34 Chapter 2 A notable area of discussion revolved around the classification of certain outcome measurement instruments. For example, the use of co-interventions as outcome measurement instrument was viewed by some as essential to proper methodology, and thus not essential to a specific COS, whereas others believed it should be included in the COS-AT. Similarly, the relevance of pain location was debated. While some considered its assessment crucial in clinical diagnosis and argued it should be a part of diagnostic criteria rather than the COS-AT, others disagreed and voted for this outcome measurement instrument as part of the COS-AT. DISCUSSION This is the first core outcome set for Achilles tendinopathy (COS-AT). Experts (patients, clinicians and researchers) agreed on 4 outcome measurement instruments to be part of the COS-AT and 6 outcome measurement instruments were provisionally endorsed. The 4 endorsed outcome measurement instruments are 1) the VISA-A questionnaire, 2) the single-leg heel rise test, 3) evaluating pain after activity using a VAS (0 -10) and 4) evaluating pain on activity/loading using a VAS (0-10). These outcome measurement instruments cover the domains pain on activity/loading, physical function capacity and disability, which means that the other identified core domains7 (patient overall rating, participation, function, quality of life, psychology, and pain over a specified time frame) are not covered by outcome measurement instruments of the COS-AT. The in-person consensus meeting highlighted the need for more detailed specification of the evaluation of pain after activity, where clarity is lacking on the exact timing of measurement. When this outcome measurement instrument is used in clinical trials, it should be explicitly stated when it is measured (e.g. an hour after activity or a day after activity) and what ‘activity’ exactly entails (e.g. walking or running). While current pain assessments in the COS-AT utilize the VAS, we suggest the Numerical Rating Scale (NRS) can also be used as a potentially more practical alternative, as the panel considered both measures largely interchangeable when used consistently on a 0-10 scale. It is possible to use a 0-100 scale if this is deemed more appropriate in certain contexts. In that case, the scores could be converted for meta-analysis. During the meeting, there was also considerable debate as to whether the use of cointerventions and the location of pain should be part of the COS-AT. Voting results showed 64% being opposed to their inclusion. Upon reviewing these results, we believe it’s crucial to emphasize that both measures are significant for sound methodology and diagnostic assessment respectively. However, their suitability as part of the COS-AT warrants further consideration and a considerable degree of reservation.
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