1c Notes from CT Exercise Screen-WORD - Wisconsin Chiropractic ...

The Exercise Screen (Spine and Trunk)
QUESTIONNAIRES:
These include the Back and Neck Bournemouth Questionnaires (B-BQ, C-
BQ). These are chosen because, 1) there are only 7 questions; 2) they
utilize a quick 0-10 numerical rating scale (easy to complete for the
patient and score for the staff); and 3) they cover three important
domains or categories of outcomes. These include
1. Pain perception (average pain level over the past week)
2. Psychometric information (depression, anxiety, and locus of
control)
3. Disability (ADLs, recreation/social, and work activities)
The scoring method of the tool is simple. The total score is calculated
by the following formula:
Patient total / Total possible (70) x 100 = ____%. More specifically,
add the individual 7 responses together, divide by 70 (the maximum
possible score IF all 7 questions are answered is 70. If all 7 items
are not completed, the denominator is decreased by 10 points for each
question left blank) times (X) 100. Once the score is calculated, it is
recommended to place the score on the Outcomes Assessment Record (OAR),
which is then placed in an easy to access place in the patient's chart.
It is recommended that the OAR be placed on the top of the right hand
side of the patient file. That way, the OA scores can be easily found
and quickly reviewed during the day while treating patients in a busy
practice setting. The following include the low back and neck BQ's and
an OAR.
Please note, permission has been granted for the reprint and use of
these outcome tools in a clinical setting. 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 Worst pain
possible
0 1 2 3 4 5 6 7 8 9 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
Unable to carry out activity
0 1 2 3 4 5 6 7 8 9 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 ______
Bolton JE, Breen AC. The Bournemouth Questionnaire: a short-form
comprehensive outcome measure.
I. Psychometric properties in back pain patients. J Manipulative Physiol
Ther 1999;22:503-10 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 Worst pain
possible
0 1 2 3 4 5 6 7 8 9 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 Unable
to carry out activity
0 1 2 3 4 5 6 7 8 9 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 ______
Bolton J, Humphreys BK. The Bournemouth Questionnaire: A short-form
comprehensive outcome measure. II. Psychometric properties in neck pain
patients. J Manipulative Physiol Ther 2002;25:141-148. OUTCOMES ASSESSMENT RECORD | | | | |
|DATE |PAIN |FUNCTION |Satisfaction|
| | |Options: |Options: |VAS & C |VAS &LB |Patient |
| |Pain | | |Disability: |Disability: |Global |
| |Drawing |1. UE |1. Headache|(circle) |(circle) |Impression |
| | |2. CTS | | |( Oswestry |Of Change |
| | |3. LE |2. |( NDI |( Roland M |(or, |
| | |4. |Dizziness |( C- BQ |( LB - BQ |% recovery) |
| | |_________ |3. SCL-90R | | | |
| | | |4. | | | |
| | | |_________ | | | |
|BASELINE | | | | | | |
| |Physiologica|1. |1. T______; |a._________/|a._________/| |
| |l |_________% |E_____ |10 |10 |NA |
|___/____/_|1. Yes |2. |Fnctn_______|b. |b. | |
|__ |2. No |Sx_______% |__ |_________/10|_________/10| |
| | |Fn______% |2. | | | |
| | |3. |T_____;P____|c.____- |c.____- | |
| | |_________% | |____/10 |____/10 | |
| | |4. |F_____;E____| | | |
| | |_________% |_ |___________%|___________%| |
| | | |3. | | | |
| | | |A_____;D____| | | |
| | | |_ | | | |
| | | |4. | | | |
| | | |____________| | | |
| | | |_ | | | |
|PROGRESS | | | | | | |
| |Physiologica|1. |1. T______; |a._________/|a._________/| |
| |l |_________% |E_____ |10 |10 | |
|___/____/_|1. Yes |2. |Fnctn_______|b. |b. |___________%|
|__ |2. No |Sx_______% |__ |_________/10|_________/10| |
| | |Fn______% |2. | | | |
| | |3. |T_____;P____|c.____- |c.____- | |
| | |_________% | |____/10 |____/10 | |
| | |4. |F_____;E____| | | |
| | |_________% |_ |_______