Validation of the Brazilian version of the Hip Sports Activity Scale (HSAS) for patients with femoroacetabular impingement: a cross-sectional study

ABSTRACT BACKGROUND: The Hip Sports Activity Scale (HSAS) is a hip-specific instrument for assessing the present levels of physical activity among patients with femoroacetabular impingement (FAI) syndrome. When evaluating treatment outcomes in patients with FAI syndrome, it is necessary to use joint-specific instruments and ones that can evaluate the levels of physical activity in these patients, such as the HSAS-Brazil. OBJECTIVE: To validate the HSAS-Brazil among a group of physically active patients after arthroscopic treatment of FAI syndrome. DESIGN AND SETTING: Cross-sectional research of quantitative and qualitative types using data obtained from July 2018 to October 2019. METHODS: A total of 58 patients of both genders diagnosed with FAI syndrome and who had undergone hip arthroscopy participated in this research. To establish reliability and validity, patients first answered the Brazilian versions of the 12-Item Short-Form Health Survey (SF-12), Nonarthritic Hip Score (NAHS), and HSAS; after a 48-hour interval, they answered the HSAS-Brazil again. RESULTS: For test-retest reliability, the interclass correlation was 0.908 (P < 0.001). The HSAS-Brazil correlated to the NAHS-Brazil (r = 0.63, P < 0.001), as well as the SF-12 (Physical Health) (r = 0.42, P = 0.001). CONCLUSION: The HSAS-Brazil was validated and proved to be a reliable and valid scale to assess sports activity levels in physically active patients with FAI syndrome after arthroscopic treatment.


INTRODUCTION
Over the past decade, femoroacetabular impingement (FAI) syndrome has become a frequent source of hip pain in physically active patients with no radiological evidence of osteoarthritis.
Initially reported by Ganz et al., 1 this event may result from two main configurations of an anatomical abnormality. The cam type of impingement, usually detected in young men, is triggered by an aberrant femoral head-neck junction such that the peripheral radius of the head moving into the acetabulum increases along with the range of motion of the hip. The pincer type of impingement, often seen in aged women, results from contact of the femoral head-neck junction on the acetabular rim as a consequence of acetabular over coverage. Most patients present associated forms of these two arrangements, categorized as mixed impingement. [2][3][4] Sports and physical exercises that demand energetic and repeated flexion and internal hip rotation are often associated with symptomatic FAI syndrome. Throughout internal rotation in flexion, the anterior portion of the head-neck juncture approaches the anterosuperior portion of the acetabular rim. These trigger recurrent tension of the labrum and contiguous cartilage.
FAI syndrome may also injure the cartilage in the hip joint and can be a subjacent reason for osteoarthritis (OA). [5][6][7] Hip arthroscopy is an increasingly performed surgical procedure for youth and mature adults with hip-related pain or dysfunction. Indications for hip arthroscopy mainly consist of frequent pain and abnormal bony morphology related to FAI syndrome, labral tears, chondral imperfections, and ligamentum teres injuries. 8,9 Youth and mature adults undergoing hip arthroscopy greatly desire to return to sports and physical activities. 8 In 2013, Naal et al. 10

OBJECTIVE
This study aimed to validate the Brazilian version of the HSAS (HSAS-Brazil) among a group of physically active patients after arthroscopic treatment of FAI syndrome.

Type of study
This was a cross-sectional study of quantitative and qualitative nature using data obtained from July 2018 to October 2019.

Ethical issues
The ethics committee of our institution approved the study (no.

Description of the Hip Sports Activity Scale (HSAS)
The HSAS determines the levels of physical activity among patients with FAI syndrome. The HSAS consists of nine distinct degrees of physical activity. It has nine topics graded from 0 to 8, with 0 for sedentary persons and 8 for high-performance athletes, without subscales. 10

Study protocol
The study protocol consisted of the following steps: requiring The patients were asked to answer all three questionnaires (first application). Then, after a 48-hour interval, they were asked to answer only the HSAS-Brazil (second application).
Finally, the second application of HSAS-Brazil was responded to using e-mail.

Reliability
The reliability of the HSAS-Brazil was evaluated through intraevaluator test-retest reliability. For this, it was necessary to apply the questionnaires to the same patient at two different times.
These two applications were evaluated using the intraclass correlation coefficient (ICC), ascertaining whether the same effects were reproduced. ICC values less than 0.5 suggest poor reliability; values between 0.5 and 0.75, moderate reliability; values between 0.75 and 0.9, good reliability; and values greater than 0.90, excellent reliability. 14,15 No inter-evaluator assessment was made due to the self-applicable scale characteristic, which does not demand any intermediation from the evaluator.

Validity
The validity of the Brazilian version of HSAS was investigated through construct and content validity. 14,15

Construct and content validity
The validity of the HSAS-Brazil was evaluated by analyzing the strength of the correlation of its scores with those of the NAHS-Brazil and SF-12. The aim was to estimate whether the construct and content validity of the Brazilian version of HSAS was convergent with or divergent from those of the other two questionnaires. To assess construct convergence, correlations between scores were examined among the three questionnaires: the HSAS-Brazil, NAHS-Brazil (total score), and SF-12 (physical health subscale). To assess the divergence of construct, the correlation between the HSAS-Brazil score and SF-12 (mental health subscale) was examined. Spearman correlation coefficient was adopted to assess both the convergent and the divergent construct validity. This generates an indicator that can vary from -1 (perfect negative correlation) to +1 (perfect positive correlation), in which zero represents the lack of correlation between the studied variables. 14-16

Statistical analysis
Descriptive

Patient characteristics
The participants selected were literate, but their level of schooling was only up to high school. Thirteen patients (22.4%) were female. The mean age of the patients was 39.4 years (range, 13 to 61 years) ( Table 1).

Questionnaire results
Score values of each outcome measurement of the HSAS-Brazil, NAHS, and SF-12 questionnaires in the final testing are presented in Table 1.

Construct and content validity
The HSAS-Brazil was moderately correlated with the NAHS-Brazil and weakly correlated with SF-12 physical and mental health subscales ( Table 2). The HSAS-Brazil presented good content validity in patients with FAI syndrome.

DISCUSSION
The HSAS was initially created and validated for Germanspeaking patients with FAI syndrome and then cross-culturally adapted and validated for a North American English-speaking population. 10 The HSAS was also translated and cross-culturally adapted into Swedish and Brazilian Portuguese languages. 11 For content validity (hip specificity), we analyzed the strength of the correlation between HSAS-Brazil and SF-12. We presumed moderate correlations (r = 0.50) with SF-12 (physical health subscale) (convergent validity). To support divergent validity, we presumed low or no correlations (r > 0.30) between the HSAS-Brazil and SF-12 (mental health subscale). 14, 16 Our results showed that   This study also has some limitations. First, the NAHS we used as a reference measure has been construct validated. Hence, the association between the HSAS and NAHS has to be considered supporting content validity (measuring the same content, i.e., hip) but not real construct validity. Another limitation is the absence of responsiveness data for the NAHS-Brazil, which was not evaluated.
When assessing treatment outcomes in patients with FAI syndrome, it is necessary to use not only joint-specific instruments, including the NAHS-Brazil or HOS-Brazil, 13,18 but also instruments that can evaluate the levels of physical activity in these patients, especially the HSAS-Brazil.
The HSAS-Brazil scale is available in Annex 1.

CONCLUSION
The Brazilian version of the HSAS was validated and proved reliable for assessing sports activity levels in physically active patients after arthroscopic treatment of FAI syndrome. Therefore, the HSAS-Brazil can be a beneficial instrument for clinicians and researchers for detailed assessment of patients with FAI syndrome who practice sports and better compare distinct therapies or patient cohorts in terms of sports levels as a prognostic factor.