Welcome back to Spine-IQ’s Back Blog! We know that you are busy, and we also know how critical your time is and that is why we are making these tools available to you. It may seem that there is not enough time to incorporate all our suggestions, but we also know that the world of clinical care and documentation is also changing. These future changes will have a significant impact on your patients, your practice, and your payment. Just by the fact that you are reading our Blogs speaks volumes about your clinical interest in not only keeping up with the latest information but also recognize that clinical excellence will be a measurable fact in every practice in the future. We thank you for your interest and your desire for excellence.
Last week, we tackled the evidence around “HOW” to implement screening tools into your practice! This week, we will focus on patient reported outcome measures (PROMs) and “HOW” to incorporate them into your practice. Current guidelines recommend that patient’s complete evidence-based PROMs at baseline and re-exams. (1)
Baseline evaluation is critical to assess not only the patient’s response to care but also the ability to assess the clinical approach you will take based on Baseline Data.
This allows you to see how the patient is responding to care and equally as important whether something about the care needs to change or not. Providing care to patients where there is no demonstrable improvement is not only difficult to defend but difficult to justify by any clinical measure.
PROMs can be extremely beneficial, valid, and reliable measures to assess patients’ pain/outcomes, but they should not replace asking patients how they are feeling. PROMs are best used in addition to genuine and honest conversations between clinician and patients. We emphasize this obvious but sometimes overlooked fact that “care” for your patient also consists of conversations with your patient and nothing builds better rapport than informative discussions. Studies have shown that patients’ perception of being heard and understood is a critical component to the outcome.
One of the best PROM for assessing patients with spinal pain is PROMIS-Pain Interference (PROMIS-PI). (2) This scale was developed and validated to accurately measures how much pain interferes with physical, mental, and social activities. On this blog, we will show you what PROMIS-PI asks, how to interpret results, and what a clinically meaningful change is.
PROMIS-PI Questions
All PROMIS measures are available free-to-use on their website. PROMIS-PI currently has 3 available options that differ in number of questions (4, 6, 8). All the questions ask about pain interference within the past 7 days. The questions are measured on a 5-point Likert scale that ranges from ‘Not at all’ (1 point) to ‘Very Much’ (5 points). The following questions are used in the 8-question short form:
- How much did pain interfere with your day-to-day activities?
- How much did pain interfere with work around the home?
- How much did pain interfere with your ability to participate in social activities?
- How much did pain interfere with your household chores?
- How much did pain interfere with the things you usually do for fun?
- How much did pain interfere with your enjoyment of social activities?
- How much did pain interfere with your enjoyment of life?
- How much did pain interfere with your family life?
PROMIS-PI Score Interpretation
The HealthMeasures website provides you with a free-to-use tool that automatically outputs the patients PROMIS-PI score for you. If you’d like to calculate it yourself then you will sum up the score for each question (‘not at all’ is 1 point, ‘very much’ is 5 points etc.). For example, if the patient said, ‘not at all’ (1 point) to all the questions on the 8 question PROMIS-PI then their raw score would be 8 points.
PROMIS tools allow you to standardize scores using T-scores. A T-score of 50 on PROMIS tools is the average score for the US general population. A higher PROMIS-PI T-score means more pain interference, which translates to worse outcome. Below is a table that will help you translate the raw score that you calculated into a T-score:
| Raw score | T-Score | Raw Score (Cont.) | T-Score (Cont.) |
| 8 | 40.7 | 25 | 62.1 |
| 9 | 47.9 | 26 | 62.8 |
| 10 | 49.9 | 27 | 63.5 |
| 11 | 51.2 | 28 | 64.1 |
| 12 | 52.3 | 29 | 64.8 |
| 13 | 53.2 | 30 | 65.5 |
| 14 | 54.1 | 31 | 66.2 |
| 15 | 55 | 32 | 66.9 |
| 16 | 55.8 | 33 | 67.7 |
| 17 | 56.6 | 34 | 68.4 |
| 18 | 57.4 | 35 | 69.2 |
| 19 | 58.1 | 36 | 70.1 |
| 20 | 58.8 | 37 | 71 |
| 21 | 59.5 | 38 | 72.1 |
| 22 | 60.2 | 39 | 73.5 |
| 23 | 60.8 | 40 | 77 |
| 24 | 61.5 |
So now you have a T-score for your patient, what does this mean? Remember, 50 points is the average T-score for the US general population with higher score meaning more (worse) pain interference. Typically, PROMIS-PI T-scores from 20-55 are considered within normal limits, 55-60 are mild, 60-70 is moderate and 70+ is severe.
If you’d like a more in-depth explanation on interpreting PROMIS-PI scores, their website has video tutorials.
PROMIS-PI Meaningful Change
It is important for clinicians to take PROMs at baseline so they can know just how severe patients pain is, but it is just as important to take PROMs at re-exam sessions to know if patients are having positive/negative or no meaningful change. How many points is a clinically meaningful change is an extremely debated topic in research. The most up-to-date evidence on PROMIS-PI meaningful change scores is 2-3 point change. (3) That means if a person has a T-score of 60 at baseline, we want them to have at most a score of 57-58 at follow-up to consider the change clinically meaningful. Remember, that a higher score means more pain interference.
Summary
Because PROMs are evidence-based tools that can help clinicians understand their patients’ clinical symptoms, they have significant impact on the documentation of care in the event of any challenges to care provided. PROMIS-PI tool is valid and reliable scale that should be taken at baseline and follow-up to help guide treatment decisions. It’s important that clinicians remember that PROMs are to be used in addition and not to replace good, genuine listening and conversation with their patient. While this may seem self-evident, the value comes when the care is challenged, and the documentation is reviewed by others.
Stay tuned for next week’s blog when we dive into how to incorporate a different patient reported outcome measures in your clinic!
References:
- National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management [Internet]. London: National Institute for Health and Care Excellence (UK); 2016 [cited 2021 Jun 11]. (National Institute for Health and Care Excellence: Clinical Guidelines). Available from: http://www.ncbi.nlm.nih.gov/books/NBK401577/
- Amtmann D, Cook KF, Jensen MP, Chen W-H, Choi S, Revicki D, et al. Development of a PROMIS item bank to measure pain interference. Pain. 2010 Jul;150(1):173–82.
- Chen CX, Kroenke K, Stump TE, Kean J, Carpenter JS, Krebs EE, et al. Estimating minimally important differences for the PROMIS pain interference scales: results from 3 randomized clinical trials. Pain. 2018 Apr;159(4):775–82.