Transcript Document

DOCUMENTING
MEDICAL NECESSITY
THRU
OUTCOMES ASSESSMENT
OUTCOMES

Outcomes Assessment
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Collection and recording of information
relative to health processes
Outcomes Management
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Using information in a way that
enhances patient care
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The
Clinical Application of Outcomes Assessment, Stamford
Connecticut, Appleton & Lange, 2000)
The Era of Outcomes
Assessment

Outcomes in clinical practice provide the
mechanism by which the health care
provider, the patient, the public, and
the payer are able to assess the end
results of care and its effect upon the
health of the patient and society.

(Anderson & Weinstein, 1994).
Survival

To survive, in fact to flourish, in this era
of accountability health care providers
must be prepared to maintain and be
able to provide appropriate
documentation and patient records in a
clinically efficient and economical
manner.
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(Hansen, 1994).
Health Policy

With the dawning, of the “era of
accountability,” there are new social
mandates directed toward health care
providers
and
health-related
facilities.
Measurements
of
quality,
satisfaction,
efficacy, and effectiveness now serve as
essential elements for health care decisions
and matters of health policy.

(Hansen DT, Mior S, Mootz RD in Yeomans SG:
The Clinical Application of Outcomes Assessment,
Stamford Connecticut, Appleton & Lange, 2000)
Outcome Meanings
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Health Care Customer - Meaning of Outcomes
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Payers-purchasers
Regulators
Administrators
Clinical Researchers
Outcomes Experts
Health Care Providers
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Cost containment
HCP compliance
Efficiency-low utilization
Proof of a premise
Patient’s benefit
Clinical-Health Status
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical
Application of Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000)
Outcomes Criteria
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Utility
Reliability
Validity
Sensitivity
Is it useful?
Is it dependable?
Does it do what it is supposed to?
Can it identify patients with a
condition?
Specificity Can it identify those that do not
have the condition?
Responsiveness Can it measure differences
over time?
Outcome Measures
Appropriate for Clinical Use
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Questionnaires
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General health status
Pain
Functional status
Patient satisfaction
Physiological outcomes
Utilization measures
Cost measures
Outcomes Measures
Appropriately Used

When outcome measures are
appropriately used and integrated
into an evidence-based, patientcentered model of practice, there is
accountability and quality assurance.

(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical
Application of Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000)
Subjective Questionnaires
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Subjective outcomes assessment
information is gathered by the patient
in self-administered questionnaires and
scored by either the:
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health care provider
staff members or
by a computer.
Subjective Questionnaires

In spite of the definition associated with
the term “subjective,” these “pen-andpaper tools” have been described as
very valid and reliable – in many cases
more so than many of the “objective’
tests that health care providers have
relied upon for years.

(Chapman-Smith, 1992; Hansen, 1994; Mootz,
1994).
Subjective vs Objective

It must be emphasized that although
the term “subjective” carries negative
connotations, the reliability/validity
data published regarding these methods
of collecting outcomes is exceptional,
typically out-performing the test-retest
reliability and validity of most
“objective” physical performance tests.
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(Chapman-Smith, 1992).
Classification of Outcome
Assessment Tools
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Subjective
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(Patient Driven)
General Health
Pain Perception
Condition or Disease
Specific
Psychometric
Disability Prediction
Patient Satisfaction
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Objective
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(HCP Driven)
Range of Motion
Strength - Endurance
Nonorganic
Proprioception
Cardiopulmonary
Developmental
Outcomes Assessment Tools
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It is important to remember
to utilize the same outcome
assessment tool through the
course of case management
with each patient.
General Health Questionnaires
(GHQ)
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One can benefit from the use of a GHQ
because it is not condition-specific and,
therefore, can be applied to virtually
any complaint.
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Yeomans SG: The Clinical Application of
Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000
Application of General Health
Questionnaires (GHQ)
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The application of a GHQ should, at
minimum, be used at the following intervals:
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At the time of the initial presentation for
baseline establishment of outcomes
assessment.
To identify problems for prompt
management.
At a plateau in care or discharge for
outcomes assessment of the treatment
benefits or lack thereof.
Six months after discharge in order to
evaluate the long-term benefits of
treatment.
Normative Data - Rand 36
General Health Questionnaire
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Scale
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Normative - Exam 1 - Exam 2
Health perception
Physical functioning
Role – Physical
Role – Emotional
Social functioning
Bodily Pain
Mental health
Energy/fatigue
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Ware et al, 1993
72
84
81
81
83
75
75
61
46
42
0
22
55
0
42
22
66
78
59
27
70
68
72
48
Rand 36 – General Health
Questionnaire
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This can serve as a very practical
reference tool to use for patient report
of findings, to insurers to justify
“medical necessity” for additional care,
and to the health care provider to
facilitate the decision making process of
case management (referral, discharge).
Rand 36 Scales
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Some of the scales – such as
physical function, pain, and role
(physical) of the RAND-36 are
sensitive to change over time and
parallel the patient’s
symptomatology quite well.
Outcome-Based Practice
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Correlating this information to the patient’s
specific clinical data and then making a
clinical decision based on the results
represents a difficult but important step in
making the “paradigm shift” into becoming an
“outcome-based” practice.
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Yeomans SG: The Clinical Application of
Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000
Pain Perception
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Visual Analogue Scales
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Reliable and valid (Jensen and Karoly,
1993).
Advantages over other measurement
methods (Scott and Huskisson 1976, Price
et al 1994).
Quadruple Visual Analogue
Scale (QVAS)
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Four specific factors - Von Korff et al, 1992
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CURRENT Pain Level
AVERAGE or TYPICAL Pain Level
Pain level at its BEST
Pain level at its WORST
Final Score
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Ratings are averaged x 10 = TOTAL SCORE
(Range 0 – 100)
QVAS – Guidelines
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Chronic Patient
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Average Pain = Last 6 months
Frequency
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Every 2 weeks since a patient’s failure to
progress over a 2-week period may
indicate a need for a change in
management approaches
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(Haldeman et al, 1993).
Condition-specific
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Over 40 low back functional questionnaires
exist with five identified by researchers as
“gold standards” (Kopec and Esdaile, 1995).
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Sickness Impact Profile (Bergner et al,
1981)
Roland-Morris Disability Questionnaire
(Roland and Morris, 1983)
Oswestry Low Back Pain Disability
Questionnaire (Fairbank et al, 1980).
Million Visual Analogue Scale (Million et al,
1982).
Waddell Disability Index (Waddell, 1984).
Oswestry Questionnaire
(Discharge Score)
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A score of 11% may be used as an
appropriate cut-off score for health care
providers to consider for discharge
and/or return to work in an
uncomplicated Low Back Pain case.
(Erhard et al 1994)
Revised Oswestry
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Retitled section 8, now identified as “Social
Life,”
This section was originally entitled “sex life”
and was left blank quite often by
respondents.
In the revised version, all ten sections are
completed more often than in the original
version.
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Hudson-Cook N, Tomes-Nicholson K, Breen AC. A
Revised Oswestry Back Disability Questionnaire.
Manchester Univ Press, 1989.
Oswestry - Score
Interpretation
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0-20%
20-40%
40-60%
60-80%
80-100%
Minimal Disability
Moderate Disability
Severe Disability
Crippled
Bed Bound or
Exaggerating
Oswestry Score –
Statistically Significant Change
(Minimal-Moderate Disability)
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Initial Score 
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0-8
5-12
9-16
13-20
17-24
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Change Necessary
2
4
5
8
8
Stratford et al, 1988
Roland-Morris Disability
Questionnaire (RMQ)
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Total Possible Score = 24.
“The best single study of assessing shortterm outcomes of primary care patients with
low back pain “(Von Korff and Saunders,
1996)
Scores greater than 13 = Significant disability
associated with an unfavorable outcome
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(Von Korff and Saunders, 1996)
Any change of less than 4 points is both too
small to matter and too small to be reliable
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(Stratford et al, 1996)
Neck Disability Inventory
(NDI)
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“was designed by modifying the
Oswestry Low Back Pain Disability
Questionnaire”
“The instrument was utilized on an
initial sample of 17 consecutive patients
with whiplash injuries with good
statistical significance reported”.
Copenhagen Neck Functional
Disability Scale (CNFDS)
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“CNFDS demonstrates
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short-term and day-to-day reliability
internal consistency
practicality
accurate patient perceptions regarding
functional status and pain
doctor’s global assessment
responsiveness to change over long periods
of time
CNFDS Score Range
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Maximum point score is 30 and
“indicates that the individual is
extremely disabled because of neck
trouble, whereas a score of 0 indicates
that there is no neck trouble present.”
Headache Disability Inventory
(HDI)
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25 question – condition specific often
used in conjunction with the NDI for
patients suffering from cervicogenic
headaches (Jacobson et al, 1994)
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12 emotional questions
13 functional questions
HDI Interpretation
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100 Points = Maximum possible Score
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Headache Severity (Jacobson et al, 1994)
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2-32 =
33-59 =
60 + =
Mild
Moderate
Severe
Positive Treatment Results
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29 point total score change
(Jacobson et al, 1994)
Dizziness Handicap Inventory
(DHI)
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25 questions evaluate the impact of
vestibular system disease or dizziness
on everyday life
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Functional: 9 items
Emotional: 9 items
Physical: 7 items
DHI Studies
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“good internal consistency, reliability, &
validity demonstrated (Jacobson &
Newman 1990).
“found to correlate with balance
function tests that included
electronystagmography, rotation
testing, and platform posturography
(Jacobson et al, 1991)
Tinnitus Handicap Inventory
(THI)
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25 questions “developed to track patients
who suffer from tinnitus pre- and posttreatment”
(Newman 1996)
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Functional: 12 items
Emotional: 8 items
Catastrophic: 5 items (identifies patients
with psychosocial concerns)
“found to be valid, responsive, and easy to
score and interpret.”
Temporomandibular Disorder
Disability Index (TMD)
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10 questions and scored similar to
Oswestry
“the tool has face-validity”
Spinal Stenosis Questionnaire
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18 items
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Symptom Severity : 7 Items
Physical Function: 5 Items
Satisfaction: 6 Items
Spinal Stenosis Studies
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“was found to be reproducible, valid,
internally consistent, and responsive to
clinical change in a geriatric spinal
stenosis population pre and postsurgery” (Stucki et al, 1996).
This measure is meant to be used in
conjunction with other existing spine
and health status instruments.
Shoulder Injury SelfAssessment of Function
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15 item ADL tool included in the
American Shoulder and Elbow Surgeons
SEF
(Barrett, 1987; Rowe, 1987)
0 = Normal
60 = Self-assessed Disabiltiy
Shoulder Pain and Disability
Index (SPADI)
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13 point questionnaire measuring
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Pain
Disability
Scale has been shown responsive to
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Improved Change
Worsened Change
Elbow Performance Index
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100 point index (Morrey, 1993)
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Pain
Motion
Stability
Function
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45 points
20 points
10 points
25 points
Carpal Tunnel Syndrome
Questionnaire (CTSQ)
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“strength lies in its ability to track outcomes
based on SYMPTOM SEVERITY and
FUNCTION, which are two of the primary
reasons presented to health care providers.”
19 questions demonstrating “reproducibility,
internal consistency, validity and
responsiveness”
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Symptom Severity: 11 items
Functional Status: 8 items
CTSQ Reproducibility and
Consistency
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“In comparing inter-rater agreement to
objective measures, Levine et al point
out the superior scores gathered by the
CTSQ compared to the inter-rater
agreement in ECG interpretation or
between radiologists regarding the
presence of osteoarthritis…” (Levine
1993)
CTSQ Measures

“this dispels the myth that so-called soft
(subjective) outcomes such as the
CTSQ are less valuable when compared
to objective measures when, in fact, the
subjective measures are often more
sensitive, specific, and responsive than
many objective measures.” (Koran,
1975)
CTSQ Validity

“CTSQ and traditional physical
examination measures of median nerve
function capture different but
complementary outcome information.
Therefore, symptom severity and
functional status cannot be reliably
compared to sensibility or nerve
conduction testing.”
(Levine et al, 1993)
Patient-Rated Wrist Evaluation
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150 point index
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Pain
Function
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-
50 points
Specific Activities Usual Activities
-
60 points
40 points
Hip Rating Questionnaire
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100 point index (Johanson et al, 1992)
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Pain
Walking
Function
Arthritis
Patellofemoral Function Scale
(PFS)
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8 item ADL tool “demonstrating
potential to detect clinical change”
(Reid, 1992)
16 = Normal
0 = Functional Disability
Subjective Knee Score
Questionnaire (SKSQ)
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8 questions rating symptoms and
specific sport functions
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Symptoms = Pain - Swelling - Stability
Sport Function = Activity Level–WalkingStairs-Running-Jumping/Twisting
100
6
=
=
Normal
Functional Disability
Ankle Grading System
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100 point index ( Mazur et al, 1979)
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Pain
Function
Walking
Support
Hills (up)
Hills (down) Stairs (up) Stairs (down)
Toe Rising Running
ROM
-
50 points
6 points
6 points
6 points
3 points
3 points
3 points
3 points
5 points
5 points
10 points
Waddell Nonorganic
Low Back Signs
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Objective measures for evaluating
abnormal psychosocial issues
(Waddell et al, 1980)
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8 tests that make up the 5 Waddell
Signs
3 or more positives, nonorganic LBP is
considered
Tests Comprising Waddell’s
Signs
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Tenderness
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Simulation
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Straight Leg Raising
Regional
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Axial loading
Trunk rotation
Distraction
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Superficial
Nonanatomic
Nonanatomic weakness
Nonanatomic sensation
Over-reaction
Psychometric Assessment
Tools - DRAM
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Distress and Risk Assessment Method
DRAM (Feuerstein 1987)
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Modifed Somatic Perception Questionnaire
(MSPQ)
Modified Zung Depression Index
DRAM – Distress and Risk
Assessment Method
Type
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Modified Zung
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Normal
At Risk
Distressed/Depressive
Distressed/Somatic
<17
17-33
>33
17-33
MSPQ
NA
<12
NA
>12
Red Flags of Low Back Pain
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Cancer
Infection
Spinal Fracture
Cauda Equina
Red Flag Questionnaire
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“Red Flags” of serious disease should be
sought from the earliest possible time.
Patient management can then focus on
de-medicalizing the problem by:
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Reassuring the patient that there is nothing
seriously wrong,
That “hurt” does not necessarily equal
“harm”,
Increasing activities as soon as possible.
Risk Factor Assessment
(Standard Questionnaire)
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Risk of a Prolonged Recovery – Score
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Mild
Moderate Severe
-
82 - 114
115 – 143
> 143
Risk Factor Assessment
(Re-Exam Questionnaire)
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Risk of a Prolonged Recovery – Score
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Mild
Moderate Severe
-
51 - 71
72 - 89
> 89
Range of Motion
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Discriminates between various
assessment and treatment outcomes
Provides important clinical information
inspite of controversies associated
Has proven to be an objective outcome
assessment tool
Strength and Endurance
Testing – Alaranta
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“valid, reliable, safe, practical, and responsive
measures of trunk strength and endurance.”
4 Tests (Alaranta et al, 1994)
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Repetitive sit-up
Repetitive arch-up
Repetitive squatting
Static back endurance
Normative values
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508 male/female employees
white-collar and blue-collar
age: 35-54
Alaranta Test Procedures
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Repetitive sit-ups - arch-ups - squatting
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50 reps maximum
2-3 seconds per repetition
“If the motion becomes clearly jerky or
asymmetrical, the test should be stopped”
Static Back Endurance
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240 seconds maximum
“test discontinued if aggravated by pain or
muscle spasm.”
Alaranta Test Guidelines
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Patient warmup for 5 minutes prior to
beginning testing (ei. bicycle ergometer, etc)
Tests are retested in the same order
1-minute interval between each test
Tester may count repetitions aloud but should
remain as neutral as possible
Test terminated if patient told more than one
time to correct trunk motion
Patient informed about mild painful feelings in
tested muscle groups during the couple of
days following the maximal test.
Alaranta Normative Values
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Age 35-54
Females
Repetitive sit-up
Repetitive arch-up
Repetitive squatting
Static endurance
Males
27 +/- 14
28 +/- 14
37 +/- 13
97 +/- 53
19 +/- 14
24 +/- 14
21 +/- 12
87 +/- 59
Satisfaction Questionnaire
(SQ)
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14 item measure of satisfaction modified from
The Chiropractic Satisfaction Questionnaire
Includes items on
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interpersonal quality
technical quality
time spent
cost of care
satisfaction with care
Median Score = 90 / 100
4 Steps to
Become Outcomes Based
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Utilize subjective/objective tools
Score the tools at the initial visit to
establish baseline measures
Repeat the instrument after 2-4 week
intervals to track the effects of
treatment changes
Base clinical decisions on the outcome
results
“Medical Necessity”

The fully developed clinical record
defines the “medical necessity” of the
case in the eyes of the insurer.
“Medical Necessity”
Documentation
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Provider must document
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Etiology of complaint
(onset, severity, frequency , duration
Patient’s health history
Current subjective complaints
Current objective clinical findings
Diagnosis
Treatment plan
Measurements of patient improvement
(outcome assessment)