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

Reliability and Validity of the German Version of the AO Spine Patient Reported Outcome Spine Trauma Questionnaire

STUDY DESIGN

A single-center validation study.

OBJECTIVE

To translate and cross-culturally adapt the AO Spine PROST (Patient Reported Outcome Spine Trauma) into German, and to test its psychometric properties among German-speaking Swiss spine trauma patients.

METHODS

Patients were recruited from a level-1 Swiss trauma center. Next to the AO Spine PROST, the EQ-5D-3L questionnaire was used for concurrent validity. Questionnaires were filled out at two-time points for test-retest reliability. Patient characteristics were analyzed using descriptive statistics. For content validity, floor, and ceiling effects, as well as any irrelevant and missing questions were analyzed. Construct validity of the AO Spine PROST questionnaire to the EQ-5D-3L was tested using Spearman correlation tests.

RESULTS

The AOSpine PROST was translated and adapted into German using established guidelines. We included 179 patients. The floor effect for all items was well within the optimal range (below 15%), while the ceiling effect of seven items was within the optimal range. None of the items displayed a problematic floor or ceiling effect. The overall test-retest reliability of the total PROST score was excellent, with an ICC of .83 (95% CI .69-.91). The Spearman correlation coefficient between the total PROST summary score and EQ-5D-3 L was ρ = .63.

CONCLUSIONS

The German version of the AO Spine PROST questionnaire demonstrated very good validity and reliability results.

Long-Term Reliability and Validity of the AO Spine PROST (Patient-Reported Outcome Spine Trauma)

STUDY DESIGN

Cross-sectional validation study.

OBJECTIVE

The aim was to validate the AO Spine Patient-Reported Outcome Spine Trauma (PROST) at a minimum of 12 months posttrauma and to evaluate patient characteristics, types of spine fractures, and treatment strategies as determinants of AO Spine PROST scores.

SUMMARY OF BACKGROUND DATA

The reliability and validity of the AO Spine PROST as a measure of health-related quality of life for more than 12 months after onset of spine trauma is unclear.

MATERIALS AND METHODS

Patients with a traumatic spine injury were recruited from a level-1 trauma center. They were asked to complete the AO Spine PROST, EuroQoL 5D-5L (EQ-5D-5L), and either Oswestry disability index (ODI) or neck disability index (NDI) for concurrent validity. Internal consistency was assessed by calculating the Cronbach α and item-total correlation coefficients. Test-retest reliability was evaluated using intraclass correlation coefficients. Spearman correlation tests were performed for the AO Spine PROST in correlation with the EQ-5D-5L, and either ODI or NDI. Determinants for AO Spine PROST score were analyzed using multivariate regression models.

RESULTS

A total of 175 patients participated in the cross-sectional arm and 49 in the test-retest arm of the study. Median duration of follow-up was 94.5 months. No floor or ceiling effects were seen. Internal consistency was excellent (α=0.98, item-total correlation coefficient: 0.73-0.91) as well as test-retest reliability (intraclass correlation coefficient=0.81). Satisfactory correlations were seen for the EQ-5D-5L (0.76; P <0.001), ODI (0.69; P <0.001), and NDI (0.68; P <0.001) with the AO Spine PROST. Multivariate linear regression models showed that having ≥1 comorbidities, duration of return to work within the range of 7 to 43 months and no return to work were significant independent determinants for a worse AO Spine PROST score.

CONCLUSIONS

Very good long-term reliability and validity results were found for the AO Spine PROST.

Reliability and Validity of the English Version of the AOSpine PROST (Patient Reported Outcome Spine Trauma)

STUDY DESIGN

Multicenter validation study.

OBJECTIVE

The aim of this study was to translate and adapt the AOSpine PROST (Patient Reported Outcome Spine Trauma) into English, and test its psychometric properties among North-American spine trauma patients.

SUMMARY OF BACKGROUND DATA

In the absence of an outcome instrument specifically designed and validated for traumatic spinal column injury patients, it is difficult to measure the effect size of various treatment options. The AOSpine Knowledge Forum Trauma initiated a project and developed the AOSpine PROST consisting of 19 items.

METHODS

Patients were recruited from two level-1 North-American trauma centers. For concurrent validity, next to AOSpine PROST also 36-item Short-Form Health Survey (SF-36) was filled out by patients. Patient characteristics were analyzed using descriptive statistics. Floor and ceiling effects as well as the number of inapplicable and missing questions were analyzed for content validity. Cronbach α and item-total correlation coefficients (ITCCs) were calculated for internal consistency. Spearman correlation tests were performed within AOSpine PROST items and in correlation to SF-36. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs). Factor analysis was performed to explore any dimensions within AOSpine PROST.

RESULTS

The AOSpine PROST was translated adapted into English using established guidelines. Of 196 enrolled patients, 162 (82.7%) met the inclusion criteria and provided sufficient data. Content validity showed good results, and no floor and ceiling effects were seen. The internal consistency was excellent (Cronbach α = 0.97; ITCC 0.50-0.90) as well as test-retest reliability (ICC = 0.97). Spearman correlations were good (0.29-0.85). The strongest correlations of AOSpine PROST with SF-36 were seen with the physical components (0.69-0.82; P < 0.001). Factor analysis revealed two possible dimensions (Eigen values >1), explaining 75.7% of variance.

CONCLUSION

The English version of AOSpine PROST showed very good validity and reliability. It is considered as a valuable tool, and has the potential to contribute to the reduction of ongoing controversies in spine trauma care.

LEVEL OF EVIDENCE

2.

Reliability, validity and responsiveness of the Dutch version of the AOSpine PROST (Patient Reported Outcome Spine Trauma)

PURPOSE

To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma).

METHODS

Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach's α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test-retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST.

RESULTS

Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach's α = 0.96, itcc 0.50-0.86), with also good Spearman correlations (0.25-0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p < .001). Also test-retest reliability was excellent (ICC = 0.92). Concerning responsiveness analysis, very good results were seen with ES = 1.81 and SRM = 2.03 (p < 0.001). Factor analysis revealed two possible dimensions (Eigenvalues > 1), explaining 65.4% of variance.

CONCLUSIONS

Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.

Methods for development of structure, process and outcome indicators for prioritized spinal cord injury rehabilitation Domains: SCI-High Project

Background: High-quality rehabilitation care following spinal cord injury or disease (SCI/D) is critical for optimizing neurorecovery and long-term health outcomes. This manuscript describes the methods used for developing, refining, and implementing a framework of structure, process, and outcome indicators that reflect high-quality rehabilitation among adults with SCI/D in Canada. Methods: This quality improvement initiative was comprised of the following processes: (1) prioritization of care Domains by key stakeholders (scientists, clinicians, therapists, patients and stakeholder organizations); (2) assembly of 11 Domain-specific Working Groups including 69 content experts; (3) conduct of literature searches, guideline and best practice reviews, and outcome synthesis by the Project Team; (4) refinement of Domain aim and construct definitions; (5) conduct of cause and effect analysis using Driver diagrams; (6) selection and development of structure, process and outcome indicators; (7) piloting and feasibility analysis of indicators and associated evaluation tools; and, (8) dissemination of the proposed indicators. Result: The Project Team established aims, constructs and related structure, process, and outcome indicators to facilitate uniform measurement and benchmarking across 11 Domains of rehabilitation, at admission and for 18 months thereafter, among adult Canadians by 2020. Conclusion: These processes led to the selection of a feasible set of indicators that once implemented should ensure that adults with SCI/D receive timely, safe, and effective rehabilitation services. These indicators can be used to assess health system performance, monitor the quality of care within and across rehabilitation settings, and evaluate the rehabilitation outcomes of the population to ultimately enhance healthcare quality and equity.

Review of Treatment for Central Spinal Neuropathic Pain and Its Effect on Quality of Life: Implications for Neuromyelitis Optica Spectrum Disorder

OBJECTIVES

Neuromyelitis optica spectrum disorder (NMOSD) causes disabling and persistent central neuropathic pain (NP). Because the pain syndrome in NMOSD is severe and often intractable to analgesic treatment, it interferes with quality of life in patients. No interventional trials have been published looking at response to interventions for pain in NMOSD. This is a synthesis of the literature surveying the impact on quality of life of interventions in all mechanisms of central spinal NP. This review has important implications for management of pain in NMOSD.

METHODS AND DATA SOURCES

A systematic database search was conducted using PubMed, Embase, and CINAHL Plus with keywords including "spinal cord," "quality of life," and "neuropathic pain" in an attempt to identify original research that targeted spinal NP treatment and used quality of life as an outcome measure. Both pharmacologic and nonpharmacologic treatments were sought out.

RESULTS

Twenty-one studies meeting our eligibility criteria were identified and evaluated, 13 using pharmacologic treatments and 8 using nonpharmacologic interventions. Overall, sample sizes were modest, and effects on decreasing pain and/or improving quality of life were suboptimal.

CONCLUSIONS

This review provides researchers with a foundation from which to start a more thorough and thoughtful investigation into the management of NP in NMOSD and underscores the importance of including quality of life as a clinically meaningful outcome measure.

Outcome indicators in the transitional care of people with spinal cord injury in China: a Delphi survey based on the International Classification of Functioning, Disability and Health

Objective: To identify the categories of the International Classification of Functioning, Disability and Health most suitable as outcome indicators in the transitional care for people with spinal cord injury in China.Methods: A three-round Delphi survey was conducted surveying 37 experts selected through purposive sampling. In the first round, each expert was required to suggest the most useful indicators in the transitional care for spinal cord injury patients. Categories of the International Classification of Functioning, Disability and Health were linked with the concepts extracted from the responses. In the second round, the experts were asked to make a yes/no judgment about the utility of those categories as outcome indicators and to rate their importance from 1 to 10. In the third round, the experts were asked to re-judge and re-rate the importance considering the second-round results.Results: Forty-one categories, seven personal factors, and three concepts not covered in the International Classification of Functioning, Disability and Health were identified. They generated agreement percentages over 80% in the third round. The means of the importance ratings ranged from 5.15 to 9.52.Conclusions: A set of categories and concepts was identified in the Delphi survey based on the International Classification of Functioning, Disability and Health. They provided a reference and a basis for establishing a system of outcome indicators in the transitional care for patients with spinal cord injury in China.Implications for rehabilitationIn China, the people with spinal cord injury who live at home after discharge urgently need professional transitional care which can be extended from medical institutions to families.The categories and concepts identified by the Delphi survey based on the International Classification of Functioning, Disability and Health reflect the focuses in the transitional care of people with spinal cord injury in China.Those categories and concepts provide a reference and a basis for establishing a system of outcome indicators in the transitional care for patients with spinal cord injury in China.

The Need of Validated Disease-Specific Outcome Instruments for Spine Trauma

This article focuses on patient-reported and clinician-reported outcome measures in spine trauma care. The measurement of the quality of care and functional and health-related quality of life outcomes of spine trauma patients has become increasingly important. However, no outcome instrument is specifically designed, validated, or universally adapted for this specific patient population. Issues specific to spinal trauma patients may not be adequately addressed by the instruments that are currently used in the literature and the daily clinical practice. The AOSpine Knowledge Forum Trauma initiated a project to develop and validate such instruments for spine trauma patients. To reflect the different perspectives of patients and the treating surgeons, 2 separate tools are being developed: the Patient Reported Outcome Spine Trauma (AOSpine PROST) and Clinician Reported Outcome Spine Trauma (AOSpine CROST). These tools hold promise, as useful instruments to measure the outcomes of spine trauma patients with and without neurological deficit, making it more feasible for clinical use as well. Treating surgeons around the world are encouraged to use the AOSpine PROST and AOSpine CROST in daily clinical practice and for research purposes to create and contribute to evidence-based and patient-centered care. Using the same outcome measures that are specifically developed and validated for traumatic spine injuries will allow us to compare the outcomes of various treatments in a valid and reproducible fashion. This contributes to a reduction of the ongoing controversies and providing the best treatments for our patients.

Outcome Instruments in Spinal Trauma Surgery: A Bibliometric Analysis

Study Design Literature review. Objective To identify outcomes instruments used in spinal trauma surgery over the past decade, their frequency of use, and usage trends. Methods Five top orthopedic journals were reviewed from 2004 to 2013 for clinical studies of surgical intervention in spinal trauma that reported patient-reported outcome instruments use or neurologic function scale use. Publication year, level of evidence (LOE), and outcome instruments were collected for each article and analyzed. Results A total of 58 studies were identified. Among them, 26 named outcome instruments and 7 improvised questionnaires were utilized. The visual analog scale (VAS) for pain was used most frequently (43.1%), followed by the Short Form 36 (34.5%), Frankel grade scale (25.9%), Oswestry Disability Index (20.7%) and American Spinal Injury Association Impairment Scale (15.5%). LOE 4 was most common (37.9%), and eight LOE 1 studies were identified (10.3%). Conclusions The VAS pain scale is the most common outcome instrument used in spinal trauma. The scope of this outcome instrument is limited, and it may not be sufficient for discriminating between more and less effective treatments. A wide variety of functional measures are used, reflecting the need for a disease-specific instrument that accurately measures functional limitation in spinal trauma.

The selection of core International Classification of Functioning, Disability, and Health (ICF) categories for patient-reported outcome measurement in spine trauma patients-results of an international consensus process

BACKGROUND CONTEXT

There is no outcome instrument specifically designed and validated for spine trauma patients without complete paralysis, which makes it difficult to compare outcomes of different treatments of the spinal column injury within and between studies.

PURPOSE

The paper aimed to report on the evidence-based consensus process that resulted in the selection of core International Classification of Functioning, Disability, and Health (ICF) categories, as well as the response scale for use in a universal patient-reported outcome measure for patients with traumatic spinal column injury.

STUDY DESIGN/SETTING

The study used a formal decision-making and consensus process.

PATIENT SAMPLE

The sample includes patients with a primary diagnosis of traumatic spinal column injury, excluding completely paralyzed and polytrauma patients.

OUTCOME MEASURES

The wide array of function and health status of patients with traumatic spinal column injury was explored through the identification of all potentially meaningful ICF categories.

METHODS

A formal decision-making and consensus process integrated evidence from four preparatory studies. Three studies aimed to identify relevant ICF categories from three different perspectives. The research perspective was covered by a systematic literature review identifying outcome measures focusing on the functioning and health of spine trauma patients. The expert perspective was explored through an international web-based survey among spine surgeons from the five AOSpine International world regions. The patient perspective was investigated in an international empirical study. A fourth study investigated various response scales for their potential use in the future universal outcome instrument. This work was supported by AOSpine. AOSpine is a clinical division of the AO Foundation, an independent medically guided non-profit organization. The AOSpine Knowledge Forums are pathology-focused working groups acting on behalf of AOSpine in their domain of scientific expertise.

RESULTS

Combining the results of the preparatory studies, the list of ICF categories presented at the consensus conference included 159 different ICF categories. Based on voting and discussion, 11 experts from 6 countries selected a total of 25 ICF categories as core categories for patient-reported outcome measurement in adult traumatic spinal column injury patients (9 body functions, 14 activities and participation, and 2 environmental factors). The experts also agreed to use the Numeric Rating Scale 0-100 as response scale in the future universal outcome instrument.

CONCLUSIONS

A formal consensus process integrating evidence and expert opinion led to a set of 25 core ICF categories for patient-reported outcome measurement in adult traumatic spinal column injury patients, as well as the response scale for use in the future universal disease-specific outcome instrument. The adopted core ICF categories could also serve as a benchmark for assessing the content validity of existing and future outcome instruments used in this specific patient population.

Cost-Effectiveness of Surgical Versus Conservative Treatment for Thoracolumbar Burst Fractures

STUDY DESIGN

Historical, register-based cohort study following 85 patients in the course of a time frame extending from 2 years before to 2 years after trauma occurrence.

OBJECTIVE

To investigate the cost-effectiveness of surgery versus conservative management for thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Despite the prevalence of thoracolumbar burst fractures, consensus has still not been reached in terms of their clinical management and whereas from a health policy point of view, efficient use of resources is equally important, literature pertaining to this aspect is limited.

METHODS

Consecutive patients who were admitted to a university clinic between 2004 and 2008 because of CT-verified AO type A3 fractures (T11-L2), age 18 to 65 years Patients with neurological compromise, osteoporosis, or malignancy were not included. The cost parameter defined primary and secondary health-care use (2010 &OV0556;) and the effect parameter was based on three alternative measures of pain medication: morphine milligram and defined daily doses (DDD) of narcotic and nonnarcotic analgesics. For cost-effectiveness analysis, we employed a difference-in-difference approach, including control for treatment selection (age, sex, and fracture type). Nonparametric bootstrapping was used to estimate conventional 95% confidence intervals of mean estimates.

RESULTS

When taking into consideration all health-care consumption, surgical management was observed to cost an additional &OV0556;10,734 (4215; 15,144) as compared with conservative management. The differences on morphine at 527(-3031; 6,016) milligram, narcotic analgesics at -8(-176; 127) DDD, and nonnarcotic analgesics at -3(-72; 58) DDD were all insignificant The probability for surgery being cost-effective did not exceed 50% for any value of willingness to pay for effect.

CONCLUSION

Surgical management does not seem to be a cost-effective strategy as compared with conservative management for traumatic thoracolumbar burst fractures without neurological deficits. In addition, higher-volume studies examining the clinical effect of alternative management strategies would be valuable.

LEVEL OF EVIDENCE

3.

Toward the Development of a Universal Outcome Instrument for Spine Trauma: A Systematic Review and Content Comparison of Outcome Measures Used in Spine Trauma Research Using the ICF as Reference

STUDY DESIGN

A systematic literature review.

OBJECTIVE

The aim of this study was (1) to identify patient-reported and clinician-based outcome measures most frequently used to evaluate the function and health of spine trauma patients, (2) to identify and quantify the concepts of these measures using the International Classification of Functioning, Disability, and Health (ICF) as reference, and (3) to describe their clinimetric properties.

SUMMARY OF BACKGROUND DATA

There is a real need for a disease-specific outcome instrument to measure the effect size of various treatment options in a variety of traumatic spinal column injuries.

METHODS

A systematic literature search was conducted in several databases. From the included studies, outcome measures were extracted. The items and underlying concepts of the identified outcome measures were specified and linked to the ICF categories. Finally, as far as available in literature, the clinimetric properties of the obtained measures were analyzed.

RESULTS

Out of 5117 screened references, 245 were included, and 17 different frequently used outcome measures were identified. Meaningful concepts of the items and response options of the retrieved outcome measures were linked to a total of 105 different ICF categories, aggregated to 57 first- or second-level categories. The categories were linked to the components activities and participation (n = 31), body functions (n = 17), environmental factors (n = 8), and body structures (n = 1). Overall, there is only limited evidence on the measurement properties, except for some disease-specific questionnaires, such as Oswestry Disability Index, Roland-Morris Disability Questionnaire, Neck Disability Index, and Cervical Spine Outcome Questionnaire.

CONCLUSION

The current systematic literature review revealed great diversity in the use and content of outcome measures to evaluate the functioning and health of spine trauma patients, with 17 different outcome measures linked to 57 unique ICF categories. This study creates an evidence base for a consensus meeting during which a core set of ICF categories for outcome measurement in spine trauma will be decided.

LEVEL OF EVIDENCE

2.

Validation of the Brazilian version of the Spinal Cord Independence Measure III

Introduction : The Spinal Cord Independence Measure (SCIM III) specifically assesses individuals with spinal cord injuries. Objective : To translate and validate the Brazilian version of SCIM III. Method : SCIM III was translated, back-translated and adapted to the Portuguese language. Two interviewers assessed 83 subjects with spinal cord injuries in each one of seven collaborating rehabilitation centers. Functional Independence Measure (FIM™) and ASIA motor and sensory indices were also used. After six months, subjects were re-evaluated with the same instruments. Results : Examiners clearly understood the Brazilian version of SCIM III. Inter-rater intraclass correlation coefficient (ICC) was 0.918, and test-retest ICC was 0.991. After six months, the variation of gains in the FIM™ positively correlated with gains in SCIM III. Conclusion : The Brazilian version of the SCIM III is easy to understand, has good psychometric properties, and is valid.

Current management review of thoracolumbar cord syndromes

BACKGROUND CONTEXT

Injuries to the thoracolumbar spine may lead to a complex array of clinical syndromes that result from dysfunction of the anterior motor units, lumbosacral nerve roots, and/or spinal cord. Neurologic dysfunction may manifest in the lower extremities as loss of fine and gross motor function, touch, pain, temperature, and proprioceptive and vibratory sense deficits. Two clinical syndromes sometimes associated with these injuries are conus medullaris syndrome (CMS) and cauda equina syndrome (CES).

PURPOSE

To review the current management of thoracolumbar spinal cord injuries.

STUDY DESIGN

Literature review.

METHODS

Index Medicus was used to search the primary literature for articles on thoracolumbar injuries. An emphasis was placed on the current management, controversies, and newer treatment options.

RESULTS/CONCLUSIONS

After blunt trauma, these syndromes may reflect a continuum of dysfunction rather than a distinct clinical entity. The transitional anatomy at the thoracolumbar junction, where the conus medullaris is present, makes it less likely that a "pure" CMS or CES syndrome will occur and more likely that a "mixed" injury will. Surgical decompression is the mainstay of treatment for incomplete spinal cord injury (SCI) and incomplete CMS and CES. The value of timing of surgical intervention in the setting of incomplete SCI is unclear at this time. This review summarizes the recent information on epidemiology, pathophysiology, diagnosis, and controversies in the management of thoracolumbar neurologic injury syndromes.