Perform four assessments on your patients to measure the progress of chiropractic rehabilitation

In the modern health care environment, chiropractors are required to be effective and efficient. We must do all we can to help decrease acute and chronic pain, as well as increase structural integrity. Our treatment plans must move from passive care (adjustments and unassisted physiotherapy modalities) to active care (adjustments and conditioning/work hardening exercise programs) with appropriate structural support.

We are now very aware of the importance of assessing and reporting the outcomes of our treatment procedures. The hallmark of an outcomes assessment is that it is quantifiable and comparable to previous and future evaluations. This process has become an essential part of health care services, and especially of rehab programs.

From the doctor’s standpoint, we need to know whether our care is improving the patient’s well-being, and if so, by how much. This helps us to plan for further care or referral. The patient should also have some way to assess the benefit (or lack thereof) of our treatment regimen to make an informed decision about whether to continue treatment. And finally, whoever is paying for this care deserves to be provided with an evaluation of the progress (or not) of the patient under our care.

Measuring Progress
Briefly, an outcomes assessment is defined as: “A form of measurement of progress toward a specific goal.” The many and varied types of evaluations that assess the outcomes of chiropractic rehabilitation fall into two general areas: subjective and objective determinations. Both can be very helpful in evaluating progress; they provide an insight into two different components of the healing process.

For subjective evaluations, use the combination of a Quadruple Visual Analog Scale for pain, the Neck/Back Bournemouth Questionnaires for measurements of a patient’s perception of progress, and the new Pain Disability Questionnaire (rated better than the Oswestry) for outcome documentation of function. In the objective realm, I like to use postural and gait evaluations as primary indicators of a patient’s progress. These assessments need to be performed on a regular schedule, generally at least monthly.

Quadruple Visual Analog Scale (QVAS)
The Quadruple Visual Analog Scale (QVAS) is a reliable and valid method for pain measurement. The QVAS is based on four specific factors:

1)    pain level at the time of the current office visit;
2)    typical or average pain since the last visit (or since the initial visit, or since the onset of the condition), depending on the chronicity of the condition;
3)    pain level at its best since the last visit, time of intake, or since the onset of the condition; and
4)    pain level at its worst since the last visit, time of intake, or since the onset of the condition.

The scores from factors 1, 2, and 4 above are averaged and then multiplied by 10 to yield a score from 0 to 100. The final score is then categorized as “low intensity” (pain < 50) or “high intensity” (pain > 50).

Neck/Back Bournemouth
The Neck/Back Bournemouth Questionnaire is a comprehensive outcome measure for back pain.

The instrument has established validity, consistency, reliability, and demonstrated responsiveness to clinical change. It is practical for the efficacy and effectiveness of back-pain treatments. It measures the following seven back-pain-model traits:

1) pain intensity;
2) daily activities;
3) recreational/social/family activities;
4) anxiousness;
5) depression;
6) work activities; and
7) pain control.

A score of 0 to 10 is possible for each of the seven categories, which provides a total possible score of 70, where 70 represents the highest disability score possible and 0 represents the best spinal health score.

Pain Disability Questionnaire
The Pain Disability Questionnaire (PDQ) is a comprehensive psychometric evaluation of functional status. The focus is primarily on disability and function. This instrument is designed for the full array of chronic disabling musculoskeletal disorders, rather than low back pain alone. The psychometric properties of the PDQ are excellent, demonstrating strong reliability, responsiveness, and validity.

The PDQ is made up of two factors: a Functional Status component, comprising a maximum score of 90, and a Psychosocial component, comprising a maximum of a 60 score. This yields a total functional disability score ranging from 0 to 150.

Postural and Gait Evaluation
In addition to the standard ortho/neuro and range-of-motion examinations done for chiropractic care, I find posture and gait evaluations to be very helpful objective evaluations when planning and measuring the impact of rehab. Human posture is based on an erect column of functional segments, which are better designed for movement than for standing still. Optimal posture allows for pain-free movement with minimum energy expenditure, and it is a sign of vigor and harmonious control of the body.

Areas with poor postural or gait alignment indicate chronic biomechanical stress, and they are frequently associated with painful or degenerative processes. Chronic spinal problems may develop secondary- to lower-extremity misalignments, such as leg-length discrepancies and pronation problems. Any of these that are present will need to be addressed to resolve the patient’s current symptoms and to prevent future back problems.

Progress Appraisal
The use of adjustments, rehabilitative exercises/supports, and subjective/objective outcome measures are crucial when a functional approach is taken. Outcomes assessments keep everyone apprised of the progress (or lack thereof) of the patient in response to health care services.

Kim D. Christensen, DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Wash. He has participated as team chiropractor for high school and university athletic programs, as a postgraduate faculty member at numerous chiropractic colleges, and as past-president of the ACA Rehab Council. He can be reached via email: kchristensen@peacehealth.org.