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Evidence-based chiropractic and documentation. Good clinical documentation . A record of a patient’s subjective complaints, objective findings, assessment, and plan for case management Should represent the thought processes involved in patient care Provides evidence of the patient’s progress.

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good clinical documentation
Good clinical documentation
  • A record of a patient’s subjective complaints, objective findings, assessment, and plan for case management
  • Should represent the thought processes involved in patient care
  • Provides evidence of the patient’s progress

Evidence-based Chiropractic

good clinical documentation cont
Good clinical documentation (cont.)
  • Practitioners are able to monitor patient progress accurately using good clinical documentation
    • Facilitates making the best possible clinical decisions
  • May alleviate problems associated with third party record reviews and medicolegal issues

Evidence-based Chiropractic

the value of valid reliable outcome measures oms
The value of valid & reliable outcome measures (OMs)
  • Beneficial to
    • Patients, because they are more likely to receive appropriate care
    • Practitioners, who use the information to formulate diagnoses and plan care
    • Third-party payers and patients, who will be more likely to receive legitimate services in return for monetary expenditures

Evidence-based Chiropractic

utility of oms
Utility of OMs
  • The utility of a test refers to its usefulness in meeting the needs of the patient, referrer, and payer
  • An OM should be sensitive to change
    • It should change in direct association with actual changes that occur in the patient characteristic being measured
    • Responsiveness

Evidence-based Chiropractic

clinical practice guidelines
Clinical practice guidelines
  • Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances
    • Developed by experts in a field using an organized process
    • Evidence is assembled on the management of the kinds of conditions handled by practitioners

Evidence-based Chiropractic

clinical practice guidelines development
Clinical practice guidelines development
  • Best evidence is located to give clinicians tools to provide optimal patient care
  • Steps in guidelines development
      • The subject area of the guideline is identified
      • Guideline development groups are assembled
      • Evidence is obtained and assessed
      • Evidence is shaped into a clinical guideline
      • The guideline is reviewed externally

Evidence-based Chiropractic

consensus opinions
Consensus opinions
  • Expert opinions are sought when there is little or no scientific evidence available
  • One must consider that they are merely the opinions of a panel of experts
  • The Delphi method
    • A method often used in guidelines development to establish a group position
    • Involves serial input from a group of panel members via questionnaires

Evidence-based Chiropractic

guidelines development cont
Guidelines development (cont.)

Evidence-based Chiropractic

guidelines differ in quality
Guidelines differ in quality
  • Quality depends on the rigor of the methods used in their development
    • e.g., the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy guidelines)
  • Evidence-based guidelines
    • Follow a rigorous development process
    • Are based on the highest quality scientific evidence

Evidence-based Chiropractic

guidelines may have disadvantages
Guidelines may have disadvantages
  • Evidence on a condition or treatment may be unavailable or of low-quality
    • In which case guidelines may only serve to inform clinicians about the lack of evidence
  • Guidelines only address one condition at a time
    • However, in practice patients often present with several complaints

Evidence-based Chiropractic

guidelines disadvantages cont
Guidelines - disadvantages (cont.)
  • Recommended treatment options may not always be appropriate
    • Each patient is unique
    • There may be contraindications to treatment
    • Patient preferences must be considered
  • Consequently, guidelines should never be utilized as a treatment “cookbook”

Evidence-based Chiropractic

guidelines disadvantages cont13
Guidelines - disadvantages (cont.)
  • Guidelines should be updated periodically to incorporate new information
    • Although the time-frame for updates is variable
    • Depends on how rapidly change occurs in a topic or field
  • The Mercy guidelines mentioned that they should be updated, but never were

Evidence-based Chiropractic

assessing the validity of guidelines
Assessing the validity of guidelines
  • Were good development methods used?
    • Methods should be thoroughly described
    • Rigorous systematic methods of evidence selection and appraisal should be used
  • Will the recommendations facilitate the care of your patients?
    • Should be applicable to the chiropractic setting and to chiropractic patients

Evidence-based Chiropractic

assessing the validity of guidelines cont
Assessing the validity of guidelines (cont.)
  • Are the patient populations from the source articles similar to your patients?
    • For instance, disease prevalence or risk factors may be different
  • Keep in mind that guidelines are not prescriptive statements
    • They are designed to provide assistance and direction to patient care

Evidence-based Chiropractic

best practices
Best practices
  • The organizational use of evidence to improve practice
  • Definition
    • Activities, disciplines and methods that are available to identify, implement and monitor the available evidence in health care
  • Sometimes confused with clinical guidelines, but they are actually different

Evidence-based Chiropractic

oms commonly used in chiropractic
OMs commonly used in chiropractic
  • The choice of OMs depends on
    • Objectives for the patient or requirements of the party or stakeholder who will receive the information
      • OMs useful to clinicians and patients involve measures such as pain and function
      • Payers are interested in cost-efficient patient management and patient satisfaction
      • Employers may be interested in seeing their injured employees return to work ASAP

Evidence-based Chiropractic

health related quality of life hrql measures
Health-related quality of life (HRQL) measures
  • Questionnaires that are designed to assess the physical, psychological, emotional, and social well-being of patients
  • Reported from the patient’s perspective
    • Criticized as being subjective and unreliable
    • However, HRQL measures are typically more reliable than “objective” OMs

Evidence-based Chiropractic

hrql measures cont
HRQL measures (cont.)
  • Findings are meaningful to patients
  • HRQL measures are helpful in the assessment of patients’ functional limitations
  • They are appropriate and useful in monitoring the effects of treatment

Evidence-based Chiropractic

two general categories of hrql measures
Two general categories of HRQL measures
  • Generic instruments
    • Designed to evaluate patients’ overall health status
    • e.g., the SF-36 health survey and the Sickness Impact Profile
  • Specific instruments
    • Designed to assess specific conditions, patient groups, or areas of function
    • e.g., the Neck Disability Index

Evidence-based Chiropractic

general categories of hrql measures cont
General categories of HRQL measures (cont.)
  • Condition-specific instruments have advantages over generic
    • They evaluate elements of function that are relevant to the specific condition under consideration
    • As a result, they are generally more responsive to changes in patients’ primary conditions

Evidence-based Chiropractic

measures of pain
Measures of pain
  • Measures of pain and function are the most commonly used OMs in chiropractic
  • It is not possible to measure pain directly
    • It must be estimated from replies to oral or written queries
    • The process can be influenced by the patient’s culture, conditioning, education, etc.
    • Then the pain replies must be interpreted by the clinician

Evidence-based Chiropractic

measures of pain cont
Measures of pain (cont.)
  • Quite a few tools are available that can convert the subjective experience of pain into valid and reliable measures
  • Once chosen, the same instrument should be used for follow-up evaluations

Evidence-based Chiropractic

numeric rating scale nrs
Numeric Rating Scale (NRS)
  • a.k.a., numeric pain scale or 11-point pain scale
  • Very common in research and practice
  • Patients estimate the severity of their pain on a 0 to 10 scale
    • 0 = no pain
    • 10 = worst possible pain

Evidence-based Chiropractic

nrs cont
NRS (cont.)
  • Patients are asked to circle the number that matches their level of pain
  • May be used verbally
      • e.g., “On a 0 to 10 scale, where 0 means no pain and 10 is the worst possible pain, what is your level of pain?”

Evidence-based Chiropractic

nrs cont26
NRS (cont.)
  • Interpretation of the intensity of NRS pain scores
    • 1-4 = mild pain
    • 5-6 = moderate pain
    • 7+ = severe pain
  • 101-point NRS(NRS-101)
    • Occasionally encountered in the literature
    • Provides little more than the 11-point scale

Evidence-based Chiropractic

visual analog scale vas
Visual Analog Scale (VAS)
  • A 10 centimeter line with descriptive phrases at each end that depict the extremes of pain

10 cm

Measure mm to mark

Evidence-based Chiropractic

other uses of nrs vas
Other uses of NRS & VAS
  • Measure the impact pain has on daily living e.g., sleep interference and lifting capacity
  • Can also be adapted to assess anxiety or depression levels in pain patients

COMPLETELY

INTERFERES

DOES NOT

INTERFERE

Evidence-based Chiropractic

characteristic pain intensity cpi
Characteristic Pain Intensity (CPI)
  • A scale that averages the patient’s pain levels right now, typical or on average, and when it is at its worst
  • Patients presenting for evaluation at a particularly good or bad time are able to convey their true pain level better
  • Uses 3 VAS pain intensity ratings that represent different points in time

Evidence-based Chiropractic

cpi cont
CPI (cont.)

Evidence-based Chiropractic

cpi cont31
CPI (cont.)
  • In research, the CPI correlated better with measures of pain-related disability, pain medication use, and standard pain measures than individual ratings
  • CPI scores were more normally distributed

Evidence-based Chiropractic

verbal rating scales vrs
Verbal Rating Scales (VRS)
  • A scale that depicts pain intensity using a series of adjectives that reflect the extremes of pain (e.g., from no pain to intense pain)
  • Patients are asked choose the adjective that best describes their pain level by selecting from a list of possibilities

Evidence-based Chiropractic

the 5 point vrs
The 5-point VRS

Evidence-based Chiropractic

vrs cont
VRS (Cont.)
  • The VRS is preferred by patients because of its simplicity
  • It is not as sensitive or reliable as other pain scales
  • VRS data can easily be misinterpreted because word descriptions may not have the same meaning for different persons

Evidence-based Chiropractic

tenderness rating scales
Tenderness Rating Scales
  • Used to quantify the degree of discomfort associated with palpation, typically of myofascial tissues
  • The patient’s interpretation of tenderness is correlated with the examiner’s observation of their reaction to a pain stimulus which can help objectify information gained from palpation

Evidence-based Chiropractic

tenderness rating of soft tissue
Tenderness rating of soft tissue

Evidence-based Chiropractic

pain drawings
Pain drawings
  • Patients simply shade or mark the regions of a blank body image where they are experiencing pain
  • Can be used independently or incorporated into questionnaires
  • Their utility can be enhanced when used along with other OMs

Evidence-based Chiropractic

pain drawings cont
Pain drawings (cont.)

Patient circles area of pain and notes ache

  • Codes are often used
  • to depict the qualities
  • of pain, e.g.,
    • A = ache
    • D = deep
    • B = burning
    • N = numbness
    • OR
    • //// = stabbing
    • 000 = pins & needles
    • XXX = burning

Evidence-based Chiropractic

slide39

Margolis system:

Patient marks areas of

pain on a blank body

image and then a trans-

parent grid depicting 45

regions of the body is

superimposed over the

completed image

Completed drawings can

be scored as to the percentage

of body surface in the shaded

regions by referring to a list of

weighted values

Evidence-based Chiropractic

slide40

Pain drawing from the American Academy of Physical Medicine & Rehabilitation

Includes a description of pain levels

Evidence-based Chiropractic

pain drawings cont41
Pain drawings (cont.)
  • Test-retest reliability has been established in several studies, even when administered in diverse settings
  • Sometimes used by clinicians to identify psychological disturbances in pain patients
    • However, this method has low sensitivity and positive predictive value

Evidence-based Chiropractic

mcgill pain questionnaire mpq
McGill Pain Questionnaire (MPQ)
  • Developed by Melzak in 1975
  • Provides a quantitative measure of pain
  • One of the most widely tested pain measures of all time
    • Often used as a gold standard, against which newly developed pain instruments are tested

Evidence-based Chiropractic

mpq cont
MPQ (cont.)
  • Made up of 3 major classes of word descriptors, including words that describe
    • Sensory qualities
    • Affective, in terms of tension, fear, and autonomic responses to the pain
    • Evaluative words that describe the intensity of the pain

Evidence-based Chiropractic

mpq cont44
MPQ (cont.)
  • Consists of 4 major parts:
    • A pain drawing
    • 78 pain descriptors (e.g., sharp, intense, pinching) that span 20 categories
    • Questions that assess how the pain changes over time and what relieves or increases it
    • A pain intensity section

Evidence-based Chiropractic

slide45

SHORT FORM McGILL PAIN QUESTIONNAIRE(SF-MPQ)

Pain drawing

1 2 3

Scored as follows:

Mild = 1

Moderate = 2

Severe = 3

Unchecked = 0

Sensory

Affective

VAS

Sensory score, 33 possible

Affective score, 12 possible

VAS score

Evidence-based Chiropractic

psychometric measures
Psychometric measures
  • Questionnaires that deal with patients’ emotional and psychological state
  • Chronic pain can bring about anxiety, depression, and hopelessness
  • It can aggravate existing depression
  • In some cases, depression can cause chronic pain

Evidence-based Chiropractic

psychometric measures cont
Psychometric measures (cont.)
  • Psychometric questionnaires can be used by chiropractors to screen pain patients
  • Mild depression associated with pain can be monitored
  • When persistent or more than mild, some patients may need a psychological referral

Evidence-based Chiropractic

beck depression inventory bdi
Beck Depression Inventory (BDI)
  • The most commonly used self-administered scale for measuring depression world-wide
  • Can be integrated into a busy clinical practice without difficulty
    • Requires no special training to administer
  • 21 items dealing with statements about how patients perceive themselves

Evidence-based Chiropractic

bdi cont
BDI (cont.)
  • For example
    • 0 – “I don't feel disappointed in myself”
    • 1 – “I am disappointed in myself”
    • 2 – “I am disgusted with myself”
    • 3 – “I hate myself”
  • Score 10-18, patient is mildly depressed
  • 19-21 may have borderline clinical depression

Evidence-based Chiropractic

bdi cont50
BDI (cont.)
  • The test’s validity and reliability has been established
  • It has high internal consistency and high content validity
  • Good discriminate validity
    • Is able to distinguish depressed from non-depressed subjects
  • It is sensitive to change

Evidence-based Chiropractic

symptom checklist 90 revised scl 90 r
Symptom Checklist-90-Revised(SCL-90-R)
  • A psychometric questionnaire that can be used to assess pain in musculoskeletal patients
  • Contains 90 items that can be completed in 12-15 minutes
  • Each item is graded on a five-point (0-4) scale of distress that ranges from “not at all” to “extremely”

Evidence-based Chiropractic

scl 90 r cont
SCL-90-R (cont.)
  • Its reliability, validity, and utility has been well-established
  • Can be used by all types of health care professionals to screen patients for psychological involvement

Evidence-based Chiropractic

measures of function
Measures of function
  • Questionnaires that evaluate activity limitations associated with a variety of conditions
    • e.g., back pain, knee pain, asthma
  • General health assessment questionnaires and many physical tests are also considered measures of function

Evidence-based Chiropractic

oswestry disability index odi
Oswestry Disability Index (ODI)
  • a.k.a., Oswestry low back pain disability questionnaire
  • One of the most commonly used OMs in the management of spinal disorders
  • Its validity and reliability has been well established
  • It is appropriate for both research and clinical practice

Evidence-based Chiropractic

odi cont
ODI (cont.)
  • At least four versions are available
  • The original authors recommend that the ODI 2.0 version be used
  • The Revised ODI omitted the original section 8 that deals with sex, replacing it with a section about the changing degree of pain

Evidence-based Chiropractic

odi cont56
ODI (cont.)
  • Consists of 10 sections that each have 6 statements dealing with activities of daily living and pain
    • Is self-administered
    • Typically completed in less than 5 minutes
    • Scoring is straightforward and can be performed by a staff member
  • Statements describe the level of disability associated with various activities

Evidence-based Chiropractic

odi cont57
ODI (cont.)
  • Scoring
    • A value is assigned for statements ranging from 0 to 5
    • The first statement has a value of 0 and the last statement a 5
  • If a patient chooses more than one box in a section, the highest score is to be taken
  • Statement values from each section are then combined to get a total score

Evidence-based Chiropractic

odi cont58
ODI (cont.)
  • Where
    • Total scored is the total of all the statements selected by the patient
    • Total possible score is the number of sections completed by the patient times five

Evidence-based Chiropractic

odi cont59
ODI (cont.)
  • If the patient completes all 10 sections, simply multiply their raw score by 2 to convert to a percentage

Not 50 because the patient left out a section

Evidence-based Chiropractic

slide60

ODI sections

Evidence-based Chiropractic

slide61

ODI sections (cont.)

Evidence-based Chiropractic

interpretation of odi scores
Interpretation of ODI scores

Evidence-based Chiropractic

odi clinically important difference
ODI clinically important difference
  • In order to distinguish patients who have improved from those who have not, the minimum clinically important difference that is needed is 6 ODI points
    • Other researchers have calculated it to be as high as 15 points
  • To be clinically important, a patient would have to improve by at least 6 ODI points

Evidence-based Chiropractic

roland morris questionnaire rmq
Roland-Morris Questionnaire (RMQ)
  • Has been shown to be a valid and reliable instrument for the assessment of low back disability
  • Sensitive to change over time for low back pain patients
  • Its popularity is comparable with ODI

Evidence-based Chiropractic

rmq cont
RMQ (cont.)
  • Consists of 24 questions that deal with low back pain and function
  • Can be completed by patients in about 5 minutes
  • Can be scored by the doctor or a staff member in about one minute

0 = no pain and normal function

24 = maximum pain and diminished function

Evidence-based Chiropractic

rmq cont66
RMQ (cont.)
  • When compared with the ODI, the Roland-Morris was found to be simpler, faster and more acceptable to patients
  • RMQ is a more sensitive measure of activity intolerances in acute and subacute patients
  • ODI is more sensitive for identifying activity intolerances in chronic patients

Evidence-based Chiropractic

slide67

RMQ questions

 1. I stay at home most of the time because of my back.

 2. I change position frequently to try to get my back comfortable.

 3. I walk more slowly than usual because of my back.

 4. Because of my back, I am not doing any jobs that I usually do around the house.

 5. Because of my back, I use a handrail to get upstairs.

 6. Because of my back, I lie down to rest more often.

 7. Because of my back, I have to hold on to something to get out of an easy chair.

 8. Because of my back, I try to get other people to do things for me.

 9. I get dressed more slowly than usual because of my back.

 10. I only stand up for short periods of time because of my back.

 11. Because of my back, I try not to bend or kneel down.

 12. I find it difficult to get out of a chair because of my back.

 13. My back is painful almost all of the time.

 14. I find it difficult to turn over in bed because of my back.

15. My appetite is not very good because of my back.

 16. I have trouble putting on my sock (or stockings) because of the pain in my back.

 17. I can only walk short distances because of my back pain.

 18. I sleep less well because of my back.

 19. Because of my back pain, I get dressed with the help of someone else.

 20. I sit down for most of the day because of my back.

 21. I avoid heavy jobs around the house because of my back.

22. Because of back pain, I am more irritable and bad tempered with people than usual.

 23. Because of my back, I go upstairs more slowly than usual.

 24. I stay in bed most of the time because of my back.

RMQ score = 4

Evidence-based Chiropractic

rmq cont68
RMQ (cont.)
  • Roland and Morris did not provide an interpretation of the varying degrees of disability as in ODI
    • However, scores of 13 or more denote significant disability and an unfavorable outcome (Von Korff and Saunders)
  • Clinical improvements over time can be graded based on the analysis of serial questionnaires

Evidence-based Chiropractic

rmq cont69
RMQ (cont.)
  • Percentage of improvement can be calculated as follows:
  • For example:
    • If a patient’s baselinescore was 12 and post score 2

Evidence-based Chiropractic

rmq clinically important difference
RMQ clinically important difference
  • The minimum clinically important difference for RMQ evaluations was 4 to 5 points in one study and 8.6 to 9.5 in another
  • A patient would have to improve by at least 4 RMQ points in order to consider their condition as being improved

Evidence-based Chiropractic

neck disability index ndi
Neck Disability Index (NDI)
  • A modification of the Oswestry Low Back Pain Disability Index
    • Developed in 1989 by Howard Vernon, DC
  • In 1991, Vernon and Mior published a study in JMPT on its reliability and validity
  • Ten other studies have confirmed the original report’s findings

Evidence-based Chiropractic

ndi cont
NDI (cont.)
  • Scored exactly the same as the ODI
  • The minimal clinically important difference for the NDI is a 5-point change in the raw score
  • Interpretation:

Evidence-based Chiropractic

example ndi section
Example NDI section
  • Section 1- Pain Intensity
    • I have no pain at the moment. 
    • The pain is very mild at the moment. 
    • The pain is moderate at the moment. 
    • The pain is fairly severe at the moment. 
    • The pain is very severe at the moment. 
    • The pain is the worst imaginable at the moment.

Evidence-based Chiropractic

example ndi section74
Example NDI section
  • Section 5- Headaches
    • I have no headaches at all. 
    • I have slight headaches which come in-frequently. 
    • I have moderate headaches which come in-frequently. 
    • I have moderate headaches which come frequently. 
    • I have severe headaches which come frequently. 
    • I have headaches almost all the time.

Evidence-based Chiropractic

other neck specific questionnaires
Other neck specific questionnaires
  • Copenhagen Neck Functional Disability Scale
  • Northwick Park Neck Pain Questionnaire
  • Neck Pain and Disability Scale
  • Patient-Specific Functional Scale
  • However, the NDI is encountered much more frequently and has been revalidated in diverse study populations

Evidence-based Chiropractic

whiplash disability questionnaire wdq
Whiplash Disability Questionnaire (WDQ)
  • Uses the basic components of the NDI, plus questions on emotional health, social activity, and fatigue
  • Uses an 11-point (0–10) numerical scale for the patients’ responses
    • The minimum clinically important difference is 15 points
  • Has excellent internal consistency and test-retest reliability

Evidence-based Chiropractic

slide78

WDQ

Evidence-based Chiropractic

headache disability inventory hdi
Headache Disability Inventory (HDI)
  • A 25 question survey designed for patients with cervicogenic headaches
    • 12 emotional questions
    • 13 functional questions
  • Useful in assessing the impact of headache on daily living
  • Construct validity, internal reliability, and test-retest reliability is good

Evidence-based Chiropractic

hdi cont
HDI (cont.)
  • The maximum HDI score is 100 points
  • HDI scores ranging from 2 to 32 are considered mild, from 33 to 59 are moderate, and 60 or greater are severe
  • At least a 29-point change must occur from test to retest before the changes can be attributed to a patient’s treatment

Evidence-based Chiropractic

slide81

HDI

4 points

2 points

0 points

Emotional

Functional

Evidence-based Chiropractic

migraine disability assessment midas questionnaire
Migraine Disability Assessment(MIDAS) questionnaire
  • Consists of only 7 items
    • 5 items contribute to the overall score
  • MIDAS is based on the Headache Impact Questionnaire (HIQ)
    • MIDAS scoring is easier and scores are more intuitively meaningful than HIQ scores
  • Test-retest reliability and internal consistency are good

Evidence-based Chiropractic

midas questionnaire cont
MIDAS questionnaire (cont.)
  • Scores are derived from 3 domains of activity

1. Lost time from work for pay

2. Housework or chores

3. Leisure activities

  • The final MIDAS score is total number of headache-related missed days from these domains

Evidence-based Chiropractic

midas questionnaire cont85
MIDAS questionnaire (cont.)

Evidence-based Chiropractic

36 item short form questionnaire sf 36
36-item short-form questionnaire (SF-36)
  • a.k.a., RAND 36-item health survey
  • A general health questionnaire that consists of 36 items
  • Assesses patients’ health status from their point of view
  • Used extensively in research and clinical practice
    • Has good internal consistency and reliability

Evidence-based Chiropractic

sf 36 cont
SF-36 (cont.)
  • Self administered
    • Takes about 5-10 minutes for patients to complete
    • Patients must be at least 14 years of age
    • Can also be administered via face-to-face interview or by telephone
  • Scoring reports on 8 health scales, 2 summary measures, and self-perceived changes in health status

Evidence-based Chiropractic

slide88
SF-36 assesses 8 health concepts related to physical, emotional, or psychological distress
  • Limitations in physical activities because of health problems
  • Limitations in usual role activities because of physical health problems
  • Bodily pain
  • General health perceptions
  • Vitality
  • Limitations in social activities because of physical or emotional problems
  • Limitations in usual role activities because of emotional problems
  • Mental health

Evidence-based Chiropractic

sf 36 vs rand 36
SF-36 vs. RAND 36
  • Both were developed as part of the Medical Outcomes Study (MOS)
  • They contain the same questions, but the scoring procedures are different
  • RAND 36 is free at:
    • http://www.rand.org/health/surveys_tools/mos/mos_core_36item.html
  • SF-36 is available for a fee at:
    • http://www.sf-36.org

Evidence-based Chiropractic

slide90
SF-36 sample questions

1. In general, would you say your health is: (Circle One Number)

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

2. Compared to one year ago, how would your rate your health in general now?(Circle One Number)

Much better now than one year ago 1

Somewhat better now than one year ago 2

About the same 3

Somewhat worse now than one year ago 4

Much worse now than one year ago 5

Evidence-based Chiropractic

slide92

20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?(Circle One Number)

Not at all 1

Slightly 2

Moderately 3

Quite a bit 4

Extremely 5

21. How much bodily pain have you had during the past 4 weeks? (Circle One Number)

None 1

Very mild 2

Mild 3

Moderate 4

Severe 5

Very severe 6

Evidence-based Chiropractic

sf 12
SF-12
  • Even shorter than theSF-36, yet it is still valid
  • Includes only 12 of the SF-36 items
    • 1 or 2 items from each of the 8 health concepts are included
  • Available from
    • http://www.sf-36.org

Evidence-based Chiropractic

dartmouth coop chart system
Dartmouth COOP chart system
  • Dartmouth Primary Care Cooperative Information Project chart system
  • A patient friendly measure of functional health status that is simple to administer and score
  • Designed for use with adults and adolescents

Evidence-based Chiropractic

dartmouth coop cont
Dartmouth COOP (cont.)
  • Queries the patient about their function in the preceding 2 weeks
  • Measures 9 dimensions of health
    • Physical, Emotional, Daily Activities, Social Activities, Social Support, Pain, and Overall Health
  • Consists of a series of 9 charts
    • Each has a title, a functional status question, and 5 responses to choose from

Evidence-based Chiropractic

dartmouth coop cont96
Dartmouth COOP (cont.)
  • Can be self-administered by the patient or administered by the clinician or staff member.
  • Scoring is reported to be easy
    • A high score (4 or 5) on any of the charts is considered abnormal
  • Available from Debbie Johnson at the Dartmouth COOP Project
    • Deborah.Johnson@Dartmouth.edu

Evidence-based Chiropractic

sample coop charts
Sample COOP charts

Evidence-based Chiropractic

sickness impact profile sip
Sickness Impact Profile (SIP)
  • A general health questionnaire that is commonly used in research
    • Rarely used in clinical practice because of its lengthiness (It consists of 136 items)
  • Consists of 14 subscales that deal with illness and the related activity levels of ill patients
  • Is valid and reliable as an OM for use with low back pain patients

Evidence-based Chiropractic

sip cont
SIP (cont.)
  • Statements only apply to patients on the day of the evaluation
  • Incorporates physical and psychosocial domains of health
  • Considered a “gold standard” as an OM of self-reported pain
    • Because of its widespread use in research and its well-established reliability and validity

Evidence-based Chiropractic

physiologic oms
Physiologic OMs
  • Assessments that are performed by the examiner
  • Includes the evaluation of range of motion, muscle strength, postural analysis, x-ray analysis, etc.
  • Often considered to be more reliable than qualitative measures, but the opposite is often true

Evidence-based Chiropractic

range of motion rom
Range of motion (ROM)
  • Commonly used in clinical practice
    • Its validity and reliability is variable
    • Depends on the region being examined and the evaluation method used
  • Lumbar ROM assessment by dual inclinometry has shown to be valid and reliable
    • Especially pertaining to forward flexion

Evidence-based Chiropractic

rom cont
ROM (cont.)
  • Other studies have concurred, but measurements were always performed apart from other exam procedures
  • In a study where ROM was measured during usual clinical practice, most scores were not reliable
  • Lumbar ROM reliability also depends on the extent of examiner training

Evidence-based Chiropractic

rom cont103
ROM (cont.)
  • The time of day measurements are taken also influences results
  • Thus, lumbar ROM evaluated in a clinical environment may not be reliable, even if experimental evidence suggests otherwise
  • Measurement of cervical spine ROM is reliable using dual inclinometry
    • However, visual observation is not

Evidence-based Chiropractic

algometry
Algometry
  • The use of an algometer (a.k.a., pain threshold meter)
    • A hand-held rubber-tipped force gauge that registers kilograms per square cm or pounds per square inch when pressure is applied
    • Used to quantify the amount of surface pressure that is associated with subjective pain tolerance or tenderness

Evidence-based Chiropractic

algometry cont
Algometry (cont.)
  • The rubber tip is placed over an area to be examined and increasing pressure is applied
  • Patients are asked to report pain or tenderness levels
    • Pressure threshold is the minimum amount of pressure needed to cause pain
    • Pressure tolerance is the maximum amount of pressure the patient can tolerate

Evidence-based Chiropractic

algometry cont106
Algometry (cont.)
  • Pain associated with algometry testing can be used in conjunction with a tenderness rating scale
  • Algometry has been tested in a variety of settings and on different types of tissues
    • Its reliability and validity has generally been good

Evidence-based Chiropractic

recommended oms to assess patients with back pain
Recommended OMs to assess patients with back pain
  • VAS
  • Roland-Morris or Oswestry questionnaire
  • SF-12 or SF-36
  • Days off work or activity intolerances to reflect disability
  • Overall satisfaction with care

Evidence-based Chiropractic

use the validated form a test in clinical practice
Use the validated form a test in clinical practice
  • Do not modify anything
  • Use the version that was presented in the original research
  • OMs that have been altered can not be considered valid
    • Even something as minor as changing the order of questions

Evidence-based Chiropractic