Cross cultural adaptation, reliability and validity of the Polish version of the Cumberland Ankle Instability Tool

Abstract

Purpose: The aim of this study was to develop a Polish version of the Cumberland Ankle Instability Tool (CAIT-PL) questionnaire and perform CAIT-PL cultural adaptation with assessment of its psychometric properties.

Methods: The original CAIT was translated into the Polish language using standard guidelines. The CAIT-PL was completed on 2 occasions by 105 participants both with and without a history of ankle sprains. Psychometric evaluation of CAIT-PL included an assessment of internal consistency, test-retest reliability, standard error of measurement, convergent and construct validity.

Results: The CAIT-PL was successfully translated and adapted into Polish culture with satisfactory internal consistency (Cronbach’s α = 0.83) and adequate test-retest reliability resulting in ICC_2,1 = 0.89 (95% CI: 0.84–0.92). Measurement error was low (SEM = 0.76 and MDC = 2.10). Convergent validity of the CAIT-PL ranged from weak to strong using Spearman’s correlation coefficient between CAIT-PL and FAOS subscales (r = 0.39–0.67; p < 0.05). Construct validity was confirmed.

Conclusion: The Polish version of the Cumberland Ankle Instability Tool is a valid and reliable questionnaire for assessment of functional ankle instability among the Polish population.

IMPLICATIONS FOR REHABILITATION

• The Cumberland Ankle Instability Tool is broadly used to assess functional ankle instability and its severity.

• The Polish version of Cumberland Ankle Instability Tool (CAIT-PL) showed adequate psychometric properties.

• The CAIT-PL is ready to be used in clinical practice and for research applications in Polish-speaking population.

Keywords:

• CAIT
• ankle instability
• polish version
• cultural adaptation
• validity and reliability

Introduction

Ankle sprains are one the most common injuries among young and physically active people. In epidemiological studies, it has been suggested that ankle sprains account for as much as 25–30% of all sports injuries [1, 2]. Although the symptoms associated with ankle sprain usually resolve within a short period of time, it is estimated that approximately 30% or more people who experience a first-time ankle sprain will develop other symptoms. These are pain, loss of function, subjective feeling of instability and subsequent recurrent injuries leading to long-term dysfunction called Chronic Ankle Instability (CAI). The International Ankle Consortium provided a short definition of CAI focused on repetitive episodes of “giving way” and self-reported dysfunction [3–6]. CAI can be separated into mechanical and functional ankle instability. Mechanical ankle instability refers to ankle ligamentous laxity, which can be assessed mainly during physical examination using anterior drawer and talar tilt tests. In addition to structural joint dysfunction, people with mechanical ankle instability may exhibit functional symptoms. On the other hand, Functional Ankle Instability (FAI) is not due to ankle joint laxity but appears to be related to neuromuscular deficits [7, 8]. To evaluate symptoms of FAI in clinical settings, balance tests, muscle strength tests and Patient Reported Outcome Measures (PROMs) are applied.

PROMs are the patients’ subjective perception of their health condition. PROMs are inexpensive, highly efficient and reliable, which makes them widely used in research and clinical practice [9]. PROMs can help clinicians and researchers set a diagnosis or measure intervention effects along with physical examination and medical imaging. There are many foot and ankle questionnaires, but their majority are used to assess general limitations according to foot and ankle regions. To assess the severity of symptoms in conditions such as ankle instability, disease-specific PROMs are needed because they include questions about key features in the particular disease. Only three instruments have been recommended by the International Ankle Consortium [6] as specific for symptoms of CAI by including questions about self-perceived instability during certain activities and ankle “giving way” incidents. These are the three following questionnaires: Ankle Instability Instrument (AII) [10], Identification of Functional Ankle Instability (IdFAI) [11] and the Cumberland Ankle Instability Tool (CAIT) [12].

The CAIT questionnaire is one of the most widely used PROMs for CAI patients. It was developed in the English language to evaluate severity of functional ankle instability and aids treatment decisions during the management of CAI. The original CAIT has been culturally adapted into multiple languages: Dutch [13], French [14], Greek [15], Chinese [16], Japanese [17], Taiwan-Chinese [18], Persian [19], Brazilian-Portuguese [20], Korean [21], Urdu [22] and even 2 Spanish versions [23, 24]. All listed versions of the CAIT have demonstrated good psychometric properties and are broadly applied in clinical practice and research among different cultures.

To the best of authors’ knowledge, there is no Polish version of the questionnaire specific to symptoms of CAI. This fact significantly hinders the diagnosis and treatment of chronic ankle instability in the Polish population. Therefore, the aim of this study was to develop a Polish version of the CAIT questionnaire, perform CAIT-PL cultural adaptation with assessment of its reliability and validity.

Methods

Ethical approval

All procedures were performed in accordance with the 1964 Helsinki declaration and its later amendments. The approval of the Bioethics Committee at the Regional Medical Association in Krakow (No. 11/KBL/OIL/2022) was obtained for this study.

Participants

Participants of this study were students both without a history of ankle trauma (control group) as well as individuals who had reported at least 1 significant ankle sprain (instability group). The division of groups was adapted from Greek [15] and Persian [19] CAIT validation studies. The inclusion criteria were as follows: i) at least 18 years of age and ii) speaking Polish as one’s first language. The participants were excluded if they had experienced any ankle injuries less than 3 months prior to study or if they had undergone lower limb surgery in the past. All the participants were informed about the research protocol in detail and provided their written informed consent to participate in the study. Sample size determination was based on guidelines from Terwee et al. [25] and it requires a minimum of 100 participants to measure questionnaire’s internal consistency, for construct validity subgroups of 50 participants are needed.

Study procedure

This study consisted of two main parts: (1) The CAIT translation and adaptation into the Polish culture, (2) psychometric evaluation of the Polish version of the CAIT. These parts are described in detail in the following sections. Each participant was supposed to individually fill out a paper version of the CAIT-PL questionnaire twice, with a 1-week interval between interventions. After that time, none of the participants reported changes regarding their health status. Both administrations were performed in the same environment at the University. In addition to the CAIT-PL questionnaire, participants also filled out the Foot and Ankle Outcome Score (FAOS) and provided demographic (age, sex) and anthropometric data (body mass, body height) as well as a history of ankle sprain incidents. We invited 118 individuals for participation in this study. Results were excluded from the analysis when a participant failed to complete the questionnaire twice (8%) or left missing answers (3%). Finally, 105 participants (89%) filled out both questionnaires correctly and their results was considered for psychometric evaluation of CAIT-PL.

Translation and cultural adaptation procedure

For the translation permission was given from the original questionnaire’s developer (Dr Hiller). Cross-cultural adaptation of the Polish version of CAIT was performed according to Beaton’s guidelines using forward-backward translation [26]. This process included the six following steps.

Step I (Initial translation) - Original English version of the CAIT was translated into Polish by 2 independent bilingual translators, with Polish as their mother tongue (one with medical background and the other without medical or clinical background). Each translator produced his own Polish version of the questionnaire.

Step II (Synthesis of the translations) - Both translators met to synthesise their versions into 1 common translation, resolving any discrepancies.

Step III (Back translation) - The synthesised version from the previous step was sent to a backward translator (English native speaker), who was totally blind to the original CAIT version. The English native speaker translated the questionnaire back into the English language. This step allows to highlight unclear wording in the translations.

Step IV (Expert committee) - All the translators, language specialists, methodologist and physiotherapist participated in the meeting of experts. Every version of the previous translations, original CAIT questionnaire and written reports were analysed by the committee. A consensus was reached at the meeting, which resulted in the creation of a pre-final Polish version of the CAIT questionnaire.

Step V (Test of the pre-final version) - The pre-final CAIT-PL was administered to 10 people with varied educational levels to confirm the comprehensibility and syntax of all questions.

Step VI (Development of the final CAIT-PL version for psychometric evaluation) - No significant changes were made to the post-pilot version of the questionnaire, which allowed for the creation of the final CAIT-PL version. The CAIT-PL questionnaire is available in Appendix A.

Instruments

The Cumberland Ankle Instability Tool

The CAIT questionnaire contains 9 items and is aimed to measure severity of ankle instability with a total score ranging from 0 - indicating extreme functional ankle instability to 30 points - indicating a stable ankle. CAIT items comprise 3 to 6 answers, while the subjects can choose only 1 best describing their ankle. The total CAIT score (CAIT_TS) is expressed as the sum of points from 9 questions. CAIT allows to separately evaluate the right and left ankle during one sitting. Developers of the CAIT calculated cut-off value as 27.5 points, which means that ankles with scores below that value are considered as unstable [12]. However, the CAIT cut-off values differ among other studies and populations from 11.5 points in a Dutch study [13] to ≤25 points in a recalibrated English version [27].

Foot and Ankle Outcome Score

The FAOS questionnaire contains 42 questions divided into 5 subscales: Pain (9 items), Symptoms/Stiffness (7 items), Activities of Daily Life (17 items), Sport and Recreation (5 items) and Ankle-Related Quality of Life (4 items). FAOS is used to assess functional limitations caused by foot or ankle dysfunctions [28]. To answer each of the questions, 5 boxes were used (“no,” “mild,” “moderate,” “severe,” “extreme”). Each item is scored from 0 to 4 points. Results of each FAOS subscale are the sum of the item’s points divided by the maximum possible number of points expressed in percentages. FAOS_TS was calculated as the mean of all subscales.

Statistical analysis

Statistical analysis was performed using PQStat v. 1.8.4 software (PQStat Software Company, Poland). Differences between groups were evaluated using χ² test (categorical variables) or independent samples t-test (numerical variables). Data distribution was checked using the Shapiro–Wilk test. Homogeneity of variance within the groups was tested via Levene’s test.The probability of Type I error below 0.05 was adopted as the level of significance.

Psychometric evaluation

Following the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist, the internal consistency, test-retest reliability, measurement error, minimal detectable change, construct and convergent validity of the CAIT-PL were assessed [29].

Internal consistency was determined using Cronbach’s α. A satisfactory internal consistency rating is provided when Cronbach’s α is between 0.70 and 0.95. In addition, internal consistency was assessed based on Spearman’s correlation coefficient between each question and total score. Correlations were considered negligible when ≤0.20, weak between 0.21 and 0.40, 0.41 to 0.60 as moderate, 0.61 to 0.80 strong, and very strong when ≥0.81 [30].

Test-retest reliability of the CAIT-PL_TS was evaluated with the two-way model single measure intraclass correlation coefficient (ICC_2,1) and 95% confidence intervals. ICC_2,1 was considered acceptable when ≥0.70 [25].

Standard error of measurement (SEM) and minimal detectable change (MDC) of CAIT-PL_TS was calculated using the following formulas: $$\mathit{SEM}=\mathit{standard} \mathit{deviation} \mathrm{of} \mathit{difference} \mathit{between} \mathit{test} \mathit{and} \mathit{retest}\times \sqrt{1-\mathit{ICC}}.$$ $$\mathit{MDC}=\mathit{SEM}\times 1.96\times \sqrt{2}.$$

According to COSMIN Delphi study in 2010, “criterion validity” was defined as adequate reflection of “gold standard” [31]. Due to the fact that there is no “gold standard” for PROM’s instruments, convergent validity was assessed in terms of consistency of the CAIT-PL_TS in relation to each of the 5 FAOS subscales and FAOS_TS. FAOS was chosen because it was already validated as a measure of functional status in individuals with chronic ankle instability [32] and previously used to validate other CAIT cross-cultural adaptations [13, 22]. Moreover, FAOS was endorsed by International Ankle Consortium as general self-reported foot and ankle function questionnaire in patients with chronic ankle instability [6].

To evaluate construct validity hypotheses testing was performed. If at least 75% of the previously formulated hypotheses were confirmed, the rating for construct validity is positive [25]. Before data collection we hypothesized moderate or strong correlations between CAIT-PL_TS and each of 5 FAOS subscales as well as FAOS_TS. Another of the hypotheses was that CAIT-PL has an appropriate discriminative power (p < 0.05) which allows to distinguish between, “known groups” (instability and control).

Results

Translation process

The systematic process according to the guidelines proposed by Beaton et al. [26] was successfully completed. This was not simple word-to-word translation. It required cultural adaptation of the CAIT to Polish maintaining each item’s semantic, conceptual and true meaning. We have asked the developer of the CAIT Dr Claire Hiller about the 2 following phases: Item 6 - “hop from side to side” and Item 8 - “roll over on my ankle (or twist)” to confirm the original intentional meaning of these questions. “Hop” means that it is performed on one leg. That was revealing, because in the Polish language, this word’ does not differentiate whether it is a one- or two-legged activity. “Rolling over on ankle” is a term not widely used in our culture, and the given synonym “twist” means “sprain” in Polish. However we could not use the “ankle sprain” phrase because it is a definition of acute injury resulting in pain, swelling and other functional limitations. Finally, we decided to choose the Polish equivalent of the phrase “giving way” due to confirmation from Dr Hiller that this is of the same meaning as “rolling over.” No other major difficulties were reported during translation, the remaining details of the CAIT-PL were set during the committee of experts. After a pilot study with 10 participants, no significant changes were made because the questionnaire was easy to understand for all respondents.

Study population

Descriptive statistics of study population are presented in Table 1. From 105 subjects who completed correctly 2 questionnaires, 52 participants (49%) had at least one ankle sprain and 35 of them (33%) had more than one sprain in the same ankle.

Table 1. Descriptive statistic (mean (SD)) of study population.

	Total sample n = 105	Instability group n = 52	Control group n = 53	p
Gender, n (%)				0.50
Female	62 (59.0)	29 (55.8)	33 (62.3)
Male	32 (41.0)	23 (44.2)	20 (37.7)
Age [years]	20.3 (1.4)	20.3 (1.4)	20.2 (1.5)	0.59
Body mass [kg]	67.0 (12.0)	66.6 (11.5)	67.4 (12.5)	0.53
Body height [cm]	171.6 (8.9)	172.1 (9.7)	171.1 (8.0)	0.17
BMI [kg/m^2]	22.6 (2.6)	22.4 (2.4)	22.9 (2.9)	0.16
CAIT Total score [pt.]	25.5 (4.8)	24.6 (5.5)	27.5 (3.0)	<0.05*
Ankle sprain, n (%)			N/A	N/A
0	53 (50.5)	0 (0.0)
1	17 (16.2)	17 (32.7)
>1	35 (33.3)	35 (67.3)

n – number of observation, p – probability of type I error, *statistically significant difference, N/A – not applicable.

Discriminative power

Participants with a history of ankle sprain (instability group) presented with significantly lower CAIT-PL_TS compared to control group (p < 0.05). It means that CAIT-PL can differentiate between functionally stable and unstable ankles. Results are presented in Table 1.

Internal consistency

The CAIT-PL showed satisfactory internal consistency for the entire questionnaire (Cronbach’s α = 0.83). Spearman’s correlation coefficients between the CAIT-PL items and CAIT-PL_TS ranged from moderate to very strong (r = 0.43–0.74). Results are presented in Table 2.

Table 2. Internal consistency of CAIT-PL.

	Cronbach’s α	Total score – item correlation^r	p
Item 1 (I have pain in my ankle)	0.81	0.74	<0.05*
Item 2 (My ankle feels unstable)	0.79	0.73	<0.05*
Item 3 (When I make sharp turns, my ankle feels unstable)	0.80	0.70	<0.05*
Item 4 (When going down the stairs, my ankle feels unstable)	0.82	0.51	<0.05*
Item 5 (My ankle feels unstable when standing on one leg)	0.82	0.68	<0.05*
Item 6 (My ankle feels unstable when)	0.82	0.62	<0.05*
Item 7 (My ankle feels unstable when)	0.80	0.74	<0.05*
Item 8 (Typically, when I start to roll over (or “twist”) on my ankle, I can stop it)	0.84	0.51	<0.05*
Item 9 (After a typical incident of my ankle rolling over, my ankle returns to normal)	0.83	0.43	<0.05*
Total score	N/A	N/A	N/A

α – Cronbach’s α if item was deleted, r - Spearman correlation coefficient, p - probability of type I error, *statistically significant difference, N/A – not applicable.

Test-retest reliability

Test-retest reliability of the CAIT-PL_TS was acceptable resulting in ICC_2,1 = 0.89 (95% CI: 0.84–0.92).

Measurement error

The measurement error of the CAIT-PL_TS was low (SEM = 0.76 and MDC = 2.10).

Convergent validity

Convergent validity was expressed as a weak to strong correlations between the CAIT-PL_TS and FAOS subscales and total score (r = 0.39 − 0.67). Results are presented in Table 3.

Table 3. Convergent validity of CAIT-PL.

	r	p
FAOS Pain	0.56	<0.05*
FAOS Symptoms/Stiffness	0.39	<0.05*
FAOS Difficulty in daily activities	0.52	<0.05*
FOAS Sport and Recreation	0.63	<0.05*
FAOS Quality of Life	0.57	<0.05*
FAOS Total	0.67	<0.05*

r - Spearman correlation coefficient, p - probability of type I error, *statistically significant correlation.

Construct validity

Good construct validity was indicated by confirming 6 of 7 (86%) hypotheses.

Discussion

The CAIT-PL questionnaire was successfully translated and adapted to the Polish culture, showing appropriate reliability and validity. For these reasons, the Polish version of the CAIT appears to reflect the intentions of the English original version. In fact, this is the first specific tool for assessment of functional ankle instability in the Polish-speaking population.

Internal consistency of CAIT-PL was expressed as Cronbach’s α = 0.83, this is the same result as in the original English version, for which Cronbach’s α = 0.83 [12]. Our results are also comparable to other CAIT adaptations in which Cronbach’s α ranged from 0.76 to 0.97 [13–24]. A satisfactory level of internal consistency rating is provided when Cronbach’s α is between 0.70 and 0.95 [25]. If alpha is too high, this may suggest that some items are redundant as they are testing the same question but in a different guise [33]. In our study, internal consistency slightly increased when question 8 was deleted, which also appeared in the Chinese [16] and Spanish [24] versions. This may result from the hypothesis context of this question (“Typically, when I start to roll over (or “twist”) on my ankle, I can stop it”), which makes it difficult to give an unambiguous answer in contrast to items from 1 to 7. In Japanese [17], Korean [21] and Persian [19] adaptations, deleting question 9 resulted in improvement of internal consistency. Items 8 and 9 are related to “rolling over on ankle” or “giving way” episodes, which we assume are the most important features of ankle instability. However, the person completing the questionnaire may not be able to distinguish between an ankle sprain and a giving way episode. Another measurement of the questionnaire’s internal consistency could be correlations between each question and the total score. In our study, Spearman’s correlation coefficient ranged from 0.43 to 0.74, which is adequate and comparable with other CAIT adaptations [14, 15, 17, 18, 21, 23].

Test-retest reliability of CAIT-PL_TS was almost perfect resulting in ICC_2,1 = 0.89 . The ICC_2,1 levels in previous studies were similar or higher than our results (ICC_2,1 = 0.91–0.98) [12–16, 18–22, 24]. Only the Japanese version of the CAIT [17] was shown to have slightly lower test-retest reliability (ICC = 0.82). This may have arisen from interval time between the initial test and retest, which was about 3 weeks in contrast to 1 week from other studies.

SEM and MDC of the CAIT-PL_TS were 0.76 and 2.10, respectively. This means that changes in point values below these levels cannot be considered as real changes in health status, but as certain inaccuracies and natural measurement errors of this questionnaire. When comparing our results to other studies, values of SEM and MDC were only lower in the Urdu CAIT version [22] (SEM = 0.33; MDC = 1.59). While the other language versions reported higher measurement errors (SEM = 0.82–2.40) and (MDC = 2.28–6.5) [13, 14, 16, 19, 21].

Validity of previous CAIT adaptations was assessed as correlation coefficients with various instruments such as the Foot and Ankle Ability Measure (FAAM), Foot and Ankle Outcome Score (FAOS), Visual Analogue Scale (VAS), Short Form 36-Item Health Survey (SF-36), Lower Extremity Functional Scale (LEFS) or Karlsson Score [12, 13, 15–17]. Our results can be compared only to those obtained in the Dutch and Urdu studies due to the use of FAOS. Validity of the Dutch CAIT [13] was shown as correlations (r = 0.36–0.48) in relation to FAOS subscales. The Urdu adaptation [22] resulted in (r = 0.02 to −0.78) between CAIT and FAOS items. The Urdu CAIT showed negative correlations between CAIT and FAOS in contrast to our study and Dutch one. We suppose this may be due to the opposite way of expressing the FAOS scale (i.e., in %). However, only the FAOS “Activities of Daily Life” subscale in the Urdu version demonstrated a very low correlation with the CAIT (r = 0.02), while other items were much stronger negatively correlated with CAIT (r = −0.53 to −0.78). In the present study, correlations ranged between (r = 0.39–0.67), which are slightly higher than in the Dutch version and similar to Urdu adaptation. Only “Symptoms/Stiffness” FAOS subscale has weak correlation (r = 0.39; p < 0.05) with CAIT-PL, which could mean that the participants’ main problems are not structural symptoms such as joint stiffness, clicking or swelling. Remaining FAOS subscales were moderate or strongly correlated with CAIT-PL_TS (r = 0.52–0.67; p < 0.05) and we can interpret this as functional problems (pain, daily activities, sport, quality of life) which is consistent with the assumptions of functional ankle instability. A priori we expected moderate or strong correlations between CAIT-PL_TS and 5 FAOS items as well as FAOS_TS. Moreover, we expected that CAIT-PL_TS has appropriate discriminative power to differentiate instability and control groups. It turned out that 6 of 7 (86%) hypotheses were confirmed indicating good construct validity. Although FAOS is not disease-specific for patients with functional ankle instability, it mainly focuses on the functional status of the patient’s ankle and foot (region-specific), such as CAIT. This means that both questionnaires examine similar, but not identical concepts (what may be confirmed as weak to strong correlations), while the CAIT contains elements regarding ‘'giving-way’’ episodes and the subjective feeling of instability during multiple activities, which is crucial in evaluating functional ankle instability. For this reason, we believe that the development of the Polish version of the CAIT, which shows adequate psychometric properties assessed in accordance with international guidelines such as the COSMIN checklist [29], it’s necessary for the proper diagnosis and treatment of functional ankle instability in the Polish population.

A strong aspect of our study was the rigorous translation process, which allowed for the creation of an instrument tailored to the Polish culture. A limitation of our study is the narrow age range of the participants, focusing on young adults with a similar level of education. The population was homogeneous in the above-mentioned respects, which allows for reproducible results, but they may not reflect the entire Polish population. In future research, we suggest evaluating the CAIT-PL among patients with CAI representing different age and physical activity levels together with assessment of responsiveness and optimal cut-off score.

Conclusions

The Polish-language version of the Cumberland Ankle Instability Tool (CAIT-PL) is a valid and reliable questionnaire for assessing functional ankle instability among the Polish population. The CAIT-PL is ready to be used in clinical practice and for research applications.

Acknowledgements

We would like to acknowledge Dr Hiller for support during the translation process. We also recognise our translators and participants who agreed to take part in this study.

Disclosure statement

The authors report no conflicts of interest.

Additional information

Funding

The study was funded by the” Research of Young Scientists’’ programme provided by the University of Physical Education in Kraków, project No. 158/MN/IRK/2022.

Appendix A.

The Polish version of the Cumberland Ankle Instability Tool (CAIT-PL).

Proszę o wybranie JEDNEGO stwierdzenia, które NAJLEPIEJ opisuje twoje stawy skokowe w KAŻDYM z wymienionych pytań.

Table

	LEWY	PRAWY	Punktacja
1. Odczuwam ból w stawie skokowym:
Nigdy	□	□	5
Podczas uprawiania sportu	□	□	4
Podczas biegania po nierównym podłożu	□	□	3
Podczas biegania po równym podłożu	□	□	2
Podczas chodzenia po nierównym podłożu	□	□	1
Podczas chodzenia po równym podłożu	□	□	0
2. Czuję, że staw skokowy jest NIESTABILNY:
Nigdy	□	□	4
Czasami podczas uprawiania sportu (nie za każdym razem)	□	□	3
Często podczas uprawiania sportu (za każdym razem)	□	□	2
Czasami podczas wykonywania codziennych aktywności	□	□	1
Często podczas wykonywania codziennych aktywności	□	□	0
3. Wykonując NAGŁE zmiany kierunku czuję, że staw skokowy jest NIESTABILNY:
Nigdy	□	□	3
Czasami podczas biegania	□	□	2
Często podczas biegania	□	□	1
Podczas chodzenia	□	□	0
4. Schodząc po schodach czuję, że staw skokowy jest NIESTABILNY
Nigdy	□	□	3
Jeśli schodzę szybko	□	□	2
Od czasu do czasu	□	□	1
Zawsze	□	□	0
5. Stojąc na JEDNEJ nodze czuję, że staw skokowy jest NIESTABILNY:
Nigdy	□	□	2
Stojąc na palcach	□	□	1
Stojąc na całej stopie	□	□	0
6. Czuję, że staw skokowy jest NIESTABILNY:
Nigdy	□	□	3
Kiedy podskakuję jednonóż na boki	□	□	2
Kiedy podskakuję jednonóż w miejscu	□	□	1
Kiedy skaczę obunóż	□	□	0
7. Czuję, że staw skokowy jest NIESTABILNY:
Nigdy	□	□	4
Kiedy biegam po nierównym podłożu	□	□	3
Kiedy truchtam po nierównym podłożu	□	□	2
Kiedy chodzę po nierównym podłożu	□	□	1
Kiedy chodzę po płaskim podłożu	□	□	0
8. ZAZWYCZAJ, kiedy staw skokowy zaczyna mi “uciekać’’ lub “podwijać się’’, jestem w stanie to przerwać:
Natychmiast	□	□	3
Często	□	□	2
Czasami	□	□	1
Nigdy	□	□	0
Nigdy mi nie ,,uciekł’’ staw skokowy	□	□	3
9. Po TYPOWYM ,,ucieknięciu’’, staw skokowy wraca do stanu sprzed incydentu:
Prawie natychmiast	□	□	3
Szybciej niż w ciągu jednego dnia	□	□	2
W ciągu 1-2 dni	□	□	1
Po 2 dniach lub więcej	□	□	0
Nigdy mi nie “uciekł’’ staw skokowy	□	□	3

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