This study describes the process of cross-cultural adaptation and validation of an Italian version of the AFAQ for Italian-speaking athletes with current musculoskeletal injuries. The AFAQ-I showed acceptable psychometric properties, as assessed with classic test theory methods.
The cross-cultural adaptation procedure followed guideline recommendations [18, 19] and assured an adequate semantic, idiomatic and conceptual equivalence between the original and the Italian version (a prerequisite for data comparability across countries). Any refinement was discussed by the Expert Committee and agreed upon with the original author. Further, the in-field test confirmed the comprehensibility and appropriateness of the translated questionnaire for the target population.
The questionnaire showed good acceptability, and was well understood and easy to self-administer. Factor analysis revealed a 1-factor structure of the scale, in line with the original authors . The main factor explained more than half of variance in the data, confirming the substantial unidimensionality.
Cronbach’s alpha showed a value acceptable for group-level comparisons, similar to that found by the original developers (0.78 vs. 0.80) , while in a Pakistani study on female medical students it was higher (0.90) . The analysis of the inter-item and item-rest correlations showed that items are, on average, reasonably homogeneous without being isomorphic with each other. However, the rather low values of items #4 (“I am not sure what my injury is”), #6 (“I am not comfortable going back to play until I am 100%”), and #9 (“I worry if I go back to play too soon I will make my injury worse”) suggest that these three items measure something slightly different from athlete fear-avoidance. Indeed, a close inspection of these three questions shows that item #4 seems to assess “unawareness of the type of injury”, while the answers to items #6 and 9 could stem from distinct protective attitudes and behaviors, including hypervigilance .
An excellent test-retest reliability emerged between the scores at baseline and after a 10-day interval. To the best of our knowledge, this is the first report of this AFAQ property in the peer-reviewed literature. Accordingly, the AFAQ-I showed a relatively low measurement error. Thus, the MDC95 was just 11% of the score range. This finding indicates, at 95% confidence level, that a change of at least 5 points in the individual score is needed to reflect a true change in athlete fear-avoidance thoughts (i.e. outside measurement error).
As for construct validity, the AFAQ-I showed the expected correlations with “legacy” tools measuring pain intensity, fear-avoidance, and catastrophizing . The correlation of the AFAQ-I with the NPRS indicates a moderate link between the degree of fear-avoidance beliefs and reported levels of pain intensity. This finding is in line with two other studies examining similar issues in athletes [9, 10]. However, due to the cross-sectional design of the current study, no causal relationship can be established between the two variables.
Consistent with the cognitive-behavioural model of fear-avoidance , the AFAQ-I scores were also associated with measures of similar constructs such as fear of movement and catastrophizing. This result supports the scale’s construct validity and suggests that individuals who persistently focus on maladaptive thinking after an athletic musculoskeletal lesion tend to be more avoidant and catastrophizers also in other stressful life events, as also found in previous studies [10, 13].
However, as suggested by the scale’s developers , the AFAQ contains sport-specific items, so the expected relationship with FABQ subscales cannot be strong. Higher correlations were found with FABQ-PA than with FABQ-W, because the items included in the latter subscale are work-related and less relevant for athletes than those related to general physical activity. The level of these correlations in our study (ρ = 0.40 with the FABQ-PA, ρ = 0.34 with the FABQ-W) was a little higher but similar to that reported by the original developers (ρ = 0.35 with the FABQ-PA; ρ = 0.14 with the FABQ-W) .
Interestingly, the AFAQ-I presented a quite good correlation with the PCS (ρ = 0.59). This in line with the findings of two previous studies [9, 15], indicating that the issues assessed in AFAQ parallel those examined by a pain catastrophizing measure .
All the above results suggest the importance of an adequate understanding of the psychological reactions in these particular patients. Also, they indicate that the AFAQ (and fear-avoidance model) may be useful to individually tailor both cognitive-behavioural and physical interventions within multimodal treatments for athletes with musculoskeletal injuries who have high levels of fear-avoidance beliefs [16, 28, 29]. Similar results were already found in non-athlete populations where other measures of pain-related fear were used [30, 31]. Thus, there is need for prospective studies in athletes with recent musculoskeletal injuries, to examine the sequential relationships between AFAQ-I and rehabilitation recovery, as well as the effects of cognitive-behavioral interventions on those with high levels of fear-avoidance [10, 28, 32].
Overall, our results indicate that the AFAQ-I has acceptable psychometric properties when used for the clinical assessment of athletes recovering from musculoskeletal injuries. However, we recommend further analyses (using advanced factor analytic and item-response-theory methods) in order to examine better the structural validity and additional metric properties of the scale at item level. This includes how well each item performs in terms of its relevance for measuring the underlying construct, the amount of the construct (i.e. fear-avoidance beliefs) targeted by each item, possible redundancy of items, and the appropriateness of the response options. Such advanced knowledge would enable to further optimize the content coverage and technical quality of this tool through selection of the most convenient type and number of items and response categories.
Our study has some limitations. First, it is a cross-sectional study so we could not assess the responsiveness or minimal important change of the AFAQ. Second, the study was based on self-administered questionnaires, and thus the relationships with clinical, functional and instrumental tests were not considered. Third, correlations between these measures of pain-related fear and quality of life questionnaires still need to be analysed. Fourth, our study was restricted to university athletes with post-acute musculoskeletal injuries and it is uncertain how well these findings may reflect other injured individuals or athletes with past (not present) injury.