Evidencebased Outcome Measures Commonly Used In Practice

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Evidence-based Outcome Measures Commonly Used
In Practice
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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

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Pain Scales
Numeric Pain Intensity Scale 0 1
2 3 4 5 6
7 8 9 10 No Pain
Moderate Pain
Worst Pain

Imaginable
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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
imaginable 0 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
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Includes Spanish and Child Pain Assessment
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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.

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American Academy of Physical Medicine
Rehabilitation
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Öhlund et al.
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1 2 3
Sensory
Affective
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Questionnaires Cont.

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

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Questionnaires Cont.

• Patient Satisfaction
• Chiropractic Satisfaction Questionnaire (Coulter)
• Patient satisfaction (Ware)

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Physiological outcomes

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

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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

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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

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Spine-specific Measures

• The Oswestry Disability Index (ODI) and the
  RolandMorris 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 1980662713.

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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

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012345
Oswestry
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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

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Scoring Cont.

• Example
• If one section is missed or not applicable the
  score is calculated

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Raw Total 22 (22/50) 100 44 or 22 2
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44
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Scoring Cont.

• Or simply double the ODI score and report as a
  percentage
• This method doesnt work if the patient forgets
  to fill out a section

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Oswestry - Score Interpretation

• 0-20 Minimal Disability
• 20-40 Moderate Disability
• 40-60 Severe Disability
• 60-80 Crippled
• 80-100 Bed Bound or Exaggerating

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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

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

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Scoring R-M Cont.

• Clinical improvements over time can be graded
  based on the analysis of serial questionnaire
  scores
• For example
• A patients initial score was 12 and the post
  score was 2 (10 points of improvement)
• Would be an 83 improvement
• 10/12 x 100 83

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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
  reports findings

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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

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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

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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.

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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.

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Scoring NDI

• Use the same scoring procedure as in ODI

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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

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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

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SF-36 Health Survey

• Is a 36-item instrument for measuring health
  status and outcomes from the patients 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

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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

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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)

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Dartmouth COOP Charts
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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.

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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

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Dr. Owens Review of Subluxation Assessment
Methods
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Poor Validity and Reliability

• Palpation procedures
• Many orthopedic tests
• Applied kinesiology

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Being Outcomes Based

• Utilize the subjective and objective tools that
  are available
• Using the tools, score the patient at the initial
  visit to establish baseline measures
• Repeat measures at 2-4 week intervals to track
  the effects of care
• Base your clinical decisions on the results of
  the outcome measures