Chiropractic & Manual Therapies 2011 (Mar 20); 19 (1): 7 ~ FULL TEXT
Barbara I Polus, Amanda J Kimpton, Max J Walsh
Division of Chiropractic, School of Health Sciences,
RMIT University, Plenty Rd Bundoora, Melbourne, Australia.
BACKGROUND: The objective was to assess the use of the Measure Yourself Medical Outcome Profile (MYMOP2) and W-BQ12 well-being questionnaire for measuring clinical change associated with a course of chiropractic treatment.
METHODS: Chiropractic care of the patients involved spinal manipulative therapy (SMT), mechanically assisted techniques, soft tissue therapy, and physiological therapeutic devices. Outcome measures used were MYMOP2 and the Well-Being Questionnaire 12 (W-BQ12).
RESULTS: Statistical and clinical significant changes were demonstrated with W-BQ12 and MYMOP2.
CONCLUSIONS: The study demonstrated that MYMOP2 was responsive to change and may be a useful instrument for assessing clinical changes among chiropractic patients who present with a variety of symptoms and clinical conditions.
From the Full-Text Article:
In an era of accountability, health care providers are increasingly required to
use reliable and valid outcome measures to assess changes in patient
characteristics, including function and activities of daily living, following
intervention. A review of outcome measures for primary care illustrates the
evolution of instruments that acknowledge the importance of subjective
perceptions of health and which focus on the measurement of function and
quality of life .
Subjective outcome measures provide another dimension in the clinician’s
understanding of the patient’s complaint when compared to standard objective
measures (such as range of motion, palpation). Common subjective outcome
measures include condition-specific tools such as the Revised Oswestry
Disability Index and Neck Disability Index for assessing functional disability
due to low back and neck pain respectively. Standardised questionnaires
such as the Short form 36 (SF36) and the Well-being Questionnaire (WBQ12)
are used to assess general health status or quality of life – especially
changes in self-concept over time following therapeutic intervention.
A recent approach is to assess change over time for specific symptoms or
complaints identified by patients to be most important to them [1–3]. The
Measure Yourself Medical Outcome Profile (MYMOP) has been recently
developed to evaluate such patient-generated measures over time following
therapeutic intervention . The MYMOP is a brief patient generated, problem
specific questionnaire which requires the respondent to specify one or two
symptoms which are concerning them most and which they are seeking treatment for. A daily activity that is being restricted or prevented by these symptoms is also documented .
The MYMOP was initially published in 1996  and was revised to MYMOP2
after a second validation in 1999 and included another section relating to
medication . It is a sensitive measure of within-person change over time; is
capable of measuring the effects of a wide variety of care; and is a brief and
simple questionnaire that can be completed during a consultation. 
It has been used successfully to evaluate patient outcomes in a number of
clinical settings including acupuncture [2, 5], massage therapy in an Aboriginal
community , acute exacerbations of chronic bronchitis , and more
recently chiropractic management of patellar tendinopathy .
In the past the Short Form 36 (SF–36) has been the principal outcome measure for
overall health in primary care. There are a number of studies that have evaluated the
effectiveness of chiropractic care on patient’s health and general health status as
measured by the Short-Form 36 [9, 10]. The MYMOP provides health practitioners with
an alternative that is more easily incorporated into the practice setting because of its
brevity. A comparative study of MYMOP and the SF–36 has been conducted. 
MYMOP concurrent validity was supported by its ability to detect different degrees of
change in relation to scores in acute and chronic conditions, and by its correlations with
SF–36 scores. MYMOP correlated more closely with the subjective clinical findings than
the SF 36. Paterson’s study also showed that the MYMOP measure was capable of
being responsive to changes in symptoms despite being brief.
The 12–item Well-being Questionnaire (W–BQ12) is another patient-centred
subjective outcome measure that is geared towards people with long-term
illness and has been found to be reliable and valid [11, 12]. The W-BQ12 and
MyMOP2 are two patient-centred outcome measures that are part of a set of
five questionnaires that have been recently assembled to assess a range of
outcomes experienced by people having acupuncture for long-term health
Two of these five patient-centred survey instruments have recently been used
to evaluate outcomes experienced by patients in response to body wall
therapies such as massage  and chiropractic . It was considered a
significant step forwards to assess the utility of these questionnaires in
another practice setting.
Therefore the aim of this observational study was to assess the utility of the MYMOP2
and W-BQ12 health outcomes measures for measuring clinical change associated with a
course of chiropractic treatment delivered by student chiropractors in a clinical teaching
facility. The W-BQ12 was also used as a tool to assess the validity of the well being
component of the MyMOP2 against the validated W-BQ12 instrument in this clinical
A prospective, multicentre, practice based, observational study was conducted using
patients presenting with spinal complaints to the RMIT University (Melbourne, Australia)
chiropractic teaching clinics. For this observational study the patient’s presenting
complaint was not limited to a specific condition. Any patient who fulfilled the inclusion
criteria was invited to participate in the study and were reviewed after 6 weekly
treatments. The RMIT Human Research Ethics Committee approved all protocols and
forms utilised for the study.
Patients were invited to participate in the study if they were: over the age of 18 years;
had no treatment from any health professional for their complaint in the preceding four
weeks; and suffered from a condition amenable to treatment by one or more chiropractic
therapies. Patients were excluded if the following criteria were met: a requirement for
immediate referral for medical treatment or where chiropractic intervention was
contraindicated such as fracture, infection e.g. septic arthritis or malignancy; any
additional physical treatment for their complaint during the course of the study; inability
to complete or understand the required informed consent or outcome measures and
inability to comply with the treatment schedule.
Under supervision of qualified chiropractic clinicians, treatment was provided by final
year student chiropractors. Assessment prior to treatment included a full clinical history,
physical, orthopaedic, neurological, palpatory and radiological examination. All
participants received one or more chiropractic techniques taught and applied in the RMIT
University chiropractic teaching clinics. These treatment protocols included: manual
manipulative procedures such as spinal manipulative technique of high-velocity and lowamplitude
thrust (SMT); soft tissue therapy; Logan Basic technique; and mechanicalforce
manually-assisted manipulation such as biomechanical blocking, drop-piece and
activator. Segmental spinal dysfunction (subluxation) was assessed as described by
Gatterman . Patient management also included advice on nutrition, exercise and
static stretching regimens as required.
Two health and well-being questionnaires were used with consenting patients prior to
and after completion of 6 treatments delivered over a minimum of one month and a
maximum of three months. The questionnaires were either self-completed or
administered by a student chiropractor if the patient requested this. The questionnaires
- 12 Item Well-being Questionnaire (W-BQ12)
- Measure Yourself Medical Outcome Profile v2 (MYMOP2 – see Figure 1)
A description of the MYMOP2 subcategories is given in Table 1.
The W-BQ12 is a 12-item scale measuring four components: positive wellbeing
(PWB), energy (E), negative well-being (NWB) and general well-being
(GWB). Items 1–4 are summed to produce the negative well-being score;
Items 5–8 produce a total energy score; and Items 9–12 produce the positive
well-being score. The negative well-being score is reversed and then added
with the energy and positive well-being scores to produce a general wellbeing
score (range: 0–36). The higher the score on this reliable and valid
instrument, the greater sense of general well-being .
The Measure Yourself Medical Outcome Profile  is a ‘patient-centred’
outcome scale where patients are asked to nominate one or two symptoms
(physical or mental) of a specific problem they need assistance with and
consider the severity of these symptoms over the last week. The third item
asks the patient to list an activity (such as walking) that they have had
difficulty completing due to their problem. The fourth item asks patients to rate
their general well-being over the last week. Student chiropractors inserted the
previously chosen symptoms and activity onto the follow-up form prior to this
being given to the patient to score. Therefore, the patient was aware of the
symptoms they had previously nominated, but not the previous score. Each
of the four items is rated on a seven point scale where 0 is ‘as good as it
could be’ and 6 ‘as bad as it could be’. Hence, a decrease in the MYMOP2
score represents an improvement in health outcome. A mean of the four item
scores is calculated and is referred to as the MYMOP2 “profile score”.
The latest version of the MYMOP2 questionnaire (MYMOP2) was used in the
present study and comprises another section relating to medication .
All data were coded and entered into an Excel spreadsheet and then imported
into SPSS v16.0 to perform statistical analysis.
The Wilcoxon signed rank test was used to compare baseline and posttreatment
values for the outcome measures to investigate the responsiveness
or sensitivity to change of both instruments.
Unpaired t-tests were used to compare the baseline (pre-treatment)
characteristics of the group of patients who completed both initial and followup
outcome measures and the initial total group. This test was completed to
ensure that there was no difference in characteristics between the two groups
(no follow-up and follow-up groups).
Chi-squared calculations were used to assess differences in pre-treatment
Correlations between MYMOP2 and W-BQ12 scales were analysed using
Spearman’s correlation coefficients (rs) as a measure of the responsiveness,
validity, in terms of well-being, and clinical usefulness of the instruments in a
chiropractic student clinic setting.
All significance levels were set at p<.05.
Fifty-two (52) patients agreed to participate in the study, with each patient
completing the MYMOP2 and W-BQ12 questionnaires prior to initial
Of the initial 52 subjects, 33 completed the full treatment schedule and were
re-assessed after six treatments. There were no significant differences
between the baseline (pre-treatment) characteristics of the total initial group
(N=52) compared to the group who completed the base-line and follow-up
Region of chief complaint
Back and/or neck pain was the most common presenting complaint,
experienced by 71.2% of the initial sample of patients, with no significant
differences between males and females in presenting region.
There was no significant difference in the distribution of region of main
symptom between the total initial sample and the treatment group.
Pre-treatment MYMOP2 scores
The MYMOP2 scores from the initial consultation are documented in Table 1.
A MYMOP2 score of 6 represents ‘as bad as it could be’ and a score of 0
represents ‘as good as it could be’.
While scores for females tended to be higher than for males for all sub-scores
of the MYMOP2, there were no statistically significant differences except for
profile scores where females had a statistically significantly higher score
The distribution of presenting (pre-treatment) MYMOP2 scores according to
age groups is shown in Figure 2.
The 52 subjects were broken down into the following age groups: <20yo (n=
5), 20–39 (n=25), 40–59 (n=15) and >60 (n=7).
The older age groups tended to have higher scores across each sub-score
but there were no significant differences between the various age groups.
Treatment effects on MYMOP2 and W-BQ12 scores
The effect of treatment on MYMOP2 and W-BQ12 scores is shown in Table 2 and Figures 3
and Figure 4 respectively. Large significant changes occurred in all
MYMOP2 categories following treatment (p< .0001), with improvements over
baseline from 40 to 65 percent.
The W-BQ-12 scores were negative well-being (NWB), Energy (E), Positive
Well-being (PWB) and General Well-being (GWB). Figure 4 compares the pre
treatment and post treatment scores. All W-BQ12 scores showed a significant
improvement in scores following treatment (p<.05), noting that a decrease in
negative well-being corresponds to a positive effect of treatment.
Presenting mean MYMOP2
scores according to age group.
Correlation between MYMOP2 and W-BQ12 scores
Correlations between MYMOP2 scales and W-BQ12 scales were assessed
using Spearman’s correlation coefficients (rs) as shown in Table 3.
The MYMOP2 scales of Symptom 1 and Profile showed a moderate negative
correlation with the General Wellbeing (GWB) and Energy scales of the WBQ12.
The Wellbeing scale of the MYMOP2 had a strong negative correlation
with the GWB, a moderate negative correlation with the PWB and Energy
scales and a positive moderate correlation with the Negative wellbeing scale.
The Activity scale of the MYMOP2 had no significant correlations with any of
the W-BQ12 scales.
Correlations between MYMOP2 scales and W-BQ12 scales were assessed
using Spearman’s correlation coefficients (rs) as shown in Table 3.
for MYMOP2 vs W-BQ12 scales
Comparison of pre and
post treatment MYMOP2 scores.
Comparison of pre and
post treatment WBQ-12 scores.
This observational study had two objectives. The first objective was to assess
the effectiveness of the MYMOP2 and W-BQ12 questionnaires in measuring
clinical changes following chiropractic care on patients attending the RMIT
University chiropractic teaching clinics. The second objective was to
investigate the validity of the MyMOP2 instrument to detect a change in wellbeing
of patients attending the RMIT chiropractic teaching clinic.
The mean baseline MYMOP2 profile score was 3.4 (+/– 1.0) for the 52
presenting chiropractic patients as demonstrated in this study which is similar
to that obtained in a study of massage therapy for subjects with chronic
musculoskeletal complaints . It is lower than those of patients attending for
acupuncture in medical practices (4.7) , and for those patients attending
general practice in the UK (4.6) . The presenting MYMOP2 scores were not
dependent on age or gender except for the Profile sub score where females
had a significantly higher score. Given there is no difference in other sub
scores there is no apparent reason why females should have a higher Profile
There was a statistically significant improvement in all MYMOP2 sub-scales
following chiropractic treatment indicating a positive effect of the therapy.
These changes were similar to changes found in the other studies referred to
The improvements were also of clinical significance defined as a change in
score that is of importance to the individual patient involved. The MYMOP2
uses a 7–point score for which the minimum clinically important change in
score after intervention should be between 0.5–1.0: any change greater than
1.0 can be considered clinically significant .
The changes in all MYMOP2 scores were equal to or greater than 1.0 (for
Symptom 1 and Symptom 2 changes were greater than 2.0), suggesting that,
in general, the effect of therapy was clinically significant to patients.
There were also significant improvements in the W-BQ12 scores, once again
suggesting a positive effect of the treatment. According to Pouwer et al ,
the W-BQ12 is a reliable and valid measure of well-being and has been used
in a number of studies to measure clinical changes following treatment
[6, 17, 18]. It is of interest to compare the changes observed in the W-BQ12 in
our study with that of another recent large study that measured a range of
treatment effects of traditional acupuncture – including changes in self
concept – the target of the W-BQ12 . In this latter setting, the W-BQ12
was not found to be responsive. The authors of this latter study attributed the
lack of responsiveness of the W-QB12 to two possible causes: either the
socioeconomically diverse population or the preponderance of
musculoskeletal problems present in their sample. While our study is unable
to comment on the first possibility, all participants in our study presented with
musculoskeletal pain of spinal origin. Therefore, in contrast to the Paterson et
al study , our study suggests that the W-BQ12 may be a useful outcome
measure for use within a chiropractic clinical practice setting.
The correlation between MYMOP2 and W-BQ12 scores was moderate to
strong for most scales other than the Activity scale of the MYMOP2 which had
no significant correlations with any of the W-BQ12 scales (see Table 3).
MYMOP2 has been shown to be highly responsive to changes in symptoms
whether acute or chronic, as well as correlating with the findings of the SF-36
Based on this and the observational findings of this study, the MYMOP2 has
potential as a clinically useful tool to assess chiropractic care in terms of
health status and general well-being. The official MYMOP website  lists
the strengths and weaknesses of the MYMOP2 questionnaire. The major
strengths are considered as: patient-centred, applicable to any problem, quick
and easy to complete and score, and very responsive to change. The main
weakness is that it is problem specific which makes it unsuitable for patients
who cannot identify their problem.
The use of a non-experimental (observational) study design has wellestablished
limitations. First, it is not possible to attribute any change to the
intervention itself as other confounding effects (notably natural history and
regression to the mean), could be responsible for the change observed.
However, as the changes observed were both statistically and clinically
significant, such an interpretation is less likely. Further, the purpose of the
study was to document how these patient-centred outcome measures
performed in a chiropractic clinical practice setting. A non-experimental,
observational research design was considered appropriate for such an
investigation and minimised disruption to the provision of the chiropractic
Another limitation of this observational study was that the practitioners were
student chiropractors with minimal clinical experience. This may have had
some impact on the observed findings as well as influencing the external
validity of the study.
This study assesses the use of the MYMOP2 and W-BQ12 questionnaires as
outcome measures to monitor changes following chiropractic therapy. Within
the limitations of this study, it was shown that both questionnaires were
responsive to change. The MYMOP2 also correlated well with the W-BQ12
questionnaire. It thus appears to be a useful instrument for assessing change
among chiropractic patients and in the assessment of patient perceived wellbeing
for chiropractic patients who present with a variety of symptoms and
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