Responsiveness of pain and disability measures for chronic whiplash

Responsiveness and minimal important change of the Family Reported Outcome Measure (FROM-16)

BACKGROUND

The FROM-16 is a generic family quality of life (QoL) instrument that measures the QoL impact of patients' disease on their family members/partners. The study aimed to assess the responsiveness of FROM-16 to change and determine Minimal Important Change (MIC).

METHODS

Responsiveness and MIC for FROM-16 were assessed prospectively with patients and their family members recruited from outpatient departments of the University Hospital Wales and University Hospital Llandough, Cardiff, United Kingdom. Patients completed the EQ-5D-3L and a global severity question (GSQ) online at baseline and at 3-month follow-up. Family members completed FROM-16 at baseline and a Global Rating of Change (GRC) in addition to FROM-16 at follow-up. Responsiveness was assessed using the distribution-based (effect size-ES, standardized response mean -SRM) and anchor-based (area under the receiver operating characteristics curve ROC-AUC) approaches and by testing hypotheses on expected correlation strength between FROM-16 change score and patient assessment tools (GSQ and EQ-5D). Cohen's criteria were used for assessing ES. The AUC ≥ 0.7 was considered a good measure of responsiveness. MIC was calculated using anchor-based (ROC analysis and adjusted predictive modelling) and distribution methods based on standard deviation (SD) and standard error of the measurement (SEM).

RESULTS

Eighty-three patients with 15 different health conditions and their relatives completed baseline and follow-up questionnaires and were included in the responsiveness analysis. The mean FROM-16 change over 3 months = 1.43 (SD = 4.98). The mean patient EQ-5D change over 3 months = -0.059 (SD = 0.14). The responsiveness analysis showed that the FROM-16 was responsive to change (ES = 0.2, SRM = 0.3; p < 0.01). The ES and SRM of FROM-16 change score ranged from small (ES = 0.2; SRM = 0.3) for the distribution-based method to large (ES = 0.8, SRM = 0.85) for anchor-based methods. The AUC value was above 0.7, indicating good responsiveness. There was a significant positive correlation between the FROM-16 change scores and the patient's disease severity change scores (p < 0.001). The MIC analysis was based on data from 100 family members of 100 patients. The MIC value of 4 was suggested for FROM-16.

CONCLUSIONS

The results of this study confirm the longitudinal validity of FROM-16 which refers to the degree to which an instrument is able to measure change in the construct to be measured. The results yield a MIC value of 4 for FROM-16. These psychometric attributes of the FROM-16 instrument are useful in both clinical research as well as clinical practice.

An Exploration of Physical Therapy Outcomes and Psychometric Properties of the Patient-Specific Functional Scale After an Interdisciplinary Pain Management Program

OBJECTIVES

The Patient-Specific Functional Scale (PSFS) has been used to assess physical functioning in various chronic pain populations. There is a lack of evidence for its use with diverse pain populations who have high-impact chronic pain (HICP). The primary aim of this study was to assess the psychometric properties of the PSFS with a heterogeneous sample of patients with HICP.

MATERIALS AND METHODS

A retrospective observational study of prospective functional outcomes collected before and after participation in an intensive pain management program: PSFS, Disabilities of the Arm, Shoulder, and Hand, Lower Extremity Functional Scale, Neck Disability Index, Oswestry Disability Index, multidimensional patient impression of change, pain intensity, pain limitation, and fear-avoidance from the charts of 509 intensive pain management program completers. The reliability, validity, and responsiveness of the PSFS were analyzed using Cronbach α, Pearson correlations, and receiver operating characteristics.

RESULTS

Statistically significant improvements were found for all outcomes after program participation (all P < 0.0001). Correlations of the PSFS with similar outcomes (convergent validity) were lower than expected ( r = 0.16 to 0.33). A low correlation ( r = -0.12) with an unrelated measure, fear avoidance, supported divergent validity. PSFS change score correlations with similar outcome measures ranged from 0.46 to 0.53. The area under the curve values for the PSFS ranged from 0.801 to 0.857, suggesting a moderate ability for the PSFS to detect improvement.

DISCUSSION

The psychometric properties of the PSFS showed mixed support for construct validity but good support for the responsiveness of the PSFS when used with a heterogeneous sample of patients with HICP.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial

BACKGROUND

Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT.

METHODS

The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes).

RESULTS

The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82).

CONCLUSIONS

In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function.

TRIAL REGISTRATION

The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

Validity and reliability of the Turkish version of the patient-specific functional scale in patients with low back pain

BACKGROUND

The Patient-Specific Functional Scale (PSFS) is among the most used measures to evaluate physical function. The PSFS has not been translated into Turkish for patients with low back pain to date. The purpose of the present study was to translate and cross-culturally adapt the PSFS into Turkish (PSFS-T) and to assess its reliability and validity in patients with low back pain.

METHODS

A total of 105 participants completed the PSFS-T, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), and Visual Analogue Scale (VAS) for pain. Sixty-nine participants completed the PSFS-T questionnaire twice in 7 days. The internal consistency of the PSFS-T was assessed using Cronbach's alpha while the Intraclass Correlation Coefficient (ICC) was used to evaluate test-retest reliability. The convergent validity of PSFS-T was determined with ODI, RMDQ, and VAS questionnaires by using Pearson's correlation coefficient analysis.

RESULTS

The PSFS-T demonstrated acceptable internal consistency (Cronbach's α = 0.79) and good test-retest reliability (ICC2,1 = 0.75) with no floor or ceiling issues. The PSFS-T showed a moderate correlation with ODI (Rp =0 .49, p<0.001) and RMDQ (Rp =0 .46, p<0.001). A poor correlation was found between PSFS-T and VAS (Rp = 0.36, p< 0.001). Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC) for the PSFS-T scores were 0.69 and 1.91 respectively.

CONCLUSION

The Turkish version of PSFS is a valid and reliable instrument for the assessment of low back patients. It may be considered a preferable scale for clinical assessment of Turkish-speaking patients with low back pain.

Efficacy of Neck-Specific Exercise With Internet Support Versus Neck-Specific Exercise at a Physiotherapy Clinic in Chronic Whiplash-Associated Disorders: Multicenter Randomized Controlled Noninferiority Trial

BACKGROUND

Neck-specific exercises (NSE) supervised by a physiotherapist twice a week for 12 weeks have shown good results in chronic whiplash-associated disorders (WADs), but the effect of exercise delivered via the internet is unknown.

OBJECTIVE

This study examined whether NSE with internet support (NSEIT) and 4 physiotherapy sessions for 12 weeks were noninferior to the same exercises supervised by a physiotherapist twice a week for 12 weeks (NSE).

METHODS

In this multicenter randomized controlled noninferiority trial with masked assessors, we recruited adults aged 18-63 years with chronic WAD grade II (ie, neck pain and clinical musculoskeletal signs) or III (ie, grade II plus neurological signs). Outcomes were measured at baseline and at 3- and 15-month follow-ups. The primary outcome was change in neck-related disability, measured with the Neck Disability Index (NDI; 0%-100%), with higher percentages indicating greater disability. Secondary outcomes were neck and arm pain intensity (Visual Analog Scale [VAS]), physical function (Whiplash Disability Questionnaire [WDQ] and Patient-Specific Functional Scale [PSFS]), health-related quality of life (EQ-5D-3L and EQ VAS), and self-rated recovery (Global Rating Scale [GRS]). The analyses were conducted on an intention-to-treat basis and with the per-protocol approach as sensitivity analyses.

RESULTS

Between April 6, 2017, and September 15, 2020, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70); 63 (90%) and 64 (91%), respectively, were followed up at 3 months, and 56 (80%) and 58 (83%), respectively, at 15 months. NSEIT demonstrated noninferiority to NSE in the primary outcome NDI, as the 1-sided 95% CI of the mean difference in change did not cross the specified noninferiority margin (7 percentage units). There were no significant between-group differences in change in NDI at the 3- or 15-month follow-up, with a mean difference of 1.4 (95% CI -2.5 to 5.3) and 0.9 (95% CI -3.6 to 5.3), respectively. In both groups, the NDI significantly decreased over time (NSEIT: mean change -10.1, 95% CI -13.7 to -6.5, effect size=1.33; NSE: mean change -9.3, 95% CI -12.8 to -5.7, effect size=1.19 at 15 months; P<.001). NSEIT was noninferior to NSE for most of the secondary outcomes except for neck pain intensity and EQ VAS, but post hoc analyses showed no differences between the groups. Similar results were seen in the per-protocol population. No serious adverse events were reported.

CONCLUSIONS

NSEIT was noninferior to NSE in chronic WAD and required less physiotherapist time. NSEIT could be used as a treatment for patients with chronic WAD grades II and III.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03022812; https://clinicaltrials.gov/ct2/show/NCT03022812.

Measurement Properties of the Patient-Specific Functional Scale and Its Current Uses: An Updated Systematic Review of 57 Studies Using COSMIN Guidelines

OBJECTIVE

To systematically review measurement properties, including acceptability, feasibility, and interpretability, and current uses of the Patient-Specific Functional Scale (PSFS).

DESIGN

Systematic review of a patient-reported outcome measure using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines.

LITERATURE SEARCH

We searched 11 databases from January 2010 to July 2020 for articles on measurement properties or use of PSFS.

STUDY SELECTION CRITERIA

Published primary articles without language restrictions.

DATA SYNTHESIS

Two independent reviewers screened all records, extracted data, and performed risk of bias assessments using COSMIN guidelines. We qualitatively synthesized findings for each measurement property in musculoskeletal and nonmusculoskeletal conditions, and 2 reviewers independently performed Grading of Recommendations Assessment, Development and Evaluation assessments. This study was preregistered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/42UZT).

RESULTS

Of the 985 articles screened, we included 57 articles on measurement properties and 255 articles on the use of PSFS. The PSFS had sufficient test-retest reliability in musculoskeletal (22 studies, 845 participants, low-to-moderate certainty) and nonmusculoskeletal conditions (6 studies, 197 participants, very low certainty), insufficient construct validity as a measure of physical function (21 studies, 2 945 participants, low-to-moderate certainty), and sufficient responsiveness (32 studies, 13 770 participants, moderate-to-high certainty). The standard error of measurement ranged from 0.35 to 1.5. The PSFS was used in 87 unique health conditions, some without prior evidence of validity.

CONCLUSION

The PSFS is an easy-to-use, reliable, and responsive scale in numerous musculoskeletal conditions, but the construct validity of PSFS remains uncertain. Further study of the measurement properties of the PSFS in nonmusculoskeletal conditions is necessary before clinical use. J Orthop Sports Phys Ther 2022;52(5):262-275. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10727.

A Systematic Review and Synthesis of Psychometric Properties of the Numeric Pain Rating Scale and the Visual Analog Scale for Use in People With Neck Pain

OBJECTIVES

To conduct a systematic search and synthesis of evidence about the measurement properties of the Numeric Pain Rating Scale (NPRS) and the Visual Analog Scale (VAS) as patient-reported outcome measures in neck pain research.

METHODS AND MATERIALS

CINAHL, Embase, PsychInfo, and MedLine databases were searched to identify studies evaluating the psychometric properties of the NPRS and the VAS used in samples of which >50% of participants were people with neck pain. Quality and consistency of findings were synthesized to arrive at recommendations.

RESULTS

A total of 46 manuscripts were included. Syntheses indicated high-to-moderate-quality evidence of good-to-excellent (intraclass correlation coefficient 0.58 to 0.93) test-retest reliability over an interval of 7 hours to 4 weeks. Moderate evidence of a clinically important difference of 1.5 to 2.5 points was found, while minimum detectable change ranged from 2.6 to 4.1 points. Moderate evidence of a moderate association (r=0.48 to 0.54) between the NPRS or VAS and the Neck Disability Index. Findings from other patient-reported outcomes indicated stronger associations with ratings of physical function than emotional status. There is limited research addressing the extent that these measures reflect outcomes that are important to patients.

DISCUSSION

It is clear NPRS and the VAS ratings are feasible to implement, provide reliable scores and relate to multi-item patient-reported outcome measures. Responsiveness (meaningful change) of the scales and interpretation of change scores requires further refinement. The NPRS can be a useful single-item assessment complimenting more comprehensive multi-item patient-reported outcome measures in neck pain research and practice.

Clinimetric Properties of Self-reported Disability Scales for Whiplash: A Systematic Review for the Whiplash Core Outcome Set (CATWAD)

OBJECTIVES

A core outcomes set (COS) for whiplash-associated disorders (WADs) has been proposed to improve consistency of outcome reporting in clinical trials. Patient-reported disability was one outcome of interest within this COS. The aim of this review was to identify the most suitable tools for measuring self-reported disability in WAD based on clinimetric performance.

METHODS

Database searches took place in 2 stages. The first identified outcome measures used to assess self-reported disability in WAD, and the second identified studies assessing the clinimetric properties of these outcome measures in WAD. Data on the study, population and outcome measure characteristics were extracted, along with clinimetric data. Quality and clinimetric performance were assessed in accordance with the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN).

RESULTS

Of 19,663 records identified in stage 1 searches, 32 were retained following stage 2 searches and screening. Both the Whiplash Disability Questionnaire and Neck Disability Index performed well in reliability (intraclass correlation coefficient=0.84 to 0.98), construct validity (74% to 82% of hypotheses accepted), and responsiveness (majority of correlations in accordance with hypotheses). Both received Category B recommendations due to a lack of evidence for content validity.

DISCUSSION

This review identified the Neck Disability Index and Whiplash Disability Questionnaire as the most appropriate patient-reported outcome measures (PROMs) for assessing self-reported disability in WAD based on moderate to high-quality evidence for sufficient reliability, construct validity and responsiveness. However, the content validity of these PROMs has yet to be established in WAD, and until this is undertaken, it is not possible to recommend 1 PROM over the other for inclusion in the WAD COS.

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial

BACKGROUND

Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery.

METHODS

We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care.

DISCUSSION

Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications.

TRIAL REGISTRATION

This study is registered as NCT03353272 at ClincialTrials.gov.

Assessment of the responsiveness of four scales in geriatric patients with chronic neck pain

The purpose of this study was to evaluate the responsiveness of Copenhagen Neck Functional Disability Scale (CNFDS), Neck Disability Index (NDI), Neck Bournemouth Questionnaire (NBQ), Neck Pain and Disability Scale (NPDS) in geriatric patients with non-specific chronic neck pain. A total of 52 geriatric patients with non-specific chronic neck pain were included in the present study. All participants were included in a physical therapy and rehabilitation program for five sessions per week that lasted 3 weeks. All participants were evaluated before and after the treatment. Pain and disability were assessed with the Visual Analog Scale-pain (VAS-pain), VAS-disability, muscle spasm, CNFDS, NDI, NBQ, NPDS scales. Additionally, patient satisfaction scores were questioned both before and after the treatment. Following the 3-week physical therapy and rehabilitation program, significant improvements were detected in the VAS-pain, VAS-disability, muscle spasm, CNFDS, NDI, NBQ, and NPDS scores (p < 0.05). Responsiveness values were found to be as follows: CNFDS [effect size (ES) = 0.78; standardized response mean (SRM) = 0.90], NDI (ES = 0.66; SRM = 1.18), NBQ (ES = 0.82; SRM = 0.97) and NPDS (ES = 0.87; SRM = 0.98). Our study demonstrated that CNFDS, NDI, NBQ, and NPDS are responsive scales in determining treatment-related changes in geriatric patients with non-specific neck pain. These results also suggest that all of these four scales can be used in the assessment of treatment induced changes in geriatric patients with chronic neck pain.

Croatian version of the neck disability index can distinguish between acute, chronic and no neck pain : Results of a validation study

OBJECTIVE

Longitudinal study to test the validity and reliability of the Croatian version of the neck disability index (NDI-CRO) for use in patients.

METHODS

Three groups were given NDI-CRO on two occasions, 48 h apart: acute whiplash neck injury group (n = 30), hospital physiotherapists-professional chronic neck pain group (n = 56) and control group (n = 65). To test validity, correlation between NDI-CRO and the pain VAS and PHQ‑9 questionnaire for depression was analyzed. Reliability testing was done using the test-retest experiment and item-total score correlation.

RESULTS

Test-retest showed excellent correlation in all groups: whiplash 0.86, control 0.95 and physiotherapist 0.89 (Spearman r). Item-total score in the 3 analyzed groups showed positive correlation in all 10 categories, varying from 0.43-0.85. The NDI-CRO score showed significant difference between groups (median whiplash 38%, physiotherapist 12% and control 6%, p < 0.05). Validity testing showed positive correlation between NDI and pain VAS (control r = 0.63, physiotherapist r = 0.68 and whiplash r = 0.83, p < 0.05) and PHQ‑9 (control r = 0.49, physiotherapist r = 0.71 and whiplash r = 0.69, p < 0.05). No correlation was found between NDI-CRO and age, gender or radiographic findings. In the whiplash injury group 75% of patients showed moderate to severe disability. The majority of physiotherapists showed mild to moderate disability due to neck pain while 40% showed no disability. In the control group two out of three people reported no disability.

CONCLUSION

The NDI-CRO is a valid index for measuring the degree of neck disability in people with acute and chronic neck pain and in control group. It is strongly correlated with pain VAS and PHQ‑9 index.

Minimal Clinically Important Differences for Measures of Pain, Lung Function, Fatigue, and Functionality in Spinal Cord Injury

OBJECTIVE

The objective of this study was to determine the minimal clinically important differences (MCIDs) for the numerical pain rating scale (NPRS), peak cough flow (PCF), peak expiratory flow (PEF), fatigue severity scale (FSS), and London chest activities of daily living scale (LCADL) in patients with spinal cord injuries (SCIs) after rehabilitation.

METHODS

Inpatients with SCI from 2 rehabilitation centers participating in a daily rehabilitation program were recruited. The NPRS, PCF, PEF, FSS, and LCADL were collected at baseline and discharge. The global rating of change scale was performed at discharge. MCIDs were calculated using anchor (linear regression, mean change, and receiver operating characteristic curves) and distribution-based methods (0.5 times the baseline SD, standard error of measurement, 1.96 times standard error of measurement, and minimal detectable change) and pooled using arithmetic weighted mean.

RESULTS

Sixty inpatients with SCI (36 males; 54.5 [15.9] years) participated. On average their rehabilitation program lasted 7.3 (1.7) weeks. Pooled MCID estimates were 1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL.

CONCLUSION

Established MCIDs for NPRS, PCF, PEF, FSS, and LCADL will help health professionals to interpret results and guide rehabilitation interventions in patients with SCI.

IMPACT

Health professionals and researchers may now use -1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL to interpret if changes in pain, cough intensity, expiratory flow, fatigue and activities of daily living after rehabilitation of patients with SCI have been clinically relevant.

Is a Combination of Exercise and Dry Needling Effective for Knee OA?

OBJECTIVE

To assess the effectiveness of adding dry needling (DN) to an exercise program on pain intensity and disability in patients with knee osteoarthritis.

DESIGN

Double-blind randomized clinical trial with one-year follow-up.

SETTING

Older adults in a multicenter study.

SUBJECTS

Sixty-two patients with knee osteoarthritis were randomly allocated into one of two groups: exercise plus DN (exercise + DN; N = 31) or exercise plus sham DN (exercise + sham DN; N = 31).

METHODS

Participants received six sessions of either DN or sham DN over the leg muscles related to knee pain from osteoarthritis plus a supervised exercise program. We evaluated between-group differences in terms of the numerical pain rating scale (NPRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. We used the EuroQol Group 5-Dimension Self-Report Questionnaire, Barthel Index, Timed Up & Go Test, and Global Rating of Change Scale to examine between-group differences for health-related quality of life, functional status evaluation, balance assessment, and clinical progress, respectively.

RESULTS

The groups were not different in terms of pain intensity (0.32 points, 95% confidence interval [CI] = -1.12 to 1.18, P = 0.92) or WOMAC score (0.29 points, 95% CI = -6.16 to 6.74, P = 0.92) at one year. Both groups presented within-group differences at all follow-up periods (F = 28.349, P < 0.0001, ηp2 = 0.32) on secondary outcomes. Nevertheless, 90.3% of the DN group had reduced medication consumption vs only 26.3% in the sham DN group.

CONCLUSIONS

The inclusion of DN to an exercise program does not reduce pain or disability in patients with knee osteoarthritis.

Core Outcome Measures for Chronic Musculoskeletal Pain Research: Recommendations from a Veterans Health Administration Work Group

OBJECTIVE

Chronic musculoskeletal pain (CMSP) disorders are among the most prevalent and disabling conditions worldwide. It would be advantageous to have common outcome measures when comparing results across different CMSP research studies.

METHODS

The Veterans Health Administration appointed a work group to recommend core outcome measures for assessing pain intensity and interference as well as important secondary domains in clinical research. The work group used three streams of data to inform their recommendations: 1) literature synthesis augmented by three recently completed trials; 2) review and comparison of measures recommended by other expert groups; 3) two Delphi surveys of work group members.

RESULTS

The single-item numerical rating scale and seven-item Brief Pain Inventory interference scale emerged as the recommended measures for assessing pain intensity and interference, respectively. The secondary domains ranked most important included physical functioning and depression, followed by sleep, anxiety, and patient-reported global impression of change (PGIC). For these domains, the work group recommended the Patient-Reported Outcome Information System four-item physical function and sleep scales, the Patient Health Questionnaire two-item depression scale, the Generalized Anxiety Disorder two-item anxiety scale, and the single-item PGIC. Finally, a single-item National Health Interview Survey item was favored for defining chronic pain.

CONCLUSIONS

Two scales comprising eight items are recommended as core outcome measures for pain intensity and interference in all studies of chronic musculoskeletal pain, and brief scales comprising 13 additional items can be added when possible to assess important secondary domains.

Translation, Cross-cultural Adaptation, and Psychometric Properties of the Hausa Versions of the Numerical Pain Rating Scale and Global Rating of Change Scale in a Low-literate Population With Chronic Low Back Pain

STUDY DESIGN

Translation, cross-cultural adaptation, and psychometric testing.

OBJECTIVE

To translate, cross-culturally adapt, and validate the Numerical Pain Rating Scale (NPRS) and the Global Rating of Change Scale (GRCS) into Hausa language.

SUMMARY OF BACKGROUND DATA

The NPRS and GRCS are commonly used patient-reported outcome measures in a variety of pain-related conditions including low back pain. To date, neither the NPRS nor GROC are available in Hausa language.

METHODS

The Hausa versions of the NPRS (NPRS-H) and GRCS (GRCS-H) were developed using recommended guidelines. The final versions were then administered to 120 patients with chronic low back pain to access their psychometric properties. Reliability assessment included calculations of intraclass correlation coefficient (ICC) and minimal detectable change among the stable group. Construct validity and concurrent validity were assessed using the Spearman rank correlation coefficient. Internal responsiveness was assessed using mean change scores, standardized effect size, and standard response mean. Receiver operating characteristic curves were plotted to determine the external responsiveness of the NPRS-H using the area under the curve, and minimal important change for small, medium, and large improvements. Outcome measures consisted of the Visual Analogue Scale for pain and Oswestry Disability Index.

RESULTS

The NPRS-H and GRCS-H were successfully developed. High test-retest reliability was demonstrated for both the NPRS-H (ICC = 0.95) and GRCS-H (ICC = 0.94) with minimal detectable change points of 1.0 and 1.2 respectively. The scales showed moderate to strong correlation with the Visual Analogue Scale for pain and Oswestry Disability Index. The mean change of the NPRS-H scores correlated moderately with the GRCS-H. Both scales demonstrated good internal responsiveness. External responsiveness of the NPRS-H was demonstrated at three levels with area under the curve  = 0.875 to 0.972, and minimal important change  = 2.5 to 3.5.

CONCLUSIONS

The NPRS and GRCS were successfully adapted into Hausa language with acceptable reliability, validity, and responsiveness. These measures are appropriate for clinical and research use among Hausa-speaking patients.

LEVEL OF EVIDENCE

2.

A uniform data set for determining outcomes in allied health primary contact services in Australia

The project aim was to develop and implement a set of metrics to capture and demonstrate the performance of newly established allied health primary contact services. Selection of the metrics and performance indicators was guided by an existing state-wide data collection system and from a review of the published literature. The metrics were refined after consultation with a working group of health service managers and clinicians. The data collection and reporting framework were developed for use in allied health primary contact services and implemented at public health facilities in Queensland, Australia. The set of metrics consists of 18 process and outcome measures. Patient-reported metrics include the global rating of change scale and patient satisfaction. Service metrics include wait times; referral source; triage category; diagnosis; occasions of service; referrals and investigations initiated; effects; care duration; discharge status; waitlist reinstatement reasons; treatment non-completion reasons; and expedited care. Safety, patient demographics and service improvement metrics were included. The metrics will enable analysis of the effectiveness of allied health primary contact services and will facilitate reporting, advocacy, service improvement, service continuity and research. The metrics are suitable for use by all providers of allied health primary contact services in hospital and primary care settings.

Medication-overuse headache: The effect of a patient educational programme-A randomized controlled trial

BACKGROUND

Little is known about the effects of non-pharmacological interventions among medication-overuse headache (MOH) patients, although non-pharmacological approaches combined with pharmacological treatment are recommended. The objective was to evaluate the effect of an educational programme as an add-on to standard treatment.

METHODS

Medication-overuse headache patients were randomized (1:1) in a single-centre setting to standard treatment with 12 weeks of education (I-group) versus standard treatment (C-group). The primary outcome was measurement of reduction in headache days/last month at 9 months' follow-up. Secondary outcomes were headache intensity, acute medication intake, bothersomeness, disability, physical activity and patient satisfaction. The between-group differences were analysed using a mixed-effects model for repeated measurements with a between group factor (I-group vs. C-group) and a time factor (baseline, 4 and 9 months).

RESULTS

Ninety-eight patients were randomized (I-group: n = 48, C-group: n = 50), with 40 and 39 patients completing the study, respectively. Intention-to-treat analyses showed that both groups experienced statistically significant reductions in headache days/last month (I-group: -4 ± 6 days (95% CI 2.47; 5.95), p < .001) versus C-group: -4 ± 9 days ([95% CI 1.53; 6.79], p = .003), but there were no significant differences between groups (mean ± SE):Δ: 0.7 days ([95% CI, -2.50; 3.93], p = .66). At follow-up, 85% from the I-group and 86% from C-group, no longer fulfilled the criteria for MOH.

CONCLUSION

The compliance rate was high, indicating that patients were motivated for receiving education, but we found no additional benefits of adding an educational programme to standard treatment. Future research focusing on the MOH complexity, group heterogeneity, duration and content of educational programmes is warranted.

SIGNIFICANCE

Randomized controlled trials (RCTs) of non-pharmacological intervention such as patient educational programmes are of great importance, as this approach is common in the clinical practice. Medication-overuse headache (MOH) is a heterogenetic patient group, which must be taken into account when conducting RCTs of non-pharmacological interventions. An educational programme based on Motivational Interviewing is well-tolerated among MOH patients, however, no superior effects were found from adding the educational programme to standard treatment versus standard treatment alone.

The NIH Minimal Dataset for Chronic Low Back Pain: Responsiveness and Minimal Clinically Important Change

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To analyze responsiveness and minimal clinically important change (MCIC) of the US National Institutes of Health (NIH) minimal dataset for chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

The NIH minimal dataset is a 40-item questionnaire developed to increase use of standardized definitions and measures for CLBP. Longitudinal validity of the total minimal dataset and the subscale Impact Stratification are unknown.

METHODS

Total outcome scores on the NIH minimal dataset, Dutch Language Version, were calculated ranging from 0 to 100 points with higher scores representing worse functioning. Responsiveness and MCIC were determined with an anchor-based method, calculating the area under the receiver operating characteristics (ROC) curve (AUC) and by determining the optimal cut-off point. Smallest detectable change (SDC) was calculated as a parameter of measurement error.

RESULTS

In total 223 patients with CLBP were included. Mean total score on the NIH minimal dataset was 44 ± 14 points at baseline. The total outcome score was responsive to change with an AUC of 0.84. MCIC was 14 points with a sensitivity of 72% and specificity 82%, and SDC was 23 points. Mean total score on Impact Stratification (scale 8-50) was 34.4 ± 7.4 points at baseline, with an AUC of 0.91, an MCIC of 7.5 with a sensitivity 96% of and specificity of 78%, and an SDC of 14 points.

CONCLUSION

The longitudinal validity of the NIH minimal dataset is adequate. An improvement of 14 points in total outcome score and 7.5 points in Impact Stratification can be interpreted as clinically important in individual patients. However, MCIC depends on baseline values and the method that is chosen to determine the optimal cut-off point. Furthermore, measurement error is larger than the MCIC. This means that individual change scores should be interpreted with caution.

LEVEL OF EVIDENCE

2.

Performance properties of health-related measurement instruments in whiplash: systematic review protocol

BACKGROUND

Whiplash is a common traumatic cervical injury which is most often a consequence of rear-end motor vehicle accidents. It has been estimated that up to 50% of the whiplash patients suffer from chronic symptoms, resulting in extensive individual and societal burden. Several measurement instruments are used for initial assessment of whiplash and evaluation of response to treatment. However, a comprehensive assessment of the performance of these measures is lacking. Furthermore, there is no consensus on the most relevant outcome domains and their corresponding measurement instruments of choice. This systematic review aims to identify, describe, and critically appraise the performance properties of health-related measurement instruments in whiplash population.

METHODS

The following literature databases will be searched from their date of establishment: PubMed, Embase®, MEDLINE, CINAHL Complete, PsycINFO, and HAPI. All original articles evaluating the reliability, validity, responsiveness, and feasibility of health-related measurement instruments in whiplash will be included, without additional restriction on their intended use, source of data, and structure. Risk of bias will be assessed using the COSMIN Risk of Bias checklist. Findings of the studies will be judged against the criteria for good measurement properties, and results from all studies will be qualitatively summarized to generate an overall quality of findings. Overall quality of evidence will be determined using a modified GRADE approach, which will be used in conjunction with the overall quality of results for generation of recommendations. Two reviewers will perform all steps of the review independently. Discrepancies will be discussed between the reviewers, and in case of remaining disagreement, the senior reviewer will make the final decision.

DISCUSSION

This systematic review will summarize the body of literature on health-related measurement instruments in whiplash, aiming to facilitate the selection of high-quality measurement instrument for researchers and physicians. Findings of this study will guide the ongoing efforts for development of a core outcome set.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO reference number CRD42018070901.

Measurement Properties of the Functional Rating Index: A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

To assess the measurement properties of the Functional Rating Index (FRI) and determine whether its measurement properties are comparable with other region-specific questionnaires.

SUMMARY OF BACKGROUND DATA

In addition to low back pain (LBP) and neck pain (NP), multiregion spinal pain (SP) is a common problem with a considerable prevalence in the general population. The FRI was built to assess physical functioning in patients with SP. However, a systematic review assessing evidence of its measurement properties in separated populations and a comparison with other questionnaires regarding each measurement property is lacking.

METHODS

Articles concerning the FRI's measurement properties or head-to-head comparison with other questionnaires on measurement properties were obtained from MEDLINE, Embase, CINAHL, and PsycINFO. Two reviewers independently reviewed the articles, extracted data, and conducted the methodological quality assessment. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to assess the methodological quality of the included studies.

RESULTS

A total of 18 studies evaluating the FRI's measurement properties, including seven that carried out head-to-head comparisons in at least one measurement property with other questionnaires, were included in the current review. Our findings show strong positive evidence for structural validity and internal consistency in patients with SP and LBP. Evidence for most of the FRI's measurement properties is limited, conflicting, or even unknown. The current evidence shows that the FRI is comparable with both the Oswestry Disability Index and the Neck Disability Index in responsiveness. However, relevant information about the majority of the other measurement properties is lacking.

CONCLUSION

Our finding suggests that clinicians and researchers should use the FRI with caution until there are more studies with high methodological quality that support the view that it is positive in all measurement properties, especially in regard to patients with multiregion SP.

LEVEL OF EVIDENCE

1.

Focused Evidence Review: Psychometric Properties of Patient-Reported Outcome Measures for Chronic Musculoskeletal Pain

BACKGROUND

Developing successful interventions for chronic musculoskeletal pain requires valid, responsive, and reliable outcome measures. The Minneapolis VA Evidence-based Synthesis Program completed a focused evidence review on key psychometric properties of 17 self-report measures of pain severity and pain-related functional impairment suitable for clinical research on chronic musculoskeletal pain.

METHODS

Pain experts of the VA Pain Measurement Outcomes Workgroup identified 17 pain measures to undergo systematic review. In addition to a MEDLINE search on these 17 measures (1/2000-1/2017), we hand-searched (without publication date limits) the reference lists of all included studies, prior systematic reviews, and-when available-Web sites dedicated to each measure (PROSPERO registration CRD42017056610). Our primary outcome was the measure's minimal important difference (MID). Secondary outcomes included responsiveness, validity, and test-retest reliability. Outcomes were synthesized through evidence mapping and qualitative comparison.

RESULTS

Of 1635 abstracts identified, 331 articles underwent full-text review, and 43 met inclusion criteria. Five measures (Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), SF-36 Bodily Pain Scale (SF-36 BPS), Numeric Rating Scale (NRS), and Visual Analog Scale (VAS)) had data reported on MID, responsiveness, validity, and test-retest reliability. Seven measures had data reported on three of the four psychometric outcomes. Eight measures had reported MIDs, though estimation methods differed substantially and often were not clinically anchored.

CONCLUSIONS

In this focused evidence review, the most evidence on key psychometric properties in chronic musculoskeletal pain populations was found for the ODI, RMDQ, SF-36 BPS, NRS, and VAS. Key limitations in the field include substantial variation in methods of estimating psychometric properties, defining chronic musculoskeletal pain, and reporting patient demographics.

TRIAL REGISTRATION

Registered in the PROSPERO database: CRD42017056610.

The Multidimensional Symptom Index: A new patient-reported outcome for pain phenotyping, prognosis and treatment decisions

BACKGROUND

There are few patient-reported outcomes routinely used that capture frequency and interference of different pain-related symptoms on a single scale. The purpose of this study was to describe the development and initial validation of the new Multidimensional Symptom Index (MSI).

METHODS

Items were generated from patient interviews of the experience of chronic pain. Health valuations were created from rankings of 82 healthy subjects for each of 120 symptom (×10) × frequency (×3) × interference (×4) combinations using preference-based health valuations (0-100). Ranks for each symptom combination were then used in scale scoring. A sample of 300 patients with acute or chronic pain subsequently completed the MSI and a battery of other tools. Exploratory (EFA) and Confirmatory (CFA) factor analyses were triangulated with theory to arrive at the factor structure. Convergent validity was tested against established measures.

RESULTS

Health rankings resulted in scores of 0-12 for each of the 10 symptom types. Factor analyses revealed two factors: MSI Somatic Symptoms and MSI Non-Somatic Symptoms. The MSI also quantified number of symptoms experienced (/10), mean frequency (/3) and mean interference (/4). The indices showed appropriate associations with the established PROs.

CONCLUSIONS

The MSI is a new symptom-focused PRO that allows patient phenotyping and may have value for screening, prognosis and evaluating change.

SIGNIFICANCE

This article presents the development and psychometric properties of a new measure of pain and related symptom frequency and interference. This measure could aid clinicians in establishing clinically relevant pain phenotypes for screening, prognosis and treatment decisions.

Responsiveness of clinical tests for people with neck pain

BACKGROUND

Responsiveness of a clinical test is highly relevant in order to evaluate the effect of a given intervention. However, the responsiveness of clinical tests for people with neck pain has not been adequately evaluated. The objective of the present study was to examine the responsiveness of four clinical tests which are low cost and easy to perform in a clinical setting, including the craniocervical flexion test, cervical active range of movement, test for the cervical extensors and pressure pain threshold testing.

METHODS

This study is a secondary analysis of data collected in a previously published randomised controlled trial. Participants were randomized to either physical training, exercises and pain education combined or pain education only. Participants were tested on the clinical tests at baseline and at 4-month follow-up. An anchor-based approach using Receiver Operator Characteristics (ROC) curves was used to evaluate responsiveness of the clinical tests. The Neck Disability Index was used to discriminate between those who had improved and those who were unchanged at the 4-month follow-up. Minimum Clinically Important Difference (MCID), together with sensitivity, specificity, positive and negative predictive values, in addition to positive and negative likelihood ratios were calculated.

RESULTS

In total, 164 participants completed the 4 month follow up. One-hundred forty four participants were classified as unchanged whereas 20 patients were considered to be improved. Twenty-six participants didn't complete all of the clinical tests, leaving a total of 138 to be included for analyses. Area Under Curve (AUC) ranged from 0.50-0.62 for the clinical tests, and were all below an acceptable level. MCID was generally large, and the corresponding sensitivity and specificity was low with sensitivity ranging from 20 to 60%, and specificity from 54 to 86%. LR+ (0.8-2.07) and LR- (0.7-1.1) showed low diagnostic value for all variables, with PPV ranging from 12.1 to 26.1 and NPV ranging from 84.7 to 89.2.

CONCLUSION

Responsiveness of the included clinical tests was generally low when using change in NDI score as the anchor from baseline to the 4-month follow up. Further investigations of responsiveness are warranted, possibly using other anchors, which to a higher degree resemble similar dimensions as the clinical tests.

Chronic neck pain patients with traumatic or non-traumatic onset: Differences in characteristics. A cross-sectional study

BACKGROUND AND AIMS

Patients with chronic neck pain can present with disability, low quality of life, psychological factors and clinical symptoms. It is unclear whether patients with a traumatic onset differ from those with a non-traumatic onset, by having more complex and severe symptoms. The purpose of this study was to investigate the clinical presentation of chronic neck pain patients with and without traumatic onset by examining cervical mobility, sensorimotor function, cervical muscle performance and pressure pain threshold in addition to the following self-reported characteristics: quality of life, neck pain and function, kinesiophobia, depression, and pain bothersomeness.

METHODS

This cross-sectional study included 200 participants with chronic neck pain: 120 with traumatic onset and 80 with non-traumatic onset. Participants were recruited from physiotherapy clinics in primary and secondary health care. For participants to be included, they were required to be at least 18 years of age, have had neck pain for at least 6 months, and experienced neck-related activity limitation as determined by a score of at least 10 on the Neck Disability Index. We conducted the following clinical tests of cervical range of motion, gaze stability, eye movement, cranio-cervical flexion, cervical extensors, and pressure pain threshold. The participants completed the following questionnaires: physical and mental component summary of the Short Form Health Survey, EuroQol-5D, Neck Disability Index, Patient-Specific Functional Scale, Pain Bothersomeness, Beck Depression Inventory-II, and TAMPA scale of kinesiophobia. The level of significance for all analyses was defined as p<0.01. Differences between groups for the continuous data were determined using either a Student's t-test or Mann Whitney U test.

RESULTS

In both groups, the majority of the participants were female (approximately 75%). Age, educational level, working situation and sleeping patterns were similar in both groups. The traumatic group had symptoms for a shorter duration (88 vs. 138 months p=0.001). Participants in the traumatic group showed worse results on all measures compared with those in the non-traumatic group, significantly on neck muscle function (cervical extension mobility p=0.005, cranio-cervical flexion test p=0.007, cervical extensor test p=0.006) and cervical pressure pain threshold bilateral (p=0.002/0.004), as well on self-reported function (Neck Disability Index p=0.001 and Patient-Specific Functional Scale p=0.007), mental quality of life (mental component summary of the Short Form Health Survey p=0.004 and EuroQol-5D p=0.001) and depression (Beck Depression Inventory-II p=0.001).

CONCLUSIONS

This study showed significant differences between chronic neck pain patients when differentiated into groups based on their onset of pain. However, no specific clinical test or self-reported characteristic could differentiate between the groups at an individual patient level.

IMPLICATIONS

Pressure pain threshold tests, cervical muscle performance tests and patient-reported characteristics about self-perceived function and psychological factors may assist in profiling chronic neck pain patients. The need for more intensive management of those with a traumatic onset compared with those with a non-traumatic onset should be examined further.

Does a combination of physical training, specific exercises and pain education improve health-related quality of life in patients with chronic neck pain? A randomised control trial with a 4-month follow up

AIM

To investigate the effect of combining pain education, specific exercises and graded physical activity training (exercise) compared with pain education alone (control) on physical health-related quality of life (HR-QoL) in chronic neck pain patients.

METHODS

A multicentre randomised controlled trial of 200 neck pain patients receiving pain education. The exercise group received additional exercises for neck/shoulder, balance and oculomotor function, plus graded physical activity training. Patient-reported outcome measures (Short Form-36 Physical and Mental component summary scores, EuroQol-5D, Beck Depression Inventory-II, Neck Disability Index, Pain Bothersomeness, Patient-Specific Functioning Scale, Tampa Scale of Kinesiophobia, Global Perceived Effect) and clinical tests (Aastrand Physical Fitness, cervical Range of Motion, Pressure Pain Threshold at infraspinatus, tibialis anterior and cervical spine, Cranio-cervical Flexion, Cervical Extension muscle function, and oculomotion) were recorded at baseline and after 4 months.

RESULTS

The exercise group showed statistically significant improvement in physical HR-QoL, mental HR-QoL, depression, cervical pressure pain threshold, cervical extension movement, muscle function, and oculomotion. Per protocol analyses confirmed these results with additional significant improvements in the exercise group compared with controls.

CONCLUSIONS

This multimodal intervention may be an effective intervention for chronic neck pain patients.

TRIAL REGISTRATION

The trial was registered on www.ClinicalTrials.govNCT01431261 and at the Regional Scientific Ethics Committee of Southern Denmark S-20100069.

Responsiveness and minimal important change for the ProFitMap-neck questionnaire and the Neck Disability Index in women with neck-shoulder pain

Purpose

The aim was to determine the responsiveness and minimal important change (MIC) of the questionnaire ProFitMap-neck that measures symptoms and functional limitations in women with neck pain. The same measurement properties were determined for Neck Disability Index (NDI) for comparison purposes.

Methods

Longitudinal data were derived from two randomized controlled trials, including 103 and 120 women with non-specific neck pain, with questionnaire measurements performed before and after interventions. Sensitivity and specificity to discriminate between improved and not or little changed participants, based on categorization of a global rating of change scale (GRCS), were determined for the ProFitMap-neck indices and NDI by using area under receiver operating characteristic curves (AUC). Correlations between the GRCS anchor and change scores of the questionnaires were also used to assess responsiveness. The change score that showed the highest combination of sensitivity and specificity was set for MIC.

Results

The ProFitMap-neck indices showed similar responsiveness as NDI with AUC exceeding 0.70 (Range: ProFitMap-neck, 0.74–0.83; NDI, 0.75–0.86). The MIC in the two samples ranged between 6.6 and 13.6 % for ProFitMap-neck indices and 5.2 and 6.3 % for NDI. Both questionnaires had significant correlations with GRCS (Spearman’s rho 0.47–0.72).

Conclusions

Validity of change scores was endorsed for the ProFitMap-neck indices and NDI with adequate ability to discriminate between improved and not or little changed participants. Values of minimal important change were presented.

Classifying Whiplash Recovery Status Using the Neck Disability Index: Optimized Cutoff Points Derived From Receiver Operating Characteristic

OBJECTIVE

Researchers often use Neck Disability Index (NDI) scores to classify recovery status in whiplash patients. The purpose of this study was to investigate the optimal cutoff point score for the NDI as a mechanism for differentiating recovery from nonrecovery after whiplash.

METHODS

Subjects (N = 123) who had previously sustained whiplash injuries were recruited from 12 clinics. Subjects rated themselves as being recovered (36%) or nonrecovered (64%). This state variable was compared with their NDI score as test variable using the receiver operating characteristic statistic. The area under the receiver operating characteristic curve and optimized cutoff points were computed for the whole group and also dichotomized for sex and age.

RESULTS

The mean NDI score for the recovered group was 7.8. It was 27.1 for the nonrecovered group. The cutoff point that optimized sensitivity and specificity for the whole group was an NDI score of 15. For women, it was 19; for older persons, it was 21.

CONCLUSION

The optimal NDI score cutoff point for differentiating the recovery state after whiplash is 15. Misclassification errors are likely when using lower values.

Confirmatory Factor Analysis and Multiple Linear Regression of the Neck Disability Index: Assessment If Subscales Are Equally Relevant in Whiplash and Nonspecific Neck Pain

OBJECTIVE

Because of previously published recommendations to modify the Neck Disability Index (NDI), we evaluated the responsiveness and dimensionality of the NDI within a population of adult whiplash-injured subjects. The purpose of the present study was to evaluate the responsiveness and dimensionality of the NDI within a population of adult whiplash-injured subjects.

METHODS

Subjects who had sustained whiplash injuries of grade 2 or higher completed an NDI questionnaire. There were 123 subjects (55% female, of which 36% had recovered and 64% had chronic symptoms. NDI subscales were analyzed using confirmatory factor analysis, considering only the subscales and, secondly, using sex as an 11th variable. The subscales were also tested with multiple linear regression modeling using the total score as a target variable.

RESULTS

When considering only the 10 NDI subscales, only a single factor emerged, with an eigenvalue of 5.4, explaining 53.7% of the total variance. Strong correlation (> .55) (P < .0001) between all variables was found. Multiple linear regression modeling revealed high internal consistency with all coefficients reaching significance (P < .0001). The 4 NDI subscales exerting the greatest effect were, in decreasing order, Sleeping, Lifting, Headaches, and Pain Intensity.

CONCLUSION

A 2-factor model of the NDI is not justified based on our results, and in this population of whiplash subjects, the NDI was unidimensional, demonstrating high internal consistency and supporting the original validation study of Vernon and Mior.

The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: a randomized clinical trial

Objectives:

The aim of this study was to compare the effect on self-rated pain, disability, and self-efficacy of 3 interventions for the management of chronic whiplash-associated disorders: physiotherapist-led neck-specific exercise (NSE), physiotherapist-led NSE with the addition of a behavioral approach, or Prescription of Physical Activity (PPA).

Materials and Methods:

A total of 216 volunteers with chronic whiplash-associated disorders participated in this randomized, assessor blinded, clinical trial of 3 exercise interventions. Self-rated pain/pain bothersomeness (Visual Analogue Scale), disability (Neck Disability Index), and self-efficacy (Self-Efficacy Scale) were evaluated at baseline and at 3 and 6 months.

Results:

The proportion of patients reaching substantial reduction in pain bothersomness (at least 50% reduction) was more evident (P<0.01) in the 2 NSE groups (29% to 48%) compared with the PPA group (5%) at 3 months. At 6 months 39% to 44% of the patients in the 2 neck-specific groups and 28% in the PPA group reported substantial pain reduction. Reduction of disability was also larger in the 2 neck-specific exercise groups at both 3 and 6 months (P<0.02). Self-efficacy was only improved in the NSE group without a behavioral approach (P=0.02). However, there were no significant differences in any outcomes between the 2 physiotherapist-led NSE groups.

Discussion:

NSE resulted in superior outcomes compared with PPA in this study, but the observed benefits of adding a behavioral approach to the implementation of exercise in this study were inconclusive.

Structural and construct validity of the Whiplash Disability Questionnaire in adults with acute whiplash-associated disorders

BACKGROUND CONTEXT

Few instruments are available to measure disability associated with whiplash-associated disorders (WAD). The Whiplash Disability Questionnaire (WDQ) was developed to measure disability resulting from WAD, but its validity is unknown for acute WAD.

PURPOSE

The aim was to determine the structural and construct validity of the WDQ in individuals with acute WAD.

STUDY DESIGN/SETTING

This was a cohort study.

PATIENT SAMPLE

Ontario adults with WAD were enrolled within 3 weeks of their motor vehicle collision.

OUTCOME MEASURES

The outcome measure was the WDQ.

METHODS

We included insurance claimants who were aged 18 years or older and diagnosed with acute WAD Grades I to III. All participants completed the WDQ, a 13-item questionnaire scored from 0 (no disability) to 130 (complete disability). We assessed the factor structure of the WDQ and tested its construct validity against self-perceived recovery, neck pain (Numerical Rating Scale [NRS]), neck disability (Neck Disability Index [NDI] and Neck Bournemouth Questionnaire), health-related quality of life (36-Item Short Form Health Survey [SF-36]), and depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D]).

RESULTS

The mean age of the 130 participants was 42.1 years (standard deviation [SD]=13.2), and 70% were women. Twenty-six percent had WAD I, 73.1% had WAD II, and 0.8% had WAD III. Mean time since injury was 6.5 days (SD=4.9). The mean WDQ score was 49.8 (SD=29.1). Our analysis suggested that the WDQ includes two factors: daily activities and emotional status. This factor structure remained stable in sensitivity analyses (eg, zeros imputed for missing values, and the item with the most missing values or resulting in complex loading excluded). Strong correlations were found between the total WDQ score and the NDI, the Bournemouth questionnaire, the SF-36 physical function, and the NRS (for the neck, shoulder, mid and low back pain) satisfying a priori hypotheses. We found a priori hypothesized moderate correlations between the WDQ, and the CES-D and SF-36 mental function.

CONCLUSIONS

The WDQ includes two factors and has strong construct validity in individuals with acute WAD. Our results demonstrate that the WDQ is valid for use as an overall summative scale or as the daily activities and emotional subscales in clinical and research settings to determine disability status.

Patient-Reported Outcome (PRO) questionnaires for people with pain in any spine region. A systematic review

BACKGROUND/OBJECTIVE

This systematic review investigates the measurement properties of Patient-Reported Outcome (PRO) questionnaires which evaluate disability associated with pain in any area of the spine.

METHOD

PRO questionnaires for people with pain in any spinal region were identified from existing systematic reviews and recent studies. Databases were searched for studies which evaluated the measurement properties of the included questionnaires to August 2015. Data synthesis used a levels of evidence approach which considered study methodological quality.

RESULTS

The Extended Aberdeen Back Pain Scale (EA), Functional Rating Index (FRI) and Spine Functional Index (SFI) were identified as eligible for this review. The FRI was evaluated in 15 studies, with positive results for internal consistency, structural validity, hypothesis testing and responsiveness, negative results for measurement error and conflicting results for reliability. The SFI was evaluated in 3 studies with positive results for internal consistency, reliability, content validity, and structural validity. Conflicting results were found for hypothesis testing. The EA was evaluated in 3 studies which found negative results for internal consistency and structural validity.

CONCLUSIONS

The FRI is provisionally recommended for the assessment of disability in people with multi-area spinal pain. This conclusion is based on studies of mainly fair methodological quality.

Accurately measuring the quality and effectiveness of cervical spine surgery in registry efforts: determining the most valid and responsive instruments

BACKGROUND CONTEXT

There is a growing demand to measure the real-world effectiveness and value of care across all specialties and disease states. Prospective registries have emerged as a feasible way to capture real-world care across large patient populations. However, the proven validity of more robust and cumbersome patient-reported outcome instruments (PROi) must be balanced with what is feasible to apply in large-scale registry efforts. Hence, commercial registry efforts that measure quality and effectiveness of care in an attempt to guide quality improvement, pay for performance, or value-based purchasing should incorporate measures that most accurately represent patient-centered improvement.

PURPOSE

We set out to establish the relative validity and responsiveness of common PROi in accurately determining effectiveness of cervical surgery for neck and arm pain in registry efforts.

STUDY DESIGN

Prospective cohort study.

PATIENT SAMPLE

Eighty-eight patients undergoing primary anterior cervical discectomy and fusion (ACDF) for neck and arm pain.

OUTCOME MEASURES

Patient-reported outcome measures for pain (numeric rating scale for neck pain [NRS-NP] and arm pain [NRS-AP]), disability (neck disability index [NDI]), general health (short-form 12-item survey physical component summary [SF-12 PCS] and mental component summary [SF-12 MCS]), and quality of life (Euro-Qol-5D [EQ-5D]) were assessed.

METHODS

Eighty-eight patients undergoing primary ACDF for neck and arm pain were entered into a Web-based prospective registry. Baseline and 12-month patient-reported outcomes (NRS-NP, NRS-AP, NDI, SF-12 PCS, SF-12 MCS, and EQ-5D) were assessed. Patients were also asked whether they experienced a level of improvement after ACDF that met their expectation (meaningful improvement). To assess the validity of NRS-NP, NRS-AP, and NDI (measures of pain and disability) to discriminate between meaningful and nonmeaningful improvement and the validity of SF-12 PCS, SF-12 MCS, and EQ-5D (measures of general health and quality of life) to discriminate between meaningful and nonmeaningful improvement, receiver-operating characteristic curves were generated for each outcome instrument. The greater the area under the curve (AUC), the more valid the discriminator. The difference between standardized response means (SRMs) in patients reporting meaningful improvement versus not was calculated to determine the relative responsiveness of each outcome instrument to changes in pain and QOL after surgery.

RESULTS

For pain and disability, both NDI (AUC=0.75) and NRS-AP (AUC=0.74) were valid discriminators of meaningful improvement. Numeric rating scale for neck pain (AUC=0.69) was a poor discriminator. Neck disability index was also most responsive to postoperative improvement (SRM difference 0.78), followed by NRS-AP (SRM difference 0.59) and NRS-NP (SRM difference 0.46). For general health and quality of life, SF-12 PCS (AUC=0.79) was the only valid discriminator of meaningful improvement. Euro-Qol-5D (AUC=0.68) and SF-12 MCS (AUC=0.44) were poor discriminators. Short-form 12 physical component summary (SRM difference 1.08) was also most responsive compared with EQ-5D (SRM difference 0.89) and SF-12 MCS (SRM difference 0.01).

CONCLUSIONS

For pain and disability, NDI is the most valid and responsive measure of improvement after surgery for neck and arm pain. Numeric rating scale for neck pain and NRS-AP are poor substitutes for NDI when measuring effectiveness of care in registry efforts. For health-related quality of life, only SF-12 PCS could accurately discriminate meaningful improvement after cervical surgery and was found to be most valid and responsive. Large-scale registry efforts aimed at measuring effectiveness of cervical spine surgery should use NDI and SF-12 to accurately assess improvements in pain, disability, and quality of life.

Identifying upper limb disability in patients with persistent whiplash

BACKGROUND

Patients with persistent whiplash associated disorders (WAD) report upper limb (UL) symptoms and functional difficulties but there is limited information regarding the nature of these complaints. Impairments in motor performance may relate to functional deficits.

OBJECTIVE

To identify symptoms and the degree and nature of UL functional difficulties.

DESIGN

Cross sectional study.

METHODS

Twenty-four age matched subjects with persistent WAD and healthy controls were surveyed using the Disabilities of the Arm, Shoulder and Hand (DASH), Neck Disability Index (NDI) and Patient Specific Functional Scale (PSFS). A series of case studies on six subjects with persistent WAD and thirteen age and gender matched controls also had their motor performance assessed using a specialised UL testing battery, including reaction time, movement speed, accuracy, co-ordination and tapping speed.

RESULTS

The results suggest that UL symptoms and functional deficits are prevalent in persistent WAD. All individual item scores on the DASH, except one, were significantly higher in the WAD group and the DASH moderately correlated to pain, NDI and PSFS. Four-choice reaction time was the only motor performance measure that was significantly impaired in the WAD compared to control group and this correlated to pain levels.

CONCLUSIONS

The findings suggest the DASH is a suitable measure for subjects with persistent WAD and could be administered when high NDI scores are present or the patient specifically reports difficulty with UL activities. Further investigation regarding UL motor performance in subjects with persistent WAD is warranted to determine relationships between symptoms and reported functional deficits.

The effect of work-based mentoring on patient outcome in musculoskeletal physiotherapy: study protocol for a randomised controlled trial

BACKGROUND

Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of postgraduate clinical mentoring on physiotherapist performance have been assessed, but the impact of this mentoring on patient outcomes remains unknown. The objective of this trial is to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes in musculoskeletal physiotherapy.

METHODS/DESIGN

A stepped wedge cluster randomised controlled trial (CRCT) has been designed to recruit a minimum of 12 senior physiotherapists who work in musculoskeletal outpatient departments of a large National Health Service (NHS) organization. Participating physiotherapists will be randomised by cluster to receive the intervention at three time periods. Patients will be blinded to whether their physiotherapist has received the intervention. The primary outcome measure will be the Patient-Specific Functional Scale; secondary outcome measures will include the EQ-5D, patient activation, patient satisfaction and physiotherapist performance. Sample size considerations used published methods describing stepped wedge designs, conventional values of 0.80 for statistical power and 0.05 for statistical significance, and pragmatic groupings of 12 participating physiotherapists in three clusters. Based on an intergroup difference of 1.0 on the PSFS with a standard deviation of 2.0, 10 patients are required to complete outcome measures per physiotherapist, at time period 1 (prior to intervention roll-out) and at each of time periods 2, 3 and 4, giving a sample size of 480 patients. To account for the potential loss to follow-up of 33%, 720 sets of patient outcomes will be collected.All physiotherapist participants will receive 150 hours of mentored clinical practice as the intervention and usual in-service training as control. Consecutive, consenting patients attending treatment by the participating physiotherapists during data collection periods will complete outcome measures at baseline, discharge and 12 months post-baseline. The lead researcher will be blinded to the allocation of the physiotherapist when analyzing outcome data; statistical analysis will involve classical linear models incorporating both an intervention effect and a random intercept term to reflect systematic differences among clusters.

TRIAL REGISTRATION

Assigned 31 July 2012: ISRCTN79599220.

Evaluative measurement properties of the patient-specific functional scale for primary shoulder complaints in physical therapy practice

STUDY DESIGN

Clinical measurement, longitudinal.

OBJECTIVES

To assess the test-retest reliability, construct validity, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with a primary shoulder complaint.

BACKGROUND

Health measurement outcomes have become increasingly important for evaluating treatment. Patient-specific questionnaires are useful tools for determining treatment goals and evaluating treatment in individual patients. These questionnaires have not yet been validated in patients with nonspecific shoulder pain.

METHODS

Patients completed the PSFS, the numeric pain rating scale, and the Shoulder Pain and Disability Index at baseline, and after 1 week and 4 to 6 weeks. Test-retest reliability was determined using intraclass correlation coefficients. To assess convergent validity, change scores of the PSFS were correlated with the numeric pain rating scale and Shoulder Pain and Disability Index change scores. Responsiveness was assessed by calculating the area under the curve, the minimal clinically important change, and minimal detectable change, using the global rating of change as an external criterion.

RESULTS

Fifty patients (37 men; mean age, 47.7 years) participated in the study. Reliability was high (intraclass correlation coefficient = 0.87; 95% confidence interval [CI]: 0.72, 0.94). The correlations between the change scores of the PSFS and those of the Shoulder Pain and Disability Index and numeric pain rating scale were 0.45 (95% CI: 0.17, 0.80) and 0.55 (95% CI: 0.29, 0.73), respectively. The area under the curve for the PSFS was 0.67 (95% CI: 0.51, 0.83). The minimal detectable change and minimal clinically important change were 0.97 and 1.29 points, respectively.

CONCLUSION

These results suggest that the PSFS is a reliable, valid, and responsive instrument that can be used as an evaluative instrument in patients with a primary shoulder complaint.

Minimum important differences for the patient-specific functional scale, 4 region-specific outcome measures, and the numeric pain rating scale

STUDY DESIGN

Multicenter, prospective, longitudinal cohort study.

OBJECTIVES

To investigate the minimum important difference (MID) of the Patient-Specific Functional Scale (PSFS), 4 region-specific outcome measures, and the numeric pain rating scale (NPRS) across 3 levels of patient-perceived global rating of change in a clinical setting.

BACKGROUND

The MID varies depending on the external anchor defining patient-perceived "importance." The MID for the PSFS has not been established across all body regions.

METHODS

One thousand seven hundred eight consecutive patients with musculoskeletal disorders were recruited from 5 physical therapy clinics. The PSFS, NPRS, and 4 region-specific outcome measures-the Oswestry Disability Index, Neck Disability Index, Upper Extremity Functional Index, and Lower Extremity Functional Scale-were assessed at the initial and final physical therapy visits. Global rating of change was assessed at the final visit. MID was calculated for the PSFS and NPRS (overall and for each body region), and for each region-specific outcome measure, across 3 levels of change defined by the global rating of change (small, medium, large change) using receiver operating characteristic curve methodology.

RESULTS

The MID for the PSFS (on a scale from 0 to 10) ranged from 1.3 (small change) to 2.3 (medium change) to 2.7 (large change), and was relatively stable across body regions. MIDs for the NPRS (-1.5 to -3.5), Oswestry Disability Index (-12), Neck Disability Index (-14), Upper Extremity Functional Index (6 to 11), and Lower Extremity Functional Scale (9 to 16) are also reported.

CONCLUSION

We reported the MID for small, medium, and large patient-perceived change on the PSFS, NPRS, Oswestry Disability Index, Neck Disability Index, Upper Extremity Functional Index, and Lower Extremity Functional Scale for use in clinical practice and research.

Mechanical diagnosis and therapy has similar effects on pain and disability as 'wait and see' and other approaches in people with neck pain: a systematic review

QUESTIONS

In people with neck pain, does Mechanical Diagnosis and Therapy (MDT) reduce pain and disability more than 'wait and see'? Does MDT reduce pain and disability more than other interventions? Are any differences in effect clinically important?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

People with neck pain.

INTERVENTION

MDT.

OUTCOME MEASURES

Pain intensity and disability due to neck pain in the short (< 3 months), intermediate (< 1 year) and long term (≥ 1 year).

RESULTS

Five trials were included. Most comparisons demonstrated mean differences in effect that favoured MDT over wait-and-see controls or other interventions, although most were statistically non-significant. For pain, all comparisons had a 95% confidence interval (CI) with lower limits that were less than 20 on a scale of 0 to 100, which suggests that the difference may not be clinically important. For disability, even the upper limits of the 95% CI were below this threshold, confirming that the differences are not clinically important. In all of the trials, some or all of the treating therapists did not have the highest level of MDT training.

CONCLUSION

The additional benefit of MDT compared with the wait-and-see approach or other therapeutic approaches may not be clinically important in terms of pain intensity and is not clinically important in terms of disability. However, these estimates of the effect of MDT may reflect suboptimal training of the treating therapists. Further research could improve the precision of the estimates and assess whether the extent of training in MDT influences its effect.

Assessing the patient-specific functional scale's ability to detect early recovery following total knee arthroplasty

BACKGROUND

The Patient-Specific Functional Scale (PSFS) has received considerable attention over the last 2 decades; however, validation studies have not examined its performance in patients after total knee arthroplasty (TKA).

OBJECTIVE

The purpose of this study was to investigate the ability of the PSFS to detect change in patients post-TKA by comparing PSFS change scores with Lower Extremity Functional Scale (LEFS) and pooled impairment change scores.

METHODS

One hundred thirty-three patients participating in a post-TKA exercise class were assessed at their initial and discharge visits. Initial assessments occurred within 28 days of arthroplasty; follow-up assessments occurred within 80 days of surgery. At both assessments, participants completed the PSFS, LEFS, and the P4 pain measure, and their knee range of motion (ROM) and extensor strength were measured. The ability to detect change was expressed as the standardized response mean (SRM) and as a correlation between the PSFS change scores and 2 reference standards: (1) LEFS change scores and (2) pooled impairment change scores. The pooled impairment measure consisted of pain, ROM, and strength change scores.

RESULTS

The SRMs were PSFS 4.60 (95% confidence interval [CI]=4.00, 5.36) for the PSFS and 2.28 (95% CI=2.04, 2.60) for the LEFS. The correlation between the PSFS and pooled impairment change scores was 0.12 (95% CI=-0.04, 0.25), and the correlation between the PSFS and LEFS changes scores was 0.18 (0.02, 0.34).

LIMITATIONS

The order of measure administration was not standardized, and fixed activity set does not reflect clinical application in many instances.

CONCLUSIONS

The results suggest that the PSFS is adept at detecting improvement in patients post-TKA but that the PSFS, like other patient-specific measures, is likely to be of limited value in distinguishing different levels of change among patients.

Bee venom acupuncture, NSAIDs or combined treatment for chronic neck pain: study protocol for a randomized, assessor-blind trial

BACKGROUND

Chronic neck pain (CNP) is a common painful medical condition with a significant socioeconomic impact. In spite of widespread usage, the effectiveness and safety of combined treatments between conventional and complementary alternative medical treatment modalities has not been fully established in a rigorous randomized clinical trial (RCT). This pilot study will provide the clinical evidence to evaluate the feasibility and refine the protocol for a full-scale RCT on combined treatment of bee venom acupuncture (BVA) and non-steroidal anti-inflammatory drugs (NSAIDs) in patients with CNP.

METHODS/DESIGN

This is a randomized, single-blind clinical trial with three parallel arms. Sixty patients between 18 and 65 years of age with non-specific, uncomplicated neck pain lasting for at least three months will be enrolled. Participants will be randomly allocated into the BVA, NSAIDs or combined treatment group. Assessors and statisticians will be blinded to the random allocation. All researchers will receive training to ensure their strict adherence to the study protocol. Patients from the BVA and combined treatment group will be treated with a bee venom increment protocol into predefined acupoints for six sessions over a three week period. BVA intervention is developed through a comprehensive discussion among interdisciplinary spine disorder experts, according to the guidelines of Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA). Patients from the NSAIDs and combined treatment groups will be prescribed loxoprofen (one tablet to be taken orally, three times a day for three weeks). Bothersomeness from CNP measured using a visual analogue scale (VAS) will be the primary outcome assessed at screening, visit two (baseline), four, six, eight (4th week assessment) and nine (8th week assessment) follow-up session. VAS for pain intensity, neck disability index (NDI), quality of life, depressive status and adverse experiences will also be analyzed.

DISCUSSION

Our study results will contribute to feasibility evaluation and to relevant RCT protocol development for a full-scale RCT on combined treatment of BVA and NSAIDs for CNP patients.

TRIAL REGISTRATION

This study is registered with the United States (US) National Institutes of Health Clinical Trials Registry: NCT01922466.

Accurately Measuring Outcomes After Surgery for Adult Chiari I Malformation

BACKGROUND:

There has been a transition to using patient-reported outcome instruments (PROi) to assess surgical effectiveness. However, none of these instruments have been validated for outcomes of adult Chiari I malformation (CMI).

OBJECTIVE:

The aim of this study was to determine the relative validity and responsiveness of various PROi in measuring outcomes after surgery for CMI.

METHODS:

Fifty patients undergoing suboccipital craniotomy for adult CMI were prospectively followed for 1 year. Baseline and 1-year patient-reported outcomes (visual analog scale for head pain and visual analog scale for neck pain, Neck Disability Index [NDI], Headache Disability Index, SF-12, Zung Self-Rating Depression Scale, and EuroQol-5D [EQ-5D]) were assessed. A level of improvement in general health after surgery was defined as meaningful improvement. Receiver-operating characteristic curves were generated to assess the validity of PROi to discriminate between meaningful improvement and not. The difference between standardized response means (SRMs) in patients reporting meaningful improvement vs not as calculated to determine the relative responsiveness of each outcome instrument.

RESULTS:

For pain and disability, the NDI was the most accurate discriminator of meaningful effectiveness (area under the curve: 0.90) and also most responsive to postoperative improvement (standardized response means difference: 1.87). For general health and quality of life, the SF-12 PCS, EQ-5D, and Zung Self-Rating Depression Scale were all accurate discriminators; however, SF-12 Physical Component Scale (SF-12 PCS) and EQ-5D were most accurate. SF-12 PCS was also most responsive.

CONCLUSION:

For pain and disability, NDI is the most valid and responsive measure of improvement after surgery for CMI. For health-related quality of life, SF-12 PCS and EQ-5D are the most valid and responsive measures. NDI with SF-12 or EQ-5D is the most valid in patients with CMI and should be considered in cost-effectiveness studies.

Detecting relevant changes and responsiveness of Neck Pain and Disability Scale and Neck Disability Index

PURPOSE

To investigate relevant change on the Neck Pain and Disability Scale (NPAD) and Neck Disability Index (NDI) and which questionnaire is the most responsive in patients with non-specific chronic neck pain (CNP).

METHODS

Seventy-six patients with non-specific CNP in an outpatient tertiary rehabilitation setting were dichotomized into "improved" and "stable" based on global perceived effect (GPE) scores. To investigate relevant change minimal detectable change (MDC) and minimal important change (MIC) with the receiver operator characteristic (ROC) cut-off point were assessed. Comparison of responsiveness was performed using areas under the ROC curve (AUC) and correlations between change scores of NPAD and NDI, and GPE.

RESULTS

MDC and MIC on NPAD (scale 0-100) were 31.7 and 11.5 points, respectively. MDC and MIC on NDI (scale 0-50) were 8.4 and 3.5 points, respectively. Changes should exceed this MDC or MIC cut-off to be interpreted as relevant. AUC was 0.75 for both NPAD and NDI. Correlations between change scores of NPAD and NDI, and GPE were, respectively, 0.48 (95 % CI 0.29-0.64) and 0.49 (95 % CI 0.30-0.64).

CONCLUSIONS

Relevant change on both NPAD and NDI assessed with MDC and MIC resulted in different cut-offs and consequently with different amounts of certainty that the patient is improved. Responsiveness of NPAD and NDI was similar.

Measurement properties of disease-specific questionnaires in patients with neck pain: a systematic review

PURPOSE

To critically appraise and compare the measurement properties of the original versions of neck-specific questionnaires.

METHODS

Bibliographic databases were searched for articles concerning the development or evaluation of the measurement properties of an original version of a self-reported questionnaire, evaluating pain and/or disability, which was specifically developed or adapted for patients with neck pain. The methodological quality of the selected studies and the results of the measurement properties were critically appraised and rated using a checklist, specifically designed for evaluating studies on measurement properties.

RESULTS

The search strategy resulted in a total of 3,641 unique hits, of which 25 articles, evaluating 8 different questionnaires, were included in our study. The Neck Disability Index is the most frequently evaluated questionnaire and shows positive results for internal consistency, content validity, structural validity, hypothesis testing, and responsiveness, but a negative result for reliability. The other questionnaires show positive results, but the evidence for each measurement property is mostly limited, and at least 50% of the information on measurement properties per questionnaire is lacking.

CONCLUSIONS

Our findings imply that studies of high methodological quality are needed to properly assess the measurement properties of the currently available questionnaires. Until high quality studies are available, we recommend using these questionnaires with caution. There is no need for the development of new neck-specific questionnaires until the current questionnaires have been adequately assessed.

The patient-specific functional scale: validity, reliability, and responsiveness in patients with upper extremity musculoskeletal problems

STUDY DESIGN

Clinical measurement, longitudinal; multicenter prospective cohort study.

OBJECTIVES

To examine the validity, reliability, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with musculoskeletal upper extremity problems being treated in physical therapy.

BACKGROUND

The clinimetric properties of the PSFS have not been established nor compared with region-specific outcome measures in patients with upper extremity problems.

METHODS

Patients completed the PSFS, Upper Extremity Functional Index (UEFI), and numeric pain rating scale (NPRS) at baseline and follow-up, and were categorized as improved, stable, or worsened, using the global rating of change. Construct validity was assessed by comparing the change scores of the stable and improved groups, using independent-samples t tests. Reliability was evaluated using intraclass correlation coefficient (ICC2,1) with 95% confidence intervals. Bland-Altman plots determined limits of agreement. Responsiveness and minimal important difference (MID) were determined with receiver operator characteristic (ROC) curves.

RESULTS

One hundred eighty patients met the inclusion criteria. Construct validity was supported for the PSFS and the UEFI (P<.001). Reliability was moderate to good for the PSFS (ICC2,1 = 0.713) and UEFI (ICC2,1 = 0.848). Reported estimates of reliability may be lower than true values because the group of "stable" patients from this cohort had, on average, a small positive change. Bland-Altman plots indicated good agreement. The area under the ROC curve (AUC) was significantly different from the null value of 0.5 for the PSFS (0.887) and the UEFI (0.877), indicating good accuracy in distinguishing improved patients from stable patients. MID was 1.2 for the PSFS (scale, 0-10) and 8.5 for the UEFI (scale, 0-80).

CONCLUSION

The PSFS is a valid, reliable, and responsive outcome measure for patients with upper extremity problems.

The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure

STUDY DESIGN

Systematic review of the literature.

OBJECTIVE

To summarize peer-reviewed literature on the reliability, validity, and responsiveness of the Patient-Specific Functional Scale (PSFS), and to identify its use as an outcome measure.

METHODS

Searches were performed of several electronic databases from 1995 to May 2010. Studies included were published articles containing (1) primary research investigating the psychometric and clinimetrics of the PSFS or (2) the implementation of the PSFS as an outcome measure. We assessed the methodological quality of studies included in the first category.

RESULTS

Two hundred forty-two articles published from 1994 to May 2010 were identified. Of these, 66 met the inclusion criteria for this review, with 13 reporting the measurement properties of the PSFS, 55 implementing the PSFS as an outcome measure, and 2 doing both of the above. The PSFS was reported to be valid, reliable, and responsive in populations with knee dysfunction, cervical radiculopathy, acute low back pain, mechanical low back pain, and neck dysfunction. The PSFS was found to be reliable and responsive in populations with chronic low back pain. The PSFS was also reported to be valid, reliable, or responsive in individuals with a limited number of acute, subacute, and chronic conditions. This review found that the PSFS is also being used as an outcome measure in many other conditions, despite a lack of published evidence supporting its validity in these conditions.

CONCLUSION

Although the use of the PSFS as an outcome measure is increasing in physiotherapy practice, there are gaps in the research literature regarding its validity, reliability, and responsiveness in many health conditions.