Neuro Rehabilitation Toolbox

Neuro Rehabilitation Toolbox Roadmap Introductions Framework for classifying tests and measures Tests and measures by clinical setting Patient case Wrap up California Physical Therapy Association Annual Conference 2011 D. Michael McKeough, PT, EdD Professor of Physical Therapy California State University Sacramento mmckeough@csus.edu Learning Objectives At the completion of this presentation, participants will be able to: Describe influence of disablement models of the selection of tests/measures Compare and contrast Nagi and ICF models of disablement Describe the characteristics of good tests and measures Select good tests/measures based on your conceptual model of clinical practice, outcome goals, patient characteristics, and clinical setting Develop basic familiarity with commonly used, valid, reliable and sensitive measures of body function and structure, activity, and participation Framework We are here to talk about neuro rehabilitation tests and measures (outcome measures, OM) What tests you select depend on your objectives Your objectives depend on what you choose to examine and what you choose to treat What you choose to examine/treat depends on your conceptual model of clinical practice Conceptual Framework For Clinical Practice APTA Model of Physical Therapy Practice 1. Model of PT Practice APTA model defines PT practice 2. Model of Disablement Describes how a patient becomes disabled 3. Hypothesis Oriented Clinical Practice Describes PT clinical reasoning 4. Theory of Motor Control Describes leading theories of how movement is controlled Evaluation Examination Diagnosis Outcomes Prognosis Intervention (Shumway Cook and Woollacott 2007) Patient Centered Care Guide to Physical Therapist Practice. 2001 1

Disablement Model How a person became disabled A conceptual explanation of the process and underlying mechanisms by which h disease, injury or birth defect impacts a person s ability to function (perform their expected role in society). Level of Analysis Cell / Organ (Arrest pathology, cell protection) [Change risk factors] System (Motor, sensory, cognitive) [ROM, strength, th pain] Person (Activities of daily living) [Mobility, gait, balance] Society (Work, culture, leisure) [Return to work/leisure] Nagi Model Primary Pathology Primary Impairment Functional Limitations Disability Nagi 1965 Hypothesis Oriented Clinical Practice Clinical reasoning Chart driven (novice clinical reasoning) Follow chart driven examina on from Q1 Qn Hypothesis oriented (expert clinical reasoning) Make an observation, then formulate an hypothesis about its cause Evaluate the hypothesis (cause) by conducting a test Level of Analysis Cell / Organ (Arrest pathology, cell protection [Change risk factors] System (Motor, sensory, cognitive) [ROM, strength, th pain] Person (Activities of daily living) [Mobility, gait, balance] Society (Work, culture, leisure) [Return to work/leisure] Nagi Model Primary Pathology Primary Impairment Functional Limitations Disability Nagi 1965 Limitations of Nagi Model Nagi is a unidimensional (pathology based) and unidirectional model of disability only Does not account for impairments and functional limitations not due to pathology Functional limitations due to lifestyle (obesity, diabetes) Disability due to environmental barriers or personal factors Theory What is done with a theory that fails to account for experimental observations (data) or has too many limitations? It is replaced by a new theory that does account for the data. 2

International Classification of Functioning, Disability and Health (ICF) The World Health Organization (WHO) authorized the International Classification of Functioning, Disability and Health (ICF) in 2001. Goes beyond disability to include functioning, health and disability Includes non pathological causes of functional limitations and impairments Context variables: potentially have effect on all levels of model It is accepted by more than 200 countries as the international standard to describe and measure health and disability. Nagi Model International Classification of Functioning, Disability and Health (ICF) Impairment Functional Limitations Disability Contextual Variables (WHO, 2002) Conclusion Nagi is a unidimensional (pathology based) and unidirectional model of disability ICF is multidimensional (bio psycho social) and multidirectional model of human health Affords opportunity to formulate multiple alternative hypotheses about the cause of the functional limitation Hypothesis Testing (Characteristics of Good Tests and Measures) Requires valid, reliable, and sensitive measures Validity Measures what it purports to measure Reliability Proper use of the instrument produces stable outcomes (Inter and intra rater reliability) Sensitivity / Responsiveness Capable of detecting change (MDC, MCID) Ceiling and floor effects Minimum Detectable Change (MDC) Reliable change or smallest real difference (Ottenbacher 1988) (MDC = SEM x Z x 2) Smallest change in score that likely reflects true change rather than measurement error (Stratford 1996) Minimal Clinically Important Difference (MCID) Magnitude of change required to produce a meaningful improvement in performance Smallest difference in a measure that is considered worthwhile or important MCID scores have limited generalizability, so they should be used only with patients having characteristics similar to those of the subjects for which MCID were reported (Haley 2006) 3

Continuum of Change Responsiveness r error Threshold fo Real but unimportant change Important Change Threshold for No change MDC MCID Continuum of Change Real and important change Large change Ceiling effects Level above which variance in performance is no longer measured FIM does not detect improvement in ambulation beyond d150 Floor effects Level below which performance cannot be measured HiMAT is incapable or assessing improvement in ambulation < 20m (Beninato 2011) Evidence based Practice (EBP) Outcome measures are a critical part of EBP Recent evidence suggests that the use of OMs in clinical practice is limited (Jette 2009, Kay TM, 2001, Huijbregts 2002) Selecting the most appropriate OM enhances clinical practice by: Identifying and quantifying body function and structure limitations Formulating the evaluation, diagnosis, and prognosis Informing the plan of care Helping to evaluate the effectiveness of physical therapy interventions Barriers to Use of OM Time constraints Difficult for patients to complete Lack of equipment Knowledge regarding OMs (Jette 2009, Van Peppen 2008, Kay 2001) How to select and apply the best OM (Huijbregts 2002) Tests and Measures by Practice setting StrokEDGE Taskforce 2011 Tests and Measures by Practice setting Acute Care In Patient and Out Patient Home Health Skilled Nursing Facility Entry Level Education 4

Patient Case 1/4 Patient Case JW referred to Inpatient PT, Dx Stroke (L MCA occlusion), Uncomplicated acute care stay (4d) Facility Specific Issues FIM 60 min initial exam, note due same day All standard PT equip available Patient History 68 yo African American male, overweight, HT, hyper lipidemia, sedentary, 20 pack year Hx of smoking Patient Goals Return to work as accountant Systems Review Cardiopulmonary WFL Integumentary WNL Musculoskeletal Gross symmetry Gross AROM Gross strength Depressed R shoulder, trunk flexed R L UE & LE WFL : R UE & LE impaired L UE & LE WFL : R UE & LE impaired Systems Review (Cont) Neuromuscular Balance Gait Patient Case 2/4 (I) static sitting w/ midline shift, unable to maintain unsupported standing, able to stand using small base Q cane w/ Min Asst Amb x 10, level surface, w/ Q cane & Min Asst w/ gait deviation in stance and swing Transfers/transitions Bed mob & transfers w/ Mod Asst Motor Function No (I) mvnt R UE Sensory function Impaired lt touch R UE/LE Other Orientation A&O x 4 Communication Able to speak clearly Behavioral responses Appropriate to situation Learning barriers None identified Educational needs Disease process, home safety, fall prevention Patient Case 3/4 Outcome Measure Selection Overall function FIM Balance Berg balance scale (BBS) Gait 10 MWT Fear of falling Activity specific balance confidence scale (ABC) L UE Seen by OT (Fugl Meyer Motor, Action Research Arm Test) Analysis of Results 4/4 Inpatient Intake D/C Change MDC MCID FIM 68/126 92/126 +24 22 BBS 35/56 45/56 +10 pts 7 pts? 10MWT 0.21 m/s 0.56 m/s +0.35 m/s 0.30 m/s? (<0.4 House amb) (Ltd comm amb.4.8m/s) Take Home Message If you are already consistently using standardized outcome measures in your clinical practice, hopefully this presentation has assisted you in deciding if the measures you use are optimal. Out patient Intake D/C Change MDC MDIC ABC 51/100 67/100 +16 pts (24%) 6 15% PD? 10 MWT 0.58 m/s 0.74 m/s 0.16 m/s 0.08 m/s 0.17 m/s If you are not already using standardized outcome measures, then hopefully this presentation has motivated you to get on board! 5

Review Learning Objectives Questions? Describe how Nagi and ICF models permit different hypotheses Describe the 3 characteristics of good tests/measures For your clinical setting, cite two examples of good tests/measures of: Body function/structure Activity Participation (mmckeough@csus.edu) References Beninato M, Portner LG. Applying concepts of responsiveness to patient management in neurologic physical therapy. JNPT 2011;35(2):75 81 Guide to Physical Therapists Practice, Phys Ther. 2001;81(1):12 746 Haley SM, Fragala Pinkham MA.Interpreting change scores of tests and measures used in physical therapy, Phys Ther. 2006;86:735 743. Huijbregts MP, Myers AM, Kay TM. Systematic outcome measurement in clinical practice: challenges experienced by physiotherapists. Physiother Can. 2002;54:25 36.http://www.neuropt.org/go/EDGE. Jette DU, Halbert J, Iverson C, Miceli E, Shah P. Use of standardized outcome measures in physical therapist practice: perceptions andapplications. applications. Phys Ther. 2009;89:125 135. 135. Kay TM, Myers AM, Huijbregts MP. How far have we come since 1992? A comparative survey of physiotherapists use of outcome measures. Physiother Can. 2001;54:268 281. Nagi SZ. Sociology and Rehabilitation. American Sociological Association; 1965:100 113 Ottenbacher K.J., Johnson M.B. and Hojem M., The significance of clinical change and clinical change of significance: issues and methods. Am J Occup Ther 42 (1988), pp. 156 163. View Record in Scopus Shumway Cook A and Woollacott M. Motor Control: Translating Research into Clinical Practice. Wolters Kluwer, Philadelphia, 2007 Stratford P.W., Binkley F.M. and Riddle D.L., Health status measures: strategies and analytic methods for assessing change scores. Phys Ther 76(1996), pp. 1109 1123. View Record in Scopus Van Peppen RP, Maissan FJF, Van Genderen FR, Van Dolder R, Van Meeteren NLU. Outcome measures in physiotherapy management of patients with stroke: a survey into self reported use, and barriers to and facilitators for use. Physiother Res Int. 2008;13:255 270. 6