Psychometric properties of the Cervical Spine Outcomes Questionnaire and its relationship to standard assessment tools used in spine research

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

OBJECTIVES

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

Content comparison of neck pain outcome measures using the international classification of functioning, disability and health

The purpose of this study was to compare the content covered by existing neck pain measures based on the linkage to the International Classification of Functioning, Disability and Health (ICF) framework to examine the extent to which the existing measures represent ICF categories and to identify content gaps in existing measures that would inform further research. Ten commonly used measures were identified, and their content was linked to ICF categories using established coding systems. Two clinical experts reviewed every measure independently and identified the central meaningful concepts from individual items of each measure. A total of 177 concepts were identified from 193 items across 10 measures. Body functions were the most represented category across measures (23-64%). The representation of activities ranged from 14 to 61% whereas the representation of participation ranged from 6 to 31% across measures. The ProFitMap-Neck was the only measure that addressed the environmental factors. The ProFit-Map neck captured a majority of concepts from body structures and function and the neck outcome score captured maximum concepts from the activities and participation categories. A combination of ProFit-Map neck and Neck Outcome Score can be used with caution to obtain a more comprehensive assessment of the impact of neck pain on function, activities and participation.

Patient Selection in Cervical Disc Arthroplasty

BACKGROUND

Patient selection for cervical disc arthroplasty (CDA) in the United States remains a topic of debate among surgeons. Many surgeons base US patient selection for CDA implantation on the Food and Drug Administration (FDA) indications/contraindications. While off-label use does occur, the frequency and extent of off-label use in the US remains largely unknown. Outside the United States, patient selection is notably less stringent; however such data also remain largely unpublished or presented/published with a low level of evidence. Here, we will review the current approved US on-label patient selection criteria for CDA and discuss the rationale and supporting evidence to expand these criteria in the United States.

METHODS

A PubMed literature search was completed using the keywords "cervical disc arthroplasty" and "cervical disc replacement." The articles were evaluated by the authors for patient selection criteria.

CONCLUSIONS

The current published data do not conclusively prove that the patients excluded from CDA by strict adherence to FDA indications would benefit from CDA surgery over anterior cervical discectomy and fusion. As surgeons, it is a difficult decision regarding when to expand indications to include off-label use of CDA. In our practice, generally CDA patient selection agrees with the FDA indications and contraindications, as there is a lack of level 1 evidence to confirm effectiveness of CDA outside of the current FDA indications. We will likely need more well-constructed studies to include prospective and controlled trials that specifically evaluate the "off-label" applications before US surgeons are convinced to expand indications and insurance companies agree to reimburse.

Tracking patient-reported outcomes in spinal disorders

Background:

Patient-reported outcome measures (PROMs) quantify health status from the patient's point of view. While the number of published outcomes studies grows each year, so too has the number of instruments being reported, leading to confusion on which instruments are appropriate to use for various spinal conditions.

Methods:

A broad search was conducted to identify commonly used PROMs in patients undergoing spinal surgery. We searched PubMed for combinations of terms related to anatomic location and a measure of patient-reported outcome in the title or text. We supplemented the search using the “related articles” feature of PubMed and by manually searching the bibliographies of selected articles.

Results:

Major categories of PROMs in spine surgery include health-related quality-of-life, pain, and disease-specific disability, for which several different instrument options were identified and detailed. The minimal clinically important difference varies between instruments and differentiates statistical significance from clinical significance. In addition, the accurate estimation of costs has become a challenging but intrinsically linked variable to outcomes as increased attention is paid to the relative value of surgical interventions.

Conclusion:

While a number of PROMs are available for tracking outcomes in spine surgery, only a handful appear to be widely used. At least one instrument from each category should be measured pre- and post-operatively to quantify treatment effect. In addition, while the primary goal is to select the most appropriate instruments for the patient's condition, one should keep in mind sustainability of efforts with regard to patient and administrative burden.

The Development and Psychometric Properties of the Patient Self-Report Neck Functional Status Questionnaire (NFSQ)

STUDY DESIGN

Retrospective analysis of cross-sectional data.

OBJECTIVE

To describe the development of a new self-report Neck Functional Status Questionnaire (NFSQ) and to assess its psychometric properties and practical application. The NFSQ was designed to assess functional status in patients with cervical (spine) disorders who seek outpatient therapy.

BACKGROUND

Many patients seek outpatient therapy due to cervical disorders. Currently, no patient-reported outcome measures exist that capture the ability to perform functional activity in a manner that reflects the experience of this patient population.

METHODS

Four hundred thirty-nine patients who were being treated for cervical disorders responded to a set of survey questions to assess activity-related functional outcomes associated with cervical disorders. Using item response theory, we assessed candidate items for unidimensionality and local independence, item fit, person separation, precision, targeting, and differential item functioning. We also compared discriminant validity of functional status measures estimated by the item response theory model (NFSQ fixed) and measures generated using a simulated computerized adaptive test (NFSQ computerized adaptive test).

RESULTS

Based on expert opinion and subsequent processing and analyses, a final set of 28 items was used to develop the NFSQ. Unidimensionality and local independence were supported. The mean ± SD sample ability level of 57.6 ± 14.3 (scale range, 0-100) matched well with the mean item difficulty of the NFSQ of 51.3 ± 7.4. Differential item functioning was negligible for levels of age group, sex, and symptom acuity. The NFSQ computerized adaptive test measures were as precise as the NFSQ fixed measures.

CONCLUSION

Study results supported the preliminary validity of the 28-item NFSQ for use in assessing patients with different levels of functional status related to their cervical disorders in outpatient rehabilitation settings.

Functional recovery in lumbar spine surgery: a controlled trial of health behavior change counseling to improve outcomes

In 2001, the Institute of Medicine issued a challenge to the American health care system to improve the quality of care by focusing on six major areas: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The patient-centered model of care directly addresses important limits of surgical care of the lumbar spine, i.e., the lack of effective methods for increasing patient participation and engagement in post-operative follow-up. Recent evidence indicates that post-surgical outcomes are better among those with higher patient activation. We therefore developed an intervention based on the principles of motivational interviewing to increase patient activation: the Functional Recovery in Lumbar Spine Surgery Health Behavior Change Counseling (HBCC) intervention. The HBCC was designed to maximize post-operative engagement and participation in physical therapy and home exercise, to improve functional recovery, and to decrease pain in individuals undergoing elective lumbar spine surgery. From December 2009 through October 2012, 120 participants were recruited and divided into two groups: those receiving (intervention group, 60) and not receiving (control group, 60) the HBCC intervention. The current manuscript provides a detailed description of the theoretical framework and study design of the HBCC and describes the implementation of this health behavior intervention in a university-based spine service. The HBCC provides a model for conducting health behavioral research in a real-world setting.

Reflecting on whiplash associated disorder through a QoL lens: an option to advance practice and research

PURPOSE

To examine the constructs of quality of life (QoL) as applied to whiplash associated disorder (WAD), its current state of measurement and suggestions for future application.

METHOD

Narrative literature review.

RESULTS

The burden of WAD on the healthcare system is substantive. Assessment of QoL issues for people with WAD may provide a broader understanding of the patient experience. No consistent framework for QoL in WAD has been adopted, nor has preference for any QoL instrument been established. Inconsistent use of terminology for what is being measured, and the measures themselves hamper clarity on the issue. Options for assessing QoL currently include a meaningful condition-specific scale that has not undergone sufficient psychometric evaluation (Whiplash Disability Questionnaire (WDQ), or generic scales with strong psychometric properties that have not undergone sufficient relevancy evaluation (e.g. SF-36, WHOQOL BREF). Generic measures can measure overlapping constructs including heath status, utility, health-related quality of life or generic QoL. The inter-relationships between these in WAD have not been defined.

CONCLUSIONS

Given the impact of WAD on QoL, additional clarity on tools and approaches are needed. There is a need for research on the relevance and clinical measurement properties of available condition-specific and generic tools to define a preferred measurement approach in WAD.

Minimum clinically important differences in the Cervical Spine Outcomes Questionnaire: results from a national multicenter study of patients treated with anterior cervical decompression and arthrodesis

BACKGROUND

The minimum clinically important difference is a clinically relevant threshold of improvement. A substantial clinical benefit is a threshold of change that correlates with clinically important improvement. The Cervical Spine Outcomes Questionnaire is a disease-specific, patient-reported outcomes instrument that was developed to be sensitive to changes associated with surgical treatment for degenerative cervical disc disease. To determine thresholds for change in these domain scores that are important from the patient's perspective, we estimated the minimum clinically important difference and substantial clinical benefit values for this questionnaire's domain scores.

METHODS

We evaluated 252 patients from the Cervical Spine Research Society Outcomes Study at their six-month follow-up visits after anterior cervical spine decompression and arthrodesis. Using a receiver operating characteristics curve, with the health transition item of the Short Form-36 as an anchor, we determined that the minimum clinically important difference (the value that maximized sensitivity and specificity to differentiate the "somewhat better" and "much better" responses from others) and the substantial clinical benefit (the value that maximized sensitivity and specificity to differentiate the "much better" response from others) for our questionnaire's domain scores. Responses were scaled between 0 and 1 point; higher scores denoted more severe impairment. Patient and clinical characteristics were tested to determine their influence on score changes.

RESULTS

The minimum clinically important difference ranged from 0.13 point (for functional disability) to 0.24 point (for arm/shoulder pain). The substantial clinical benefit score ranged from 0.20 point (for functional disability or physical symptoms other than pain) to 0.30 point (for neck or arm/shoulder pain). Age, sex, and duration of current symptoms were not associated with change in our questionnaire's domain scores.

CONCLUSIONS

A 0.13-point change in the functional disability domain score indicated a clinically important difference in a self-reported outcome after anterior cervical spine surgery. A 0.30-point change in neck pain after surgery indicated a clinically important clinical benefit. This information, coupled with previous reports of the psychometric stability of the Cervical Spine Outcomes Questionnaire, should increase the clinical utility of this patient-reported outcomes instrument.

Concurrent validation of the DASH and the QuickDASH in comparison to neck-specific scales in patients with neck pain

STUDY DESIGN

Concurrent validity study.

OBJECTIVE

To examine the validity of the Disabilities of Arm, Shoulder, and Hand (DASH) and the QuickDASH in patients with neck pain in comparison with the Neck Disability Index (NDI), the Cervical Spine Outcome Questionnaire (CSOQ), and the Visual Analogue Scale (VAS) for pain. To examine the agreement between the DASH and the QuickDASH and assess whether the QuickDASH can be used instead of full DASH in patients with neck pain.

SUMMARY OF BACKGROUND DATA

NDI is commonly used for measuring neck-related disability in patients with neck pain; but it does not offer to assess the potential for upper extremity disability.

METHODS

Patients with neck pain (N = 66) were assessed on one occasion. They completed the NDI and the DASH, and 42 of them completed the CSOQ. The QuickDASH scores were extracted from the full DASH. Correlations were tested between both versions of the DASH, the NDI, the subscales of the CSOQ, and the VAS-pain. Correlations were considered high with r >0.75. Ranked item difficulty analysis was performed for both versions of the DASH and the NDI. The Bland and Altman technique was used to assess the nature and size of score differences between 2 versions of the DASH.

RESULTS

Item ranks identified the DASH and the QuickDASH items to be as problematic to patients as NDI items. Both the versions of DASH showed high correlation (0.82-0.83) with the NDI and moderate correlation with the CSOQ and VAS-pain. The mean QuickDASH scores were higher (2.77 points) compared to the full DASH.

CONCLUSION

Though the QuickDASH reported higher disability compared to the full DASH in this patient group, high correlation between the QuickDASH and the NDI and agreement between both versions of the DASH provide preliminary evidence that the QuickDASH can be used to measure upper extremity disability in patients with neck pain.

Health related quality of life assessment in metastatic disease of the spine: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To examine the available literature on health related quality of life (HRQOL) assessment in metastatic disease of the spine and identify the optimal functional outcome scales to be used in developing a disease-specific tool.

SUMMARY OF BACKGROUND DATA

There is a lack of consensus in the use of HRQOL measures in patients with metastatic spine disease.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, the Science Citation Index (ISI), the Cumulative Index to Nursing and Allied Health Literature, the PsycINFO, the Allied and Complementary Medicine (AMED), Cochrane Reviews and Global Health databases for clinical studies addressing metastatic spine disease from 1966 through 2008. The validity of outcome tools was established by linkage analysis with the International Classification of Functioning Disability and Health (ICF).

RESULTS

One hundred forty-one clinical studies met inclusion criteria including 10,347 patients. Only 5 moderate grade and 1 high grade study were identified. Thirty- four studies used a patient self-assessment instrument to assess health status. None of the instruments were validated for metastatic spine patients. The most commonly used Pi-by-no tools were SF-36, SIP 5, and the ADL. None of the studies defined health related quality of life (HRQOL) or justified the choice of instrument. The most commonly used cancer-specific tools were ECOG, EORTC QCQ-C30, and EUROQOL 5D. Based on frequency of citation and on correlation with the International Classification of Functioning Disability and Health, the ECOG and SF36 were judged as most valid and reliable.

CONCLUSION

A systematic review of the available evidence suggests that valid and reliable health related quality of life measures exist for the assessment of oncology patients; however, a disease-specific tool for metastatic spine disease awaits development. Until such time as a disease-specific tool is available, we recommend that the ECOG and SF-36 be considered for use in studies addressing the outcome assessment of patients with metastatic spine disease.

Measurement properties of the neck disability index: a systematic review

STUDY DESIGN

Systematic review of clinical measurement.

OBJECTIVE

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

BACKGROUND

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

METHODS AND MEASURES

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

RESULTS

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

CONCLUSION

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

Patient satisfaction in the cervical spine research society outcomes study: relationship to improved clinical outcome

BACKGROUND AND CONTEXT

Satisfaction is a key indicator of how health care has met patient expectations.

PURPOSE

To examine relationship between clinical and functional outcome and patient satisfaction.

STUDY DESIGN/SETTING

Prospective analysis of outcomes.

PATIENT SAMPLE

A total of 428 patients undergoing cervical spine surgery consecutively enrolled at 23 nationwide sites.

OUTCOME MEASURES

Cervical Spine Outcomes Questionnaire (CSOQ).

METHODS

We used the CSOQ to evaluate 428 patients undergoing cervical spine surgery at 23 nationwide sites. Satisfaction was assessed at 3 months by self-report. Clinical improvement was defined at 3 months as decreased postoperative CSOQ domain scores. Principal components analysis (PCA) was used to demonstrate adherence of the CSOQ to domains of clinical and functional recovery and to identify items measuring patient satisfaction. Psychometric properties of items measuring patient satisfaction were examined. The association between patient satisfaction and 3 month clinical and functional outcome was tested.

RESULTS

On repeat administration in a subset of 50 patients, these four items demonstrated good test-retest reliability (Cronbach's alpha=0.784). PCA extracted factors adhering to the domain structure of the CSOQ. A unique factor was characterized by the following: recommend to friend (loading=0.658), compare favorably with others (loading=0.525) and with expectations (loading=0.701), and show overall satisfaction (loading=0.513). Structural equation models revealed influence of CSOQ domain scores and socioeconomic status on patient satisfaction. All reported comparisons were significant at p<.001.

CONCLUSIONS

Satisfaction is unobservable, but can be assessed through self-report. Clinical improvement, especially in neck pain, after surgery is associated with improved patient satisfaction.

Predictors of outcome after anterior cervical discectomy and fusion: a multivariate analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Perform a multivariate analysis to identify important predictors of poor outcome following anterior cervical discectomy and fusion.

SUMMARY OF BACKGROUND DATA

Identifying prognostic factors is important to aid surgical decision-making and counseling of patients. Recent randomized control trials of disc arthroplasty devices have established a large cohort of patients treated with fusion and 2-year outcomes that allow analysis of prognostic factors.

METHODS

The patient cohort was the fusion control patients (n = 488) from 2 randomized controlled studies of disc replacements. Surgical indications were recalcitrant single-level subaxial radiculopathy or myelopathy. The surgery included anterior discectomy and fusion with allograft and plate. Patients were assessed by neck and arm pain, neck disability index (NDI), SF-36, neurologic examination, and return to work. Overall clinical success was defined based on meeting all 4 of these criteria: >15-point improvement in NDI; maintained or improved neurologic examination; no serious adverse event related to the procedure; and no revision of the plate or graft. Patient's outcomes were recorded, at 3, 6, 12, and 24 months, with 77% follow-up at 24 months.The outcome variables for this analysis were overall clinical success and >15-point improvement in NDI. We studied the relationship between each of the outcome variables and 26 potential important variables including demographics, medical conditions, socioeconomic factors, and disease state. Two statistical models were used to explore the association between outcome variables and baseline measures: multivariate logistical regression of the full model with every prognostic variable included and the model with the variables selected by the stepwise selection procedure.

RESULTS

In the full-model logistic analysis for overall success, worker's compensation and weak narcotic use were negative predictors while higher preoperative NDI score and normal sensory function were positive predictors. For NDI success, only the preoperative NDI scores (higher disability predictive of improvement) appeared to have strong influence on the outcome.In the stepwise regression model, preoperative normal sensory function was a positive predictor and worker's compensation a negative predictors of overall clinical success. Greater age, higher preoperative NDI score, and gainful employment were positive predictors and spinal litigation was a negative predictor of NDI success.

CONCLUSION

We found that important predictors of outcome were work status, sensory function, involvement in litigation, and higher disability scores.