Evidence-based chiropractic and documentation

1
Evidence-based chiropractic and documentation
2
Good clinical documentation

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

3
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

4
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

5
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

6
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

7
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

8
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

9
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

10
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

11
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

12
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 patients perspective
• Criticized as being subjective and unreliable
• However, HRQL measures are typically more
  reliable than objective OMs

13
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

14
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

15
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

16
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 patients
  culture, conditioning, education, etc.
• Then the pain replies must be interpreted by the
  clinician

17
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

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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

19
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
20
Characteristic Pain Intensity (CPI)

• A scale that averages the patients 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

21
CPI (cont.)
22
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 to choose the adjective that
  best describes their pain level by selecting from
  a list of possibilities

23
The 5-point VRS
Score Description
0 No pain
1 Mild pain
2 Moderate pain
3 Severe pain
4 Very severe pain
24
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

25
Tenderness Rating Scales

• Used to quantify the degree of discomfort
  associated with palpation, typically of
  myofascial tissues
• The patients interpretation of tenderness is
  correlated with the examiners observation of
  their reaction to a pain stimulus which can help
  objectify information gained from palpation

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Tenderness rating of soft tissue
Grade 0 1 2 3 4 Definition No tenderness Mild tenderness without grimace or flinch Moderate tenderness with grimace or flinch Severe tenderness with marked flinch or withdrawal Unbearable tenderness, patient withdraws with light touch
27
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

28
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
29
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
30
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

31
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

32
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

33
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

34
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

35
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

36
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

37
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

38
BDI (cont.)

• The tests 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

39
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

40
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

41
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

42
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

43
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

Section 8 Sex Life My sex life is normal and causes no extra pain. My sex life is normal but causes some extra pain. My sex life is nearly normal but is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex life at all
44
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

45
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

46
ODI (cont.)

• If the patient completes all 10 sections, simply
  multiply their raw score by 2 to convert to a
  percentage

ODI score () 18 ? 100 40
ODI score () 45 ? 100 40
Not 50 because the patient left out a section
47
ODI sections
Section 1 - Pain Intensity The pain comes and goes and is very mild. The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain comes and goes and is severe. The pain is severe and does not vary much. Section 6 - Standing I can stand as long as I want without pain. I have some pain on standing but it does not increase with time. I cannot stand for longer than 1 hour without increasing pain. I cannot stand for longer than 1/2 hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases the pain immediately.
Section 2 - Personal Care washing, dressing, etc. I do not have to change my way of washing or dressing in order to avoid pain. I do not normally change my way of washing or dressing even though it causes some pain. Washing and dressing increases the pain but I manage not to change my way of doing it. Washing and dressing increases the pain and I find it necessary to change my way of doing it. Because of the pain I am unable to do some washing and dressing without help. Because of the pain I am unable to do any washing and dressing without help. Section 7 - Sleeping I get no pain in bed. I get pain in bed but it does not prevent me from sleeping well. Because of pain my normal night's sleep is reduced by less than 1/4. Because of pain my normal night's sleep is reduced by less than 1/2. Because of pain my normal night's sleep is reduced by less than 3/4. Pain prevents me from sleeping at all.
Section 3 - Lifting I can lift heavy weights without extra pain. I can lift heavy weights, but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example, on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights at the most. Section 8 - Social Life My social life is normal and gives me no pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc. Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I have no social life because of pain.
48
ODI sections (cont.)
Section 4 - Walking I have no pain walking. I have some pain with walking but it does not increase with distance. I cannot walk more than 1 mile without increasing pain. I cannot walk more than 1/2 mile without increasing pain. I cannot walk more than 1/4 mile without increasing pain. I cannot walk at all without increasing pain. Section 9 - Traveling I get no pain while traveling. I get some pain from traveling, but none of my usual forms of travel make it any worse. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. I get extra pain while traveling, which compels me to seek alternative forms of travel. Pain restricts all forms of travel. Pain prevents all forms of travel except that done lying down.
Section 5 - Sitting I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting for more than one hour. Pain prevents me from sitting for more than 1/2 hour. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all. Section 10 - Changing Degree of Pain My pain is rapidly getting better. My pain fluctuates but overall it is definitely getting better. My pain seems to be getting better but improvement is slow at present. My pain is neither getting better nor worse. My pain is gradually worsening. My pain is rapidly worsening.
49
Interpretation of ODI scores
ODI Score Interpretation
0-20 Minimal Disability
20-40 Moderate Disability
40-60 Severe Disability
60-80 Crippled
80-100 Bed-bound or exaggerating
50
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

51
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

52
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

53
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

54
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
?
?
55
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

56
RMQ (cont.)

• Percentage of improvement can be calculated as
  follows
• For example
• If a patients baseline score was 12 and post
  score 2

Baseline RMQ score - Follow-up RMQ score ? 100
Baseline RMQ score ? 100
12-2 ? 100 83 improvement
12 ? 100 83 improvement
57
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

58
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
  reports findings

59
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

Raw NDI Score 0 - 4 5 - 14 15 - 24 25 - 34 ? 35 Disability Level No disability Mild disability Moderate disability Severe disability Complete disability
60
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.

61
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

62
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

63

• 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

64
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_c
  ore_36item.html
• SF-36 is available for a fee at
• http//www.sf-36.org

65

• 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

66
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle One Number on Each Line) The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle One Number on Each Line) The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle One Number on Each Line) The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle One Number on Each Line)
Yes, Limited a Lot Yes, Limited a Little No, Not limited at All
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports 1 2 3
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3
5. Lifting or carrying groceries 1 2 3
6. Climbing several flights of stairs 1 2 3
7. Climbing one flight of stairs 1 2 3
8. Bending, kneeling, or stooping 1 2 3
9. Walking more than a mile 1 2 3
10. Walking several blocks 1 2 3
11. Walking one block 1 2 3
12. Bathing or dressing yourself 1 2 3
67
SF-12

• Even shorter than the SF-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

68
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

69
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

70
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

71
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

72
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

73
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

74
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

75
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

76
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

77
Recommended OMs to assess patients with back pain

1. VAS
2. Roland-Morris or Oswestry questionnaire
3. SF-12 or SF-36
4. Days off work or activity intolerances to reflect
   disability
5. Overall satisfaction with care

78
Use the validated form of 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