The Functional Rating Index: A Validated Spinal Outcome Measure That Saves Time
By J. Michael Menke, MA, DC, PhD and Ronald Feise, DC
Patient-reported outcome measures (PROs) are increasingly necessary elements of good clinical practice in light of evidence-based protocols requiring outcomes measurement. Use of PROs can quantify patient function and progress.1-2
Moreover, self-evaluation as reported in PROs is thought to be a more accurate reflection of patient clinical state and progress than many objective clinical or physiological indexes measures (e.g., X-rays, range of motion, muscle strength) upon which we have traditionally relied.2-6
PROs can help determine whether treatment is necessary or effective, and when to stop care.7
Although the benefits of outcome measures are numerous, there are many barriers to their implementation and use.
Benefits of Using Outcome Measures
By using a clinically meaningful outcome measure at the initial assessment and measuring change in signs and symptoms over time, you can track shifts in patient progress, and thereby improve clinical decisions.8-10 Documenting treatment necessity (which can improve and facilitate reimbursement and decrease insurance denials) can fine-tune your treatment regime and provide a rationale for ongoing treatment.8-10 Outcome measures are particularly useful in establishing maximum therapeutic recovery. PRO responses can also identify patients at risk for poor outcomes and enhance the thoroughness of examination by collecting information about personal dimensions that might not have been measured with a routine physical examination.11
When validated measures are used, communications with health care providers, patients and payers are enhanced.8-10 Measures of the patient's personal perception of a health condition also enhance the patient's feeling of being understood, and the observation of progress may encourage patient adherence with to a treatment plan. Additionally, outcome measures can provide data for quality improvement initiatives.
Barriers to the Implementation of Outcome Measures
Even with all the benefits of using outcome measures, some practitioners resist using them in everyday practice. Researchers have found that logistical problems such as time, inconvenience, or lack of familiarity, know-how and training in their use and interpretation are typical.12-17 Moreover, in a recent cross-sectional study of both users and non-users, more than 70 percent of respondents felt it takes too much time for patients to complete and for clinicians to score and interpret.10 Other research teams affirm that time is the predominant reason for the failure to use PROs.15-20 Although there are numerous measures available, most of the self-reporting instruments measuring spinal pain and dysfunction are underutilized in daily practice because they require too much time for patients to answer (5-10 minutes per instrument) and health care workers to score (1-5 minutes per instrument).21
The Functional Rating Index
Table 1. Psychometric Qualities of the Functional Rating Index.
Reliability: Test-retest: Intraclass correlation coefficient was good (weighted mean value 0.85); Cronbach's alpha was excellent (weighted mean value 0.91); FRI is equivalent to the other measures.
Validity: FRI has good convergent validity (weighted mean value r=0.70) with pain and function self-report scales and a weaker correlation (weighted mean value r=0.41) with items that measure different constructs. It has a stronger convergent correlation than the comparative PROs.
Responsiveness: FRI was similar to the comparative PROs for standardized response mean (weighted mean value FRI=0.85), effect size (weighted mean value FRI=0.84) and receiver operating curve (weighted mean value FRI=0.76) statistics.
Clinical Utility: time required by the patient and staff averaged 78 seconds per administration, and there were few missing responses.
Outcome measures that have been formally validated in the scientific literature are preferable to those that have not been validated. A quality measurement tool must at least demonstrate reliability, validity, responsiveness and practicality.22-24
The Functional Rating Index (FRI) was originally tested and the results published in Spine
Initial research showed that FRI had good reliability, validity and responsiveness, and reduced the typical administrative burden. Since its development, nine independent research teams have also tested the psychometric qualities of the FRI. A recent review
of all 10 studies found the psychometric qualities acceptable for clinical and research.25
(See table 1
for the full psychometric quality details.)
The FRI instrument contains 10 short items that measure pain and function of the spinal musculoskeletal system: eight refer to activities of daily living that might be adversely affected by a spinal condition; two refer to different attributes of pain. Function is considered the strongest measure of severity, and pain is the most common measure.6,26 The FRI requires only about one minute for a patient to complete and about 20 seconds for a health care worker to score. This instrument can be used with cervical, thoracic or lumbar conditions, which reduces the need for multiple instruments for spine-related conditions.
The practice of evidence-based chiropractic is becoming the standard of care, and outcome measures assessed by PROs are the universal language for communicating the effectiveness of care over time and for inter-professional referral. Additionally, the judicious use of outcome measures establishes credibility and positions your clinic to gain market share with patients, medical doctors, managed care organizations, and large employers. The FRI is a useful, validated outcome measure you can use in your practice.
- Beurskens AJ, de Vet HC, Koke AJ, et al. Measuring the functional status of patients with low back pain. Assessment of the quality of four disease-specific questionnaires. Spine, 1995;20:1017-28.
- Deyo RA. Measuring the functional status of patients with low back pain. Arch Phys Med Rehabil, 1988;69:1044-53.
- Deyo RA, Anderson G, Bombardier C, et al. Outcome measures for studying patients with low back pain. Spine, 1994;19:2032S-6S.
- Bogduk N. Musculoskeletal pain: Towards precision diagnosis. In: Progress in Pain Research and Management, Volume 8. Seattle: IASP Press, 1997:507-25.
- Epstein AM. The outcomes movement: will it get us where we want to go? N Engl J Med, 1990;323:266-70.
- Waddell G, Main CJ, Morris EW, et al. Chronic low back pain, psychological distress, and illness behavior. Spine, 1984;9:209-13.
- Finley GA, McGrath PJ. Measurement of Pain in Infants and Children. In: Progress in Pain Research and Management, Volume 10. Seattle: IASP Press, 1998.
- Torenbeek M, Caulfield B, Garrett M, Van Harten W. Current use of outcome measures for stroke and low back pain rehabilitation in five European countries: first results of the ACROSS project. Int J Rehabil Res, 2001;24:95-101.
- Huijbregts MPJ, Myers AM, Kay TM, Gavin TS. Systematic outcome measurement in clinical practice: challenges experienced by physiotherapists. Physiother Can, Winter 2002:25-31, 36.
- Jette DU, Halbert J, Iverson C, et al. Use of standardized outcome measures in physical therapist practice: perceptions and applications. Phys Ther, 2009, 89:125-35.
- Rebbeck T, Sindhusake D, Cameron ID, et al. A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population. Inj Prev, 2006;12:93-8.
- Huijbregts MPJ, op cit.
- Turner-Stokes L, Turner-Stokes T. The use of standardized outcome measures in rehabilitation centres in the UK. Clin Rehabil, 1997;11:306-13.
- Hatfield DR, Ogles BM. Why some clinicians use outcomes measures and others do not. Adm Policy Ment Health Ment Health Serv Res, 2007;34:283-91.
- Kay T, Myers A, Huijbregts M. How far have we come since 1992? A comparative survey of physiotherapists' use of outcome measures. Physiother Can, 2001;53:268-75.
- Russek L, Wooden M, Ekadahl S, Bush A. Attitudes toward standardized data collection. Phys Ther, 1997;77:714-29.
- Abrams D, Davidson M, Harrick J, et al. Monitoring the change: current trends in outcome measure usage in physiotherapy. Man Ther, 2006 Feb;11(1):46-53.
- Cole B, Finch E, Gowland C, et al. Physical Rehabilitation Outcome Measures. Ottawa: Communication Group, 1994.
- Copeland JM, Taylor WJ, Dean SG. Factors influencing the use of outcome measures for patients with low back pain: a survey of New Zealand physical therapists. Phys Ther, 2008;88:1492-505.
- Chesson R, Macleod M, Massie S. Outcome measures used in therapy departments in Scotland. Physiother Theory Pract, 1996;82:673-9.
- Feise RJ, Menke JM. Functional Rating Index: a new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Spine, 2001;26:78-87.
- McHorney CA, Tarlov AR. Individual-patient monitoring in clinical practice: are available health status surveys adequate? Qual Life Res 1995;4:293-307.
- Bouter LM, van Tulder MW, Koes BW. Methodologic issues in low back pain research in primary care. Spine 1998;23:2014-20.
- Stratford PW, Binkley JM. A comparison study of the back pain functional scale and Roland Morris Questionnaire. J Rheumatol, 2000;27:1928-36.
- Feise RJ, Menke JM. Functional rating index: literature review. Med Sci Monit, 2010 Feb;16:RA25-36.
- Roach KE, Brown MD, Dunigan KM, et al. Test-retest reliability of patient reports of low back pain. J Orthop Sports Phys Ther, 1997;26:253-9.
The Functional Rating Index is available royalty-free for noncommercial use by licensed health care providers at www.chiroevidence.com.
for previous articles by J. Michael Menke, MA, DC, PhD.
Ron Feise, DC, is the president of the Institute of Evidence-Based Chiropractic, an organization that helps chiropractors achieve optimal patient outcomes through the use of evidence-based strategies.