The current practice of medicine and physical therapy is based upon the Newtonian model of reality.  This model is primarily a viewpoint that sees the world as an intricate mechanism.  Doctors and therapists conceptualize the body as a type of grand machine, which is controlled by the brain and peripheral nervous system: the ultimate biological computer.  But are the human beings really glorified machines?  Or are they complex biological mechanisms, which are in dynamic interplay with series of interpenetrating vital energy fields…the so-called “ghost in the machine”?

The Einsteinian paradigm sees human being as networks of complex energy fields that interface with physical / cellular systems.  The recognition that all matter is energy forms the foundation for understanding how human beings can be considered dynamic energetic systems.  Through his famous equation, E=mc², Albert Einstein proved that energy and matter are dual expressions of the same universal substance.  That universal substance is a primal energy or vibration of which we are all composed.  Although the Einsteinian viewpoint has slowly found acceptance and applications in the minds of physicists, Einstein’s profound insight have yet to be incorporated into the way medicine looks at human beings and illness.

      Present-day medicine still sees the human body as a complex machine.  Conventional medicine is misguided by the notation that one can cure all illness by physically repairing or eliminating abnormal systems.  Through drugs and surgery, doctors try to reroute dysfunctional components of the body to cure patients.  Physical therapists try to help low back pain patients by creating a positive advancement in measures of physical impairment.

      Traditional impairment measures as strength, range of motion, endurance, gait, sensation, edema, posture, and so on are still used as a core measurements to demonstrate improvement in physical therapy.  However, these often unspecific measurements do not adequately quantify the patient’s progress toward functional goals, and there is not a direct relationship between a positive improvement in a measure of physical impairment and a concomitant improvement in function, and only a very loose association to patient’s quality of life (1,2).

      A comprehensive outcome measurement system designed today typically includes patient-reported measures, clinician-reported measures, and appropriate demographic indicators.  Patient-reported outcomes have focused on the measurement of pain, patient satisfaction but recently also quality of life, or more specific health related quality of life.  Clinician-reported outcomes should concentrate on functional outcomes, not on changes in impairment measures.  Functional outcomes may include activities of daily living, psychological function, recreational activities, social function, and health perception.  Population descriptive indicators include the age, gender, ethnicity, income, and education level of the patient as well as source of insurance, primary and secondary diagnoses, comorbidities, and the episode of the condition.  Patient-reported outcome measures give the most valuable information of patient’s biopsychosocial illness in the case of low back pain.

Subjective experience of the pain is multidimensional and therefore effected by physical, psychological, and social factors. Pain measurement scales are a common method of assessing patient outcome in back pain.  The majority of these ask the patient to indicate the intensity or severity of pain on a visual analog or five-point Likert scale.  However, the presence and severity of pain alone is narrow definition of health outcome.  In particular, such scales correlate poorly with quality of life and even with measures of physical function.  They concentrate on impairment, rather than focusing on disability, and are therefore of only limited use in assessment of patient outcome.

On the other hand, condition specific measures, which ask specific questions relating to symptoms and signs or assess the specific impact of back pain on health, has some advantages over more general health measures.  Clinically derived condition-specific outcome questionnaire may be more sensitive to small yet clinically significant changes in health status over short periods.  It may judge between different levels of health among those most severely affected by pain.  It may incorporate the type of questions asked when taking a medical history from the patient with low back pain and therefore make it easy for patients to complete.

A good example of clinically derived condition-specific outcome questionnaire is Aberdeen Low Back Pain Scale.  It has high validity and reliability as well as high correlation with all the varied aspects of health measured by the SF-36. The questions selected for this pain scale are:

1.      Duration of pain

2.      Number of pain killers taken

3.      Pain made worse by : coughing, sneezing, sitting, standing, bending, walking

4.      Pain made better by lying down

5.      Pain in: the buttock, in the thigh, in the shin/calf, in the foot/ankle on right side

6.      Pain in: the buttock, in the thigh, in the shin/calf, in the foot/ankle on left side

7.      Loss of feeling in legs

8.      Weakness or power loss in areas of: the hip, the knee, the ankle, the foot

9.      How far you can bend without pain.

10.  Interference with sleep

11.  Interference with sitting

12.  Interference with standing

13.  Interference with walking

14.  Interference with work, etc

15.  Duration of confinement to bed

16.  Interference with sex life

17.  Interference with leisure

18.  Interference with self care, etc

19.  Interference with self care, etc.

This kind of clinically based pain scale questionnaire is recommended tool while assessing outcomes for patients with low back pain.  Because it is sensitive in showing change over time and discriminating between patients it is useful in the management of individual patients.  Together with a general measure of the health it can provide a valid and reliable package four routine assessment of perceived health in patients with low back pain.

In the daily treatment of patients, therapists must remember that the technical skills and physical treatment are only a small portion of the healing process they impart.  The physical appearance of the facility, center operations, and therapist interaction are all effecting to outcomes.  That is why the measurement of patient’s perception by a standard satisfaction survey is increasingly important to the outcome management.

The top 15 questions that correlates to overall satisfaction at orthopedic outpatient settings are:

1.      Explanation of treatment

2.      Amount of personal attention

3.      Number of treating clinicians

4.      How knowledgeable clinician was about care

5.      Amount of personal input in setting goals

6.      Frequency clinicians made aware of progress

7.      Amount of empathy expressed by clinician

8.      Orientation of the center

9.      Helpfulness and courteousness of office staff

10.  Billing were clearly explained

11.  Billing statements were accurate

12.  Amount of waiting time during treatment

13.  Appearance of center

14.  How quickly first appointment scheduled

15.  Convenience of operating hours.

The amount of satisfaction may be measured by using five-point scale.  The five responses might be the following:

1.      Very satisfied

2.      Somewhat satisfied

3.      Neither satisfied nor dissatisfied

4.      Somewhat dissatisfied

5.      Very dissatisfied.

Measuring without having anything to compare it with does not allow one to understand if the measurement is high, low, or average.  The ideal would be to benchmark to an external database.  If that is not possible, internal benchmarking allows compare peers.

            Patient satisfaction survey should be a part of outcome management because of its ability to point out factors important to effectiveness of treatment process.  It may even give an idea why the very same treatment for the same diagnosis might give totally different outcomes when comparing two different rehabilitation settings.  Remembering that the top five satisfaction items were therapist related, therapist’s interpersonal skills play an important role.  Therapist’s attitude, intention, amount of empathy and respect to the patient may improve the treatment outcomes and have a direct impact to patient’s quality of life.

      The quality of life has been defined as “the extent to which our hopes and ambitions are matched by experience.”  To improve a patient’s quality of life through medical care would be to “ narrow the cap between a patient’s hopes and expectations and what actually happens.”  Clinical measures of health status, concentrating on physiological and physical measurements, describe only limited aspects of patient’s life.  Such measures reflect clinician’s perception of disease and correlate poorly with patient’s perception of health.

      A truly valid measure of outcome that reflect the patient’s perception of their health and has meaning and relevance in the context of their lives would possess the following characteristics:

  • It would describe the effect of a condition on those aspects of patients’ lives that they consider to be of greatest importance;
  • It would allow patients to rate the extent to which those aspects of life are affected by conditions;
  • It would be sensitive to changes in health over time, and also would allow patients to judge the value of those changes;
  • It should be reproducible;
  • It should be suitable for wide variety of patients in different settings; and
  • It should be brief and simple for patients to complete

The Patient-Generated Index (PGI) combines existing techniques in two unrelated fields to develop a measure that attempts to fulfill these criteria.

      PGI assesses the quality of life by asking patients to list the five most important areas or activities of their life affected by their condition and rate how badly affected they are in each of their chosen area on a scale of 0 to 100.  Patients are also asked to imagine that they can improve some or all of the chosen areas of their life.  They are given 60 “points” that they can choose to spend across one ore more areas.  The points they allocate to each area represent the relative importance of potential improvements in that area.  The resulting score is designed to represent the extend to which reality falls short of patient’s hopes and expectations in those area of life in which they would most value an improvement.  This kind of quality of life score demonstrates a high correlation with the clinical low back pain score and significant correlation with seven of the SF-36 scales.  The scales that show the highest correlation were pain, social functioning, and role limitations.

      To compare the effectiveness of treatment programs for chronic low back pain the unified evaluation of patient functioning at follow-up time is needed.  However, the determination of functioning has been based on a conceptual model of pain not on biopsychosocial concept of illness.  In physical therapy objective clinician-reported measurements are used to assess patient’s physical function.  This very limited perception of the function is based on Newtonian model of reality.   The biopsychosocial concept of illness should be accepted into physical therapy to allow unified outcome assessment of  “functional universe”.  It is time to stop thinking a patient as a mechanical machine and realize that there is more than one can see.

 

References:

Talo S, Rtökoski U, Puukka P, Alanen E, Niitsuo L, Hämäläinen A, Vaara M, Tuomaala M.  An empirical investigation of the ‘Biopsychosocial Disease Consequence Model’: psychological impairment, disability and handicap in chronic pain patients.  Disabil Rehabil 1995; 17(6):281-292.

Waddel G. A new clinical model for the treatment of low back pain.  Spine 1987;12:632-644.

Patric DL, Deyo RA, Atlas JS, Singer DE, Chapin A, Keller RB.  Assessing health-related quality of life in patients with sciatica.  Spine 1995;20(17):1899-1909.

Ruta DA, Garratt AM, Leng M, Russell IT, MacDonald LM.  A new approach to the measurement of quality of life: The Patient-Generated Index.  Med Care 1994;32(11)1109-1126.

Beurskens AJ, de Vet HC, Köke AJ.  Responsiveness od functional status in low back pain: a comparison of different instruments. Pain 1996;65:71-76.

Di Fabio RP, Mackey G, Holte JB.  Disability and functional status in patients with low back pain receiving workers’ compensation: a descriptive study with implications for the efficacy of physical therapy.  Phys Ther 1995;75(3):180-193.

Jette DU, Jette MA.  Physical therapy and health outcomes in patients with spinal impairments.  Phys Ther1996;76(9):930-941.

Deyo RA, Andersson G, Bombardier C, Cherkin DC, et al.  Outcome measures for studying patients with low back pain.  Spine 1994;19(18S):2032S-2036S.

Ruta DA, Garratt AM, Wardlaw D, Russell IT.  Developing a valid and reliable measure of health outcome for patients with low back pain.  Spine 1994;19(17);1887-1896.

Gatchel RJ, Polatin PB, Kinney RK.  Predicting outcome of chronic back pain using clinical predictors of psychopathology: A prospective analysis.  Health Psychol 1995;14(5):415-420.

Leave a Reply