Reliability and responsiveness of the Dutch version of the Neck Disability Index in patients with acute neck pain in general practice

Does having an external focus in immersive virtual reality increase range of motion in people with neck pain?

BACKGROUND

When instructing exercises to improve Range of Motion (ROM), clinicians often create an internal focus of attention, while motor performance may improve more when using an external focus.

OBJECTIVES

Using Virtual Reality (VR), we investigated the effect of tasks with an internal and external focus on maximal ROM in people with neck pain and explored whether this effect was associated with fear of movement.

METHOD

In this cross-over experimental design study, the cervical ROM of 54 participants was measured while performing a target-seeking exercise in a VR-environment (external focus task) and during three maximal rotation and flexion-extension movements with the VR-headset on, without signal (internal focus task). The main statistical analysis included two dependent T-tests. Pearson correlation coefficients were calculated to investigate whether the differences in ROM in both conditions were correlated to fear of movement.

RESULTS

Maximal neck rotation was larger in the external focus condition than in the internal focus condition (mean difference: 26.4°, 95% CI [20.6, 32.3]; p < 0.001, d = 1.24). However, there was a difference favouring the internal focus condition for flexion-extension (mean difference: 8.2°, 95% CI [-14.9, -1.5]; p = 0.018, d = 0.33). The variability in ROM was not explained by variability in fear of movement (for all correlations p ≥ 0.197).

CONCLUSION

An external focus resulted in a larger range of rotation, but our flexion-extension findings suggest that the task has to be specific to elicit such an effect. Further research, using a task that sufficiently elicits movement in all directions, is needed to determine the value of an external focus during exercise.

Illness perceptions in people with chronic and disabling non-specific neck pain seeking primary healthcare: a qualitative study

BACKGROUND

Illness perceptions can affect the way people with musculoskeletal pain emotionally and behaviorally cope with their health condition. Understanding patients illness perceptions may help facilitate patient-centered care. The purpose of this study was to explore illness perceptions and the origin of those perceptions in people with chronic disabling non-specific neck pain seeking primary care.

METHODS

A qualitative study using a deductive and inductive analytical approach was conducted in 20 people with persistent (> 3 months) and disabling (i.e., Neck Disability Index ≥ 15) neck pain. Using a semi-structured format, participants were interviewed about their illness perceptions according to Leventhal's Common Sense Model. Purposive sampling and member checking were used to secure validity of study results.

RESULTS

Participants reported multiple symptoms, thoughts and emotions related to their neck pain, which continuously required attention and action. They felt trapped within a complex multifactorial problem. Although some participants had a broader biopsychosocial perspective to understand their symptoms, a biomedical perspective was dominant in the labelling of their condition and their way of coping (e.g., limiting load, building strength and resilience, regaining mobility, keep moving and being meaningful). Their perceptions were strongly influenced by information from clinicians. Several participants indicated that they felt uncertain, because the information they received was contradictory or did not match their own experiences.

CONCLUSION

Most participants reported that understanding their pain was important to them and influenced how they coped with pain. Addressing this 'sense making process' is a prerequisite for providing patient-centered care.

Cross-Cultural Adaptation and Psychometric Validation of the Hindi Version of the Neck Disability Index in Patients With Chronic Neck Pain

STUDY DESIGN

Translation and psychometric testing.

OBJECTIVES

To cross-culturally adapt the Neck Disability Index (NDI) into the Hindi language, the local language of India, and to investigate the psychometric properties of the Neck Disability Index-Hindi (NDI-H) version in patients with neck pain.

SUMMARY OF BACKGROUND DATA

The NDI is the most used self-reported outcome measure for neck pain. The previous NDI-H version did not obtain advance permission from Mapi trust to translate this scale. As a result, this scale's availability is limited.

MATERIALS AND METHODS

Following established guidelines, the NDI was translated and culturally adapted into Hindi. A total of 120 chronic neck pain patients (20 for cognitive interviews and 100 for psychometric testing) participated in this study. The content validity, construct validity, internal consistency, test-retest reliability, and responsiveness of the NDI-H were all evaluated. The intraclass correlation coefficient was computed to determine test-retest reliability. Internal consistency was assessed using Cronbach α. The NDI's factor structure was investigated using principal component factor analysis. The Neck Pain and Disability Scale, Numeric Pain Rating Scale, and Anxiety and Depression scales were used to test criterion validity. The receiver operating characteristic curve analysis was used to determine the cut-off point and the area under the curve.

RESULTS

The NDI-H demonstrated good test-retest reliability (intraclass correlation coefficient = 0.92) and excellent internal consistency (Cronbach α = 0.90). The one-factor structure was revealed by the factor analysis. The NDI has a strong relationship with the Neck Pain and Disability Scale and Numeric Pain Rating Scale, as well as the Anxiety and Depression scales. The cut-point for detecting a change was 9.3.

CONCLUSIONS

The NDI was successfully translated into Hindi in this study. The NDI-H is a reliable and valid and responsive instrument that can be used to treat patients with chronic neck pain in clinical and research settings.

Visual feedback manipulation in virtual reality to influence pain-free range of motion. Are people with non-specific neck pain who are fearful of movement more susceptible?

BACKGROUND

Movement-evoked pain may have a protective or learned component, influenced by visual cues which suggest that the person is moving towards a position that may be perceived as threatening. We investigated whether visual feedback manipulation in virtual reality (VR) had a different effect on cervical pain-free range of motion (ROM) in people with fear of movement.

METHOD

In this cross-sectional study, seventy-five people with non-specific neck pain (i.e., neck pain without a specific underlying pathology) rotated their head until the onset of pain, while wearing a VR-headset. Visual feedback about the amount of movement was equal, 30% smaller or 30% larger than their actual rotation. ROM was measured using the VR-headset sensors. The effect of VR manipulation in fearful (N = 19 using the Tampa Scale for Kinesiophobia (TSK) and N = 18 using the Fear Avoidance Beliefs Questionnaire-physical activity (FABQpa)) and non-fearful (N = 46; non-fearful on both scales) people was compared using mixed-design ANOVAs.

RESULTS

Fear of movement, influenced the effect of visual feedback manipulation on cervical pain-free ROM (TSK: p = 0.036, ղp2 = 0.060; FABQpa: p = 0.020, ղp2 = 0.077); a greater amplitude of pain-free movement was found when visual feedback reduced the perceived rotation angle compared to the control condition (TSK: p = 0.090, ղp2 = 0.104; FABQpa: p = 0.030, ղp2 = 0.073). Independent of the presence of fear, visual feedback manipulation reduced the cervical pain-free ROM in the overstated condition (TSK: p< 0.001, ղp2 = 0.195; FABQpa: p<0.001, ղp2 = 0.329).

DISCUSSION

Cervical pain-free ROM can be influenced by visual perception of the amount of rotation and people with fear of movement seem to be more susceptible to this effect. Further research in people with moderate/severe fear is needed to determine whether manipulating visual feedback may have clinical applicability to make patients aware that ROM may be influenced more by fear than tissue pathology.

Long-term results of the NECK trial-implanting a disc prosthesis after cervical anterior discectomy cannot prevent adjacent segment disease: five-year clinical follow-up of a double-blinded randomised controlled trial

BACKGROUND CONTEXT

Motion preserving anterior cervical disc arthroplasty (ACDA) in patients with cervical radiculopathy was introduced to prevent symptomatic adjacent segment disease as compared to anterior cervical discectomy and fusion (ACDF).

PURPOSE

To evaluate the long-term outcome in patients with cervical radiculopathy due to a herniated disc undergoing ACDA, ACDF or ACD (no cage, no plate) in terms of clinical outcome measured by the Neck Disability Index (NDI). Likewise, clinically relevant adjacent segment disease is assessed as a long-term result.

STUDY DESIGN

Double-blinded randomized controlled trial.

PATIENT SAMPLE

A total of 109 patients with one level herniated disc were randomized to one of the following treatments: ACDA, ACDF with intervertebral cage, ACD without cage.

OUTCOME MEASURES

Clinical outcome was measured by patients' self-reported NDI, Visual Analogue Scale (VAS) neck pain, VAS arm pain, SF36, EQ-5D, perceived recovery and reoperation rate. Radiological outcome was assessed by radiographic cervical curvature and adjacent segment degeneration (ASD) parameters at baseline and up until five years after surgery.

METHODS

To account for the correlation between repeated measurements of the same individual Generalized Estimated Equations (GEE) were used to calculate treatment effects, expressed in difference in marginal mean values for NDI per treatment group.

RESULTS

Clinical outcome parameters were comparable in the ACDA and ACDF group, but significantly worse in the ACD group, though not reaching clinical relevance. Annual reoperation rate was 3.6% in the first two years after surgery, declined to 1.9% in the years thereafter. The number of reoperations for ASD was not lower in the ACDA group, while the number of reoperations at the index level was higher after ACD, when compared to ACDF and ACDA.

CONCLUSIONS

A persisting absence of clinical superiority was demonstrated for the cervical disc prosthesis five years after surgery. Specifically, clinically relevant adjacent level disease was not prevented by implanting a prosthesis. Single level ACD without implanting an intervertebral device provided worse clinical outcome, which was hypothesized to be caused by delayed fusion. This stresses the need for focusing on timely fusion in future research.

A randomized controlled trial on the effects of "Global Postural Re-education" versus neck specific exercise on pain, disability, postural control, and neuromuscular features in women with chronic non-specific neck pain

BACKGROUND

Neck pain is associated with decreased health-related quality of life, decreased work productivity, and increased visits to health care providers.

AIM

The aim of this study was to assess the effectiveness of "Global Postural Re-education" (GPR) versus a neck specific exercise (SE) program on neck pain, disability, cervical range of movement, postural stability, and activity of the superficial cervical flexor muscles.

DESIGN

A parallel-group and single-blinded clinical trial.

SETTING

Community interventions.

POPULATION

Fifty women with non-specific chronic neck pain (NSCNP).

METHODS

Participants were randomly assigned to one of the two intervention groups (GPR [N.=25] or SE [N.=25]). Both interventions consisted of eight sessions of ~40 minutes duration, performed twice a week, for four weeks. Outcomes included neck pain intensity and disability, cervical range of motion (CROM), postural sway, and activity of the superficial neck flexor muscles during a cranio-cervical flexion test (CCFT). All outcomes were assessed twice before the intervention and immediately following eight treatment sessions over four weeks.

RESULTS

Both interventions were equally effective in reducing neck pain (P<0.001, ŋp²=0.770) and disability (P<0.001, ŋp²=0.306), improving neck mobility (P<0.001, 0.385≤ŋp²≤0.623, for all measurements) and decreasing the activity of the superficial cervical flexor muscles (P>0.001). Neither intervention altered postural sway.

CONCLUSIONS

Our results revealed that GPR and SE induced significant positive results in all measures apart from postural stability but with no difference between the interventions.

CLINICAL REHABILITATION IMPACT

"Global Postural Re-education" (GPR) and neck SE interventions are equally effective in reducing neck pain and disability, and improving neck mobility in women with NSCNP. Overall, this study indicates that GPR and SE interventions can be used to effectively manage patients with NSCNP.

The type of cervical disc herniation on MRI does not correlate to clinical outcomes

AIMS

The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment.

METHODS

The type and extent of disc herniation at the time of presentation in 108 patients who underwent anterior discectomy for cervical radiculopathy were analyzed on MRI, using a four-point scale. These were dichotomized into disc bulge and disc herniation groups. Clinical outcomes were evaluated using the Neck Disability Index (NDI), 36-Item Short Form Survey (SF-36), and a visual analogue scale (VAS) for pain in the neck and arm at baseline and two years postoperatively. The perceived recovery was also assessed at this time.

RESULTS

At baseline, 46 patients had a disc bulge and 62 had a herniation. There was no significant difference in the mean NDI and SF-36 between the two groups at baseline. Those in the disc bulge group had a mean NDI of 44.6 (SD 15.2) compared with 43.8 (SD 16.0) in the herniation group (p = 0.799), and a mean SF-36 of 59.2 (SD 6.9) compared with 59.4 (SD 7.7) (p = 0.895). Likewise, there was no significant difference in the incidence of disabling arm pain in the disc bulge and herniation groups (84% vs 73%; p = 0.163), and no significant difference in the incidence of disabling neck pain in the two groups (70.5% (n = 31) vs 63% (n = 39); p = 0.491). At two years after surgery, no significant difference was found in any of the clinical parameters between the two groups.

CONCLUSION

In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively.Cite this article: Bone Joint J 2022;104-B(11):1242-1248.

Responsiveness of the German version of the Neck Disability Index in chronic neck pain patients: a prospective cohort study with a seven-week follow-up

Background

The need for an efficient and feasible strategy to deal with neck pain has a high priority for many countries. Validated assessment tools like the Neck Disability Index (NDI) to evaluate the functional status of a neck pain patient are urgently needed to treat and to follow-up patients purposefully. A German version (NDI-G) was shown to be valid and reliable, but has so far not been tested for responsiveness. The aim of this study was to evaluate the NDI-G`s responsiveness.

Methods

This was a prospective cohort study with a seven-week follow-up. Fifty chronic neck pain patients filled out NDI-G twice. Additionally, the Patients’ Global Impression of Change score (PGIC) was assessed at follow-up. Wilcoxon and Spearman tests were used to assess direction and strength of the association between the change in NDI-G and PGIC. The receiver operating characteristics method and the area under the curve (AUC) were calculated to assess sensitivity and specificity of the NDI-G change over time.

Results

The Wilcoxon test showed statistically significant differences for NDI-G at baseline and follow-up in the total sample, the “clinically improved” and “clinically not improved” subgroups as indicated in the PGIC. Spearman test resulted in a moderate correlation between the NDI-G and the PGIC (rS = -0.53, p = 0.01) at follow-up. AUC showed an acceptable discrimination [AUC = 0.78 (95% confidence interval 0.64 – 0.91)] of the NDI-G, with a cutoff score of 1.5, between clinically improved and clinically not improved patients, based on the PGIC.

Conclusions

The NDI-G is responsive to change in chronic neck pain. Together with the results of a previous study on its validity and reliability, the NDI-G can be recommended for research and clinical settings in patients with neck pain in German speaking countries.

Trial registration

NCT02676141. February 8, 2016.

The Clinical Relevance of the Cervical Disc Prosthesis: Combining Clinical Results of Two RCTs

STUDY DESIGN

Retrospective analysis was performed on data from 251 patients that were included in two randomized, double-blinded clinical trials comparing clinical results of anterior cervical discectomy and arthroplasty (ACDA) to anterior cervical discectomy and fusion (ACDF), and anterior cervical discectomy (ACD), for single-level disc herniation.

OBJECTIVE

This study aimed to investigate whether the ACDA procedure offers superior clinical results 2 years after surgery, to either ACDF or ACD without instrumentation, in the entire group of patients or in a particular subgroup of patients.

SUMMARY OF BACKGROUND DATA

The cervical disc prosthesis was introduced to provide superior clinical outcomes after ACD.

METHODS

Neck Disability Index (NDI), and subscales of the 36-item short-form health survey (SF-36) and McGill pain score were collected at baseline, 1 year and 2 years after surgery. Reoperations and complications were also evaluated. A preliminary subgroup analysis was performed for age, disc height, body mass index (BMI), smoking, and sex.

RESULTS

The NDI decreased comparably in all treatment arms to circa 50% of the baseline value and marginal mean NDI differences varied from 0.4 to 1.1 on a 100 point NDI scale, with confidence intervals never exceeding the 20-point minimal clinical important difference (MCID). Secondary outcome parameters showed comparable results. Preliminary subgroup analysis could not demonstrate clinically relevant differences in NDI between treatments after 2 years.

CONCLUSION

After combining data from two Randomized Controlled Trials it can be concluded that there is no clinical benefit for ACDA, when compared with ACDF or ACD 2 years after surgery. Preliminary subgroup analysis indicated outcomes were similar between treatment groups, and that no subgroup could be appointed that benefited more from either ACD, ACDF, or ACDA.Level of Evidence: 1.

The impact of mental health on outcome after anterior cervical discectomy: cohort study assessing the influence of mental health using predictive modelling

BACKGROUND

Depression and anxiety are common mental disorders among patients with chronic pain. It is hypothesised that patients suffering from these disorders benefit less from cervical spine surgery than mentally healthy patients. Therefore, this study aimed to quantify the effect of mental health status on functional outcome after anterior cervical discectomy in a post hoc analysis on RCT data.

METHODS

One hundred eight patients from the NECK trial, with radiculopathy due to a one-level herniated disc, underwent anterior cervical discectomy and were included into this analysis. Functional outcome was quantified using the Neck Disability Index (NDI), and mental health status was measured using the Hospital Anxiety and Depression Score (HADS) questionnaire. NDI differences were assessed using generalised estimated equations (GEE), crude means, a predictive linear mixed model (LMM) using baseline scores and over time with an explanatory LMM.

RESULTS

At baseline, 24% and 32% of patients were respectively depressed and anxious and had statistically significant and clinically relevant higher NDI scores during follow-up. However, in those patients in which the HADS returned to normal during follow-up, NDI values decreased comparably to the non-depression or non-anxiety cases. Those patients that demonstrated persisting high HADS values had convincingly worse NDI scores. A predictive LMM showed that combining baseline NDI and HADS scores was highly predictive of NDI during follow-up. The R shiny application enabled the effective, visual communication of results from the predictive LMM.

CONCLUSION

This study shows that mental health status and disability are strongly associated and provides insight into the size of the effect, as well as a way to use this relation to improve preoperative patient counselling. These findings give rise to the suggestion that incorporating mental health screening in the preoperative assessment of patients could help to adequately manage patients' expectations for functional recovery.

TRIAL REGISTRATION

Dutch Trial Register Number: NTR1289.

Transcultural adaptation of the neck disability index to mexican spanish and assessment of its psychometric properties

PURPOSE

To transculturally adapt the Neck Disability Index to Mexican Spanish (NDI-Mx) and to evaluate its psychometric properties.

METHODS

Translation and transcultural adaptation of the NDI were conducted according to published guidelines. The test-retest reliability of the NDI-Mx was assessed with intraclass correlation coefficient (ICC_3,1), the student t-test, standard error of measurement, minimal detectable change and Bland-Altman plot. Cronbach's α coefficient was used to evaluate internal consistency. Floor and ceiling effects were also evaluated. Convergent validity was assessed by comparison of the NDI-Mx with the Northwick Park Neck Pain Questionnaire (NPQ) through the Spearman correlation coefficient. Finally, a confirmatory factor analysis (CFA) was conducted.

RESULTS

The sample was composed of 113 subjects (38 men and 75 women) with a mean age of 30 (SD, 12.19) years. All items of the NDI-Mx showed good test-retest reliability (ICC_3,1 = 0.86) and good internal consistency (Cronbach's α = 0.85). Floor and ceiling effects were not observed. There was good convergent validity with a high correlation between NDI-Mx and NPQ (ρ = 0.83). The CFA revealed that a one-factor solution fitted adequately the data (χ²(32) = 41.18, p = .13).

CONCLUSION

The NDI-Mx seems to be a valid and reliable tool that can be used in clinical practice and research on Mexican populations with neck pain.

Validation of the Nepali versions of the Neck Disability Index and the Numerical Rating Scale for Neck Pain

STUDY DESIGN

A cross-sectional study with a test-retest design.

OBJECTIVE

To translate and culturally adapt the numerical rating scale (NRS) for neck pain intensity and the Neck Disability Index (NDI), and asses their measurement properties in a Nepalese neck pain population.

SUMMARY OF BACKGROUND DATA

Neck pain is one of the most common musculoskeletal disorders in Nepal. Research on neck pain disorders has been hampered by lack of standardized patient-reported outcome measures (PROMs) in Nepali language. Therefore, we aimed at validating a Nepali version of the NDI and NRS neck pain.

METHODS

At Dhulikhel hospital in Nepal, 150 patients with neck pain and/or cervical radiculopathy completed the translated self-administered questionnaires. We had made one cultural adaption of the NDI driving item in the final Nepali version. Relative reliability was analyzed with intraclass correlation coefficient (ICC 2.1) and absolute reliability with the smallest detectable change (SDC). Internal consistency was assessed by Cronbach alpha. Construct and discriminative validity was assessed by Spearman correlation for a priori hypotheses, receiver-operating characteristics curves, and analysis of variance. Time spent and assistance needed to complete the questionnaires were used to assess feasibility.

RESULTS

Test-restest reliability was excellent with ICC (95% confidence intervals) of 0.87 (0.66, 0.94) for NDI and 0.97 (0.94, 0.99) for NRS neck pain. The absolute reliability was acceptable (a SDC of 1.6 for NRS and 9.3 for NDI) and a Cronbach alpha (internal consistency) of 0.70 for NDI, as well as acceptable construct validity, discriminative validity, and feasibility.

CONCLUSION

The Nepali versions of the NRS neck pain and NDI can be recommended for assessing pain and disability among patients with neck pain and cervical radiculopathy, but their responsiveness to change remains to be tested.Level of Evidence: 2.

Paravertebral Muscle Mechanical Properties and Spinal Range of Motion in Patients with Acute Neck or Low Back Pain: A Case-Control Study

Our aims were to identify potential differences in muscle mechanical properties (MMPs) of cervical and lumbar tissues and in spinal range of motion (ROM) between patients with acute low back pain (LBP) or acute neck pain (NP) and healthy controls, and to identify if ROMs and MMPs are able to identify subjects among the three groups. Clinical variables (pain, disability, fear of movement, kinesiophobia, quality of life), MMPs and ROMs were obtained in 33 subjects with acute LBP, 33 with acute NP, and 33 healthy control subjects. Between-groups differences and explanatory models to discriminate groups depending on MMPs and ROMs were calculated. The results showed that cervical tone was higher in patients with acute NP than in controls, while cervical decrement was higher in both spinal pain groups. Patients with acute NP showed reduced cervical flexion when compared to acute LBP and control groups, and also cervical rotation, but just against controls. Furthermore, lumbar flexion was reduced in patients with acute LBP when compared to those with acute NP. Cervical decrement was able to discriminate spinal pain individuals from controls in a multinominal regression (R²: Cox–Snell estimation = 0.533; Nagelkerke estimation = 0.600). Lumbar flexion differentiated patients with acute LBP and controls, whereas cervical flexion differentiated patients with acute NP and controls. This study supports a tendency of the affectation of other spinal regions when only one is affected.

Headache- and Dizziness-Specific Health-Related Quality-of-Life Impairments Persist for 1 in 4 Amateur Athletes Who Are Cleared to Return to Sporting Activity Following Sport-Related Concussion: A Prospective Matched-Cohort Study

OBJECTIVES

To prospectively investigate the recovery of athlete-reported symptoms and the condition-specific health-related quality of life (HRQoL) following sport-related concussion.

DESIGN

Prospective matched-cohort study.

METHODS

We recruited amateur athletes who were diagnosed with sport-related concussion by emergency department physicians. Study participants were assessed at 3 time points following sport-related concussion. At each assessment, participants completed 5 condition-specific HRQoL patient-reported outcome measures to evaluate participants' perceptions of the effects of specific concussion-related symptoms on their HRQoL. We performed log-linear analyses to assess the proportion of concussed participants with clinically impaired condition-specific HRQoL compared with the proportion of participants in the control group with clinically impaired condition-specific HRQoL.

RESULTS

Fifty participants with sport-related concussion and 50 control participants matched by sex, age, and activity completed the study. Upon return to sporting activity, there was a significantly greater proportion of participants in the concussion group who perceived that headache, neck pain, and dizziness had an adverse effect on their HRQoL compared with the control group. Two weeks after return to sporting activity, there was still a significantly greater proportion of participants in the concussion group who perceived that headache (χ²₁ = 9.0; odds ratio [OR] = 4.4; 95% confidence interval [CI]: 1.5, 15.2; P = .003) and dizziness (χ²₁ = 9.5; OR = 13.5; 95% CI: 1.8, 604.9; P = .006) had an adverse effect on their HRQoL compared with the proportion of clinically impaired participants in the control group.

CONCLUSION

Of concussed participants, 1 in 4 perceived that headache and dizziness had adverse effects on their HRQoL after returning to sporting activity following sport-related concussion compared with nonconcussed, control participants. J Orthop Sports Phys Ther 2020;50(12):692-701. doi:10.2519/jospt.2020.9485.

Questionnaires for the evaluation of the cervical and lumbar spine in Italian language: a systematic review of the structural and psychometric characteristics

INTRODUCTION

There has been an increase in the use of questionnaires as tools for the subjective evaluation of patients with neuro-musculoskeletal problems. The aim of this study was to analyze the psychometric properties of the questionnaires published in Italian for the evaluation of cervical and lumbar spine pain and related dysfunction.

EVIDENCE ACQUISITION

Two blinded bibliographical searches were carried out on seven databases, regarding back, lumbar and/or cervical musculoskeletal problems. Both the structural characteristics and the psychometric aspects of each of the questionnaires were extracted from each of the selected articles. The structural characteristics were: full name, acronym, author and date of adaptation to the Italian language, what it measures, number of items, time to complete, the result scale, where the points are located and the cost. The psychometric aspects were: standard error of measurement (SEM), minimum detectable change (MDC), minimal clinically important difference (MCID), test-retest reliability, internal consistency, criterion validity, construct validity and sensitivity to changes.

EVIDENCE SYNTHESIS

For the structural characteristics of the questionnaires identified for the valuation of the lumbar area, the number of items ranged between 10 and 24. Only two of the questionnaires presented specific categories, and the time to complete ranged between 5 and 7 minutes. The reliability of the questionnaires ranged between 0.869 and 0.961. None of the questionnaires calculated the inter-observer reliability. The internal consistency ranged between 0.82 and 0.90 for criterion validity. None of the questionnaires calculated sensitivity, SEM, MDC or MCID, with the exception of the Fear-Avoidance Beliefs Questionnaire, which showed a value of 12 on MDC. For the assessment of the cervical region, the number of items ranged from 6 to 20. Three of the questionnaires had sub-categories, and the time to complete them ranged between 2 and 5 minutes. The test-retest reliability ranged between 0.78 and 0.997. The internal consistency ranged between 0.842 and 0.942.

CONCLUSIONS

The Italian versions of the questionnaires present good basic structural and psychometric characteristics for the evaluation of patients with back, lumbar and/or cervical musculoskeletal disorders. The analysis of the structural and psychometric characteristics of these questionnaires is fundamental to identify the best tools to use in research and in clinical practice.

Cross-cultural adaptation and validation of the Dutch language version of the Pictorial Fear of Activity Scale - Cervical

Background

The Pictorial Fear of Activity Scale-Cervical (PFActS-C) is a reliable and valid instrument to assess fear of movement in people with whiplash associated disorders. It is not available in Dutch and has not been evaluated in other neck pain populations. This study aimed to systematically translate the PFActS-C into Dutch and evaluate the psychometric properties of this Dutch Language Version (DLV) in people with non-specific neck pain.

Methods

The PFActS-C was translated according to international guidelines. Internal consistency, test-retest reliability, floor and ceiling effects, face validity and construct validity (convergent and discriminant validity by hypotheses testing and structural validity by confirmatory and exploratory factor-analyses) of the PFActS-C-DLV were tested in 125 people with non-specific neck pain.

Results

The PFActS-C-DLV showed good to excellent internal consistency (Cronbach’s alpha: 0.98) and stability over time (ICC: 0.90 [95%CI: 0.82–0.93). Four out of five a priori formulated hypotheses regarding related (convergent validity) and unrelated (discriminant validity) constructs were confirmed. However, the confirmatory factor analysis could not confirm the expected 1-factor solution. Furthermore, the exploratory factor analyses revealed that also a higher factor solution would not lead to a good fit of the model.

Conclusions

The PFActS-C-DLV is a reliable region-specific instrument for people with non-specific neck pain. The construct validity was supported, based on hypotheses testing. However, factor analyses could not confirm a 1-factor solution, so the underlying construct of the PFActS-C-DLV remains unclear. Given the PFActS-C’s photographic format, we believe these findings also have relevance for the original English version.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12891-020-03724-1.

Comparing Heterotopic Ossification in Two Cervical Disc Prostheses

STUDY DESIGN

Retrospective analysis using data from randomized clinical trials.

OBJECTIVE

To compare the occurrence of heterotopic ossification (HO) between two cervical disc prostheses. Clinical outcome and range of motion (ROM) were also evaluated.

SUMMARY OF BACKGROUND DATA

Cervical arthroplasty was reported to be able to maintain the segmental ROM. However, controversy exists since the difference of the occurrence of HO concerning cervical prosthesis is still huge.

METHODS

Patients who underwent anterior cervical discectomy with arthroplasty for a cervical radiculopathy due to a herniated disc from the The Netherlands Cervical Kinematics (NECK) trial (activC; metal endplates with a polyethylene inlay and a keel for primary stability) and the PROCON trial (Bryan; metal-on-polymer with titanium coated endplates without a keel) were analyzed for HO at 12 and 24 months postoperatively. HO was scored according to the McAfee-Mehren classification. Segmental ROM was defined by a custom developed image analysis tool, and global cervical ROM was measured by Cobb's angle. Clinical outcome was evaluated by means of the neck disability index (NDI) as well as physical-component summary (PCS) and mental-component summary (MCS).

RESULTS

At 2-year follow-up, the occurrence of HO was 68% in patients treated with the activC prosthesis (severe HO 55%), which was comparable with 85% (P = 0.12) in patients with the Bryan disc (severe HO 44%; P = 0.43). The HO progression was similar between groups. Clinically, the patients had comparable NDI, PCS, and MCS at 2-year follow-up, and comparable improvement of clinical outcomes. The global ROM in the Bryan group (56.4 ± 10.8°) was significantly higher than in the activC group (49.5 ± 14.0, P = 0.044) at 2-year follow-up.

CONCLUSION

In comparison of two cervical disc prostheses the development of HO is independent on their architecture. Although global ROM was higher in the Bryan prosthesis group, this difference was not deemed clinically important, particularly because the clinical condition of patients with and without severe HO was comparable.

LEVEL OF EVIDENCE

2.

Porous titanium cervical interbody fusion device in the treatment of degenerative cervical radiculopathy; 1-year results of a prospective controlled trial

BACKGROUND CONTEXT

Anterior cervical discectomy with an interbody cage (ACDF) to obtain fusion is a common procedure in cervical spine surgery. Presently, polyetheretherketone (PEEK) with (auto) graft is frequently used for interbody fusion although alternative implant technology like 3-D printing titanium has been introduced recently.

PURPOSE

Reporting the clinical and quantitative radiological outcome of a prospective cohort of 3-D printed porous titanium implants.

STUDY DESIGN/SETTING

Prospective study of patients with single level ACDF using 3-D printed porous titanium cervical implants. These data were compared with 48 patients from the PEEK with autograft group of the previously performed CAncellous Structured Ceramic Arthrodesis DEvice trial.

PATIENT SAMPLE

Fourty-nine patients were included.

OUTCOME MEASURES

Neck disability index (NDI), visual analog scale (VAS), self-reported perceived recovery, and fusion status.

METHODS

The clinical outcomes and fusion rates were documented at 3, 6, and 12 months. Dynamic X-rays were analyzed to determine range of motion (ROM) of the operated level. Fusion was defined as rotation ≤4° and ≤1.25 mm translation on flexion-extension films.

RESULTS

The mean NDI improved from 41.2 preoperatively to 19.4 at 12 months postoperatively. Both VAS arm and VAS neck improved significantly after surgery and 77.1% of the patients reported complete or nearly complete recovery at 12 months. The mean ROM of the affected disc level decreased from 8.7° (range 2.6-21.4) before surgery to 1.6° (0.0-4.6°) after 12 months. The fusion rate at 3, 6, and 12 months was 84%, 89%, and 91% respectively, compared with 67%, 72%, and 90%, in the PEEK group.

CONCLUSIONS

3-D printed porous titanium cervical implants resulted in significant clinical improvement after surgery. The fusion rate of porous titanium compared with PEEK with autograft at 12 months was similar, although porous titanium resulted in faster consolidation. In addition, one level anterior cervical fusion can be successfully achieved without additional plating.

Association between Modic changes, disc degeneration, and neck pain in the cervical spine: a systematic review of literature

BACKGROUND

The contribution of Modic changes (MCs) in relation to spinal pain and degenerative changes has been evaluated frequently. However, most studies focus on lumbar spine. The association between MCs, neck pain, and cervical disc degeneration is not clear.

PURPOSE

The objective of this study was to review current literature on the association between MCs, cervical disc degeneration, and neck pain.

STUDY DESIGN

A systematic review METHODS: A literature search was performed in PubMed, Embase, and Web of Science using a sensitive search string combination. Studies were selected by predefined selection criteria and risk of bias was assessed using a validated Cochrane Checklist adjusted for this purpose.

RESULTS

Fourteen articles that associated MCs with neck pain and/or cervical disc degeneration were included in the present study. Ten articles showed low risk of bias and four showed intermediate risk of bias. The prevalence of MCs in cervical spine varied from 5% to 40% and type II was predominant. Patients with MCs were reported to experience more neck pain and disability. Cervical disc degeneration was detected more frequently in patients with MCs.

CONCLUSIONS

Modic changes were found to be associated with neck pain and with disc degeneration. Therefore, the large variation in prevalence that is reported is highly dependent on the nature of the studied population.

Relatively short term test re-test reliability of Neck Disability Index by long term test re-retest reliability method of Oswestry Disability Index in healthy office workers

BACKGROUND

Assessment of local condition specific outcome measures in combination to obtain an idea about the disability status of the whole spine is a conventional method. Oswestry Disability Index (ODI) and Neck Disability Index (NDI) are two outcome measures used together. Test re-test reliability of ODI in healthy subjects has clinical importance and the test re-test reliability of NDI may have clinical significance.

OBJECTIVE

The purpose of this study is to investigate the test re-test reliability of the NDI by using long-term test re-test reliability method of ODI on healthy office workers.

METHODS

Participants who have no chronic neck pain history were included in the study. Subjects were assessed by the Turkish-NDI (e-forms) on 1st, 2nd, 4th, 8th, 15th, 30th days. 49 (20 female, 29 male) of 106 participants (57 female, 49 male) completed the study. Kolmogorov-Smirnov and Friedman tests were used.

RESULTS

The difference between median score of each day (χ= 9.275, p > 0.05) was neither statistically nor clinically significant.

CONCLUSIONS

NDI has test re-test reliability in healthy subjects over a 1-month time interval and the test re-test reliability is also valid in cases where both questionnaires are used in combination in this time interval.

Maintaining range of motion after cervical discectomy does not prevent adjacent segment degeneration

BACKGROUND

Motion preservation prostheses were introduced to prevent adjacent disc degeneration (ASD) and to diminish neck disability in the postsurgical follow-up. However, it is still a controversial issue, and the relationship between range of motion (ROM) and ASD has not been studied.

PURPOSE

To compare the correlation between ROM of the cervical spine and the presence of radiological ASD after anterior discectomy. Clinical outcome was also correlated to ROM and ASD.

STUDY DESIGN

Retrospective cohort study.

METHODS

In all, 253 patients who underwent anterior discectomy for cervical radiculopathy due to a herniated disc were analyzed for segmental and global cervical ROM and the presence of ASD both preoperatively, and 12 and 24 months postoperatively. Patients who were included in two randomized, double-blinded trials comparing anterior cervical discectomy with arthroplasty, anterior cervical discectomy with intervertebral cage, or anterior cervical discectomy without intervertebral cage for one level disc herniation were analyzed. ROM was defined by a custom-developed image analysis tool. ASD was defined by decrease in disc height and anterior osteophyte formation on X-rays. Clinical outcome was evaluated by means of the Neck Disability Index (NDI).

RESULTS

Two years postoperatively, no correlation was demonstrated between ROM and ASD. The incidence of ASD was comparable in the three groups, being 34% at baseline, and 58% at 2-year follow-up. Likewise, ASD progression was comparable in the three treatment arms. No correlation was demonstrated between ROM and NDI or ASD and NDI.

CONCLUSIONS

Since ROM is not correlated to ASD, and clinical outcome is not correlated to ROM either, the relevance of continued ROM at the target level seems absent.

The association of cervical sagittal alignment with adjacent segment degeneration

Purpose

Cervical spine surgery may affect sagittal alignment parameters and induce accelerated degeneration of the cervical spine. Cervical sagittal alignment parameters of surgical patients will be correlated with radiological adjacent segment degeneration (ASD) and with clinical outcome parameters.

Methods

Patients were analysed from two randomized, double-blinded trials comparing anterior cervical discectomy with arthroplasty (ACDA), with intervertebral cage (ACDF) and without intervertebral cage (ACD). C2–C7 lordosis, T1 slope, C2–C7 sagittal vertical axis (SVA) and the occipito-cervical angle (OCI) were determined as cervical sagittal alignment parameters. Radiological ASD was scored by the combination of decrease in disc height and anterior osteophyte formation. Neck disability index (NDI), SF-36 PCS and MCS were evaluated as clinical outcomes.

Results

The cervical sagittal alignment parameters were comparable between the three treatment groups, both at baseline and at 2-year follow-up. Irrespective of surgical method, C2–C7 lordosis was found to increase from 11° to 13°, but the other parameters remained stable during follow-up. Only the OCI was demonstrated to be associated with the presence and positive progression of radiological ASD, both at baseline and at 2-year follow-up. NDI, SF-36 PCS and MCS were demonstrated not to be correlated with cervical sagittal alignment. Likewise, a correlation with the value or change of the OCI was absent.

Conclusion

OCI, an important factor to maintain horizontal gaze, was demonstrated to be associated with radiological ASD, suggesting that the occipito-cervical angle influences accelerated cervical degeneration. Since OCI did not change after surgery, degeneration of the cervical spine may be predicted by the value of OCI.

NECK trial

Dutch Trial Register Number NTR1289.

PROCON trial

Trial Register Number ISRCTN41681847.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

The NECK trial: Effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blinded randomized controlled trial

BACKGROUND

Motion preserving anterior cervical disc arthroplasty (ACDA) in patients with cervical radiculopathy was introduced to prevent symptomatic adjacent disc degeneration as compared with anterior cervical discectomy and fusion (ACDF). Prior reports suggest that ACDF is not more effective than anterior cervical discectomy (ACD) alone for the treatment of cervical radiculopathy.

PURPOSE

To evaluate whether patients with cervical radiculopathy due to a herniated disc benefit more from undergoing ACDA, ACDF, or ACD in terms of clinical outcome measured by the neck disability index (NDI).

STUDY DESIGN

Double-blinded randomized controlled trial.

METHODS

One hundred-nine patients with one level herniated disc were randomized to one of the following treatments: ACDA, ACDF with intervertebral cage, ACD without fusion. Clinical and radiological outcome was measured by NDI, Visual Analogue Scale (VAS) neck pain, VAS arm pain, SF36, EQ-5D, patients' self-reported perceived recovery, radiographic cervical curvature, and adjacent segment degeneration parameters at baseline and until two years after surgery. BBraun Medical paid €298.837 to cover the costs for research nurses.

RESULTS

The NDI declined from 41 to 47 points at baseline to 19 ± 15 in the ACD group, 19 ± 18 in the ACDF group, and 20 ± 22 in the ACDA group after surgery (p=.929). VAS arm and neck pain declined to half its baseline value and decreased below the critical value of 40 mm. Quality of life, measured by the EQ-5D, increased in all three groups. Adjacent segment degeneration parameters were comparable in all three groups as well. No statistical differences were demonstrated between the treatment groups.

CONCLUSIONS

The hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or ACD could not be confirmed during a 2-year follow-up time period. Single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA.

Is there a difference in response to manual cranial bone tissue assessment techniques between participants with cervical and/or temporomandibular complaints versus a control group?

AIM

Manual cranial bone tissue techniques (CBTT) are used by physiotherapists as a tool for assessment and treatment of complaints in the craniocervical, face, and head regions. The goal of this study was to determine whether CBTT were able to discriminate between subjects with cervical and/or temporomandibular disorders (TMD) and a healthy group. In addition, the inter-rater reliability when applying CBTT was also investigated.

METHODS

A cross-sectional study was conducted and included 60 participants. Six standardized passive techniques were applied and judged for resistance, compliance, and sensory answer. In order to evaluate the inter-rater reliability of these techniques a cohort of participants was measured twice (by two evaluators) prospectively. A logistic regression model and Receiver Operating Curve (ROC) analyses were used to determining the discriminative validity of these techniques.

RESULTS

Logistic regression identified a significant difference for five techniques for resistance and/or compliance and/or the sensory answer between the groups. Based on the Area Under the Curve (AUC) analysis, the discriminative ability of the temporal rotation to distinguish between the groups was fair to good (for resistance AUC = 0.7775 and for compliance AUC = 0.8065). The highest agreement between the two assessors was for the resistance with occipital compression (73%) technique.

CONCLUSION

This study highlights that some of the CBTT could be potentially useful in distinguishing subjects with cervical and/or TMD from healthy subjects. Inter-rater reliability was moderate. CBTT could be potentially integrated in the examination of participants with complaints in the craniofacial region.

Comparison of high-intensity laser therapy and combination of ultrasound treatment and transcutaneous nerve stimulation in patients with cervical spondylosis: a randomized controlled trial

The aim of the study was to compare the effect of high-intensity laser therapy (HILT) and a combination of ultrasound (US) treatment and transcutaneous nerve stimulation (TENS) on pain, range of motion (ROM), and functional activity in patients with cervical spondylosis (CS). A total of 84 patients with a mean age of 51.54 years (52 women and 32 men) affected by CS were enrolled in this study. Patients were randomly divided into two groups. In group A (42 subjects), patients received 12 sessions of HILT plus exercise, while in group B (42 subjects), they received a combination of US, TENS, and exercise. The outcomes measured were cervical segment ROM, pain level measured by visual analogue scale (VAS), and functional activity measured by neck disability index (NDI) at the end of the therapy. The level of statistical significance was set as p < 0.05. In the two groups, cervical ROM, VAS, and functional scores showed significant changes. Both HILT plus exercise and US/TENS plus exercise effectively increased cervical ROM and reduced pain (with a significant greater decrease in group A). Statistically significant differences in NDI scores were observed after treatment sessions with better results for participants enrolled in group A (HILT plus exercise) Both therapeutic modalities demonstrated analgesic efficacy and improved function in patients affected by cervical spondylosis 4 weeks after the therapy. HILT plus exercise was more effective than US/TENS plus exercise. HILT can be promoted and used in this pathology with positive outcomes. However, further studies are needed to optimize the dose and duration of HILT therapy.

Development and Validation of Taiwanese Version of the Neck Disability Index

STUDY DESIGN

Cross-cultural adaptation and cross-sectional psychometric testing in a convenience sample of patients with neck pain.

OBJECTIVE

To translate and cross-culturally adapt the Neck Disability Index (NDI) into a Taiwanese version and to assess the psychometric properties.

SUMMARY OF BACKGROUND DATA

The Taiwanese NDI has not been developed or validated.

METHODS

The NDI was first translated and culturally adapted to the Taiwanese version. The test-retest reliability within 1 week was examined (n = 32). The factor structure was assessed by confirmatory factor analysis (n = 137). The construct validity was assessed by examining the relationship between the NDI and other well-known measures (n = 137).

RESULTS

The Taiwanese version was successfully translated and cross-culturally adapted. The internal consistency was excellent, with Cronbach α = 0.89. High test-retest reliability was demonstrated with intraclass correlation coefficients of 0.87. The minimal detectable change was 8.74. The two-factor model (pain and function factors) was better than the one-factor model, with higher factor loadings and better goodness-of-fit statistics. The convergent validity was supported by moderate correlation of the pain factor with the Visual Analogue Scale (|rho| = 0.45), and high correlation of the function factor with the physical component summary of the Short-From 36 (SF-36) (|rho| = 0.60).

CONCLUSION

The Taiwanese NDI is a reliable and valid disease-specific measure for assessment of pain and functional status in patients with neck pain.

LEVEL OF EVIDENCE

3.

Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial

Background

Manual therapy according to the School of Manual Therapy Utrecht (MTU) is a specific type of passive manual joint mobilization. MTU has not yet been systematically compared to other manual therapies and physical therapy. In this study the effectiveness of MTU is compared to physical therapy, particularly active exercise therapy (PT) in patients with non-specific neck pain.

Methods

Patients neck pain, aged between 18–70 years, were included in a pragmatic randomized controlled trial with a one-year follow-up. Primary outcome measures were global perceived effect and functioning (Neck Disability Index), the secondary outcome was pain intensity (Numeric Rating Scale for Pain). Outcomes were measured at 3, 7, 13, 26 and 52 weeks. Multilevel analyses (intention-to-treat) were the primary analyses for overall between-group differences. Additional to the primary and secondary outcomes the number of treatment sessions of the MTU group and PT group was analyzed. Data were collected from September 2008 to February 2011.

Results

A total of 181 patients were included. Multilevel analyses showed no statistically significant overall differences at one year between the MTU and PT groups on any of the primary and secondary outcomes. The MTU group showed significantly lower treatment sessions compared to the PT group (respectively 3.1 vs. 5.9 after 7 weeks; 6.1 vs. 10.0 after 52 weeks).

Conclusions

Patients with neck pain improved in both groups without statistical significantly or clinically relevant differences between the MTU and PT groups during one-year follow-up.

Trial registration

ClinicalTrials.gov Identifier: NCT00713843.

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.

The Dutch-Flemish PROMIS Physical Function item bank exhibited strong psychometric properties in patients with chronic pain

OBJECTIVE

The objective of this study was to assess the psychometric properties of the Dutch-Flemish Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function item bank in Dutch patients with chronic pain.

STUDY DESIGN AND SETTING

A bank of 121 items was administered to 1,247 Dutch patients with chronic pain. Unidimensionality was assessed by fitting a one-factor confirmatory factor analysis and evaluating resulting fit statistics. Items were calibrated with the graded response model and its fit was evaluated. Cross-cultural validity was assessed by testing items for differential item functioning (DIF) based on language (Dutch vs. English). Construct validity was evaluated by calculation correlations between scores on the Dutch-Flemish PROMIS Physical Function measure and scores on generic and disease-specific measures.

RESULTS

Results supported the Dutch-Flemish PROMIS Physical Function item bank's unidimensionality (Comparative Fit Index = 0.976, Tucker Lewis Index = 0.976) and model fit. Item thresholds targeted a wide range of physical function construct (threshold-parameters range: -4.2 to 5.6). Cross-cultural validity was good as four items only showed DIF for language and their impact on item scores was minimal. Physical Function scores were strongly associated with scores on all other measures (all correlations ≤ -0.60 as expected).

CONCLUSION

The Dutch-Flemish PROMIS Physical Function item bank exhibited good psychometric properties. Development of a computer adaptive test based on the large bank is warranted.

Measurement of outcomes for patients with centralising versus non-centralising neck pain

OBJECTIVE

The purpose of this study is to determine whether individuals with neck pain who demonstrate centralisation of symptoms have more favourable outcome than individuals who do not demonstrate centralisation.

METHODS

Eleven subjects with neck pain were evaluated and treated by two physical therapists certified in Mechanical Diagnosis and Therapy (MDT). Eleven physical therapy patients underwent a routine initial evaluation and were treated 2-3 times per week using MDT principles and other physical therapy interventions. The Neck Disability Index (NDI) tool was administered at the initial examination, approximately 2 weeks following the initial examination, each subsequent re-evaluation, and at discharge from the study to measure changes in functional outcomes for each subject. Patients continued with treatments until they were discharged or removed from the study. Four subjects were referred back to their physician by treating physical therapist secondary to non-centralisation (NC) and worsening of symptoms.

RESULTS

Of the 11 subjects, six demonstrated centralisation (CEN) and five demonstrated NC. At initial evaluation, the average NDI score for the CEN group was 51.0 (SD ± 19.4) and 56.4 (SD ± 17.6) for the NC group. For the CEN group, the average change in NDI score between initial evaluation and discharge was 41.2 (SD ± 13.2 and 12.2 (SD ± 13.0) for the NC group. The correlation coefficient of CEN and change in NDI score was 0.772 and was statistically significant (P = 0.005).

CONCLUSIONS

In this limited sample, people with neck pain demonstrated more favourable outcomes when the CEN phenomenon was observed. Future research on CEN should be investigated with a larger sample size and with a greater number of clinicians trained in the MDT approach.

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.

Patient-reported outcome measures for non-specific neck pain validated in the Italian-language: a systematic review

BACKGROUND

Patient-reported outcome measures can improve the management of patients with non-specific neck pain. The choice of measure greatly depends on its content and psychometric properties. Most questionnaires were developed for English-speaking people, and need to undergo cross-cultural validation for use in different language contexts. To help Italian clinicians select the most appropriate tool, we systematically reviewed the validated Italian-language outcome measures for non-specific neck pain, and analyzed their psychometric properties and clinical utility.

METHODS

The search was performed in MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and Cochrane Library. All articles published in English or Italian regarding the development, translation, or validation of patient-reported outcome measures available in the Italian language were included. Two reviewers independently selected the studies, extracted data, and assessed methodological quality using the COSMIN checklist.

RESULTS

Out of 4891articles screened, 66 were eligible. Overall, they were of poor or fair methodological quality. Four instruments measuring function and disability (Neck Disability Index, Neck Pain and Disability Scale, Neck Bournemouth Questionnaire, and Core Outcome Measures Index), and one measuring activity-related fear of movement (NeckPix©) were identified. Each scale showed some psychometric weaknesses or problems with functioning, and none emerged as a gold standard.

CONCLUSIONS

Several patient-reported outcome measures are now available for assessing Italian people with non-specific neck pain. While the Neck Disability Index is the one most widely used, the Neck Bournemouth Questionnaire appears the most promising tool from a psychometric point of view.

Calibration and Validation of the Dutch-Flemish PROMIS Pain Interference Item Bank in Patients with Chronic Pain

The Dutch-Flemish PROMIS Group translated the adult PROMIS Pain Interference item bank into Dutch-Flemish. The aims of the current study were to calibrate the parameters of these items using an item response theory (IRT) model, to evaluate the cross-cultural validity of the Dutch-Flemish translations compared to the original English items, and to evaluate their reliability and construct validity. The 40 items in the bank were completed by 1085 Dutch chronic pain patients. Before calibrating the items, IRT model assumptions were evaluated using confirmatory factor analysis (CFA). Items were calibrated using the graded response model (GRM), an IRT model appropriate for items with more than two response options. To evaluate cross-cultural validity, differential item functioning (DIF) for language (Dutch vs. English) was examined. Reliability was evaluated based on standard errors and Cronbach's alpha. To evaluate construct validity correlations with scores on legacy instruments (e.g., the Disabilities of the Arm, Shoulder and Hand Questionnaire) were calculated. Unidimensionality of the Dutch-Flemish PROMIS Pain Interference item bank was supported by CFA tests of model fit (CFI = 0.986, TLI = 0.986). Furthermore, the data fit the GRM and showed good coverage across the pain interference continuum (threshold-parameters range: -3.04 to 3.44). The Dutch-Flemish PROMIS Pain Interference item bank has good cross-cultural validity (only two out of 40 items showing DIF), good reliability (Cronbach's alpha = 0.98), and good construct validity (Pearson correlations between 0.62 and 0.75). A computer adaptive test (CAT) and Dutch-Flemish PROMIS short forms of the Dutch-Flemish PROMIS Pain Interference item bank can now be developed.

Cross-cultural adaptation, reliability and validity of the Turkish version of the spine functional index

Background

The Spine Functional Index (SFI) is a patient reported outcome measure with sound clinimetric properties and clinical viability for the determination of whole-spine impairment. To date, no validated Turkish version is available. The purpose of this study is to cross-culturally adapted the SFI for Turkish-speaking patients (SFI-Tk) and determine the psychometric properties of reliability, validity and factor structure in a Turkish population with spine musculoskeletal disorders.

Methods

The SFI English version was culturally adapted and translated into Turkish using a double forward and backward method according to established guidelines. Patients (n = 285, cervical = l29, lumbar = 151, cervical and lumbar region = 5, 73% female, age 45 ± 1) with spine musculoskeletal disorders completed the SFI-Tk at baseline and after a seven day period for test-retest reliability. For criterion validity the Turkish version of the Functional Rating Index (FRI) was used plus the Neck Disability Index (NDI) for cervical patients and the Oswestry Disability Index (ODI) for back patients. Additional psychometric properties were determined for internal consistency (Chronbach’s α), criterion validity and factor structure.

Results

There was a high degree of internal consistency (α = 0.85, item range 0.80-0.88) and test-retest reliability (r = 0.93, item range = 0.75-0.95). The factor analysis demonstrated a one-factor solution explaining 24.2% of total variance. Criterion validity with the ODI was high (r = 0.71, p < 0.001) while the FRI and NDI were fair (r = 0.52 and r = 0.58, respectively). The SFI-Tk showed no missing responses with the ‘half-mark’ option used in 11.75% of total responses by 77.9% of participants. Measurement error from SEM and MDC₉₀ were respectively 2.96% and 7.12%.

Conclusions

The SFI-Tk demonstrated a one-factor solution and is a reliable and valid instrument. The SFI-Tk consists of simple and easily understood wording and may be used to assess spine region musculoskeletal disorders in Turkish speaking patients.

Cultural adaptation, reliability, and validity of neck disability index in Indian rural population: a Marathi version study

STUDY DESIGN

A cross-sectional study to develop a cultural adaptation of the Marathi-neck disability index (NDI) and to investigate its validity and reliability.

OBJECTIVE

To conduct a study concerning the cultural adaptation of the NDI and investigate the validity and reliability of its Marathi version in patients with neck pain.

SUMMARY OF BACKGROUND DATA

The NDI is a reliable instrument for evaluating self-rated disability due to neck pain, but there is no published Marathi version and also it has not been tested on a rural population yet. Successful linguistic and cultural translation may allow appropriate cross-cultural comparison for clinical and laboratory research analysis, even in the rural parts of the Maharashtra state of India, where English is not the language of communication.

METHODS

Eighty-one patients having neck pain for at least 3 months were included in the study. The NDI and visual analogue scale for pain were completed by all subjects. Test-retest reliability was determined by using intraclass correlation coefficient and Pearson correlation analysis. For the determination of construct validity, the relation between the NDI and visual analogue scale was examined by Pearson correlation analysis.

RESULTS

Intraclass correlation coefficient score for test-retest reliability was 0.95 and the Cronbach α was 0.97. For construct-related validity the correlation of the NDI-Marathi version was found to be 0.95 (P < 0.0001). These results showed that the construct validity of the Marathi version of the NDI was excellent.

CONCLUSION

The results suggest that the Marathi version of the NDI that is validated in this study is an easy to comprehend, reliable, and valid instrument for the measurement for the limitation of activities of daily living and pain caused by neck disorders in the Marathi-speaking population.

Cross-cultural adaptation and validation of the neck disability index to European Portuguese language

STUDY DESIGN

Cross-cultural adaptation and psychometric testing.

OBJECTIVE

To complete the cultural adaptation of the European Portuguese version of the neck disability index (NDI-PT) and to investigate its reliability and validity in patients with chronic neck pain (CNP).

SUMMARY OF BACKGROUND DATA

The NDI is the most widely used instrument for self-reporting of disability due to neck pain. Although the NDI has demonstrated both good reliability and validity, a recent systematic review called attention for the poor methodological quality of the translation processes and psychometric studies.

METHODS

The NDI-PT was first piloted in a sample of 40 patients with CNP. Then, 113 patients with CNP completed the numeric pain rating scale and twice the NPI-PT with an interval of 4 to 7 days. Factor structure of the NDI was explored through principal component factor analysis. The internal consistency was estimated using the Cronbach α coefficient. Reliability was determined by repeatability using intraclass correlation coefficient (2,1) for the total sample and for the subsample of participants who remained stable in CNP status between the initial and follow-up assessment based upon the global rating of change scale, and agreement using the concept of "limits of agreement." Construct validity was assessed with correlations between the NDI-PT and the numeric pain rating scale for convergent validity, using Pearson correlation analysis.

RESULTS

Exploratory factor analysis revealed the existence of 1 major factor that explained 54.7% of the variance. Test-retest reliability was 0.9 and internal consistency was 0.95. No systematic trend was observed in the Bland and Altman method. The NDI-PT showed a good correlation with pain intensity (r = 0.525, P < 0.01).

CONCLUSION

The NDI-PT demonstrated excellent reliability and good construct validity and it may be useful for assessing functional status of Portuguese-speaking patients with CNP.

Physical dysfunction and nonorganic signs in patients with chronic neck pain: exploratory study into interobserver reliability and construct validity

STUDY DESIGN

Repeated-measurement design.

OBJECTIVES

To explore interobserver reliability of the modified physical dysfunction severity (mPDS) as a measure for impairment of the cervical spine and the modified cervical nonorganic signs (mcNOS) as a measure for behavioral signs, and to explore construct validity of the mPDS and mcNOS.

BACKGROUND

The PDS has been used for evaluation of treatment efficacy in controlled trials in primary care. The cervical nonorganic signs were developed to assess illness behavior in patients with neck pain.

METHODS

Two observers independently assessed the mPDS and mcNOS in 51 patients with chronic neck pain in an outpatient tertiary rehabilitation setting, with a 3-week interval between assessments. Interobserver reliability for total scores of the mPDS and mcNOS was expressed as an intraclass correlation coefficient. Interobserver agreement for individual mcNOS tests was calculated as absolute agreement and Cohen kappa. Construct validity was expressed as Spearman correlation between the mPDS and mcNOS with the Neck Pain and Disability Scale and numeric pain rating scale for pain.

RESULTS

The interobserver reliability of the mPDS and mcNOS had intraclass correlation coefficients of 0.72 and 0.78, respectively. Agreement for individual mcNOS tests ranged from 63% to 88%, and kappa values ranged from 0.14 to 0.54. Correlation with the Neck Pain and Disability Scale was 0.26 for the mPDS and 0.49 for the mcNOS, and the correlation with the numeric pain rating scale was 0.32 for the mPDS and 0.37 for the mcNOS.

CONCLUSION

Interobserver reliability of both the mPDS and mcNOS was acceptable. The interobserver agreement for the individual mcNOS tests ranged from poor to acceptable. Construct validity of the mPDS and mcNOS appeared satisfactory.

The influence of study population and definition of improvement on the smallest detectable change and the minimal important change of the neck disability index

Background

Reported values of the minimal important change (MIC) and the smallest detectable change (SDC) for the neck disability index (NDI) differ strongly, raising questions about the generalizability of these parameters. The SDC and the MIC are possibly influenced by the study design or by the study population. We studied the influence of the type of anchor, the definition of improvement and population characteristics on the SDC and the MIC of the NDI.

Methods

A cohort study including 101 patients with non-specific, chronic neck pain. SDC and MIC were calculated using two types of external anchors. For each anchor we applied two different definitions to dichotomize the population into improved and unimproved patients. The influence of patient characteristics was assessed in relevant subgroups: patients with or without radiating pain and patients with different baseline scores.

Results

The influence of different anchors and different definitions of improvement on estimates of the SDC and the MIC was only minimal. The SDC and the MIC were similar for subgroups of patients with or without radiation, but differed strongly for subgroups of patients with higher or lower baseline scores.

Conclusions

Our study shows that estimates of the SDC and the MIC of the NDI can be influenced by population characteristics. It is concluded that we cannot adopt a single change score to define relevant change by combining the result of previous studies.

Reliability and responsiveness of the Norwegian version of the Neck Disability Index

Background and aim

The Norwegian version of the Neck Disability Index (NDI) has been widely used in previous studies. To our knowledge, the test–retest reliability and responsiveness of the NDI have not been investigated. Thus, the aim of the present study was to investigate the test–retest reliability and responsiveness of the Norwegian version of the NDI in neck pain patients seen in a specialized outpatient clinic.

Methods

This study included patients referred to the neck and back outpatient clinic at Oslo University Hospital. A total of 255 patients were included in the study, of which 42 participated in the test–retest portion of the study. The intraclass correlation coefficient (ICC) was used to assess test-retest reliability. A total of 113 patients participated in the responsiveness analyses. Based on their responses on the Global Rating Scale of Change (GRS), patients were categorized into the following groups: worsened (n = 24), unchanged (n = 7) and improved (n = 62). The minimal detectable change (MDC) for the NDI was calculated. Responsiveness was assessed by constructing a Receiver Operating Characteristic curve (ROC curve) to distinguish patients who had improved or worsened from those who remained unchanged. The minimum clinically important difference (MCID) was estimated.

Results

The test–retest reliability between the baseline scores and the retest NDI scores was very good (ICC = 0.84; 95% CI 0.72–0.91). The ability of the NDI to discriminate between improved and unchanged patients (responsiveness) over time was acceptable based on the ROC curve analysis (AUC = 0.70; 95% CI 0.58–0.82). The estimated MDC for the Norwegian version of the NDI is 12.3%, and the MCID is 16.6%.

Conclusion

The Norwegian version of the NDI proved to be an instrument with good test–retest reliability and acceptable responsiveness for assessing neck pain-related disability among neck pain patients in a specialized outpatient clinic

The CASCADE trial: effectiveness of ceramic versus PEEK cages for anterior cervical discectomy with interbody fusion; protocol of a blinded randomized controlled trial

Background

Anterior cervical discectomy with interbody fusion cages is considered the standard surgical procedure in patients with cervical disc herniation. However, PEEK or metal cages have some undesirable imaging characteristics, leading to a search for alternative materials not creating artifacts on images; silicon nitride ceramic. Whether patients treated with silicon nitride ceramic cages have similar functional outcome as patients treated with PEEK cages is not known. We present the design of the CASCADE trial on effectiveness of ceramic cages versus PEEK cages in patients with cervical disc herniation and/or osteophytes.

Methods/Design

Patients (age 18–75 years) with monoradicular symptoms in one or both arms lasting more than 8 weeks, due to disc herniation and/or osteophytes, are eligible for the trial. The study is designed as a randomized controlled equivalence trial in which patients are blinded to the type of cage for 1 year. The total follow-up period is 2 years. The primary outcome measure is improvement in the Neck and Disability Index (NDI). Secondary outcomes measures include improvement in arm pain and neck pain (VAS), SF-36 and patients' perceived recovery. The final elements of comparison are perioperative statistics including operating time, blood loss, length of hospital stay, and adverse events. Lateral plane films at each follow-up visit and CT scan (at 6 months) will be used to judge fusion and the incidence of subsidence. Based on a power of 90% and assuming 8% loss to follow-up, 100 patients will be randomized into the 2 groups. The first analysis will be conducted when all patients have 1 year of follow-up, and the groups will be followed for 1 additional year to judge stability of outcomes.

Discussion

While the new ceramic cage has received the CE Mark based on standard compliance and animal studies, a randomized comparative study with the golden standard product will provide more conclusive information for clinicians. Implementation of any new device should only be done after completion of randomized controlled effectiveness trials.

Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: a randomized controlled study

BACKGROUND

Although exercise can be effective for relief of neck pain, little is known about the effect of exercise on the neural control of neck muscles.

METHODS

A randomized controlled trial was conducted on 46 women with chronic neck pain to investigate the immediate effectiveness of an 8-week exercise programme on pain and directional specificity of neck muscle activity. At baseline, the patients completed questionnaires including the neck disability index (NDI) and performed a circular contraction of their head in the horizontal plane at 15 N force, with continuous change in force direction in the range 0-360°. Electromyography (EMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SCap) muscles. Tuning curves of the EMG amplitude were computed, which depicts muscle activity over a range of force directions. The mean point of the tuning curves defined a directional vector, which determined the specificity of muscle activity. Patients were randomly assigned either to a training or control group.

RESULTS

A significant between-group difference in the change in NDI was observed. A reduction in NDI was observed following training (pre: 18.2 ± 7.4; post: 14.1 ± 6.5; p < 0.01) but not for the control group (pre: 17.5 ± 6.3; post: 16.6 ± 7.4). The training group showed higher specificity of muscle activity post-intervention (pre: 18.6 ± 9.8%, post: 24.7 ± 14.3%; p < 0.05), whereas no change occurred for the control group (pre: 19.4 ± 11.9%, post: 18.2 ± 10.1%).

CONCLUSION

An exercise programme that aims to enhance motor control of the cervical spine improves the specificity of neck muscle activity and reduces pain and disability in patients with neck pain.