Academy of Chiropractic’s Doctors PI Program

Narratives #71

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

“Using Indexes (i.e.) Oswestry, Neck & Back”

WHO DO THEY HELP?

The utilization of guidelines is a wonderful tool and has tremendous and consistent benefit… usually to the insurance carriers and defense lawyers. To fully comprehend what guidelines are, you must have an in-depth understanding of why and how they were originally created. After you understand the etiology, I will give you solutions of what to use in a contemporary practice. Ensure you carefully read… WHAT TO DO, but do not take a short cut and bypass the explanation…BECAUSE:

 

Reference: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=819:ranges-of-motion-as-a-utility-for-outcome-assessments-chiropractic-taking-a-lead-role-in-rendering-accurate-assessments-for-spine&Itemid=377

Outcome assessments were originally created as “tools” for research purposes, specifically to objectify whether specific treatments were working on a global scale within a population.  Measurement of the effectiveness of treatment is important for the clinician, but the history related to outcome assessment is based upon making assumptions on large groups of people to make a homogenous statement or predictive statement based on a large group of very different people.  In research, investigators want to “group everybody together” and generalize so that they can obtain a starting point to understand the issue they are researching. In this case, the research topic is the effectiveness of a specific treatment, response to chiropractic care in our offices. 

With it comes to patient treatment in general and proving effectiveness in an individual patient, we want to be explicit regarding a specific diagnosis for that specific patient, it is not a process whereby we work off of generalizations.  An experienced practitioner shouldn’t conclude a definitive prognosis based on what’s going on with the rest of the world or even with larger groups of patients. A prognosis should be based upon that particular patient’s response at that particular time. As an example, if a patient were to lose a pinky finger in a work-related accident and that patient was a forest ranger, his day would most likely consist of hiking through the woods. That would render one set of conclusions regarding outcomes and his ability to function. However, if that sample patient earned his living as a concert pianist, there would be a major difference in perceived outcomes and his ability to function in their respective occupations.  Although we could give both men an impairment rating for the loss of that digit, how that loss might affect their lives is very different and specific to each patient. That is what “patient centered care” is all about, focusing on the individual patient not on the population to which that patient is part.  A lot of the most outcome assessment tools are designed give providers treatment pathways, however, to obtain the complete picture, you need to asses each patient’s complete clinical documentation, such as changes in pain levels, motor and sensory function, range of motion, location and degree of muscle spasm, neurological function or any other clinically valid finding.  Initially in care, perhaps only modalities could be utilized, but later, it could be possible to render chiropractic spinal adjustments, changing the prognosis and plan for future outcome improvements. Therefore, the utilization of a “single assessment tool” can do harm to a patient if not all tools available are considered.    

Based upon the last sentence, the inclusion of any “single” assessment tool would appear to be as irresponsible as the exclusion of any “single” assessment tool. You must consider multiple parameters, both in clinical evaluations combined with a detailed history to conclude an outcome.

Bombardier (2000) wrote, “Clinicians and researches increasingly recognize the importance of the patient’s perspective in the evaluations of effective of treatment” (p. 3100). This statement is consistent with Sackett, Rosenberg, Gary, Haynes and Richardson (1996) who stated, “Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions” (p. 73).

Both articles realized that effective healthcare requires more than just published research and must include patient feedback is valid in helping to determine the direction of care and outcomes. However, it cannot stop here and therein lies the problem. It is not possible to determine permanencies or lack thereof with a simple “subjective response” to make a conclusive prognosis. Evidence-based care includes 1) published research, 2) the doctor’s experience and input, and 3) the patient’s input, both verbally and through test results so that the care can be “evidence-based.”  The “evidence” for care comes from three distinct areas and therefore the results of the intervention must also meet the same level of complexity.  There are no shortcuts.

Bombardier (2000) also reported, “A core set of measures should include the following five domains” (p. 3100). This information is leaning a little bit more towards research, however, if you can grasp this general concept, you will begin to understand the miscommunication relating to outcome assessments and what is required to tell the patient’s “true story.” “A core set of measures should include the following five domains: back specific function, generic health status, pain, work disability, and patient satisfaction” (Bombardier, 2000, p. 3100).

When looking at a specific region of the spine, one should focus on these five domains and generically inquire as to what the patient’s presentation is overall. Is he/she an obese smoker? Is he/she fit and active? Are there other comorbidities such as diabetes, a missing limb, etc.?  His/her pain should be documented in detail including whether he/she is completely or partially disabled, what his/her work duties are, and, ultimately, whether he/she is satisfied with his/her care. We know that patient satisfaction is a driver of compliance and if we have compliant patients, then we have people that are adhering to their treatment plan, and historically we’re going to get better outcomes. 

When it comes to specific back function, there are two main outcome assessments: The Roland-Morris Disability Questionnaire and the Oswestry Disability and both are related directly to spine, specifically the lower back.  Historically, chiropractic has considered the spine to be one contiguous organ, but many within the profession are now considering treating the spine segmentally and ignoring the whole. Medicine, conversely started by treating the spine segmentally and is now embracing a whole spine model which in part, is based upon the scientific papers published in neurosurgery journals (following chiropractic’s historic lead). Spinal biomechanics dictates that a whole spine model is critical in spinal stability and long-term spinal health.   If you do not consider creating a homeostatic model, then any corrections made will be temporary at best and perhaps undo any compensatory mechanisms within the spinal system.  Proper full spine biomechanical analysis is being embraced by the neurosurgical community at a very high level particularly, since it has been shown to influence spinal surgery outcomes and chiropractic shares the same goal; to create a homeostatic, biomechanically balanced spine “post-treatment.”

Scheer et al. (2016) wrote:

Patients with thoracolumbar deformity [scoliosis] without preoperative CD [cervical deformity aka loss of cervical lordosis] are likely to have greater improvements in HRQOL [health related quality of life] after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment [cervical lordosis] in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID [minimal clinically important difference] at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity. (p.109)

Scheer, J. K., Passias, P. G., Sorocean, A. M., Boniello, A. J., Mundis Jr, G. M., Klineberg, E.,...Shaffrey, C. I. (2016). Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients: Presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. Journal of Neurosurgery: Spine24(1), 108-115.

Neither Roland-Morris nor Oswestry takes into consideration whether the patient’s entire spine is involved. As an example, the lumbar spine is in pain, but is it a compensatory lesion with the primary lesion being in the cervical region?  Roland-Morris and Oswestry continue to fragment the spine into regions which really are not regions at all, but part of an entire model or organ system. That is a significant drawback in that they’re only “assessing” one part of the spine and, therefore, only a portion of an organ system and ultimately only part of the patient’s real spinal dysfunction.

SOLUTIONS

Very few individual measures are clearly superior, and we must understand that it is the totality of your findings and your patient reports in their entirety that create an accurate picture. If a lawyer, an insurance adjuster, or a medical doctor asks what type of outcome measures you use, the proper answer is, “I use the patient’s objective clinical findings correlated to his/her subjective improvement.  That objective data is obtained every visit through my touching the patient, feeling for spasm, determining if the patient can move, stressing joints, and correlating those findings to his/her pain and the historical etiology of the accident/injury/episode, as well as basic and advanced imaging and electrodiagnostics.”  It reflects the comprehensive patient assessment performed and becomes close to “bulletproof!”

 

Most court rulings I have read over the last 40 years have focused on what the patient can no longer do vs. what they could do prior to their accident. Therefore, KEEP IT REAL in your evaluation and re-evaluations. As an example, “Mrs. Jones was able to do the dishes for over an hour prior to the accident and today, she can only do the dishes for 15 minutes and has to stop as the pain is too severe.” This is a “real-life” example and makes it specific to your patient. Although Colossus wants you to break this up in a “duties under duress vs. loss of enjoyment of life” scenario, you must keep it real for the courts. At the end of the day, this is how you get those pieces of information into the carriers Colossus algorithms and accomplish both concurrently. Without this level of reporting, how else will you get this information into the carrier’s system? By just adding it to a narrative at the end of the case only satisfies the courts and not the carriers algorithms.

 

Never lose sight of the fact that a population-based study considers those on the extreme right and the extreme left and averages the rest of the population. For research, this works… but the patient in front of you, all that matters as whet you have concluded in your VERY LAST EVALUATION, which consists of a thorough history and physical examination to clinically correlate an accurate picture of function, or lack thereof.

 

CAVEAT: Some carriers MANDATE outcome tools, therefore for those you must use them to get paid. For me, I would use them exclusively as mandated and nothing more.