Validity and sensitivity to change of the NASS questionnaire for patients with cervical spine disorders

Pre-operative expectations of patients with Degenerative Cervical Myelopathy: An observational study from the Canadian Spine Outcomes and Research Network

BACKGROUND

Despite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about pre-operative expectations of these patients.

PURPOSE

The primary objective was to describe patient pre-operative expectations. Secondary objectives included identifying patient characteristics associated with high pre-operative expectations and to determine if expectations varied depending on myelopathy severity.

STUDY DESIGN

This was a retrospective study of a prospective multicenter, observational cohort of patients with DCM.

PATIENT SAMPLE

Patients who consented to undergo surgical treatment between January 2019 and September 2022 were included.

OUTCOMES MEASURES

An 11-domain expectation questionnaire was completed pre-operatively whereby patients quantified the expected change in each domain.

METHODS

The most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models.

RESULTS

There were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p< 0.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59- -0.10, p= 0.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35-1.19, p= 0.02), no contribution from "failure of other treatments" on the decision to undergo surgery (OR 1.49, 95% CI 0.56-2.71, p= 0.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05- 0.37, p= 0.01).

CONCLUSIONS

Most patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study

OBJECTIVE

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients.

METHODS

Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected.

RESULTS

There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34-0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not.

CONCLUSIONS

Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

Reliability and validity of the Turkish version of the Core Outcome Measures Index for the neck pain

PURPOSE

The Core Outcome Measures Index (COMI) is a short and multidimensional scale covering all domains recommended to be included in outcome measures for patients with neck pain. The purpose of the present study was to translate and cross culturally adapt the COMI into Turkish and to test its reliability and validity in patients with neck pain.

METHODS

One hundred and six patients with a complaint of chronic neck pain (> 3 months) were enrolled in the present study. Participants completed a questionnaire booklet containing the COMI-neck, Neck Disability Index (NDI), Neck Pain and Disability Scale (NPDS), Short Form-36 (SF-36), and pain Numeric Rating Scale (NRS). The validation of the COMI included the assessment of its construct validity and reliability.

RESULTS

Cronbach's alpha value of the questionnaire was found to be 0.774 indicating a high internal consistency. Intraclass correlation coefficient values for test-retest reliability were found to be in the range of 0.817-0.986, which indicates a sufficient level of test-retest reliability. Pearson's correlation coefficient values of the COMI with SF-36, NDI, NPDS, and NRS ranged between 0.417 and 0.700, indicating a good correlation.

CONCLUSION

Considering the analyses, it was concluded that the Turkish version of the COMI is a valid and reliable scale for chronic neck pain patients. These slides can be retrieved under Electronic Supplementary Material.

Factor analysis of the North American Spine Society outcome assessment instrument: a study based on a spine registry of patients treated with lumbar and cervical disc arthroplasty

BACKGROUND CONTEXT

Studies involving factor analysis (FA) of the items in the North American Spine Society (NASS) outcome assessment instrument have revealed inconsistent factor structures for the individual items.

PURPOSE

This study examined whether the factor structure of the NASS varied in relation to the severity of the back/neck problem and differed from that originally recommended by the developers of the questionnaire, by analyzing data before and after surgery in a large series of patients undergoing lumbar or cervical disc arthroplasty.

STUDY DESIGN/SETTING

Prospective multicenter observational case series.

PATIENT SAMPLE

Three hundred ninety-one patients with low back pain and 553 patients with neck pain completed questionnaires preoperatively and again at 3 to 6 and 12 months follow-ups (FUs), in connection with the SWISSspine disc arthroplasty registry.

OUTCOME MEASURES

North American Spine Society outcome assessment instrument.

METHODS

First, an exploratory FA without a priori assumptions and subsequently a confirmatory FA were performed on the 17 items of the NASS-lumbar and 19 items of the NASS-cervical collected at each assessment time point. The item-loading invariance was tested in the German version of the questionnaire for baseline and FU.

RESULTS

Both NASS-lumbar and NASS-cervical factor structures differed between baseline and postoperative data sets. The confirmatory analysis and item-loading invariance showed better fit for a three-factor (3F) structure for NASS-lumbar, containing items on "disability," "back pain," and "radiating pain, numbness, and weakness (leg/foot)" and for a 5F structure for NASS-cervical including disability, "neck pain," "radiating pain and numbness (arm/hand)," "weakness (arm/hand)," and "motor deficit (legs)."

CONCLUSIONS

The best-fitting factor structure at both baseline and FU was selected for both the lumbar- and cervical-NASS questionnaires. It differed from that proposed by the originators of the NASS instruments. Although the NASS questionnaire represents a valid outcome measure for degenerative spine diseases, it is able to distinguish among all major symptom domains (factors) in patients undergoing lumbar and cervical disc arthroplasty; overall, the item structure could be improved. Any potential revision of the NASS should consider its factorial structure; factorial invariance over time should be aimed for, to allow for more precise interpretations of treatment success.

Reliability and validity of the Polish version of the Core Outcome Measures Index for the neck

PURPOSE

Patient reported outcome measures play an increasingly important role in the outcomes research. The Core Outcome Measures Index (COMI) is a short, multidimensional instrument initially developed for the use by patients with low back pain. This study is an evaluation of a Polish version of COMI adapted for neck pain.

METHODS

One hundred twenty-three patients complaining of neck pain were enrolled. All of them completed a questionnaire booklet containing COMI-neck, Neck Disability Index and Likert-type questions regarding the frequency of use of pain medications and pain frequency. Ninety-eight patients returned the retest questionnaire. Data quality was also assessed. Assessment of psychometric properties included examination of data quality, construct validity, test-retest reliability and factor analysis.

RESULTS

The quality of data was good with no missing answers and a little floor effect. Exploratory factor analysis revealed a single-factor structure. Reliability expressed as intraclass correlation coefficient was 0.88 (95% CI 0.84-0.92) for the overall COMI score and was generally good for most of individual core items. The minimum detectable change (MDC95%) was 1.97.

CONCLUSION

This version of the COMI-neck is a valid and reliable instrument, with good psychometric properties. It can be recommended for Polish-speaking patients.

A summary of assessment tools for patients suffering from cervical spondylotic myelopathy: a systematic review on validity, reliability and responsiveness

PURPOSE

One of the objectives of this review is to summarize the important features of a good scale. A second aim is to conduct a systematic review to identify scales that can detect the presence of cervical myelopathy and to determine their psychometric properties including validity, reliability and responsiveness.

METHODS

A thorough literature search was performed using MEDLINE, MEDLINE in process, EMBASE, and Cochrane Central Register of Controlled Trials. Articles were included in this study if they compared scale measurements between a control and a myelopathic patient population or if they discussed any psychometric property of a scale.

RESULTS

An ideal scale should be one that is quantifiable, valid, sensitive, responsive and easy to perform, has high inter/intra-rater reliability, internal consistency and a suitable distribution, and is one-dimensional and relevant. In the context of cervical spondylotic myelopathy, it is essential that the scale also addresses the pathophysiology, its key signs and symptoms as well as its natural history. For the systematic review, the search yielded 5,745 citations. Of these, 37 met inclusion criteria, 10 explored the ability of a scale to detect myelopathy, 23 examined validity by assessing correlation between scales, 10 reported reliability, 8 analyzed responsiveness, and 6 discussed internal consistency. The most frequently reported scale was short form-36 (n = 16) followed by Nurick grade (n = 14), Japanese Orthopaedic Association (n = 13), (modified) Japanese Orthopaedic Association (n = 7) and grip and release test (n = 6). Four studies each presented results on the Cooper, Harsh and 30-m walking test.

CONCLUSION

This review summarizes outcome measures used to assess the presence and severity of cervical myelopathy. It includes several validation studies as well as those that have reported the responsiveness and reliability of various measures.

German translation, cross-cultural adaptation and validation of the whiplash disability questionnaire

BACKGROUND

The Australian Whiplash Disability Questionnaire (WDQ) was cross-culturally translated, adapted, and tested for validity to be used in German-speaking patients. The self-administered questionnaire evaluates actual pain intensity, problems in personal care, role performance, sleep disturbances, tiredness, social and leisure activities, emotional and concentration impairments with 13 questions rated on an 11-point rating scale from zero to ten.

METHODS

In a first part, the Australian-based WDQ was forward and backward translated. In a consensus conference with all translators and health care professionals, who were experts in the treatment of patients with a whiplash associated disorder (WAD), formulations were refined. Original authors were contacted for clarification and approval of the forward-backward translated version. The German version (WDQ-G) was evaluated for comprehensiveness and clarity in a pre-study patient survey by a random sample of German-speaking patients after WAD and four healthy twelve to thirteen year old teenagers. In a second part, the WDQ-G was evaluated in a patient validation study including patients affected by a WAD. Inpatients had to complete the WDQ-G, the North American Spine Society questionnaire (NASS cervical pain), and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) at entry in the rehabilitation centre.

RESULTS

In the pre-study patient survey (response rate 31%) patients rated clarity for title 9.6 ± 0.9, instruction 9.3 ± 1.4 and questions 9.6 ± 0.7, and comprehensiveness for title 9.6 ± 0.7, instruction 9.3 ± 1.4 and questions 9.8 ± 0.4. Time needed to fill in was 13.7 ± 9.0 minutes. In total, 70 patients (47 females, age = 43.4 ± 12.5 years, time since injury: 1.5 ± 2.6 years) were included in the validation study. WDQ-G total score was 74.0 ± 21.3 points (range between 15 and 117 points). Time needed to fill in was 6.7 ± 3.4 minutes with data from 22 patients. Internal consistency was confirmed with Cronbachs's α = 0.89. Concurrent validity showed a highly significant correlation with subscale pain and disability (NASS) at r = 0.74 and subscale pain (SF-36) at r = 0.71.

CONCLUSIONS

The officially translated and adapted WDQ-G can be used in German-speaking patients affected by a WAD to evaluate patients' impairments in different domains. The WDQ-G is a self-administered outcome measure showing a high internal consistency and good concurrent validity.

German version of the whiplash disability questionnaire: reproducibility and responsiveness

BACKGROUND

The Whiplash Disability Questionnaire (WDQ) poses a validated tool for the assessment of patients who experience whiplash-associated disorders. A German translation and cross-cultural adaptation was recently produced and presented high validity and internal consistency. As a follow-up, the presented study tests the translated Whiplash Disability Questionnaire's (WDQ-G) retest reliability and responsiveness to change.

METHODS

The WDQ-G was assessed on three different measurement events: first upon entry (ME1), second four days after entry (ME2), and third at discharge (ME3). Test-retest reliability data from ME1 and ME2 was analysed in a group of stable patients to obtain the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). To test the instrument's responsiveness, WDQ-G change data were compared to concurrent instruments. The probability of each instrument, to correctly distinguish patients of the stable phase (ME1 to ME2) from patients who deemed to have improved between from ME1 to ME3, was analysed.

RESULTS

In total, 53 patients (35 females, age=45 ± 12.2) were recruited. WDQ-G scores changed from ME1 to ME2 by 5.41 ± 11.6 points in a stable group. This corresponds to a test-retest reliability of ICC=0.91 (95% CI=0.80-0.95) with a SEM of 6.14 points. Minimal Detectable Change, at 95% confidence, was calculated to be 17 points change in scores. Area under Receiver Operator Characteristics of the WDQ-G's responsiveness revealed a probability of 84.6% (95% CI=76.2%-93%) to correctly distinguish between improved and stable patients. Optimal sensitivity (73.2%) and specificity (76.2%) was established at 11-point change.

CONCLUSIONS

High retest reliability and good responsiveness of the WDQ-G support clinical implementation of the translated version. The data suggest, that change in total score greater than eleven points can be interpreted as clinical relevant from a patient's perspective. Minimal Important Change is suggested at 15 points where there is still high specificity and a 90% confidence MDC.

An evidence-based medicine process to determine outcomes after cervical spine trauma: what surgeons should be telling their patients

STUDY DESIGN

A systematic review of the available medical literature from 1980 to 2010 was conducted and combined with expert opinion from a recent survey of experts regarding cervical spine fractures. Using an objective, hierarchical approach, the best available evidence is presented for health-related quality-of-life outcomes for these injuries.

OBJECTIVE

To provide an evidence-based set of guidelines for cervical spine injuries in order to reduce variability in the information given to patients and their families.

SUMMARY OF BACKGROUND DATA

Patients' expectations regarding quality-of-life outcomes are highly dependent on the information provided by surgeons early in the treatment course. Our previous work has demonstrated that there is substantial variability in what surgeons tell patients regarding outcomes of cervical spine injuries, thus patients' expectations will differ and outcomes vary.

METHODS

Four common cervical spine injuries (C1 burst, Hangman fracture, odontoid fracture, and unilateral facet fracture) treated both surgically and nonsurgically were considered. We assessed the evidence regarding 5 health-related quality-of-life outcomes: time to return to work, activity level, hospital stay, the proportion of patients who are pain free and patients who have regained full range of motion at 1 year after the injury.

RESULTS

Published outcome data were available for most injuries. Using consensus expert opinion and the literature, answers to each question were achieved. Overall, expert opinion was relatively homogeneous across injury types, suggesting that experts do not distinguish between specific injuries when advising patients of expected outcomes such as pain.

CONCLUSION

By overcoming gaps in the literature with consensus expert opinion, our study provides surgeons and others with evidence-based medicine guidelines for patient-centered outcomes after cervical spine injury. This information can be presented to patients to frame expectations of typical outcomes during and after treatment to optimize patient care and quality of life.

TLR9 provokes inflammation in response to fetal DNA: mechanism for fetal loss in preterm birth and preeclampsia

Preterm birth, the major cause of neonatal mortality in developed countries, is associated with intrauterine infections and inflammation, although the exact mechanisms underlying this event are unclear. In this study, we show that circulating fetal DNA, which is elevated in pregnancies complicated by preterm labor or preeclampsia, triggers an inflammatory reaction that results in spontaneous preterm birth. Fetal DNA activates NF-κB, shown by IκBα degradation in human PBMCs resulting in production of proinflammatory IL-6. We show that fetal resorption and preterm birth are rapidly induced in mice after i.p. injection of CpG or fetal DNA (300 μg/dam) on gestational day 10-14. In contrast, TLR9(-/-) mice were protected from these effects. Furthermore, this effect was blocked by oral administration of the TLR9 inhibitor chloroquine. Our data therefore provide a novel mechanism for preterm birth and preeclampsia, highlighting TLR9 as a potential therapeutic target for these common disorders of pregnancy.

Validity and responsiveness of the Core Outcome Measures Index (COMI) for the neck

PURPOSE

Patient-orientated outcome questionnaires are essential to evaluate treatment success. To compare different treatments, hospitals, and surgeons, standardised questionnaires are required. The present study examined the validity and responsiveness of the Core Outcome Measurement Index for neck pain (COMI-neck), a short, multidimensional outcome instrument.

METHODS

Questionnaires were completed by patients with degenerative problems of the cervical spine undergoing cervical disc arthroplasty before (N = 89) and 3 months after (N = 75) surgery. The questionnaires comprised the EuroQol-Five Dimension (EQ-5D), the North American Spine Society Cervical Spine Outcome Assessment Instrument (NASS-cervical) and the COMI-neck.

RESULTS

The COMI and NASS-cervical scores displayed no notable floor or ceiling effects at any time point whereas for the EQ-5D, the highest values [corrected] were reached in around 32.5% of patients at follow-up. With one exception (symptom-specific well-being), the individual COMI items and the COMI summary score correlated to the expected extent (R = 0.4-0.8) with the scores of the chosen reference questionnaires. The area under the curve (AUC) generated by ROC analysis was significantly higher for the COMI (0.96) than for any other instrument/subscale when self reported treatment outcome was used as the external criterion, dichotomised as "good" (operation helped a lot/helped) versus "poor" (operation helped only a little/didn't help/made things worse). The COMI had a high effect size (standardised response mean; SRM) (2.34) for the good global outcome group and a low SRM for the poor outcome group (0.34). The EQ-5D and the NASS-cervical lacked this ability to differentiate between the two groups, showing less distinct SRMs for good and poor outcome groups.

CONCLUSIONS

This study provides evidence that the COMI-neck is a valid and responsive questionnaire in the population of patients examined. Further investigations should examine its applicability in other patient groups with less severe neck pain or undergoing other treatment modalities.

Responsiveness of the cervical Northern American Spine Society questionnaire (NASS) and the Short Form 36 (SF-36) in chronic whiplash

Objective: To determine and compare the sensitivity to change of the condition-specific cervical Northern American Spine Society (NASS) and the generic Short Form 36 (SF-36).

Design: Prospective cohort study.

Subjects: One hundred and seventy five patients after whiplash injury.

Interventions: Four-week inpatient interdisciplinary pain management programme.

Main measures, analysis: Responsiveness of the NASS and the SF-36 was quantified by effect size and standardized response mean and compared within the same construct by the modified Jacknife test. Ability to detect improvement was compared using sensitivities determined from receiver operating characteristics curves.

Results: In pain, the NASS was comparable responsive to the SF-36 at the one-month follow-up ( n = 175): effect sizes: 0.62 (NASS) versus 0.61 (SF-36), P = 0.914. The NASS was less responsive than the SF-36 in function: 0.23 versus 0.63, P < 0.001 and in pain+function: 0.35 versus 0.58 ( P = 0.001). These relationships remained consistent using standardized response means, at the six-month follow-up ( n = 103), and in the comparison of the sensitivities. Sensitivities at one month, pain: 70% (NASS) versus 62% (SF-36), P = 0.234; function: 65% versus 80%, P = 0.002; pain+function: 68% versus 78%, P = 0.035. The six-month data were similar.

Conclusions: The generic SF-36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF-36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.

Are existing outcome instruments suitable for assessment of spinal trauma patients?

Object

Valid outcome assessment tools specific for spinal trauma patients are necessary to establish the efficacy of different treatment options. So far, no validated specific outcome measures are available for this patient population. The purpose of this study was to assess the current state of outcome measurement in spinal trauma patients and to address the question of whether this group is adequately served by current disease-specific and generic health-related quality-of-life instruments.

Methods

A number of widely used outcome measures deemed most appropriate were reviewed, and their applicability to spinal trauma outcome discussed. An overview of recent movements in the theoretical foundations of outcome assessment, as it pertains to spinal trauma patients has been attempted, along with a discussion of domains important for spinal trauma.

Commonly used outcome measures that are recommended for use in trauma patients were reviewed from the perspective of spinal trauma. The authors further sought to select a number of spine trauma–relevant domains from the WHO's comprehensive International Classification of Functioning, Disability and Health (ICF) as a benchmark for assessing the content coverage of the commonly used outcome measurements reviewed.

Results

The study showed that there are no psychometrically validated outcome measurements for the spinal trauma population and there are no commonly used outcome measures that provide adequate content coverage for spinal trauma domains.

Conclusions

Spinal trauma patients are currently followed either as a subset of the polytrauma population in the acute and early postacute setting or as a subset of neurological injury in the long-term revalidation medicine setting.

Functional outcomes assessment for cervical degenerative disease

Object

The objective of this systematic review was to use evidence-based medicine to identify valid, reliable, and responsive measures of functional outcome after treatment for cervical degenerative disease.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to functional outcomes. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Myelopathy Disability Index, Japanese Orthopaedic Association scale, 36-Item Short Form Health Survey, and gait analysis were found to be valid and reliable measures (Class II) for assessing cervical spondylotic myelopathy. The Patient-Specific Functional Scale, the North American Spine Society scale, and the Neck Disability Index were found to be reliable, valid, and responsive (Class II) for assessing radiculopathy for nonoperative therapy. The Cervical Spine Outcomes Questionnaire was a reliable and valid method (Class II) to assess operative therapy for cervical radiculopathy.

Conclusions

Several functional outcome measures are available to assess cervical spondylotic myelopathy and cervical radiculopathy.

Evaluation of the core outcome measure in whiplash

STUDY DESIGN

Reanalysis of data derived from longitudinal cohort studies.

OBJECTIVE

To comprehensively evaluate the psychometric properties of a 5-item version of the Core Outcome Measure in people with whiplash.

SUMMARY OF BACKGROUND DATA

The 7-item Core Outcome Measure was initially proposed as a brief health outcome measure for use in low back pain. To date, this measure has not been comprehensively assessed in a whiplash population. METHOD.: Data were sourced from 3 separate whiplash cohorts (total 481) encompassing acute, early chronic, and late-chronic whiplash among primary care and insurance populations. Subjects completed a 5-item version of the Core Outcome Measure for whiplash (Core Whiplash Outcome Measure [CWOM]), the Functional Rating Index, Neck Disability Index, SF-36, and perceived recovery questionnaires at baseline and short and long-term follow-up periods. Psychometric evaluation of the CWOM included assessing questionnaire responses, internal consistency, construct validity, and internal and external responsiveness.

RESULTS

Internal consistency was excellent at all stages of whiplash (Cronbach alpha = 0.76 in the acute stage and 0.83 in the late-chronic stage). Convergent validity was observed between the CWOM and Functional Rating Index (Pearson r = 0.81), Neck Disability Index (Pearson r = 0.76), and SF-36 physical health summary measure (Pearson r = -0.65). Divergent validity was observed between the CWOM and SF-36 mental health summary measure (Pearson r = -0.45). The internal and external responsiveness of the CWOM was similar to other neck-specific outcome measures.

CONCLUSIONS

We recommend the 5-item CWOM as a brief clinical measure for whiplash because it is quick to administer and score, and has excellent measurement properties. The CWOM may need to be supplemented with other questionnaires (e.g., when assessment of psychological or emotional health is required).