Evaluation of the core outcome measure in whiplash

Minimal clinical datasets for spine-related musculoskeletal disorders in primary and outpatient care settings: a scoping review

OBJECTIVES

Effective measurement and monitoring of health status in patients with spine-related musculoskeletal (MSK) disorders are essential for providing appropriate care and improving outcomes. Minimal clinical datasets are standardized sets of key data elements and patient-centered outcomes that can be measured and recorded during routine clinical care. Our scoping review aimed to identify and map current evidence on minimal clinical datasets for measuring and monitoring health status in patients with spine-related MSK disorders in primary and outpatient healthcare settings.

STUDY DESIGN AND SETTING

We followed the JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. MEDLINE, CINAHL, Cochrane Library, Index to Chiropractic Literature, MANTIS, ProQuest Dissertations and Theses Global, and medRxiv preprint repository were searched from database inception to August 1, 2021. Two reviewers independently screened titles and abstracts, full-text articles, and charted the evidence. Findings were synthesized and summarized descriptively.

RESULTS

After screening 5,583 citations and 301 full-text articles, 104 studies about 32 individual minimal clinical datasets were included. Most minimal clinical datasets were developed for patient populations with spine-involving inflammatory arthritis, nonspecific or degenerative spinal pain, and MSK disorders in general. The minimal clinical datasets varied substantially in terms of the author-reported time-to-complete (1-48 minutes) and the number of items (5-100 items). Fifty percent of the datasets involved healthcare professionals in their development process, and only 28% involved patients. Health domain items were most frequently linked to the components of activities and participation (43.9%) and body functions (28.6%), according to the International Classification of Functioning, Disability, and Health. There is no standardized definition of minimal clinical datasets to measure and monitor health status of patients with spine-related MSK disorders in routine clinical practice. Common core elements identified were practicality, feasibility in a busy routine practice, time efficiency, and the capability to be used across different healthcare settings.

CONCLUSION

Due to the absence of a standard definition for minimal clinical datasets for patients with spine-related MSK disorders, there is a lack of consistency in the selection of key data elements and patient-centered outcomes that should be included. More research on the implementation and feasibility of minimal clinical datasets in routine care settings is warranted and needed. It is essential to involve all relevant partners in the development process of minimal clinical datasets to ensure successful implementation and adoption in routine primary care.

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.

Responsiveness of Minimal Clinically Important Change for the Persian Functional Rating Index in Patients with Chronic Low Back Pain

STUDY DESIGN

A prospective, within-group cohort study of 46 patients with chronic low-back pain (CLBP).

PURPOSE

To assess the responsiveness of the Persian Functional Rating Index (PFRI) and to determine the minimal clinically important change (MCIC) of the PFRI in a cohort of patients with CLBP.

OVERVIEW OF LITERATURE

The FRI is an instrument for assessing pain and disability in patients with low-back pain. No study so far has examined the responsiveness of the PFRI.

METHODS

Forty-six patients with CLBP with a mean age of 50.33±14.28 completed the PFRI, the Persian Roland-Morris Disability Questionnaire (PRMDQ), and a Visual Analog Scale (VAS) before and after 10 physiotherapy sessions. A Global Rating of Change Scale (GRCS) was completed after treatment.

RESULTS

The changes in PFRI scores were statistically significant using the paired t-test (p<0.001). The PFRI revealed high effect sizes (range, 0.93-1.82). The PFRI showed significant correlations with the VAS (0.86), the PRMDQ (0.66), and the GRCS (0.45). The area under the receiver operator characteristic curve for the PFRI was good (0.76; 95% confidence interval, 0.56-0.95). The MCIC for PFRI was 10.63 points.

CONCLUSIONS

The results supported the responsiveness of the PFRI in patients with CLBP and showed the amount of change in PFRI scores perceived as worthwhile by the patients.

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.

Urdu version of the neck disability index: a reliability and validity study

Background

Despite the wide use of the neck disability index (NDI) for assessing disability in patients with neck pain, the NDI has not yet been translated and validated in Urdu. The first purpose of the present study was to translate and cross-culturally adapt the NDI into the Urdu language (NDI-U). The second purpose was to investigate the reliability, validity and responsiveness of the NDI-U in Urdu-speaking patients experiencing chronic mechanical neck pain (CMNP).

Methods

Translation and cross-cultural adaptation of the original version of the NDI were carried out using previously described procedures. Seventy-six patients with CMNP and thirty healthy participants were recruited for the study. NDI-U and visual analogue scales for pain intensity (VAS_pain) and disability (VAS_disability) were administered to all the participants at baseline and to the patients 3 weeks after receiving physiotherapy intervention. The global rating of change scale (GROC) was also administered at this time. Test-retest reliability and internal consistency were carried out on forty-six randomly selected patients two days after they completed the NDI-U. The NDI-U was evaluated for factor analysis, content validity, construct validity (discriminative and convergent validity) and responsiveness.

Results

An intra-class correlation coefficient (ICC_2,1) revealed excellent test-retest reliability for all items (ICC_2,1 = 0.86–0.98) and total scores (ICC_2,1 = 0.99) of the NDI-U. The NDI-U was found internally consistent with a Cronbach’s alpha of 0.90 and a fair to good correlation between single items and the NDI-U total scores (r = 0.34 to 0.89). Factor analysis of the NDI-U produced two factors explaining 66.71% of the variance. Content validity was good, as no floor or ceiling effects were detected for the NDI-U total score. To determine discriminative validity, an independent t-test revealed a significant difference in the NDI-U total scores between the patients and healthy controls (P < 0.001). For convergent validity, Pearson’s correlation coefficient showed a strong correlation between NDI-U and VAS_disability (r = 0.83, P < 0.001) and a moderate correlation between NDI-U and VAS_pain (r = 0.62, P < 0.001). To measure responsiveness, an independent t-test showed a significant difference in the NDI-U change scores between the stable and the improved groups (P < 0.001). Furthermore, moderate correlations were found between the NDI-U change scores and the GROC (r = 0.50, P < 0.001), VAS_disability change scores (r = 0.58, P < 0.001) and VAS_pain change scores (r = 0.55, P < 0.001).

Conclusion

The results showed that the NDI-U is a reliable, valid and responsive questionnaire to measure disability in Urdu-speaking patients with CMNP.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1469-5) contains supplementary material, which is available to authorized users.

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.

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.

Validation of the simplified Chinese version of the functional rating index for patients with nonspecific neck pain in mainland China

STUDY DESIGN

Validation of a self-report questionnaire, Functional Rating Index (FRI).

OBJECTIVE

To evaluate the psychometric properties of the simplified Chinese (SC) version of FRI in patients with nonspecific neck pain (NP).

SUMMARY OF BACKGROUND DATA

FRI has been cross-culturally validated in few languages with excellent reliability, validity, and clinical utility when it is applied in patients with low back pain. Recently, it has been pointed out that FRI can be employed to assess patients with NP. However, FRI has not been validated in patients with NP in China.

METHODS

The cross-culturally adapted 10-item SC-FRI was completed by 122 patients with nonspecific NP, along with the Neck Disability Index, Neck Pain and Disability Scale, 36-Item Short Form Health Survey, and Pain Visual Analogue Scale. Psychometric evaluation included score distribution, internal consistency, test-retest reliability, and construct validity.

RESULTS

SC-FRI attained a high completion rate (96.9%). Each item was scored with a normal distribution without any floor and ceiling effects. The internal consistency and test-retest reliability were good to excellent (Cronbach α coefficient = 0.86; intraclass r = 0.97). Construct validity was confirmed by a strong correlation with Neck Disability Index, Neck Pain and Disability Scale, and Visual Analogue Scale (r = 0.77, 0.78, and 0.86, respectively, all P < 0.0001), and with the physical functioning and bodily pain domains (r = -0.69 and -0.66, respectively, both P < 0.0001), and by a weak correlation with the vitality, role-emotional, and mental health domains of 36-Item Short Form Health Survey.

CONCLUSION

SC-FRI showed satisfactory clinical utility, internal consistency, test-retest reliability, and construct validity in Chinese-speaking patients with nonspecific NP.

LEVEL OF EVIDENCE

3.

What does 'recovery' mean to people with neck pain? Results of a descriptive thematic analysis

OBJECTIVES

To describe the meaning of being recovered as perceived by people with chronic mechanical neck pain.

METHODS

To determine the way people with neck pain would describe a recovered state a descriptive thematic approach was used. A nominal focus group technique, written reflections, and one-on-one semi-structured interviews were used to collect sufficient data. Data from the focus groups were analyzed both through vote tallying and thematic analysis. Reflections and interviews were analyzed thematically by two independent researchers. Triangulation and member-checking were employed to establish trustworthiness of results.

RESULTS

A total of 35 people, primarily females with neck pain of traumatic origin, participated in this study. Thematic analysis identified 6 themes that adequately described the data: absent or manageable symptoms, having the physical capacity one ought to have, participation in life roles, feeling positive emotions, autonomy & spontaneity, and re-establishing a sense of self. Member checking and triangulation suggested data saturation and accuracy of the generated themes.

DISCUSSION

Recovery from neck pain appears to be informed by factors that fit with existing models of health, quality of life and satisfaction. Basing recovery solely on symptom or activity-level measures risks inaccurate estimates of recovery trajectories from traumatic or non-traumatic neck pain.

The functional rating index: reliability and validity of the Persian language version in patients with neck pain

STUDY DESIGN

Psychometric testing of the Persian Functional Rating Index (PFRI).

OBJECTIVE

To determine the reliability and validity of the PFRI in Persian-speaking subjects with neck pain (NP).

SUMMARY OF BACKGROUND DATA

The Functional Rating Index is a self-report questionnaire that can be used for patients with back pain or NP. The PFRI has been recently validated in patients with low back pain, whereas it is not validated in patients with NP.

METHODS

One hundred patients with NP, mean age of 42 years, participated in the study; 50 patients agreed to be tested on 2 occasions during a 7-day interval for the reliability phase of the study. A visual analogue scale, the Neck Disability Index, and the Neck Pain and Disability Scale were also completed to assess validity. Fifty healthy subjects completed the PFRI for discriminative validity.

RESULTS

Floor and ceiling effects were not observed. Independent t test showed a statistically significant difference in PFRI total scores between patients and healthy subjects supporting the discriminative validity of the PFRI (P < 0.001). PFRI and visual analogue scale demonstrated concurrent criterion validity, with Pearson correlation coefficients of 0.75 for test and 0.70 for retest. Construct validity was supported by a significant Pearson correlation between the PFRI and the Neck Disability Index (r = 0.72, P < 0.0001) and between the PFRI and the Neck Pain and Disability Scale (r = 0.63, P < 0.0001). Factor analysis revealed a 2-factor solution, which jointly accounted for 64.75% of the total variance. Additional factor analysis suggested 8-item PFRI as a unidimensional functional instrument for patients with NP. Internal consistency for the PFRI was high. (Cronbach α coefficients were 0.88 for test, 0.89 for retest, and 0.89 for 8-item PFRI.) Reproducibility assessed by test-retest reliability was excellent (intraclass correlation coefficient [ICC](agreement) of 0.96, P < 0.0001).

CONCLUSION

The PFRI is valid and reliable for use in a Persian-speaking population with NP.

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 functional rating index: reliability and validity of the Persian language version in patients with low back pain

STUDY DESIGN

Crosscultural adaptation and psychometric measurements of the Functional Rating Index (FRI).

OBJECTIVE

To develop and investigate the reliability and validity of the Persian version of the FRI when applied to patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The FRI is a self-report questionnaire designed to assess patient's perception of function and pain. Despite the use of this outcome measure in clinical trials in Iran, it was not translated and culturally adapted.

METHODS

The FRI was translated into Persian language and crossculturally adapted. The Persian FRI was administered to 100 patients with LBP (male patients/female patients = 22/78). A numerical rating scale, the Roland-Morris Disability Questionnaire, the Oswestry Disability Questionnaire, and the Quebec Back Pain Disability Scale were also recorded. The test-retest reliability (time interval = 7 days) was assessed in 50 patients.

RESULTS

There were no missing responses and floor or ceiling effects. The examination of discriminative validity showed that the questionnaire discriminated clearly between patients and healthy participants (P < 0.001). The concurrent criterion validity was confirmed by the Spearman rank correlation between the Persian FRI and the numerical rating scale (0.73, P < 0.0001 for test; and 0.77 for retest, P < 0.0001). Evidence for construct validity was found with a significant Pearson correlation between the FRI and the Roland-Morris Disability Questionnaire (r = 0.61; P < 0.0001), the Oswestry Disability Questionnaire (r = 0.75; P < 0.0001), or Quebec Back Pain Disability Scale (r = 0.76; P < 0.0001). Internal consistency reliability estimates (Cronbach α) for the Persian FRI were high, with 0.89 for test and 0.92 for retest. The test-retest reliability for the total score was excellent with an intraclass correlation coefficient (agreement) (ICCagreement) of 0.81 (P < 0.0001).

CONCLUSION

The Persian version of the FRI seems to have an excellent reliability and validity when applied to patients with LBP.

Global rating of change scales: a review of strengths and weaknesses and considerations for design

Most clinicians ask their patients to rate whether their health condition has improved or deteriorated over time and then use this information to guide management decisions. Many studies also use patient-rated change as an outcome measure to determine the efficacy of a particular treatment. Global rating of change (GRC) scales provide a method of obtaining this information in a manner that is quick, flexible, and efficient. As with any outcome measure, however, meaningful interpretation of results can only be undertaken with due consideration of the clinimetric properties, strengths, and weaknesses of the instrument. The purpose of this article is to summarize this information to assist appropriate interpretation of the GRC results and to provide evidence-informed advice to guide design and administration of GRC scales. These considerations are relevant and applicable to the use of GRC scales both in the clinic and in research.

Methodological quality of studies on the measurement properties of neck pain and disability questionnaires: a systematic review

OBJECTIVE

The aim of this study was to obtain an overview of the methodological quality of studies on the measurement properties of neck pain and disability questionnaires and to describe how well various aspects of the design and statistical analyses of studies on measurement properties are performed.

METHODS

A systematic review was performed of published studies on the measurement properties of neck pain and disability questionnaires. Two reviewers independently rated the quality of the studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. This checklist was developed in an international Delphi consensus study.

RESULTS

A total of 47 articles were included on the measurement properties of 8 different questionnaires. The methodological quality of the included studies was adequate on some aspects (often, adequate statistical analyses are used for assessing reliability, measurement error, and construct validity) but can be improved on other aspects. The most important methodological aspects that need to be improved are as follows: assessing unidimensionality in internal consistency analysis, stable patients and similar test conditions in studies on reliability and measurement error, and more emphasis on the relevance and comprehensiveness of the items in content validity studies. Furthermore, it is recommended that studies on construct validity and responsiveness should be based on predefined hypotheses and that better statistical methods should be used in responsiveness studies.

CONCLUSION

Considering the importance of adequate measurement properties, it is concluded that, in the field of measuring neck pain and disability, there is room for improvement in the methodological quality of studies measurement properties.

Measurement properties of the neck disability index: a systematic review

STUDY DESIGN

Systematic review of clinical measurement.

OBJECTIVE

To find and synthesize evidence on the psychometric properties and usefulness of the neck disability index (NDI).

BACKGROUND

The NDI is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations.

METHODS AND MEASURES

Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed.

RESULTS

Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement [SEM] or minimum detectable change [MDC]). Most studies suggest that the NDI has acceptable reliability, although intraclass correlation coefficients (ICCs) range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The NDI is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The MDC is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference (CID) is inconsistent across different studies ranging from 5/50 to 19/50. The NDI is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health.

CONCLUSION

The NDI has sufficient support and usefulness to retain its current status as the most commonly used self-report measure for neck pain. More studies of CID in different clinical populations and the relationship to subjective/work/function categories are required.

Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations

BACKGROUND

Musculoskeletal problems such as low back pain, neck, knee and shoulder pain are leading causes of disability and activity limitation in adults and are most frequently managed within primary care. There is a clear trend towards large, high quality trials testing the effectiveness of common non-pharmacological interventions for these conditions showing, at best, small to moderate benefits. This paper summarises the main lessons learnt from recent trials of the effectiveness of non-pharmacological therapies for common musculoskeletal conditions in primary care and provides agreed research priorities for future clinical trials.

METHODS

Consensus development using nominal group techniques through national (UK) and international workshops. During a national Clinical Trials Thinktank workshop in April 2007 in the UK, a group of 30 senior researchers experienced in clinical trials for musculoskeletal conditions and 2 patient representatives debated the possible explanations for the findings of recent high quality trials of non-pharmacological interventions. Using the qualitative method of nominal group technique, these experts developed and ranked a set of priorities for future research, guided by the evidence from recent trials of treatments for common musculoskeletal problems. The recommendations from the national workshop were presented and further ranked at an international symposium (hosted in Canada) in June 2007.

RESULTS

22 recommended research priorities were developed, of which 12 reached consensus as priorities for future research from the UK workshop. The 12 recommendations were reduced to 7 agreed priorities at the international symposium. These were: to increase the focus on implementation (research into practice); to develop national musculoskeletal research networks in which large trials can be sited and smaller trials supported; to use more innovative trial designs such as those based on stepped care and subgrouping for targeted treatment models; to routinely incorporate health economic analysis into future trials; to include more patient-centred outcome measures; to develop a core set of outcomes for new trials of interventions for musculoskeletal problems; and to focus on studies that advance methodological approaches for clinical trials in this field.

CONCLUSION

A set of research priorities for future trials of non-pharmacological therapies for common musculoskeletal conditions has been developed and agreed through national (UK) and international consensus processes. These priorities provide useful direction for researchers and research funders alike and impetus for improvement in the quality and methodology of clinical trials in this field.

Psychometric characteristics of the Spanish version of instruments to measure neck pain disability

BACKGROUND

The NDI, COM and NPQ are evaluation instruments for disability due to NP. There was no Spanish version of NDI or COM for which psychometric characteristics were known. The objectives of this study were to translate and culturally adapt the Spanish version of the Neck Disability Index Questionnaire (NDI), and the Core Outcome Measure (COM), to validate its use in Spanish speaking patients with non-specific neck pain (NP), and to compare their psychometric characteristics with those of the Spanish version of the Northwick Pain Questionnaire (NPQ).

METHODS

Translation/re-translation of the English versions of the NDI and the COM was done blindly and independently by a multidisciplinary team. The study was done in 9 primary care Centers and 12 specialty services from 9 regions in Spain, with 221 acute, subacute and chronic patients who visited their physician for NP: 54 in the pilot phase and 167 in the validation phase. Neck pain (VAS), referred pain (VAS), disability (NDI, COM and NPQ), catastrophizing (CSQ) and quality of life (SF-12) were measured on their first visit and 14 days later. Patients' self-assessment was used as the external criterion for pain and disability. In the pilot phase, patients' understanding of each item in the NDI and COM was assessed, and on day 1 test-retest reliability was estimated by giving a second NDI and COM in which the name of the questionnaires and the order of the items had been changed.

RESULTS

Comprehensibility of NDI and COM were good. Minutes needed to fill out the questionnaires [median, (P25, P75)]: NDI. 4 (2.2, 10.0), COM: 2.1 (1.0, 4.9). Reliability: [ICC, (95%CI)]: NDI: 0.88 (0.80, 0.93). COM: 0.85 (0.75,0.91). Sensitivity to change: Effect size for patients having worsened, not changed and improved between days 1 and 15, according to the external criterion for disability: NDI: -0.24, 0.15, 0.66; NPQ: -0.14, 0.06, 0.67; COM: 0.05, 0.19, 0.92.

VALIDITY

Results of NDI, NPQ and COM were consistent with the external criterion for disability, whereas only those from NDI were consistent with the one for pain. Correlations with VAS, CSQ and SF-12 were similar for NDI and NPQ (absolute values between 0.36 and 0.50 on day 1, between 0.38 and 0.70 on day 15), and slightly lower for COM (between 0.36 and 0.48 on day 1, and between 0.33 and 0.61 on day 15). Correlation between NDI and NPQ: r = 0.84 on day 1, r = 0.91 on day 15. Correlation between COM and NPQ: r = 0.63 on day 1, r = 0.71 on day 15.

CONCLUSION

Although most psychometric characteristics of NDI, NPQ and COM are similar, those from the latter one are worse and its use may lead to patients' evolution seeming more positive than it actually is. NDI seems to be the best instrument for measuring NP-related disability, since its results are the most consistent with patient's assessment of their own clinical status and evolution. It takes two more minutes to answer the NDI than to answer the COM, but it can be reliably filled out by the patient without assistance.

TRIAL REGISTRATION

Clinical Trials Register NCT00349544.

Legislative change is associated with improved health status in people with whiplash

STUDY DESIGN

Interrupted time series.

OBJECTIVE

To assess whether a change in legislation improved health status and quality of life for people with whiplash.

SUMMARY OF BACKGROUND DATA

Whiplash was the most prevalent injury in a compulsory, fault based, third party motor vehicle insurance scheme in New South Wales, Australia. Legislative change removed financial compensation for "pain and suffering" for whiplash, introduced clinical practice guidelines for its treatment; and changed regulations to permit earlier acceptance of compensation claims, and earlier access to treatment, for all types of injury.

METHODS

Three independent groups of people with whiplash were identified from insurance data (before legislative change--the 1999 group and, after legislative change--the 2001 and 2003 groups). Health status was assessed 2 years after injury by a telephone interviewer blinded to the study hypotheses. The main outcome measure was disability, as assessed by the Functional Rating Index (FRI). Pain and health-related quality of life was also assessed.

RESULTS

The mean FRI at 2 years after injury was 38.0% (SE, 1.9) for the 1999 group, 31.8% (SE, 2.1) for the 2001 group, and 30.1% (SE, 1.8) for the 2003 group (F = 5.0, P = 0.007). Improvement in secondary outcomes, including pain, also occurred.

CONCLUSION

Health status of people with whiplash improved after legislative change. Design of compensation schemes should be undertaken with the understanding that the scheme structure may have substantial effects on the long-term health of injured people.