Clinical Practice, Exercise Therapy, Rehabilitation

Cervical Spine Proprioceptive Retraining

There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms.(1) The evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits.(1)

Dizziness that occurs after concussion/mTBI presents with varied characteristics and several potential sources and mechanisms, including the inner ear, the brain, the cervical spine, and/or the integration of afferent input and tuning within the sensorimotor control system.(2) Vestibular rehabilitation therapy (VRT) has been used to treat persistent dizziness after concussion/mTBI, but recent attention has examined the possible role of the cervical spine in post-concussive dizziness.(2) Dizziness after concussion/mTBI has been shown to improve when manual therapy and specific sensorimotor control exercises for the cervical spine were added to standard care VRT.(2)

Hammerle et al (2) compared traditional VRT with cervical spine proprioceptive retraining (CSPR) in patients with recurring dizziness after concussion/mTBI who had at least 1 abnormal cervical spine proprioceptive test (e.g. cervical joint position error or smooth pursuit neck torsion test), regardless of the presence or absence of neck pain. Patients were excluded from the study if they had dizziness with a clear peripheral vestibular or central symptom origin (e.g. BPPV, consistent saccadic intrusions on smooth pursuits, gaze holding nystagmus, loss of gaze holding during VOR cancellation testing). The results demonstrated that patients who received CSPR were 30 times more likely to report improvement in dizziness symptoms compared with those who received VRT when abnormal CSP tests were present.(2) 

References:

1. Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther [Internet]. 2017;47(7):492–502. Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=28622488&retmode=ref&cmd=prlinks

2. Hammerle M, Swan AA, Nelson JT, Treleaven JM. Retrospective Review: Effectiveness of Cervical Proprioception Retraining for Dizziness After Mild Traumatic Brain Injury in a Military Population With Abnormal Cervical Proprioception. J Manipulative Physiol Ther [Internet]. 2019;42(6):399–406. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0161475418300411

Clinical Practice, Mental Health, Outcome Measures, Psychosocial

New Questionnaire: Assess and Monitor the Severity of Anxiety Disorder Symptoms with GAD-7

A new questionnaire is available with your Erepsonline subscription. The Generalised Anxiety Disorder Assessment (GAD-7) is a brief measure of general anxiety symptoms, and is commonly used in a wide variety of healthcare and research contexts. The GAD-7 was developed to overcome issues with traditional anxiety measures, such as taking too long and requiring in-person administration, by streamlining the process with a 7-item self-administered assessment that is quick and easy to administer.

The GAD-7 asks patients to evaluate their level of symptoms over the last two weeks, and can be used to track treatment progress over time. Given the simple language used in the assessment it is appropriate for individuals as young as 14 years. When used as a screening tool, further evaluation is recommended when the score is 10 or greater.

Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for generalised anxiety disorder. It is moderately good at screening three other common anxiety disorders – panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and post-traumatic stress disorder (sensitivity 66%, specificity 81%) (Kroenke, et al. 2007).

The GAD-7 joins the PHQ-9, DASS, Kessler Psychological Distress Scale (K10), Professional Quality of Life Scale (ProQOL), plus many other questionnaires in Erepsonline for measuring mental health symptoms. 

You can now add the GAD-7 to your clinical assessment, and the completion of all Erepsonline prescribed outcome measures will generate a PDF report for review. The questionnaires are automatically scored, with a total score being presented alongside raw responses, trends over time, and other contextual information to help you and your patient understand the results:

Clinical Practice, Outcome Measures

Patient-Reported Outcome Measures (PROMs): what to select clinically and how to reduce human scoring errors

Self-reported outcome instruments or patient-reported outcome measures (PROMs) are gaining popularity.(1) Recently, there has been interest in using PROMs to aid management of individual patients – this is mainly due to the importance of monitoring the subjective effectiveness of received treatments, required in the current healthcare system to assess treatment quality.(1,2)

In Australia, WorkSafe (3) expects that all healthcare professionals who provide services to injured workers for longer than 4-6 weeks will use standardised or customised outcome measures to assist in the clinical justification of their services. (read more here)

The outcome of objective tests (e.g. orthopaedic tests performed by a clinician) does not necessarily correspond with subjective feelings of patients, whereas PROMs provide feedback on patients’ view of their complaints.(1)

PROMs can be used in clinical practice in various ways: they can be used as one-time screening questionnaires; alternatively, they can be administered serially to monitor patients’ progress and facilitate identification of problems.(2)

Worksafe and The Transport Accident Commission (TAC) note the need to evaluate the appropriateness of PROMs based on the individual patient’s needs and the clinician’s own professional expertise.(3,4) Furthermore, the TAC (4) state “It is often best to use more than one measure.” As such, clinicians need to select multiple PROMs in an attempt to cover the various domains of a patients’ presenting complaint(s).

Listed below are PROMs  grouped according to their primary focus (3,4). As a  general guideline, clinicians should select one PROM from each primary focus group, for each region (e.g. a patient presents with neck pain – the clinician would select one PROM for pain, another PROM for neck disability / function etc)

  1. Pain
    • e.g. Quadruple Numerical Rating Scale (QNRS)
  2. Disability / Function
    • e.g. Upper Extremity Functional Index (UEFI), Shoulder Pain and Disability Index (SPADI), Lower Extremity Functional Scale (LEFS)
, Neck Disability Index (NDI)
, Whiplash Disability Questionnaire (WDI), Quebec Back Pain Disability Scale (QBPDS)
  3. Risk Identification / Predicting response to treatment (‘Yellow Flags’)
  4. General Health Status (Quality of Life)
    • Short-Form 12 Health Survey (SF-12), RAND 36-Item Health Survey (SF-36)

Importantly, it has been shown that clinicians have incorrectly scored PROMs at a level that is of concern, and problematic!(5) A study by Matthey et al (5) suggest that clinicians adopt using scoring templates and a double adding-up procedure to reduce scoring errors… one of the great things about Erepsonline, is that you can save time and remove the human error when scoring outcome measures.

Easily administer, score and interpret outcome measures through Erepsonline – which may be used to assist your clinical practice. You must evaluate the appropriateness of the outcome measures based on the individual’s needs and your own professional expertise.

 

References

  1. Vuurberg G, Kluit L, van Dijk CN. The Cumberland Ankle Instability Tool (CAIT) in the Dutch population with and without complaints of ankle instability. Knee Surgery Sports Traumatol Arthrosc. 2018;26:882-891
  2. Snyder CF, Aaronson NK. Use of patient-reported outcomes in clinical practice. The Lancet. 2009;374(9687):369–70.
  3. WorkSafe. (n.d.). Outcome Measures. Retrieved from: http://www.worksafe.vic.gov.au/health-professionals/treating-injured-workers/outcome-measures
  4. TAC (Transport Accident Commission). Standard Outcome Measures. Retrieved from: http://www.tac.vic.gov.au/providers/working-with-tac-clients/clinical-resources/outcome-measures
  5. Matthey S, Lee C, Črnčec R, Trapolini T. Errors in scoring the Edinburgh Postnatal Depression scale. Arch Womens Ment Health. 2013 Apr;16(2):117-22.
Clinical Practice, Outcome Measures

The Central Sensitization Inventory (CSI)

Central Sensitization (CS) has been proposed as a common neurophysiological phenomenon to explain related syndromes for which no specific organic cause can be found.(1) The term Central Sensitivity Syndrome (CSS) is a newly proposed category for a group of inter-related disorders for which CS is a common etiology, including:(1,2)

  • Fibromyalgia
  • Myofascial Pain Syndrome
  • Chronic Fatigue Syndrome
  • Temporomandibular Joint Disorder
  • Irritable Bowel Syndrome
  • Migraine/Tension Type Headaches
  • Restless Leg Syndrome
  • Multiple Chemical Sensitivity

The Central Sensitization Inventory (CSI) was developed by Mayer et al (1) in 2012 to assess the overlapping health-related symptom dimensions of CS/CSSs. It was originally designed as a screening instrument to help identify when a patient’s presenting symptoms may indicate the presence of a CSS diagnosis, so that potentially unnecessary diagnostic and treatment procedures can be avoided, and biopsychosocial treatment planning can be initiated.

The CSI has been found to have a high degree of test-retest reliability and internal consistency.(1) A 2017 systematic review looking at the measurement properties of the CSI concluded “…the tool generates reliable and valid data that quantifies the severity of several symptoms of CS.”(3)

A 2015 study found that patients with high CSI scores (>40) before knee replacement reported more severe postsurgical pain intensity, required higher dosage of postsurgical analgesics, and were at higher risk of persistent pain 3 months later.(5) Use of the CSI, with the 40-point cut-off score, has also been recommended to help classify chronic pain patients with CS, and to help differentiate them from patients with neuropathic and nocioceptive pain.(6,7)

Total scores on the CSI range from 0-100, with the following severity ranges recommended:

  • Subclinical = 0 to 29;
  • Mild = 30 to 39;
  • Moderate = 40 to 49;
  • Severe = 50 to 59;
  • Extreme = 60 to 100.

A 2017 study provided “support for these CSI severity levels as a guideline for healthcare providers and researchers in interpreting CSI scores and evaluating treatment responsiveness.”(4)

In summary, the CSI is appropriate for clinical purposes with higher CSI scores, indicating a higher probability of CS. Additionally, a CSI score of >40-points is clinically significant, providing both good sensitivity and specificity for the presence of CSS.

Easily administer, score and interpret outcome measures – including the CSI – through Erepsonline. For more information on selecting and viewing outcome measures, see the Erepsonline Video Tutorials, or check out the Quick Start Guide

 

References:

  1. Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, et al. The development and psychometric validation of the central sensitization inventory. Pain Pract. 2012 Apr;12(4):276–85.
  2. PRIDE; c2017 [cited 2017 September 13]. Available from: https://www.pridedallas.com/questionnaires/
  3. Scerbo T, Colasurdo J, Dunn S, Unger J, Nijs J, Cook C. Measurement Properties of the Central Sensitization Inventory: A Systematic Review. Pain Pract. 2017 Aug 29.
  4. Neblett R, Hartzell MM, Mayer TG, Cohen H, Gatchel RJ. Establishing Clinically Relevant Severity Levels for the Central Sensitization Inventory. Pain Pract. 3rd ed. 2017 Feb 1;17(2):166–75.
  5. Kim SH, Yoon KB, Yoon DM, Yoo JH, Ahn KR. Influence of centrally mediated symptoms on postoperative pain in osteoarthritis patients undergoing total knee arthro- plasty: a prospective observational evaluation. Pain Pract. 2015;15:E46–E53.
  6. Nijs J, Torres-Cueco R, van Wilgen CP, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17:447–457.
  7. Nijs J, Apeldoorn A, Hallegraeff H, et al. Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician. 2015;18:E333–E346.
Clinical Practice, Outcome Measures, Psychosocial Factors

Short Form Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ-10)

Evidence suggests that clinicians are limited in their ability to identify psychosocial factors in patients presenting with musculoskeletal (MSK) pain.(1,2) As such, it is important to use screening tools to improve clinical recognition and the contribution of psychosocial factors in MSK pain disorders.(3-5)

The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) has had several studies demonstrate its clinical utility in the identification of psychosocial factors.(6-8) However, calls were made to reduce the 21-item ÖMPSQ to a shorter form. A shorter version of the ÖMPSQ would improve practicality and reduce the burden on patients, clinicians and researchers.

The ÖMPSQ short version (ÖMPSQ-10) has recently been shown to be valid in identifying potential risk of pain-related disability and long-term work absence.(9) The ÖMPSQ-10 includes 10 items selected from the full version.(9)  These items are scored 0-10, where 0 refers to absence of impairment and 10 to severe impairment.

The total score will range between 1 and 100, with a score >50 correlating with greater long-term sick leave and poorer outcomes (high risk patient).(9)

In conclusion, the ÖMSPQ-10 is appropriate for clinical and research purposes, since it is nearly as accurate as the longer version.(9) It can also be used to monitor patient progress (e.g. administer the ÖMSPQ-10 monthly or every 3-months to monitor changes over time).

Easily administer, score and interpret outcome measures – including the ÖMSPQ-10- through Erepsonline. For more information on selecting and viewing outcome measures, see the Erepsonline Video Tutorials, or check out the Quick Start Quide

 

References:

  1. Bishop A, Foster NE. Do physical therapists in the United kingdom recognize psychosocial factors in patients with acute low back pain? Spine 2005;30:1316-22.[PMID: 15928559]
  2. Hill JC, Vohora K, Dunn KM, et al. Comparing the STarT back screening tool’s subgroup allocation of individual patients with that of independent clinical experts. Clin J Pain2010;26:783-7. [PMID: 20842014]
  3. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based mamagement of acute musculoskeletal pain. Brisbane: Australian Government: National Health and Medical Research Council, 2003. [pdf]
  4. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine 2007;147:478-91. [PMID: 17909209]
  5. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15 Suppl 2:S169-91. [PMID: 16550447]
  6. Gabel CP, Burkett B, Neller A, Yelland M. Can long term impairment in General Practitioner Whiplash patients be predicted using screening and Patient Report Outcomes? Int J Rehabil Res 2008; 31(1): 79-80.
  7. Gabel CP, Melloh M, Yelland M, Burkett B, Roiko A. Predictive Ability of a Modified Örebro Musculoskeletal Pain Questionnaire in an Acute Low Back Pain Working Population. Eur Spine J 2011; 20(3): 449-57.
  8. Gabel CP, Burkett B, Yelland M, Melloh M, Osborne J. The Örebro Musculoskeletal Screening Questionnaire: validation of a modified primary care musculoskeletal screening tool in an acute work injured population. Man Ther 2012;17(6):554-65
  9. Linton, S. J., Nicholas, M., & MacDonald, S. (2011). Development of a short form of the Orebro Musculoskeletal Pain Screening Questionnaire. Spine, 36(22), 1891-1895.[PMID: 21192286]
Clinical Practice, Patient Adherence

Patient Adherence and Treatment Outcomes

Adherence has been defined as: “the extent to which a person’s behaviour… corresponds with agreed recommendations from a healthcare provider” (1)

Adherence with treatment is an important factor which can influence the outcome of that treatment (2). It has been suggested that adherent patients are likely to have better treatment outcomes than non-adherent patients (3).

For practitioners of manual therapy, rehabilitation and exercise therapy prescription is part of a multimodal management strategy utilised to improve clinical outcomes. It has been shown that patients who are more committed to their therapy after hip resurfacing returned to higher levels of functionality and were more satisfied following their surgery.(4) Conversely, it has been suggested that non-adherence with treatment could be as high as 70% (5).

Martin et al (6)  have stated: “Patient non-adherence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. In some disease conditions, more than 40% of patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice.”

While no single intervention strategy can improve the adherence of all patients, home exercise programs – such as the ones you can create on Erepsonline – have been shown to increase patient adherence.(4, 7-9)

Visit the Help & Support page to watch short video clips of the various features of Erepsonline.

 

References:

  1. WHO . World Health Organisation; Geneva: 2003. Adherence to Long Term Therapies – Evidence for Action.
  2. Hayden J.A., van Tulder M.W., Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine. 2005;142(9):776–785.
  3. Vermeire E., Hearnshaw H., Van Royen P., Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. Journal of Clinical Pharmacy and Therapeutics. 2001;26(5):331–342.
  4. Marker DR, Seyler TM, Bhave A, Zywiel MG, Mont MA. Does commitment to rehabilitation influence clinical outcome of total hip resurfacing arthroplasty? Journal of Orthopaedic Surgery and Research 2010, 5:20
  5. Vasey L. DNAs and DNCTs – why do patients fail to begin or complete a course of physiotherapy treatment? Physiotherapy. 1990:76575–76578.
  6. Martin LR, Wiliams SL, HAskars KB, DiMatteo MR. The challenge of patient adherence. Ther Clin Risk Manag. 2005 Sep; 1(3): 189–199.
  7. Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. J Physio. 2013;59(4):219-26
  8. Latham NK, Harris BA, Bean JF, Heeren T, Goodyear C, Zawack S, Heislein DM, Mustafa J, Pardasaney P, Giorgetti M, Holt N, Lori Goehring L, Jette AM. Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture: A Randomized Clinical Trial. JAMA. 2014;311(7):700-708.
  9. Jan MH, Hung JY, Lin JC, Wang SF, Liu TK, Tang PF. Effects of a home program on strength, walking speed, and function after total hip replacement. Arch Phys Med Rehabil. 2004 Dec;85(12):1943-51.
Clinical Practice, Outcome Measures

The Fear Avoidance Beliefs Questionnaire (FABQ): The importance of its utilisation in clinical practice

The Fear Avoidance Belief Questionnaire (FABQ) was developed by Waddell to investigate the fear-avoidance beliefs of patients with chronic low back pain.(1) The Rehabilitation Measures Database states that the FABQ “focuses specifically on how a patient’s fear-avoidance beliefs about physical activity and work may affect and contribute to their low back pain (i.e. the cognitive/affective components of pain that are differentiated from specific tissue damage, injury, and nociception) and resulting disability.”(2)

The FABQ has been demonstrated to be valid and reliable in a chronic LBP population and appears to be a useful screening tool for identifying acute low back pain patients who will not return to work by 4 weeks. (1,3)

The FABQ consists of 2 subscales:

  • The Physical Activity subscale (FABQPA)
    • FABQPA of 15 or greater is considered a high score.
  • The Work subscale (FABQW).
    • FABQW of 34 or greater is considered a high score.

A patient with work related low back pain and a “positive” FABQ-W test result (score >34) has a higher probability of not returning to work in four-weeks.

Not only can the FABQ help determine the probability of current and future work loss and disability, the FABQ can also help healthcare professionals choose clinical interventions that have an increased probability of a successful outcome (i.e. the FABQ can predict successful outcomes from clinical interventions or predict decreased probability of successful outcomes).

For example, the FABQ can be used for the following clinical prediction rules:

  • Sacroiliac Joint Manipulation
    • A low FABQW score (less than 19) is one of 5 variables in a clinical prediction rule that increased the probability of success from sacroiliac region manipulation in individuals with low back pain.(4)
  • Stabilization Exercise
    • A low FABQPA score (less than 9) would decrease the probability of success of a stabilisation exercise program in individuals with low back pain.(5)
  • A predictor of 6-month outcomes following 4-weeks of physical therapy.
    • FABQW scores greater than 20 indicated an increased risk of reporting no improvement in 6-month ODQ scores.(6)

*The Oswestry Disability Questionnaire (ODQ) is considered the ‘gold  standard’ of low back functional outcome tools.

In conclusion, healthcare professionals should be administering the FABQ within clinical practice. The FABQ can help determine the probability of current and future work loss and disability, as well as indicate increased risk of poor treatment outcomes. Practitioners utilising manipulation and exercise therapy in the management of low back pain, can derive information from the FABQ to determine the probability of success – or lack thereof – when deciding to implement these two clinical interventions.

 

Easily administer, score and interpret outcome measures – including the FABQ – through Erepsonline. For more information on selecting and viewing outcome measures, see the Erepsonline Video Tutorials, or check out the Quick Start Quide

 

 

References:

  1. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52:157-168
  2. Mordini N. (2014, June). Rehab Measures: Fear-Avoidance Beliefs Questionnaire. Retrieved from: http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1200
  3. Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain 2001; 94:7-15. 3.
  4. Flynn T, Fritz J, Whitman J, Wainner R, et al. Clinical Prediction Rule for Classifying Patients with Low Back Pain Likely to Respond to a Manipulation Technique. Spine (Phila Pa 1976). 2002;27(24):2835-43.
  5. Hicks G et al.  Prelimary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to Stabilization Exercise Program. Arch Phys Med Rehabil. 2005;86:1753-1762.
Clinical Practice, Outcome Measures

The importance of using outcome measures within clinical practice

In 2014, Mark Zimmerman, MD¹ posted in the Psychiatric Times: “Imagine going to your primary care physician with a fever and symptoms of an upper respiratory tract infection. The doctor puts his or her palm to your forehead and agrees that you feel warm. A course of treatment is recommended, you return in a couple of days, and he or she again feels your forehead and notes that you are cooler. Would you be happy with this approach to care? Would you continue to see a doctor who evaluated your body temperature in this way? We would not accept this level of care from an internist, a family practitioner, or a pediatrician… To determine the impact of treatment, it is necessary to evaluate outcome.”

Outcome measures are assessment/diagnostic tools to measure performance, ability, or function of patients. Outcome measures can also enhance a patients’ experience, improve patient compliance and improve your own practice.

In Australia, WorkSafe¹ expects that all healthcare professionals who provide services to injured workers for longer than 4-6 weeks will use standardised or customised outcome measures to assist in the clinical justification of their services.

WorkSafe¹ also states that, “Outcome measures reduce administrative time for treating healthcare professionals by providing the following benefits:

  • The questionnaires can be completed independently of the treating healthcare professional
  • Instead of the healthcare professional having to ask a number of questions as part of their subjective assessment, they can scan the questionnaires to pick out the most important issues
  • Assessment of the outcome of treatment is determined more rapidly and with greater objectivity using standardised measures
  • Outcome measures abbreviate information that is required by external parties
  • Subsequent reports are also abbreviated by simply referring to the scores over time and how they have varied”

However, research³ suggests that standardized outcome assessment tools are not being used to evaluate outcome in clinical practice. In the Zimmerman and McGlinchey³ study, healthcare providers were asked the reasons for not routinely using scales in their clinical practice. More than one-quarter of them indicated that they did not believe using scales would be clinically helpful, that they take too much time to use, or that they were not trained in their use.

Importantly, research4 suggests that patients value periodic reviews of therapy. And it has been demonstrated that clients who complete regular outcome measures have significantly better clinical outcomes.4

Easily administer, score and interpret outcome measures through Erepsonline – which may be used to assist your clinical practice. You must evaluate the appropriateness of the outcome measures based on the individual’s needs and your own professional expertise.

 

References

  1. WorkSafe. (n.d.). Outcome Measures. Retrieved from: http://www.worksafe.vic.gov.au/health-professionals/treating-injured-workers/outcome-measures
  2. Zimmerman M. (2014, October 1). The Importance of Measuring Outcomes in Clinical Practice. Retrieved from: http://www.psychiatrictimes.com/uspc2014/importance-measuring-outcomes-clinical-practice
  3. Zimmerman M, McGlinchey JB. Why don’t psychiatrists use scales to measure outcome when treating depressed patients? J Clin Psychiatry. 2008;69:1916-1919.
  4. Lambert M. Presidential address: What we have learned from a decade of research aimed at improving psychotherapy outcome in routine. Psychotherapy Research. 2007; 17(1):1-14.

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