Yeomans Chiropractic Center

Yeomans/Edinger
Chiropractic Center, SC

Applying Outcomes Management Into Clinical Practice

FROM: JNMS: Journal of the Neuromusculoskeletal System 1997; 5 (1): 1–14

Steven G. Yeomans, D.C., FACO
404 Eureka St, Box 263
Ripon, WI 54971-0263
(414) 748-3644
fax (414) 748-3642 Craig Liebenson, D.C.
10474 Santa Monica Blvd., #202
Los Angeles, CA 90025
(310) 470-2909
fax (310) 470-3286

The paradigm shift in health care from case management to cost contained, outcomes management (OM) has vaulted the study and use of valid and reliable outcomes tools . OM, when used appropriately, can measure progress, or the lack thereof, in three critical areas which include pain management, physical capacity (impairment), and disability (activity intolerance). This article describes various outcomes instruments and their respective goals in OM. An extensive literature search as well as conversations with various authors were utilized in this study, which categorizes and classifies OM tools and provides a brief discussion of each. In addition, a time-line recommending a “when to use what” approach is offered.

Key words: Outcomes assessment, Outcomes management, Quality assurance

Introduction

Outcomes management (OM) is becoming a popular approach utilized in modern managed care to assure quality and contain costs. OM can be defined as the measurement of symptom and/or function of a patient's clinical status. The process of assessing outcomes starts on the initial visit which is essential in order to establish baselines and to help in goal setting. Of importance, OM tools are simple to administer, low in cost (many OM tools are patient, rather than doctor driven), and low-tech oriented (no expensive equipment is required). The critical issue is to establish functional goals, and then to follow those goals by documenting patient status and progress over time by utilizing OM.

The promotion of quality without sacrificing cost is a critical component of outcomes management. [1] The ratio of quality to cost as described by Frymoyer defines value. [2] Quality can be assessed by the demonstration of improved outcomes. Therefore, evidence based treatments can be assessed for both value and quality by the use of OM. [3] The primary goal of care in the acute stage is symptomatic relief of pain, and in the sub-acute to chronic stage, prevention of disability. These goals are achieved by focusing on returning function (reducing impairment) which result in activity limitations/intolerance, and the use of OM can help the provider determine when to focus on each of these goals. To clarify, the term disability refers to "...a decrease in, or the loss or absence of, the capacity of an individual to meet personal, social, or occupational demands, or to meet statutory or regulatory requirements." (4. AMA 1994, 317. -see ref 32) On the other hand, the term impairment refers to "...the loss, loss of use, or derangement of any body part, system, or function." (4 Ibid. p.315). Therefore, these do not mean the same thing as the same loss of function or impairment may result in a different level of disability. More specifically, a concert pianist who amputates a digit may be completely disabled from his/her vocation as a performing musician thus resulting in a high level of disability. However, the same impairment in a worker who does not necessitate the use of the amputated digit in their vocation or avocation, may not be disabled what so ever. Therefore, impairment has to do with dysfunction while disability has to do with how that dysfunction affects their activities of daily living (ADL's).

Case management refers to the care of a patient, taking into consideration all the complexities with which they present. In some cases, there are little if any complexities that interfere with the resolution of their presenting complaint. A stereotypic example is a young man or woman who sustains a low level, mechanical back injury for the first time. If past history is non-contributory and the patient complies with treatment recommendations, resolution can be expected without significant complications. However, in some cases, especially those who present with chronic conditions where the etiology is multifactorial, a successful outcome may depend on identifying one or several barriers which may interfere with recovery, thus further reinforcing chronicity. The care one renders to the complicated, multifactorial case may necessitate treatment of a psychosocial issue such as job dissatisfaction, low pain tolerance, depression, an abusive job or ADL task, and so on, more so than their physical impairment. Hence, if the provider is being sought in a primary care setting and proper case management is practiced, it is necessary to obtain a complete current and past history (including medical, family, occupational, social and habits history), perform a complete exam, and review past health care provider records. The health care provider must then weigh the information obtained to determine where care is most needed.

Table 1
To make this process less cumbersome, a "continuum of care" should be followed to achieve quality assurance (see Table 1). By keeping track of these steps, the provider can stay focused on treatment goals and address important issues as they arise.

In general, outcomes management is designed to establish baselines, document progress, assist in goal setting, and motivate patients. It has something to offer the patient, provider, and payor.

OVERVIEW: CATEGORIES OF OM TOOLS

There are many different outcomes management (OM) tools and determining what tool is most appropriate and when to use that tool is no easy task. To assist the provider in determining when each of the goals of care are reached, OM includes valid and reliable, quantifiable measurements of patients symptoms, impairment/functional limitations, and disability/functional capacity. Other outcomes categories include general health, patient satisfaction, and psychometric information regarding abnormal illness behavior.

The various outcome management tools can be divided into two large categories, those which are patient driven or subjective and those which are provider driven or objective. For example, the measurement of pain has classically been a subjective measure as the provider is generally, requesting a patient to verbally respond to a noxious stimulus.

Examples of subjective/patient driven OA tools include the
Visual analog scale (measures pain intensity) [4],

pain diagram (measures location and quality of pain) [5], and

McGill Pain Questionnaire (measures sensory, cognitive, and motivational evaluation to pain). [6, 7]
However, pain perception can also be objectively assessed by use of algometry or use of the Rheumatology Rating Scale (8) (Grade 0–IV) (see table 2). In the latter, the provider rates the patient response to a palpatory stimulus not by asking the patient to rate the pain level but rather, by observing for facial grimace, signs of withdrawl, i.e., pain behavior. By comparing the painful sites to uninvolved body areas, the provider can determine if the response is increased physiologically (appropriate behavior), exaggerated or, non-organic in character (an exaggerated response to a non-noxious stimulus). By combining this objective pain assessment technique with a subjective numerical pain scale, the provider can determine the patient's perception of their pain tolerance in relation to the observed behavior. By doing so, consistency between the two (or the lack thereof) gives the provider important information regarding patient pain threshold as well as sincerity. Using a 0 to 10 numerical pain scale, severe pain intensity has been considered by some as pain greater than 6 (usually documented as "6/10", allowing the reader to understand that a 0–10 scale was used.). [4] Other methods of tracking outcomes based on pain perception will be covered in more depth later in this paper.

The measurement of physical capacity (isolated function of muscles and/or joints) using inexpensive, low-tech approaches has also been reported. [9–11] These tests in essence, evaluate impairment or dysfunction. For example, Range of Motion, Strength, and Endurance can all be tested. Alaranta showed that low-tech tests are reliable and valid and normative data has also been published on these simple and inexpensive, squatting, trunk flexion, and trunk extension tests. [9–11]

There are a number of questionnaires available for identifying the patient’s perception of his or her disability or activity intolerance.

A partial list includes:
Oswestry Low Back Pain Disability Questionnaire [12, 13] (see Figure 1);

Spinal Function Sort and Hand Function Sort [14],

Neck Disability Index [15],

Roland-Morris Questionnaire [16], and

Functional Assessment Screening Questionnaire (FASQ) [17].

Figure 1
Table 2
Table 3
An example of an instrument representing this category of OM tools is the Oswestry Low Back Disability Questionnaire (Figure 1). [13] This instrument captures activity intolerance such as personal care, lifting, walking, sitting, standing, sleeping, traveling, and others. Since these describe disability issues, they are an excellent source for tracking outcomes from treatment intervention. These tools are discussed more thoroughly later in this article.

Functional capacity or whole-body movement tests [14, 18] can also be measured, although testing is usually more complicated and time consuming. Examples of functional capacity tests include: lifting, carrying, aerobic capacity, static positional tolerance, balancing, and hand function.

CRITERIA

Some of the criteria used for judging whether an OM tool is good or not are summarized in Table 2. These criteria will help you determine whether a specific tool is worth the financial expense or time spent in your clinic. [16].

Outcome assessment tools should be time efficient, inexpensive and valid to be of practical use for you in your clinic. Table 3 outlines the different types of validity and includes a brief definition of each. [21]

CLASSIFICATION OF OUTCOMES ASSESSMENT TOOLS

A pen and paper questionnaire approach is particularly valuable for gathering outcomes information as they represent time-efficient, inexpensive, and simple methods for gathering information. They are easy to administer and score and do not take up a significant amount of provider or staff time while providing valid and useful information to assess outcomes. Tools such as an inclinometer are also invaluable for quantifying objective data of a patient's functional status and therefore, can determine progress.

Symptoms/Pain

Pain level can be assessed by the use of some type of scale, such as a 0–10 scale. Use of this addresses the patient's perception of their pain level. Tracking of pain is important as severe pain intensity is described as one of the four factors which predicts that a patient's condition may be complicated and outlast the usual natural history. [42] Examples of OA instruments belonging in this category include the VAS (Visual Analogue Scale) (4), NPS (Numerical Pain Scale) [21, 22], and the McGill/Melzack Pain Questionnaire. [6, 7]

Figure 2
The VAS instrument can be divided into three scores [4] (see Figure 2):

‘pain level right now’
‘average pain grade’
‘worst pain grade’
When describing the "average pain grade" for the chronic patient, request their pain level as it relates to the last 6 months. To reduce the three numbers to one, the AVERAGE of the 3 ratings is obtained and then multiplied by 10 to yield a score 0–100 score. The final score can then be categorized as "Low Intensity" (pain<50); or "High Intensity" (pain >50). [4] The VAS, like other measures of a patient's progress, should be performed every 2 weeks, since a patient's failure to progress over a 2 week period may indicate a need for a change in the management approach. [42]

Another option in the “pain perception” category includes the McGill/Melzack Pain Questionnaire. [7] This instrument was designed to measure three items [8]:

Sensory discrimination
Motivational evaluation
Cognitive evaluation
The Pain Drawing is a very popular tool used to assess pain in terms of quality (sharp, ache, numb, burning, etc.) and location. Though this method of assessing pain is primarily qualitative, a scoring method has recently been reviewed and found to correlate reliably with the Hy (Hypochondriasis) and Hs (Hysterical) scales of the Minnesota Multiphasic Personality Inventory (MMPI). [23] The reviewers concluded that this could screen out 93% of patients with “poor psychometrics,” and hence, could prompt an appropriate psychological consultation or referral (patient/case specific).

Table 4
A quantifiable method of assessing tissue tenderness following the American College of Rheumatology recommendations is also available (Table 4). [24] In this approach, the provider rates the patient response to palpatory stimulus not by asking the patient to rate the pain level, but rather by observing for facial grimace and signs of withdrawal (ie., pain behavior). By comparing the painful sites to uninvolved body areas, the provider can determine if the response is increased physiologically (appropriate behavior) or exaggerated or nonorganic in character ( an exaggerated response to a non-noxious stimulus). By combining this objective pain assessment technique with a subjective numerical pain scale, the provider can determine the patient’s perception of their pain tolerance in relation to the observed behavior. By doing so, consistency between the two (or the lack thereof) gives the provider important information regarding patient pain threshold as well as sincerity. Using a 0–10 numerical pain scale, severe pain intensity has been considered by some as pain greater than 6 (usually documented as “6/10,” allowing the reader to understand that a 0–10 scale was used). [5]

Physical Capacity (Impairment)

Physical capacity tests measure function such as joint mobility, muscle strength and endurance. Examples include cervical rotation mobility, hip range of motion and trunk extensor endurance. Excellent reliability and normative databases have been found for spinal and extremity rangeof- motion testing (25–38). These tests are inexpensive, time efficient, reliable, valid, and have normative databases. Hence, they serve as objective outcomes data and therefore, can help determine the level of function change before and after treatment or rehabilitation intervention. Since no test is 100% valid or reliable, the provider is encouraged to follow the referenced protocol when performing physical capacity tests to improve accuracy and reduce the changes for error. More specifically, Ekstrand and Gillquist observed an improvement in the CV (coefficient of variation) from 7.5 +/– 2.9 to 1.9 +/– 0.7 after using the tests for 2 months and making subsequent refinements which included (32):

Standardized inclinometer placement to ensure the pendulum of the gravity type swings freely
Stiffening of the exam table (plywood with Velcro bands)
Identify bony anatomical landmarks (mark on skin)
Standardizing the exam bench height for each visit

Figure 3
One of the more published physical capacity tests is the Sorenson test, or the “static back extensor endurance test” (9, 38). The Sorenson test has been found to be able to predict first time onset of low back pain (LBP) in healthy individuals, as well as predict recurrence rates in those already suffering a LBP episode (39, 40). The test is performed with the prone patient’s pubic bone at the edge of the table and their upper torso off the table. With the subject’s arms folded across his or her chest, he or she is asked to raise his or her trunk up to horizontal and maintain the position as long as possible. The “normal” is age and gender specific, but averages between 1 and 1.5 minutes, with a maximum of 4 minutes prior to terminating the test) (9) (see Figure 3). This, as well as other strength and endurance tests, should not be prescribed to a patient who is in an acute stage of their injury. Rather, the Sorensen test is performed when the patient has stabilized sufficiently to allow for strength and endurance forms of rehabilitation, typically 2 to 4 weeks after presenting with uncomplicated low back pain (patient/case specific)

Functional Capacity (Disability)
a) Condition specific questionnaires

Condition-specific Questionnaires (a.k.a. Disease-specific questionnaires) are available for many regional complaints. Lower back, neck, headache, upper extremity and lower extremity regions all lend themselves to independent functional questionnaires regarding functional limitations.

Regarding low back pain (LBP), the Oswestry Low Back Pain Questionnaire [12, 13], the Roland-Morris Disability Questionnaire (16), the Dallas Pain Questionnaire [41], and the Low Back Pain TyPEs (Technology of Patient Experience specification) [42] are examples. In addition, there are many others, of which some have been more recently introduced. [43, 44]

The Oswestry Low Back Pain Questionnaire [12] is very popular and often used as a "gold standard" in studies comparing other low back questionnaires. [43–45] A "Revised" version measures both impairment (function) and disability (limited ADL's). [13] Erhard and Delitto reported that a score of 11% was necessary for discharge and return to work readiness. [46]

Roland-Morris Disability Questionnaire [16] was originally derived from the sickness illness profile (SIP) [47] but was modified for the low back and is often used with the VAS. There are 24 items to check off to describe their condition as it feels today. Scores range from 0–24 covering a range from no complaint to extreme disability. Reliability has been established when compared to the SIP and its major subscales. [48]

The Low Back Outcome Score was recently introduced by Ruta et al., who utilized a stringent reliability and validity process to screen this instrument. [46] The validity and reliability of the instrument was established. This article also contains a good literature review and includes several of the previously mentioned instruments.

Similarly, the Quebec Back Pain Disability Scale was also recently introduced, demonstrating a test-retest reliability of 0.92, and Cronbach's alpha coefficient of 0.96. [44] This instrument was also compared to the Roland-Morris, Oswestry, and SF-36 scales and found reliable and valid. It was recommended to be used to monitor a patient's progress in treatment or rehabilitation programs.

Low Back Pain TyPEs (Technology of Patient Experience specification) [42] was not designed to result in a single score. Rather, each question is sufficiently important to stand alone and serve as a baseline for future comparative assessment (per communication with Deyo). In essence, this instrument serves as an excellent history form specifically designed for LBP patients.

The Neck Disability Index [15] was designed to assess the disability associated with conditions of the cervical spine. This instrument was patterned after the Oswestry Low-Back Pain Disability Questionnaire, is scored similarly, and was validated and found reliable.

The Headache Questionnaire [49] consists of 85 questions and was used by Whittingham, et. al., in testing the treatment efficacy of manipulation for headaches. No scoring method was received (personal correspondence with the author) and therefore, this may serve as an excellent history gathering device, void of a quantitative numerical score. More recently, the Headache Disability Inventory (HDI) was developed and met validity/reliability criteria and is able to be scored. [50] In addition, 48 of the possible 100 points represent functional information and 52 of the 100 points represents emotional information. In addition to the Low Back TyPEs, the Health Outcomes Institute has developed many other condition-specific questionnaires or "TyPEs" (Technology of Patient Experience specification).

These include the following conditions:
1. carpal tunnel syndrome;
2. asthma;
3. chronic obstructive pulmonary disease;
4. depression;
5. hypertension/lipid disorders;
6. osteoarthritis;
7. rheumatoid arthritis;
8. allergic rhinitis; and,
9. smoking cessation. [51]
There are several instruments which can be used to assess upper extremity (UE) dysfunction. For example, shoulder injuries can be assessed by the use of the Self-assessment of Function questionnaire. [52] This is a 15 question instrument which includes activities of daily living as the main outcomes assessing gathering method. A scoring method is available for quantification. The shoulder can also be assessed by the use of the "American shoulder and elbow surgeons shoulder evaluation form". [53] This consists of five sections which include pain (5–0 scale), motion (5–0 scale), strength (5–0 scale), stability (5–0 scale), and function (4–0 scale). The latter comprises aspects of a physical exam with some exception regarding the history. Upper extremity pain can be assessed by the use of the Upper Extremity Pain Questionnaire. [54] This is ideal for elbow, wrist/hand, or carpal tunnel complaints. This instrument consists of 17 items which represent activities of daily living (ADL's), which are scored on a 0 to 10 scale, similar to a visual or numerical pain scale.

Figure 4
The knee can be assessed by using the Functional Index Questionnaire (FIQ). [55] This is an 8 item questionnaire regarding ADL's associated with lower extremity function. Each question is responded to by choosing one of four options which include "no problem", "can do with problem", "unable" or "unknown" (Figure 4). When used in series, this instrument can yield outcome information which can provide the practitioner with information which can help determine a treatment plan or clinical decision.

b) General Disability Questionnaires

The Disability category includes questionnaires which can help predict the "difficult to manage" case. One example of such an assessment scale used to attempt to determine who is at risk for becoming permanently disabled from chronic pain is called the Vermont questionnaire. The use of this instrument was compared to the ability of a group of physicians to predict disability based solely on experience. [56] This model had a predictive value of 89% and was better in predicting disability than the physician group across all samples. The study indicated two potential uses for this type of predictive model. The first is to stratify patients into those who:
1. are going to return to work (RTW) with certainty, almost regardless of the treatment type received (very low disability scores).

2. will be resistant to treatment and may not RTW "no matter what" (very high scores).

3. are likely to RTW if treated effectively.
The second potential use is to alert health care providers to the critical risk factors associated with difficult LBP cases. There is a short version with a total of 14 questions which requires approximately 3–5 minutes to complete. Both validity and reliability of this instrument has been reported in a recently publish article by the Vermont Rehabilitation Engineering Research Center for Low Back Pain. [57]

The FASQ (Functional Assessment Screening Questionnaire) is a 15 item checklist designed for a primary care population in evaluating disability associated with chronic pain. [17] A third scale, FABQ (Fear Avoidance Beliefs Questionnaire) is also available. [58] This instrument may be used when assessing the chronic pain patient where fear avoidance behavior is suspected. This questionnaire is also useful as a psycho-social screening test as fear of pain associated with activity is common in the chronically painful patient.

c) Functional Capacity Tests

Functional capacity tests assess whole body movements or functions as opposed to single functions such as straight leg raise or spinal ROM's. Hence, since multiple functions are assessed by this method, this type of testing is often utilized when assessing work capacities when returning an injured worker back to the work place or when determining an individuals level of disability. Various tasks are assessed when assessing a patient for returning to work which may include the following:
Lifting and carrying — assessed by the PILE (Progressive Isoinertial Lifting Evaluation) [59] and the Job Demands Questionnaire [14]

Aerobic — assessed by a cycle ergometer, treadmill tests, step tests, or by field tests [60]

Static position tolerance — assesses position tolerances which include reaching from standing, stooping, crouching, and kneeling positions. [14]

Balancing — assessed by a one-leg balance tests [61]

Hand function — assessed by Matheson's hand sort where the patient matches activities from charts which correlate with their particular occupation. [14]
The Spine and Hand Function Sort are methods of gathering information from the patient which helps define their current vocational or work level. [14] This is completed by the patient matching work and other activities of daily living (ADL's) with charts which correlate to their particular work and lifestyle activities. This information is important as it helps identify the typical physical stressors the patient is confronted with on a daily basis. In addition, when combined with physical measurements of function, such as ROM, strength, balance, lift/carry, etc., the spine and/or hand sort is a key piece of data from which work restrictions can be logically and intelligently established.

OTHER TYPES:

Psycho-social issues are a major complicating factor in patient management and must be identified early in patient management. This outcomes assessment category is described as "Psychometrics." If improvement is not noted, certainly by the end of the initial 6 weeks of care, this issue should be thoroughly investigated. Patients with significant problems in this area may require a tertiary treatment center or a multidisciplinary team. At minimum, the addition of a clinical psychologist who specializes in chronic pain behavior is a necessary addition to the management team.
Patients in this category often have one or more of the following [62]:

job dissatisfaction
previous disability
high anxiety
depression
symptom magnification
pain avoidance behavior
catastrophizing and poor coping strategy
drug or alcohol dependency
family problems
A partial list of instruments in this category include:
1. HSQ (last 3 questions, #36–8) [51];
2. Waddell Non-Organic LBP Signs* [63];
3. SARS (Somatic Amplification Rating Scale)* [64];
4. Modified Zung Depression Index [65];
5. Modified Somatic Perception questionnaire [66];
6. SCL-90R [67];
7. DRAM (Distress and Risk Assessment Method) [59];
8. Beck's Depression scale [69]; and
9. Fear Avoidance Beliefs Questionnaire (FABQ). [58]
*Obtained through physical examination procedures, NOT by questionnaires.
Of those listed above, Waddell's Non-organic LBP signs (#2) and the SARS (#3) are physical examination procedures. The former has been well accepted and used as a "gold standard" in many studies. It is made up of 8 tests which are placed into 5 categories. The SARS is a 7 item scale which is made up of many of the 8 test/5 category scale items introduced by Waddell but are "graded" with reference to severity.

The Waddell signs include the following categories:
1. Pain – Superficial and Deep (2 tests)
2. Simulation – Axial compression and Trunk rotation (2 tests)
3. Distraction – Supine verses sitting straight leg raise test ("flip sign")
4. Regional Neurology – Non-anatomical neurological findings (2 tests) a. Motor b. Sensory
5. Overreaction or Exaggeration
Waddell states that neck pain and nerve root tension may be provoked by the two simulation tests (axial compression and trunk rotation, respectively), and that care must be practiced to avoid a "false positive" Waddell sign if either of these conditions exist.

The SCL-90-R (Symptom Checklist-90, Revised) appears to be an increasingly popular instrument for measurement of maladjustment in a chronic low back pain (CLBP) population. [67] It is comprised of nine scales but only two common important factors are represented, i.e., general psychological discomfort and physical symptoms. Hence, two scales were identified as being sufficient to separate the measurement of physical symptoms (somatization scale) from the more reliable composite measure (Global severity index or, GSI) which measures psychological discomfort. Therefore, advantages of this instrument include its brevity, ease of administration, its face validity to CLBP patients, and its superior reliability.

Regardless of the psychometric instrument utilized, it must be remembered that these instruments are only "screens" for psychological distress. If scores are relatively high, a psychological referral will most likely lead to the most appropriate care.

Patient Satisfaction has become an important outcomes issue, especially with managed care companies and with quality control assessment. [70] These instruments yield important information about the quality of the health care service as perceived by the patient by assessing the following:
1. Acceptance of care
2. Perception of the technical competence of a health care provider
3. The setting where care was provided
4. The effectiveness of the health care provider
This instrument was used in a study comparing MD and DC patient satisfaction with regard to the "report of findings" given to the patient by the health care provider [71], and with overall patient satisfaction. [67] There are several varieties which can be used in a clinical setting.

These include:

Visit-Specific Questionnaire [72, 73]
Patient Satisfaction Questionnaire [74]
The Chiropractic Satisfaction Questionnaire [75]

The next category measures Job Dissatisfaction. One method of assessing outcomes is the Modified Work APGAR which resulted from working with 3,020 aircraft employees to identify job dissatisfaction risk factors for reporting acute back pain at work. [76]

Figure 5
Factors identified in the MMPI (psychosocial responses) and certain work perceptions resulted in the following observations and these findings prompted the formation of the Modified Work APGAR (Figure 5):
1. Those who "hardly ever" enjoyed their job tasks were 2.5 times more likely to report a low back injury (P=0.0001) than subjects who "almost always" enjoyed their work.

2. Subjects scoring highest on the Scale-3 (Hy) of the MMPI were 2.0 times more likely to report a low back injury than subjects with the lowest score (P=0.0001).
Some caution should be used when considering the use of the work APGAR as many patients may be unwilling to filling out this form for fear of employer retribution (per communication with Erhard).

THE INTEGRATION OF OA'S INTO CLINICAL PRACTICE

Once an instrument is selected for use in the clinical setting, deciding when it should be used is another challenge. To assist in answering this question, case management may be broken down into the following stages:
1. Initial/Base line
2. Follow-up/Re-examination
3. At times of exacerbation
4. At the conclusion or discharge of the case
There has been a great influx of new instruments reported in many referenced journals claiming to be able to assess various problems or conditions. Many of these outcomes assessment tools are reported to be valid and reliable. Because of the increasing number of instruments now available, it is practical to categorize these by variety or assessment goal. More specifically, some OA tools yield information regarding general health while others are condition-specific such as low back pain questionnaires. When instruments from several categories are utilized and grouped together, the interpretation of the valid information obtained will facilitate case management of a patient by identifying the pain and disability issues as well as the impact the condition is having on the patient's general health or lifestyle. By identifying these items, appropriate goals can then be addressed. Many of these groupings or, outcomes management systems, address demographics, diagnosis, lifestyle risk factors, co-morbidity issues, prognosis issues and treatment. Most importantly, once an instrument is chosen, it should be utilized throughout the remainder of the patient's care, since these instruments are not interchangeable.

Categories may include:
1. Pain perception;
2. Condition-specific functional disability questionnaires;
3. General health;
4. Psychometrics;
5. Patient satisfaction;
6. Job dissatisfaction; and
7. General Disability, and
8. Job Demands (see Table 5).

Table 5. Outcome Assessment Classification

CATEGORY BASED ON ASSESSMENT GOALS OUTCOME ASSESSMENT INSTRUMENT

1. PAIN LEVEL 1. Numerical Pain Scale (NPS) [19, 21]
2. Visual Analogue Scale (VAS) [4]
3. McGill/Melzack pain questionnaire [6, 7]

2. REGION/CONDITION-SPECIFIC DISABILITY Q's

        LBP 4. Oswestry Low Back Pain Disability Questionnaire [12, 13]
5. Roland-Morris Low Back Questionnaire [16]
6. Dallas Pain Questionnaire [41]
7. Low Back Pain "TyPE" [42]

        NECK 8. Neck Disability Index (NDI) [15]

        HEADACHE 9. Headache Disability Questionnaire (HDI) [50]

3. GENERAL HEALTH 10. Dartmouth COOP charts (74)
11. Health Status Questionnaire 2.0 [51]
12. Short Form (SF)-36 [74, 75]

4. PSYCHOMETRICS 13. HSQ 2.0 (Mental Health scale and questions 37–39)* [51]
14. SF-36* , (Mental Health scale) [74, 75]
15. Waddell's Non-organic LBP signs [60] **
16. Modified Zung Questionnaire [62]
17. Modified Somatic Perception Q. (MSPQ) [63]
18. Beck's Depression Scale [66]
19. Fear Avoidance Beliefs Questionnaire [58]
20. SCL-90-R [64]

5. PATIENT SATISFACTION 21. Patient Satisfaction Q. [68]
22. Visit specific Q. [69, 70]
23. Chiropractic Satisfaction Q. [72]

6. JOB DISSATISFACTION 24. APGAR [73]

7. GENERAL DISABILITY 25. Vermont Disability Questionnaire [56]
26. Vermont Disability Q. – Brief form [57]
27. Functional Assessment Screening Questionnaire (FASQ) [17]
28. Fear Avoidance Beliefs Q. (FABQ) [58]

8. JOB DEMANDS 29. Job Demands Questionnaire (JDQ) [14]

* Only parts of the questionnaire relate to the categories.
** Represents physical examination tests, not self-administered questionnaires [8]

Figure 6
Although there are many opinions as to which of the many instruments should be utilized at initial visit, reexamination, exacerbation, or discharge, one thing is clear. In order to determine outcomes, one must utilize the same instruments on follow-up that were initially used at baseline. Failure to do so will not allow for an accurate assessment of outcomes as different instruments have different methods of scoring, do not carry the same reliability or validity, and are not interchangeable (See Figure 6).

CONCLUSION: A PRACTICAL APPROACH

With a little training, Outcomes Management (OM) can contribute greatly to the musculoskeletal practice. Improved goal setting, patient motivation, determining end points of care, and chart documentation are all clear benefits. Most of the resources mentioned in this article are demonstrated in a practical workbook and videotape by S. Yeomans. [77] Also, there is software available to process the outcomes data generated from all the outcome assessment tools described in this article. [78]

OM is here to stay. Instead of relying on unreliable, invalidated assessments of our patients status which are of little value in a managed care environment, it is now possible to modernize your practice with little expense. OM will continue to become streamlined. Of greatest benefit will be the ability to compare patient data for epidemiological and clinical research purposes.

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CATEGORY BASED ON ASSESSMENT GOALS	OUTCOME ASSESSMENT INSTRUMENT

1. PAIN LEVEL	1. Numerical Pain Scale (NPS) [19, 21] 2. Visual Analogue Scale (VAS) [4] 3. McGill/Melzack pain questionnaire [6, 7]

2. REGION/CONDITION-SPECIFIC DISABILITY Q's

LBP	4. Oswestry Low Back Pain Disability Questionnaire [12, 13] 5. Roland-Morris Low Back Questionnaire [16] 6. Dallas Pain Questionnaire [41] 7. Low Back Pain "TyPE" [42]

NECK	8. Neck Disability Index (NDI) [15]

HEADACHE	9. Headache Disability Questionnaire (HDI) [50]

3. GENERAL HEALTH	10. Dartmouth COOP charts (74) 11. Health Status Questionnaire 2.0 [51] 12. Short Form (SF)-36 [74, 75]

4. PSYCHOMETRICS	13. HSQ 2.0 (Mental Health scale and questions 37–39)* [51] 14. SF-36* , (Mental Health scale) [74, 75] 15. Waddell's Non-organic LBP signs [60] ** 16. Modified Zung Questionnaire [62] 17. Modified Somatic Perception Q. (MSPQ) [63] 18. Beck's Depression Scale [66] 19. Fear Avoidance Beliefs Questionnaire [58] 20. SCL-90-R [64]

5. PATIENT SATISFACTION	21. Patient Satisfaction Q. [68] 22. Visit specific Q. [69, 70] 23. Chiropractic Satisfaction Q. [72]

6. JOB DISSATISFACTION	24. APGAR [73]

7. GENERAL DISABILITY	25. Vermont Disability Questionnaire [56] 26. Vermont Disability Q. – Brief form [57] 27. Functional Assessment Screening Questionnaire (FASQ) [17] 28. Fear Avoidance Beliefs Q. (FABQ) [58]

8. JOB DEMANDS	29. Job Demands Questionnaire (JDQ) [14]