The Lysholm score: Cross cultural validation and evaluation of psychometric properties of the Spanish version
The Lysholm score: Cross cultural validation and evaluation of psychometric properties of the Spanish version
Manuel Arroyo-Morales 0 2
Jose Martin-Alguacil 2
Mario Lozano-Lozano 0 2
Antonio I. Cuesta-Vargas 1 2
Andre? s J. Fern a?ndez-Fern a?ndez 0 2
Jose A. Gonza? lezID 2
Yelverton Tegner 2
Irene Cantarero-Villanueva 0 2
0 Department of Physical Therapy, University of Granada , Granada , Spain , 2 Biohealth Research Institute in Granada (ibs.GRANADA) , Granada , Spain , 3 Sport and Health University Research Institute (iMUDS) , Granada , Spain , 4 Orthopedic Surgery Service Hospital Nuestra Sen?ora de la Salud , Granada , Spain
1 Department of Physical Therapy, Faculty of Health Sciencies, University of M a ?laga, Andalucia Tech, Instituto de Investigacio ? n en Biomedica de M a ?laga (IBIMA), Grupo de Clinimetria , Malaga , Spain , 6 School of Clinical Sciences, The Queensland University of Technology , Brisbane , Australia , 7 Department of Computer Science, University of Sheffield , Sheffield , United Kingdom , 8 Division of Medical Sciences, Department of Health Sciences, Lulea? University of Technology , Lulea? , Sweden
2 Editor: Ce ?sar Calvo-Lobo, Universidad de Leon , SPAIN
Funding: This study takes place thanks to the
additional funding from the University of Granada,
Plan Propio de Investigacio?n 2016, Excellence
actions: Units of Excellence; Unit of Excellence on
Exercise and Health (UCEES). The funders had no
role in study design, data collection and analysis,
decision to publish, or preparation of the
Competing interests: The authors have declared
that no competing interests exist.
The Spanish Lysholm score demonstrated that it is a reliable and valid instrument that can
be used to assess knee function after ligament injuries.
Anterior cruciate ligament (ACL) injuries account for more than 50% of all sustained knee
]. In fact, ACL rupture has epidemiological importance of the first order, since it has
been estimated that annually one out of every 3000 people suffers an ACL tear in the United
States. Focusing on Europe, and more specifically on Spain, this percentage reaches 40% [
Approximately 70% of all ACL injuries are noncontact in nature and 30% are contact injuries
. In addition, ACL lesions have been associated with giving-way episodes and development
of meniscus tears and knee osteoarthritis [
]. One study states that the incidence of meniscus
tears in patients with an ACL lesion is 40% in the first year, 60% in the fifth year and up to 80%
10 years after the injury [
]. It is important to highlight the relationship between the ACL
lesion and the stability and activity of the patient. A third of people with an ACL injury will
compensate well and will successfully return to their activities without surgery. However,
another third could return to recreational activities with effort and a last third may not be able
to return due to instability of the knee, requiring surgery [
]. For all this, it is vitally important
to monitor patients over time after the ACL injury. In addition, the evaluation of the medium
and long-term consequences must be carried out. The Lysholm score was developed to
evaluate function and activity after ACL surgery in terms of stability [
] and graded activity [
has also been validated as an instrument administered by the patient to measure symptoms
and function in patients with various knee injuries [
Cultural adaptations of the Lysholm score have been developed previously in many
languages and countries [
]. Spanish is one of the most widely used languages in the world,
and its use is projected to increase in future years. In the United States alone, there has been a
200% increase in the number of Spanish speakers since 1980 [
]. A Spanish version of this
score could facilitate the comparison of research results from Spanish speaking patients
suffering from knee conditions with data previously reported in the literature [
This study aims to report the psychometric properties of the Spanish version of the Lysholm
Materials and methods
Study design and participants
A psychometric prospective observational study was planned to achieve the objective of the
study. First, a double forward and backward translation [
] of the Lysholm score [
carried out following COSMIN recommendations [
]. A preliminary study was carried out with
35 patients (14 females, age = 22.6?7.0 years) on a waiting list for ACL surgery to evaluate
whether the meaning of the original version was maintained in the Lysholm Spanish version
(S1 Lysholm Spanish Version).
In the second stage, an observational prospective assessment of the psychometric properties
of the Spanish Lysholm score was carried out with 95 native Spanish speakers who were
waiting to undergo surgery for an ACL injury.
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Characteristics descriptive of the participants, as well as demographic data for patients are
shown in Table 1.
The CEIC Hospital Universitario ?San Cecilio? ethics committee from Granada approved this
study (P16-R13). In addition, all participants were informed, both verbally and in writing
about the study, and signed the corresponding written informed consent.
Procedures: Translation and validation
The Lysholm score was translated into Spanish language considering cultural linguistic
adaptations to provide the new version of the questionnaire without language difficulties or other
conceptual misunderstandings (see S1 Lysholm Spanish Version).
Validity understood as the degree to which the instrument measure the construct it
purposes to measure [
] was assessed using content, construct and criterion validity. To
determinate the construct validity and factor structure, maximum likelihood extraction (MLE) with a
priori extraction requirements was employed. The requirements were established in relation to
satisfaction of the following criteria: an eigen value >1.0, screeplot inflection and variance
]. A single factor structure was the result of the exploratory factor analysis [
fit of the confirmatory factor analysis was acceptable if the comparative and normalized fit
indices (CFI and NFI, respectively) were greater than 0.90, with a value of 0.08 deemed the
acceptable root mean square error of approximation (RMSEA) [
Construct validity was assessed through the concurrent comparison of Spanish version of
the Lysholm score with the following two questionnaires: the SF-36 and HKQ questionnaires,
as well as the one leg jump test (OLJT) functional knee test. The SF36, HKQ and OLJT were
used to assess discriminate construct, divergent validity and convergent validity, respectively.
Poor to moderate positive (SF-36 and OLJT) and negative (HFQ) correlations with Lysholm
score were expected. The ceiling and floor effects were analyzed by the percentage of patients
with maximum and minimum scores, respectively.
The Spanish version of HKQ has 7 items focusing on pain, function and symptoms. This
version has shown adequate reliability [
]. The SF-36 is a well-known instrument with 36
questions using a Likert-type scale, which assesses physical and general mental health. The
Spanish version of the SF36 has shown adequate validity [
]. Finally, the vertical jump test
was measured using an infrared photocell mat (Ergo-jump Globus, Codogne, Italy). The best
performance of three trials was used in the analysis [
In this study, several aspects of reliability were assessed, such as test-retest reliability and
internal consistency. Test-retest reliability was studied comparing the Spanish Lysholm score
values at baseline and one week later through the Intraclass Correlation Coefficient (ICC)
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Type 2.1 in a random sub-sample of 42 participants. An ICC > 0.70 considered to be
acceptable test-retest reliability [
]. Internal consistency of the multi-item questionnaire was
assessed by Cronbach?s alpha coefficient [
]. As recommended by Nunnally [
], an expected
Cronbach?s alpha coefficient of 0.7 or grater was considered to be adequate to confirm internal
Feasibility was assessed by missing responses as calculated from the total number of
Sensitivity was studied through the minimally detectable change (MDC90) estimation by
following the Stratford approach [
A sample size of 95 participants was selected in accordance with to ensure stability of the
variance?covariance matrix and required range of 4 to 10 responses for each item [
minimum recommended ratio of ten participants per item was satisfied [
Distribution and normality were assessed using the one sample Kolmogorov-Smirnov test.
Gender differences were assessed using one-way analysis of variance (ANOVA). To verify that
there were no significant differences in sociodemographic and clinical characteristics between
the total sample and the subsample, a t-student or chi square was carried out, as appropriate. A
Pearson?s r correlation coefficient values between 0.3 and 0.7 (0.3 and ?0.7) indicate a
moderate positive (negative) linear relationship [
]. SPSS version 22.0 for Mac OS (IBM, Chicago,
IL) and LISREL version 8.8 for Windows (SSI Inc., Lincolnwood, USA) were selected as the
statistical analysis software for this study [
A Ceiling effect of 12% and a floor effect of 1% were found in the present study. For construct
validity was developed by factor analysis, the correlation matrix for the Spanish version of
Lysholm was determined to be suitable based on the Kaiser-Meyer-Oklin values (0.86) and
Bartlett?s Test of Sphericity (p<0.01). This indicated that the correlation matrix was unlikely to
be an identity matrix and, therefore, suitable for MLE. One factor solution was found to be
accurate when the a-priori criteria were considered, as illustrated in Fig 1.
Only one of the factors had eigen values >1.0 and accounted for 51.5% of the variance. The
item loading for the one-factor solution and the average score for each item are shown in
Table 2. The confirmatory factor analysis showed an acceptable fit with a CFI of 0.98 and NFI
of 0.94 and appropriate error (RMSEA = 0.07; Standardized RMR = 0.05) under the
recommended value of 0.08 [
]. The x2 test for the one-factor model was significant (x2 = 29.58,
df = 20, p < 0.08) (Fig 2).
The convergent criterion validity was tested with correlation between the SF-36 Physical
Functioning Scale and the Lysholm score and it was moderate and positive (r = -0.30 and
p<0.01). There was no significant correlation between the SF-36 Mental Health Subscale and
the Lysholm score (r = 0.38; p = 0.09). The correlation between the HFQ and the Lysholm
score was moderate and positive (r = 0.50 and p<0.01). Finally, the correlation between OLJT
and Lysholm score was moderate and positive (r = 0.59, p<0.01).
Test-retest reliability was high (ICC2.1 = 0.92, 95% CI 0.88 to 0.94, p 0.001). Moreover, there
was an appropriate degree of internal consistency: ? = 0.77 (95% CI, 0.69?0.83). Finally, there
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were no significant differences between total sample and the subsample in clinical and
For the Lysholm score, there were no significant missing responses. No significant gender
differences were found in the item responses.
The measurement error from MDC90 was 3.9%.
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Fig 2. The x2 test for the 1-factor model Lysholm score.
The Spanish version of the Lysholm score showed adequate psychometric properties in
patients with ACL injuries when assessed for reliability, validity, feasibility and sensitivity.
In the absence of a real gold standard, the Lysholm score is considered to be the standard
for assessing ACL injury deficits [
]. With regard to criterion validity the correlations were
] and similar to other validated versions . An unexpected result of this study
was the higher correlation between the Lysholm score and the functional jump test which
could be interpreted as a reflection of a close relationship between this scale and knee
performance in patients with ACL injuries. Feasibility was adequate in this study as there were no
missing data and an acceptable error for MDC90.
Further affirming the level of validity of the Spanish version of the Lysholm score, acceptable
level of ceiling and floor effects were found and higher than those reported in previous studies
], which may be due to the peculiarity of the sample selected in this study (age and type of
sport activity of the sample). With respect to factor analysis, this study revealed a satisfactory
percentage of total variance explained by one factor at 51.5% which guaranteed a correct
confirmatory factor analysis. This one factor structure is in line with the original version .
It demonstrated the same level of test-retest reliability than a previous study [
] and a
higher level of test-retest reliability than other cross-cultural validation studies [
] or a
similar ACL injury population . The degree of internal consistency (? = 0.77) was lower
than in other studies [
], but adequate for health-related studies with patients [
This research was not free of limitations. A number of different validations aspects were not
assessed in this study, including responsiveness and content validity. Also, only one center was
involved. New research is warranted to fill theses gaps of knowledge.
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In conclusion, the Spanish version of the Lysholm score has similar reliability and validity
to the original version and other adaptations.
S1 Lysholm Spanish Version. Spanish version of Lysholm Scale.
Conceptualization: Manuel Arroyo-Morales, Antonio I. Cuesta-Vargas, Jose A. Gonza?lez,
Yelverton Tegner, Irene Cantarero-Villanueva.
Data curation: Manuel Arroyo-Morales, Irene Cantarero-Villanueva.
Formal analysis: Jose Martin-Alguacil, Mario Lozano-Lozano, Jose A. Gonza?lez, Irene
Funding acquisition: Manuel Arroyo-Morales.
Investigation: Jose Martin-Alguacil, Mario Lozano-Lozano, Antonio I. Cuesta-Vargas, Andre?s
Methodology: Jose Martin-Alguacil, Antonio I. Cuesta-Vargas, Andre?s J.
Ferna?ndez-Ferna?ndez, Yelverton Tegner, Irene Cantarero-Villanueva.
Project administration: Antonio I. Cuesta-Vargas, Jose A. Gonza?lez, Irene
Resources: Irene Cantarero-Villanueva.
Supervision: Manuel Arroyo-Morales, Mario Lozano-Lozano, Jose A. Gonza?lez, Yelverton
Tegner, Irene Cantarero-Villanueva.
Validation: Manuel Arroyo-Morales, Yelverton Tegner, Irene Cantarero-Villanueva.
Visualization: Irene Cantarero-Villanueva.
Writing ? original draft: Jose Martin-Alguacil, Andre?s J. Ferna?ndez-Ferna?ndez.
Writing ? review & editing: Manuel Arroyo-Morales, Mario Lozano-Lozano, Antonio I.
Cuesta-Vargas, Jose A. Gonza?lez, Yelverton Tegner, Irene Cantarero-Villanueva.
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Wang W, Liu L, Chang X, Jia ZY, Zhao JZ, Xu WD. Cross-cultural translation of the Lysholm knee score
in Chinese and its validation in patients with anterior cruciate ligament injury. BMC Musculoskelet
Disord. 2016; 17: 436. https://doi.org/10.1186/s12891-016-1283-5 PMID: 27756266
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