External validation and updating of prognostic models for predicting recovery of disability in people with (sub)acute neck pain was successful: broad external validation in a new prospective cohort.

QUESTION: Can existing post-treatment prognostic models for predicting neck pain recovery (primarily in terms of disability and secondarily in terms of pain intensity and perceived improvement) be externally validated and updated at the end of the treatment period and at 6 and 12 weeks of follow-up in a new Dutch cohort of people with neck pain treated with guideline-based usual care physiotherapy? DESIGN: External validation and model updating in a new prospective cohort of three previously developed prognostic models. PARTICIPANTS: People with (sub)acute neck pain and registered for primary care physiotherapy treatment. OUTCOME MEASURES: Recovery of disability, pain intensity, and perceived recovery at 6 and 12 weeks and at the end of the treatment period. RESULTS: Discriminative performance (c-statistic) of the disability model at 6 weeks was 0.73 (95% CI 0.69 to 0.77) and reasonably well calibrated after intercept recalibration. The disability model at 12 weeks and at the end of the treatment period showed discriminative c-statistic performance values of 0.69 (95% CI 0.64 to 0.73) and 0.68 (95% CI 0.63 to 0.72), respectively, and was well calibrated. Pain models and perceived recovery models did not reach acceptable performance. Cervical mobility added value to the disability models and pain catastrophising to the disability and pain models at 6 weeks. DISCUSSION: Broad external validation of the disability model was successful in people with (sub)acute neck pain and clinicians may use this model in clinical practice with reasonable accuracy. Further research is required to assess the disability model's clinical impact and generalisability, and to identify additional valuable model predictors. REGISTRATION: https://osf.io/a6r3k/.

Development and internal validation of prognostic models for recovery in patients with non-specific neck pain presenting in primary care.

OBJECTIVES: Development and internal validation of prognostic models for post-treatment and 1-year recovery in patients with neck pain in primary care. DESIGN: Prospective cohort study. SETTING: Primary care manual therapy practices. PARTICIPANTS: Patients with non-specific neck pain of any duration (n=1193). INTERVENTION: Usual care manual therapy. OUTCOME MEASURES: Recovery defined in terms of pain intensity, disability, and global perceived improvement directly post-treatment and at 1-year follow-up. RESULTS: All post-treatment models exhibited acceptable discriminative performance after derivation (AUC≥0.7). The developed post-treatment disability model exhibited the best overall performance (R2=0.24; IQR, 0.22-0.26), discrimination (AUC=0.75; 95% CI, 0.63-0.84), and calibration (slope 0.92; IQR, 0.91-0.93). After internal validation and penalization, this model retained acceptable discriminative performance (AUC=0.74). The five other models, including those predicting 1-year recovery, did not reach acceptable discriminative performance after internal validation. Baseline pain duration, disability, and pain intensity were consistent predictors across models. CONCLUSION: A post-treatment prognostic model for disability was successfully developed and internally validated. This model has potential to inform primary care clinicians about a patient's individual prognosis after treatment, but external validation is required before clinical use can be recommended.

External validation of prognostic models for recovery in patients with neck pain.

BACKGROUND: Neck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice. OBJECTIVE: The purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care. METHODS: This validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models' discrimination and calibration were evaluated. RESULTS: The Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available. CONCLUSIONS: External validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.

Challenges and solutions in prognostic prediction models in spinal disorders.

Methodological shortcomings in prognostic modeling for patients with spinal disorders are highly common. This general commentary discusses methodological challenges related to the specific nature of this field. Five specific methodological challenges in prognostic modeling for patients with spinal disorders are presented with their potential solutions, as related to the choice of study participants, purpose of studies, limitations in measurements of outcomes and predictors, complexity of recovery predictions, and confusion of prognosis and treatment response. Large studies specifically designed for prognostic model research are needed, using standard baseline measurement sets, clearly describing participants' recruitment and accounting and correcting for measurement limitations.

Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review.

QUESTION: Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care? DESIGN: Systematic review of studies evaluating multivariable prognostic models. PARTICIPANTS: People with non-specific neck pain presenting at primary care. DETERMINANTS: Baseline characteristics of the participants. OUTCOME MEASURES: Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up. RESULTS: Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models. CONCLUSION: Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated. REGISTRATION: PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16-23].