Developing and assessing the measurement properties of an instrument to assess the impact of musculoskeletal pain in children aged 9 to 12-the pediatric musculoskeletal pain impact summary score.

BACKGROUND: Despite the high prevalence of musculoskeletal (MSK) pain in children, there is a lack of instruments to measure the impact of MSK pain on children's activity and participation. OBJECTIVE: To assess the reliability and construct validity of the Pediatric MSK Pain Impact summary score in school children (aged 9 to 12) with MSK pain. METHODS: We used a pragmatic approach in a reflective framework to assess internal consistency, structural validity, convergent validity, and discriminative validity in a sample of 615 children with MSK pain. RESULTS: The confirmatory factor analysis results indicate that the summary score has limited internal consistency and construct validity. The estimated Cronbach's alpha was 0.63, and most goodness of fit indices met the recommended thresholds (SRMR = 0.030; GFI = 0.993, CFI = 0.955, RMSEA 0.073), although they were close to the lower bounds of the thresholds. The convergent validity showed appropriate correlation of the summary score with quality of life (r = -0.33), care-seeking (r = 0.45), and medication intake (r = 0.37). Discriminative validity showed that the instrument can discriminate between the impact of pain on children with frequent and infrequent (2.93; 95% CI: 2.36 - 3.50) MSK pain. CONCLUSION: The Pediatric MSK Pain Impact summary showed limited internal consistency and construct validity; however, it can discriminate between children with frequent and infrequent pain. The results are promising for clinical and research practices as it is a short and convenient tool to be used in school-aged children.

Trajectories of disability in low back pain.

INTRODUCTION: Low back pain (LBP) is the leading course of years lived with disability. Unfortunately, not much knowledge exists about distinct trajectories of recovery from disability after LBP and their potential psychological predictors. OBJECTIVES: Hence, the aim of the present study was to identify trajectories of functional disability in LBP and their potential baseline psychological predictors. METHODS: A 1-year consecutive cohort (N = 1048) of patients with LBP referred to the Spine Centre if they have not improved satisfactorily from a course of treatment in primary care after 1 to 2 months were assessed by self-report questionnaires at their first visit and at 6- and 12-month follow-up. Data from patients who responded to the Roland Morris Disability Questionnaire at least twice (N = 747) were used to assess trajectories of functional disability by Latent Growth Mixture Modeling. The following measures were used as baseline predictors of the trajectories: Pain Intensity Numerical Rating Scales, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Hospital Anxiety and Depression Scale. RESULTS: Four distinct trajectories were identified: high-stable (22.0%), high-decreasing (20.4%), medium-stable (29.7%), and low-decreasing (27.9%). Using the low-decreasing trajectory as reference, baseline pain intensity, depressive symptoms, and pain-catastrophizing predicted membership of all 3 symptomatic trajectories. However, using the high-decreasing trajectory as reference, age, baseline pain intensity, and depression were predictors of the high-stable trajectory. CONCLUSION: In particular, the finding of a high-stable trajectory characterized by high levels of baseline psychological distress is of potential clinical importance because psychological distress may be targeted by cognitive behavioral therapeutic approaches.

Danish translation, adaptation and validation of the ABILHAND-Kids questionnaire for children with cerebral palsy.

PURPOSE: To translate and cross-culturally adapt the ABILHAND-Kids questionnaire into Danish and assess its psychometric properties in children with cerebral palsy (CP). MATERIALS AND METHODS: A Danish version of the parent-reported ABILHAND-Kids questionnaire was created through a standardized translation process. Dimensionality (confirmatory factor analysis), reliability, smallest detectable change, floor and ceiling effects, and Rasch analysis were carried out. RESULTS: One-hundred-and-fifty children diagnosed with CP were included. No parent had difficulty completing the ABILHAND-Kids (DK). Psychometric testing demonstrated a unidimensional scale, excellent test-retest reliability (ICC2.1A = 0.97) and internal consistency (α = 0.96). A smallest detectable change of 5.15 points was considered acceptable. One item showed Differential Item Functioning, four pairs of items showed signs of local dependence and one item had disordered thresholds. Nevertheless, analyses did not lead to the removal of any items. Item thresholds covered most levels of person abilities. Lastly, 24.7% scored within measurement error at the ceiling of the scale, indicating that it was not possible to measure further improvement. CONCLUSION: ABILHAND-Kids (DK) seems to be a valid, reliable and comprehensive measurement scale to assess manual ability in children with CP. It can be used in goal setting and to inform future interventions and rehabilitation evaluation.IMPLICATIONS FOR REHABILITATIONImpaired hand function leads to limited participation in activities of everyday life in children with cerebral palsy.Adequate outcome measures of hand function are crucial for the planning and evaluation of interventions.The Danish version of ABILHAND-Kids is a valid and reliable measure of manual ability in children with cerebral palsy, and it can be used in clinical practice and for research purposes.

Early identification of toe walking gait in preschool children - Development and application of a quasi-automated video screening procedure.

PURPOSE: To develop and test the application of a quasi-automated screening procedure identifying probable toe walking in a large population of preschool children. METHODS: The proposed screening procedure was designed to identify children exhibiting signs of toe walking in a previously recruited cohort of preschool children (MiPS cohort). The procedure combines parent observation (step 1), objective parameters of foot contact during gait by an automated screening of 3-D video recordings (step 2), and clinical video screening of the children identified in step 1 and/or 2 (step 3). FINDINGS: From 879 children, gait trials were obtained from 87% (n = 766). Step 1 (parent observation) identified 34 children with potential toe walking, step 2 (automated screening) 122. Fourteen were identified in both step 1 and 2. Thus, 142 children were selected for step 3 (clinical video screening), from which 41 children were classified as showing symmetric signs of toe walking, and five children were identified with asymmetrical signs of toe walking. Of the 41, five had been identified by step 1 only, 32 by step 2 only and four by both steps. INTERPRETATION: Application of a quasi-automated screening algorithm was feasible and may assist in early detection of toe walking. Disagreements found between parent reported toe walking and video screening, indicate added value in quasi-automated video screening. However, thresholds of heel lift and clinical criteria of toe walking in the algorithm and video screening need to be addressed and validated to confidently identify toe walking gait.

Global Consensus From Clinicians Regarding Low Back Pain Outcome Indicators for Older Adults: Pairwise Wiki Survey Using Crowdsourcing.

BACKGROUND: Low back pain (LBP) is one of the most debilitating conditions among older adults. Unfortunately, existing LBP outcome questionnaires are not adapted for specific circumstances related to old age, which may make these measures less than ideal for evaluating LBP in older adults. OBJECTIVE: To explore the necessity of developing age-specific outcome measures, crowdsourcing was conducted to solicit opinions from clinicians globally. METHODS: Clinicians around the world voted and/or prioritized various LBP outcome indicators for older adults on a pairwise wiki survey website. Seven seed outcome indicators were posted for voting while respondents were encouraged to suggest new indicators for others to vote/prioritize. The website was promoted on the social media of various health care professional organizations. An established algorithm calculated the mean scores of all ideas. A score >50 points means that the idea has >50% probability of beating another randomly presented indicator. RESULTS: Within 42 days, 128 respondents from 6 continents cast 2466 votes and proposed 14 ideas. Indicators pertinent to improvements of physical functioning and age-related social functioning scored >50 while self-perceived reduction of LBP scored 32. CONCLUSIONS: This is the first crowdsourcing study to address LBP outcome indicators for older adults. The study noted that age-specific outcome indicators should be integrated into future LBP outcome measures for older adults. Future research should solicit opinions from older patients with LBP to develop age-specific back pain outcome measures that suit clinicians and patients alike.

Translation, Cultural Adaptation, and Psychometric Properties of the Danish Version of the Anti-Clot Treatment Scale.

Background The Anti-Clot Treatment Scale (ACTS) is a 17-item, 2-factor (Burdens and Benefits), patient-reported outcome instrument to evaluate patient satisfaction with oral anticoagulant treatment. Objectives This study aimed to translate and culturally adapt the English version of the ACTS into Danish and to subsequently validate the Danish version in a population of patients treated with dabigatran etexilate for atrial fibrillation. Methods The ACTS was translated into Danish and culturally adapted. This prospective phase 4 study included 232 respondents who completed the Danish ACTS after 1 month of treatment with dabigatran etexilate for atrial fibrillation. Psychometric properties were evaluated. For test-retest reliability, the ACTS was measured twice, 2 weeks apart, in a subgroup of 50 stable patients. Results Generally, a high level of treatment satisfaction was found. Confirmatory factor analysis showed a suboptimal fit for the two-factor model of the original version. Using modification indices of confirmatory factor analysis, a four-factor model had the best fit. Cronbach's α for internal consistency was acceptable at 0.78. There was good test-retest reliability with intraclass correlation at 0.80. Smallest detectable changes (SDCs) for individual patients were 5.89 points for the total ACTS, 5.57 for the reverse Burdens, and 3.34 for Benefits scores. Group SDCs were 0.39, 0.37, and 0.22 respectively. Substantial ceiling effects limit the ability to detect improvement at the high end of the scale. Conclusion The Danish version of the ACTS has inadequate structural validity. Reliability was acceptable. Ceiling effects challenge detection of improvement of treatment satisfaction in clinical practice in this patient population.

The Danish Neck Disability Index: New Insights into Factor Structure, Generalizability, and Responsiveness.

OBJECTIVE: To (1) translate and culturally adapt and (2) determine the clinimetric properties of the Danish 8-item Neck Disability Index (NDI-8) in primary sector patients (PSPs) and secondary sector patients (SSPs). METHODS: Analyses included 326 patients with neck pain. Validity and reliability were assessed using a cross-validation factor analytical design, hypothesis testing, internal consistency, measurement error, the smallest detectable change (SDC), and a generalizability study. Criterion and construct responsiveness, minimal important change (MIC), and floor and ceiling effects were determined. RESULTS: The original Danish version of the NDI was not unidimensional. Omitting 2 items (pain, headache) revealed a 1-factor structure (NDI-8). Construct validity correctly predicted 88% of the hypotheses. Internal consistency (Cronbach's α) ranged between 0.88 and 0.89, and generalizability was high (Φ = 0.90). The SDC was 6.8 in PSPs and 5.9 in SSPs. Criterion responsiveness revealed poor areas under the curve for SSPs (0.58 to 0.64), and construct responsiveness was poor for PSPs (43% correctly predicted hypothesis). A floor effect of 26.5% was found in PSPs, with a change of 4 points representing the MIC. CONCLUSION: The modified Danish 8-item NDI was unidimensional, had construct validity, and was reproducible with a large but acceptable measurement error. However, responsiveness was poor and a significant floor effect was found in PSPs. A change score representing the MIC is proposed for PSPs.

What influences retrospective self-appraised recovery status among Danes with low-back problems? A comparative qualitative investigation.

STUDY DESIGN: Phenomenological, qualitative investigation. The discord between commonly used outcome measures and patients' self-perceived recovery is problematic in the investigation and rehabilitation of low-back pain-related disorders. To better understand the course and development of this costly and disabling condition, the complex process of patient recovery requires further elucidation. OBJECTIVE: To explore issues and experiences impacting retrospective, self-appraised recovery. METHODS: Semi-structured interviews were conducted with 32 purposively sampled individuals, after which computer-assisted substantive categorization and thematic analysis was performed. RESULTS: Self-appraised status could be determined as "recovered" for 17 respondents, "unsure" for 6, and "not recovered" for 9. Recovery/non-recovery hinged on continued pain-related issues and the perception that injury/trauma made recovery impossible. Individuals who had difficulties relating the recovery construct to their context as well as those who were sceptical of pain-free periods were unable to appraise their status. CONCLUSION: This investigation confirms that pain is central to the resolution of recurrent low-back pain associated disorders. However, recovery also involves "redefinition" and "readjustment". In the investigation and rehabilitation of ambiguous, regional musculoskeletal disorders, our results provide further sensitizing concepts, derived through naturalistic observation, that are useful in the development of a more comprehensive explanatory framework of patient recovery.

Rasch analysis of the 23-item version of the Roland Morris Disability Questionnaire.

OBJECTIVE: To determine the psychometric properties of the 23-item version of the Roland Morris Disability Questionnaire (RMDQ-23) and to quantify their stability across 2 cultures/languages and 2 types of care-settings. METHODS: Rasch analysis of data from 1,000 patients with low back pain from primary care (UK and Denmark) and secondary care (Denmark). RESULTS: The RMDQ-23 is unidimensional if local item dependency issues are accommodated, but contains several misfitting or overdiscriminating items, some poor targeting of items, and the scoring of 4-5 items is differentially affected by common clinical characteristics (such as age, gender, pain intensity, pain duration and care setting), depending on the country. CONCLUSION: As similar results have been found for the RMDQ-24, we believe it is timely to reconsider whether: (i) the RMDQ should be reconstructed using an item-response theory-based approach that includes consideration of new items and response options; or (ii) the use of alternative questionnaires should be recommended, such as the Oswestry Disability Index, that have shown evidence of fitting the Rasch model; or (iii) a completely new condition-specific questionnaire should be developed, perhaps utilizing a computerized adaptive testing platform.

Chiropractic management of a patient with benign paroxysmal positional vertigo: a case report.

OBJECTIVE: This article describes and discusses the case of a patient with benign paroxysmal positional vertigo (BPPV) characterized by severe vertigo with dizziness, nausea, and nystagmus, treated without the use of spinal manipulation by a doctor of chiropractic. CLINICAL FEATURES: A 46-year-old woman presented for care with complaints of acute vertigo and dizziness. INTERVENTION AND OUTCOME: The patient was examined and diagnosed with left posterior canalolithiasis by means of the Dix-Hallpike maneuver. She was treated successfully with the Epley maneuver once and subsequently discharged without further treatment. CONCLUSION: This case demonstrates the importance of correctly identifying patients with BPPV. This case also demonstrates the successful treatment of BPPV.

Choice of external criteria in back pain research: Does it matter? Recommendations based on analysis of responsiveness.

Understanding a change score is indispensable for interpretation of results from clinical studies. One way of determining the relevance of change scores is through the use of transition questions that assesses patients' retrospective perception of treatment effect. Unfortunately, results from studies using transition questions are difficult to compare since wording of questions and definitions of important improvements vary between studies. The objectives of this study were to determine the consequence of using different transition questions on pain and disability measures and make proposals for a standardised use of such questions. Two hundred and thirty-three patients with low back pain and/or leg pain were recruited. Participants were followed over an 8-week period and randomised to two groups receiving a 7- (TQ1) and 15-point (TQ2) transition question, respectively, in addition to a numeric rating scale evaluating the importance of the perceived change. Four external criteria were generated using both stringent and less stringent standards to dichotomise patients. Discrimination was determined using area under the receiver operating characteristic curve (ROC(auc)) and responsiveness using standardised response mean (SRM). Results demonstrated small variations in ROC(auc) across the external criteria for all outcome measures. 7% more patients were classified as improved in the group receiving the 15-point TQ compared to the 7-point TQ (stringent standard). SRMs were higher for the retrospective TQs in primary sector patients compared to the serial measures with no difference between TQ1 and TQ2. On the basis of our findings we have outlined a proposal for a standardised use of transition questions.

Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients.

BACKGROUND: The choice of an evaluative instrument has been hampered by the lack of head-to-head comparisons of responsiveness and the minimal clinically important difference (MCID) in subpopulations of low back pain (LBP). The objective of this study was to concurrently compare responsiveness and MCID for commonly used pain scales and functional instruments in four subpopulations of LBP patients. METHODS: The Danish versions of the Oswestry Disability Index (ODI), the 23-item Roland Morris Disability Questionnaire (RMQ), the physical function and bodily pain subscales of the SF36, the Low Back Pain Rating Scale (LBPRS) and a numerical rating scale for pain (0-10) were completed by 191 patients from the primary and secondary sectors of the Danish health care system. Clinical change was estimated using a 7-point transition question and a numeric rating scale for importance. Responsiveness was operationalized using standardized response mean (SRM), area under the receiver operating characteristic curve (ROC), and cut-point analysis. Subpopulation analyses were carried out on primary and secondary sector patients with LBP only or leg pain +/- LBP. RESULTS: RMQ was the most responsive instrument in primary and secondary sector patients with LBP only (SRM = 0.5-1.4; ROC = 0.75-0.94) whereas ODI and RMQ showed almost similar responsiveness in primary and secondary sector patients with leg pain (ODI: SRM = 0.4-0.9; ROC = 0.76-0.89; RMQ: SRM = 0.3-0.9; ROC = 0.72-0.88). In improved patients, the RMQ was more responsive in primary and secondary sector patients and LBP only patients (SRM = 1.3-1.7) while the RMQ and ODI were equally responsive in leg pain patients (SRM = 1.3 and 1.2 respectively). All pain measures demonstrated almost equal responsiveness. The MCID increased with increasing baseline score in primary sector and LBP only patients but was only marginally affected by patient entry point and pain location. The MCID of the percentage change score remained constant for the ODI (51%) and RMQ (38%) specifically and differed in the subpopulations. CONCLUSION: RMQ is suitable for measuring change in LBP only patients and both ODI and RMQ are suitable for leg pain patients irrespectively of patient entry point. The MCID is baseline score dependent but only in certain subpopulations. Relative change measured using the ODI and RMQ was not affected by baseline score when patients quantified an important improvement.