despite their
knee pain.25
As found in the original validation
study and subsequent adaptations, the
scores on the VISA-P scale discriminate
between groups of asymptomatic indi-
viduals and athletes with patellar tendi-
Downloaded from www.jospt.org at on June 2, 2020. For personal use only. No other uses without permission.
nopathy. As the authors suggested in the
original publication, the VISA-P should
not be considered a diagnostic tool, be-
cause there were no significant differ-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ences between the scores of athletes with
tendinopathy and those of patients with
other knee injuries.12,28,29,39
In the study of VISA-P-Sp correlation
with SF-36 components, participants
with higher levels of symptoms had, as
expected, a poorer quality of life related
to health. This finding helps to confirm
the external validity of the questionnaire
Journal of Orthopaedic & Sports Physical Therapy®
and its adaptation.
The sample had a high number of
male athletes (86.7%), which might be
a limitation for the generalizability of
the findings. Moreover, we used a conve-
nience sample of 150 individuals. Though
this is not a large number, we had 5 ath-
letes per item in the main groups, which
is the absolute minimum with which a
factor analysis should be conducted.10
Furthermore, we recruited individuals
from different cities of Spain to minimize
bias due to cultural, semantic, or demo-
graphic factors.
According to Coleman et al,7 an impor-
tant source of error in obtaining results
about treatments of patellar tendinopa-
thy is the lack of reliable and valid out-
come measures for estimating changes or
effects after clinical intervention. In this
case, we considered it important to have
a valid adapted tool that met the quality
standards for use with Spanish-speaking
athletes with patellar tendinopathy and
588 | august 2011 | volume 41 | number 8 | journal of orthopaedic & sports physical therapy
41-08 Hernandez-Sanchez.indd 588
for standardized use in daily clinical
practice.4 Increased international collab-
oration in clinical research and the expo-
nential growth of multinational research
projects have generated a need for suit-
able and valid versions of tools that can
be used across languages and cultures.15
Reaching consensus and unifying the
use of assessment tools can help improve
the quality and quantity of scientific evi-
dence, because different studies can re-
port results in a similar manner, enabling
comparison and integration through sys-
tematic reviews and meta-analyses. 32
CONCLUSIONS
C
onsidering the data obtained
from the cross-cultural adaptation
and validation process, the VISA-
P-Sp questionnaire has good reliability,
validity, and sensitivity to change for use
with Spanish-speaking athletes with pa-
tellar tendinopathy.
Future research will examine the
cross-cultural validity of different ver-
sions of the VISA-P questionnaire and
other aspects of responsiveness to in-
crease its clinical applicability. This re-
search could consolidate its use as an
international reference outcome mea-
sure in prospective studies on patellar
tendinopathy. t
KEY POINTS
FINDINGS: We found that the Spanish
adaptation of the VISA-P scale is a valid
and responsive instrument to assess the
severity of symptoms of athletes with
patellar tendinopathy. The VISA-P-Sp
is comparable with the original version
and other published international ver-
sions of the questionnaire.
IMPLICATIONS: This adapted VISA-P scale
can be used by clinicians and research-
ers as an outcome measure in the ex-
amination of Spanish-speaking athletes
with patellar tendinopathy.
CAUTION: The sample consisted primarily
of male participants, which may limit
the generalization of the results. Further
research is necessary to better establish
]
the responsiveness of the scale.
ACKNOWLEDGEMENTS: The authors acknowl-
edge all athlete and physiotherapist par-
ticipants for their valuable and essential
collaboration in the study. We gratefully thank
Professor Karim Khan for his guidance during
the adaptation process.
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@ MORE INFORMATION
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589
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 [ research report ]
APPENDIX

FINAL VERSION OF THE VISA-P-SP

Este es un cuestionario para la valoración de la gravedad de los síntomas en individuos con tendinopatía rotuliana. El término “dolor” en el cuestionario
hace referencia a la zona específica del tendón rotuliano. Para indicar su intensidad de dolor, por favor, marque de 0 a 10 en la escala teniendo en cuenta
que.

0 = ausencia de dolor y 10 = máximo dolor que imagina.

1. ¿Durante cuántos minutos puede estar sentado sin dolor?

Puntos
0-15 min 15-30 min 30-60 min 60-90 min 90-120 min > 120 min
0 2 4 6 8 10
Downloaded from www.jospt.org at on June 2, 2020. For personal use only. No other uses without permission.

2. ¿Le duele al bajar escaleras con paso normal?

Puntos
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Sin dolor 0 1 2 3 4 5 6 7 8 9 10 Dolor muy intenso

10 9 8 7 6 5 4 3 2 1 0

3. ¿Le duele la rodilla al extenderla completamente sin apoyar el pie en el suelo?

Puntos
Sin dolor 0 1 2 3 4 5 6 7 8 9 10 Dolor muy intenso
10 9 8 7 6 5 4 3 2 1 0
Journal of Orthopaedic & Sports Physical Therapy®

4. ¿Tiene dolor en la rodilla al realizar un gesto de “zancada” (flexión de rodilla tras un movimiento amplio hacia delante con carga completa del peso
corporal sobre la pierna adelantada)? Ver ilustración.

Sin dolor 0 1 2 3 4 5 6 7 8 9 10 Dolor muy intenso Puntos

10 9 8 7 6 5 4 3 2 1 0

5. ¿Tiene problemas para ponerse en cuclillas?

Puntos
Sin problemas 0 1 2 3 4 5 6 7 8 9 10 Dolor muy intenso/incapaz
10 9 8 7 6 5 4 3 2 1 0

6. ¿Le duele al hacer 10 saltos seguidos sobre la pierna afectada o inmediatamente después de hacerlos?
Puntos
Sin dolor 0 1 2 3 4 5 6 7 8 9 10 Dolor muy intenso/incapaz
10 9 8 7 6 5 4 3 2 1 0

590 | august 2011 | volume 41 | number 8 | journal of orthopaedic & sports physical therapy

41-08 Hernandez-Sanchez.indd 590 7/20/2011 2:46:31 PM

 APPENDIX

7. ¿Practica algún deporte o actividad física en la actualidad?

0  No, en absoluto
Puntos
4  Entrenamiento modificado y/o competición modificada
7  Entrenamiento completo y/o competición, pero a menor nivel que cuando empezaron los síntomas
10  Competición al mismo nivel o mayor que cuando empezaron los síntomas

8. Por favor, conteste A, B o C en esta pregunta según el estado actual de su lesión:

• Si no tiene dolor al realizar deporte, por favor, conteste sólo a la pregunta 8A.
• Si tiene dolor mientras realiza el deporte pero éste no le impide completar la actividad, por favor, conteste únicamente la pregunta 8B.
• Si tiene dolor en la rodilla y éste le impide realizar deporte, por favor, conteste solamente la pregunta 8C.
Downloaded from www.jospt.org at on June 2, 2020. For personal use only. No other uses without permission.

8A. Si no tiene dolor mientras realiza deporte, ¿cuánto tiempo puede estar entrenando o practicando?
Puntos
0-20 minutos 20-40 minutos 40-60 minutos 60-90 minutos >90 minutos
6 12 18 24 30
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

8B. Si tiene cierto dolor mientras realiza deporte pero éste no obliga a interrumpir el entrenamiento o la actividad física, ¿cuánto tiempo puede estar
entrenando o haciendo deporte?
Puntos
0-15 minutos 15-30 minutos 30-45 minutos 45-60 minutos >60 minutos
0 5 10 15 20
Journal of Orthopaedic & Sports Physical Therapy®

8C. Si tiene dolor que le obliga a detener el entrenamiento o práctica deportiva, ¿cuánto tiempo puede aguantar haciendo el deporte o la actividad física?
Puntos
Nada 0-10 minutos 10-20 minutos 20-30 minutos >30 minutos
0 2 5 7 10

Puntuación Total: /100

Nombre:
Fecha:

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