Development, Validity and Reliability of the Avoidance of Sports Activities Photo Scale (ASAP-Shoulder-Scale) in Athletes With Shoulder Pain

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Abstract
Background: Fear-avoidance beliefs and kinesiophobia can contribute to shoulder pain–related avoidance behavior. In athletes, symptoms may only become apparent during training and competition. To identify shoulder pain–related avoidance behaviors, a standardized screening tool is needed. Hypothesis: Avoidance of Sports Activities Photo Scale (ASAP-Shoulder-Scale) will demonstrate strong psychometric properties. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: A total of 162 athletes with shoulder pain were recruited for this study. The ASAP-Shoulder-Scale was developed through an item bank compiled from the International Classification of Functioning, Disability and Health (ICF), with consensus reached by an expert panel. Intraclass correlation coefficients (ICC) were calculated to assess test-retest reliability, along with the standard error of measurement (SEM) and minimal detectable change (MDC). For validation purposes, the Avoidance Daily Activities Photo Scale (ADAP), Shoulder Pain and Disability Index (SPADI), Kerlan-Jobe Orthopaedic-Clinic Shoulder-Elbow Score (KJOC), Tampa Scale for Kinesiophobia (TSK), Pain-Catastrophizing Scale (PCS), and Fear-Avoidance Beliefs Questionnaire (FABQ) were used. Results: A total of 102 preselected activities were evaluated. The scale consisted of 8 activities, with 16 photographic representations that attained 80.0% agreement by the expert panel and demonstrated excellent reliability (ICC, 0.88) with a Cronbach's alpha value of 0.95, a SEM of 20.1 points, and a MDC of 55.8 points. The ASAP-Shoulder-Scale showed significant correlations with ADAP, SPADI, TSK, PCD, and FABQ scores, with correlation coefficients ranging between 0.183 and 0.750 ( P < 0.05). Conclusion: The ASAP-Shoulder-Scale is a reliable and valid instrument for assessing avoidance behavior in athletes with shoulder pain. Clinical Relevance: ASAP-Shoulder-Scale is a novel score to feasibly guide clinicians to monitor avoidance behavior during sports activities. A difference of more than 55.8 points can be accepted as a clinically relevant improvement.

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