Archives for October 2011

Liebenson’s Clinical Audit Process (CAP)

Craig Liebenson, DC wrote a landmark text in the world of rehab, Rehabilitation of the Spine, which is now in it’s second edition, parts of what is described below can be found in chapter 32.  In his seminars Dr. Liebenson often describes the Clinical Audit Process (CAP).  I suspect many leave the seminar with an appreciation for how powerful this process is, and some understanding of how it works, but my guess is that they would also benefit from time to sit back, read about it, and appreciate it’s simplicity. This is analogous to people’s initial understanding of McKenzie (MDT).  Those who have a cursory understanding think McKenzie is extension exercises.  Those who possess a sophomoric understanding believe it is about directional preference.  Those who actually understand it realize it’s about patient participation and the audit (test-retest) process and using centralization and peripheralization as markers of progress.

To say the CAP is simple does not mean it’s easy. Liebenson’s CAP is a synthesis of some great concepts, ideas, and techniques that were previously distant and are now bundled into one package and process.  Here is my understanding, a simplified but hopefully complete version for those who it may be new to.  Also there is some dovetail with the work of Gray Cook and the scoring systems of FMS and SFMA systems, for those familiar with those concepts they will be incorporated below.

After taking the Lumbar McKenzie course years ago, I realized the link Dr. Liebenson had often spoke of.  The foundation of the CAP is in McKenzie, only it has been expanded to incorporate functional assessment and corrective exercise, such as the work of the Prague School, as well as to address patients who do not have a clear mechanical sensitivity.  What I value most about the Audit Process is that it can be applied to any technique, any type of treatment, and holds us accountable for our choices.  I am the type of provider who likes to collect tools, I enjoy having a multitude of ways to treat a patient’s condition from soft tissue techniques, ergonomic sparing advice, mobilization or manipulation, stretching, movement pattern training, or stabilization exercise.

Training movement patterns with lunges

The CAP allows any of them to be used and simply directs us to which is most beneficial for the particular patient.  As a clinician, I need to have an assortment of great tools at my disposal and my job is to pick the right one.  I let the Audit Process determine which tool I use, it makes my job simple. (Side note: It is human nature to occasionally fall in love with a particular tool, and while I am guilty of that to some extent, the CAP forces me to reassess what I’m doing and why I’m doing it.)

Side plank exercise for stabilization

Dying Bug exercise on foam roller for combined core stabilization and movement pattern training.

Steps to the Clinical Audit Process:
Steps before the audit process:
A) Rule out Red Flags.

B) Mutual goal setting with the patient.
C) Identify/recognize yellow flags (comorbidities, psychosocial factors, and other complications).
1. Identify the Activity Intolerance (AI).
What activity is bothersome or limited due to the patient’s condition. This often becomes part of the process of mutual goal setting.  Remember to help keep the goal reasonable and attainable.
2. Identify the Mechanical Sensitivity (MS).  What motion or position increases the patient’s symptoms?  For those familiar with FMS scoring this is a 0 score. In SMFA scoring this could be a FP (or DP, but FP is much preferred).  I typically do not want this to just be ‘uncomfortable’ but to truly reproduce the patient’s primary complaint.  In McKenzie this would be ‘increased’ and likely ‘worse’. (In some cases you may not find a clear MS, see below for how to handle this.)
3. Identify Abnormal Motor Control (AMC).  What movement patterns/exercises does the patient have significant flaws in? What movements are they unable to perform? Or perform with unacceptable levels of compensation?  FMS scoring of 1, asymmetries (left right scores that differ), or possibly heavily compensated 2.  SFMA score of DN.  This part of the process is not considered in McKenzie (Mechanical Diagnosis and Treatment) and is one of the brilliant aspects of Liebenson’s CAP.

SFMA movement abbreviations: FN= Functional Non-Painful FP=Functional painful DN= Dysfunctional Non-Painful DP= Dysfunctional Painful

If there is an identifiable MS, we will use that as our benchmark.  If there is not a clear MS, we will use the most pertinent AMC as our benchmark.

Once your bench mark is identified it is time to begin treatment.   Choosing from your clinical toolbox, select a corrective exercise, movement, or treatment you suspect will help clear up your benchmark.  Have thSupported Functional Reache patient perform the activity or provide the treatment you determine and retest the benchmark.  Does it improve?  Does it improve significantly?  When you have made the right selection the benchmark will change readily and rapidly, it should be obvious to you and likely to the patient.  If you did not find this, choose a different tool and try again.  When you’ve found the right tool it will be obvious.  When watching those who have mastered the Audit Process, the greed for change is obvious.  As I started this process any improvement was a good sign to me.  As this process is refined you learn to look for the ‘best’ or ‘biggest’ change.  Find the exercise or treatment that gives you the biggest bang for your buck.

This process can be frustrating and daunting at first.  There are so many treatments that ‘should’ work according to protocol based care, prior experience, or clinical prediction rules.  However, we must remember and respect that each patient and each situation is different.  The Clinical Audit Process forces us to be scientific in our approach where we are continually performing clinical trials where N=1.  Nobel prize winner Rene Dubos said, ‘the measurable drives out the useful‘, do not rely solely on quantitative analysis, be sure to look at the quality of movements.  To put this another way, Bruce Lee would say, “What works in a movie doesn’t work in the street. What works in the street doesn’t work in a movie.”  While it may work in a controlled clinical trial, we need to also be sure it will work in the clinic for this particular patient.

As you become fluent with the process you will find it more and more rewarding to have your choices justified or challenged and debunked.  This process holds your care to the high standard that we all strive to achieve.  Most importantly the CAP reminds us that each patient and each case is unique and we must choose our treatments accordingly, this is truly a patient centered model.

“The CAP allows clinicians to adjudicate within-session what treatments are most efficacious.”, Craig Liebenson, Dynamic Chiropractic Article.  This is important because Hahne et al explains that, within-session reassessment was shown to predict between-session improvement.  If post-treatment audit of the Mechanical Sensitivity (MS) showed improvement those patients were at least 3.5X more likely to have between session improvement. – Hahne A, Keating JL, Wilson S. Australian Journal of Physiotherapy 2004;50:17-23.

To see this in action, make sure you make it to one of Dr. Liebenson’s seminars often with discounts for ISCRS members.