Reliability, Measurement Error, Responsiveness, and Minimal Important Change of the Patient-Specific Functional Scale 2.0 for Patients With Nonspecific Neck Pain.

OBJECTIVE: The Patient-Specific Functional Scale (PSFS) is a patient-reported outcome measure used to assess functional limitations. Recently, the PSFS 2.0 was proposed; this instrument includes an inverse numeric rating scale and an additional list of activities that patients can choose. The aim of this study was to assess the test-retest reliability, measurement error, responsiveness, and minimal important change of the PSFS 2.0 when used by patients with nonspecific neck pain. METHODS: Patients with nonspecific neck pain completed a numeric rating scale, the PSFS 2.0, and the Neck Disability Index at baseline and again after 12 weeks. The Global Perceived Effect (GPE) was also collected at 12 weeks and used as an anchor. Test-retest measurement was assessed by completion of a second PSFS 2.0 after 1 week. Measurement error was calculated using a Bland-Altman plot. The receiver operating characteristic method with the anchor (GPE) functions as the reference standard was used for calculating the minimal important change. RESULTS: One hundred patients were included, with 5 lost at follow-up. No floor and ceiling effects were reported. In the test-retest analysis, the mean difference was 0.15 (4.70 at first test and 4.50 at second test). The ICC (mixed models) was 0.95, indicating high agreement (95% CI = 0.92-0.97). For measurement error, the upper and lower limits of agreement were 0.95 and -1.25 points, respectively, with a smallest detectable change of 1.10. The minimal important change was determined to be 2.67 points. The PSFS 2.0 showed satisfactory responsiveness, with an area under the curve of 0.82 (95% CI = 0.70-0.93). There were substantial to high correlations between the change scores of the PSFS 2.0 and the Neck Disability Index and GPE (0.60 and 0.52, respectively; P < .001). CONCLUSION: The PSFS 2.0 is a reliable and responsive patient-reported outcome measure for use by patients with neck pain.

Clinical validation of grouping conservative treatments in neck pain for use in a network meta-analysis: a Delphi consensus study.

BACKGROUND: A network meta-analysis aims to help clinicians make clinical decisions on the most effective treatment for a certain condition. Neck pain is multifactorial, with various classification systems and treatment options. Classifying patients and grouping interventions in clinically relevant treatment nodes for a NMA is essential, but this process is poorly defined. OBJECTIVE: Our aim is to obtain consensus among experts on neck pain classifications and the grouping of interventions into nodes for a future network meta-analysis. DESIGN: A Delphi consensus study involving neck pain experts worldwide. METHODS: We invited authors of neck pain clinical practice guidelines published from 2014 onwards. The Delphi baseline questionnaire was developed based on the findings of a scoping review, including four items on classifications and 19 nodes. Participants were asked to record their level of agreement on a seven-point Likert scale or using Yes/No/Not sure answer options for the various statements. We used descriptive analysis to summarise the responses on each statement with content analysis of the free-text comments. RESULTS: In total, 18/80 experts (22.5%) agreed to participate in one or more Delphi rounds. We needed three rounds to reach consensus for two classification of neck pain: one based on aetiology and one on duration. In addition, we also reached consensus on the grouping of interventions, including a definition of each node, with the number of nodes reduced to 17. CONCLUSION: With this consensus we clinically validated two neck pain classifications and grouped conservative treatments into 17 well-defined and clinically relevant nodes.

Treatment classifications and interventions for neck pain: a scoping review.

OBJECTIVES: Our aim is to provide an overview of how neck pain is classified in the literature, define and group conservative interventions into 'nodes', and develop draft networks of interventions in preparation for a network meta-analysis (NMA). STUDY DESIGN AND SETTINGS: We performed a scoping review. For feasibility reasons, we searched for randomized clinical trials (RCTs) via neck pain clinical practice guidelines (CPGs) published from 2014. We used standardized data extraction forms to extract data about classification of neck pain and interventions evaluated in the included RCTs. We calculated frequencies of neck pain classifications and grouped interventions into nodes based on the definitions used in Cochrane reviews. Draft network graphs comparing interventions were constructed using the online Shiny R application CINEMA. RESULTS: We included 242 RCTs from seven CPGs, evaluating 28,581 patients. We found three different classification systems of which The Neck Pain Task Force classification was used most often. We defined and grouped all interventions into 19 discrete potential nodes. CONCLUSION: We found a wide variation in neck pain classifications and conservative interventions. Grouping the interventions was challenging and needs further evaluation before conducting a final NMA.

The Effect of a New Payment System on Physiotherapeutic Management of Patients With Low Back Pain in Primary Care.

OBJECTIVE: To evaluate differences regarding the number of treatment sessions, costs, and outcomes (including relapses) between a regular payment-per-session system and the recently introduced product payment system in The Netherlands. DESIGN: Prospective cohort study. SETTING: Dutch physical therapy practices in primary care over a 2-year period. PARTICIPANTS: 16,103 patients with low back pain (LBP). INTERVENTION: The new product payment system is compared with the regular payment-per-session system. MAIN OUTCOME MEASURES: Pain, disability, recovery, number of physical therapy sessions, therapy duration, costs (per episode), and LBP relapse. RESULTS: At baseline, we found greater pain and disability scores associated with an increased risk profile in both payment systems. With regard to the payment systems, we found greater costs (€283.8 vs €210.8) and a greater percentage of relapse (4.5% vs 2.8%) for the product payment system compared with the payment-per-session system. Comparing the 2 payment systems within each risk strata, we found no significant differences, except for a decrease in pain in the medium-risk stratum. Concerning the therapy characteristics, we found that in the payment-per-session group, the therapy took 6 days longer for low-risk patients (median 27 vs 21 days) and 7 days shorter for high-risk patients (median 42 vs 49 days) compared with the product payment group. Moreover, the mean number of sessions in the payment-per-session group was greater for low-risk patients (5.4 vs 4.8 sessions) and lower for high-risk patients (7.7 vs 8.1 sessions) compared with the payment-per-session group. Finally, the costs were significantly greater in all strata of the product payment group compared with the payment-per-session group. CONCLUSIONS: The 2 payment systems are largely comparable regarding patient outcomes, therapy duration, and treatment sessions. Both the average cost per patient per LBP episode and the number of relapses in the product payment system are statistically significantly greater than in the payment-per-session system.

Guideline adherence of physiotherapists in the treatment of patients with low back pain: A qualitative study.

RATIONALE: Adherence rates to guidelines show room for improvement, and increase in adherence to guidelines may potentially lead to better outcomes and reduced costs of treatment. To improve adherence, it is essential to understand the considerations of physiotherapists regarding the assessment and management of low back pain (LBP). The purpose of this study is to gain insight in the considerations of Dutch physiotherapists on adherence to the national physiotherapy guideline in the treatment of patients with LBP. METHODS: This is a qualitative study, using an interpretive approach of semi-structured interviews with 14 physiotherapists who regularly treat patients with LBP. Thematic analysis was conducted with open coding using an existing framework. This framework distinguishes five components to adherence based on patient factors, provider factors, guideline characteristics, institutional factors and the implementation process. RESULTS: Participating physiotherapists mentioned that the guideline should provide more information about psychosocial prognostic factors and psychosocial treatment options. The participants experienced difficulties in addressing patient expectations that conflict with guideline recommendations. The implementation process of the guideline was considered insufficient. Physiotherapists might rely too much on their experience, and knowledge of evidence-based treatment might be improved. In general, the interviewed physiotherapists thought they were mainly non-adherent to the guidelines. However, when comparing their considerations with the actual guideline recommendations they were mainly adherent. CONCLUSION: To improve adherence, the guideline should provide more information about addressing psychosocial prognostic factors, and Dutch physiotherapists might be trained in communication skills to better address patient expectations. A more extensive implementation process is warranted for the next guideline to increase the physiotherapists' knowledge of evidence-based treatment.

Improving the Predictive Validity of the Dutch STarT Back Tool.

OBJECTIVE: The purpose of this study was to evaluate whether the predictive validity of the Dutch version of the STarT Back Tool (SBT) can be improved by (1) using other cut-off values, (2) changing the items, or (3) adding prognostic factors to the SBT. DESIGN: This was a secondary analysis of a prospective cohort study (PRINS study: Prevalence of Risk groups in Neck- and back pain patients according to the STarT back screening tool) in patients with low back or neck pain. METHODS: The predictive validity was calculated with a relative risk ratio and a Spearman correlation. The new cut-off values were calculated with receiver operating characteristic curves. Replacing items of the SBT and adding new items were assessed with logistic regression analyses. RESULTS: A total of 150 patients were included; 51% were categorized as having low risk, 39% as moderate risk, and 11% as high risk. Changing the cut-off total score to ≤2 and the subscore to ≥5 led to an improvement of the Spearman correlation and RR. Adding the item "duration of the complaints" improved the RR for moderate risk (3.6) (95% CI = 1.6-7.9) and for high risk (9.0) (95% CI = 4.2-19.1) compared with low risk. The new Spearman correlation was improved to rs = 0.37. CONCLUSION: The predictive validity was improved by adding the item "duration of the complaints" and changing the cut-off values.

Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain.

The Royal Dutch Society for Physical Therapy (KNGF) issued a clinical practice guideline for physical therapists that addresses the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, in Dutch primary care. Recommendations were based on a review of published systematic reviews.During the intake, the patient is screened for serious pathologies and corresponding patterns. Patients with cervical radiculopathy can be included or excluded through corresponding signs and symptoms and possibly diagnostic tests (Spurling test, traction/distraction test, and Upper Limb Tension Test). History taking is done to gather information about patients' limitations, course of pain, and prognostic factors (eg, coping style) and answers to health-related questions.In case of a normal recovery (treatment profile A), management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement "acting as usual."In case of a delayed/deviant recovery (treatment profile B), the physical therapist is advised to use, in addition to the recommendations for treatment profile A, forms of mobilization and/or manipulation in combination with exercise therapy. Other interventions may also be considered. The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar.In case of a delayed/deviant recovery with clear and/or dominant psychosocial prognostic factors (treatment profile C), these factors should first be addressed by the physical therapist, when possible, or the patient should be referred to a specialist, when necessary.In case of neck pain grade III (treatment profile D), the therapy resembles that for profile B, but the use of a cervical collar for pain reduction may be considered. The advice is to use it sparingly: only for a short period per day and only for a few weeks.

Can Primary Care for Back and/or Neck Pain in the Netherlands Benefit From Stratification for Risk Groups According to the STarT Back Tool Classification?

OBJECTIVE: To evaluate whether current Dutch primary care clinicians offer tailored treatment to patients with low back pain (LBP) or neck pain (NP) according to their risk stratification, based on the Keele STarT (Subgroup Targeted Treatment) Back-Screening Tool (SBT). DESIGN: Prospective cohort study with 3-month follow-up. SETTING: Primary care. PARTICIPANTS: General practitioners (GPs) and physiotherapists included patients (N=284) with nonspecific LBP, NP, or both. INTERVENTIONS: Patients completed a baseline questionnaire, including the Dutch SBT, for either LBP or NP. A follow-up measurement was conducted after 3 months to determine recovery (using Global Perceived Effect Scale), pain (using Numeric Pain Rating Scale), and function (using Roland Disability Questionnaire or Neck Disability Index). A questionnaire was sent to the GPs and physiotherapists to evaluate the provided treatment. MAIN OUTCOME MEASURES: Prevalence of patients' risk profile and clinicians' applied care, and the percentage of patients with persisting disability at follow-up. A distinction was made between patients receiving the recommended treatment and those receiving the nonrecommended treatment. RESULTS: In total, 12 GPs and 33 physiotherapists included patients. After 3 months, we analyzed 184 patients with LBP and 100 patients with NP. In the LBP group, 52.2% of the patients were at low risk for persisting disability, 38.0% were at medium risk, and 9.8% were at high risk. Overall, 24.5% of the patients with LBP received a low-risk treatment approach, 73.5% a medium-risk, and 2.0% a high-risk treatment approach. The specific agreement between the risk profile and the received treatment for patients with LBP was poor for the low-risk and high-risk patients (21.1% and 10.0%, respectively), and fair for medium-risk patients (51.4%). In the NP group, 58.0% of the patients were at low risk for persisting disability, 37.0% were at medium risk, and 5.0% were at high risk. Only 6.1% of the patients with NP received the low-risk treatment approach. The medium-risk treatment approach was offered the most (90.8%), and the high-risk approach was applied in only 3.1% of the patients. The specific agreement between the risk profile and received treatment for patients with NP was poor for low-risk and medium-risk patients (6.3% and 48.0%, respectively); agreement for high-risk patients could not be calculated. CONCLUSIONS: Current Dutch primary care for patients with nonspecific LBP, NP, or both does not correspond to the recommended stratified-care approach based on the SBT, as most patients receive medium-risk treatment. Most low-risk patients are overtreated, and most high-risk patients are undertreated. Although the stratified-care approach has not yet been validated in Dutch primary care, these results indicate there may be substantial room for improvement.

Patient Nonadherence to Guideline-Recommended Care in Acute Low Back Pain.

OBJECTIVE: To describe the magnitude of patient-reported nonadherence with guideline-recommended care for acute low back pain. DESIGN: Secondary analysis of data from participants enrolled in the Paracetamol for Acute Low Back Pain study trial, a randomized controlled trial evaluating the effectiveness of paracetamol for acute low back pain. SETTING: Primary care, general practitioner. PARTICIPANTS: Data from participants with acute low back pain (N=1643). INTERVENTIONS: Guideline-recommended care, including reassurance, simple analgesia, and the advice to stay active and avoid bed rest. Also, advice against additional treatments and referral for imaging. MAIN OUTCOME MEASURES: Proportion of nonadherence with guideline-recommended care. Nonadherence was defined as (1) failure to consume the advised paracetamol dose, or (2) receipt of additional health care, tests, or medication during the trial treatment period (4wk). Multivariable logistic regression analysis was performed to determine the factors associated with nonadherence. RESULTS: In the first week of treatment, 39.7% of participants were classified as nonadherent. Over the 4-week treatment period, 70.0% were nonadherent, and 57.5% did not complete the advised paracetamol regimen. Higher perceived risk of persistent pain, lower level of disability, and not claiming workers' compensation were associated with nonadherence, with odds ratios ranging from .46 to 1.05. CONCLUSIONS: Adherence to guideline-recommended care for acute low back pain was poor. Most participants do not complete the advised paracetamol regimen. Higher perceived risk of persistence of complaints, lower baseline disability, and participants not claiming workers' compensation were independently associated with nonadherence.

Validity and reproducibility of the modified STarT Back Tool (Dutch version) for patients with neck pain in primary care.

OBJECTIVE: To evaluate the reliability and validity of the Dutch version of the STarT Back screening Tool (SBT), for patients with neck pain. METHODS: We modified the SBT to fit patients with neck pain. General practitioners and physiotherapists included patients who completed both a baseline and a follow-up questionnaire at 3 days and 3 months, respectively. The construct validity was assessed using Pearson's correlation between the SBT and the reference questionnaires. The reproducibility was assessed in the first week using the quadratic weighted kappa and the specific agreement. Predictive validity was assessed using a relative-risk ratio (RR) for, amongst others, persisting disability at 3 months. Content validity was analysed using both floor and ceiling effects. RESULTS: In total, 100 patients were included; 58% were categorised as being at "low risk" for persisting disability, 37% at "medium risk" and 5% at "high risk". As expected for the construct validity, we found a moderate to high correlation for all questions except for activity question 3. The reproducibility had a quadratic-weighted kappa of 0.58, and a specific agreement of 90.9% for "low-risk" and 66.7% for "medium-risk" patients. The RRs for persisting disability for "medium-risk" against "low-risk" patients were 1.5 (95% C.I. 0.9-2.4) and 1.5 (95% C.I. 0.5-4.1) for pain. The sample size for high-risk patients was low. CONCLUSION: The original SBT is modified to fit patients with neck pain in Dutch primary care. The psychometric analysis indicates sufficiently reliable outcomes, although the predictive validity showed statistically insignificant results.

Validity and Reproducibility of the STarT Back Tool (Dutch Version) in Patients With Low Back Pain in Primary Care Settings.

OBJECTIVE: The purpose of this study was to translate and to investigate the reliability and validity of the STarT Back screening tool (SBT) in the primary care setting among patients with nonspecific low back pain (LBP). DESIGN: The SBT was formally translated into Dutch following a multistep approach for forward and backward translation. General practitioners and physical therapists included patients with LBP. METHODS: Patients completed a baseline questionnaire and a follow-up at 3 days and 3 months. The construct validity was calculated with Pearson's correlation coefficient. The reproducibility was assessed using the quadratic weighted kappa and the specific agreement. Predictive validity was assessed using relative risk ratios for persisting disability at 3 months. Content validity was analyzed using floor and ceiling effects. RESULTS: In total, 184 patients were included; 52.2% were categorized in the "low-risk" subgroup, 38.0% "medium-risk," and 9.8% "high-risk." For the construct validity we found, as expected, a moderate to high Pearson's correlation for questions 3 to 9 and a low correlation for questions 1 and 2 with their respective reference questionnaires. The reproducibility had a quadratic weighted kappa of 0.65 and the specific agreement of 82.4% for "low-risk," 53.3% for "medium-risk," and 33.3% for "high-risk." For the predictive validity for persisting disability we found a relative risk ratio for "medium-risk" of 1.8 (95% confidence interval [CI]: 1.0-3.1) and 2.7 (95% CI: 1.4-4.9) for "high-risk" compared with "low-risk." For the content validity, we found that no floor and ceiling effects were present. LIMITATIONS: There was a relatively small sample size for the retest reliability study. Patients were not compared between physical therapist and GP, as there were not enough patients in both groups. For practical reasons, the patients filled out the baseline questionnaire after receiving the first treatment/consultation; however, the questionnaire is intended to be filled in before the first consultation/treatment. CONCLUSION: The SBT has been successfully translated into Dutch. The psychometric analysis showed acceptable results and, therefore, the SBT is a valid screening tool for patients with LBP in Dutch primary care.