Responsiveness of the EuroQoL 5-dimension (EQ-5D) in adolescent idiopathic scoliosis

Measurement properties of the EQ-5D in children and adolescents: a systematic review protocol

BACKGROUND

Although the EQ-5D instruments have been initially designed for adult populations, there are new studies evaluating and applying these instruments to children and adolescents. The EuroQol Group adapted and created two versions designed for these groups, i.e., the EQ-5D-Y versions. The measurement properties of the EQ-5D have been systematically reviewed in different health conditions. However, there is a lack of a proper systematic assessment including the studies' risk of bias and focusing on recent studies assessing the EQ-5D instruments in children and adolescents. The lack of a systematic assessment of the EQ-5D versions does not allow us to have a comprehensive evaluation of the validity, reliability, and responsiveness of these instruments among children and adolescents. This systematic review aims to critically appraise and summarize the evidence on the measurement properties of the EQ-5D instruments (self-reported version - answered by children and adolescents; and proxy versions - versions reported by parents, caregivers, or health professionals) in children and adolescents.

METHODS

A systematic review searching the following electronic databases: MEDLINE, EMBASE, CINAHL, EconLit, National Health Service Economic Evaluation Database (NHS-EED), Health Technology Assessment (HTA) database. Two independent reviewers will screen titles and abstracts and select full texts for eligibility. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology will be followed to conduct three main assessment steps: risk of bias, quality criteria for measurement properties, and evidence synthesis.

DISCUSSION

This systematic review will provide comprehensive information about the evidence regarding the measurement properties of EQ-5D instruments in children and adolescents of different settings and countries.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework with Registration https://osf.io/r8kt9/ and PROSPERO: CRD42020218382.

Psychosocial Effect of Brace Treatment in Adolescent Idiopathic Scoliosis: A Study Using EQ-5D

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate psychosocial effect of brace treatment in adolescent idiopathic scoliosis (AIS) using EuroQoL 5-dimension (EQ-5D) depression and anxiety category.

BACKGROUND

AIS is a structural abnormality of the spine often affecting patients during the puberty, a critical period of developing psychosocial problems. Many questionnaires had been adapted to evaluate mental health and health-related quality of life of AIS patients. However, these questionnaires are often time consuming and difficult to obtain. Therefore, a simpler substitute-EQ-5D-was evaluated.

METHODS

This is a single-center retrospective cohort analysis of adult idiopathic scoliosis patients aged between 8 and 19, visiting outpatient's clinic. Beck's depression inventory, EQ-5D and EuroQoL visual assessment scale, and Objectified Body Consciousness Scale for Youth were compared between brace group and non-brace group of AIS patients. Furthermore, difference between male and female were evaluated within brace group.

RESULTS

None of the questionnaire showed significant difference between brace and non-brace group. However, when male and female patients were compared within brace group, female patients were significantly more susceptible to depression and anxiety based on EQ-5D and body consciousness. Furthermore, depression and anxiety according to both BDI and EQ-5D were significantly correlated to health-related quality of life.

CONCLUSION

During brace treatment of female AIS patients, psychosocial status played a significant role in health-related quality of life. EQ-5D is a simple way to monitor the mental health status.

Comparing EQ-5D-3L and EQ-5D-5L in measuring the HRQoL burden of 4 health conditions in China

BACKGROUND

EQ-5D-3L has been used in the National Health Services Survey of China since 2008 to monitor population health. The five-level version of EQ-5D was developed, but there lacks evidence to support the use of five-level version of EQ-5D in China. This study was conducted to compare the measurement properties of both the EQ-5D-3L and EQ-5D-5L in quantifying health-related quality of life (HRQoL) burden for 4 different health conditions in China.

METHODS

Participants from China were recruited to complete the 3L and 5L questionnaire via Internet. Quota was set to recruit five groups of individuals, with one group of individuals without any health condition and one group of generalized anxiety disorder (GAD), HIV/AIDS, chronic Hepatitis B (CHB), or depression, respectively. The 3L and 5L were compared in terms of response distributions, percentages of reporting 'no problems', index value distributions, known-group validity and their relative efficiency.

RESULTS

In total, 500 individuals completed the online survey, including 140 healthy individuals, 122 individuals with hepatitis B, 107 with depression, 90 individuals with GAD and 101 with HIV/AIDS. 5L also had smoother and less clustered index value distributions. Healthy group showed different response distributions to the four condition groups. The percentage of reporting 'no problems' decreased significantly in the 5L in all domains (P < 0.01), especially in the pain/discomfort dimension (relative difference: 43.10%). Relative efficiency suggested that 5L had a higher absolute discriminatory power than the 3L version between healthy participant and the other 4 condition groups, especially for the HIV/AIDS group when the 3L results was not significant.

CONCLUSIONS

The 5L version may be preferable to the 3L, as it demonstrated superior performance with respect to higher sensitivity to mild health problems, better relative efficiency and responses and index value distributions.

Normative Values and Psychometric Properties of EQ-5D-Y-3L in Chilean Youth Population among Different Weight Statuses

BACKGROUND

This study aimed to provide population norms among children and adolescents in Chile using the EQ-5D-Y-3L questionnaire and to examine its feasibility and validity among body weight statuses.

METHODS

This was a cross-sectional study in which 2204 children and adolescents (aged 8-18 years) from Chile completed a set of questionnaires providing sociodemographic, anthropometric and health-related quality of life (HRQoL) data using the five EQ-5D-Y-3L dimensions and its visual analogue scale (EQ-VAS). Descriptive statistics of the five dimensions and the EQ-VAS were categorized into body weight status groups for the EQ-5D-Y-3L population norms. The ceiling effect, feasibility and discriminant/convergent validity of the EQ-5D-Y-3L were tested.

RESULTS

The dimensions of the EQ-5D-Y-3L questionnaire presented more ceiling effects than the EQ-VAS. The validity showed that the EQ-VAS could discriminate among body weight statuses. However, the EQ-5D-Y-3L index (EQ-Index) demonstrated a non-acceptable discriminant validity. Furthermore, both the EQ-Index and the EQ-VAS presented an acceptable concurrent validity among weight statuses.

CONCLUSIONS

The normative values of the EQ-5D-Y-3L indicated its potential use as a reference for future studies. However, the validity of the EQ-5D-Y-3L for comparing the HRQoL among weight statuses could be insufficient.

Health-related quality of life in patients 40 years after diagnosis of an idiopathic scoliosis

AIMS

Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL.

METHODS

We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves.

RESULTS

The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains.

CONCLUSION

In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis.Cite this article: Bone Joint J 2023;105-B(2):166-171.

Inventory of Patient-Reported Outcome Measures Used in the Non-Operative Care of Scoliosis: A Scoping Review

It is unclear which patient-reported outcome measures (PROMs) can assess non-operative care for scoliosis. Most existing tools aim to assess the effects of surgery. This scoping review aimed to inventory the PROMs used to assess non-operative scoliosis treatment by population and languages. We searched Medline (OVID) as per COSMIN guidelines. Studies were included if patients were diagnosed with idiopathic scoliosis or adult degenerative scoliosis and used PROMs. Studies without quantitative data or reporting on fewer than 10 participants were excluded. Nine reviewers extracted the PROMs used, the population(s), language(s), and study setting(s). We screened 3724 titles and abstracts. Of these, the full texts of 900 articles were assessed. Data were extracted from 488 studies, in which 145 PROMs were identified across 22 languages and 5 populations (Adolescent Idiopathic Scoliosis, Adult Degenerative Scoliosis, Adult Idiopathic Scoliosis, Adult Spine Deformity, and an Unclear category). Overall, the most used PROMs were the Oswestry Disability Index (ODI, 37.3%), Scoliosis Research Society-22 (SRS-22, 34.8%), and the Short Form-36 (SF-36, 20.1%), but the frequency varied by population. It is now necessary to determine the PROMs that demonstrate the best measurement properties in the non-operative treatment of scoliosis to include in a core set of outcomes.

Health-Related Quality of Life in Spanish Schoolchildren and Its Association with the Fitness Status and Adherence to the Mediterranean Diet

Background: Health-related quality of life (HRQoL) allows knowing the subject’s feelings in distress and well-being, as well as perception of current and future health. Objective: To assess associations between health-related quality of life, fitness status, and adherence to the Mediterranean diet in Spanish children and adolescents. Methods: A cross-sectional study was carried out in a sample of 305 (47.2% women) children and adolescents aged between 8 and 16 years, in the primary and secondary schools of the province of Ávila (central Spain) (NCT05380674). Subjects were classified according to their quality of life: group 1 (highest quality of life) > group 2 (medium quality of life) > group 3 (lowest quality of life). Results: More participants in group 1 showed higher adherence to Mediterranean diet (70.8%) than other groups (group 2: 55.0%; group 3: 43.4%). It was less likely to find optimal levels of muscle strength as quality of life decreased (OR; 95% CI: group 2: 0.535; 0.303−0.955; and group 3: 0.424; 0.234−0.768). Similar trends were found for speed and agility, but only group 3 showed significant results (OR; 95% CI: group 3: 0.297; 0.162−0.545). Flexibility was also the worst in groups 2 and 3 (OR; 95% CI: G2: 0.403; 0.213−0.762; and group 3: 0.520; 0.282−0.958). Conclusion: High fitness status and adherence to the Mediterranean diet were associated with improved health-related quality of life in schoolchildren of central Spain.

Six-Month Results on Treatment Adherence, Physical Activity, Spinal Appearance, Spinal Deformity, and Quality of Life in an Ongoing Randomised Trial on Conservative Treatment for Adolescent Idiopathic Scoliosis (CONTRAIS)

Adolescents with idiopathic scoliosis (AIS) often receive conservative treatments aiming to prevent progression of the spinal deformity during puberty. This study aimed to explore patient adherence and secondary outcomes during the first 6 months in an ongoing randomised controlled trial of three treatment interventions. Interventions consisted of physical activity combined with either hypercorrective Boston brace night shift (NB), scoliosis-specific exercise (SSE), or physical activity alone (PA). Measures at baseline and 6 months included angle of trunk rotation (ATR), Cobb angle, International Physical Activity Questionnaire short form (IPAQ-SF), pictorial Spinal Appearance Questionnaire (pSAQ), Scoliosis Research Society (SRS-22r), EuroQol 5-Dimensions Youth (EQ-5D-Y) and Visual Analogue Scale (EQ-VAS). Patient adherence, motivation, and capability in performing the intervention were reported at 6 months. The study included 135 patients (111 females) with AIS and >1-year estimated remaining growth, mean age 12.7 (1.4) years, and mean Cobb angle 31 (±5.3). At 6 months, the proportion of patients in the groups reporting high to very high adherence ranged between 72 and 95%, while motivation ranged between 65 and 92%, with the highest proportion seen in the NB group (p = 0.014, p= 0.002). IPAQ-SF displayed significant between group main effects regarding moderate activity (F = 5.7; p = 0.004; ηp2 = 0.10), with a medium-sized increase favouring the SSE group compared to NB. Walking showed significant between group main effects, as did metabolic equivalent (MET-min/week), with medium (F = 6.8, p = 0.002; ηp2 = 0.11, and large (F = 8.3, p = < 0.001, ηp2 = 0.14) increases, respectively, for the SSE and PA groups compared to NB. From baseline to 6 months, ATR showed significant between group medium-sized main effects (F = 1.2, p = 0.019, ηp2 = 0.007) favouring the NB group compared to PA, but not reaching a clinically relevant level. In conclusion, patients reported high adherence and motivation to treatment, especially in the NB group. Patients in the SSE and PA groups increased their physical activity levels without other clinically relevant differences between groups in other clinical measures or patient-reported outcomes. The results suggest that the prescribed treatments are viable first-step options during the first 6 months.

Responsiveness of the EuroQoL 5-Dimension (EQ-5D) questionnaire in patients with spondyloarthritis

Background

Spondyloarthritis (SpA) has a significant impact on patients’ quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for cost-utility analysis of health care interventions and calculation of quality-adjusted life-years. It has been validated in patients with SpA. However, its responsiveness property is unclear. Hence, the aim of study is to test the responsiveness properties of the EQ-5D health measure for Chinese patients with SpA.

Methods

Prospective and consecutive recruitment of 151 Chinese patients with SpA was conducted with follow-up assessments 6 months later. Demographic data including smoking and drinking habits, education level, income and occupation was collected. Disease-associated data including disease duration, presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS), mental health (HADS) and the EQ-5D scores were recorded. Responsiveness was tested against the global rating of change scale (GRC) and changes in disease activity using BASDAI and ASDAS-CRP.

Results

A total of 113 (74.8%) patients completed the follow-up assessments. Most patients (61.6%) had low disease activity level with BASDAI <4 and 39.7% of patients had inactive disease by ASDAS-CRP. EQ-5D scores was well discriminated along with BASDAI and BASFI scores. EQ-5D scores also correlated well with HADS. The GRC was not able to discriminate adequately. No significant ceiling or floor effect was observed.

Conclusions

EQ-5D demonstrates satisfactory responsiveness property for assessment of changes in SpA disease activity.

Level of evidence

II

Controversies with nonoperative management for adolescent idiopathic scoliosis: Study from the APSS Scoliosis Focus Group

PURPOSE

To determine consensus among Asia-Pacific surgeons regarding nonoperative management for adolescent idiopathic scoliosis (AIS).

METHODS

An online REDCap questionnaire was circulated to surgeons in the Asia-Pacific region during the period of July 2019 to September 2019 to inquire about various components of nonoperative treatment for AIS. Aspects under study included access to screening, when MRIs were obtained, quality-of-life assessments used, role of scoliosis-specific exercises, bracing criteria, type of brace used, maturity parameters used, brace wear regimen, follow-up criteria, and how braces were weaned. Comparisons were made between middle-high income and low-income countries, and experience with nonoperative treatment.

RESULTS

A total of 103 responses were collected. About half (52.4%) of the responders had scoliosis screening programs and were particularly situated in middle-high income countries. Up to 34% obtained MRIs for all cases, while most would obtain MRIs for neurological problems. The brace criteria were highly variable and was usually based on menarche status (74.7%), age (59%), and Risser staging (92.8%). Up to 52.4% of surgeons elected to brace patients with large curves before offering surgery. Only 28% of responders utilized CAD-CAM techniques for brace fabrication and most (76.8%) still utilized negative molds. There were no standardized criteria for brace weaning.

CONCLUSION

There are highly variable practices related to nonoperative treatment for AIS and may be related to availability of resources in certain countries. Relative consensus was achieved for when MRI should be obtained and an acceptable brace compliance should be more than 16 hours a day.

Responsiveness and minimal clinically important difference of the EQ-5D-5L in cervical intraepithelial neoplasia: a longitudinal study

Background

With the widespread clinical application of the five-level version of the EuroQol five-dimensional questionnaire (EQ-5D-5L), whether the questionnaire scores are responsive to changes in patients’ health and how much changes in questionnaire scores represent patients’ real health changes require consideration. Consequently, we assessed responsiveness and estimated the minimal clinically important difference (MCID) of the EQ-5D-5L in surgically treated patients with cervical intraepithelial neoplasia (CIN) to determine the relationship between MCID and minimal detectable change (MDC).

Methods

We conducted a longitudinal, observational study. Participants were patients with CIN from the gynecology inpatient department of a grade-A tertiary hospital in Shihezi, Xinjiang, China. Participants completed the EQ-5D-5L and the Global Rating of Change Questionnaire (GRCQ) at baseline and one month post-surgery. The Wilcoxon signed-rank test was used to compare EQ-5D-5L scores pre- and post-treatment. We calculated the effect size (ES) and the standardized response mean (SRM) to quantitatively assess responsiveness. Distribution-based, anchor-based, and instrument-defined methods were used to estimate MCID. MCID to MDC ratios at individual- and group-levels were also calculated.

Results

Fifty patients with CIN completed the follow-up investigation (mean age 44.76 ± 8.72 years; mean follow-up time 32.28 ± 1.43 days). The index value and EQ visual analogue scale (EQ VAS) of the EQ-5D-5L improved by 0.025 and 6.92 (all p < 0.05) at follow-up as compared to baseline respectively. The ES and the SRM of the index value were 0.47 and 0.42 respectively, indicating small responsiveness; while the ES and the SRM of EQ VAS were 0.50 and 0.49 respectively, indicating small to moderate responsiveness. The average (range) of MCIDs for index value and EQ VAS were 0.039 (0.023–0.064) and 5.35 (3.12–6.99) respectively. These values can only be used to determine whether patients have experienced clinically meaningful health improvements at the group level.

Conclusions

The EQ-5D-5L has only small to moderate responsiveness in post-surgical patients with CIN, and the MCIDs developed in this study can be used for group-level health assessment. However, further study is needed concerning health changes at the individual level.

Effectiveness of scoliosis-specific exercises for alleviating adolescent idiopathic scoliosis: a systematic review

Background

Adolescent idiopathic scoliosis (AIS) is the most common pediatric spinal deformity with reported complications including pain, mental health concern and respiratory dysfunction. The scoliosis-specific exercise (SSE) is prescribed throughout pubertal growth to slow progression although effects are unclear. This review aims to establish the effectiveness of SSE for alleviating AIS in terms of reducing Cobb angle, improving trunk asymmetry and quality of life (QoL). Additionally, it aims to define the effects of age, skeletal maturity, curve magnitude and exercise compliance on the outcomes of SSE.

Methods

A systematic reviewed was conducted to net SSE articles. Searched databases included PubMed, MEDLINE, Cochrane Library, Scopus, CINAHL and Google scholar. The quality of study was critically appraised according to the PEDro scale.

Results

A total of ten trials with an average PEDro score of 6.9/10 were examined in this study. Two randomized controlled trials (RCTs) and two clinical controlled trials suggested that SSE alone and with bracing or traditional exercise had clinical significance in reducing Cobb angle more than 5°. One RCT specifically implicated no comparable effects between bracing and SSE in prevention of curve progression for moderate scoliosis. There was insufficient evidence to support the positive effects of SSE on improving truck asymmetry (n = 4) and QoL (n = 3). Five studies evaluated the interaction effects of age (n = 2), skeletal maturity (n = 1) and curve magnitude (n = 2) with SSE in reducing Cobb angle yet without drawing any firm conclusions.

Conclusions

Insufficient evidence is available to prove that SSE with or without other conservative treatments can reduce Cobb angle, improve trunk balance and QoL. The interaction effects of age, skeletal maturity, curve magnitude, and exercise compliance with SSE in reducing Cobb angle are not proven. Future studies should investigate the relationship of influencing factors and SSE in treating AIS but not only testing its effectiveness.

Trial registration

INPLASY202050100.

Measurement Properties of Commonly Used Generic Preference-Based Measures in East and South-East Asia: A Systematic Review

OBJECTIVES

Our aim was to systematically review published evidence on the construct validity, test-retest reliability and responsiveness of generic preference-based measures (PBMs) used in East and South-East Asia.

METHODS

This systematic review was guided by the COSMIN guideline. A literature search on the MEDLINE, EMBASE, PsycINFO and PubMed databases up to August 2019 was conducted for measurement properties validation papers of the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), Health Utilities Index (HUI), Quality of Well-Being (QWB), 15-Dimensional (15D) and Assessment of Quality of Life (AQOL) in East and South-East Asian countries. Included papers were disaggregated into individual studies whose results and quality of design were rated separately. The population-specific measurement properties (construct validity, test-retest reliability and responsiveness) of each PBM were assessed separately using relevant studies. The overall methodological quality of the studies used in each of the assessments was also rated.

RESULTS

A total of 79 papers containing 1504 studies were included in this systematic review. The methodological quality was 'very good' or 'adequate' for the majority of the construct validity studies (99%) and responsiveness studies (61%), but for only a small portion of the test-retest reliability studies (23%). EQ-5D was most widely assessed and was found to have 'sufficient' construct validity and responsiveness in many populations, while the SF-6D and EuroQol-Visual Analog Scale (EQ-VAS) exhibited 'inconsistent' construct validity in some populations. Scarce evidence was available on HUI and QWB, but current evidence supported the use of HUI.

CONCLUSIONS

This systematic review provides a summary of the quality of existing generic PBMs in Asian populations. The current evidence supports the use of EQ-5D as the preferred choice when a generic PBM is needed, and continuous testing of all PBMs in the region.

Responsiveness of EQ-5D Youth version 5-level (EQ-5D-5L-Y) and 3-level (EQ-5D-3L-Y) in Patients With Idiopathic Scoliosis

STUDY DESIGN

Prospective cohort study OBJECTIVE.: The aim of this study was to evaluate the responsiveness of EQ-5D Youth version (EQ-5D-Y) 5-level and 3-level in patients with idiopathic scoliosis SUMMARY OF BACKGROUND DATA.: A new version of EQ-5D-Y increasing the number of response levels from 3 (3LY) to 5 (5LY) has been recently introduced. Although the validity and reliability of 5LY and 3LY for use in idiopathic scoliosis patients are compared, responsiveness of two questionnaires among children and adolescents is unknown.

METHODS

A total of 129 children or adolescents attending the spine clinics of a tertiary hospital in Hong Kong, China, completed 3LY and 5LY. At 3-month follow-up, 110 (85.2%) patients completed two EQ-5D-Y questionnaires, and the single-item Global Rating on Change Scale determining "worsened,", "unchanged,", or "improved" global health. Among those indicating "unchanged" in global health from baseline to follow-up, agreement in responses to each 3LY and 5LY item was examined. Mean changes in EQ-5D-Y scores during the past 3 months in patients with "worsened," "unchanged," and "improved" health were calculated.

RESULTS

Most patients (82.7%) reported no change in global health, whereas about 12.7% and 4.5% of them felt better and worse, respectively, compared to baseline. Among those reporting "unchanged health," the "Looking after myself" item exhibited the largest proportion of agreement in responses (5LY: 96.36%; 3LY: 95.50%), followed by "Mobility" (5LY 90.91%; 3LY 90.99%), "Usual activities" (5LY 83.64%; 3LY 87.39%), "Pain/discomfort"(5LY 68.18%; 3LY 76.58%), and "Feeling worried/sad/unhappy" (5LY 66.36%; 3LY 72.07%). In the "improved" or "worsened" group, the 3-month follow-up 5LY and 3LY scores were higher or lower compared with baseline, respectively.

CONCLUSION

The 5LY is demonstrated as responsive as the 3LY for patients with idiopathic scoliosis.

LEVEL OF EVIDENCE

2.

When Should We Wean Bracing for Adolescent Idiopathic Scoliosis?

BACKGROUND

Current brace weaning criteria for adolescents with idiopathic scoliosis (AIS) are not well defined. Risser Stage 4, ≥ 2 years since the onset of menarche, and no further increase in body height over 6 months are considered justifications for stopping bracing. However, despite adherence to such standards, curve progression still occurs in some patients, and so better criteria for brace discontinuation are needed.

QUESTIONS/PURPOSES

(1) Is no change in height measurements over 6 months and Risser Stage 4 sufficient for initiating brace weaning? (2) What is the association between larger curves (45°) at brace weaning and the progression risk? (3) Are a more advanced Risser stage, Sanders stage, or distal radius and ulna classification associated with a decreased risk of curve progression? (4) When should we wean patients with AIS off bracing to reduce the time for brace wear while limiting the risk of postweaning curve progression?

METHODS

All AIS patients who were weaned off their braces from June 2014 to March 2016 were prospectively recruited and followed up for at least 2 years after weaning. A total of 144 patients were recruited with mean followup of 36 ± 21 months. No patients were lost to followup. Patients were referred for brace weaning based on the following criteria: they were Risser Stage 4, did not grow in height in the past 6 months of followup, and were at least 2 years postmenarche. Skeletal maturity was assessed with Risser staging, Sanders staging, and the distal radius and ulna classification. Curve progression was determined as any > 5° increase in the Cobb angle between two measurements from any subsequent six monthly followup visits. All radiographic measurements were performed by spine surgeons independently as part of their routine consultations and without knowledge of this study. Statistical analyses included an intergroup comparison of patients with and without curve progression, binomial stepwise logistic regression analysis, odds ratios (ORs) with their 95% confidence intervals (CIs), and a risk-ratio calculation. A reasonable protective maturity stage would generate an OR < 1.

RESULTS

Among patients braced until they had no change in height for 6 months, were 2 years postmenarche for girls, and Risser Stage 4, 29% experienced curve progression after brace weaning. Large curves (≥ 45°) were associated with greater curve progression (OR, 5.0; 95% CI, 1.7-14.8; p = 0.002) as an independent risk factor. Patients weaned at Sanders Stage 7 (OR, 4.7; 95% CI, 2.1-10.7; p < 0.001), radius Grade 9 (OR, 3.9; 95% CI, 1.75-8.51; p = 0.001), and ulna Grade 7 (OR, 3.1; 95% CI, 1.27-7.38; p = 0.013) were more likely to experience curve progression. The earliest maturity indices with a reasonable protective association were Sanders Stage 8 (OR, 0.21; 95% CI, 0.09-0.48; p < 0.001), and radius Grade 10 (OR, 0.42; 95% CI, 0.19-0.97; p = 0.042) with ulna Grade 9 (no patients with curve progression).

CONCLUSION

Brace weaning indications using Risser staging are inadequate. Curve progression is expected in patients with large curves, irrespective of maturity status. Bone age measurement by either Sanders staging or the distal radius and ulna classification provides clearer guidelines for brace weaning, resulting in the least postweaning curve progression. Weaning in patients with Sanders Stage 8 and radius Grade 10/ulna Grade 9 provides the earliest and most protective timepoints for initiating brace weaning.

LEVEL OF EVIDENCE

Level II, prognostic study.

Normative Profile of Health-Related Quality of Life for Hong Kong General Population Using Preference-Based Instrument EQ-5D-5L

OBJECTIVES

To establish a normative profile of health-related quality of life (HRQoL) for Hong Kong (HK) Chinese residents aged 18 years and above and to examine the relationship between socioeconomic characteristics and health conditions and the preference-based health index.

METHODS

We recruited 1014 representative Cantonese-speaking residents across 18 geographical districts. The normative profiles of HRQoL were derived using established HK value sets. Mean values were computed by sex, age group, and educational attainment to obtain the EQ-5D HK normative profile for the general HK population. To explore the relationships among potential covariates (socioeconomic characteristics and health conditions) and the HK health index, a multivariable homoscedastic Tobit regression model was employed for the analysis.

RESULTS

The mean index value was 0.919 using the EQ-5D-5L HK value set. Younger ages reported greater problems with anxiety or depression than did older ages, whereas older ages reported greater problems with pain or discomfort than did younger ages. Persons with higher educational attainment and those who reported higher life satisfaction reported significantly higher health index scores (P < .05). On the contrary, receiving government allowance and having experienced a serious illness were significantly associated (P < .05) with a lower health index.

CONCLUSIONS

The norm values fully represent the societal preferences of the HK population, and knowledge of societal preferences can enable policy makers to allocate resources and prioritize service planning. The study was conducted with the EuroQol International EQ-5D-5L Valuation Protocol and therefore enabled us to compare the EQ-5D-5L values with other countries to facilitate understanding of societal preferences in different jurisdictions.

A head-to-head comparison of five-level (EQ-5D-5L-Y) and three-level EQ-5D-Y questionnaires in paediatric patients

PURPOSE

The aim of this study was to assess the psychometric properties of a youth version of the EQ-5D five-level questionnaire (5LY) and its three-level version (3LY) in a sample of Chinese paediatric patients.

METHODS

A consecutive sample of idiopathic scoliosis patients were recruited from a referral outpatient scoliosis center at Hong Kong, China in October 2017 and completed the two versions of EQ-5D-Y. Redistribution properties in each dimension of EQ-5D-Y were analyzed between 5LY and 3LY by logistics regressions. Absolute reduction and relative reduction in ceiling effects from the 3LY to the 5LY were calculated. Test-retest reliability was assessed by examining the Gwet's agreement coefficient (Gwet's AC) for five individual dimension responses over the 2-week period.

RESULTS

A total of 129 idiopathic scoliosis patients completed the two versions of EQ-5D-Y at baseline assessment, among which 70 patients completed the test-retest interview in 2-3 weeks after baseline assessment. For redistribution properties, the proportion of inconsistency was low in all the dimensions, ranging from 0.0% ("Usual activities") to 3.9% ("Pain/discomfort"). Ceiling effects were reduced in four dimensions. "Usual activities" dimension showed significant reduction (absolute and relative reductions: 3.9% and 4.3%; p = 0.025) and the "worried/sad/unhappy" dimension showed the largest significant reduction in ceiling effects (absolute and relative reductions: 7.8% and 9.8%; p = 0.012). The 3LY and 5LY showed very good agreement (> 80%) of individual dimension responses between two assessments, except for the "worried/sad/unhappy" dimension in 3LY.

CONCLUSION

Through this head-to-head comparison, the 5LY had significant improvements in ceiling effects in two dimensions when compared to 3LY but other measurement properties of 3LY and 5LY performed similar in the idiopathic scoliosis patient group.

An Insight Into the Health-Related Quality of Life of Adolescent Idiopathic Scoliosis Patients Who Are Braced, Observed, and Previously Braced

STUDY DESIGN

Prospective cross-sectional study.

OBJECTIVE

To determine the health-related quality of life (HRQoL) of adolescent idiopathic scoliosis (AIS) patients undergoing bracing, previously braced and observation only.

SUMMARY OF BACKGROUND DATA

HRQoL is an important treatment outcome measure for AIS. A poor HRQoL may also negatively influence the success of bracing by reducing the likelihood of good brace compliance. Yet, the HRQoL thresholds for patients undergoing observation only, brace treatment or previous brace treatment is not well understood.

METHODS

Chinese AIS patients with refined Scoliosis Research Society 22-item (SRS-22r) Questionnaire and 5-level EQ-5D (EQ-5D-5L) Questionnaire scores were consecutively recruited for this cross-sectional study. Patients were grouped based on their treatment modality (observation only, bracing, previously braced, and postoperatively). Coronal and sagittal Cobb angles, degree of apical vertebral rotation, and curve type were studied. Spearman correlation test, independent t test, and one-way analysis of variance (ANOVA) with Tukey Post-hoc test were performed for statistical analysis.

RESULTS

A total of 652 AIS patients with mean age of 14.8 ± 1.9 years and mean Cobb angle of 18.6° ± 10.0° was studied. The respective mean SRS-22r total scores for bracing, observation, and previously braced groups were 4.20, 4.54, and 4.42, and mean EQ-5D-5L scores were 0.87, 0.95, and 0.92. The total and domain scores were correlated with coronal Cobb angles (P < 0.001) while only EQ-5D-5L correlated with sagittal Cobb angles (P < 0.001). Curves greater than 40° had worse HRQoL (P < 0.001). Currently braced patients had significantly worse HRQoL than those under observation, as indicated by lower EQ-5D-5L (0.08) and SRS-22r (0.35) scores (P < 0.001 to P < 0.05). Previously braced patients had better HRQoL than currently braced patients, with 0.05 higher EQ-5D-5L score (P < 0.001), and 0.23 higher SRS-22r score (P < 0.001). However, currently braced patients were more satisfied with treatment (1.94 difference; P < 0.001) than previously braced. There were no gross differences between patients previously braced and undergoing observation only.

CONCLUSION

The negative impact of bracing on HRQoL is only transient as previously braced patients have superior HRQoL. It appears as though the EQ-5D-5L scores are more sensitive to changes in the sagittal profile as compared with SRS-22r. Our study highlights the differences in HRQoL between patients only being observed, undergoing bracing or previous brace treatment and the importance of monitoring HRQoL throughout follow-up. Further longitudinal studies may help determine the timing and threshold of HRQoL changes during the entire duration of bracing as well as after brace weaning.

LEVEL OF EVIDENCE

2.

Responsiveness of the EQ-5D-3L and EQ-5D-5L in patients following total hip or knee replacement

PURPOSE

To examine the responsiveness of the EQ-5D-3L and EQ-5D-5L among total hip/knee replacement (THR/TKR) patients.

METHODS

The EQ-5D (3L or 5L) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) have been routinely administered to all THR/TKR patients before and at 3 months after surgery in Alberta, Canada, since 2010. Patients were included in this analysis if they completed the WOMAC and the same version of EQ-5D at baseline and 3-month follow-up. The WOMAC was used as an anchor to categorize patients into 9 subgroups according to the relative change from baseline, i.e., no change, and 4 categories each for the amount of deterioration or improvement: large (≥ 70%), moderate (50% ≤ change < 70%), small but important (20% ≤ change < 50%), and very mild (0 < change ≤ 20%). The responsiveness of the EQ-5D-3L and EQ-5D-5L for each subgroup was assessed using effect size, standardized response mean, and Guyatt's Responsiveness Index.

RESULTS

A total of 1594 patients completed the EQ-5D-3L and WOMAC (60% females, mean age 66 years, N = 646 [41%] THR), and 3180 completed the EQ-5D-5L and WOMAC (60% females, mean age 66 years, N = 1352 [43.2%] THR) at baseline and 3-month follow-up. For both THR and TKR patients with "small but important" improvement, the EQ-5D-5L was consistently more responsive than the EQ-5D-3L.

CONCLUSION

Our study demonstrated that the EQ-5D-5L is more responsive than the EQ-5D-3L in identifying health-related quality of life changes in THR/TKR patients. We recommend using the EQ-5D-5L in longitudinal studies in this patient population.

Psychometric validation of the EuroQoL 5-dimension (EQ-5D) questionnaire in patients with spondyloarthritis

BACKGROUND

Spondyloarthritis (SpA) has a significant impact on patients' quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for the cost-utility analysis of health care interventions and calculation of quality-adjusted life years. However, the applicability of the EQ-5D health measure in Chinese patients with SpA is currently unknown. Hence, the aim of the study is to test the psychometric properties and to validate the use of the EQ-5D health measure for utility analyses in Chinese patients with SpA.

METHODS

Prospective and consecutive recruitment of 220 Chinese patients with SpA was conducted. Demographic data including smoking and drinking habits, education level, income, and occupation was collected. Disease-associated data including disease duration, the presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS, ODI), mental health (HADS depression and anxiety), and the EQ-5D scores were recorded. SF-36 scores were used to verify the findings. Baseline correlations were performed along with test-retest reliability, validity, and internal consistency tests. Specifically, the relationship between EQ-5D and disease activity and functional scores was studied.

RESULTS

EQ-5D scores achieved acceptable internal consistency and reliability. A ceiling effect was observed for all domains of the EQ-5D except for pain/discomfort. No floor effect was observed. Significant negative correlations were observed between ODI, HADS, BASFI, BASMI, BASDAI, and ASDAS-CRP and with EQ-5D. A higher disease activity was well-differentiated by EQ-5D, as with the disability and mental health scores.

CONCLUSIONS

The EQ-5D demonstrates satisfactory psychometric properties for assessment of SpA patients. It has high utility for demonstrating changes in disease activity and disability.

APSS-ASJ Best Clinical Research Award: Predictability of Curve Progression in Adolescent Idiopathic Scoliosis Using the Distal Radius and Ulna Classification

Study Design

Prospective study.

Purpose

To determine the risk of clinically significant curve progression in adolescent idiopathic scoliosis (AIS) based on the initial Cobb angle and to test the utility of the distal radius and ulna (DRU) classification in predicting these outcomes.

Overview of Literature

Determining the remaining growth potential in AIS patients is necessary for predicting prognosis and initiating treatment. Limiting the maturity Cobb angle to <40° and <50° reduces the risk of adulthood progression and need for surgery, respectively. The risk of curve progression is the greatest with skeletally immature patients and thus warrants close monitoring or early intervention. Many parameters exist for measuring the skeletal maturity status in AIS patients, but the DRU classification has been shown to be superior in predicting peak growth and growth cessation. However, its predictive capabilities for curve progression are unknown.

Methods

Totally, 513 AIS patients who presented with Risser 0–3 were followed until either skeletal maturity or the need for surgery, with a minimum 2-year follow-up period. Outcomes of 40° and 50° were used for probability analysis based on the cut-offs of adulthood progression risk and surgical threshold, respectively.

Results

At the R6/U5 grade, most curves (probability of ≥48.1%–55.5%) beyond a Cobb angle of 25° progressed to the 40° threshold. For curves of ≥35°, there was a high risk of unfavorable outcomes, regardless of skeletal maturity. Most patients with the R9 grade did not progress, regardless of the initial curve magnitude (probability of 0% to reach the 50° threshold for an initial Cobb angle of ≥35°).

Conclusions

This large-scale study illustrates the utility of the DRU classification for predicting curve progression and how it may effectively guide the timing of surgery. Bracing may be indicated for skeletally immature patients at an initial Cobb angle of 25°, and those with a scoliosis ≥35° are at an increased risk of an unfavorable outcome, despite being near skeletal maturity.