24 The Functional Rating Index: A Validated Spinal Outcome Measure That Saves Time
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Dynamic Chiropractic – July 1, 2010, Vol. 28, Issue 14

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.21 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.


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The Functional Rating Index is available royalty-free for noncommercial use by licensed health care providers at www.chiroevidence.com.

Click here for previous articles by J. Michael Menke, MA, DC, PhD.

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