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Objective: Pain interference and pain behavior are highly relevant outcomes in patients with rheumatoid arthritis (RA). The Patient-Reported Outcomes Measurement Information System (PROMIS) is a universally applicable set of item banks measuring patient-reported health, and if applied as computerized adaptive tests (CATs), more efficiently and precisely than current instruments. The objective was to study the psychometric properties of the Dutch-Flemish PROMIS pain interference (PROMIS-PI) and the PROMIS pain behavior (PROMIS-PB) item banks in patients with RA., Methods: A total of 2,029 patients with RA completed the full PROMIS-PI (version 1.1, 40 items), and 1,554 patients completed the full PROMIS-PB (version 1.1, 39 items). The following psychometric properties were studied: unidimensionality, local dependence, monotonicity and graded response model (GRM) fit, cross-cultural validity (differential item functioning [DIF] for language [Dutch versus Flemish]), other forms of measurement invariance, construct validity, reliability, and floor and ceiling effects., Results: The PROMIS-PI and PROMIS-PB banks were sufficiently unidimensional (Omega-hierarchical [Omega-H] 0.99, 0.95, and explained common variance 0.95, 0.78, respectively), had negligible local dependence (0.3-1.4% of item pairs), good monotonicity (H 0.75, 0.46), and a good GRM model fit (no misfitting items). Furthermore, both item banks showed good cross-cultural validity (no DIF for language), measurement invariance (no DIF for age, sex, administration mode, and disease activity), good construct validity (all hypotheses met), high reliability (>0.90 in the range of patients with RA), and an absence of floor and ceiling effects (0% minimum or maximum score, respectively)., Conclusion: Both PROMIS-PI and PROMIS-PB banks showed good psychometric properties in patients with RA and can be used as CATs in research and clinical practice., (© 2019, American College of Rheumatology.)

Study Design: Prospective cohort study., Objective: To analyze responsiveness and minimal clinically important change (MCIC) of the US National Institutes of Health (NIH) minimal dataset for chronic low back pain (CLBP)., Summary of Background Data: The NIH minimal dataset is a 40-item questionnaire developed to increase use of standardized definitions and measures for CLBP. Longitudinal validity of the total minimal dataset and the subscale Impact Stratification are unknown., Methods: Total outcome scores on the NIH minimal dataset, Dutch Language Version, were calculated ranging from 0 to 100 points with higher scores representing worse functioning. Responsiveness and MCIC were determined with an anchor-based method, calculating the area under the receiver operating characteristics (ROC) curve (AUC) and by determining the optimal cut-off point. Smallest detectable change (SDC) was calculated as a parameter of measurement error., Results: In total 223 patients with CLBP were included. Mean total score on the NIH minimal dataset was 44 ± 14 points at baseline. The total outcome score was responsive to change with an AUC of 0.84. MCIC was 14 points with a sensitivity of 72% and specificity 82%, and SDC was 23 points. Mean total score on Impact Stratification (scale 8-50) was 34.4 ± 7.4 points at baseline, with an AUC of 0.91, an MCIC of 7.5 with a sensitivity 96% of and specificity of 78%, and an SDC of 14 points., Conclusion: The longitudinal validity of the NIH minimal dataset is adequate. An improvement of 14 points in total outcome score and 7.5 points in Impact Stratification can be interpreted as clinically important in individual patients. However, MCIC depends on baseline values and the method that is chosen to determine the optimal cut-off point. Furthermore, measurement error is larger than the MCIC. This means that individual change scores should be interpreted with caution., Level of Evidence: 2.

Background: The Single Assessment Numeric Evaluation Method (SANEM) is a holistic patient-reported outcome measure (PROM) that includes all aspects involving the shoulder. It is simple and easy to administer. It consists of only one question, namely how would you rate your shoulder today as a percentage of normal (0 to 100% with 100% being normal)? The purpose of this study was to translate the SANEM in Dutch and to assess its construct validity, reliability, and responsiveness., Methods: The SANEM was translated into Dutch using forward and backward translation. Hypothesis testing was used to determine construct validity and responsiveness, 75% needed to be confirmed. Previous validated PROMs were used as comparator instrument for testing construct validity. Test-retest reliability (2-week interval), Standard Error of Measurement, and Smallest Detectable Change were calculated as reliability analyses. One year after baseline, we evaluated the responsiveness., Results: One hundred seven patients (55% women) with a mean age of 54 years were included. Of the hypotheses formed in advance to assess construct validity, 67% was confirmed, meaning there was no adequate construct validity and the SANEM cannot replace all other PROMs. With an intraclass correlation coefficient of 0.95, excellent test-retest reliability was found. Of the hypotheses formed in advance to evaluate the responsiveness, 75% was confirmed, indicating the SANEM has good responsiveness., Conclusion: Although the SANEM cannot replace all other PROMs, it is a reliable instrument to assess if a patients' shoulder, regarding the whole shoulder, changes over time or stays unchanged., Level of Evidence: Level II.

Background: Fractures of the hand and wrist are one of the most common injuries seen in adults. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire has been developed as a patient-reported assessment of pain and disability to evaluate the outcome after hand and wrist injuries. Patient reported outcomes (PROs) can be interpreted as pain, function or patient satisfaction. To be able to interpret clinical relevance of a PRO, the structural validity and internal consistency is tested. The Dutch version of the DASH has not yet been validated. The aim of this study was to evaluate the structural validity and the internal consistency of the existing Dutch version of the DASH. The relevance of reporting subscale scores was investigated., Methods: This study was a retrospective analysis of cross-sectional data of 370 patients with an isolated hand or wrist injury. Adult patients aged 18 to 65 years treated conservatively or surgically were included. Patients unable to understand or read the Dutch language were excluded. Confirmatory factor analysis was used to investigate the structural validity, while Cronbach's alpha and coefficient omega were used to assess internal consistency., Results: All investigated models (a single factor model, a 3-correlated factor, and a bifactor model) were associated with a good model fit. Both the single factor and the 3-correlated factor model were associated with factor loadings of at least 0.70. In addition, the covariance between the factors in the 3-correlated factor model was positive (at least 0.89) and statistically significant (p < 0.001). In the bifactor model, the additional value of subscales was limited as the items loaded high on the general factor but low on the subscale factors., Conclusion: This study indicates that the Dutch version of the DASH should be considered as an unidimensional trait. A single score should be reported.

Objectives: Detection and measurement of pain in persons with dementia by using observational pain measurement tools is essential. However, the evidence for the psychometric properties of existing observational tools remains limited. Therefore, a new meta-tool has been developed: Pain Assessment in Impaired Cognition (PAIC), as a collaborative EU action. The aim is to describe the translation procedure and content validity of the Dutch version of the PAIC., Methods: Translation of the PAIC into Dutch followed the forward-backward approach of the Guidelines for Establishing Cultural Equivalence of Instruments. A questionnaire survey was administered to clinical nursing home experts (20 physicians and 20 nurses) to determine whether the PAIC items are indicative of pain and whether items are specific for pain or for other disorders (anxiety disorder, delirium, dementia, or depression). To quantify content validity, mean scores per item were calculated., Results: Eleven items were indicative of pain, for example, "frowning," "freezing," and "groaning." Fifteen items were considered to be pain-specific, for example, "frowning," "curling up," and "complaining." There were discrepancies between the notion of pain characteristics according to nurses and physicians, especially in the facial expressions domain., Discussion: Within the body movement domain, PAIC items correspond well with the clinical experience of the physicians and nurses. However, items in the facial expressions and vocalizations domains need further study with respect to item reduction. Also, differences were revealed in the notion of pain characteristics between physicians and nurses, suggesting the need for more interdisciplinary education on pain in dementia., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Study Design: Validation study with cross-sectional and longitudinal measurements., Objective: To translate the US National Institutes of Health (NIH)-minimal dataset for clinical research on chronic low back pain into the Dutch language and to test its validity and reliability among people with chronic low back pain., Summary of Background Data: The NIH developed a minimal dataset to encourage more complete and consistent reporting of clinical research and to be able to compare studies across countries in patients with low back pain. In the Netherlands, the NIH-minimal dataset has not been translated before and measurement properties are unknown., Methods: Cross-cultural validity was tested by a formal forward-backward translation. Structural validity was tested with exploratory factor analyses (comparative fit index, Tucker-Lewis index, and root mean square error of approximation). Hypothesis testing was performed to compare subscales of the NIH dataset with the Pain Disability Index and the EurQol-5D (Pearson correlation coefficients). Internal consistency was tested with Cronbach α and test-retest reliability at 2 weeks was calculated in a subsample of patients with Intraclass Correlation Coefficients and weighted Kappa (κω)., Results: In total, 452 patients were included of which 52 were included for the test-retest study., Validity: factor analysis for structural validity pointed into the direction of a seven-factor model (Cronbach α = 0.78). Factors and total score of the NIH-minimal dataset showed fair to good correlations with Pain Disability Index (r = 0.43-0.70) and EuroQol-5D (r = -0.41 to -0.64). Reliability: test-retest reliability per item showed substantial agreement (κω=0.65). Test-retest reliability per factor was moderate to good (Intraclass Correlation Coefficient = 0.71)., Conclusion: The Dutch language version measurement properties of the NIH-minimal were satisfactory., Level of Evidence: N/A.

Objective: The aim was to establish reference curves of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN), a widely used questionnaire assessing hand complaints., Methods: Analyses were performed in a population-based sample, The Netherlands Epidemiology of Obesity study (n = 6671, aged 45-65 years). Factors associated with AUSCAN scores were analysed with ordered logistic regression, because AUSCAN data were zero inflated, dividing AUSCAN into three categories (0 vs 1-5 vs >5). Age- and sex-specific reference curves for the AUSCAN (range 0-60; higher is worse) were developed using quantile regression in conjunction with fractional polynomials. Observed scores in relevant subgroups were compared with the reference curves., Results: The median age was 56 [interquartile range (IQR): 50-61] years; 56% were women and 12% had hand OA according to ACR criteria. AUSCAN scores were low (median 1; IQR: 0-4). Reference curves where higher for women, and increased moderately with age: 95% percentiles for AUSCAN in men and women were, respectively, 5.0 and 12.3 points for a 45-year-old, and 15.2 and 33.6 points for a 65-year-old individual. Additional associated factors included hand OA, inflammatory rheumatic diseases, FM, socio-economic status and BMI. Median AUSCAN pain subscale scores of women with hand OA lay between the 75th and 90th centiles of the general population., Conclusion: AUSCAN scores in the middle-aged Dutch population were low overall, and higher in women than in men. AUSCAN reference curves could serve as a benchmark in research and clinical practice settings. However, the AUSCAN does not measure hand complaints specific for hand OA., (© The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

The Nociception Coma Scale (NCS) is a pain observation tool, developed for patients with disorders of consciousness (DOC) due to acquired brain injury (ABI). The aim of this study was to assess the interrater reliability of the NCS and NCS-R among nurses for the assessment of pain in ABI patients with DOC. A secondary aim was further validation of both scales by assessing its discriminating abilities for the presence or absence of pain. Hospitalized patients with ABI (n = 10) were recorded on film during three conditions: baseline, after tactile stimulation, and after noxious stimulation. All stimulations were part of daily treatment for these patients. The 30 recordings were assessed with the NCS and NCS-R by 27 nurses from three university hospitals in the Netherlands. Each nurse viewed 9 to 12 recordings, totaling 270 assessments. Interrater reliability of the NCS/NCS-R items and total scores were estimated by intraclass correlations (ICC), which showed excellent and equal average measures reliability for the NCS and NCR-R total scores (ICC 0.95), and item scores (range 0.87-0.95). Secondary analysis was performed to assess differences in ICCs among nurses' education and experience and to assess the scales discriminating properties for the presence of pain. The NCS and NCS-R are valid and reproducible scales that can be used by nurses with an associate (of science) in nursing degree or baccalaureate (of science) in nursing degree. It seems that more experience with ABI patients is not a predictor for good agreement in the assessment of the NCS(-R)., (Copyright © 2014 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Quality of care gains transparency with the help of performance indicators. For Dutch nursing homes, the current set of performance indicators does not include pain. To determine the feasibility of pain assessment as performance indicator, information about pain prevalence and analgesic prescription in one nursing home was collected. Within the time span of 3 days, pain intensity was measured in 91% of the residents (201 out of 221), either with a numeric rating scale, a verbal rating scale, or the Rotterdam Elderly Pain Observation Scale (REPOS). Numerical rating was used for 72%, verbal rating for 3%, and REPOS observation for 25% of the residents. Pain was substantial in 65 residents (32%), who received the following analgesic prescription: World Health Organization (WHO) step 1, 45%; WHO step 3, 12%; and neuroactive agents, 5%. Thirty-eight percent of these residents were in pain and received no analgesics. Residents with substantial pain significantly more often received analgesics (p = .007). Results suggest that pain assessment is feasible in a nursing home and would stimulate staff attention to pain. Further investigation is necessary to find out if a pain algorithm is feasible and will lead to improved pain treatment., (Copyright © 2013 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to determine a cutoff score for the observational Pain Assessment in Advanced Dementia (PAINAD), to adequately assess pain in clinical nursing home practice and research., Design and Setting: We used data from multiple sources. We performed a literature review on PAINAD, performed secondary data analysis of a study examining psychometric properties of PAINAD in nursing home patients with dementia, and performed another study in nursing home patients with dementia specifically aimed at determining a cutoff score for PAINAD., Participants: Patients with dementia in long term care facilities., Measurements: We related PAINAD scores (range 0 to 10) to (1) self-reported and proxy-reported pain by global clinical judgment and (2) scores on another pain assessment instrument (DOLOPLUS-2), and (3) we compared scores between painful and supposedly less painful conditions., Results: Findings from this study showed that a cutoff value of 2 should serve as a trigger for a trial with pain treatment. Although the majority of patients scoring 1 or 0 were not in pain, pain could be ruled out., Conclusion: Based on the findings of multiple available data sources, we recommend that a PAINAD score of 2 or more can be used as an indicator of probable pain. A score of 1 is a sign to be attentive to possible pain. Future work may focus on cutoff scores for the presence of pain and severe pain in other frequently used pain tools, and on further development of methodology to assess cutoff scores., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: According to the Word Health Organization, patients who can benefit from palliative care should be identified earlier to enable proactive palliative care. Up to now, this is not common practice and has hardly been addressed in scientific literature. Still, palliative care is limited to the terminal phase and restricted to patients with cancer. Therefore, we trained general practitioners (GPs) in identifying palliative patients in an earlier phase of their disease trajectory and in delivering structured proactive palliative care. The aim of our study is to determine if this training, in combination with consulting an expert in palliative care regarding each palliative patient's tailored care plan, can improve different aspects of the quality of the remaining life of patients with severe chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure and cancer., Methods/design: A two-armed randomized controlled trial was performed. As outcome variables we studied: place of death, number of hospital admissions and number of GP out of hours contacts., Discussion: We expect that this study will increase the number of identified palliative care patients and improve different aspects of quality of palliative care. This is of importance to improve palliative care for patients with COPD, CHF and cancer and their informal caregivers, and to empower the GP. The study protocol is described and possible strengths and weaknesses and possible consequences have been outlined., Trial Registration: The Netherlands National Trial Register: NTR2815.

Background: In many countries, the need for physical therapists to use standardised measures has been recognised and is recommended in clinical practice guidelines. Research has shown a lack of clinimetric knowledge and clinical application of measurement instruments in daily practice may hamper implementation of these guidelines., Objectives: The aims of our study were a) to investigate the current use of measurement instruments by Dutch physical therapists; b) to investigate the facilitators and barriers in using measurement instruments., Methods: To get a complete and valid overview of relevant barriers and facilitators, different methods of data collection were used. We conducted a literature search, semi-structured interviews with 20 physical therapists and an online survey., Results: Facilitators are the fact that most therapists indicated a positive attitude and were convinced of the advantages of the use of measurement instruments. The most important barriers to the use of measurement instruments included physical therapists' competence and problems in changing behaviour, practice organisation (no room; no time) and the unavailability and feasibility of measurement instruments. Furthermore, physical therapists indicated the need to have a core set of measurement instruments with a short user's instruction on application, scoring and interpretation., Conclusions: The main barriers are on the level of the physical therapist (lack of knowledge; not focusing on the use of outcome measures) and organisation (lack of time; availability; lack of management support).There seems to be a disparity between what physical therapists say and what they do. The majority of participating physical therapists indicated a positive attitude and were convinced of the advantages of the use of measurement instruments. However, the main problem for physical therapists is when to use which instrument for what patient (lack of knowledge). Furthermore, physical therapists indicated a need to compile a core set of measurement instruments with instructions concerning application, scoring and interpretation. Based on the identified factors, a number of strategies will be developed and evaluated in future studies., (© 2011 Swinkels et al; licensee BioMed Central Ltd.)

Objectives: Traditionally, pain is divided into two main groups: nociceptive pain due to an excess of nociception and neuropathic pain associated with an injury or dysfunction of the central or peripheral nervous system. The French neuropathic pain group has developed a specific questionnaire, the DN4, to help clinicians in the differential diagnosis of neuropathic and non-neuropathic pain. In order to allow this questionnaire to be used in international studies, it has been translated and linguistically validated into Dutch, German, Greek and Hungarian, using a well-established procedure., Methods: The same method was used for each country and involved four stages: (1) two forward translations followed by comparison and reconciliation of the translations, (2) one backward translation, (3) review by an expert clinician, and (4) cognitive testing of the first seven items on patients., Results: The translation work produced three types of situations. Either the original wording could be translated literally or semantic issues were discussed as the original wording was not always sufficiently clear and had to be clarified by adding an explanation, or, in the case of idiomatic phrases such as "pins and needles", it was necessary to use different expressions, the challenge being to retain the original concept while doing so. The versions proposed to patients and experts were well understood., Conclusion: The DN4 items were linguistically validated in each of the target languages, thus providing the means for standardising the diagnosis of neuropathic pain and pooling the data collected during clinical research in the different countries involved.

Study Design: Cross-cultural adaptation of an outcome questionnaire., Objective: The aim of the study was to cross-culturally adapt the Neck Bournemouth Questionnaire (NBQ) for the Dutch language in a population of people with subacute and chronic whiplash associated disorders (WAD), and to assess its psychometric qualities., Summary of Background Data: The NBQ covers the salient dimensions of the biopsychosocial model of pain, and has been shown to be reliable, valid, and responsive to clinically significant change in patients with non specific neck pain. However, no Dutch validated version was available for patients with WAD at the time our study was initiated., Methods: The English version of the NBQ was translated into Dutch (NBQ-NL) and back-translated according to established guidelines. The internal consistency (with help of Cronbach's alpha), construct validity, and convergent validity were estimated in a different group of 92 patients. Agreement and correlation between the NBQ-NL scores and counterpart questionnaires (SF-36, Neck Disability Index, Hospital Anxiety and Depression Scale, the General Perceived Self-Efficacy and a numerical rating scale for perceived pain) were investigated, using Bland and Altman method and Spearman rank correlation coefficient. Subsequently, 34 patients with subacute WAD completed the questionnaire twice over 1 to 3 weeks, to assess its test-retest reliability., Results: Ninety-two patients, with subacute and chronic WAD, completed the study. Their mean age was 41 years (SD = 11). There were relative high mean scores on the Neck Disability Index (25.5; SD = 8.2), and the NBQ (43.9; SD = 14.8). The NBQ-NL was granted face-validity. Spearman rank correlation coefficient was 0.51 to 0.82 (except for General Perceived Self-Efficacy (0.21). The limits of agreement of normalized scores were relative variable, from small to wide. Cronbach's alpha (internal consistency) for the NBQ-NL whole scale was 0.87. The Intraclass correlation coefficient for the test-retest reliability was excellent (0.92) and the SEM was relatively low (3.7)., Conclusion: Overall, the rank correlation level in general was good, whereas the agreement between questionnaires outcome was variable, most of which seems to be attributable to absolute scale differences. The NBQ-NL is a useable patient-orientated tool for assessing disability in clinical studies and clinical diagnosis in Dutch speaking patients with WAD.

Aim. To compare pain reports of nursing home residents to ratings by proxies. Background. It is not easy to assess pain in cognitively impaired residents. For residents who are unable to report pain intensity themselves, proxies (i.e. relatives or caregivers) might serve as sources of information. The utility of these proxies in assessing residents' pain is not clear however. Design. A multicenter cross-sectional study. Methods. Pain intensity was rated on a Numeric Rating Scale; proxies were asked how certain they were about their observations. Agreements on ratings were computed by means of intra class correlation (ICC) coefficients for continuous variables and multiple linear regression analyses were performed with the level of pain intensity by proxies as the dependent variable. Results. The sample consisted of 174 residents (median age 82 years), of whom 124 were cognitively impaired and 50 intact, and 293 proxies: 171 caregivers and 122 relatives. All three parties reported median pain intensity during the preceding week as 6.0. Data were consistent with low-to-moderate correlation coefficients between residents and caregivers (ICC = -0.12 to 0.25), residents and relatives (ICC = -0.51 to 0.48) and caregivers and relatives (ICC = 0.03 to 0.31). Residents themselves judged pain intensity at rest significantly higher than did proxies (p = 0.05). Caregivers scored significantly higher ratings for residents on analgesics (p = 0.001) and significantly lower pain ratings if they were more satisfied with the prescribed analgesics (p = 0.01). Conclusions. Proxy report of relatives and caregivers on presence and intensity of pain is unreliable, especially for cognitively impaired persons. The use of a standardised pain observation scale could be helpful. Relevance to clinical practice. Pain management in nursing home residents could be improved by educating caregivers about assessment and treatment of chronic pain. Relatives should be informed about chronic pain and learn how to alleviate pain through non-pharmacological interventions.

Study Design: Literature review, expert panel, and a workshop during the "VIII International Forum on Primary Care Research on Low Back Pain" (Amsterdam, June 2006)., Objective: To develop practical guidance regarding the minimal important change (MIC) on frequently used measures of pain and functional status for low back pain., Summary of Background Data: Empirical studies have tried to determine meaningful changes for back pain, using different methodologies. This has led to confusion about what change is clinically important for commonly used back pain outcome measures., Methods: This study covered the Visual Analogue Scale (0-100) and the Numerical Rating Scale (0-10) for pain and for function, the Roland Disability Questionnaire (0-24), the Oswestry Disability Index (0-100), and the Quebec Back Pain Disability Questionnaire (0-100). The literature was reviewed for empirical evidence. Additionally, experts and participants of the VIII International Forum on Primary Care Research on Low Back Pain were consulted to develop international consensus on clinical interpretation., Results: There was wide variation in study design and the methods used to estimate MICs, and in values found for MIC, where MIC is the improvement in clinical status of an individual patient. However, after discussion among experts and workshop participants a reasonable consensus was achieved. Proposed MIC values are: 15 for the Visual Analogue Scale, 2 for the Numerical Rating Scale, 5 for the Roland Disability Questionnaire, 10 for the Oswestry Disability Index, and 20 for the QBDQ. When the baseline score is taken into account, a 30% improvement was considered a useful threshold for identifying clinically meaningful improvement on each of these measures., Conclusion: For a range of commonly used back pain outcome measures, a 30% change from baseline may be considered clinically meaningful improvement when comparing before and after measures for individual patients. It is hoped that these proposals facilitate the use of these measures in clinical practice and the comparability of future studies. The proposed MIC values are not the final answer but offer a common starting point for future research.

Background: The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms, such as pain-avoidance and pain-persistence patterns, has been proposed to underlie varying treatment outcomes in patients with fibromyalgia (FM)., Purpose: To investigate the validity of a screening instrument to discriminate between pain-persistence and pain-avoidance patterns in FM., Method: In a three-part study, a self-reported screening instrument that assesses pain-avoidance behavior was used to distinguish patients with pain-persistence and pain-avoidance patterns. The resultant groups were compared with regard to several pain-related cognitive-behavioral factors, performance on a physical fitness test, and with regard to the judgments of trained therapists based on a semi-structured interview., Results: The validity of the screening instrument to distinguish between pain-avoidance and pain-persistence patterns was supported by other validated self-report questionnaires for pain-related cognitive-behavioral factors, physical exercise tests, as well as by a high correspondence with blinded therapist judgment after intake assessments., Conclusion: These findings suggest that a short self-report screening instrument can be used to distinguish between pain-avoidance and pain-persistence patterns within the heterogeneous population of FM patients, which offers promising possibilities to improve treatment efficacy by tailoring treatment to specific patient patterns.

Background: Several instruments can be used to identify patients with an unfavourable course of low back pain in general practice. However, it is unclear which instrument is the predictor of outcome., Aim: To compare the predictive performance (that is, calibration and discrimination) of risk estimation by GPs with assessments using the Orebro Musculoskeletal Pain Screening Questionnaire, the Low Back Pain Perception Scale (LBPPS), and a prediction rule developed for this purpose., Design of Study: A prospective cohort study with 1-year follow-up., Setting: General practice in The Netherlands., Method: The outcome 'unfavourable course of low back pain' was defined as having no clinically important improvement at minimally 50% of the measurements at 6, 13, 26, and 52 weeks. Logistic regression analyses were used to study associations between potential predictors and outcome., Results: In total, 60 GPs recruited 314 patients to the study (16 patients were excluded from analysis due to missing data on the course of low back pain). Over a third of patients (112/298) showed an unfavourable course of low back pain on follow-up. Risk estimation by GPs, the Orebro questionnaire, the LBPPS, and the prediction rule had discriminative ability (area under the curve) of 0.59 (95% CI [confidence intervals] = 0.52 to 0.66); 0.61 (95% CI = 0.54 to 0.67); 0.59 (95% CI = 0.52 to 0.66); and 0.75 (95% CI = 0.69 to 0.81) respectively. The prediction rule included history of low back pain, self-perceived risk to develop chronic low back pain, no solicitous responses of the patient's partner (as reported by the patient), frequent walking at work, and 'pain catastrophising'., Conclusion: Although the prediction rule performed best with regard to calibration and discrimination, it needs to be externally validated. Risk estimation by GPs performs as well as other instruments and, at present, seems to be the best available option.

Purpose: To compare the validity, reliability and responsiveness of a single, global quality of life question to multi-item scales., Method: Data were obtained from 83 consecutive patients with oesophageal adenocarcinoma undergoing either transhiatal or transthoracic oesophagectomy. Quality of life was measured at baseline, 5 weeks, 3 and 12 months post-operatively with a single-item Visual Analogue Scale (VAS) ranging from 0 to 100, the multi-item Medical Outcomes Study Short Form-20 (MOS SF-20) and Rotterdam Symptom Check-List (RSCL). Convergent and discriminant validity, test-retest reliability and both distribution-based and anchor-based responsiveness were evaluated., Major Findings: At baseline and at 5 weeks, the VAS showed high correlations with the MOS SF-20 health perceptions scale (r = 0.70 and 0.72) and moderate to high correlations with all other subscales of the MOS SF-20 and RSCL (r = 0.29-0.70). The test-retest reliability intra-class correlation for the VAS was 0.87. At 5 weeks post-operatively, the distribution-based responsiveness was moderate for the VAS (standardised response mean: -0.47; effect size: -0.56), high for the physical subscales of the MOS SF-20 and RSCL (-1.08 to -1.51) and low for the psychological subscales (0.11 to -0.25). Five weeks post-operatively, anchor-based responsiveness was highest for the VAS (r = 0.54)., Conclusion: The VAS is an instrument with good validity, excellent reliability, moderate distribution-based responsiveness and good anchor-based responsiveness compared to multi-item questionnaires. Its use is recommended in clinical trials to assess global quality of life.

To establish the generalizability (external validity) of the Health Utilities Index Mark 3 (HUI3) as a single-summary score generic outcome measure in numerous countries/subgroups (including children), repeated studies of community preferences should be performed in various settings. In performing multiple HUI3 studies, a mailed questionnaire approach, if feasible and reliable, might be substituted for oral interviews. In the present study, we assessed the feasibility and reliability of a mailed questionnaire approach originally developed for the EQ-5D, for the purpose of collecting Visual Analogue Scale (VAS) valuations from parents as surrogate responders for 65 pediatric HUI3 health states and for the state of being dead. Untransformed mean VAS scores of the health states and scores converted into preliminary Standard Gamble (SG)-utilities were compared with Canadian and French multiattribute utility estimates. A random sample of 1920 parents of schoolchildren (aged 4 to 13) received a mailed questionnaire. Each parent was asked to rate 6 HUI3 health states on a 0 to 100 VAS. Response was 70%. Mean completion time was 20 minutes (SD 9). The questionnaire was rated difficult by only 9%. The current format was, however, inappropriate for valuing the state of being dead. Interrater reliability of health state valuations was.87. Spearman's rank correlations, Pearson-R correlations and intra class correlation coefficients (ICCs) between untransformed VAS valuations and Canadian/French utility estimates were > or =.87. However, preliminary SG-utilities showed diminished ICCs (.71 to.72). The data support the feasibility and reliability of mailed HUI3 valuation questionnaires to a considerable extent, but further methodological studies regarding other formats and different populations are recommended.

The Discomfort Scale--Dementia of Alzheimer Type (DS-DAT) measures discomfort in severely demented patients with scores on nine items with behavioral descriptors. Direct observation of behaviour is the preferred method in severely demented patients, but is not feasible for some types of research. Alternatively, a patient's score may be assessed 'retrospectively', scoring an overall picture of the patient. To assess validity and reliability of such retrospective assessments, five observers--three nursing home physicians and two paramedicals--gave a DS-DAT score for 77 nursing home patients by direct observation, and, two weeks later, retrospectively. The mean score of the five observers was not different. The Intra-class Correlation Coefficient for intra-observer reliability was 0.50 for the five observers, and 0.55 for the three nursing home physicians. Our study demonstrated the possibility of a reasonably valid, but moderately reliable retrospective assessment of the Dutch version of the DS-DAT. Appropriate training of nursing home physicians who know their patients well may be required for this.

The role of the observer in the reliability of the Dutch Discomfort Scale-Dementia of Alzheimer Type (DS-DAT). The Discomfort Scale of Dementia of the Alzheimer Type (DS-DAT) is an instrument to assess discomfort in severely demented patients. No data on the reliability of assessment using a Dutch translation were available. In this paper, we analyse the role of the observer in the reliability of rating. This is of importance for studies in which many physicians perform multiple assessments. Twenty-eight nursing home physicians in training rated the DS-DAT in five nursing home patients with dementia presented on videotape. This was repeated after five months. All the physicians were previously trained in the use of the instrument. The results were statistically analysed using random effects analysis of variance. The Intra-class Correlation Coefficient (ICC) was 0.74 for inter-observer reliability and 0.97 for intra-observer reliability. Variance between subsequent assessments was small, but physicians appeared to differ somewhat among themselves in the way they rated the videotaped patients. A future complete reliability assessment of rating the DS-DAT in clinical practice would involve patient variation as well, scoring patients in clinical practice.

Objectives: To study the validity and nature of self-assessed symptoms among patients with fibromyalgia syndrome (FMS) and to compare our data with findings reported in the US. To determine whether tender point scores correlate with self-reported pain and other symptoms and to study the influence of disease duration., Methods: Tender point scores were assessed in 113 consecutive patients with FMS. All patients completed 2 self-assessment questionnaires (an extended Campbell list, the Enschede Fibromyalgia Questionnaire, and the Dutch Arthritis Impact Measurement Scales)., Results: The self-assessed symptoms of the Dutch FMS patients seem to be valid and are comparable with those of American patients. No association between disease duration and number of self-reported symptoms was found. An association between self-reported pain and mean tender point score was lacking for patients with disease of shorter duration and was weak for patients with disease of longer duration., Conclusions: The use of a self-report questionnaire for patients with FMS is feasible and appears to be valid. Tender point scores and self-reported pain represent very different aspects of pain in FMS.