Minimal Clinically Important Difference

Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand (DASH) and the Shortened Version of the DASH (QuickDASH) in People With Musculoskeletal Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to perform a meta-analysis of the minimal clinically important difference (MCID) of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and its shortened version (ie, the QuickDASH).

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, Cochrane Library, and Scopus were searched up to July 2022. Studies on people with upper limb musculoskeletal disorders that calculated the MCID by anchor-based methods were included. Descriptive and quantitative synthesis was used for the MCID and the minimal detectable change with 90% confidence (MDC90). Fixed-effects models and random-effect models were used for the meta-analysis. I2 statistics was computed to assess heterogeneity. The methodological quality of studies was assessed with the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist for measurement error and an adaptation of the checklist for the studies on MCID proposed by Bohannon and Glenney.

RESULTS

Twelve studies (1677 patients) were included, producing 17 MCID estimates ranging from 8.3 to 18.0 DASH points and 8.0 to 18.1 QuickDASH points. The pooled MCIDs were 11.00 DASH points (95% CI = 8.59-13.41; I2 = 0%) and 11.97 QuickDASH points (95% CI = 9.60-14.33; I2 = 0%). The pooled MDC90s were 9.04 DASH points (95% CI = 6.46-11.62; I2 = 0%) and 9.03 QuickDASH points (95% CI = 6.36-11.71; I2 = 18%). Great methodological heterogeneity in the calculation of the MCID was identified among the primary studies.

CONCLUSION

Reasonable MCID ranges of 12 to 14 DASH points and 12 to 15 QuickDASH points were established. The lower boundaries represent the first available measure above the pooled MDC90, and the upper limits represent the upper 95% CI of the pooled MCID.

IMPACT

Reasonable ranges for the MCID of 12 to 14 DASH points and 12 to 15 QuickDASH points were proposed. The lower boundaries represent the first available measure above the pooled MDC90, and the upper limits represent the upper 95% CI of the pooled MCID. Information regarding the interpretability of the 2 questionnaires was derived from very different methodologies, making it difficult to identify reliable thresholds. Now clinicians and researchers can rely on more credible data. The proposed MCIDs should be used to assess people with musculoskeletal disorders. Heterogeneity was found related particularly to the anchor levels used in the primary studies. To promote comparability of MCID values, shared rules defining the most appropriate types of anchoring will be needed in the near future.

Anchor-based minimal important difference values are often sensitive to the distribution of the change score

PURPOSE

Anchor-based studies are today the most popular approach to determine a minimal important difference value for an outcome variable. However, a variety of construction methods for such values do exist. This constitutes a challenge to the field. In order to distinguish between more or less adequate construction methods, meaningful minimal requirements can be helpful. For example, minimal important difference values should not reflect the intervention(s) the patients are exposed to in the study used for construction, as they should later allow to compare interventions. This requires that they are not sensitive to the distribution of the change score observed. This study aims at investigating to which degree established construction methods fulfil this minimal requirement.

METHODS

Six constructions methods were considered, covering very popular and recently suggested methods. The sensitivity of MID values to the distribution of the change score was investigated in a simulation study for these six construction methods.

RESULTS

Five out of six construction methods turned out to yield MID values which are sensitive to the distribution of the change score to a degree that questions their usefulness. Insensitivity can be obtained by using construction methods based solely on an estimate of the conditional distribution of the anchor variable given the change score.

CONCLUSION

In future the computation of MID values should be based on construction methods avoiding sensitivity to the distribution of the change score.

Challenges in applying minimal clinically important difference: a critical review

Healthcare clinicians strive to make meaningful changes in patient function and participation. A minimal clinically important difference (MCID) is an estimate of the magnitude of change needed to be meaningful to a patient. Clinicians and investigators may assume that a cited MCID is a valid and generalizable estimate of effect. There are, however, at least two concerns about this assumption. First, multiple methods exist for calculating an MCID that can yield divergent values and raise doubt as to which one to apply. Second, MCID values may be erroneously generalized to patients with dissimilar health conditions. With this in mind, we reviewed the methods used to calculate MCID and citations of reported MCID values for outcome measures commonly used in neurologic, orthopedic, and geriatric populations. Our goal was to assess whether the calculation methods were acknowledged in the cited work and whether the enrolled patients were similar to the sample from which the MCID estimate was derived. We found a concerning variation in the methods employed to estimate MCID. We also found a lack of transparency in identifying calculation methods and applicable health conditions in the cited work. Thus, clinicians and researchers must pay close attention and exercise caution in assuming changes in patient status that exceed a specific MCID reflect meaningful improvements in health status. A common standard for the calculation and reporting of an MCID is needed to address threats to the validity of conclusions drawn from the interpretation of an MCID.

Minimal important change and difference in health outcome: An overview of approaches, concepts, and methods

OBJECTIVE

To provide an overview of approaches, concepts, and methods used to define and assess minimal important change and difference in health outcome.

METHOD

A narrative review of the literature, guided by a conceptual framework.

RESULTS

We distinguish between (i) interpretation of health outcome in individuals versus groups, (ii) change within individuals or groups versus difference between change within individuals or groups; and (iii) the responder approach (based on the proportion of patients that obtain a defined response) versus the group average approach (based on the average amount of change in a group). We review approaches, concepts, and methods.

CONCLUSION

By bringing together and juxtaposing various approaches, concepts, and methods, we set a precursory step in the direction of consensus building in the field concerned with defining and assessing minimal important change and difference in health outcome. We emphasize the need for conceptual clarification and terminological standardization. We argue that assessing minimal importance of change and difference in health outcome is essentially a value judgment involving a range of considerations and perspectives.

Minimal clinically important difference (MCID) and minimal detectable change (MDC) of Spinal Cord Ability Ruler (SCAR)

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To find minimal clinically important difference (MCID) and minimal detectable change (MDC) of Spinal Cord Ability Ruler (SCAR) in Thai participants with spinal cord injury (SCI).

SETTING

Rehabilitation ward at Maharaj Nakorn Chiang Mai Hospital.

METHODS

Data of individuals with SCI who were not diagnosed with central cord syndrome and were admitted for the first time for rehabilitation were analyzed. Upper extremities motor score, self-care and mobility items of Spinal Cord Independence Measure version III were collected and used to calculate SCAR difference between data on date of admission and discharge. MCID and MDC were calculated by distribution-based method and categorized for each subgroup according to SCI characteristics.

RESULTS

From data of 311 individuals, MCID of SCAR is approximately 4 for individual with tetraplegia AIS A, B, C; and individual with AIS D at any level, and 2 for individual with paraplegia AIS A, B, C. MDC of SCAR should be 1 for individual with tetraplegia AIS A, B, C; and individual with AIS D at any level and 0.5 for individual with paraplegia AIS A, B, C.

CONCLUSION

This study provides MCID and MDC of SCAR in each subgroup. These values could be used as a benchmark for clinicians and researchers to determine whether participant has significant improvement or not after receiving an intervention.

Minimal Clinically Important Difference of Tinnitus Outcome Measurement Instruments-A Scoping Review

OBJECTIVE

Tinnitus assessment and outcome measurement are complex, as tinnitus is a purely subjective phenomenon. Instruments used for the outcome measurement of tinnitus in the context of clinical trials include self-report questionnaires, visual analogue or numeric rating scales and psychoacoustic measurements of tinnitus loudness. For the evaluation of therapeutic interventions, it is critical to know which changes in outcome measurement instruments can be considered as clinically relevant. For this purpose, the concept of the minimal clinically important difference (MCID) has been introduced.

STUDY DESIGN

Here we performed a literature research in PubMed in order to identify for which tinnitus outcome measurements MCID criteria have been estimated and which of these estimates fulfil the current methodological standards and can thus be considered as established.

RESULTS

For most, but not all tinnitus outcome instruments, MCID calculations have been performed. The MCIDs for the Tinnitus Handicap Inventory (THI), the Tinnitus Questionnaire (TQ), the Tinnitus Functional Index (TFI) and visual analogue scales (VAS) vary considerably across studies. Psychoacoustic assessments of tinnitus such as loudness matching have not shown sufficient reliability and validity for the use as an outcome measurement.

CONCLUSION

Future research should aim at the confirmation of the available estimates in large samples involving various therapeutic interventions and under the consideration of time intervals and baseline values. As a rule of thumb, an improvement of about 15% can be considered clinically meaningful, analogous to what has been seen in other entirely subjective pathologies like chronic pain.

Minimal clinically important difference of the Michigan Hand Outcomes Questionnaire score and the pain visual analogue scale in conservative treatment of trigger finger

We investigated the minimal clinically important difference (MCID) of the Michigan Hand Outcomes Questionnaire (MHQ) and the pain visual analogue scale (VAS-pain) after conservative treatment of trigger finger. This secondary analysis of a randomized controlled trial compared pain reduction, symptoms and functional improvement at 12 weeks. Patients included were at least 18 years old and able to complete MHQ and VAS-pain at enrolment and 12 weeks after treatment. The MCIDs of MHQ and VAS-pain were evaluated using a distribution-based, anchor-based and receiver operating characteristic (ROC) curve-based approach. Of the 117 patients, the MCIDs of MHQ and VAS-pain using a distribution-based approach were 5.3 and 0.6, respectively; applying ROC method were 23.5 and 2.5, respectively; and using anchor questions were 15 and 2, respectively. These MCID values by anchor-based method with a minimal difference of 15 for MHQ and 2 for VAS-pain are recommended as primary evidence to determine clinically significant improvement after conservative treatment of trigger finger.Level of evidence: I.

Facial involvement is reflective of patients' global perception of vitiligo extent

BACKGROUND

The involvement of visible areas in vitiligo has been found to be correlated with increased psychiatric morbidity. Although multiple tools have been developed to assess vitiligo, no cutoff for improvement or worsening of vitiligo from a patient's perspective has been established.

OBJECTIVES

To determine the minimal clinically important difference (MCID) of the Self-Assessment Vitiligo Extent Score (SA-VES) in patients with vitiligo and to evaluate, from the patient's perspective, the importance of the change in the involvement of visible areas (face and hands) in patients' overall perception of disease worsening or improving.

METHODS

This was a cross-sectional study in the context of the ComPaRe e-cohort. Adult patients with vitiligo were invited to answer online questionnaires. They completed the SA-VES twice, 1 year apart. In addition, patients answered a 5-point Likert anchor question aimed at assessing their perception of the evolution of the extent of their vitiligo. The MCID was calculated using distribution- and anchor-based approaches. Using ordinal logistic regression, the change of vitiliginous lesions on the face or hands was compared to the overall extent of vitiligo (patches on all body areas).

RESULTS

In total, 244 patients with vitiligo were included in the analyses; 20 (8%) were found to have an improvement in their vitiligo. The MCID in worsened patients was equal to a 1.3% body surface area [95% confidence interval (CI) 1.01-1.43] increase in the SA-VES. For participants with improved vitiligo, the MCID was equal to a decrease in total SA-VES of 1.3% (95% CI 0.867-1.697). Patients' perceptions of change in their vitiligo was increased sevenfold when it affected the face vs. the rest of the body.

CONCLUSIONS

Changes in the facial SA-VES were highly correlated with patients' impressions of the extent of vitiligo.

Clinically important change for the FACIT-Fatigue scale in paroxysmal nocturnal hemoglobinuria: a derivation from international PNH registry patient data

BACKGROUND

Fatigue is the most common symptom associated with paroxysmal nocturnal hemoglobinuria (PNH). The objective of this analysis was to estimate values that would suggest a clinically important change (CIC) for the functional assessment of chronic illness therapy-fatigue scale (FACIT-Fatigue) in patients with PNH.

METHODS

Adults with PNH who initiated eculizumab within 28 days of enrollment in the International PNH Registry as of January 2021 with baseline FACIT-Fatigue scores were included in the analysis. Distribution-based estimates of likely difference were calculated using 0.5 × SD and SEM. Anchor-based estimates of CIC considered the European Organization for Research and Treatment of Cancer (EORTC) global health status/quality of life summary score and the EORTC Fatigue Scale score. Changes in anchors and high disease activity (HDA) shift from start of eculizumab treatment to each follow-up visit were then assessed by FACIT-Fatigue score change (≤ 1 CIC, no change, or ≥ 1 CIC).

RESULTS

At baseline, 93% of 423 patients had fatigue documented in their medical history. The distribution-based estimates for FACIT-Fatigue were 6.5 using 0.5 × SD and 4.6 using SEM; internal consistency was high (α = 0.87). For anchor-based estimates, the FACIT-Fatigue CIC ranged from 2.5 to 15.5, and generally supported 5 points as a reasonable lower end of the value for meaningful individual change. The percentage of patients who changed from having HDA at baseline to no HDA at eculizumab-treated follow-up visits increased over time.

CONCLUSION

These results support the use of 5 points as the CIC for FACIT-Fatigue in patients with PNH, which is within range of the CICs reported in other diseases (3-5 points).

Responsiveness and minimal clinically important changes to physical therapy interventions of Persian versions of copenhagen neck functional disability index, neck bournemouth questionnaire and spine functional index questionnaires in people with chronic neck pain

BACKGROUND AND PURPOSE

Chronic neck pain has a significant impact on the patient's quality of life. Specific outcome measures like Copenhagen Neck Functional Disability Index (CNFDI), Neck Bournemouth questionnaire (NBQ), and Spine Functional Index (SFI) are reliable and valid measures that have been used for comprehensively evaluating neck-related disabilities. However, responsiveness has not yet been investigated. The aim of this study was to examine the responsiveness and clinically meaningful changes of the CNFDI, NBQ, and SFI for Persian patients with chronic neck pain.

METHODS

Prospective recruitment of 145 patients with chronic neck pain was conducted. Participants completed the Persian versions of CNFDI, NBQ, and SFI at baseline and after 4 weeks of physical therapy. Also, the Global Rating of Change Scale (GRCS) was completed in the post-intervention assessment. The Receiver Operating Characteristics (ROC) curve and correlational analysis were used for evaluating the responsiveness. In addition, the Minimal Clinically Important Change (MCIC) was determined.

RESULTS

All selected outcome measures revealed an area under the curve of 0.96. The MCICs of 10, 7, and 10 points were found for the CNFDI, NBQ, and SFI, respectively. The results showed an excellent Gamma correlation coefficient of the CNFDI (_γ = 0.98), NBQ (_γ = 0.99), and SFI (_γ = 0.99) with the GRCS.

CONCLUSION

The Persian versions of the CNFDI, NBQ, and SFI have acceptable responsiveness properties for evaluating the changes in health status in patients with chronic neck pain following physical therapy interventions.

Using minimal clinically important differences to measure long-term transitions of osteosarcopenia: The New Mexico Aging Process Study

BACKGROUND/OBJECTIVE

By having a better understanding of transitions in osteosarcopenia, interventions to reduce morbidity and mortality can be better targeted. The aim of this study was to show the rationale and method of using minimal clinically important differences (MCID's) to classify transitions, and the effects of demographic variables on transitions in a 9-year follow-up data from the New Mexico Aging Process Study (NMAPS).

METHODS

Transitions were identified in four aspects of osteosarcopenia: bone mineral density (BMD), appendicular skeletal muscle mass/body mass index ratio (ASM/BMI), grip strength and gait speed. Transitions were identified using a MCID score. As there is currently no available MCID for BMD and ASM/BMI, those were determined using a distribution-based and an anchor-based method. Total transitions were calculated for all four measures of osteosarcopenia in all transition categories (maintaining a health status, beneficial transition, harmful transitions). Poisson regression was used to test for effects of demographic variables, including age, sex, physical activity, medication, and health status, on transitions.

RESULTS

Over the 9-year follow-up, a total of 2163 MCID-derived BMD transitions were reported, 1689 ASM/BMI transitions, 2339 grip strength transitions, and 2151 gait speed transitions. Additionally, some MCID-derived transition categories were associated with sex, age, and health status.

CONCLUSION

Use of MCID-derived transitions reflected the fluctuation and the dynamic nature of health in older adults. Future research should focus on transitions of modifiable markers in osteosarcopenia to design intervention trials.

Patient-Reported Outcomes following Total Knee Replacement in Patients Aged 65 Years and Over-A Systematic Review

A previous systematic review showed positive patient-reported outcomes following total knee replacement (TKR) in patients aged < 65 years. However, the question remains as to whether these results are replicated for older individuals. This systematic review evaluated the patient-reported outcomes following TKR in individuals aged ≥ 65 years. A systematic search of Ovid MEDLINE, EMBASE, and Cochrane library were performed to identify studies examining disease-specific or health-related quality of life outcomes following TKR. Qualitative evidence synthesis was performed. Eighteen studies with low (n = 1), moderate (n = 6), or serious (n = 11) overall risk of bias were included, with evidence syntheses derived from 20,826 patients. Four studies reported on pain scales, showing improvement of pain from 6 months to 10 years postoperatively. Nine studies examined functional outcomes, showing significant improvements from 6 months to 10 years after TKR. Improvement in health-related quality of life was evident in six studies over 6 months to 2 years. All four studies examining satisfaction reported overall satisfaction with TKR results. TKR results in reduced pain, improved function, and increased quality of life for individuals aged ≥ 65 years. The improvement in patient-reported outcomes needs to be utilised in conjunction with physician expertise to determine what would comprise clinically significant differences.

The minimal important change for measures of balance and postural control in older adults: a systematic review

The minimal important change and analogous terms (MIC) can provide a measure of change in health outcome variables that is associated with a level of importance for participant/patient. This review explores the availability of the MIC for different balance measures used with older adults in research and clinical settings. PubMed, ProQuest and Web of Science search engines were used and based on the inclusion and exclusion criteria, 11 studies were deemed suitable for data extraction and analysis. The results demonstrated that MIC is available for the following balance-associated tests: Berg Balance Scale, Timed Up and Go, Short Physical Performance Battery, BESTest and the Tinetti test. A range of MIC values were shown, reflective of different older adult health conditions, calculation methods and anchors used. It was also evident that the responsiveness of the test was not always available or appropriately determined, questioning the validity of the MIC value published. Greater research is needed to establish MIC for balance measurements for use with older adults with different health conditions, preferably using objective measures such as falls. The calculation of such statistics will improve the evaluation of intervention effectiveness.

Clinical outcomes of patients with pigmented villonodular synovitis of the shoulder after arthroscopic synovectomy

BACKGROUND

Shoulder pigmented villonodular synovitis (PVNS) is a severe clinical condition, while few studies have focused on this situation due to its rarity. This study was to investigate the efficacy of arthroscopic treatment of patients diagnosed with shoulder PVNS.

METHODS

From Jan 1^st, 2010 to Dec. 31^st, 2019, 6 patients (5 females and 1 male) diagnosed with shoulder PVNS underwent arthroscopic synovectomy in our hospital and combined rotator cuff repair was performed in 3 of them. The outcomes of this study include Constant score, Visual Analogue Scale (VAS), University of California, Los Angeles (UCLA) score and American Shoulder and Elbow Surgeons (ASES) score. The data were retrieved from the patients' medical records.

RESULTS

With a mean follow-up of 52.0 months (range, 28-92 months), the mean difference of Constant, VAS, UCLA and ASES scores were 27.83 ± 21.60, 2.83 ± 2.56, 11.67 ± 10.93 and 17.83 ± 25.35, respectively. Statistically significant improvements were detected in all the patient-reported outcomes except ASES score. One of the patients suffered from recurrence. Two patients suffered from mild complications after the surgeries while both of them achieved satisfactory recovery finally.

CONCLUSION

Arthroscopic synovectomy in the setting of shoulder PVNS can improve patients' function. A concurrent rotator cuff repair is recommended if it is needed. The conclusion still needs testifying by further high-quality research with larger sample size.

Efficacy and Safety of Lidocaine Patch in the Management of Acute Postoperative Wound Pain: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study sought to quantify the pooled effects of lidocaine patch (LP) on postoperative pain and side-effects through a comprehensive review and meta-analysis.

APPROACH

The study followed PRISMA, AMSTAR and the Cochrane Collaboration. Randomized controlled trials s comparing LP with placebo were retrieved from five electronic databases. Primary outcome in the study was cumulative intravenous morphine equivalent consumption (mg) within 24 hours postoperatively.

RESULTS

Twelve trials comprising 617 patients were included in the final analysis. Primary result indicated that the analgesic effects LP were only statistical but not clinically significant of postoperative intravenous morphine consumption within 24 hours (mean difference, -4.61 mg; 95% CI, -8.09, -1.14). Interestingly, the results of subgroup and meta-regression analysis indicated that preoperative administration of LP had potential advantages in postoperative wound pain management. It is also worthwhile to mention that LP provided a clinically important benefit in rest pain scores within 24-hour postoperatively. Apart from these, other secondary outcome analysis did not uncover any particularly significant analgesic or safety advantages to LP. Finally, LP also does not increase the risk of any local anesthetic-related side effects.

INNOVATION

This systematic review and meta-analysis provides moderate-to-high quality evidence undermining the role of LP for management of acute postoperative wound pain following surgical procedures and the justification for the associated extra costs.

CONCLUSION

Taken together, the current evidence does not support LP as part of a routine multimodal analgesia strategy to alleviate early postoperative acute pain. However, further studies should explore the clinical value of preoperative administration and the long-term effect of LP.

Machine learning algorithms do not outperform preoperative thresholds in predicting clinically meaningful improvements after total knee arthroplasty

PURPOSE

Patient-reported outcome measures (PROMs) are important measures of success after total knee arthroplasty (TKA) and being able to predict their improvements could enhance preoperative decision-making. Our study aims to compare the predictive performance of machine learning (ML) algorithms and preoperative PROM thresholds in predicting minimal clinically important difference (MCID) attainment at 2 years after TKA.

METHODS

Prospectively collected data of 2840 primary TKA performed between 2008 and 2018 was extracted from our joint replacement registry and split into a training set (80%) and test set (20%). Using the training set, ML algorithms were developed using patient demographics, comorbidities and preoperative PROMs, whereas the optimal preoperative threshold was determined using ROC analysis. Both methods were used to predict MCID attainment for the SF-36 PCS, MCS and WOMAC at 2 years postoperatively, with predictive performance evaluated on the independent test set.

RESULTS

ML algorithms and preoperative PROM models performed similarly in predicting MCID for the SF-36 PCS (AUC: 0.77 vs 0.74), MCS (AUC: 0.95 vs 0.95) and WOMAC (AUC: 0.89 vs 0.88). For each outcome, the most important predictor of MCID attainment was the patient's preoperative PROM score. ROC analysis also identified optimal preoperative threshold values of 33.6, 54.1 and 72.7 for the SF-36 PCS, MCS and WOMAC, respectively.

CONCLUSION

ML algorithms did not perform significantly better than preoperative PROM thresholds in predicting MCID attainment after TKA. Future research should routinely compare the predictive ability of ML algorithms with existing methods and determine the type of clinical problems which may benefit the most from it.

LEVEL OF EVIDENCE

II.

PROMs Following Root Canal Treatment and Surgical Endodontic Treatment

The FDI is currently working on developing a tool to encompass patient-reported outcome measures (PROMs) within the overall assessment of outcomes of endodontic treatment. The outcome of endodontic treatment has traditionally been determined by various clinical and radiographic criteria. However, these parameters do not address the impact of treatment on a patient's oral health-related quality of life (OHRQoL). OHRQoL, a crucial PROM, can be used to understand treatment outcome from a patient-centred perspective, thus improving clinician-patient communication whilst guiding decision-making. This focussed review aims to recount the OHRQoL of patients following nonsurgical root canal treatment and surgical endodontic treatment, with a specific focus on the minimal important difference (MID; the minimum score changes of an outcome instrument for a patient to register a clinically significant change in their OHRQoL and/or oral condition) and the methods used to determine it. The current evidence indicates that the OHRQoL of patients requiring root canal treatment is poorer than those without such need. Accordingly, the literature suggests that OHRQoL improves following nonsurgical or surgical endodontic treatment. However, study methodologies vary widely, and conclusions cannot be drawn with high confidence, nor can MID recommendations be provided. Well-designed clinical studies with baseline measurements and appropriate follow-up time frames are therefore needed. Despite that the literature is rife with outcome studies, research on PROMs is an area that deserves greater attention, particularly in relation to the MID. Determining the MID will facilitate the understanding of changes in outcome scores from the patients' perspective, thus allowing for more informed decision-making in clinical practice.

Responsiveness and Minimal Important Change of the Quebec Back Pain Disability Scale in Italian patients with chronic low back pain undergoing multidisciplinary rehabilitation

BACKGROUND

There is still a lack of information concerning Minimal Important Change (MIC) of the Quebec Back Pain Disability Scale (QBPDS), that limits its use for clinical and research purposes.

AIM

Evaluating responsiveness and MIC of the QBPDS in Italians with chronic low back pain (LBP).

DESIGN

This is a methodological research based on an observational study.

SETTING

Outpatient rehabilitation hospital.

POPULATION

Two hundred and one patients with chronic LBP.

METHODS

At the beginning and end of a multidisciplinary rehabilitation program, patients completed the QBPDS. At the end of treatment, they completed a 7-level global perceived effect (GPE) scale, which was split to obtain a dichotomous outcome (improved vs. stable). Responsiveness was calculated by distribution-based (effect size [ES]; standardized response mean [SRM]; minimum detectable change [MDC<inf>95</inf>]) and anchor-based methods (receiver operating characteristics [ROC] curves). ROC curves were also used to compute the MIC (based on QBPDS change score, both absolute and expressed as percentage). Correlations between the change score of the QBPDS and GPE were calculated.

RESULTS

The ES was 0.29, the SRM was 0.43, and the MDC<inf>95</inf> was 12 points. ROC analysis of the absolute change scores showed a MIC value of 6 points, with an area under the curve (AUC), sensitivity, and specificity of 0.83 (95% CI: 0.77-0.90), 77.7% and 80.8%, respectively. ROC analysis based on the percent change score from baseline revealed a MIC of 18% with an AUC, sensitivity and specificity of 0.85 (95% CI: 0.79-0.91), 80.6% and 80.8%, respectively. Correlation between change score of the QBPDS and GPE was ρ=-0.67.

CONCLUSIONS

The QBPDS score change (expressed in both absolute value and percentage from baseline) was sensitive in detecting clinical changes in Italian subjects with chronic LBP undergoing multidisciplinary rehabilitation. In clinical practice, where absolute change is lower than MDC we recommend to rely on the MIC taking into account the percentage change from baseline condition.

CLINICAL REHABILITATION IMPACT

The present study investigated the responsiveness and MIC of the QBPDS in a group of patients with chronic LBP. Our findings showed that the QBPDS score may classify with good to excellent discriminatory accuracy subjects who consider themselves as improved. Where examining change, we recommend considering both MICs we provided (expressing score change both in absolute value and as a percentage from baseline), and disregard values lower than MDC<inf>95</inf>, not being discernible from measurement error.

Fundamentals of osteoarthritis: outcome evaluation with patient-reported measures and functional tests

Evaluating outcome in osteoarthritis (OA) clinical research and practice requires reliable, valid and responsive patient-reported outcome measures (PROMs) and functional tests that reflect important problems experienced by people with OA. The goal of this work is to provide information to start to guide the reader in selecting measures for people with OA. In this narrative review, we begin by providing an overview of measurement properties that can help clinicians and researchers in making decisions about whether a measure might be appropriate for use in their research or clinical context. We then report evidence supporting the use of measures of pain (e.g., Pain Visual Analogue (VAS), Numeric Pain Rating Scale (NPRS), Intermittent and Constant Osteoarthritis Pain, PROMIS Pain Interference, and, for screening in research, the painDETECT and the Self-report Leeds Assessment of Neuropathic Symptoms and Signs) and fatigue (e.g., PROMIS-Fatigue) at a group level in clinical research. Several multi-dimensional joint-specific measures (e.g., Western Ontario McMaster Universities' Osteoarthritis Outcomes Scale, Knee/Hip Injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Scale) also have evidence for group-level use. Functional tests (e.g., timed walk tests, 30 Second Chair Stand, Timed Up and Go, etc.) have measurement properties supporting their use at the group level in clinical research and at the individual patient level as do the pain VAS and NPRS. Other generic and disease-specific PROMs have been used in or could be used in OA studies but their measurement properties require further evaluation in people with OA.

Establishing Minimal Clinically Important Differences for the Quality of Life Instrument in Patients With Breast Cancer QLICP-BR (V2.0) Based on Anchor-Based and Distribution-Based Methods

Objective

To determine the minimal clinically important differences (MCIDs) for the breast cancer scale QLICP-BR (V2.0) among the Quality of Life Instruments system for cancer patients (QLICP), which consist of the general module of 32 items classifying into 4 domains and the specific module of 10 items.

Methods

According to the scoring rule of QLICP-BR (V2.0), the scores of each domain and the overall scale were calculated. The MCIDs of this scale were established by anchor-based and distribution-based methods. The anchor method used the Q29 item in the EORTC QLQ-C30 scale as anchors and defined the treatment effectiveness of the anchor-based method using criteria A (one level improvement after treatment) and B (at least one level improvement after treatment), while methods of effect size (ES), standard error of measurement (SEM), and reliability change index (RCI) were used in distribution-based methods.

Results

Using the anchor-based method, according to standard A, the MCIDs of the physical domain (PHD), psychological domain (PSD), social domain (SOD), common symptoms and side effect domain (SSD), core/general module (CGD), specific domain (SPD), and the total score (TOT) were 16.24, 11.37, 11.31, 12.07, 11.49, 10.69, and 11.23 respectively; according to standard B, the MCIDs of PHD, PSD, SOD, SSD, CGD, SPD, and TOT were 18.88, 15.14, 14.10, 14.50, 13.93, 12.17, and 14.23 respectively. In the distribution-based MCID study, when ES = 0.8, the MCID values of each domain and the total score of the scale were 9.14, 10.34, 8.34, 10.54, 6.79, 9.73, and 6.96 respectively. The MCIDs calculated when a SEM of 1.96 was used as the intermediary index were 8.38, 11.04, 8.67, 10.00, 7.44, 9.83, and 7.81. The MCIDs calculated when a RCI of 1.96 was used as the intermediary index were 11.84, 15.61, 12.27, 14.14, 10.52, 13.90, and 11.05. Additionally, the MCID value calculated by the two standards of the anchor method was similar to 0.8 ES, 1.96 SEM, and 1.96 RCI.

Conclusion

Using the anchor-based method, 0.8ES, 1.96SEM, and 1.96RCI have a better effect on the minimal clinically important difference of breast cancer scale and were recommended to be the preferred methods for establishing MCID.

Defining Failure in Primary Total Joint Arthroplasty: The Minimal Clinically Important Difference for Worsening Score

BACKGROUND

We define the value of the Minimal Clinically Important Difference for Worsening (MCID-W) for Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PROMIS-PF-10a) score for primary total joint arthroplasty (TJA) of the hip and knee and describe the risk factors for patients scoring worse than the MCID-W.

METHODS

This retrospective study was performed using 3414 primary TJA patients. PROMIS-PF-10a scores were collected at the preoperatively and postoperatively, and patients were classified based on reaching Minimal Clinically Importance Difference for Improvement (MCID-I), MCID-W, or "no significant change" after TJA (scores betweex`n MCID-W and MCID-I). MCID-W and MCID-I values were determined by a distribution method. The association between numerous variables and scoring worse than the MCID-W of PROMIS-PF-10a was then evaluated through multiple logistic regression. A threshold for preoperative PROMIS-PF-10a score predicting decline past MCID-W was determined using the Youden index and receiver operating characteristic curve.

RESULTS

The MCID-W for TJA was -1.89. Notably, increasing length of stay (odds ratio [OR] 1.073, 95% confidence interval [CI] 1.029-1.119, P < .001) and increasing preoperative PROMIS-PF-10a scores (OR 1.117, 95% CI 1.091-1.144, P < .001) were associated with increased likelihood of decline past the MCID-W of the PROMIS-PF-10a for TJA compared with patients who achieved the MCID-I. A community hospital with a dedicated joint replacement center was associated with a decreased risk for decline past the MCID-W (OR 0.601, 95% CI 0.402-0.899; P = .013).

CONCLUSION

We described the MCID-W value (-1.89) for the PROMIS-PF-10a questionnaire for knee and hip TJA and associated patient- and hospital-level risk factors for failure after TJA. Healthcare funding initiatives should be directed toward modifiable factors associated with clinically significant worse outcomes after TJA.

Toward a rigorous assessment of the statistical performances of methods to estimate the Minimal Important Difference of Patient-Reported Outcomes: a protocol for a large-scale simulation study

Interpreting observed changes over time in Patient-Reported Outcomes (PRO) measures is still considered a challenge. Indeed, concluding an observed change at group level is statistically significant does not necessarily equate this change is meaningful from the perspective of the patient. To help interpret within and/or between group changes in the measure over time, the estimation of the Minimal Important Difference (MID) of the instrument - the smallest value that patients consider as a perceived change - is useful. In the last 30 years, a plethora of methods and estimators have been proposed to derive this MID value using clinical data from sample of patients. MIDs for hundreds of PROs have been estimated, with frequently a substantial variability in the results depending on the method used. Nonetheless, a rigorous assessment of the statistical performances of numerous proposed methods for estimating MIDs by experimental design such as Monte-Carlo study has never been performed. The purpose of this paper is to thoroughly depict a protocol for a large-scale simulation study designed to investigate the statistical performances, especially bias against a true populational value, of the common proposed estimators for MID. This paper depicts how investigated methods and estimators were retained after the conduct of a systematic review, the design of a conceptual model that formally defines what is the true populational MID value and the translation of the conceptual model into a model allowing the simulation of responses of items to a hypothetical PRO at two times of measurement along with the response to a Patient Global Rating of Change at the second time under the constraint of a known true MID value. A statistical analysis plan is depicted in order to conclude if working hypotheses on what could be appropriate MID estimators will be verified. Strengths, assumptions, and limits of the simulation model are exposed. Finally, we show how this protocol could be the basis for fostering future methodological research on the issue of interpreting changes in PRO measures.

Estimating the minimal clinically important difference for balance and gait outcome measures in individuals with vestibular disorders

BACKGROUND

Vestibular Rehabilitation Therapists (VRT) utilize outcome measures to quantify gait and balance abilities in individuals with vestibular disorders (IVD). The minimal clinically important difference (MCID) in gait and balance outcome measures for IVD is unknown.

OBJECTIVE

The purpose of this study is to estimate the MCID of the Activities-specific Balance Confidence Scale (ABC), Functional Gait Assessment (FGA), and Gait Speed (GS) using distribution and anchor-based methods relative to the Dizziness Handicap Inventory (DHI) in IVD.

METHODS

Data were collected using a retrospective chart review from two outpatient Vestibular Rehabilitation (VR) clinics. Data included demographic characteristics, diagnosis, VR course, and pre and post outcome measures including DHI, ABC, FGA, and GS. The DHI was used to classify subjects as "responders" or "non-responders" in order to calculate MCID values.

RESULTS

The total number of subjects analyzed for each outcome measure was 222 for the ABC, 220 for FGA, and 237 for GS. Subjects made statistically significant improvements in ABC, DHI, FGA, and GS (p <  0.001) from pre to post VR. The MCID calculated for ABC, FGA, and GS using the anchor-based approach was 18.1%, 4 points, and 0.09 m/s respectively. The MCIDs calculated using distribution-based approach for the ABC ranged between 7.5-23.5%, FGA ranged between 1.31-4.15 points, and GS ranged between 0.07 m/s-0.22 m/s.

CONCLUSIONS

The anchor-based calculations of the MCID of 18.1%, 4 points, and 0.09 m/s for ABC, FGA, and GS respectively for IVD should be used over distribution-based calculations. This is due to strength of DHI as the anchor and statistical analysis. VRT and researches can use these values to indicate meaningful changes in gait and balance function in IVD.

Responsiveness and minimal important change of the Pain Catastrophizing Scale in people with chronic low back pain undergoing multidisciplinary rehabilitation

BACKGROUND

The Pain Catastrophizing Scale (PCS), a widely used tool to assess catastrophizing related to spinal disorders, shows valid psychometric properties in general but the minimal important change (MIC) is still not determined.

AIM

The aim of this study was to assess responsiveness and MIC of the PCS in individuals with chronic low back pain (LBP) undergoing multidisciplinary rehabilitation.

DESIGN

Prospective observational study.

SETTING

The setting was outpatient rehabilitation hospital.

POPULATION

Two hundred and five patients with chronic LBP.

METHODS

Before and after an 8-week multidisciplinary rehabilitation program, 205 patients completed the Italian version of the PCS (PCS-I). We calculated the PCS-I responsiveness by distribution-based methods (effect size [ES], standardized response mean [SRM], and minimum detectable change [MDC]) and anchor-based methods [receiver operating characteristic (ROC) curves]. After the program, participants completed a 7-point global perceived effect scale (GPE), based on which they were classified as "improved" vs. "stable." ROC curves computed the best cut-off level (taken as the MIC) between the two groups. ROC analysis was also performed on subgroups according to patients' baseline PCS scores.

RESULTS

ES, SRM and MDC were 0.71, 0.67 and 7.73, respectively. ROC analysis yielded an MIC of 8 points (95% confidence interval [CI]: 6-10; area under the curve [AUC]: 0.88). ROC analysis of the PCS subgroups confirmed an MIC of 8 points (95%CI: 6-10) for no/low catastrophizers (score <30, N.=159; AUC: 0.90) and indicated an MIC of 11 points (95%CI: 8-14) for catastrophizers (score >30, N.=33; AUC: 0.84).

CONCLUSIONS

The PCS-I showed good ability to detect patient-perceived clinical changes in chronic LBP postrehabilitation. The MIC values we determined provide a benchmark for assessing individual improvement in this clinical context.

CLINICAL REHABILITATION IMPACT

The present study calculated - in a sample of people with chronic LBP - the responsiveness and MIC of the PCS. These values increase confidence in interpreting score changes, enhancing their meaningfulness for both research and clinical contexts.

Substantial clinical benefit and patient acceptable symptom states of the Forgotten Joint Score 12 after primary knee arthroplasty

Background and purpose - Knowing how to interpret values obtained with patient reported outcome measures (PROMs) is essential. We estimated the substantial clinical benefit (SCB) and patient acceptable symptom state (PASS) for Forgotten Joint Score 12 (FJS) and explored differences depending on methods used for the estimates. Patients and methods - The study was based on 195 knee arthroplasties (KA) performed at a university hospital. We used 1 item from the Knee injury and Osteoarthritis Outcome Score domain quality of life and satisfaction with surgery, obtained 1-year postoperatively, to assess SCB and PASS thresholds of the FJS with anchor-based methods. We used different combinations of anchor questions for SCB and PASS (satisfied, satisfied with no or mild knee difficulties, and satisfied with no knee difficulties). A novel predictive approach and receiver-operating characteristics curve were applied for the estimates. Results - 70 and 113 KAs were available for the SCB and PASS estimates, respectively. Depending on method, SCB of the FJS (range 0-100) was 28 (95% CI 21-35) and 22 (12-45) respectively. PASS was 31 (2-39) and 20 (10-29) for satisfied patients, 40 (31-47) and 38 (32-43) for satisfied patients with no/mild difficulties, and 76 (39-80) and 64 (55-74) for satisfied patients with no difficulties. The areas under the curve ranged from 0.82 to 0.88. Interpretation - Both the SCB and PASS thresholds varied depending on methodology. This may indicate a problem using meaningful values from other studies defining outcomes after KA. This study supports the premise of the FJS as a PROM with good discriminatory ability in patients undergoing KA.

Reliability, minimum detectable change, and minimum clinically important difference of the balance subtest of the Bruininks-Oseretsky test of motor proficiency-second edition in children with cerebral palsy

PURPOSE

This study aimed to investigate the internal consistency, inter-rater, and test-retest reliability of the balance subtest of the Bruininks-Oseretsky test of motor proficiency-second edition (BOT-2) and to estimate the minimum detectable change (MDC) and minimum clinically important difference (MCID) of the balance subtest of the BOT-2 in children with cerebral palsy (CP).

METHODS

In total, 20 children with CP participated in the present study. Internal consistency, test-retest, and inter-rater reliability were computed to establish reliability of the balance subtest of the BOT-2. The MDC95 was estimated from the standard error of measurement (SEM) to determine a real change for an individual child with CP. The anchor- and distribution-based MCID were calculated to determine the smallest change that might be important to clinicians. For concurrent validity, the correlation between the balance subtest of the BOT-2 and the pediatric balance scale (PBS) were calculated using Spearman's correlation.

RESULTS

Internal consistency was good (Cronbach's alpha coefficient = 0.89). The BOT-2 had excellent test-retest (ICC = 0.99, p < 0.001) and inter-rater reliability (ICC = 0.99, p < 0.001). The balance subtest of the BOT-2 had an SEM of 0.70, MDC95 of 9.61, and MCIDs of 2.54 (anchor-based) and 1.38 (distribution-based). Additionally, there was a moderate positive correlation between the balance subtest of the BOT-2 and the PBS (Spearman's rho = 0.629, p = 0.003).

CONCLUSIONS

Our experimental results indicate that the balance subtest of the BOT-2 had good internal consistency, along with excellent test-retest and inter-rater reliability. The change in scores of an individual child with CP should attain 9.61 points on the balance subtest of the BOT-2 to indicate a clinically important change. The MDC95 and MCID values could be helpful in understanding therapeutic effects and evaluating balancing ability using the balance subtest of the BOT-2 in children with CP.

Understanding Clinical Significance in Rehabilitation: A Primer for Researchers and Clinicians

ABSTRACT

The objective of this review was to summarize the concept of clinical significance and associated methods focusing on the area of rehabilitation to provide a resource to rehabilitation researchers and clinicians. Studies were searched on electronic databases from inception until July 28, 2020, with no date or language limits. Manual searches as well as Scopus forward citation for relevant references were performed. Narrative synthesis of study results was performed. Definitions of the concepts related to clinical significance, ways of calculating, and interpreting each method were provided using rehabilitation examples. An explanation of methods to evaluate clinical significance (distribution, anchor, and opinion-based methods) and their advantages and disadvantages were also provided. Considering the limitations of statistical significance in assuring meaningfulness of results, clinical interpretation of research outcomes and the report of clinical significance in intervention trials should be a priority in rehabilitation research. When possible, the use of multiple methods (distribution, anchor, and opinion based) is recommended. Thus, clinical researchers are encouraged to present results in a manner that allow the rehabilitation professionals to easily interpret and implement those results in their clinical practice.

A systematic survey identified methodological issues in studies estimating anchor-based minimal important differences in patient-reported outcomes

OBJECTIVE

To systematically survey the literature addressing the reporting of studies estimating anchor-based minimal important differences (MIDs) and choice of optimal MIDs.

STUDY DESIGN AND SETTING

We searched Medline, Embase and PsycINFO from 1987 to March 2020. Teams of two reviewers independently identified eligible publications and extracted quotations addressing relevant issues for reporting and/or selecting anchor-based MIDs. Using a coding list, we assigned the same code to quotations capturing similar or related issues. For each code, we generated an 'item', i.e. a specific phrase or sentence capturing the underlying concept. When multiple concepts existed under a single code, the team created multiple items for that code. We clustered codes addressing a broader methodological issue into a 'category' and classified items as relevant for reporting, relevant for selecting an anchor-based MID, or both.

RESULTS

We identified 136 eligible publications that provided 6 categories (MID definition, anchors, patient-reported outcome measures, generalizability and statistics) and 24 codes. These codes contained 34 items related to reporting MID studies, of which 29 were also related to selecting MIDs.

CONCLUSION

The systematic survey identified items related to reporting of anchor-based MID studies and selecting optimal MIDs. These provide a conceptual framework to inform the design of studies related to MIDs, and a basis for developing a reporting standard and a selection approach for MIDs.

The Analgesic Benefits of Ketorolac to Local Anesthetic Wound Infiltration Is Statistically Significant But Clinically Unimportant: A Comprehensive Systematic Review and Meta-Analysis

Objective: Even though ketorolac-infiltration is said to provide superior postoperative analgesic benefits in different surgical procedures, its safety and efficacy remain to be validated because of the lack of high-quality evidence. We aimed to summarize the efficacy and safety of ketorolac-infiltration based on published randomized-controlled trials (RCTs). Approach: This work followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, assessing the methodological quality of systematic reviews and the Cochrane Collaboration recommendations. We searched for RCTs evaluating the efficacy of ketorolac-infiltration in adults in the PubMed, Web of Science, Embase, Cochrane Library, Chinese databases, and Google Scholar. The two co-primary outcomes of this meta-analysis were rescue analgesic consumption in the 24-h postoperative period and rest pain scores. Results: Twelve trials (761 patients) were analyzed. Ketorolac-infiltration provided a clinically unimportant benefit in morphine consumption (mean difference, -2.81 mg; 95% confidence interval [CI], -5.11 to -0.50; p = 0.02; moderate-quality evidence). Low-to-moderate quality evidence supported a brief (2-6 h), clinically subtle, but statistically consistent effect of surgical site ketorolac-infiltration in reducing wound pain at rest. High-quality evidence supported shorter hospital stays for surgical patients receiving local ketorolac-infiltration when compared to controls (mean difference, -0.12 days; 95% CI, -0.17 to -0.08; p < 0.00001). Further, ketorolac-infiltration does not improve any opioid-related side effects. Innovation: Ketorolac-infiltration provides statistically significant but clinically unimportant benefits for improving postoperative wound pain. Conclusion: Overall, despite the fact that current moderate-to-high quality of evidence does not support routine using of ketorolac as an adjuvant to local anesthetic for wound infiltration, these findings underscore the importance of optimizing agents and sustained delivery parameters in postoperative local anesthetic practice. Clinical Trials.gov ID: CRD42021229095.

Effects of yoga and mindfulness practices on the autonomous nervous system in primary school children: A non-randomised controlled study

OBJECTIVES

The present study examined the effects of a yoga and mindfulness-based programme on the autonomic nervous system of primary school children by using heart rate variability parameters.

DESIGN

A two-arm non-randomised controlled trial compared an integrated yoga and mindfulness-based programme (16 weeks) to conventional primary school lessons.

SETTING

Primary school classrooms and conference rooms.

INTERVENTIONS

Participants were allocated to a 16-week integrated yoga-based programme or conventional school lessons. A subgroup was randomised to receive 24h electrocardiogram-recordings.

MAIN OUTCOME MEASURES

Heart rate variability indices were measured, both linear (time and frequency domain) and non-linear (symbolic dynamics, compression entropy), calculated from 30-minute extracts of Holter-electrocardiogram-recordings. Assessments were conducted at baseline and at the end of intervention.

RESULTS

40 participants (42.5% female) were included into the analysis of HRV. No significant changes in heart rate variability parameters were observed between the groups after 16 weeks. In the intervention group, a trend towards increased parasympathetic activity could be seen over time, although not significantly enhanced compared to the control group.

CONCLUSION

Results obtained here do not clearly show that children in German primary school settings benefit from an integrated yoga-based intervention. However, exploratory post-hoc analyses point interestingly to an increased nocturnal parasympathetic activity in the intervention group. Further studies are required with high-quality study designs, larger sample sizes and longer-term follow-ups.

Results of cementless total knee arthroplasty in patients over 70 years of age

OBJECTIVE

To analyze the clinical and radiologic results, the survival and complications obtained in 70 year or older patients who underwent cementless total knee arthroplasty (TKA).

MATERIAL AND METHOD

An observational study of patients operated between January 2014 and December 2016 was carried out according to the Natural Knee model (Zimmer®, USA). The main variables were the Oxford Knee Score, the visual analog scale, the presence of radiolucencies, complications, survival and reasons for revision.

RESULTS

Of 104 TKA, 86 were available for revision. The median age was 76 years. The mean follow-up was 5.4 years (range 3.7-6.9). The Oxford Knee Score punctuation showed a median of 17 presurgical (range 0-40) and 37 post surgical (range 5-48), P<.001. The 87.2% of the patients obtained a clinically significant improvement. The median visual analog scale punctuation was 8 for presurgical (range 4-10) and 2 for post surgical (range 1-9), P<.001. The 88.3% of the patients obtained a clinically significant decrease. Three months after the surgery, the 55.81% of the TKAs presented radiolucencies around the tibial plateau. At the end of the follow-up, radiolucencies were present in 30.23% of the TKAs. Survival from all causes was 91.86% at 77.2 months and 96.5% due to aseptic loosening.

CONCLUSION

Cementless knee prostheses are a valid option in patients aged 70 or older, presenting good clinical, radiological and survival results.

Obesity Increases Risk of Failure to Achieve the 1-Year PROMIS PF-10a Minimal Clinically Important Difference Following Total Joint Arthroplasty

INTRODUCTION

The aims of this study were to determine if increasing body mass index (BMI) is a risk factor for failure to attain the 1-year Patient Reported Outcomes Measurement Information System Physical Function (PROMIS PF-10a) minimal clinically important difference (MCID) following total joint arthroplasty (TJA) and to determine a possible BMI threshold beyond which this risk increases significantly.

METHODS

This retrospective study was performed using 3506 TJAs sourced from a regional-based registry. An anchor-based MCID threshold of 7.9 was chosen. PROMIS PF-10a scores were collected at the preoperative and 1-year postoperative timepoints, and the change was used to determine failure to achieve the 1-year MCID. Demographic and surgical variables were also collected. The association between BMI and failure to achieve 1-year PROMIS PF-10 MCID was then evaluated using logistic regression. A BMI threshold was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Increasing BMI assessed continuously was a significant risk factor for failure to achieve the MCID (P < .001). "Obese Class I" (30-35 kg/m²), "Obese Class II" (35-40 kg/m²), and "Obese Class III" (>40 kg/m²) subgroups compared to "Normal BMI" (<25 kg/m²) were significantly associated (P < .05) with this adverse outcome as well.

CONCLUSION

Our study showed that increasing BMI is a risk factor for failure to achieve the 1-year PROMIS PF-10a MCID following TJA. Among our patients, an increase in 1 kg/m² increased the risk of failure to achieve the MCID by 2%. With these findings, surgeons will be better equipped to preoperatively advise patients with elevated BMIs considering TJA.

Tobacco use in the Myeloproliferative neoplasms: symptom burden, patient opinions, and care

BACKGROUND

Patients with Philadelphia-negative Myeloproliferative Neoplasms (MPN) suffer from numerous symptoms and decreased quality of life. Smoking is associated with an increased symptom burden in several malignancies. The aim of this study was to analyze the association between smoking and MPN-related symptom burden and explore MPN patients' opinions on smoking.

METHODS

A total of 435 patients with MPN participated in a cross-sectional internet-based survey developed by the Mayo Clinic and the Myeloproliferative Neoplasm Quality of Life Group. Patients reported their demographics, disease characteristics, tobacco use, and opinions on tobacco use. In addition, MPN-related symptoms were reported via the validated 10-item version of the Myeloproliferative Neoplasms Symptom Assessment Form.

RESULTS

Current/former smokers reported worse fatigue (mean severity 5.6 vs. 5.0, p = 0.02) and inactivity (mean severity 4.0 vs. 3.4, p = 0.03) than never smokers. Moreover, current/former smokers more frequently experienced early satiety (68.5% vs. 58.3%, p = 0.03), inactivity (79.9% vs. 71.1%, p = 0.04), and concentration difficulties (82.1% vs. 73.1%, p = 0.04). Although not significant, a higher total symptom burden was observed for current/former smokers (mean 30.4 vs. 27.0, p = 0.07). Accordingly, overall quality of life was significantly better among never smokers than current/former smokers (mean 3.5 vs. 3.9, p = 0.03). Only 43.2% of the current/former smokers reported having discussed tobacco use with their physician, and 17.5% did not believe smoking increased the risk of thrombosis.

CONCLUSION

The current study suggests that smoking may be associated with increased prevalence and severity of MPN symptoms and underscores the need to enhance patient education and address tobacco use in the care of MPN patients.

Measurement properties of selected patient-reported outcome measures for use in randomised controlled trials in patients with systemic lupus erythematosus: a systematic review

OBJECTIVE

The heterogeneous multisystem manifestations of SLE include fatigue, pain, depression, sleep disturbance and cognitive dysfunction, and underscore the importance of a multidimensional approach when assessing health-related quality of life. The US Food and Drug Administration has emphasised the importance of patient-reported outcomes (PROs) for approval of new medications and Outcome Measures in Rheumatology has mandated demonstration of appropriate measurement properties of selected PRO instruments.

METHODS

Published information regarding psychometric properties of the Medical Outcomes Survey Short Form 36 (SF-36), Lupus Quality of Life Questionnaire (LupusQoL) and Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-F), and their suitability as end points in randomised controlled trials (RCTs) and longitudinal observational studies (LOS) were assessed. A search of English-language literature using MEDLINE and EMBASE identified studies related to development and validation of these instruments. Evidence addressed content validity, reliability (internal consistency and test-retest reliability), construct validity (convergent and divergent) and longitudinal responsiveness, including thresholds of meaning and discrimination.

RESULTS

All instruments demonstrated strong internal consistency, reliability and appropriate face/content validity, indicating items within each instrument that measure the intended concept. SF-36 and LupusQoL demonstrated test-retest reliability; although not published with FACIT-F in SLE supported by evidence from other rheumatic diseases. All instruments demonstrated convergent validity with other comparable PROs and responsivity to treatment.

CONCLUSION

The measurement properties of PRO instruments with published data from RCTs including: SF-36, LupusQoL and FACIT-F indicate their value as secondary end points to support labelling claims in RCTs and LOS evaluating the efficacy of SLE treatments.

The minimal important change for the seven-item disability of the arm, shoulder, and hand (DASH 7) questionnaire - Assessing shoulder function in patients with subacromial pain

Background

The DASH 7 is a recently published activity-related 7-item short form of the disability of the arm, shoulder, and hand (DASH) questionnaire developed to assess shoulder function in patients with subacromial pain. Before implementation in both intervention studies and in clinical practice, it is essential to evaluate its responsiveness. The objective of this study was to determine the minimal important change (MIC) in the DASH 7 questionnaire for patients with subacromial pain after a 3 months exercise intervention in a primary care context.

Methods

In this psychometric study the anchor-based MIC-distribution method was used to establish the MIC. The Patient Global Impression of Change (PGIC) was used as external criterion. Data from a clinical implementation study, aimed to implement a specific exercise strategy for patients with subacromial pain among physiotherapists in primary care, were used. Data from 70 patients were included in the analyses.

Results

The correlation coefficient between Patient Global Impression of Change and the DASH 7 score change was 0.67 and the area under the curve was 0.94 (95% confidence interval: 0.88-1.0). The MIC_ROC for improvement was detected at a mean change in 6.5 points with the sensitivity at 0.98 (98%) and the specificity at 0.78 (78%), and the MIC_{95% limit} for improvement was detected at a mean change of 25.7 points. There were 77% of the patients who reached at least this MIC_ROC and 51% who reached at least the MIC_{95% limit} after 3 months of exercise intervention_.

Conclusion

The DASH 7 is responsive to change over time and can discriminate between patients considered to be improved and patients considered not improved. These MIC values for patients with subacromial pain in the primary care setting can be used in clinical practice and in intervention studies as an indication on the patients clinically important level of score change for improvement.

Determining the Minimal Important Difference for the Wound-QoL Questionnaire

BACKGROUND

The questionnaire for the quality of life with chronic wounds (Wound-QoL) is a valid and reliable instrument to determine the disease-specific health-related QoL of patients with chronic wounds. For the interpretation of HRQoL scores, it is additionally important to know which differences in scores are considered meaningful. The minimal important difference (MID) is defined as a change in HRQoL that a patient would consider meaningful, such that the patient would judge a treatment to be beneficial and worthy of repeating.

OBJECTIVE

To interpret changes in the Wound-QoL scores and draw conclusions regarding the relevance of detected changes; the purpose of this study was to estimate the MID of the Wound-QoL global score and its subscales for patients with chronic wounds.

PATIENTS AND METHODS

Patients completed the Wound-QoL before and four to six weeks after treatment and additionally gave a global rating of wound status change after treatment. The global rating of change served as an anchor question. MIDs were calculated based on an anchor-based and a distribution-based method.

RESULTS

In total, 227 patients participated in the study. The mean age of the study population was 66.9 (± 12.7) median was 69.5, and 51.5% of the patients were female. MIDs for the Wound-QoL global score ranged from 0.47 to 0.52, proposing an overall estimation of 0.50.

CONCLUSION

The results can be used to measure and interpret changes in wound-specific QoL over time.

Measurement Properties and Translation to Brazilian-Portuguese of the Challenge for Children and Adolescents with Cerebral Palsy

Aims: Translate the Challenge assessment into Brazilian-Portuguese, determine its face validity, evaluate the reliability of the total score and score per item, investigate whether the child's gross motor level (classified by the Gross Motor Function Classification System-GMFCS) influences the reliability levels, and estimate responsiveness to change.Methods: The translation followed four stages: translation, synthesis, back-translation, and review. For face validity, ten physical therapists evaluated item relevance. Children and adolescents with cerebral palsy (n = 50, 5-18 years of age) GMFCS I and II were evaluated by two therapists for inter and intra-rater reliability. Thirty of these participants were recruited for the instrument's responsiveness evaluation and reassessed (n = 28) after three months of treatment. Minimal Detectable Change (MDC), and Minimal Clinically Important Difference (MCID) were estimated.Results: The back-translated version was similar to the English version. All test items were considered relevant by the physical therapists. Total score intra and inter-rater reliability were excellent for both GMFCS levels (ICC = 0.94-0.99). Items' intra- and inter- rater reliability varied from low to almost perfect (kw=-0.14-0.94). MDC90 and MDC95 values were 3.90-6.35 and 4.63-7.54, respectively. MCID values were 3.57-4.56.Conclusion: The translated version of the Challenge showed excellent face validity and reliability and was able to document longitudinal change.

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.

Patient-Reported Outcomes Following Total Knee Replacement in Patients <65 Years of Age-A Systematic Review and Meta-Analysis

An increasing number of total knee replacements (TKRs) are being performed in response to the growing burden of osteoarthritis. Patients <65 years of age represent the fastest growing group of TKR recipients and are expected to account for an increasing number of primary and revision procedures. Concerns have been raised about the outcomes that can be expected by this age demographic who are more active, physically demanding, and have longer life expectancies compared to older TKR recipients. This systematic review and meta-analysis evaluated the effectiveness of TKR for osteoarthritis in patients <65 years of age, compared to older individuals. A systematic search of Embase and Medline was conducted to identify studies which examined patient-reported outcomes measured using disease-specific and generic health-related quality of life instruments. Ten studies met our inclusion criteria and were included in this review. These studies comprised 1747 TKRs performed between 1977 and 2014. In the meta-analysis of two prospective studies (288 TKRs), patients <65 years of age were able to attain large and clinically meaningful improvements in pain, function, and quality of life. One of these studies (61 TKRs) suggested that patients <55 years of age attained a larger degree of improvement compared to older individuals. Results into the second postoperative decade were less certain, with some data suggesting a high prevalence of pain and patterns of functional decline. Further research is required to investigate longer-term outcomes following TKR for osteoarthritis in younger patients.

Outcome measures for chronic inflammatory demyelinating polyneuropathy in research: relevance and applicability to clinical practice

Outcome measures are recommended in the management of chronic inflammatory demyelinating polyneuropathy (CIDP). Various scales have been proposed in recent years, some now commonly utilized in daily clinical practice. The available evidence base relies itself on randomized controlled trial data obtained over the past 30 years, with several studies using different primary and secondary outcomes. We here review the different outcome measures used in CIDP research in relation to those currently recommended for clinical management. We consider the evidence base for CIDP treatment from the primary and secondary outcomes used in these studies and attempt to assess how this may relate to current clinical practice of routine evaluation of treatment effects and long-term monitoring.

The Potential of Functional Near-Infrared Spectroscopy-Based Neurofeedback-A Systematic Review and Recommendations for Best Practice

Background: The effects of electroencephalography (EEG) and functional magnetic resonance imaging (fMRI)-neurofeedback on brain activation and behaviors have been studied extensively in the past. More recently, researchers have begun to investigate the effects of functional near-infrared spectroscopy-based neurofeedback (fNIRS-neurofeedback). FNIRS is a functional neuroimaging technique based on brain hemodynamics, which is easy to use, portable, inexpensive, and has reduced sensitivity to movement artifacts.

Method: We provide the first systematic review and database of fNIRS-neurofeedback studies, synthesizing findings from 22 peer-reviewed studies (including a total of N = 441 participants; 337 healthy, 104 patients). We (1) give a comprehensive overview of how fNIRS-neurofeedback training protocols were implemented, (2) review the online signal-processing methods used, (3) evaluate the quality of studies using pre-set methodological and reporting quality criteria and also present statistical sensitivity/power analyses, (4) investigate the effectiveness of fNIRS-neurofeedback in modulating brain activation, and (5) review its effectiveness in changing behavior in healthy and pathological populations.

Results and discussion: (1–2) Published studies are heterogeneous (e.g., neurofeedback targets, investigated populations, applied training protocols, and methods). (3) Large randomized controlled trials are still lacking. In view of the novelty of the field, the quality of the published studies is moderate. We identified room for improvement in reporting important information and statistical power to detect realistic effects. (4) Several studies show that people can regulate hemodynamic signals from cortical brain regions with fNIRS-neurofeedback and (5) these studies indicate the feasibility of modulating motor control and prefrontal brain functioning in healthy participants and ameliorating symptoms in clinical populations (stroke, ADHD, autism, and social anxiety). However, valid conclusions about specificity or potential clinical utility are premature.

Conclusion: Due to the advantages of practicability and relatively low cost, fNIRS-neurofeedback might provide a suitable and powerful alternative to EEG and fMRI neurofeedback and has great potential for clinical translation of neurofeedback. Together with more rigorous research and reporting practices, further methodological improvements may lead to a more solid understanding of fNIRS-neurofeedback. Future research will benefit from exploiting the advantages of fNIRS, which offers unique opportunities for neurofeedback research.

Consensus on the reporting and experimental design of clinical and cognitive-behavioural neurofeedback studies (CRED-nf checklist)

Neurofeedback has begun to attract the attention and scrutiny of the scientific and medical mainstream. Here, neurofeedback researchers present a consensus-derived checklist that aims to improve the reporting and experimental design standards in the field.

Meaningful change in 6-minute walk in people with peripheral artery disease

OBJECTIVE

The 6-minute walk test is a common outcome measure in clinical trials of people with lower extremity peripheral artery disease (PAD). However, what constitutes a meaningful change in the 6-minute walk distance has not been well defined for people with PAD. The present study related the change in the 6-minute walk distance to the degree of participant-reported improvement or decline in the 6-minute walk distance to define a meaningful change in the 6-minute walk distance for those with PAD.

METHODS

Participants with PAD from three observational longitudinal studies completed the walking impairment questionnaire (WIQ) distance score and 6-minute walk at baseline and 1 year later. The WIQ distance score measures participants' perceived difficulty walking seven different distances without stopping (ranging from walking around the home to walking 5 blocks) on a 0 to 4 Likert scale, with 0 representing an inability to walk the distance and 4 representing no difficulty. The mean changes in the 6-minute walk distance corresponding to the participants' report of no change, 1-unit change, or 2-unit change, respectively, in the Likert scale score between the baseline and 1-year follow-up measures were calculated for each WIQ distance.

RESULTS

A total of 777 participants with PAD (mean age, 71.2 ± 8.8 years; mean baseline 6-minute walk distance, 350.1 ± 118.1 meters) completed 5439 questions about their difficulty walking each WIQ distance at baseline and follow-up. Participants with PAD who reported no change in their difficulty in walking each WIQ distance between baseline and follow-up had a decline of 7.2 meters (95% confidence interval [CI], -11.6 to -2.8 meters) in the 6-minute walk test. Relative to those reporting no change in difficulty walking, the participants reporting 1- and 2-point improvements in walking ability showed 6-minute walk distance improvements of 7.8 meters (95% CI, -0.3 to 15.9 meters) and 20.1 meters (95% CI, 1.1-39.2 meters), respectively. Relative to those reporting no change in walking difficulty, those reporting 1- and 2-point declines in perceived walking difficulty showed declines of -11.2 meters (95% CI, -19.0 to -3.4 meters) and -23.8 meters (95% CI, -37.4 to -10.3 meters) in the 6-minute walk distance.

CONCLUSIONS

Among people with PAD, ∼8- and ∼20-meter improvements in the 6-minute walk distance represent small and large improvements in walking ability, respectively. People with PAD who reported no change in their ability to walk distances over 1 year simultaneously declined by a mean of 7 meters in the 6-minute walk test. These findings will be useful for interpreting the results from randomized trials of interventions to improve the walking performance of people with PAD.