Evidence-based Outcome Measures Commonly Used In Practice

1. Evidence-based Outcome Measures Commonly Used In Practice

2. Questionnaires • General health status • Sickness Impact Profile (136 items) • SF-36 and SF-12 (Rand-36) • Dartmouth COOP Functional Health Assessment Charts • Pain • Visual analog scales/numeric rating scale • McGill Pain Questionnaire • Pain drawing

3. Visual Analog Scale No Pain Worst Pain Imaginable (10 cm long) Pain Scales Numeric Pain Intensity Scale 0 1 2 3 4 5 6 7 8 9 10 No Pain Moderate Pain Worst Pain Imaginable

4. Quadruple VAS VISUAL ANALOGUE SCALE OF PAIN LEVEL Please circle the number below that best describes your level of pain: How bad is your pain RIGHT NOW? No pain worst pain imaginable 0 1 2 3 4 5 6 7 8 9 10 How bad is your TYPICAL or AVERAGE pain? No pain worst pain imaginable0 1 2 3 4 5 6 7 8 9 10 How bad is your pain when it is AT ITS BEST? No pain worst pain imaginable 0 1 2 3 4 5 6 7 8 9 10 How bad is your pain when it is AT ITS WORST? No pain worst pain imaginable 0 1 2 3 4 5 6 7 8 9 10

6. Includes Spanish and Child Pain Assessment

7. Pain Drawings • The patient is asked to draw the area of pain on a body outline • Codes are used to depict the various qualities of pain • A = ache, D = deep, etc. • //// = stabbing, 000 = pins & needles, etc.

8. A = ACHE B = BURNING N = NUMBNESS P = PINS & NEEDLES S = STABBINGO = OTHER

9. American Academy of Physical Medicine & Rehabilitation

10. Öhlund et al.

11. 1 2 3 Sensory Affective

12. Questionnaires Cont. • Functional status (disability) • Neck Disability Index • Roland-Morris Disability Questionnaire • Oswestry Disability Questionnaire • Waddell Disability Index • Pain Disability Index

13. Questionnaires Cont. • Patient Satisfaction • Chiropractic Satisfaction Questionnaire (Coulter) • Patient satisfaction (Ware)

14. Physiological outcomes • Ranges of motion (inclinometer) • Straight leg raising • Dynamometer measures (strength) • Physical tests • Electromyography • Mobility by x-ray

15. Utilization Measures • Number services (visits) per occurrence • Treatment days (weeks) per occurrence • Utilization of technology • Especially expensive tests like MRI or electrical tests • Episode duration

16. Cost Measures • Charges per occurrence • Charges per service • Disability compensation • How much are the disability payments for someone under chiropractic vs. medical care? • Return-to-work

17. Spine-specific Measures The Oswestry Disability Index (ODI) and the Roland–Morris disability questionnaire (R-M) are the most commonly used outcome measures for spinal disorders The ODI questionnaire was originally published in 1980 Fairbank J, Couper J, Davies J, et al. The Oswestry low back pain questionnaire. Physiotherapy 1980;66:271–3.

18. ODI Cont. • The ODI has been published in at least four formats in English and in nine other languages • It has stood the test of time and many reviews • ODI scores for a variety of spinal conditions are consistent with clinical experience

19. 012345 Oswestry

20. Scoring ODI • For each section the total possible score is 5: • If the first statement is marked the section score = 0 • If the last statement is marked it = 5 • If all ten sections are completed the score is calculated as follows:

21. Scoring Cont. • Example: • If one section is missed or not applicable the score is calculated:

22. Raw Total = 22 (22/50) * 100 = 44 or 22 * 2 = 44% 44

23. Scoring Cont. • Or simply double the ODI score and report as a percentage • This method doesn’t work if the patient forgets to fill out a section

24. Oswestry - Score Interpretation • 0-20% Minimal Disability • 20-40% Moderate Disability • 40-60% Severe Disability • 60-80% Crippled • 80-100% Bed Bound or Exaggerating

25. R-M • When compared with the ODI, the Roland-Morris was found to be simpler, faster and more acceptable to patients • R-M is a more sensitive measure of activity intolerances in acute and subacute patients • ODI is more sensitive for identifying activity intolerances in chronic patients

26. Roland-Morris 24 Total (or 18 in a short version)

27. Scoring Roland-Morris • The patient is instructed to put a mark next to each appropriate statement • The total number of marked statements are totaled • Roland and Morris did not provide descriptions of the varying degrees of disability as in ODI

28. Scoring R-M Cont. • Clinical improvements over time can be graded based on the analysis of serial questionnaire scores • For example: • A patient’s initial score was 12 and the post score was 2 (10 points of improvement) • Would be an 83% improvement • 10/12 x 100 = 83%

29. Neck Disability Index (NDI) • Developed in 1989 by Howard Vernon, DC • Is a modification of the Oswestry Low Back Pain Disability Index • 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

30. NDI Cont. • Has become a standard instrument for measuring self-rated disability due to neck pain • Used by clinicians and researchers alike • Ten sections are scored from 0 – 5 (maximum score is 50) • Total score used to ascertain level of disability

31. Interpretation of Oswestry and NDI Scores (Per Vernon) 0 - 4 = no disability 5 - 14 = mild 15 - 24 = moderate 25 - 34 = severe above 34 = complete disability

32. NDI Sections • 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.

33. NDI Sections Cont. • 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.

34. Scoring NDI • Use the same scoring procedure as in ODI

37. Headache Disability Inventory (HDI) • A 25 question survey designed for patients with cervicogenic headaches (Jacobson et al, 1994) • 12 emotional questions • 13 functional questions • Useful in assessing the impact of headache on daily living

38. Health Questionnaires • Are not condition-specific • can be applied to virtually any type of physical complaint • Can be (should be) used in practice, but are commonly used in research

39. SF-36®Health Survey • Is a 36-item instrument for measuring health status and outcomes from the patient’s point of view • It yields an 8-scale profile of functional health and well-being scores • It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group

40. SF-36 Cont. • There is also an even shorter (1-page, 2-minute) survey form called the SF-12 • A much shorter, yet valid, alternative to the SF-36 • SF-12 includes one or two items from each of the eight SF-36 health concepts • Rand 36 contains the same questions, but has a different scoring method

41. SF-36 – 8 Scales • Limitations in physical activities because of physical health problems • Limitations in usual role activities (physical) • Bodily pain • General health perceptions • Vitality (energy and fatigue) • Limitations in social activities (physical or emotional) • Limitations in usual role activities (emotional) • Mental health (psychological distress/well-being)

46. Dartmouth COOP Charts

47. Many More Available • There are other questionnaires • Dealing with specific conditions • Dizziness Handicap Inventory • Tinnitus Handicap Inventory • Temporomandibular Disorder Disability Index • Spinal Stenosis Questionnaire • Subjective Knee Score Questionnaire • Shoulder Pain and Disability Index • Elbow Performance Index • Carpal Tunnel Syndrome Questionnaire - Etc.

48. Physiologic Measures • Range of Motion • Considered to be an objective outcome assessment tool • Muscle strength and endurance testing • e.g., Alaranta exercise test • Algometry • Instrument tests the amount of pressure required to cause pain • Has some reliability, but weak

49. Dr. Owens – Review of Subluxation Assessment Methods