Clinical Guidelines for Chiropractic Practice in Canada
Chapter 9 - Reassessment
Chapter Outline
I OVERVIEW
The health professions are entering a new era of accountability. Consumers are becoming more informed and are demanding higher quality care and value for their money. Third party payors wish to reduce health care costs, and improve the quality of care. In this context reassessment, including assessment of outcomes or results of treatment, is becoming an increasingly important aspect of patient management.
Reassessment includes all patient evaluations performed after the initiation of patient care. Reassessment provides justification for the type, duration and frequency of care; documentation of improvement for the chiropractor, the patient and third parties; indication of the point of maximal clinical improvement; a basis for modification of the goals of treatment when necessary; a basis for clinical research because of consistent evaluations of the effect of chiropractic care over time; and assistance in establishing practice guidelines for specific patients and conditions (Chapman-Smith, 1992).
This chapter will discuss the different forms of reassessment and indications for reassessment, and will provide recommendations as to when a reassessment should take place. It should be noted that the various methods of outcome assessment are discussed in Chapter 12 which is titled 'Outcome Assessments'.
II DEFINITIONS
For definitions see the Glossary at the end of this publication.
Assessment
Evaluation
Initial Patient Evaluation
Diagnosis
Baseline
Reassessment
Different forms of reassessment are:
Interactive reassessment: Evaluation of a patient by procedures utilized on each visit to assess the immediate need for intervention.
Periodic reassessment: Evaluation of a patient at intervals of weeks or months, for the purpose of assessing the need for continued care, modified care, cessation of care or referral.
Follow-up reassessment: Evaluation of a patient at some interval after a course of management has been completed, to determine the long-term effects or implications of that type of management.
Progress: Any change in the patient's condition. It does not necessarily mean improvement.
III SUB-TOPICS
A. General Principles
B. Indications for reassessment
C. Specific Conditions - Scoliosis
D. Follow-up reassessment
IV LITERATURE REVIEW
While there is abundant literature on the subject of periodic health examination (Reith 1991, Battista 1990, Spasoff 1990) and on methods of reassessment (Nelson 1989, Ferraz 1990, Daltroy 1991), there are few detailed discussions on periodic reassessment. However, there are provincial and national regulations and guidelines which stress the importance of ongoing or periodic reassessment (CCPA Manual, Provincial Peer Review Guidelines) and different methods of reassessment are seen in the various clinical studies (Mierau et al. 1987, Meade et al. 1990, Hadler and Curtis 1988). Furthermore provincial laws provide for reassessment so that third party payors may have necessary information regarding the claimant's condition (Saskatchewan Government Insurance, WCB).
Reassessment can be classified in terms of three temporal categories: ongoing or interactive assessment, periodic reassessment, and follow-up reassessment (Haldeman et al. 1992). In chiropractic some type of patient reassessment or evaluation is required at each patient visit. This type of assessment, called interactive assessment, enables the chiropractor to determine the need for and precise nature of spinal adjustment and other care. Such an interactive assessment may include evaluation of subjective complaints and objective signs (e.g. SLR; motor weakness; localized areas of tenderness etc.) and the investigation of any new complaints. An interactive assessment should conform to minimal standards recommended by provincial and national governing bodies (eg. CCPA, provincial licensing boards and associations).
Periodic assessments are a more complete form of reassessment that takes places a period of weeks or months after care has been initiated. Such reassessment may include:
1. Repetition of actions or clinical procedures which upon prior examination provided information about the chief complaint and which led to the clinical impression. Examples include range of motion, tenderness and positive pain provocation signs.
2. Repetition of tests which detected abnormalities on initial examination (e.g. deep tendon reflexes)
3. New procedures not previously performed but indicated by the patient's clinical condition.
4. Special studies (e.g. CT scan) which may impact the course of therapy when there has been failure to improve or deterioration in the patient's condition.
Follow-up assessments are similar to periodic assessments except that they are performed after the course of treatment has been completed. The frequency and nature of periodic and follow-up assessments may vary. In one study to determine the effectiveness of manipulation Mierau et al. (1987) had a population of chronic low-back pain patients all of whom showed no progressive neurological, bone or joint disorder, and were fully disabled. They received periodic then follow-up assessments at one, four, seven, ten, thirteen, and sixteen month intervals.
In a study of a similar population of patients Meade et al. (1990) had a protocol allowing for treatment over a period of 12 months. These patients received periodic then follow-up assessments at six weeks, six months, one year and two years after commencement of treatment. In a trial of manipulation for patients with sub-acute low-back pain Hadler and Curtis (1988) adopted a protocol of periodic assessment every three days for two weeks after treatment had commenced.
In clinical practice, the frequency of periodic assessment is usually determined by a number of factors, such as the severity of the condition, the likelihood of progression and degeneration, and third party payor requirements. More limited forms of periodic reassessment can be frequent. Patient survey instruments for spinal pain/disability (e.g. Oswestry Questionnaire, Roland-Morris Questionnaire, Neck Pain Disability Index) should be used with such frequency as change is expected, which may be two week intervals (Meeker 1992.)
Scoliosis is an excellent example of a condition in which the frequency of reassessment varies with the severity and location of the condition, the age of the patient, and history of prior progression (Haldeman et al. 1992). For instance, children in high-risk categories (progressive curvature, twenty to thirty degree range, skeletally immature individual) should be examined every four to six months until skeletal maturity has been attained. A full-spine radiograph should be taken as long as progression is suspected (Nykoliation et al. 1986, Winter 1990).
V. ASSESSMENT CRITERIA
Rating System 1 and 2 assessment criteria are used in this chapter. For an explanation of this system (see p. xxiii).
VI. RECOMMENDATIONS (GUIDELINES)
A. General Principles
9.1 Reassessment is an essential component of case management. Some form of reassessment should be made at each visit to establish therapeutic necessity. A more extensive form of reassessment should be made following an appropriate period of care or following material changes in a patient's condition.
Rating: Necessary
Evidence: Class I, II, III
Evidence: level: 1
9.2 Reassessment is the responsibility of the practitioner. All tests should be performed by persons appropriately trained and qualified in the specific procedures.
Rating: Necessary
Evidence: Class II, III
Evidence: level: 1
9.3 Reassessment should include review of the case history, including all relevant previous findings, and evaluation of any new findings.
Rating: Necessary
Evidence: Class I, II, III
Evidence: level: 1
B. Indications for reassessment
A reassessment should be performed after a reasonable length of time with no clinical improvement, with a deterioration of clinical status, with the manifestation of clinical signs or symptoms not previously observed, or when requested by third party payors.
Rating: Necessary
Evidence: Class II, III
Evidence: level: 1
C. Scoliosis (idiopathic)
Children in a high risk category should be examined at appropriate intervals, until skeletal maturity has been attained. Appropriate A/P or P/A radiographs should be taken to monitor progression.
Rating: Recommended
Evidence: Class I, II, III
Evidence: level: 1
D. Follow-up reassessment
9.4 Follow-up reassessments should be performed at appropriate interval(s), to assess the long-term effects or implications of management.
Rating: Recommended
Evidence: Class II, III
Evidence: level: 1
VII. COMMENTS, SUMMARY OR CONCLUSION
Appropriate and timely reassessment of patients is an important aspect of health care practice. The way in which reassessments are made needs considerable clarification. Interactive procedures in chiropractic practice should be simple and allow for assessment on an ongoing basis. Periodic evaluations should have more formal structure and detail. However, exact evaluative procedures chosen, and frequency of periodic and follow-up reassessment, will be determined by the precise nature of each case.
VIII. REFERENCES
Battista R, et al. Assessing the Clinical Effectiveness Preventative Maneuvers: Analytic Principles and Systematic Methods in Reviewing Evidence and Developing Clinical Practice Recommendations. A Report by the Canadian Task Force on the Periodic Health Examination. J Clinical Epidemiology 1990; 43(9):891-905.
Canadian Chiropractic Protection Association. Information/Risk Management Manual. Toronto: CCPA, 1988: 34, 41-47.
Chapman-Smith D. Measuring Results - The New Importance of Patient Questionnaires. The Chiropractic Report 1992; 7(1).
Daltroy LH, et al. A Modification of the Health Assessment. Questionnaire for the Spondyloarthropathies. J Rheum 1990. 17(7):946-950.
Ferraz MB, et al. Crosscultural Reliability of the Physical Ability Dimension of the Health Assessment Questionnaire. J Rheum 1990; 17(6):813-817.
Haldeman S, Chapman-Smith D, Peterson DM, (eds).
Guidelines for Chiropractic Quality Assurance and Practice Parameters
The Mercy Conference ~ Major Recommendations
Gaithersburg, Md: Aspen Publishers Inc; 1993.
Hadler N, Curtis P. A Benefit of Spinal Manipulation as Adjunctive Therapy for Acute Low Back Pain: A Stratified Controlled Trial. Spine 1987; 12(7):703-706.
Meade TW, Dyer S, Browne W, Frank AO.
Randomized Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain:
Results from Extended Follow Up
British Medical Journal 1995 (Aug 5); 311 (7001): 349–351
Meeker W. Recommendations for Measurement of Outcomes in Your Practice. In: Chapman-Smith DA, (ed). The Chiropractic Report 1992; 7(1).
Mierau D, Cassidy D, McGregor M, Kirkaldy-Willis WH. A comparison of the effectiveness of spinal manipulative therapy for low back pain. Patients with and without spondylolisthesis. J Manipulative Physiol Ther 1987; 10:49-55.
Nelson EC, et al. The Measurement of Health Status in Clinical Practice. Medical Care 1989; Mar 27(3 Suppl):577-590.
Nykoliation J, Cassidy J, Arthur B, Wedge J. An Algorithm for the Management of Scoliosis. J Manipulative Physiol Ther 1986; 9:1-14.
Reith P. The Periodic Health Examination in College Students Revisited. J Am College Health 1991; 40(3):119-123.
Spasoff R. Current trends in Canadian health care: disease prevention and health promotion. J Public Health Policy. 1990; 11(2):161-168.
Winter RB. Spinal problems in paediatric orthopaedics. In: Morrissy RT, (ed). Paediatric Orthopaedics. Philadelphia: Lippincott, 1990.
IX. MINORITY OPINIONS |