Validity and Reliability of Visual Analog Scale Foot and Ankle: The Turkish Version

Transcultural Adaptation and Validation of the Spanish Version of the Visual Analogue Scale for the Foot and Ankle (VASFA)

BACKGROUND

The main aim of this study is to perform a cross-cultural adaptation and validation of the Visual Analogue Scale for the Foot and Ankle (VASFA) questionnaire, creating a Spanish-language version (VASFA-Sp), and to determine the measurement properties of this instrument.

METHODS

VASFA was cross-culturally translated into Spanish following the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). The study sample was composed of 228 participants who were recruited from February to May 2022. All were at least 18 years old, gave signed informed consent to take part and properly completed the Foot and Ankle Ability Measures-Sp and VASFA-Sp questionnaires. Cronbach's alpha and test/re-test reliability values were calculated. Structural validity was assessed via exploratory factor analysis.

RESULTS

The 228 patients included in the final analysis presented the following characteristics: 35.53% were male and 64.47% were female; the mean age was 35.95 (18-81) years; and the mean body mass index was 23.79. Internal consistency was excellent. The Cronbach's alpha for VASFA-Sp was 0.96 and the intraclass correlation coefficient was 0.932 (95% CI; 0.84 to 0.97). Exploratory factor analysis identified one main factor.

CONCLUSIONS

VASFA-Sp is a reliable, valid and sensitive questionnaire that is suitable for measuring perceived foot and ankle function impairment in a Spanish-speaking population.

Comparing the Efficacy of Local Corticosteroid Injection, Platelet-Rich Plasma, and Extracorporeal Shockwave Therapy in the Treatment of Pes Anserine Bursitis: A Prospective, Randomized, Comparative Study

Background

Pes anserine bursitis (PAB) is one of the most common causes of painful knee syndromes. This study aimed at examining the efficacy of local corticosteroid injection, platelet-rich plasma (PRP) injection, and extracorporeal shock wave therapy (ESWT) as different modalities to alleviate pain and enhance function in patients with pes anserine bursitis (PAB).

Methods

A prospective, randomized, comparative study was conducted on 180 patients diagnosed with chronic PAB. They were equally divided into three groups as follows: Group I received a local corticosteroid injection of 40 mg of methylprednisolone acetate/1 ml; Group II received a PRP injection; and in Group III, ESWT was used. Outcome measures included the visual analog scale (VAS), Western Ontario and McMaster Universities (WOMAC) pain score, WOMAC physical function score, and Ritchie articular index (RAI) for tenderness, which were recorded at the baseline, after 1 week, and after 8 weeks.

Results

Before the application of procedures, there was a statistically significant increase in the WOMAC pain score in the local corticosteroid group compared to the PRP group and the ESWT group (P < 0.001). After the application of procedures, there was a statistically significant improvement in the 1-week and 8-week WOMAC pain score, WOMAC physical function score, and VAS in the local corticosteroid group in comparison to the PRP group and the ESWT group. (P < 0.001). Moreover, RAI for tenderness shows statistically significant improvement at 8 weeks in the local corticosteroid groups compared to the PRP groups (P < 0.001) and ESWT groups (P < 0.001). Similarly, a statistically significant difference was found between the PRP and ESWT groups (P=0.023).

Conclusion

Our data suggest that in patients with PAB, local corticosteroid injection is more efficient than PRP injection and ESWT for reducing pain and enhancing function.

Lateral Talar Subluxation Measurements in Nonoperatively Managed Weber B Ankle Fractures

Background

Lateral talar subluxation (LTS) was introduced as a measurement tool for evaluating isolated Weber B ankle fractures, with LTS >4 mm on gravity stress (GS) radiographs possibly indicating need for surgery. This study reviews LTS measurements in nonoperatively managed isolated Weber B fibula fractures to further investigate the validity of this previously stated cutoff.

Methods

The senior authors previously reported outcomes of a novel algorithm for nonoperative management of isolated Weber B ankle fractures. Outcome scores reported include American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for activities of daily living (FAAM/ADL), and visual analog scale (VAS) scores. All patients achieved union of their fracture. LTS was measured on GS radiographs of both injured and contralateral uninjured extremities.

Results

Forty-two patients were included with minimum 1-year follow-up. Average age was 49 years (range 19-72). Mean measurements on injury GS radiographs were as follows: medial clear space (MCS) 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0-4.7 mm), with 35 (83.3%) patients having injury LTS ≤4 mm. Mean measurements on contralateral (uninjured) GS radiographs were as follows: MCS 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0-4.8 mm). There was no statistically significant difference in all outcome measures based on amount of LTS (<2 mm, 2-4 mm, >4 mm).

Conclusion

Most patients had injury LTS ≤4 mm, although those with LTS >4 mm had excellent outcome scores. LTS measurements on normal ankles reveal a large range. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but the 4-mm cutoff may not be entirely reliable. Further studies are required to validate LTS as a decision-making tool.

Level of Evidence

Level IV, case series.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

Cervical and scapula-focused resistance exercise program versus trapezius massage in patients with chronic neck pain: A randomized controlled trial

OBJECTIVE

The purpose of this study was to investigate the effects of resistance exercise in comparison with those of common exercise on chronic neck pain (CNP) to provide useful clinical guidelines for reducing pain or increasing cervical range of motion (ROM), upper trapezius tone, disability level, and quality of life (QOL).

METHODS

The subjects were randomized into a cervical and scapula-focused resistance exercise group (CSREG, n = 21) or trapezius massage group (TMG, n = 20). All groups received a 4-week, five times per week CSRE or TM program for CNP. The visual analogue scale (VAS) score, cervical ROM, myotonometer measures (upper trapezius tone, stiffness, and elasticity), neck disability index (NDI), and short form-36 (SF-36) were identified as the primary outcomes.

RESULTS

Within-group changes in VAS, cervical ROM, myotonometer measures, NDI, and SF-36 were significant in the CSREG and TMG (P < .05). The between-group changes in VAS, cervical rotation, myotonometer (upper trapezius tone and stiffness), NDI, and SF-36 after intervention showed significant differences between the CSREG and TMG (P < .05).

CONCLUSION

These results suggest that the CSRE program is effective in improving pain, cervical ROM, upper trapezius tone, disability level, and QOL in patients with CNP. More comprehensive studies with longer follow-up durations are needed to better understand the potential effects of the CSRE program in patients with CNP.

Structural and Construct Validity of the Foot and Ankle Ability Measure (FAAM) With an Emphasis on Pain and Functionality After Foot Surgery: A Multicenter Study

The Foot and Ankle Ability Measure (FAAM) is a patient-reported outcome measure that is available in several languages. We aim to assess the structural and construct validity of the FAAM with an emphasis on pain and functionality after foot surgery. The activities of daily living (ADL) and Sports subscales of the Finnish version of the FAAM were completed by 182 patients who underwent operative treatment for disorders of the foot. Convergent validity was assessed by principal component analysis using Spearman's correlation coefficient between the FAAM subscales and the principal components (Function-PC and Pain-PC) derived from validated patient-reported outcome measures. Subscales were studied for floor and ceiling effects, internal consistency and unidimensionality. Internal consistency was examined with Cronbach's alpha and the subscale structure with exploratory factor analysis. FAAM-ADL had high correlation with the Function-PC (r = 0.87, 95% confidence interval [CI] 0.81-0.91) and the Pain-PC (r = 0.75, 95% CI 0.65-0.83). FAAM-Sports had moderate correlation (r = 0.64, 95% CI 0.50-0.74) with the Function-PC and high correlation (r = 0.74, 95% CI 0.64-0.82) with the Pain-PC. No floor or ceiling effects were observed. Cronbach's alpha was 0.97 (95% CI 0.96-0.98) for the ADL and 0.93 (95% CI 0.91-0.95) for the Sports subscales. The results supported the unidimensionality of the FAAM-Sports. Within the ADL subscale, 3 factors were identified, suggesting a 3-factor model for the FAAM overall. Results highlighted the inter-relationship of pain and physical function. Further research on longitudinal validity is needed.

Radiofrequency Microtenotomy or Physical Therapy for Achilles Tendinopathy: Results of a Randomized Clinical Trial

Background:

Achilles tendinopathy is a painful disorder, and various treatment options are available. Bipolar radiofrequency microtenotomy (RFM) has shown promising results in treating tendinosis.

Purpose/Hypothesis:

The purpose was to compare the results between treatment with bipolar RFM and physical therapy (PT) for patients with midportion Achilles tendinopathy. It was hypothesized that RFM would be equivalent or superior to PT.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 38 patients with midportion Achilles tendinopathy were evaluated for 2 years. The patients were randomized to receive either RFM or PT. There were 20 patients in the RFM group and 18 patients in the PT group. Clinical outcomes were assessed using the visual analog scale (VAS) for pain and the Foot and Ankle Outcome Score (FAOS). The degree of tendinosis was evaluated with magnetic resonance imaging (MRI) of the affected ankle performed before intervention and 2 years after intervention.

Results:

In both groups, the VAS scores at the 2-year follow-up were significantly improved compared with preintervention: from 7.2 ± 1.5 to 1.0 ± 1.4 for the RFM group and from 5.9 ± 1.3 to 3.1 ± 1.8 for the PT group (P < .01 for both). Compared with the PT group, the RFM group had significantly better VAS scores at both the 1- and 2-year follow-ups (P < .01 for both) and better scores on 4 of the 5 FAOS subscales at the 2-year follow-up (P < .01 for all). MRI revealed an improvement in the tendinosis score in both groups, without any significant difference between the groups.

Conclusion:

In this randomized study, the clinical assessments revealed significant improvements in the VAS, FAOS, and tendinosis score as seen on MRI 2 years after intervention with either RFM or PT in patients with midportion Achilles tendinopathy. The improvement was significantly better in the RFM group with regard to VAS and FAOS, but not in the MRI appearance.

Registration:

NCT03274557 (ClinicalTrials.gov identifier).

Effects of ultrasound guided leukocyte-rich platelet-rich plasma (LR-PRP) injection in patients with pes anserinus tendinobursitis

OBJECTIVES

To demonstrate the efficacy and safety of ultrasound guided leukocyte-rich platelet-rich plasma (LR-PRP) injection in patients with pes anserinus tendinobursitis (PATB).

METHODS

A prospective, randomized and single-blinded study of 60 patients with PATB were randomly assigned into 2 groups. Whereas 2 mL LR-PRP injection was applied to one grup, once accompanied by ultrasonography (USG), 2 mL LR-PRP injection was applied to the other group accompanied by USG twice with a one-week interval. Visual Analog Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 6-minute walking test (6MWT), Likert Scale were evaluated pre-treatment, at the 4th and 12th weeks after treatment.

RESULTS

There was no statistical difference between the two groups in terms of age, gender, body mass index, duration of symptoms, affected side. When both groups are compared within themselves before and after treatment, there was a significant improvement in all VAS, in all WOMAC subgroups, 6MWT, at the 4th and 12th weeks after treatment. When the two groups are compared with each other, there was no statistical difference. In addition, when all patients were evaluated with Likert scale in the 12th week after treatment, complete healing in 22(36.7 %) patients, significant relief in 25(41.7 %) patients, mild relief in 4(6.7 %) patients, 5(8.3 %) same as before treatment patients, and worsened pain in 4(6.7 %) patients were seen.

CONCLUSION

Both single-dose and double-dose local LR-PRP is a safe and effective treatment option for patients with PATB syndrome. We believe that once LR-PRP injection may be sufficient for the treatment efficacy in PATB.

Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery

BACKGROUND

Patient-reported outcomes (PROs) are widely accepted measures for evaluating outcomes of surgical interventions. As patient-reported information is stored in electronic health records, it is essential that there are valid electronic PRO (ePRO) instruments available for clinicians and researchers. The aim of this study was to evaluate the validity of electronic versions of five widely used foot and ankle specific PRO instruments.

METHODS

Altogether 111 consecutive elective foot/ankle surgery patients were invited face-to-face to participate in this study. Patients completed electronic versions of the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the modified Lower Extremity Function Scale (LEFS), the Manchester-Oxford Foot Questionnaire (MOXFQ), and the Visual Analogue Scale Foot and Ankle (VAS-FA) on the day of elective foot and/or ankle surgery. Construct validity, coverage, and targeting of the scales were assessed.

RESULTS

Based on general and predefined thresholds, construct validity, coverage, and targeting of the ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA were acceptable. Major issues arose with score distribution and convergent validity of the modified LEFS instrument.

CONCLUSIONS

The ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA provide valid scores for foot and ankle patients. However, our findings do not support the use of the modified LEFS as an electronic outcome measure for patients with orthopedic foot and/or ankle pathologies.

Comparison of the lower extremity function of patients with foot problems according to the level of kinesiophobia

PURPOSE

The presence of kinesiophobia was identified in patients with foot problems. There was no finding of foot functionality according to the level of kinesiophobia in lower extremity problems. The aim of this study was to compare the lower extremity functional status in foot problems with a low or high level of kinesiophobia.

MATERIALS AND METHODS

Evaluated herein were 37 patients with foot problems (plantar fasciitis, hallux valgus, flat foot). Physical and demographic characteristics were recorded. Patients were divided into two groups based on if they had a high or low level of kinesiophobia using the Tampa kinesiophobia scale. Ankle plantar flexor and knee flexor muscles tightness were recorded. The foot posture was evaluated using the Foot Posture Index. Foot-related pain was measured using the Visual Analog Scale Foot & Ankle. The Foot Function Index and the American Orthopaedics Foot and Ankle Foundation Ankle-Hindfoot Scale and Hallux Metatarsophalangeal-Interphalangeal Scale were used to assess the foot function. The general functional status of the lower extremities was evaluated using the Lower Extremity Functional Scale.

RESULTS

Foot function was better in patients with a low level of kinesiophobia (p < 0.05). Pain was higher in patients with high level of kinesiophobia than in patients with a low level of kinesiophobia (p < 0.05). There was no difference between the groups in terms of foot posture index and muscle tightness (p > 0.05). The general lower extremity function was more negatively affected in patients with a high level of kinesiophobia (p < 0.05).

CONCLUSIONS

Patients with a high level of kinesiophobia presented with more functional problems in the foot and whole lower extremity; hence, function-based rehabilitation and pain coping strategies should be a crucial part of the rehabilitation program at the earliest opportunity.

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury

BACKGROUND

The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma.

METHODS

In total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested.

RESULTS

AOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach's alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample.

CONCLUSIONS

Our data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.

Assessment of the structural validity of three foot and ankle specific patient-reported outcome measures

BACKGROUND

The structural validity of the Lower extremity functional scale (LEFS), the Visual analogue scale foot and ankle (VAS-FA), and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) has not been compared earlier in patients after foot and ankle surgery.

METHODS

Altogether 165 previously operated patients completed the foot and ankle specific instruments, the 15D health-related quality of life (HRQoL) instrument, and general health (VAS).

RESULTS

The LEFS, the VAS-FA and the WOMAC had slight differences in their measurement properties. The VAS-FA had the best targeting and coverage. All three foot and ankle measures accounted for mobility and usual activities when compared to the different aspects of generic HRQoL.

CONCLUSIONS

The LEFS, the VAS-FA and the WOMAC have relatively similar psychometric properties among foot and ankle patients, yet the VAS-FA provides the best targeting and coverage.

Validation of the Western Ontario and McMaster Universities Osteoarthritis Index in Patients Having Undergone Ankle Fracture Surgery

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a patient-reported outcome measure (PROM) that is widely used to evaluate the pain, stiffness, and physical function of patients with osteoarthritis of the hip and knee. Although the WOMAC has also been used for patients after foot and ankle surgery, it has not been validated for this purpose. A total of 130 patients with surgically treated ankle fractures completed the WOMAC, Visual Analogue Scale Foot and Ankle (VAS FA), Lower Extremity Functional Scale (LEFS), 15D Health-Related Quality-of-Life Questionnaire (15D), and Visual Analog Scale for General Health (VAS general health) after foot and ankle surgery. The structural validity of the WOMAC was assessed by using Cronbach's α, and convergent validity was tested between the WOMAC and reference outcome measures. Cronbach's α for the index score was 0.98 and 0.95, 0.86, and 0.98 for the Pain, Stiffness, and Physical Function subscales, respectively. The Spearman correlation coefficients were ‒0.84, ‒0.74, ‒0.58, and 0.55 for the VAS-FA, LEFS, 15D, and VAS general health, respectively. The relationships with the VAS-FA, LEFS, 15D, and VAS general health were strong. All relationships were statistically significant (p < .001). The WOMAC provides valid scores for assessing pain, stiffness, and physical function in patients having undergone ankle fracture surgery.