Reliability and validity of self-reported questionnaires to measure pain and disability in adults with neck pain and its associated disorders: part 3—a systematic review from the CADRE Collaboration

Abstract

Purpose

To determine the reliability and validity of self-reported questionnaires to measure pain and disability in adults with grades I–IV neck pain and its associated disorders (NAD).

Methods

We updated the systematic review of the 2000–2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and systematically searched databases from 2005 to 2017. Independent reviewers screened and critically appraised studies using standardized tools. Evidence from low-risk-of-bias studies was synthesized according to best evidence synthesis principles. Validity studies were ranked according to the Sackett and Haynes classification.

Results

We screened 2823 articles, and 26 were eligible for critical appraisal; 18 were low risk of bias. Preliminary evidence suggests that the Neck Disability Index (original and short versions), Whiplash Disability Questionnaire, Neck Pain Driving Index, and ProFitMap-Neck may be valid and reliable to measure disability in patients with NAD. We found preliminary evidence for the validity and reliability of pain measurements including the Body Pain Diagram, Visual Analogue Scale, the Numeric Rating Scale and the Pain-DETECT Questionnaire.

Conclusion

The evidence supporting the validity and reliability of instruments used to measure pain and disability is preliminary. Further validity studies are needed to confirm the clinical utility of self-reported questionnaires to assess pain and disability in patients with NAD.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

Appendices

Appendix 1: Definition of neck pain and associated disorders

Neck pain is pain located in the anatomic region of the neck outlined in Fig. 2 [8]

Fig. 2

The anatomic region on the neck from the back (a) and the side (b) as defined by the Bone and joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders

NAD includes non-traumatic neck pain and neck pain subsequent to a traffic collision (whiplash), with or without its associated disorders, which include arm pain radiating from the neck and upper thoracic pain, and/or headache, and/or temporomandibular joint pain where they are associated with neck pain.

According to the Neck Pain Task Force [8], NAD is classified into four grades:

• Grade I Pain related to low levels of disability and no or minor interference with activities of daily living. No signs or symptoms suggestive of major structural.

• Grade II Pain associated with high level of disability and major interference with activities of daily living. No signs or symptoms of major structural pathology.

• Grade III No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness, and/or sensory deficits.

• Grade IV Pain associated with signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or systemic disease; requires prompt investigation and treatment.

The Québec Task Force Classification of Grades of Whiplash-associated Disorders [9].

• 1. Grade I WAD Neck pain and associated symptoms in the absence of objective physical signs.

• 2. Grade II WAD Neck pain and associated symptoms in the presence of objective physical signs and without evidence of neurological involvement.

• 3. Grade III WAD Neck pain and associated symptoms with evidence of neurological involvement including decreased or absent reflexes, decreased or limited sensation, or muscular weakness.

• 4. Grade IV WAD Neck pain and associated symptoms accompanied by fracture and dislocation.

Appendix 2: Medline search strategy

• 1. MH “Reproducibility of Results+”

• 2. MH “Sensitivity and Specificity”

• 3. MH “Predictive Value of Tests”

• 4. reproducibility

• 5. sensitiv*

• 6. specificity

• 7. predict* n2 value*

• 8. reliab*

• 9. valid*

• 10. false positiv*

• 11. false negativ*

• 12. accura*

• 13. roc curve* or received operating characteristic*

• 14. kappa coefficient* or kappa co-efficient*

• 15. MH “Observer Variation”

• 16. intra-rater* or inter-rater* or interrrater* or intrarater* or rater* or intra-examiner* or inter-examiner* or intraexaminer* or interexaminer* or inter-observ* or intra-observ* or interobserv* or intraobserv*

• 17. utility n2 test*

• 18. likelihood ratio*

• 19. likelihood function*

• 20. MH “Odds Ratio”

• 21. odds ratio*

• 22. MH “Likelihood Functions”

• 23. MH “ROC Curve”

• 24. test–retest* or test* n2 re-test*

• 25. responsive*

• 26. MH “Diagnosis”

• 27. MH “Diagnostic Techniques and Procedures”

• 28. MH “Diagnostic Self Evaluation”

• 29. diagnos* n2 (neck* or cervical* or technique* or procedur* or evaluat*)

• 30. assess* n2 (neck* or cervical*)

• 31. evaluat* n2 (neck* or cervical*)

• 32. exam* n2 (neck* or cervical*)

• 33. procedure* n2 (neck* or cervical*)

• 34. screen* n2 (neck* or cervical*)

• 35. or/1-34

• 36. MH “Neck Pain”

• 37. MH “Neck Injuries+”

• 38. MH “Whiplash Injuries”

• 39. MH “Radiculopathy”

• 40. MH “Brachial Plexus Neuropathies”

• 41. MH “Torticollis”

• 42. MH “Neck Muscles”

• 43. MH “Cervical Vertebrae + ”

• 44. MH “Cervical Cord”

• 45. neck-pain* or “neck pain” or neck pain* or pain* n2 neck*

• 46. neck/shoulder pain*

• 47. neck* n2 injur*

• 48. whiplash*

• 49. (radiculopath* or radiating or radicular*) n2 cervical*

• 50. (radiculopath* or radiating or radicular*) n2 neck*

• 51. brachial plexus n2 neuropath*

• 52. torticollis*

• 53. cervical* n2 headache*

• 54. cervical* n2 pain*

• 55. neck* n2 ache* or neckache*

• 56. cervicalg*

• 57. cervicodyn*

• 58. neck* n2 (sprain* or strain*)

• 59. neck* n2 muscle*

• 60. (neck or cervical) n2 vertebr*

• 61. cervical axis

• 62. cervical cord

• 63. cervical disc n2 herniat* or cervical disk* n2 herniat* or (herniated dis* n2 neck*) or (herniated dis* n2 cervical*) or (disk herniat* n2 neck*) or (disc herniat* n2 cervical*) cervical disc herniation or cervical disk herniation

• 64. cervical* n2 stenos*

• 65. cervical* n2 spine*

• 66. cervical* n2 muscle*

• 67. cervical plexus*

• 68. cervical* n2 (sprain* or strain*)

• 69. cervical* n2 (sore* or discomfort* or dysfunction*) or neck* n2 (sore* or discomfort* or dysfunction*)

• 70. or/36–69

• 71. MH Self-report

• 72. MH Surveys and Questionnaires

• 73. MH Pain Measurement

• 74. MH Outcome Assessment (Health Care)

• 75. MH Patient Outcome Assessment

• 76. MH Symptom Assessment

• 77. Questionnaire*

• 78. Pain measurement*

• 79. Symptom assessment*

• 80. Outcome assessment*

• 81. Outcome measure*

• 82. Self-report*

• 83. Patient-report*

• 84. PROM

• 85. Self-administer*

• 86. Self-assess*

• 87. Self-complete*

• 88. Self-evaluat*

• 89. Instrument* n2 rating

• 90. pain n2 (diagram* or drawing*)

• 91. body n2 (diagram* or drawing*)

• 92. Score* n2 (pain* or outcome* or NDI or SF-12 or SF-36)

• 93. Scale*

• 94. Survey*

• 95. Aberdeen Spine Pain Scale*

• 96. Total Disability Index*

• 97. Bournemouth Questionnaire*

• 98. Cervical Spine Outcome Questionnaire*

• 99. Short Form-36 or Short Form-12 or sf-36 or sf-12

• 100. Core Outcome Measures Index*

• 101. Current Perceived Health-42

• 102. Neck Disability Index*

• 103. Problem Elicitation Technique*

• 104. Sickness Impact Profile*

• 105. Visual Analog Scale* or Visual Analogue Scale*

• 106. Whiplash Disability Questionnaire*

• 107. Quality-of-Life

• 108. Copenhagen Neck*

• 109. Global Assessment of Neck Pain

• 110. (Neck Pain*) n2 “Disability Scale”

• 111. Northwick Park Neck*

• 112. Numeric Rating Scale*

• 113. Patient-Specific Functional Scale*

• 114. Neck Functional Status Questionnaire

• 115. (Global Rating*) n2 “Change Scale”

• 116. Tampa Scale n2 Kinesiophobia

• 117. Functional Rating Index*

• 118. Health Assessment Questionnaire*

• 119. Wong-Baker FACES*

• 120. Or/71-120

• 121. 35 AND 70 AND 120

• 122. Limits ENGLISH, FRENCH

• 123. Limits Jan 2000-current date

Appendix 3: Validity studies classification [18]

This classification system is useful to determine the level of scrutiny to which a test has been subjected and determine its clinical utility. Diagnostic studies are classified into four phases based on the type of research question: (1) Phase I: Do test results in patients with the target disorder differ from those in normal people?; (2) Phase II: Are patients with certain test results more likely to have the target disorder than patients with other test results?; (3) Phase III: Does the test result distinguish patients with and without the target disorder among patients in whom it is clinically reasonable to suspect that the disease is present?; (4) Phase IV: Do patients who undergo this diagnostic test fare better (in their health outcomes) than similar patients who are not tested? Phase I or II studies of novel tests provide preliminary evidence of clinical utility, whereas phase III or IV studies are needed to inform the validity and utility of a test in clinical practice [18].

Appendix 4: Glossary for all the questionnaires included in our low-risk-of-bias articles

Body Pain Diagram

The Body Pain Diagram consists of an outline of the entire body from anterior and posterior views. As recommended by Margolis et al. [55], an overlay was created dividing the Body Pain Diagram into 45 anatomical regions. An electronic overlay was used to score the electronic diagrams on a desktop computer. An identical overlay (converted to a transparency) was used to score the paper diagrams. The overlay was placed over the Body Pain Diagram, and the examiner recorded a score of 1 if pain was indicated and 0 if no pain was indicated in each of the 45 regions. Pain was considered present if any portion of the region was shaded, no matter how small. Marks outside the body and marks directing the examiners’ attention to severity of the pain rather than intensity were not counted. Circled areas were treated as though the entire circle was shaded [29].

Disabilities of Arm, Shoulder and Hand (DASH) or simplified version Quick DASH

Self-reported questionnaire conceptualizes the upper limb as a single functional unit. The DASH consists of one 30-item module assessing upper limb function and symptoms and two optional 4-item modules evaluating symptoms and function related to work and recreational activities. A 5-point Likert scale is used to score each item, which is totalled, divided by the number of responses, subtracted by one and multiplied by 25 to provide a score out of 100 (most severe disability) [56]. The Quick DASH consists of 11 items derived from the DASH [31].

Neck Disability Index (NDI)

Self-reported questionnaire assesses symptom severity and disability due to neck pain. It includes 10 items individually quoted from 0 (no disability) to 5 (maximal disability) for a total score of 50. Patients with higher scores have higher disability [57].

Neck Pain Driving Index (NPDI)

Self-reported questionnaire includes 12 driving tasks to assess the degree of perceived driving difficulty in the chronic whiplash population. Questions could have the following answers: no difficulty (score = 0), slight difficulty (score = 1), moderate difficulty (score = 2) and great difficulty (score = 4). The total score is then translated in percentages. Higher percentages represent a higher limitation to drive [25].

Numerical Pain Rating Scale (NPRS)

Verbal scale from 0 (no pain) to 10 (maximal pain) assesses pain intensity [58].

Pain-DETECT Questionnaire (PD-Q)

Self-report tool consists of seven weighted sensory descriptor items, plus one item related to temporal pain characteristics and one item related to spatial pain characteristics [59].

Profile fitness mapping neck pain

The symptom scale consists of two indices of separate aspects of symptomatology, the intensity and the frequency of the symptoms, and the functional limitation scale yields one function index. Each scale had 6 levels: (1) from 1 (never or rarely) to 6 (very often, always) for pain frequency; (2) from 7 (no pain) to 12 (maximal pain) for pain intensity; (3) from 13 (no limitation) to 18 (very difficult, impossible) for activity limitations [23].

Patient-Specific Functional Scale (PSFS)

A functional outcome scale requires patients to list three activities that are difficult to perform as a result of their symptoms, injury, or disorder. The patient rates each activity on a 0–10 scale, with 0 representing the inability to perform the activity and 10 representing the ability to perform the activity, and they could before the onset of symptoms. The final score is determined by averaging the three activity scores. Higher scores represent a greater level of function [36].

Visual Analogue Scale (VAS)

It measures pain intensity with a visual scale from 0 (no pain) to 10 (maximal pain) [60].

Whiplash Disability Questionnaire (WDQ)

Thirteen items measure the effect of whiplash. Each item is scored on a numerical scale from 0 (no impact) to 10 (greatest impact). The responses are summed from 0 (no disability) to 130 (complete disability) [34]. As recommended by developers, missing item values were considered zeros in the summation to obtain a total WDQ score [61].