Outcome Assessment

Identifying Patient-Reported Outcome Measure Documentation in Veterans Health Administration Chiropractic Clinic Notes: Natural Language Processing Analysis

By Frank M. Painter|April 13, 2025|Outcome Assessment, Patient Satisfaction, Veterans|

Identifying Patient-Reported Outcome Measure Documentation in Veterans Health Administration Chiropractic Clinic Notes: Natural Language Processing Analysis

SOURCE: JMIR Medical Informatics 2025 (Apr 2): 13: e66466

Brian C Coleman • Kelsey L Corcoran • Cynthia A Brandt
Joseph L Goulet • Stephen L Luther • Anthony J Lisi

Pain Research, Informatics, Multimorbidities, and Education Center,
VA Connecticut Healthcare System,
950 Campbell Ave,
West Haven, CT, 06516

Background: The use of patient-reported outcome measures (PROMs) is an expected component of high-quality, measurement-based chiropractic care. The largest health care system offering integrated chiropractic care is the Veterans Health Administration (VHA). Challenges limit monitoring PROM use as a care quality metric at a national scale in the VHA. Structured data are unavailable, with PROMs often embedded within clinic text notes as unstructured data requiring time-intensive, peer-conducted chart review for evaluation. Natural language processing (NLP) of clinic text notes is one promising solution to extracting care quality data from unstructured text.

Objective: This study aims to test NLP approaches to identify PROMs documented in VHA chiropractic text notes.

Methods: VHA chiropractic notes from October 1, 2017, to September 30, 2020, were obtained from the VHA Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort. A rule-based NLP model built using medspaCy and spaCy was evaluated on text matching and note categorization tasks. SpaCy was used to build bag-of-words, convoluted neural networks, and ensemble models for note categorization. Performance metrics for each model and task included precision, recall, and F-measure. Cross-validation was used to validate performance metric estimates for the statistical and machine-learning models.

Results: Our sample included 377,213 visit notes from 56,628 patients. The rule-based model performance was good for soft-boundary text-matching (precision=81.1%, recall=96.7%, and F-measure=88.2%) and excellent for note categorization (precision=90.3%, recall=99.5%, and F-measure=94.7%). Cross-validation performance of the statistical and machine learning models for the note categorization task was very good overall, but lower than rule-based model performance. The overall prevalence of PROM documentation was low (17.0%).

Conclusions: We evaluated multiple NLP methods across a series of tasks, with optimal performance achieved using a rule-based method. By leveraging NLP approaches, we can overcome the challenges posed by unstructured clinical text notes to track documented PROM use. Overall documented use of PROMs in chiropractic notes was low and highlights a potential for quality improvement. This work represents a methodological advancement in the identification and monitoring of documented use of PROMs to ensure consistent, high-quality chiropractic care for veterans.

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Pain-Related Fear-Dissociable Neural Sources

By Frank M. Painter|January 15, 2019|Fear Avoidance, Outcome Assessment, Pain Management|

Pain-Related Fear-Dissociable Neural Sources of Different Fear Constructs

The Chiro.Org Blog

SOURCE: eNeuro. 2019 (Jan 3); 5 (6) pii: ENEURO.0107-18.2018

Michael Lukas Meier, Andrea Vrana, Barry Kim Humphreys, Erich Seifritz, Philipp Stämpfli, and Petra Schweinhardt

Integrative Spinal Research,
Department of Chiropractic Medicine,
Balgrist University Hospital,
8008 Zurich, Switzerland.

Fear of pain demonstrates significant prognostic value regarding the development of persistent musculoskeletal pain and disability. Its assessment often relies on self-report measures of pain-related fear by a variety of questionnaires. However, based either on “fear of movement/(re)injury/kinesiophobia,” “fear avoidance beliefs,” or “pain anxiety,” pain-related fear constructs plausibly differ while it is unclear how specific the questionnaires are in assessing these different constructs. Furthermore, the relationship of pain-related fear to other anxiety measures such as state or trait anxiety remains ambiguous. Advances in neuroimaging such as machine learning on brain activity patterns recorded by functional magnetic resonance imaging might help to dissect commonalities or differences across pain-related fear constructs. We applied a pattern regression approach in 20 human patients with nonspecific chronic low back pain to reveal predictive relationships between fear-related neural pattern information and different pain-related fear questionnaires.

More specifically, the applied multiple kernel learning approach allowed the generation of models to predict the questionnaire scores based on a hierarchical ranking of fear-related neural patterns induced by viewing videos of activities potentially harmful for the back. We sought to find evidence for or against overlapping pain-related fear constructs by comparing the questionnaire prediction models according to their predictive abilities and associated neural contributors. By demonstrating evidence of nonoverlapping neural predictors within fear-processing regions, the results underpin the diversity of pain-related fear constructs. This neuroscientific approach might ultimately help to further understand and dissect psychological pain-related fear constructs.

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Pain Location Matters: The Impact of Leg Pain on Health Care Use, Work Disability and Quality of Life in Patients with Low Back Pain

By Frank M. Painter|April 5, 2017|Low Back Pain, Outcome Assessment, Sciatica|

Pain Location Matters: The Impact of Leg Pain on Health Care Use, Work Disability and Quality of Life in Patients with Low Back Pain

The Chiro.Org Blog

SOURCE: Eur Spine J. 2015 (Mar); 24 (3): 444–451

Samantha L. Hider, David G. T. Whitehurst,
Elaine Thomas, Nadine E. Foster

Arthritis Research UK Primary Care Centre,
Keele University, Keele,
Staffordshire, ST5 5BG, UK.

PURPOSE: In low back pain (LBP) patients, those with radiating leg pain or sciatica have poorer pain and disability outcomes. Few studies have assessed the effect of leg pain on health care use and quality of life.

METHODS: Prospective cohort study of 1,581 UK LBP primary care consulters. Back pain, employment, health care utilisation, and quality of life (EQ-5D) data were collected at baseline, 6 and 12 months. At baseline, patients were classified as reporting

(1) LBP only

(2) LBP and leg pain above the knee only (LBP + AK) or

(3) LBP and leg pain extending below the knee (LBP + BK).

RESULTS: Self-reported leg pain was common; at baseline 645 (41%) reported LBP only, 392 (25%) reported LBP + AK and 544 (34%) reported LBP + BK. Patients with LBP + BK, compared to those with LBP only, were significantly more likely to be unemployed, take time off work, consult their family doctor, receive physical therapy, or be referred to other health care practitioners. There were statistically significant decrements in EQ-5D scores for LBP + AK compared to LBP only, and for LBP + BK compared to LBP + AK (p ≤ 0.05 for all comparisons).

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Assessment of Patients With Neck Pain

By Frank M. Painter|October 20, 2014|Diagnosis, Outcome Assessment|

Assessment of Patients With Neck Pain: A Review of Definitions, Selection Criteria, and Measurement Tools

The Chiro.Org Blog

SOURCE: J Chiropractic Medicine 2010 (Jun); 9 (2): 49–59 ~ FULL TEXT

Victoria Misailidou, Paraskevi Malliou, Anastasia Beneka,
Alexandros Karagiannidis, and Georgios Godolias

Laboratory Instructor, Department of Physical Therapy,
Technological Educational Institute of Thessaloniki,
57400, Thessaloniki, Greece

OBJECTIVE: The purpose of this literature review was to synthesize the existing literature on various definitions, classifications, selection criteria, and outcome measures used in different studies in patients with neck pain.

METHODS: A literature search of MEDLINE and CINAHL through September 2008 was performed to gather articles on the reliability, validity, and utility of a wide variety of outcome measurements for neck pain.

RESULTS: Different types of definitions appear in the literature based on anatomical location, etiology, severity, and duration of symptoms. Classifications according to severity and duration of pain and the establishment of selection criteria seem to play a crucial role in study designs and in clinical settings to ensure homogeneous groups and effective interventions. A series of objective tests and subjective self-report measures are useful in assessing physical abilities, pain, functional ability, psychosocial well-being, general health status, and quality of life in patients with neck pain. Self-administered questionnaires are commonly used in clinical practice and research projects.

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Spinal Manipulation Compared with Back School and with Individually Delivered Physiotherapy

By Frank M. Painter|January 30, 2014|Chiropractic Care, Evidence-based Medicine, Low Back Pain, Outcome Assessment|

Spinal Manipulation Compared with Back School and with Individually Delivered Physiotherapy for the Treatment of Chronic Low Back Pain: A Randomized Trial with One-year Follow-up

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SOURCE: Clinical Rehabilitation 2010 (Jan); 24 (1): 26–36

Francesca Cecchi, Raffaello Molino-Lova, Massimiliano Chiti,
Guido Pasquini, Anita Paperini, Andrea A Conti, and Claudio Macchi

Fondazione Don Carlo Gnocchi,
Scientific Institute,
Florence, Italy.
francescacecchi2002@libero.it

FROM: Health Insights Today

A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1-hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4-6 20-minute sessions once-a-week.

Outcome measures were the Roland Morris Disability Questionnaire (scoring 0-24) and Pain Rating Scale (scoring 0-6), assessed at baseline, discharge, and at 3, 6, and 12 months. 205 patients completed the study.

At discharge, disability score decreased by:

3.7 +/- 4.1 for back school,4.4 +/- 3.7 for individual physiotherapy, and

6.7 +/- 3.9 for manipulation.

The pain score reduction was 0.9 +/- 1.1, 1.1 +/- 1.0, 1.0 +/- 1.1, respectively. At 12 months, disability score reduction was 4.2 +/- 4.8 for back school, 4.0 +/- 5.1 for individual physiotherapy, 5.9 +/- 4.6 for manipulation; pain score reduction was 0.7 +/- 1.2, 0.4 +/- 1.3, and 1.5 +/- 1.1, respectively.

Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy, but received more further treatment at follow-ups;

pain recurrences and drug intake were also reduced compared to back school or individual physiotherapy.

The difference in their improved scores is quite dramatic:

After 12 months

Intervention	Disability Score	Pain Rating
At Discharge
Spinal Manipulation	6.7 +/- 3.9	1.0 +/- 1.1
Individual Physiotherapy	4.4 +/- 3.7	1.1 +/- 1.0
Back School	3.7 +/- 4.1	0.9 +/- 1.1
Spinal Manipulation	5.9 +/- 4.6	1.5 +/- 1.1
Individual Physiotherapy	4.0 +/- 5.1	0.4 +/- 1.3
Back School	4.2 +/- 4.8	0.7 +/- 1.2

NOTE: These numbers indicate the reductions in scores on the Roland Morris Disability Questionnaire and the Pain Rating Scale.

The Abstract:

OBJECTIVE: To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain.

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Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain:

By Frank M. Painter|January 19, 2014|Depression Screening, Low Back Pain, Outcome Assessment|

Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity

The Chiro.Org Blog

Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4

Alice Kongsted, Benedicte Aambakk, Sanne Bossen and Lise Hestbaek

The Nordic Institute of Chiropractic and Clinical Biomechanics,
Campusvej 55,
5230 Odense, M, Denmark

Background Depression is an important prognostic factor in low back pain (LBP) that appears to be infrequent in chiropractic populations. Identification of depression in few patients would consequently implicate screening of many. It is therefore desirable to have brief screening tools for depression. The objective of this study was to investigate if one or two items from the Major Depression Inventory (MDI) could be a reasonable substitute for the complete scale.

Methods The MDI was completed by 925 patients consulting a chiropractor due to a new episode of LBP. Outcome measures were LBP intensity and activity limitation at 3-months and 12-months follow-up. Single items on the MDI that correlated strongest and explained most variance in the total score were tested for associations with outcome. Finally, the predictive capacity was compared between the total scale and the items that showed the strongest associations with outcome measures.

Results In this cohort 9% had signs of depression. The total MDI was significantly associated with outcome but explained very little of the variance in outcome. Four single items performed comparable to the total scale as prognostic factors. Items 1 and 3 explained the most variance in all outcome measures, and their predictive accuracies in terms of area under the curve were at least as high as for the categorised complete scale.

Conclusions Baseline depression measured by the MDI was associated with a worse outcome in chiropractic patients with LBP. A single item (no. 1 or 3) was a reasonable substitute for the entire scale when screening for depression as a prognostic factor.

From the FULL TEXT Article:

Introduction

Pain and depression often co-exist [1-3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6].

Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].

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