Craig Liebenson, D.C.
We have all heard the statistics that say 85% of patients
are better in 6 weeks. Is this universally advertised short term
outcome true? What do we mean by better? If our goal is to
improve the quality of care for back pain patients then we first
need to establish benchmark outcomes of recovery.
If improvement is the goal then 90% of patients are
improving after only 3 weeks. But, if asymptomatic is the goal
then only 46% reached this goal after 7 weeks. If not having any
activity limitations due to pain is the goal, as AHCPR suggests,
then only 38% have achieved this goal by 7 weeks.
A new outcome question to ask patients has been proposed by
Cherkin and Deyo. They suggest asking "If you spent the rest of
your life with the symptoms of the last 24 hours how satisfied
would you be?" It turns out that 1/3 of patients are satisfied
after 1 week. But, that 1/3 are dissatisfied after 7 weeks.
Offering overly optimistic forecasts for recovery risks
disappointed 1/3 of our patients.
Two recent papers, one by Cherkin, et al and one by Van
Korff and Saunders both suggest that the natural history is not
so rosey for low back disorders as was believed. In fact, we
should evaluate outcomes relative to recovery from the acute
episode as well as recurrences one year later. Key outcomes
include pain intensity (VAS), activity limitations (Oswestry,
Roland-Morris, Neck Disability Index), use of pain medication,
time off work, and utilization or cost of health care services.
Measuring these outcomes on a regular basis will allow us to
defend appropriate care and establish a universal database for
chiropractic care. James Weinstein, DO the chief editor of Spine
said at our chiropractic centeniel in Washington, D.C. that
research in the future will be done not by randomized, controlled
clinical trials, but by hundreds of clinics capturing outcomes on
patients classified into meaningful groups.
A key classifications is sciatica patients. Sciatica
patients have a worse prognosis than mechanical back pain
patients. Which other patients are at greater risk of prolonged
recovery or recurrences? Patients with job dissatisfaction,
depression, and poor self-rated health.
How can you learn more about gathering outcomes and
documenting patient prognosis and recovery? Steven Yeomans,
teaches this material as part of L.A.C.C.'s rehabilitation
Diplomate program- call LACC (562) 902-3379.
Synergy Solutions has developed a software package that captures
this data and autowrites initial and progress reports - Call
the Gym Ball
Store @ (800) 393-7255 for more information.
1. Cherkin DC, Deyo RA, Street JH, Barlow W. "Predicting poor
outcomes for back pain seen in primary care using patients' own
Spine 1996; 21: 2900-2907
2. Von Korff M, Saunders K. "The course of back pain in primary
Spine 1996; 21: 2833-2839
3. Bigos S, Bowyer O, Braen G, et al. "Acute low back problems
in adults. Clinical Practice Guideline."
Rockville, MD: U.S. Department of Health and Human Services,
Public Health Service, Agency for Health Care Policy and
4. CareTrack Outcome System. Synergy Solutions. Grand Rapids,
MN (800) 950-8133
5. Yeomans SG, Liebenson C. "Applying outcomes to clinical
JNMS 1997; 5(1); 14
6. Liebenson C, Yeomans SG. "Outcomes assessment in
Manual Therapy 1997; 2(2): 67-74
7. Bolton JE. "Evaluation of treatment of back pain patients:
clinical outcome measures."
European J of Chiro 1994; 42: 29-40
8. Bolton JE. "Methods of assessing low back pain and related
European J of Chiro 1993; 41: 31-38
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