1
THE CLINICAL APPLICATION OF
OUTCOMES ASSESSMENT
TABLE OF CONTENTS and HOUR BY HOUR OUTLINE
Content
1. Overview: Steps to Follow in Evidence-based Case Management; Red
& Yellow Flags
2. The 3 steps required to become outcomes/evidence based
3. How to implement OA into a busy practice
4. Possible OA scenarios
5. Outcomes Assessment (Subjective)
6. Tables: OATs Classification
7. OATs Summary Form
8. SF-12 (or 36) Summary Form
9. Table of contents of text Appendix of forms and New forms
10. Outcome tool: Patient Global Impression of Change
11. Outcome tool: Back Bournemouth Questionnaire
12. Outcome tool: Neck Bournemouth Questionnaire
13. Objective OATs
Page #
2
14. QFCE forms and normative data tables
15. Rehab Options summary (Table of contents of Exercise CD / Manual)
15-23
24
16. Assessment / Plan
25
17. Protocol For Transitioning Patients From Passive Into Active Care
18. Patient profiling / “Yellow Flags”
TOTAL HOURS
CONTACT INFORMATION
Steven G. Yeomans, DC, FACO
404 Eureka Street
Ripon, WI 64971-0263
920-748-3644 (Ph)
920-748-3642 (Fax)
[email protected]
www.yeomansdc.com
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3
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5
6-7
8
8-11
12
13
14
15
26
27-30
HOUR #
Day 1 /
Hour 1
2
Break
3-5
6 (End Day 1)
DAY 2
Hour 1
2
Break
2.5 – 5
Break
END Day 2
Hour 6
12
2
I Introduction
•
•
Give overview of the importance for proper documentation in a chiropractic rehabilitation setting.
Discuss the reasons for outcome assessment and how it benefits everyone involved.
A. Steps to Follow in Evidence-based Case Management
1) Diagnostic Triage (rule out red flags)
2) Identify yellow flags and attend those that are manageable
3) Reassurance/Advice
4) Provide Symptomatic Relief
5) Utilize Outcomes Management
6) Promote Functional Restoration
7) Determine End Points of Care
B. Diagnostic Triage – See Classifications form (CareTrak)
1) The 4 Red Flags (AHCPR and others)
a. Cauda equina syndrome
b. Cancer
1. > 50 y.o.
2. + past history of CA: 98% specificity (Deyo, 1992)
3. Unexplained weight loss
4. Pain > 1 month
5. No improvement with conservative Tx
-------------------------6. Low back pain
7. Positive Neurological losses (Weinstein, 1987)
8. X-ray: 99% were identified on initial x-ray
9. No improvement with bed rest (↑ sensitivity, ↓ specificity)
________________________________
Deyo reported that at least one of the first 5 items listed were present in a group of
known cancer patients while physical examination findings were essentially normal.
1. Weinstein JN, McLain F. Primary tumors of the spine. Spine 1987; 12: 843-851.
2. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?
JAMA 1992 Aug 12;268(6):760-5.
c. Infection
d. Fracture
* See Red Flag Questionnaire*
2) DD Dx: Mechanical vs. Nerve Root spinal pain
C. Identify yellow flags
1. S: Depression screener questions (taken from the SF/HSQ-12 or 36)
2. SF/HSQ-12 or 36: Mental Health Scale, Emotional Scale
3. SCL-90-R (depression and anxiety subscales) or Beck Depression Inventory (BDI)
4. 3 questions from the Bournemouth Questionnaire
D. Discuss the remaining A3-7
3) Reassurance/Advice
4) Provide Symptomatic Relief
5) Utilize Outcomes Management
6) Promote Functional Restoration
7) Determine End Points of Care
3
OUTCOMES ASSESSMENT
I. INTRODUCTION: Why bother? Who benefits?
A. THREE STEPS TO BECOMING EVIDENCE-BASED
1. Orientation to what outcomes assessment tools (OATs) are available
(Oswestry Low Back Disability Questionnaire, Neck Disability Index,
Headache Disability Index, QVAS, Pain Drawing, etc.)
2. Score the tool and write the score on the Outcomes Score Card (p56 in
“Sample Forms for Documentation”).
3. Repeat the SAME OATs at re-exams AND REVIEW THE SCORE
RESULTS TO DETERMINE THE UPDATED TREATMENT PLAN.
B. HOW TO IMPLEMENT AN EVIDENCE-BASED DOCUMENTATION SYSTEM
INTO A BUSY CLINICAL SETTING
1) Hold a CA staff meeting explaining the importance of outcome assessment tools (OATs) prior to or
shortly after implementing the tools (warn them about probable patient resistance of completing paper
work)
a) Stress the point to patients: “Insurers are beginning to require proof for the need of care. By
completing and scoring these forms, we can most effectively prove this to the insurer.”
b) Discuss other important reasons for using OATs.
1. If your injured in the future, we will be able to compare your present status to your past to
prove that further injury has occurred. After completing care, we will both know if you’ve
returned to a pre-accident level of function. This is especially important in car accident cases,
personal injury cases, new insurance – not willing to cover pre-existing conditions, etc.).
2) Give the new patient a clipboard including all your intake forms on their first visit. DO NOT allow
them to sit in your front office filling out forms for more than 15 minutes (pre-appointment time period
– due to poor attention span which reduces the quality of the information).
3) The clipboard follows the patient around from exam room to treatment room to x-ray room, to PT
room. In most cases, patients will complete the forms prior to the conclusion of their first visit. They
may take home the remaining forms if they do not complete them all (expect about a 50% return rate in
which case, re-administer uncompleted forms at the 2nd visit). When you enter to examine the patient,
THANK them for taking care when completing the forms, and the importance of tracking care
accurately – to insure patient satisfaction.
4
C. POSSIBLE OA SCENARIOS:
1. A plateau (Max. Therapeutic Benefit – MTB) short of pre-injury resolution has been reached:
a. Refer for further tests & services
b. Wean care to justify supportive care (determine if patient’s condition deteriorates
with reduced care frequency)
c. Discharge with or without PPD (ONLY if applicable).
d. Explain to patient care may be required when home-based therapies are nonsatisfying.
2. A plateau has not been established (frequent remission/exacerbations)
a. Consider additional forms of care including:
1. Home based exercise program
2. If already implemented, in-office rehab with pre- and post-QFCE to objectively
support the “medical necessity”
3. Co-treatment with allied health care providers, esp if no in-office rehab avail.
3. Patient’s OATs scores are worsening
a. Review patient’s history for exacerbations
b. Discuss with patient outside/home-work physical demands & tolerance
c. Consider ergonomic factors / work station evaluation
d. Consider poor patient compliance
e. Consider inappropriate care (iatrogenic cause)
4) Prove the long-term benefits of chiropractic care by sending the patient the same OATs forms at a 6and/or 12 month point post-discharge. This will also serve as an excellent patient recall/reminder if their
condition is unstable/failing/recurrent (see Table 2).
II. OUTCOMES ASSESSMENT (SUBJECTIVE)
A. OVERVIEW: WHICH TOOL(S) TO UTILIZE?
1.
An immediate practical challenge for the clinician is to determine which instrument or
instruments would be most optimal in assessing specific outcomes.
2.
Table 1 offers an abridged summary of the goals of the outcomes assessment tool and
several instruments one may choose from. Once an instrument is chosen, it should be utilized
throughout the remainder of the patient's care, since these instruments are not interchangeable.
Care should be exercised in avoiding duplication of instruments and goals.
B. PAPER TOOLS
1. Refer to tables 1 & 2
TABLE 1
5
ASSESSMENT GOALS
1. GENERAL HEALTH
2. PAIN PERCEPTION
3. CONDITION-SPECIFIC
a. LBP
b. NECK
c. Extremities
4. PSYCHOMETRICS
INSTRUMENT(S)
COOP health charts, HSQ, SF-36, SF-12
NPS / VAS, Pain Drawing
a. Oswestry, Roland-Morris, FRI, many others
b. NDI, Headache Q. , Bournemouth Q (C & LB)
c. CTS, UE, Shoulder, Ankle, Knee, Hip
SF-36* , SF-12*, Waddell's signs**, SARS**, Mod. Zung,
Mod. Somatic Perception, MMPI, Beck’s Depression
Scale, BQ (3 Q’s) , & others
Chiropractic satisfaction Q., Visit specific Q.
5. PATIENT SATISFACTION
6. JOB DISSATISFACTION
Work APGAR
Vermont DP Questionnaire, Severity Index
7. DISABILITY
8. HYBRID QUESTIONNAIRES
Bournemouth Q. (BQ) (for LBP or Neck);
Table 1. This is a partial list of categories of outcomes assessment instruments and their respective goals.
* Only parts of the questionnaire relate to the categories.
** These are physical examination procedures, not questionnaire tests.
C. WHEN SHOULD THE TOOLS BE USED?
NOTE: 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
TABLE 2 (offers suggestions for when these various instruments could be applied)
DISEXACERRETEST
1ST
DAILY
RTW
6CHARGE
BATIONS
EXAM
VISIT VISITS
&/or
MONTH
Follow Up
2 weeks 2-4/weeks
X
Possibly
X
1. GEN.HEALTH
X
X
X
X
X
X
X
2. PAIN Q.'s
X
X
X
X
X
3. Pain Drawing
X
X
X
X
X
X
4. CONDITIONSPECIFIC / HYBRID
Possibly
Possibly
Possibly
5. PSYCHOMETRIC
X
X
X
6. Pt. SATISFACTION
Possibly
Possibly
Possibly
7. JOB
DISSATISFACTION
Possibly
Possibly
8. DISABILITY PRED. Possibly
4
1
3
4+
4
5+
2
TOTALS
Table 2. This is a summary of the various instruments and when they may be applied.
X= represents when the instrument category could be used during case management.
Stay with your initial or baseline choice for all follow-up evaluations as the instruments are not interchangeable.
6
OUTCOMES ASSESSMENT RECORD
PAIN
DATE
VAS
(Miscell.)
a. Now
b. Ave.
c. Range
CC______
FUNCTION
Options:
Pain
Drawing
1.
2.
3.
4.
UE
CTS
Shoulder
Knee
Options:
VAS &
• Neck
1. Headache
Disability
2. Dizziness
(NDI)
3. SCL-90R
•
CBQ
4. ________
VAS &LB
Disability:
Patient
• Oswestry
• Roland M
Global
Impression
Of Change
• LB - BQ
BASELINE
___/____/___
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
a._______/10
b. ______/10
c.___- ___/10
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
a._______/10
b. ______/10
c.___- ___/10
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
_________%
1. _______%
2. Sx____%
Fn____%
3. ______%
4. ______%
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
a._______/10
b. ______/10
c.___- ___/10
a._______/10
b. ______/10
c.___- ___/10
_________%
_________%
PROGRESS
___/____/___
___/____/___
___/____/___
___/____/___
___/____/___
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
1. T____; E____
Fnctn_______
2. T_____;P____
F_____;E____
3. A_____;D____
4. ________
DISCHARGE
___/____/___
a._____/10
Physiological
b. _____/10
1. Yes
c.___- ___/10
2. No
_________%
Key: VAS visual analogue scale; CC Chief complaint; UE upper extremity; CTS carpal tunnel syndrome; SCL90-R Symptom checklist 90-revised; NDI Neck disability index; LB low back; Sx Symptoms; Fn Function
NAME: __________________________ DATE: __________ DOA:____________ AGE/BD_____________
7
OUTCOMES ASSESSMENT RECORD (Example)
PAIN
DATE
VAS
Cervical
a. Now
b. Ave.
c. Range
BASELINE
Initial
Presentation
3/17/97
PROGRESS
4/16/97
6-2-97
Knee is
reported as
primary
complaint
7-16-97
Pt received
cortisone
shot in knee
8-15-97
10-22-97
Drawing
Cervical
a. 4-5/10
b. 4-5/10
c. 0-5/10
Physiological
1. Yes
a. 0/10
b. 0-2/10
c. 0-5/10
Physiological
1. Yes
a. 0/10
b. 0-2/10
c. 0-2/10
a. 0/10
b. 0-1/10
c. 0-2/10
a. 0/10
b. 0-1/10
c. 0-2/10
a. 0/10
b. 0-1/10
c. 0-2/10
Physiological
1. Yes
Physiological
1. Yes
Physiological
1. Yes
Physiological
1. Yes
Sent for
cortisone
shot shoulder
FUNCTION
VAS
a. Now
b. Ave.
c. Range
Health
Status
Circle: SF-36
HSQ, COOP
R-Knee
a. 2/10
b. 2/10
c. 0-6/10
See separate
report
Knee Q.= 35%
Shlder Q=28%
R-Knee
a. 0/10
b. 0-2/10
c. 0-3/10
See separate
report
R-Knee
a. 0/10
b. 4-6/10
c. 0-8/10
R-Knee
a. 0/10
b. 2-4/10
c. 0-5/10
R-Knee
a. 0/10
b. 2-3/10
c. 0-4/10
R-Knee
a. 0/10
b. 2-3/10
c. 0-4/10
Neck
Disability
(NDI)
%
Improvement
(subj)
26 %
NA
22 %
Knee Q.= 30%
Shlder Q=22%
See separate
report
(6-19-97)
18%
Knee Q.= 56%
Shlder Q=18%
See separate
report
14%
Knee Q.= 32%
Shlder Q=15%
See separate
report
10%
Knee Q.= 22%
Shlder Q=12%
See separate
report
8%
Knee Q.= 20%
Shlder Q=18%
1. C-30%
2. R Shlder
20%
3. R Knee
60-70%
1. C-50%
2. R Shlder
30%
3. R Knee
20%
1. C-60%
2. R Shlder
50%
3. R Knee
40%
1. C-70%
2. R Shlder
50%
3. R Knee
50%
1. C-75%
2. R Shlder
40%
3. R Knee
40%
Patient
Satisfaction
NA
100 %
100 %
100 %
100 %
DISCHARGE
2-4-98
D/C with
PI=14% WP
a. 0/10
b. 0-1/10
c. 0-2/10
Physiological
1. Yes
R-Knee
a. 0/10
b. 3-4/10
c. 0-5/10
See separate
report
10%
Knee Q.= 18%
Shlder Q=12%
1. C-75%
2. R Shlder
50-60%
3. R Knee
50%
100 %
NAME: __________________________ DATE: __________ DOA:____________ AGE/BD_____________
8
HEALTH STATUS QUESTIONNAIRE / SF 36 RESULTS (Blank)
MEAN
SCALE
1. HEALTH PERCEPTION
2. PHYSCIAL FUNCTION
3. ROLE-PHYSICAL
4. ROLE-EMOTIONAL
5. SOCIAL FUNCTION
6. BODILY PAIN
7. MENTAL HEALTH
8. ENERGY FATIGUE
9. MAJOR DEPRESSION
10. DYSTHYMIA
11. BOTH 9 & 10
77.0
90.5
86.1
85.9
88.1
81.2
73.8
60.7
NA
NA
NA
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
This can be placed into a document and insert the results with the corresponding date in each column. Columns
can be added or deleted, depending on the number of times the outcome measure was used. BOLD the “yes” or
“no” for numbers 9-11 regarding depression issues.
Forms CD Table of Contents (from text book appendix)
NOTE: The bold/highlighted forms are routinely used in my office.
A-1.
A-2.
A-3.
A-4.
A-5.
A-6.
A-7.
A-8.
A CHAPTER 5: GENERAL HEALTH QUESTIONNAIRES.........................493
Health Status Questionnaire (HSQ-36): Decoded Version/493
Health Status Questionnaire (HSQ-36)/497
SF-36 Health Status Summary/500
Health Status Questionnaire (HSQ-12): Decoded Version/501
Health Status Questionnaire (HSQ-12)/504
SF-12 Health Status Summary/506
Dartmouth Coop Charts/507
Dartmouth Coop General Health Questionnaire Summary of Results/510
B CHAPTER 6: ASSESSMENT OF PAIN......................................511
B-1. Quadruple Visual Analogue Scale/511
B-2. Pain Related Questionnaire/512
B-3. Short-Form McGill Pain Questionnaire/513
C CHAPTER 7: CONDITION-SPECIFIC OUTCOME ASSESSMENT TOOLS ………..514
C-1. Low Back Pain and Disability Questionnaire/514
C-2. Revised Oswestry Low Back Pain Disability Questionnaire/515
C-3. The Quebec Back Pain Disability Scale/517
C-4. North American Spine Society Low Back Pain Outcome Instrument (NASS)/518
C-5a. Sample Curtin Back Screening Questionnaire/529
C-5b. Curtin Back Screening Questionnaire/530
C-6. Activities Discomfort Scale/531
C-7. Low Back Outcome Scale: Scoring Template/532
C-8. Clinical Back Pain Questionnaire/533
C-9. Spinal Stenosis Treatment Outcome Questionnaire/535
C-10. Neck Disability Index Questionnaire (NDI)/537
9
C-11. Headache Disability Index/539
C-12. Dizziness Handicap Inventory/540
C-13. Tinnitus Handicap Inventory/541
C-14. Hearing Handicap Inventory for Adults/542
C-15a. TMD Disability Index
C-15b. TMD Symptom Intensity Scale (SIS) and Symptom Frequency Scale (SFS)/545
C-15c. Scoring Method for the TMD Disability Index/546
C-16. Carpal Tunnel Syndrome Questionnaire (CTSQ)/547
C-17a. Shoulder Evaluation Form (American Shoulder and Elbow Surgeons)/548
C-17b. Shoulder Injury Self-Assessment of Function/549
C-18. Rating Scale of the American Shoulder and Elbow Surgeons/550
C-19. Simple Shoulder Test Questionnaire/551
C-20. University of California at Los Angeles Shoulder Rating Scale/552
C-21. Patellofemoral Function Scale/553
C-22. Subjective Knee Score Questionnaire/554
C-23. Rating of Knee Replacement Results/556
C-24. Rating of Hip Replacement Results/558
C-25. Beck Depression Inventory/560
C-26. Modified Somatic Perception Questionnaire/561
C-27. Modified Zung Depression Index/562
D CHAPTER 9: PATIENT SATISFACTION AND EXPERIENCE.............................
D-1.
D-2.
563
Example of a Client Experience Survey/563
The Chiropractic Satisfaction Questionaire/564
E CHAPTER 14: SPINAL RANGE OF MOTION................................ 565
E-1.
McKenzie Examination Form/565
F. CHAPTER 15: OUTCOME MEASURES FOR THE UPPER AND LOWER EXTREMITIES … 567
F-1.
F-2.
F-3.
F-4.
F-5.
F-6.
F-7.
F-8.
F-9.
F-10.
F-11.
F-12.
F-13.
F-14.
F-15.
F-16.
F-17.
F-18.
F-19.
F-20.
F-21.
F-22.
Constant Scale/567
Hospital for Special Surgery Score Sheet for Total Shoulder Replacement/568
Shoulder Function Assessment Scale/569
Croft’s Measurement of Shoulder-related Disability/567
Wolfgang’s Assessment of Rotator Cuff Injury/571
Shoulder Pain and Disability Index (SPADI)/572
Shoulder Rating Questionnaire (SRQ)/573
Athletic Shoulder Outcome Rating Scale/576
University of Washington Shoulder Information Form/578
Preoperative and postoperative Scores Obtained Using the 12-Item Shoulder Questionnaire/579
Mayo Elbow Performance Index/581
Elbow Functional Rating Index/582
Patient-rated Wrist Evaluation/583
Functional Disability Index for the Rheumatoid Hand/585
Patient-specific Index (Hip)/586
Hip-Rating Questionnaire/588
Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index/590
Index of Severity for Hip Osteoarthritis/593
International Knee Documentation Committee Assessment Form/594
American Knee Society’s Assessment System/596
Anterior Knee Pain Questionnaire/598
Harrison’s Patellofemoral Pain Syndrome Scale/600
10
F-23.
F-24.
F-25.
F-26.
F-27.
F-28.
Index of Severity for Knee Osteoarthritis/601
Scoring system of Subjective Clinical Evaluation (Ankle)/602
Olerud and Molander Scoring System (Ankle)/603
Ankle Clinical Scoring System/604
Ankle Grading System/606
A Performance Test Protocol and Scoring Scale for the Evaluation of Ankle Injuries/608
G CHAPTER 16: MEASURING PHYSICAL PERFORMANCE...609
G-1. Health-related Fitness Test Battery for Adults/609
G-2. Prone Press-up Examination Form/610
G-3. NIOSH Distinguishing LBP Tests/611
G-4. Sacroiliac Examination Form/612
G-5. Visual Analogue Scale (VAS)/613
G-6. Quantitative Functional Capacity Evaluation/614
G-7. Quantitative Functional Capacity Results/618
G-8. Qualitative Functional Tests/620
G-9. Posture, Gait and Movement Pattern Assessment/634
G-10. Static Position Tolerance Tests/636
H CHAPTER 19: CASE MANAGEMENT IN AN EVIDENCE-BASED PRACTICE............................683
H-1. CareTrak Checklist: Low Back Classification/638
H-2. Red Flags Checklist (AHCPR)/640
H-3. CareTrak Checklist: Cervical Classification/642
H-4. Outcomes Assessment Record/644
H-5. Job Demands Questionnaire/646
H-6. Assessment and Treatment Plan/648
H-7. Modified Work APGAR/651
H-8 Vermont Disability Prediction Questionnaire/652
I CHAPTER 21: IDENTIFICATION OF THE PATIENT AT RISK FOR LOW BACK TROUBLE...654
I-1.
I-2.
I-3.
Risk Factor Assessment: Standard Questionnaire/654
Risk Factor Assessment: Re-examination Questionnaire/656
Scoring/657
J CHAPTER 22: PUTTING OUTCOMES-BASED MANAGEMENT INTO PRACTICE …………. 660
J-1. Physical Therapy Log/660
J-2. Nutrition/Medication/Brace-Orthotic log/662
J-3. Photocopy Log/663
J-4. Daily SOAP Notes/664
J-4a. Abbreviation Key for SOAP Notes/666
J-5a. Consultation/History/667
J-5b. Past history/668
J-5c. Review of Systems (ROS)/669
J-5d. Cervical Spine and Lumbar Spine Examination Forms/670
J-6. Sample X-ray Report/674
J-7. Attending Physician’s Return to Work Recommendations/675
J-8.
Route Slip/676
NEW FORMS DISC (Outcome measures published since 2000 – not included in the textbook)
11
TABLE OF CONTENTS (Bundled with the Forms CD)
OA Tool
Author / Reference
SUBJECTIVE OUTCOME TOOLS
1. Back Pain Functional Scales
2. Cervical Spine – Bournemouth Questionnaire
3. Low Back – Bournemouth Questionnaire
4. Copenhagen Neck Functional Disability Scale
5. Dallas Pain Questionnaire (in French)
6. Shoulder Pain Disability Index – SPADI
7. Functional Rating Index (FRI)
8. Functional Assessment Screen Q (FASQ)
9. Fear-Avoidance Beliefs Q (FABQ)
10. Symptom Check List 90-R (SCL-90-R)
11. Rehab SOAP note*
12. Functional Assessment Scale (Knee)
13. Upper Extremity Function Scale
Questionnaire
14. Spanish Q’s
15. Informed Consent form
Stratford / Spine, 2000
Bolton, Humphreys / JMPT, 2002
Bolton, Breen, JMPT, 1999
Jordan / JMPT, 1998
Lawlis / Spine, 1989
Roach / Arthritis Care Res, 1991
Feise / Spine, 2001
Millard / Arch Phys Med Rehabil., 1989
Waddell / Pain, 1993
Derogatic LR / Administration, Scoring
and Procedures Manual-I & II, 1983
Yeomans / Rehab Course notes, 1995-2003
Wegener L, Kisner C, Nichols D. Static and
dynamic balance responses in persons with bilateral
knee osteoarthritis. JOSPT 1997;25:13
Pransky G, Feuerstein M, Himmelstein J,
Katz JN, Vickers-Lahti M. / JOEM, 1997
Oswestry, RM-24, NDI, SF-36
NA
* The Rehab SOAP note (#11) is not a peer-reviewed outcomes assessment form but rather, an optional documentation
approach when administering rehabilitation services.
OBJECTIVE OUTCOME TOOLS
1. Cervical Spine QFCE
2. Cervical Non-organic signs (see 1 for form)
Yeomans / CMCC 10/2001 lecture
Sobel / Arch Phys Med Rehabil 2000
Sports Screen
3. Sports Screen
Yeomans / Research tool (not yet
published)
Pre-Employment Exam
4. Pre-employment Exam*
Yeomans / Research tool (not yet
published)
* It is highly recommended that the Spinal Function Sort be included with this examination.
NOTE: This material is packaged with the “Forms CD” which contains all the outcomes assessment
tools and documentation forms found in the text, The Clinical Application of Outcomes
Assessment. Ed. SG Yeomans, Appleton & Lange, 2000.
For software scoring capabilities: visit www.caretrak-outcomes.com and other outcomes assessment
distance-learning approaches visit www.yeomansdc.com or see the following description of materials:
**REVIEW OA FORMS – SCORING TECHNIQUES (Overheads)**
12
Global Impression of Change
Since the start of my care at the clinic, my overall status is:
1. □ Very Much Improved
2. □ Much Improved
3. □ Minimally Improved
4. □ No Change
5. □ Minimally Worse
6. □ Much Worse
7. □ Very Much Worse
Farra JT, Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain
intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149-158.
Hagg O. Fritzell P:, Nordwall A. The clinical importance of changes in outcome scores after treatment for
chronic low back pain. Eur Spine J 2003;12:12-20.
Name ________________________ Signature _______________________ Date _________________
13
The BACK Bournemouth Questionnaire
The following scales have been designed to find out about your back pain and how it is affecting you. Please
answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:
1. Over the past week, on average, how would you rate your back pain?
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain possible
10
2. Over the past week, how much has your back pain interfered with your daily activities (housework,
washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?
No interference
0
1
2
3
4
5
6
7
8
9
Unable to carry out activity
10
3. Over the past week, how much has your back pain interfered with your ability to take part in recreational,
social, and family activities?
No interference
Unable to carry out activity
0
1
2
3
4
5
6
7
8
9
10
4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have your
been feeling?
Not at all anxious
Extremely anxious
0
1
2
3
4
5
6
7
8
9
10
5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you
been feeling?
Not at all depressed
Extremely depressed
0
1
2
3
4
5
6
7
8
9
10
6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would
affect) your back pain?
Have made it no worse
Have made it much worse
0
1
2
3
4
5
6
7
8
9
10
7. Over the past week, how much have you been able to control (reduce/help) your back pain on your own?
Completely control it
No control whatsoever
0
1
2
3
4
5
6
7
8
9
10
Patient name ____________________________ Patient signature _________________________ Date ______
14
The NECK Bournemouth Questionnaire
The following scales have been designed to find out about your neck pain and how it is affecting you. Please
answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:
1. Over the past week, on average, how would you rate your neck pain?
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain possible
10
2. Over the past week, how much has your neck pain interfered with your daily activities (housework, washing,
dressing, lifting, reading, driving)?
No interference
0
1
2
3
4
5
6
7
8
9
Unable to carry out activity
10
3. Over the past week, how much has your neck pain interfered with your ability to take part in recreational,
social, and family activities?
No interference
Unable to carry out activity
0
1
2
3
4
5
6
7
8
9
10
4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have your
been feeling?
Not at all anxious
Extremely anxious
0
1
2
3
4
5
6
7
8
9
10
5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you
been feeling?
Not at all depressed
Extremely depressed
0
1
2
3
4
5
6
7
8
9
10
6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would
affect) your neck pain?
Have made it no worse
Have made it much worse
0
1
2
3
4
5
6
7
8
9
10
7. Over the past week, how much have you been able to control (reduce/help) your neck pain on your own?
Completely control it
No control whatsoever
0
1
2
3
4
5
6
7
8
9
10
Patient name ____________________________ Patient signature _________________________ Date ______
II. OUTCOMES ASSESSMENT (OBJECTIVE)
14
15
QUANTITATIVE FUNCTIONAL CAPACITY EVALUATION
NAME_____________________DATE__________DOB__________DOI__________TIME IN___________
Dx:______________________________________________________________________________________
TEST
INITIAL
Standing
1. Pre-Test VAS
2. 3-minute Step Test (pulse)
Date:
Date:
Date:
Date:
________/10
________/10
________/10
________/10
3. ROM:
SCALE:
LUMBAR
FLEXION
EXTENSION
RT. LAT. FLEX
LT. LAT. FLEX
1st Re-exam 2nd Re-exam
______pre ______ post-
____pre ______ post-
______pre ______ post-
3rd Re-exam
______pre ______ post-
PAIN
EXTREMITY (L/R)
(FORW.FLEX)
(BACKWARD EXT)
(ABDUCTION)
(ADDUCTION)
4. PAIN
(Superficial):Waddell #1
5. SIMULATION: Waddell
#2
a. Trunk Rotation
b. Axial Compression (5 kg)
TESTS
6. Gastroc/Ankle DF (Knee extd)
7. Soleus/Ankle DF (Knee flexed)
FL _____ +2,1,0,-1,2
EXT____ +2,1,0,-1,2
RLF____ +2,1,0,-1,2
LLF_____ +2,1,0,-1,2
FL _____ +2,1,0,-1,2
EXT____ +2,1,0,-1,2
RLF____ +2,1,0,-1,2
LLF_____ +2,1,0,-1,2
+/-
+/-
+/-
+/-
+/+/-
+/+/-
+/+/-
+/+/-
L
R
L
R
FL _____ +2,1,0,-1,2
EXT____ +2,1,0,-1,2
RLF____ +2,1,0,-1,2
LLF_____ +2,1,0,-1,2
L
FL ________ +2,1,0,-1,2
EXT_______ +2,1,0,-1,2
RLF_______ +2,1,0,-1,2
LLF________ +2,1,0,-1,2
R
L
R
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
_____°
___Sec.
___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec.
8a.* One-Leg Stand (eyes open)
___Sec.
___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec.
8b.* One-Leg Stand (eyes closed)
+/+/+/+/9. Exaggeration (Waddell
#5)
10. Rep. Squat (feet 15cm apart)
____ # of reps. ____ # of reps. ____ # of reps.
____ # of reps.
•Thigh horizontal, 1 rep/2-3 s,
• Note # of reps; max. reps 50
Seated
TESTS
11. Sitting SLR /
DISTRACTION (Waddell
#3; see #13) ↑ LBP: (circle)
12. Regional Neuro. (Waddell #4)
13. ROM:
PAIN
SCALE:
CERVICAL
FLEXION
EXTENSION
RT. LAT. FLEX
LT. LAT. FLEX
RT. ROTATION
EXTREMITY (L/R)
(FORW.FLEX)
(BACKWARD EXT)
(ABDUCTION)
(ADDUCTION)
(EXT. ROT.)
L
R
L
R
L
↑LBP:
↑LBP:
↑LBP:
↑LBP:
↑LBP:
↑LBP:
↑LBP:
↑LBP:
yes / no
yes / no
yes / no
yes / no
yes / no
yes / no
yes / no
yes / no
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
FL ______ +2,1,0,-1,2
EXT____ +2,1,0,-1,2
RLF_____ +2,1,0,-1,2
LLF_____ +2,1,0,-1,2
FL _____ +2,1,0,-1,2
EXT____ +2,1,0,-1,2
RLF____ +2,1,0,-1,2
LLF_____ +2,1,0,-1,2
R
FL ______ +2,1,0,-1,2
EXT_____ +2,1,0,-1,2
RLF_____ +2,1,0,-1,2
LLF______ +2,1,0,-1,2
L
R
FL _______ +2,1,0,-1,2
EXT______ +2,1,0,-1,2
RLF______ +2,1,0,-1,2
LLF______ +2,1,0,-1,2
RR ____+2,1,0,-1,2 RR ____+2,1,0,-1,2 RR ____+2,1,0,-1,2 RR ____+2,1,0,-1,2
LR ____+2,1,0,-1,2 LR ____+2,1,0,-1,2 LR ____+2,1,0,-1,2 LR ____+2,1,0,-1,2
ROM PAIN SCALE: -2 = centralization; -1 = decreased pain;
0 = no change in pain;
+1 = increased pain; +2 = peripheralization
LT. ROTATION
(INT. ROT.)
GO TO PAGE 2
⇒
⇒
⇒
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15
16
NAME________________________________________ DATE_______________DOI________________
Supine TESTS
L
R
L
R
L
R
L
R
Endurance
Endurance
Endurance
Endurance
14. Repetitive Sit-up Test
• Sit-up, knees 90°, feet
anchored, 1 rep/2-3 sec, touch
reps_________/ 50
reps_________/ 50
reps_________/ 50
reps_________/ 50
thenar to patella, curl back
down; max.50 reps
15.* (2 methods)
Fl______ RLF_______
Fl______ RLF_______
Fl______ RLF_______
Fl______ RLF_______
CERVICAL STRENGTH –
Ext_____ LLF_______ Ext_____ LLF_______
Ext_____ LLF_______ Ext_____
mmHg (dynamometer)
C-Flexion Test:
C-Flexion Test:
C-Flexion Test:
LLF_______
CHIN FLEXION TEST
C-Flexion Test:
_______/________ Sec.
_______/________ Sec.
_______/________ Sec.
(timed) Time to the point of
Shakes / Drops
Shakes / Drops
Shakes / Drops
_______/________ Sec.
Shakes / Drops head
16. Hip Flexion Test /
Modified Thomas
• Measure: Passive Hip
extension (psoas tension)
17. Hip Flexion/Supine SLR
a. Waddell #3: supine + vs. sit- SLR
b. Measure angle: at point of knee
Shakes / Drops
a. _____°
a. _____°
a. _____°
a. _____°
a. _____°
a. _____°
a. _____°
a. _____°
a. + / - a. + / - a. + / -
a. + / - a. + / -
a. + / -
a. + / -
a. + / -
b.___° b.___° b.___°
b.___° b.___°
b.___°
b.___°
b.___°
flexion
18. Double Leg Lowering
(maintain lordosis < 65 °)
Prone
TESTS
19. Repetitive Arch Up Test
•
Repetitive arch up: Waist at table's edge
fixed at ankle flexed 45° raises up to
horizontal; 1 rep/2-3 seconds; max. 50reps
20. Knee Flexion Test /
Modified Nachlas Test
21. Hip ROM
•
Internal Rotation
•
External Rotation
22. Horizontal Side Bridge
(record in seconds)
TESTS
23. Grip Dynamometry
Dominant: Left / Right (circle)
•
Use Jamar
•
Use Position 1 or 2
•
Three trials (average)
24. Static Back Endurance
•
Static Back Endurance: Pt holds trunk
horizontal up to max. of 240 sec.
25. Post-Test VAS
_________ degrees
L
R
_________ degrees
L
R
Reps______/50 Reps_____/50
______°
______°
_________ degrees
_________ degrees
L
L
R
Reps______/50
______°
______°
R
Reps______/50
______°
______°
______°
______°
IR ____°
IR ____°
IR ____°
IR ____°
IR ____°
IR ____°
IR ____°
IR ____°
ER ___°
ER ___°
ER ___°
ER ___°
ER ___°
ER ___°
ER ___°
ER ___°
Time/sec
Time/sec
Time/sec
Time/sec
Time/sec
Time/sec
Time/sec
Time/sec
_____
_____
_____
_____
_____
______
______
_____
L
R
L
R
L
R
L
R
1._____
1._____
1._____
1._____
1._____
1._____
1._____
1._____
2._____
2._____
2._____
2._____
2._____
2._____
2._____
2._____
3._____
3._____
3._____
3._____
3._____
3._____
3._____
3._____
ave_____
ave_____
ave_____
ave_____
ave_____
ave_____
ave_____
ave_____
Static
Static
Static
Static
Time_____/240 Time_____/240 Time______/240 Time______/240
sec.
sec.
sec.
sec.
_____/10
_____/10
_____/10
_____/10
SIGNED_______________________________DATE_______________TIME OUT_________________
16
17
QUANTITATIVE FUNCTIONAL CAPACITY RESULTS
NAME: ________________________Occupation: WC / BC* DATE:________BD:_______AGE:_______
Dx:______________________Test #: 1, 2, 3, 4 Symptom Duration:__________Prior Episodes: YES / NO
TEST NAME
NORMAL
PATIENT RESULT
PERCENT OF
NORMAL
0/10
/10
1. Pre-test VAS
______ /______yo F
___ Pre-____Post%
2. 3-minute Step Test (pulse)
M
3. ROM / Lumbar Spine
65°
°
%
Flexion
30°
°
%
Extension
25°
°
%
Rt. Lateral Flexion
25°
°
%
Lt. Lateral Flexion
Negative
Positive / Negative
NA
4. Waddell #1: Pain
Negative
Positive / Negative
NA
5. Waddell #2: Simulation
23°
Lt.:
Rt.:
%
%
6. Gastrocnemius /Ankle DF
25°
Lt.:
Rt.:
%
%
7. Soleus / Ankle DF
EO____sec. EC_____
L___/___ R___/___
L___/___ R___/___
8a & b. One leg standing test
Negative
Positive / Negative
NA
9. Waddell #5: Exaggeration
/ (max 50)
/(
)
%
10. Repetitive Squat *
LBP: YES / NO
LBP: YES / NO
NA
11. Sitting SLR/ Distraction w/ #17a
Negative
Positive / Negative
NA
12. Waddell #4: Regional Neuro
13. ROM / Cervical
50°
°
%
Flexion
63°
°
%
Extension
45°
°
%
Rt. Lateral Flexion
45°
°
%
Lt. Lateral Flexion
85°
°
%
Rt Rotation
85°
°
%
Lt Rotation
________ (max. 50)
_______/ (
)
%
14. Repetitive Sit-Up *
NOT ESTABLISHED
Fl________
C-Flexion Test:
15. Cervical spine strength
RLF________
Shake/drop
2 methods: 1) Sphyg; 2) C-Flex T
Ext_______
LLF________
____/____Sec.
16. Hip flexion/Modified Thomas
84°
Lt.:
Rt.:
%
%
Iliopsoas
Negative
Positive / Negative
NA
17a. Waddell #3: Distraction/SLR
80°
Lt.:
Rt.:
%
%
17b. Straight Leg Raise *
<65 degrees w/ pelvic
18. Double leg lowering
tilt
________ degrees
__________ %
_______ (max. 50)
_______/ (
)
%
19. Repetitive Arch-Up *
147 +/- 1.6
Lt.:
Rt.:
%
%
20. Knee Flexion
21. Hip Rotation ROM
41-45 (43)
Lt.:
Rt.:
%
%
Internal Rotation ROM
41-43 (42)
Lt.:
Rt.:
%
%
External Rotation ROM
______ (max. 240 sec.)
______ sec.
%
22. Horizontal Side Bridge
Lt.:
Rt.:
Lt.:
Rt.:
%
%
23. Grip Strength (Kg) *
______ (max. 240 sec.)
_______ seconds
%
24. Static Back Endurance *
0/10
/10
25. Post-test VAS
AGE years
EYES OPEN (seconds)
EYES CLOSED (seconds)
20-59
29-30
21-28.8 (25 Sec. ave.)
60-69
22.5 ave
10
70-79
14.2
4.3
* Normative data is determined by age, sex and occupation (Blue vs. white collar: BC / WC)
** A positive test #13 (Supine SLR) and a negative sitting / distracted SLR (test #8)= +Waddell sign for Distraction
17
18
QUANTITATIVE FUNCTIONAL CAPACITY RESULTS
NAME:
Keann Esthetic
Occupation: WC DATE: 10-30-98 BD: 1-19-58 AGE:
Dx: LBP w/o leg pain Test #: 1, 2, 3, 4 Symptom Duration: 3 weeks Prior Episodes: YES / NO
TEST NAME
NORMAL
PATIENT RESULT
1. Pre-test VAS
2. 3-minute Step Test (pulse)
3. ROM / Lumbar Spine
Flexion
Extension
Rt. Lateral Flexion
Lt. Lateral Flexion
4. Waddell #1: Pain
5. Waddell #2: Simulation
6. Horizontal Side Bridge
7. Gastrocnemius /Ankle DF
8. Soleus / Ankle DF
9a & b. One leg standing test
2 /10
__81_ Pre- _92_Post-
65°
30°
25°
25°
Negative
Negative
96M, 75W(max.
240sec.)
23°
25°
EO_30_sec. EC_30__
56 °
25__ °
27 °
28 °
Positive / Negative
Positive / Negative
Lt__89_/Rt__91_ sec.
86%
83%
108%
112 %
NA
NA
93% 9 5 %
Lt.: 21
Rt.: 24
Lt.: 23
Rt.: 26
L_30/17_ R_28/13_
91%
104%
92%
104%
L 100% / 57%
R 93% / 43%
NA
93%
NA
NA
Negative
45
/ (max 50)
LBP: YES / NO
Negative
Flexion
Extension
Rt. Lateral Flexion
Lt. Lateral Flexion
Rt Rotation
Lt Rotation
15. Cervical spine strength
2 methods: 1) Sphyg; 2) C-Flex T.
50°
63°
45°
45°
85°
85°
NOT ESTABLISHED
20. Static Back Endurance *
21. Knee Flexion
22. Hip Rotation ROM
Internal Rotation ROM
External Rotation ROM
23. Grip Strength (Kg) *
24. Repetitive Arch-Up *
25. Post-test VAS
PERCENT OF
NORMAL
80%
78%
0/10
___40_yo F M
10. Waddell #5: Exaggeration
11. Repetitive Squat *
12. Sitting SLR/ Distraction w/ #18a
13. Waddell #4: Regional Neuro
14. ROM / Cervical
16. Repetitive Sit-Up *
17. Hip flexion/Modified Thomas
Iliopsoas
18a. Waddell #3: Distraction/SLR
18b. Straight Leg Raise *
19. Double leg lowering
40
___34___ (max. 50)
84°
Negative
80°
<65 degrees w/ pelvic
tilt
__129__ (max. 240 sec.)
147 +/- 1.6
Positive / Negative
42
/ ( 45 )
LBP: YES / NO
Positive / Negative
56
58_
44_
42
78
82
Fl___8___
RLF___6___
Ext__16___
LLF__6____
__46___/ (
°
°
°
°
°
°
112%
92%
98%
93%
92%
96%
C-Flexion Test:
Shake/drop15/35 Sec
34 )
125 %
Lt.: 76
Rt.: 64
Positive / Negative
Lt.: 76
Rt.: 70
____76__ degrees
90 %
76 %
NA
100 % 100 %
86%
___96__ seconds
Lt.: 126
Rt.: 135
86 %
74%
92 %
41-45 (43)
Lt.: 40
Rt.: 43
93 %
100 %
41-43 (42)
Lt.: 41
Rt.: 43
98 %
102 %
Lt.: 47
Rt.: 49
Lt.: 52
Rt.: 58
111 %
118 %
____36__ (max. 50)
___45__/ ( 36 )
125 %
0/10
1 /10
90%
AGE years
EYES OPEN (seconds)
EYES CLOSED (seconds)
20-59
29-30
21-28.8 (25 Sec. ave.)
60-69
22.5 ave
10
70-79
14.2
4.3
* Normative data is determined by age, sex and occupation (Blue vs. white collar: BC / WC)
** A positive test #18a (Supine SLR) and a negative sitting / distracted SLR (test #12)= +Waddell sign for Distraction
18
19
Please refer to the following charts for the normative data of the tests that vary due to age &/or gender tests
(tests 2, 9, 11, 16, 20, 23, & 24). The norms for the other tests (not broken down by age/gender/work
classification) are listed in the left of the 3 columns to right of the test name in the QFCE Summary Chart (in
the “Normal” column).
STRENGTH AND ENDURANCE NORMATIVE DATA
1. Repetitive Squatting Test
AGE
MALES (n=242)
White Collar
Blue
All
Collar
x
SD
x
SD
x
SD
Blue
Collar
x
SD
35-39
40-44
45-49
50-54
35-54
24
22
19
13
20
39
34
30
28
33
13
14
12
14
14
46
45
40
41
43
8
9
11
11
10
42
38
33
33
37
12
13
13
14
13
2. Repetitive Sit-up Test
AGE
MALES (n=242)
White Collar
Blue
All
Collar
x
SD
x
SD
x
SD
35-39
40-44
45-49
50-54
35-54
29
22
19
17
23
13
11
11
13
13
35
34
33
36
35
13
12
15
16
13
32
27
24
23
27
13
13
14
16
14
FEMALES (n=233)
11
13
12
10
12
White Collar
All
x
SD
x
SD
27
18
26
18
23
12
8
13
14
12
26
20
22
14
21
12
12
13
11
12
FEMALES (n=233)
Blue
Collar
x
SD
24
18
17
9
17
12
12
14
10
13
White Collar
All
x
SD
x
SD
30
19
22
20
24
16
13
15
13
15
27
19
19
11
19
14
12
14
11
14
3. Repetitive Arch-up Test
AGE
MALES (n=242)
Blue
Collar
x
SD
35-39
40-44
45-49
50-54
35-54
26
23
24
21
24
11
12
13
11
12
FEMALES (n=233)
White Collar
All
x
SD
x
SD
34
36
34
35
35
14
14
16
17
15
29
28
28
26
28
13
14
15
15
14
Blue
Collar
x
SD
28
25
25
18
24
13
14
15
14
14
White Collar
All
x
SD
x
SD
27
20
31
26
26
11
11
16
14
13
27
23
27
19
24
12
13
15
14
14
19
20
4. Static back endurance test (sec)
AGE
MALES (n=242)
White Collar
Blue
All
Collar
x
SD
x
SD
x
SD
Blue
Collar
x
SD
White Collar
x
SD
x
SD
35-39
40-44
45-49
50-54
35-54
91
89
90
62
82
95
67
122
99
94
48
51
73
78
62
93
80
102
69
87
55
55
64
60
59
87
83
81
73
82
38
51
45
47
45
113
129
131
121
123
47
57
64
56
55
97
101
99
89
97
43
57
58
55
53
FEMALES (n=233)
61
57
55
55
58
All
X = AVERAGE; SD = Standard deviation; Note: The last row represents the average of all the
ages (35-54)
REFERENCES
1. Alaranta H, Hurri H, Heliovaara M, et al. Non-dynamometric trunk performance tests:
Reliability and normative data. Scand J Rehab Med 1994; 26:211-215.
2. The Clinical Application of Outcomes Assessment. Ed.: Yeomans, SG. (Stamford, CT:) Appleton &
Lange. 2000; chapters 12 & 16. ISBN #: 0-8385-1528-2.
3. Yeomans S, Liebenson C. Quantitative functional Capacity Evaluation: The Missing Link to
Outcomes Assessment. Top Clin Chiro 1996; 3(1): 32-43.
The Horizontal Side-bridge
McGill SM, Childs A, Leibenson C. endurance times for stabilization exercises: clinical targets for testing and
training from a normal database. Arch Phys Med Rehabil 1999; 80:941-4.
Abstract:
Objective: to establish isometric endurance holding times, as well as ratios between torso extensors, flexors,
and lateral flexors (stabilizers), for clinical assessment and rehabilitation targets.
Design: simple measurement of endurance times in four tests performed in random order by a healthy cohort. To measure
reliability, a subsample also perform the tests again 8 weeks later.
Setting: university laboratory.
Participants: 75 young healthy subjects (31 men, 44 women).
Results: women had longer endurance times than men for torso extension, but not for torso flexion or for the "side bridge"
exercise, which challenges the lateral flexors (stabilizers). Men could sustain the "side bridge" for 65 percent of the
extensor time and 99 percent of the flexion time, whereas women could sustain the "side bridge" for only 39 percent of the
extensor time and 79 percent of the flexion time. The tests proved to be reliable, with reliability coefficients of > 0.97 for
the repeated tests on five consecutive days and again 8 weeks later.
Conclusion: healthy young men and women possess different endurance profiles for the spine stabilizing musculature.
Given the growing support for quantification of endurance, these data of endurance times and thigh ratios between
extensor, flexors, and lateral flexors groups in healthy normal subjects are useful for patient evaluation and providing
clinical training targets.
20
21
The Horizontal Side Bridge
Task
Extensor
Flexor
Side Bridge, Rt
Side Bridge, Lt
Mean
146
144
94
97
Men
SD
51
76
34
35
Ratio
1.0
0.99
0.64
0.66
Average: 95
Mean
189
149
72
77
Women
SD
60
99
31
35
Ratio
1.0
0.79
0.38
0.40
Mean
177
147
81
85
All
SD
60
90
34
36
Ratio
1.0
0.86
0.47
0.5
75
Patient position: side lateral, top leg in front of lower leg resting on lower hip/thigh and elbow. The upper arm is placed
against chest with the hand touching the anterior lower shoulder. The pelvis is raised off the table and held in a line with a
long axis of the body supporting the weight between the feet and elbow. The down side QL is being tested.
GRIP AND PINCH STRENGTH NORMATIVE DATA
TABLE 1
Grip Strength
(Kg)
MALES
FEMALES
OCCUPATION
Major hand
Minor hand
Major hand
Minor hand
47.0
45.4
26.8
24.4
Skilled
47.2
44.1
23.1
21.1
Sedentary
48.5
44.6
24.2
22.0
Manual
47.6
45.0
24.6
22.4
Average
Table 1. The normative data for dominant (“major hand”) and non-dominant (“minor hand”) grip strength (in
kilograms) broken down by occupation (left hand column) and gender.
TABLE 2
Grip Strength
(Kg)
MALES
FEMALES
AGE GROUP
Major hand
Minor hand
Major hand
Minor hand
45.2
42.6
23.8
22.8
<20
48.5
46.2
24.6
22.7
20-29
49.2
44.5
30.8
28.0
30-39
49.0
47.3
23.4
21.5
40-49
45.9
43.5
22.3
18.2
50-59
Table 2. The normative data for dominant (“major hand”) and non-dominant (“minor hand”) grip strength (in
kilograms) broken down by age (left hand column) and gender.
TABLE 3
PINCH Strength
(Kg)
MALES
FEMALES
OCCUPATION
Major hand
Minor hand
Major hand
Minor hand
6.6
6.4
4.4
4.3
Skilled
6.3
6.1
4.1
3.9
Sedentary
8.5
7.7
6.0
5.5
Manual
7.5
7.1
4.9
4.7
Average
Table 3. The normative data for dominant (“major hand”) and non-dominant (“minor hand”) pinch strength (in
kilograms) broken down by occupation (left hand column) and gender.
21
22
Reprinted with permission from Swanson AB, Matev IB, de Groot Swanson G. The strength of the hand.
AMA Guides, 1993, 4th edition, pg. 64, Table 31; p. 65, Table 32; pg. 65, Table 33.
3-MINUTE STEP TEST
•
•
•
Check the patient’s pre-test pulse (30 x 2 standing): R/O Tachycardia (>100b/m)
Patient steps up and down off of a 12” bench at the rate of 24 steps per minute for 3-minutes
(Metronome 96 b/m) “up, up, down, down”
Immediately (within 5 seconds), sit patient down and recheck the patient’s pulse for a full minute
and compare to the normative data
3 Minute Step Test Normative Data for Men
Rating
%
ranking
Men
Men
Men
Men
Men
Men
Age 18-25
Age 26-35
Age 36-45
Age 46-55
Age 56-65
Age >65
72
72
78
72
73
70
74
74
81
74
76
bpm
86
82
84
81
79
72
78
89
89
89
86
83
82
Good
85
92
93
93
90
85
85
80
95
97
96
94
88
88
75
97
98
99
98
91
91
Above
70
100
100
101
100
94
94
Avg
65
102
101
103
102
97
97
60
105
101
104
101
105
Average
109
55
108
103
109
102
109
113
50
111
106
113
104
111
115
45
Below
107
109
113
118
113
114
40
110
113
116
120
116
116
Avg
35
114
116
118
121
118
119
30
122
122
124
120
119
118
Poor
25
126
125
126
124
122
121
20
128
128
130
128
126
126
15
133
131
135
132
130
131
Very
10
140
136
145
142
140
137
Poor
5
152
150
158
168
164
164
0
Aerobic capacity values and rankings for 3-minute step test for men.
(Adapted from Y’s Way to physical Fitness with permission of the YMCA of the USA, 101
N. Wacker Drive, Chicago, Il 60606.)
Excellent
100
95
90
22
23
3 Minute Step Test Normative Data for Women
Rating
%
ranking
Women
Women
Women
Women
Women
Women
Age 18-25
Age 26-35
Age 36-45
Age 46-55
Age 56-65
Age >65
73
74
76
74
72
72
83
83
88
80
80
bpm
86
92
93
87
86
79
83
Good
93
97
96
93
91
88
85
97
99
100
97
93
93
80
100
103
102
101
97
97
75
104
106
106
104
103
100
Above
70
108
109
111
106
106
103
Avg
65
114
111
113
109
110
106
60
117
113
117
111
112
110
Average
55
120
116
118
114
116
112
50
121
117
120
117
118
116
45
123
119
121
120
121
118
Below
40
126
123
124
122
124
122
Avg
35
127
127
126
127
127
124
30
129
129
127
130
129
128
Poor
25
132
132
131
135
131
133
20
134
136
133
138
135
137
15
135
142
138
143
141
142
Very
10
149
148
147
146
148
149
Poor
5
151
151
152
152
154
155
0
Aerobic capacity values and rankings for 3-minute step test for women.
__________________________________________________________________________________________
Excellent
100
95
90
REHAB OPTIONS
Exercise CD: Table of Contents (Partial)
23
24
Rehab options for tests < 85% of normal (computer file name in bold)
Tests
1. VAS
2. 3-minute Step Test
NA: note if pain > 6 / 10, consider safety in QFCE/Rehab, catastrophization/chronic pain
3. ROM / Lumbar Spine
Use: L-ROM exercise Master Sheet.doc
Exercises: Consider the following for ALL L-ROM impairments after the acute stage.
1) Pelvic Stabilization – Gym Ball – pelvic tilts, bridge, sit-backs/abds, wall-squats, superman, see-saw (levels I,
II, III) Use with the companion Pelvic stab Gym Ball documentation form
2) Pelvic Stabilization – Floor pelvic tilt, 4-point, lunges, dead-bug, swimmers, bridges, curl-ups; Use with the
companion Pelvic stab floor documentation form
3) Proprioception exercises – see test 9 exercise form
1) Flexion biased exercises - Include 11 exercises – Williams; Stretch: hamstrings (2 methods), adductors,
lumbar erector spinae, piriformis, and trunk rotators; Strengthen: abdominal muscles, squats
1) Extension biased exercises – McKenzie – Include 6 methods of self-extension, side-gliding, and the handheel rock exercise
1) Lat flexion & rotation Floor exerc – include Lat. fl / scoliosis, Lat fl w/ hand wts, chair twists, knee to floor
supine rotations
2) Lat flexors & rotators GBall exercise – include trunk rotations, lat fl side-lying
When 3 of 5 positive signs – consider Psychometrics: promote active care / minimize passive care, emphasize work return;
consider co-management if off work > 4 weeks; identify early! See files in folder for further discussion.
1)
2)
Flexion
Extension
Lateral Flexion
4. Waddell #1: Pain
5. Waddell #2: Simulation
6. Horizontal Side-bridge
7. Gastrocnemius /Ankle DF
8. Soleus / Ankle DF
9a & b. One leg standing test
10. Waddell #5: Exaggeration
11. Repetitive Squat
12. Waddell #3: Distraction
13. Waddell #4: Regional Neuro
14. ROM / Cervical
Flexion
Extension
Lateral Flexion
Rotation
15. Cervical spine strength
16. Repetitive Sit-Up
17. Modified Thomas Iliopsoas
18a. Waddell #3: Distraction
18b. Straight Leg Raise
19. Double leg lowering
20. Static Back Endurance
21. Knee Flexion
22. Hip Rotation ROM
Internal Rotation ROM
External Rotation ROM
23. Grip Strength
Exercise Log – a form for home-documenting the exercises utilized
Exercise Options Sheet: includes a method for calculating the 85% Max. Heart Reserve (exercise
examples include): Running, Walking, Stepper, Jump rope, Treadmill, Cross-country ski machine,
Cycling, Rowing
SEE #4
1) Side Bridge Exercises
2) See Test 3, Pelvic Stabilization – Floor
1) Calf Stretch Options - Stretch gastroc/soleus muscles: calf-wall stretch, heels off step - ankle DF/PF stretch, rocker
and wobble board with appropriate balance challenges
SEE #7
1) Balance challenge exercise options - Proprioception exercises: ball, one-leg stand, rocker and wobble boards,
balance sandals; playing catch during trunk curl
SEE #4
Lunges; wall squats; quad. Sets; muscle stretch of hamstrings, iliopsoas, gastroc/soleus; proprioception exercises ball,
one-leg stand, rocker and wobble boards, balance sandals
SEE #4 (see test 18a for supine SLR Waddell Sign portion of the test)
SEE #4
1) Test 14 & 15 Cervical spine ROM & strength – circle exercises that are indicated for each individual patient
Stretch extensors, strengthen flexors, promote chin retraction posture correction
Stretch flexors, strengthen extensors, promote chin retraction posture correction
Stretch contralateral lateral flexors (LF), strengthen homolateral LF, promote chin retraction posture correction
Circumduction, stretch and strengthen appropriate muscles (based on exam findings)
1) Test 14 & 15 Cervical spine ROM & strength - Use slightly deflated beach ball with isometric resistance in
frontal & sagittal planes; PIR, self-stretches, self-strengthening exercises
1) Abdominal Strengthening Exercises
Strengthen: abdominals (obliques > rectus) curl-ups, GM; QL; Stretch: Iliopsoas, L-erector spinae; side-bridge (see
Figure 16-34)
1) Psoas stretch exercises - Stretch iliopsoas
SEE #4
Stretch hamstrings, adductors, TFL, iliopsoas, MRTs
1) Abdominal Strengthening Exercises Lower abdominal strengthening; sit-up track
1) Extensor Strengthening exercises
Strengthen: Lumbar extensors-see pelvic stabilization: superman, see-saw, Lumbar extensions; reps of arch-ups, or
from floor, reverse sit-up, side-bridge
1) Quadriceps femoris stretch
Quadriceps stretch and strengthening (emphasize last 5° of extension-VMO); stretch
Hamstrings
1) Hip ROM Exercises
Stretch tight external rotators (piriformis, GMed), hip capsule stretch)
Stretch tight internal rotators, hip capsule stretch
1) Grip & wrist strength exercises
2) Grip & wrist stretch – CTS exercises
3) Theratube Grip & wrist strength exercises
24
25
24. Repetitive Arch-Up
25. Post-test VAS
1) Extensor Strengthening
Strengthen: Lumbar extensors-see pelvic stabilization; reverse sit-ups; side-bridge
Compare to initial score, give home instructions of appropriate item such as ice, rest
**REVIEW QFCE SLIDES OF TESTS & EXERCISE PRESCRIPTIONS**
Assessment
1) List the ICD-9 Diagnostic codes
2) List the abnormal (<85%) tests by the biomechanical
lesion/pathology (eg., 54% weak abdominal muscles).
3) Include a list of “yellow flags” or barriers to recovery (this will
enlighten the insurer that a longer than expected positive
outcome is likely)
4) Include any ergonomic, work station, and/or any other
vocational related information that may be extending care
beyond an expected point (very important!).
Plan
1) Discuss the “new” treatment plan or exercises to be taught in an
in-office setting based on the abnormal (<85% norm) QFCE
tests.
2) Discuss any ergonomic modifications, work station evaluation
plans, and/or any other vocational related information that may
be necessary to bring the case to a stable point. Examples may
include: ordering an occupational therapist eval of a patient’s
work station (if you don’t offer that service), a Work Capacity
Evaluation, a meeting with the plant supervisor &/or engineer.
3) Discuss the passive vs. active care treatment plan. Example:
“Passive care/CMT will be gradually decreased during the time
active care is administered. The patient will present on a
3x/week basis for 4 weeks for active/exercise care and 1x/week
for passive/CMT care.”
4) Procedures performed today included: CMT of the ….;
Exercises included: …….
25
26
PROTOCOL FOR TRANSITIONING PATIENTS FROM PASSIVE INTO ACTIVE CARE (Example):
1) First 4 weeks: CMT plus home-based exercises (examples: Williams’ LB Flexion, McKenzie
Extension, Cervical ROM, etc.)
2) After 4-6th week: if continued signs and symptoms, a more intensive program is indicated
3) Quantitative Functional Capacity Evaluation (QFCE): compares patient’s performance to
peer-reviewed, evidence-based normative data
4) In-office rehab training specifically tailored to the abnormal QFCE tests
5) Re-evaluate at 4 weeks with 2nd QFCE to determine goal attainment / rehab outcome
By following this method and using the recommended documentation, “medical necessity” is established to
warrant the inclusion of a rehabilitation program if home-based exercises failed to adequately return the patient
to a satisfactory end-point (steps 1 & 2). The abnormal tests found during the QFCE establishes proof of
deconditioning and the need for a more guided rehabilitation process (step 3 & 4). The exercises/rehab
prescription is based on the abnormal tests derived from the QFCE (step 4) and proof of compliance and benefit
is determined by a follow-up QFCE at 4 weeks (step 5). When the QFCE results improve and the in-office
rehab is being performed accurately/safely, the patient can independently continue the exercise protocols at
home and a repeat QFCE at a 3-month point can be considered.
When the proper documentation is used and present in the patient’s chart, reimbursement is easy to support.
COMMONLY ASKED QUESTIONS:
1. Why are we as chiropractors not excited about doing re-examinations? It is because orthopedic tests are
usually negative after 4-6 weeks of time, when nociception normalizes. Therefore, little useful information is
obtained that directly affects our treatment approach. Because our primary mode of treatment is manual, various
approaches of palpation help us decide the location, force, and variety of manipulation, which are performed on
every treatment visit. In order to affect our treatment plan, the tests used must impact our treatment decision.
Therefore, discontinuing provocative testing approaches with tests that measure physical performance makes
sense AND, have treatment decision value (see #3 - below).
2. But why do patients frequently continue complaining when the orthopedic tests are negative? This is
because their kinetic dysfunction and deconditioning have not yet been addressed.
3. How can deconditioning and dysfunction be properly assessed? Through the use of physical performance
tests or, the QFCE. These are tests that measure loss of function including strength, balance or proprioception,
range of motion, and muscle length. By including a QFCE as a 4th to 6th week “re-examination”, deconditioning
and functional impairment can be identified and re-measured at a later date to determine the benefits of the new
treatment plan consisting of rehabilitation (active care) concepts. Weaning patients from passive to active care
is obtained in this process. But which exercises should be used – there are so many? Specific exercises found
in the Exercise CD and manual are designed after each QFCE test. Therefore, a new treatment plan emphasizing
rehab concepts can be easily & immediately implemented following the QFCE examination. Hence, by
performing the QFCE, a renewed value in the examination process will be appreciated.
Tools needed for implementing an evidence-based case management approach (See Order form pp37-38):
1) Subjective: Easy access to OATs (Options: CD of forms, Appendix of text, Sample forms)
2) Objective: QFCE manual / video and associated forms
3) Assessment: List positive QFCE tests (<85%) and the associated kinetic pathology
4) Plan: QFCE Exercise manual / CD to address each abnormal (<85%) test
Note: To facilitate dictation, the Macro Disc allows for a copy/paste or macro creation approach
26
27
PATIENT PROFILING / “YELLOW FLAGS”
Since 1995, I have been asked many questions regarding how to apply the QFCE into the clinical setting.
The answers to these questions are not simple since the clinical presentation of a patient is so highly
variable. Though the tests included in the QFCE are usually performed as a group, each individual test
can be utilized separately in a typical daily office visit. Because each test of the QFCE is prescriptive,
that is, each test drives a specific treatment change or addition, the use of any of these tests at any time in
the course of patient care can be appropriate. I will define 3 classic patient presentations, typical in a
chiropractic clinical setting to emphasize this point.
PATIENT PROFILES (Treatment selection)
1. Type I. “Typical”
(_____%)
_______________________________________________________________________________
2. Type II. Chronic/recurrent
(_____%)
_______________________________________________________________________________
3. Type III Chronic pain behavior
(_____%)
_______________________________________________________________________________
Type I Patient Presentation:
•
Status 1-3 weeks post-initiation of care and condition is 50-75% back to a pre-injury point
•
Minimal risk factors of Chronicity exist (see Table 1)
•
Patient remains unsatisfied with their current status
•
Patient has been trained in a home-based exercise approach and is compliant
•
Orthopedic tests initially helpful no longer support the patient’s ongoing complaints
In this case, performing a partial QFCE consisting of 1 or more test(s) is justified, as additional treatment
recommendations will result from the inclusion such test(s). For example, weak low back extensors may
be identified with the Static Back Endurance test and/or the Repetitive Arch-up test and specific
exercises for strengthening the low back extensors will be prompted. These may include (and is not
limited to):
Rehab options (but not limited to):
•
Prone or quadruped opposite arm & leg extensions
•
Floor or Gymnastic ball “superman” or “scissors” exercises
•
Roman Chair or reversed sit-ups
27
•
28
Checking for a pelvic-crossed syndrome and utilizing manual release techniques and/or proprioceptive
challenged exercises to improve sensory-motor integration
Similarly, if an inclinometer placed on the patient’s tibia measuring the straight leg raise reveals over-tight
hamstrings as a limiting functional pathology, the inclusion of manual release techniques for inhibiting the
over-tight tight hamstrings and home exercises to reinforce the same is added to the treatment plan. It is
difficult to criticize the “medical necessity” and additional work utilized on this particular office visit if the
SOAP note includes (at least in part) the following:
S Incomplete resolution of the condition (include a pain grade and a persistent ADL loss)
O The SLR limitation (for example, “52/80° or 65 % of normal”)
A Hamstring shortness 65 % of normal
P Manual release technique - such as contract-hold of the hamstrings, an overly tight
synergist (eg., adductor) or reciprocal inhibition of an overly short/tight psoas muscle )plus
any other treatment rendered on that particular date of visit)
Type II Patient Presentation:
•
Status 4-6 weeks post-initiation of care and condition is short of a pre-injury point.
•
Risk factors of chronicity may be more significant (see Table 1)
•
Patient remains unsatisfied with their current status
•
Patient has been trained in a home-based exercise approach and is compliant
•
Orthopedic tests initially present may continue support the patient’s ongoing complaints but remain
essentially unchanged since the patients last examination
In this case, performing a full QFCE is justified as additional treatment recommendations will result
from the inclusion such tests and prevention of chronicity is a primary concern. More specifically, the
prevention of chronicity is a recommendation emphasized by all the latest guidelines (AHCPR, British,
New Zealand, Canadian). Depending on the specific case of a type II patient, a one-on-one rehabilitation
process may be the best approach as patient fear-avoidant behavior often interferes or prohibits a
successful self-directed exercise approach. The inclusion of the QFCE in this type of patient presentation
provides the following:
•
Proves the “medical necessity” for rehabilitation to 3rd party payers
•
Proves the need for rehabilitation to the patient (they gain an appreciation for the need for rehab based on
the presence of quite often, significant abnormal findings)
•
Proves the need for rehabilitation to the health care provider, often resulting in an encouraging alternative
to the current treatment plan
28
•
29
Reinforces patient compliance with the rehab process as they know they are going to be re-tested in 30
days
In other words, everyone benefits from this approach – the payer, the provider and most importantly, the
patient.
Type III Patient Presentation:
•
Status 6 or more weeks post-initiation of care and condition is short of a pre-injury point.
•
Risk factors of chronicity are significant (see Table 1) including failed multiple previous therapies
•
Patient remains unsatisfied with their current status
•
Patient has been trained in a home-based exercise approach and may be compliant
•
Orthopedic tests initially present may continue support the patient’s ongoing complaints but remain
essentially unchanged since the patients last examination
This type of patient requires a very aggressive active care treatment approach utilizing a one-on-one
approach. The QFCE offers a advantage in managing this type of patient as usually, the patient needs to
be encouraged to participate in rehab as fear-avoidant behavior is very prevalent. Without some devise
or tool to stimulate compliance as well as identify the key functional pathologies, a successful outcome
with this type of patient may be more difficult. If the patient is not working at an 8 week point, this is a
clear indication for the need for a change or addition in the patient care approach.
The clear difference between these 3 types of patients is not the presenting complaint or diagnosis but
rather, the number of psychometric risk factors, often referred to as “yellow flags’ (Kendall NAS,
Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors
for long-term disability and work loss. Accident Rehabilitation & Compensation Insurance
Corporation
of New Zealand and the National Health Committee. Wellington, NZ. Available from
htp://www.nhc.govt.nz).
Treatment approaches can be broken down into 3 types:
•
Primary Care – care that the patient can access without a referral (eg., medical, chiropractic, osteopathic)
•
Secondary Care – care that requires a direct referral (eg., physiatrist, physical therapy, occupational
therapy)
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Tertiary Care – care that is determined after a multidisciplinary team assessment usually including (but is
not limited to) psychology, physical therapy, vocational assessment, occupational therapy
and a “quarterback” – often a physiatrist – puts together a multidisciplinary treatment approach or
determines a different pain management approach (case dependent)
Tertiary Care is often needed for the difficult to manage, Type III type of case and perhaps at times with
Type II patients. Please be aware that categorizing patients into 3 distinct categories has its advantages
(offers a clear definition) and its disadvantages (often, patients do not fit neatly into any one category
and may possess qualities from all three patient types). Therefore, and what should be obvious, is that
each case that presents to a health care provider must be individually assessed and an algorithm of care
administered prior to concluding that the need exists for a multidisciplinary team (tertiary care).
However, often patients qualifying as a type III or chronic pain patient are not being
identified early into care and their chronicity may be then further ingrained by the administration of
prolonged passive treatment approaches. Ideally, identifying a patient belonging to this small percentage
group (but most costly in terms of health care dollars) early into intervention allows for the prompt
administration of active care approaches. See Table 1 and refer to Sections 2 and 3 of my text book,
particularly chapters 10 and 21, to determine ways to identify the chronic pain patient early into primary
care intervention. Chapter 8 offers an overview of different tools clinical psychologists utilize to measure
psychosocial outcomes in clinical practice (usually at a tertiary care level).
Table 1 Risk factors of a prolonged recovery: Yellow Flags
A past history of prior
episodes
Severe pain intensity (>6/10)
Duration of symptoms (>1
mo.)
Anxiety
Sleep is affected by pain
Depression
Sciatica
Catastrophizing
Job
dissatisfaction
Activity
intolerance
Duration of symptoms before the 1st visit
(>1wk)
Multiples sites of pain
Tolerance for light work
Physical activity makes pain worse
Belief that shouldn’t work with current
pain
Other Risk Factors of chronicity
Abnormal illness behavior
Heavy Job Classification
Pre-existing structural pathology or skeletal
anomaly
Weak back extensor musculature
Smokes 1 pack or greater / day
Poor self-rated health
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