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

Developing a shortened spine functional index (SFI-10) for patients with sub-acute/chronic spinal disorders: a cross-sectional study

BACKGROUND

Brief whole-spine patient-reported outcome measures (PROMs) provide regional solutions and future directions for quantifying functional status, evidence, and effective interventions. The whole-spine regional Spine Functional Index (SFI-25) is used internationally in clinical and scientific contexts to assess general sub-acute/chronic spine populations. However, to improve structural validity and practicality a shortened version is recommended. This study developed a shortened-SFI from the determined optimal number of item questions that: correlated with criteria PROMs being highly with whole-spine, moderately with regional-spine, condition-specific and patient-specific, and moderately-low with general-health and pain; retained one-dimensional structural validity and high internal consistency; and improved practicality to reduce administrative burden.

METHODS

A cross-sectional study (n = 505, age = 18-87 yrs., average = 40.3 ± 10.1 yrs) of sub-acute/chronic spine physiotherapy outpatients from an international sample of convenience. Three shortened versions of the original SFI-25 were developed using 1) qualitative 'content-retention' methodology, 2) quantitative 'factorial' methodology, and 3) quantitative 'Rasch' methodology, with a fourth 'random' version produced as a comparative control. The clinimetric properties were established for structural validity with exploratory (EFA) and confirmatory (CFA) factorial analysis, and Rasch analysis. Criterion validity used the: whole-spine SFI-25 and Functional Rating Index (FRI); regional-spine Neck Disability Index (NDI), Oswestry Disability Index (ODI), and Roland Morris Questionnaire (RMQ), condition-specific Whiplash Disability Questionnaire (WDQ); and patient-specific functional scale (PSFS); and determined floor/ceiling effect. A post-hoc pooled international sub-acute/chronic spine sample (n = 1433, age = 18-91 yrs., average = 42.0 ± 15.7 yrs) clarified the findings and employed the general-health EuroQuol-Index (EQ-5D), and 11-point Pain Numerical Rating Scale (P-NRS) criteria.

RESULTS

A 10-item SFI retained structural validity with optimal practicality requiring no computational aid. The SFI-10 concept-retention-version demonstrated preferred criterion validity with whole-spine criteria (SFI-25 = 0.967, FRI = 0.810) and exceeded cut-off minimums with regional-spine, condition-specific, and patient-specific measures. An unequivocal one-dimensional structure was determined. Internal consistency was satisfactory (α = 0.80) with no floor/ceiling effect. Post-hoc analysis of the international sample confirmed these findings.

CONCLUSION

The SFI-10 qualitative concept-retention version was preferred to quantitative factorial and Rasch versions, demonstrated structural and criterion validity, and preferred correlation with criteria measures. Further longitudinal research is required for reliability, error, and responsiveness, plus an examination of the practical characteristics of readability and administrative burden.

Interdisciplinary Multimodal Pain Rehabilitation in Patients with Chronic Musculoskeletal Pain in Primary Care-A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Chronic pain is a major public health issue. Mounting evidence suggests that interdisciplinary multimodal pain rehabilitation programs (IMMRPs) performed in specialist pain care are an effective treatment for patients with chronic pain, but the effects of such treatment if performed in primary care settings have been less studied. The aims of this pragmatic study were to (1) describe characteristics of patients participating in IMMRPs in primary care; (2) examine whether IMMRPs in primary care improve pain, disability, quality of life, and sick leave 1-year post discharge in patients with chronic pain; and (3) investigate if outcomes differ between women and men. Data from 744 (645 women and 99 men, age range 18-65 years) patients with non-malignant chronic pain included in the Swedish Quality Registry for Pain Rehabilitation Primary Care were used to describe patient characteristics and changes in health and sick leave. At 1-year follow-up, the patients had improved significantly (p < 0.01) in all health outcome measures and had reduced sick leave except in men, where no significant change was shown in physical activity level. This study indicates that MMRPs in primary care improved pain and physical and emotional health and reduced sick leave, which was maintained at the 1-year follow-up.

Does Online Professional Development for Physical Therapists Enhance Clinical Practice and Patient Outcomes? Protocol for a Mixed Methods, Randomized Controlled Trial

OBJECTIVE

Online clinical mentoring has shown potential as a flexible professional development activity that enhances physical therapist practice. Online delivery can overcome time and distance barriers to participation in professional development. The impact of this learning activity on physical therapist practice and patient outcomes has not been rigorously tested. Thus, the aim of this study is to determine whether online clinical mentoring is more effective than asynchronous online lectures at improving physical therapist practice and patient outcomes. An additional aim is to explore the lived experience of physical therapist learners who participate in online clinical mentoring.

METHODS

In this mixed methods evaluation, 24 physical therapist learners will be randomized to 1 of 2 online professional development activities. Experimental group physical therapists will complete 6 online clinical mentoring sessions. Control group physical therapists will complete 6 online lectures. The primary outcome evaluated will be the effect on the physical therapist's patients, using the Patient-Specific Functional Scale. Physical therapist learner secondary outcomes are confidence, self-reflection, and satisfaction. Accounting for possible dropouts, a sample size of 216 patients was determined using a pragmatic sample of 24 physical therapists, power of 0.80, alpha of 0.05, and between-group differences of 1.0 (SD = 2.0) on the Patient-Specific Functional Scale. Consecutive, eligible patients under the care of the physical therapist learners will complete outcome measures at initial appointment and at 4 weeks follow-up. Linear mixed model regression analysis will be used to estimate treatment effects from the posttreatment group means at 4 weeks. Participants undertaking online clinical mentoring will complete semi-structured interviews that will be thematically analyzed using a phenomenological approach.

IMPACT

This research study will establish the effectiveness of online clinical mentoring to inform future professional development. The qualitative component will identify the potential mechanisms by which online clinical mentoring might be effective, thus informing future implementation of this professional development activity.

Cross-cultural adaptation and validation of the Polish version of the Spine Functional Index

PURPOSE

The purpose of this study was a cross-cultural adaptation of the Spine Functional Index to produce a Polish version (SFI-PL). Further, the psychometric properties were evaluated with standardized criteria patient reported outcome measures (PROMs) in a symptomatic Polish spine population.

METHODS

Linguistic adaptation complied with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines to produce the SFI-PL. Subjects with spine conditions, all areas and multi-area, were recruited from a Polish Specialist Hospital (n = 225, age = 45.7 ± 16.0 years, range 18-87, female = 60%, symptoms duration = 13.93 ± 27.56 weeks, range 5-84). Baseline internal consistency, reliability and validity were examined and included the SFI-PL, Oswestry Disability Index (ODI), Neck Disability Index (NDI), EuroQol 5 Dimensions, 5-level version (EQ-5D-5L) and an 11-point pain Numerical Rating Scale (NRS) with retest at 3-7 days (= 5 days). Practicality for readability was considered within the face and content validity and completion and scoring time calculated.

RESULTS

Statistical analysis showed excellent internal consistency (α = 0.90) and high test-retest reliability (ICC = 0.98). The error score was determined with the SEM = 3.14 (MDC 90% CI = 7.33%). The construct validity analysis demonstrated strong correlations between the SFI-PL, the NDI (r = 0.73) and the ODI (r = 0.82); moderate with the EQ index value (0.70) and EQ-VAS (r = 0.56). Time to complete (229 s) and score (27 s) were determined.

CONCLUSIONS

The SFI-PL is a psychometrically sound PROM for Polish-speaking patients with spine conditions. The results support previous findings from the original-English and six other language versions for internal consistency, reliability, measurement error and validity. These slides can be retrieved under Electronic Supplementary Material.

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

STUDY DESIGN

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

PURPOSE

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

OVERVIEW OF LITERATURE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

1.

Content and psychometric evaluations of questionnaires for assessing physical function in people with low back disorders. A systematic review of the literature

Purpose: The purpose was to investigate how physical function is assessed in people with musculoskeletal disorders in the low back. Specifically:Which questionnaires are used to assess physical function in people with musculoskeletal disorders in the low back?What aspects of physical function do those questionnaires measure?What are the measurement properties of the questionnaires?Materials and methods: A systematic review was performed to identify questionnaires and psychometric evaluations of them. The content of the questionnaires was categorised according to the International Classification of Function, Disability and Health, and the psychometric evaluations were categorised using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist.Results: The questionnaires measured disability or ability to cope in everyday life, rather than physical function as such. Different aspects of a person's mobility and ability to attend to one's personal care were most often included regarding activity and participation. For body functions, items about sleep and pain were most often included. The Oswestry Disability Index and the Quebec Back Pain Disability Scale showed adequate psychometric properties in most evaluations.Conclusions: The extent of psychometric evaluations differed substantially, as did the items included. Focus of measurement was predominantly on activities in daily life.Implications for rehabilitationValid and reliable instruments that measure relevant aspects of low back disorders are needed to provide early diagnostics and effective treatment.Most questionnaires need more psychometric evaluations to establish the quality.The Oswestry Disability Index and the Quebec Back Pain Disability Scale showed adequate psychometric properties in most evaluations.The results may be useful when making decisions about which measurement instruments to use when evaluating low back disorders.

Cross-cultural validation of simplified Chinese version of spine functional index

BACKGROUND

No effective constructs were available in mainland China to assess the whole spine function. The SFI was developed to evaluate spinal function based on the concept of a single kinetic chain concept for whole spine. The SFI has been translated to Spanish and Turkish with accepted psychometric properties. It is imperative to introduce the SFI in mainland China and further to explore the measurement properties.

METHODS

The English versions of the SFI was cross-culturally translated according to international guidelines. Measurement properties (content validity, construct validity and reliability) were tested in accordance with the COSMIN checklists. A total of 271 patients were included in this study, and 61 participants with neck pain and 64 participants with back pain paid a second visit three to seven days later. Confirmatory factor analysis (CFA) and principal factor analysis (PCA) were applied to test the factor structure. The Functional Rating Index (FRI), Neck Disability Index (NDI), Oswestry Disability Index (ODI), SF-12 and a Visual Analogue Scale (VAS) were employed to evaluate the construct validity. Cronbach's alpha and an intra-class correlation coefficient (ICC) were calculated for internal consistency and reproducibility.

RESULTS

The means score of SC-SFI was 63.60 in patients with spinal musculoskeletal disorders. A high response rate was acquired (265/271). No item was removed due to abnormal distribution or low item-total correlation. Results of CFA did not support that one-factor structure was in goodness of fit (CMIN/DF = 3.306, NNFI = 0.687, CFI = 0.756, GFI = 0.771 and RMSEA = 0.092). Yet, PCA suggested a one-factor structure was the best, accounting for 32% of the total variance. For structural validity, the SC-SFI correlated highly with the FRI, NDI, ODI, and PF, BP in SF-12 (r = 0.661, 0.610, 0.750, 0.709, 0.605, respectively). All the a priori hypotheses were verified. The Cronbach's alpha for the SC-SFI was 0.91, and ICC was 0.96 (95% CI, 0.94-0.98). Bland-Altman plot also confirmed excellent test-retest reliability.

CONCLUSIONS

The SFI has been culturally adapted into SC-SFI with remarkable clinical acceptance, excellent internal consistency, reproducibility, and construct validity when applied to patients with spinal musculoskeletal disorders. The results of current study suggest that SC-SFI can be applied by physicians and researchers to measure whole-spine functional status in mainland China.

Core Outcome Sets and Multidimensional Assessment Tools for Harmonizing Outcome Measure in Chronic Pain and Back Pain

Core Outcome Sets (COSs) are a set of domains and measurement instruments recommended for application in any clinical trial to ensure comparable outcome assessment (both domains and instruments). COSs are not exclusively recommended for clinical trials, but also for daily record keeping in routine care. There are several COS recommendations considering clinical trials as well as multidimensional assessment tools to support daily record keeping in low back pain. In this article, relevant initiatives will be described, and implications for research in COS development in chronic pain and back pain will be discussed.