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Revista Brasileira de Reumatologia

Print version ISSN 0482-5004On-line version ISSN 1809-4570

Rev. Bras. Reumatol. vol.56 no.1 São Paulo Jan./Feb. 2016 

Original articles

Analysis of the psychometric properties of the American Orthopaedic Foot and Ankle Society Score (AOFAS) in rheumatoid arthritis patients: application of the Rasch model

Cristiano Sena da Conceiçãoa  b  * 

Mansueto Gomes Netoa  c 

Anolino Costa Netoa 

Selena M.D Mendesb 

Abrahão Fontes Baptistad 

Kátia Nunes Sáb 

aBiofunction Department, Physical Therapy, Universidade Federal da Bahia, Salvador, BA, Brazil

bMedicine and Health Program, Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil

cMedicine and Health Program, Universidade Federal da Bahia, Salvador, Bahia, Brazil

dBiointeraction Department, Universidade Federal da Bahia, Salvador, BA, Brazil



To tested the reliability and validity of Aofas in a sample of rheumatoid arthritis patients.


The scale was applicable to rheumatoid arthritis patients, twice by the interviewer 1 and once by the interviewer 2. The Aofas was subjected to test-retest reliability analysis (with 20 Rheumatoid arthritis subjects). The psychometric properties were investigated using Rasch analysis on 33 Rheumatoid arthritis patients.


Intra-Class Correlation Coefficient (ICC) were (0.90 < ICC < 0.95; p < 0.001) for intra-observer reliability and (0.75 < ICC < 0.91; p < 0.001) for inter-observer reliability. Subjects separation rates were 1.9 and 4.75 for the items, showing that patients fell into three ability levels, and the items were divided into six difficulties levels. The Rasch analysis showed that eight items was satisfactory. One erroneous item have been identified, showing percentages above the 5% allowed by the statistical model. Further Rasch modeling suggested revising the original item 8.


The results suggest that the Brazilian versions of Aofas exhibit adequate reliability, construct validity, response stability. These findings indicate that Aofas Ankle-Hindfoot scale presents a significant potential for clinical applicability in individuals with rheumatoid arthritis. Other studies in populations with other characteristics are now underway.

Keywords: Rheumatoid arthritis; Disability; Scale; Evaluation; Rasch analysis


Rheumatoid Arthritis is a chronic disabling condition and may result in impairments in functions including musculoskeletal pain, joint stiffness, loss of range of motion, muscular weakness, and joint damage. The disability causes limitations of activities and restrictions in participation.1

The number of clinical studies addressing functioning as a study endpoint in patients with Rheumatoid Arthritis has steadily increased during the past decade.2 It is also important to recognize that measures in Rheumatoid Arthritis have been developed to measure the disease consequences but with little attention to functional aspects.3 Most trials involving Rheumatoid Arthritis have used the Health Assessment Questionnaire (HAQ). This questionnaire is influenced by social factors such as education level and requires a major change in score to represent a significant functioning change in the patient.4,5 The HAQ has lower consistency compared with other measures such as C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), number of tender joints and patient/physician global assessment.6 Furthermore, HAQ is a tool with considerable “celling-effect” and thus are unable to detect worsening after reaching a maximum score.7

Foot impairment occurs in 85–100% of Rheumatoid Arthritis patients and erosive synovitis is the primary reason for high levels of pain and/or disability.8,9 Others standardized method more specifically to assess the disability caused by the dysfunction of the feet and gait in Rheumatoid Arthritis patients is necessary for practice clinical. In 1994, the American Orthopaedic Foot and Ankle Society (AOFAS) developed rating scales for the ankle-hindfoot, midfoot, hallux metatarsophalangeal–interphalangeal, and lesser metatarsophalangeal–interphalangeal sites allowing them to be applied to different kinds of injuries and treatments.10 AOFAS clinical domains were designed to assess foot or ankle problems and are very widely used for this purposed despite the limited evidence, until now, for their reliability and validity in other circumstances.11

Rehabilitation programs priorities will be based increasingly on evidence of the cost-effectiveness of interventions on functioning. The reliability of such evidence is substantially dependent on the validity of the methods used to assess health and functioning status. In study of Rodrigues et al.,12 the AOFAS was translated and culturally adapt for Brazilian Portuguese and its reproducibility and validity were tested for patients with clinical diagnostic of ankle or hindfoot injuries. Up to this date, we do not know of their validation for patients with Rheumatoid Arthritis in Brazil. In the current study, we have tested the reliability and validity of AOFAS in a sample of Rheumatoid Arthritis patients.

Materials and methods


The study comprised a convenience sample including 33 patients from Arthritis Rheumatoid Service of the Bahia School of Medicine and Public Health. Patients were eligible for inclusion if they had more than 18 years and have a diagnoses of Rheumatoid Arthritis by a rheumatologist satisfying the American Rheumatism Association revised criteria for Rheumatoid arthritis13 and demonstrated the ability to walking with or without assistive devices. Patients were excluded if had neurologic dysfunction, cognitive deficits on the Mini Mental State Examination,14 skin lesions, surgery in the lower limb, pregnants or in rheumatoid arthritis remission stage (≤2.6 on DAS-28).15 In about 25% of cases Rheumatoid Arthritis is intermittent with periods of remission and this stage may generate a confounding effect and overestimate the results.

The study was approved by the Research Ethics Committee of the Estacio of Bahia University Center, n. 657.528 and the participants signed informed consent forms.

Procedures and instrument of measure

The questionnaire AOFAS is composed of nine items, distributed over three categories: pain, functional aspects and alignment. Patients were asked to rate the pain on a scale of 0–40 points. Function was calculated as the total score of activity limitations (0–10), maximum walking distance (0–5), walking surface (0–5), gait abnormality (0–8), sagittal motion (0–8), hindfoot motion (0–6), and ankle-hindfoot stability (0–8). Alignment was rated from 0 to 10 points (good, fair, poor), giving a total score of 100 points.10,12 Sagittal and hindfoot motion were physical examination of joint motion measured by trained professional with goniometer.

In stage one, the AOFAS were submitted to test–retest reliability analysis by two trained professionals to use the instrument. To test their reliability, the AOFAS was applied twice with a three to five-days interval to the first 20 individuals with Rheumatoid Arthritis included in the study. In stage two, the Brazilian version of AOFAS was measured using Rasch analysis.

Statistical analysis

Descriptive statistics were utilized to characterize the sample. Intra-class correlation coefficients (ICCs) were used to assess the intra- and inter-rater reliabilities. The ICC was chosen in preference to the Pearson correlation which may overestimate reliability.16 All analyses were performed with SPSS for Windows (SPSS Inc., Chicago, IL, USA) and the significance level were set at 0.05.

Rasch techniques have been shown to successfully reduce the number of items on questionnaires, a particularly important issue when developing questionnaires for disabled populations.17Rasch analysis is a probabilistic model widely used in the field of rehabilitation to evaluate the psychometric properties of scales.18 Is based on a probabilistic relationship between item difficulty and person ability, with the difference known as the functional reserve or functional ability.19

Item fit statistics are employed in the assessment of unidimensionality, which demonstrates whether the questionnaire or subscale is measuring a single concept. Values such as MnSq and t in two formats: infit and outfit was performed using software Winsteps.20 The infit statistic is sensitive to the variation of scores representing the subject's abilities, and the outfit statistic reflects the occurrence of unexpected responses. These values are used to determine whether the items fit with the unidimensionality concept, with values of MnSq = 1 ± 0.4 associated with t = ±2 being acceptable. The condition in which more than 5% of the items of a scale exhibit erratic scores indicate that the corresponding combination of items is not able to measure a unidimensional construct.21,22

The Rasch model further includes the person and item separation indices and the satisfactory test divides the subjects into at least three ability levels: low, medium, and high.23 The estimated values of reliability to calibrate the measures must be >0.80.24


Sample characterization

Thirty-three females with rheumatoid arthritis were evaluated with a mean age of 53 ± 10.9 years (ranging from 30 to 75). Demographic and clinical characteristics of the subjects are reported in Table 1.

Table 1 Subjects demographic and clinical characteristics. 

n = 33
Age (years) 53.0 (10.97) [30 – 75]
Years post rheumatoid arthritis 12.21 (7.54) [5 – 19.9]
Body mass index, kg/m2 25.7 (5.52) [19.98 – 41.66]
DAS 28 5.1 (0.9) [3.5 – 7.3]
Disability (HAQ)+ 1.68 (0.65)
White 4 (12.2%)
Black 15 (45.4%)
Brown 14 (42.4%)
Level of physical activity
Sedentary 28 (84.8%)
Sporadic practitioner 5 (15.2%)
Use of antiflamatory drug 33 (100%)

Values are mean (standard deviation) [range] or frequency (percentage)

Test–retest reliability

Table 2 gives the ICC values for the intra- and inter-rater reliabilities. As can be noted, significant and adequate values of intra- (0.90 < ICC < 0.95; p < 0.001) and inter-rater (0.77 < ICC < 0.91; p < 0.001) reliabilities were obtained. In the present study, the application of the AOFAS lasted 5.5 min on average, ranging from 4 to 7 min.

Table 2 Intraclass coefficients (ICC) Values for the intra and interrater reliability of domain and total score AOFAS. 

Intra Inter
AOFAS – pain 0.90 * 0.77 *
AOFAS – function 0.92 * 0.81 *
AOFAS – total 0.95 * 0.91 *

*p ≤ 0.001.

Rasch analysis

In the AOFAS, the calibration stability of the items and individuals was 0.96 and 0.80, respectively. Results of Rasch's analysis are presented in Table 3, in which the values of the calibration or difficulty of items, MnSq and t (infit and outfit) are individually reported. The items are contained in decreasing order of difficulty. Item 9 “Alignment” was the most difficult, and item 5, “Gait abnormality”, was the easiest one.

Table 3 Calibration of AOFAS items. 

Calibration Infit Outfit
Item MnSq t MnSq t
9. Alignment 57.11 0.96 0.0 0.61 −0.9
1. Pain ** 55.96 0.35 −3.0 0.48 −1.6
4. Walking surfaces 54.07 0.79 −0.8 0.94 −0.1
8. Ankle-hindfoot stability * 50.05 1.62 2.4 1.49 2.0
3. Max continuous walking distance 48.98 0.61 −2.0 0.64 −1.8
7. Hindfoot motion 48.77 0.92 −0.3 0.91 −0.4
2. Activity limitations 46.50 1.02 0.2 1.03 0.2
6. Sagittal motion 46.06 1.30 1.3 1.17 0.7
5. Gait abnormality 42.48 1.31 1.2 1.34 1.4

*Erratic item: MnSq > 1.4 and t > 2.

**Predictable item: MnSq < 0.6.

Out of the 9 items of the questionnaire, 1 (11.1%) did not fulfill the expectations of the model: numbers 8 (ankle-hindfoot stability [anterior drawer, varus-valgus stress]) demonstrated MnSq > 1.4 and t > 2.

The individual separation index was 1.9, which indicates that the items distributed the subjects among three ability levels. The item separation index was 4.75, which corresponds to approximately six levels of difficulties.

Fig. 1 displays a map that depicts the continuum of the difficulty of the items on the left and the sample ability continuum on the right. Most items had medium difficulty, whereas items allowing the assessment of individuals with very high or very low ability were lacking.

Fig. 1 Map representing the distribution of subjects anditems from equilibrium measured by the AOFAS. The numbers on the left represent the test items, and thesubjects are on the right (the number identifies the age). 


The AOFAS clinical rating system consists of four site-specific scales that enable a focus on target sites or diseases.10,12 Since the AOFAS was developed in English, it was necessary to carry out a transcultural adaptation of the questionnaire (i.e., a literal translation is not enough), as well as an evaluation of the psychometric properties of the population where it was supposed to be used.24

The Rasch analysis performed in the present study showed a calibration stability of the items and individuals in both investigated tests, indicating that the measures were stable and reproducible. The value found for the index of separation of the sample's individuals (1.9) indicates that they were divided into three levels of ability: low, intermediate, and high.

The Rasch analysis detected one item (11.1%) with erratic behaviors (number 8) which was superior to what is recommended (5%) to indicate that the instrument measured a unidimensional concept. In this item, “Ankle-hindfoot stability”, the subject responds if considering your ankle stable or unstable, then there are only two score possibilities: 8 (stable) and 0 (unstable). While the further items of AOFAS have at least 03 possible answers, a fact that stratifies better and leaves clearer the possibilities for response: In addition, Rheumatoid Arthritis is a disease that affects the feet of patients in 85 a 100% of cases; recurrent synovitis damages the tissues and the stability of the ankle-hindfoot, that worsens with advancing disease.8 Thus it proved possible to note that individuals with longer disease claimed his ankle unstable and those with shorter disease qualified as your ankles stable.

The results of the present study show that the AOFAS exhibit a satisfactory ability to detect subtle disability deficits, thus making the distinction among persons with Rheumatoid Arthritis disability. The presence of very easy or very difficult items constitutes an advantage for the instrument. Fig. 1 items/map shows the continuous of disability by questionnaire items. This is a representation of the relationship between examined individuals Rheumatoid Arthritis severity with disability levels discriminated by scales items. We can see some items at the top, with no alignment to any individual, which means that these items measure a very high disability degree and no individuals existed in this sample with a high level of disability, the lack of individuals with high level of disability must be due to the established criterion of patients walk independently.

In this paper, we have been able to demonstrate good and excellent values of inter and intra-rater reliabilities and validity of the AOFAS. These findings provide strong support for the reliability and validity of the AOFAS measures, suggesting that they perform well in patients undergoing Rheumatoid Arthritis. The ICCs are shown as the preferred and most adequate indices for reliability analyses of interval ratio data, since they represent both correlations and levels of agreement.23,24 According to Portney and Watkins,25 ICC values of ≥0.75 are indicative of acceptable reliability and those below 0.75 are considered poor to moderate.

As found in the present results, for both intra- and inter-rater reliabilities, the ICC values were considered to be acceptable. These results are consistent with those of the study by Rodrigues et al.,12 which assessed the values of intra and inter-rater reliabilities of the AOFAS in patients with clinical diagnostic of ankle or hindfoot injuries and found values of ICC greater than 0.9.

Although our sample shows ability to read, since most of the volunteers had completed high school education, we believe that because the subjective component of the Brazilian version of the AOFAS ankle-hindfoot scale is administered as interviews, potential interpretation errors are minimized.26

For further studies, it is important that the AOFAS be applied with other samples, so that the validity of the instrument can be more broadly examined. If in other kinds of samples from a number of erratic items above 5% persists, modifications to the AOFAS scale in item 8 are warranted, for example increasing the number of possible answers followed by studies on the modified version.


The instrument was shown to be clinically useful for the Rheumatoid arthritis sample assessed in this study. However caution must be exercised when interpreting the results, and the answers pattern must be observed, especially for items 8 regarded as erratic item.


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Received: August 26, 2014; Accepted: December 1, 2014

*Corresponding author. E-mail: (C.S. Conceic¸ão).

Conflicts of interest

The authors declare no conflicts of interests.

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