Individualized quality of life in patients with low back pain: reliability and validity of the Patient Generated Index

Objective: To evaluate the reliability and validity of the improved version of the Patient Generated Index (PGI) in patients with low back pain. Methods: The PGI was administered to 90 patients attending care in 1 of 6 institutions in Norway and evaluated for reliability and validity. The questionnaire was given out to 61 patients for re-test purposes. Results: The PGI was completed correctly by 80 (88.9%) patients and, of the 61 patients responding to the re-test, 50 (82.0%) completed both surveys correctly. PGI scores were approximately normally distributed, with a median of 40 (range 80), where 100 is the best possible quality of life. There were no floor or ceiling effects. The 5 most frequently listed areas affecting quality of life were pain, sleep, stiffness, socializing and housework. The test-retest intraclass correlation coefficient was 0.73. The smallest detectable changes for individual and group purposes were 32.8 and 4.6, respectively. The correlations between PGI scores and other instrument scores followed a priori hypotheses of low to moderate correlations. Discussion: The PGI has evidence for reliability and validity in Norwegian patients with low back pain at the group level and may be considered for application in intervention studies when a comprehensive evaluation of quality of life is important. However, the smallest detectable change, of approximately 30 points, may be considered too large for individual purposes in clinical application

Anterior surgical treatment for cervical degenerative radiculopathy: a prediction model for non-success

Purpose By using data from the Norwegian Registry for Spine Surgery, we wanted to develop and validate prediction models for non-success in patients operated with anterior surgical techniques for cervical degenerative radiculopathy (CDR). Methods This is a multicentre longitudinal study of 2022 patients undergoing CDR surgery and followed for 12 months to fnd prognostic models for non-success in neck disability and arm pain using multivariable logistic regression analysis. Model performance was evaluated by area under the receiver operating characteristic curve (AUC) and a calibration test. Internal validation by bootstrapping re-sampling with 1000 repetitions was applied to correct for over-optimism. The clinical usefulness of the neck disability model was explored by developing a risk matrix for individual case examples. Results Thirty-eight percent of patients experienced non-success in neck disability and 35% in arm pain. Loss to follow-up was 35% for both groups. Predictors for non-success in neck disability were high physical demands in work, low level of education, pending litigation, previous neck surgery, long duration of arm pain, medium-to-high baseline disability score and presence of anxiety/depression. AUC was 0.78 (95% CI, 0.75, 0.82). For the arm pain model, all predictors for non-success in neck disability, except for anxiety/depression, were found to be signifcant in addition to foreign mother tongue, smoking and medium-to-high baseline arm pain. AUC was 0.68 (95% CI, 0.64, 0.72). Conclusion The neck disability model showed high discriminative performance, whereas the arm pain model was shown to be acceptable. Based upon the models, individualized risk estimates can be made and applied in shared decision-making with patients referred for surgical assessment

Comparison of the SF6D, the EQ5D, and the oswestry disability index in patients with chronic low back pain and degenerative disc disease

Background The need for cost effectiveness analyses in randomized controlled trials that compare treatment options is increasing. The selection of the optimal utility measure is important, and a central question is whether the two most commonly used indexes - the EuroQuol 5D (EQ5D) and the Short Form 6D (SF6D) – can be used interchangeably. The aim of the present study was to compare change scores of the EQ5D and SF6D utility indexes in terms of some important measurement properties. The psychometric properties of the two utility indexes were compared to a disease-specific instrument, the Oswestry Disability Index (ODI), in the setting of a randomized controlled trial for degenerative disc disease. Methods In a randomized controlled multicentre trial, 172 patients who had experienced low back pain for an average of 6 years were randomized to either treatment with an intensive back rehabilitation program or surgery to insert disc prostheses. Patients filled out the ODI, EQ5D, and SF-36 at baseline and two-year follow up. The utility indexes was compared with respect to measurement error, structural validity, criterion validity, responsiveness, and interpretability according to the COSMIN taxonomy. Results At follow up, 113 patients had change score values for all three instruments. The SF6D had better similarity with the disease-specific instrument (ODI) regarding sensitivity, specificity, and responsiveness. Measurement error was lower for the SF6D (0.056) compared to the EQ5D (0.155). The minimal important change score value was 0.031 for SF6D and 0.173 for EQ5D. The minimal detectable change score value at a 95% confidence level were 0.157 for SF6D and 0.429 for EQ5D, and the difference in mean change score values (SD) between them was 0.23 (0.29) and so exceeded the clinical significant change score value for both instruments. Analysis of psychometric properties indicated that the indexes are unidimensional when considered separately, but that they do not exactly measure the same underlying construct. Conclusions This study indicates that the difference in important measurement properties between EQ5D and SF6D is too large to consider them interchangeable. Since the similarity with the “gold standard” (the disease-specific instrument) was quite different, this could indicate that the choice of index should be determined by the diagnosis

A nationwide study of patients operated for cervical degenerative disorders in public and private hospitals

During the last decades, there has been an increase in the rate of surgery for degenerative disorders of the cervical spine and in the use of supplementary private health insurance. Still, there is limited knowledge about the diferences in characteristics of patients operated in public and private hospitals. Therefore, we aimed at comparing sociodemographic-, clinical- and patient management data on patients operated for degenerative cervical radiculopathy and degenerative cervical myelopathy in public and private hospitals in Norway. This was a cross-sectional study on patients in the Norwegian Registry for Spine Surgery operated for degenerative cervical radiculopathy and degenerative cervical myelopathy between January 2012 and December 2020. At admission for surgery, we assessed disability by the following patient reported outcome measures (PROMs): neck disability index (NDI), EuroQol-5D (EQ-5D) and numerical rating scales for neck pain (NRS-NP) and arm pain (NRS-AP). Among 9161 patients, 7344 (80.2%) procedures were performed in public hospitals and 1817 (19.8%) in private hospitals. Mean age was 52.1 years in public hospitals and 49.7 years in private hospitals (P< 0.001). More women were operated in public hospitals (47.9%) than in private hospitals (31.6%) (P< 0.001). A larger proportion of patients in private hospitals had high education (≥4 years of college or university) (42.9% vs 35.6%, P< 0.001). Patients in public hospitals had worse disease-specifc health problems than those in private hospitals: unadjusted NDI mean diference was 5.2 (95% CI 4.4 – 6.0; P< 0.001) and adjusted NDI mean diference was 3.4 (95% CI 2.5 – 4.2; P< 0.001), and they also had longer duration of symptoms (P< 0.001). Duration of surgery (mean diference 29 minutes, 95% CI 27.1 – 30.7; P< 0.001) and length of hospital stay (mean diference 2 days, 95% CI 2.3 – 2.4; P< 0.001) were longer in public hospitals. In conclusion, patients operated for degenerative cervical spine in private hospitals were healthier, younger, better educated and more often men. They also had less and shorter duration of symptoms and seemed to be managed more efciently. Our fndings indicate that access to cervical spine surgery in private hospitals could be skewed in favour of patients with higher socioeconomic status

New insight to the characteristics and clinical course of clusters of patients with imaging confirmed disc-related sciatica.

BACKGROUND: Referral to secondary care is common for a considerable proportion of patients with persistent sciatica symptoms. It is unclear if information from clinical assessment can further identify distinct subgroups of disc-related sciatica, with perhaps different clinical courses. AIMS: This study aims to identify and describe clusters of imaging confirmed disc-related sciatica patients using latent class analysis, and compare their clinical course. METHODS: The study population were 466 patients with disc-related sciatica. Variables from clinical assessment were included in the analysis. Characteristics of the identified clusters were described and their clinical course over two years, was compared. RESULTS: A four cluster solution was optimal. Cluster 1 (n=110) had mild back and leg pain; cluster 2 (n=59) had moderate back and leg pain, cluster 3 (n=158) had mild back pain and severe leg pain; cluster 4 (n=139) had severe back and leg pain. Patients in cluster 4 had the most severe profile in terms of disability, distress and comorbidity and the lowest reported global change and the smallest proportion of patients with a successful outcome at two years. Of the 135 patients who underwent surgery, 42% and 41% were in clusters 3 and 4 respectively. CONCLUSIONS: Using a strict diagnosis of sciatica, this work identified four clusters of patients primarily differentiated by back and leg pain severity. Patients with severe back and leg pain had the most severe profile at baseline and follow-up irrespective of intervention. This simple classification system may be useful when considering prognosis and management with sciatica patients. This article is protected by copyright. All rights reserved

The rates of lumbar spinal stenosis surgery in Norwegian public hospitals: a threefold increase from 1999 to 2013

Accepted manuscript version of the following article: Grøvle, L., Fjeld, O.R., Haugen, A.J., Helgeland, J., Småstuen, M.C., Solberg, T., ... Grotle, M. (2018). The rates of lumbar spinal stenosis surgery in Norwegian public hospitals: a threefold increase from 1999 to 2013. Spine. Published version available at https://doi.org/10.1097/BRS.0000000000002858.Study Design: Retrospective administrative database study. Objective: To assess temporal and regional trends, and length of hospital stay, in lumbar spinal stenosis (LSS) surgery in Norwegian public hospitals from 1999 to 2013. Summary of Background Data: Studies from several countries have reported increasing rates of LSS surgery over the last decades. No such data have been presented from Norway. Methods: A database consisting of discharges from all Norwegian public hospitals was established. Inclusion criteria were discharges including a surgical procedure of lumbar spinal decompression and/or fusion in combination with an ICD-10 diagnosis of Spinal Stenosis (M48.0) or Other Spondylosis with Radiculopathy (M47.2), and a patient age of 18 years or older. Discharges with diagnoses indicating deformity, i.e. spondylolisthesis or scoliosis were not included. Results: During the 15-year period, 19 543 discharges were identified. The annual rate of decompressions increased from 10.7 to 36.2 and fusions increased from 2.5 to 4.4 per 100 000 people of the general Norwegian population. The proportion of fusion surgery decreased from 19.3% to 10.9%. Among individuals older than 65 years, the annual rate of surgery per 10000, including both decompressions and fusions, more than quadrupled from 40.2 to 170.3. The regional variation was modest, differing with a factor of 1.4 between the region with the highest and the lowest surgical rates. The mean length of hospital stay decreased from 11.0 (SD 8.0) days in 1999 to 5.0 (4.6) days in 2013, but patients who received fusion surgery stayed on average 3.6 days longer than those who received decompression only. Conclusions: The rate of LSS surgery more than tripled in Norway from 1999 to 2013. The mean length of hospital stay was reduced from 11 to 5 days. Conclusions: Level of Evidence: 4</p

Accumulation of health complaints is associated with persistent musculoskeletal pain two years later in adolescents: The Fit Futures Study

There is limited knowledge on the association between different health complaints and the development of persistent musculoskeletal pain in adolescents. The aims of this study were to assess whether specific health complaints, and an accumulation of health complaints, in the first year of upper-secondary school, were associated with persistent musculoskeletal pain 2 years later. We used data from a population-based cohort study (the Fit Futures Study in Norway), including 551 adolescents without persistent musculoskeletal pain at baseline. The outcome was persistent musculoskeletal pain (≥3 months) 2 years after inclusion. The following self-reported health complaints were investigated as individual exposures at baseline: asthma, allergic rhinitis, atopic eczema, headache, abdominal pain and psychological distress. We also investigated the association between the accumulated number of self-reported health complaints and persistent musculoskeletal pain 2 years later. Logistic regression analyses estimated adjusted odds ratios (ORs) with 95% confidence intervals (CIs). At the 2-year follow-up, 13.8% (95% CI [11.2–16.9]) reported persistent musculoskeletal pain. Baseline abdominal pain was associated with persistent musculoskeletal pain 2 years later (OR 2.33, 95% CI [1.29–4.19], p = 0.01). Our analyses showed no statistically significant associations between asthma, allergic rhinitis, atopic eczema, headache or psychological distress and persistent musculoskeletal pain at the 2-year follow-up. For the accumulated number of health complaints, a higher odds of persistent musculoskeletal pain at the 2-year follow-up was observed for each additional health complaint at baseline (OR 1.33, 95% CI [1.07–1.66], p = 0.01). Health care providers might need to take preventive actions in adolescents with abdominal pain and in adolescents with an accumulation of health complaints to prevent development of persistent musculoskeletal pain. The potential multimorbidity perspective of adolescent musculoskeletal pain is an important topic for future research to understand the underlying patterns of persistent pain conditions in adolescents