Impairment measure correlating to function (Full Version)

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SJBird55 -> Impairment measure correlating to function (December 31, 2005 3:42:00 AM)

Has anyone read the Dec 2005 JOSPT?

One of the questions I always pose in my head (and chances are most therapists question the same thing) is how do we predict outcomes? We all have to write goals - which is basically predicting the outcome with physical therapy intervention. How high do we set goals and what process do we use to surmise that a patient will reach those goals?

I haven't seen much literature on using impairments to assist with predicting outcomes, but the ankle fracture article ties together the type of ankle fracture and the initial amount of dorsiflexion available right after the cast is removed. I'm not as familiar with the OMAS nor am I as familiar with the way dorsiflexion was measured, but there was an obvious difference in function in folks with bimalleolar fractures and less dorsiflexion initially available and folks with unimalleolar fracture and more dorsiflexion initially.

Predicting outcomes is also important, in a way, in determining when enough is enough in regard to provision of physical therapy services. It helps in determining the likelihood that a patient will make significant gains in a specific period of time.

The article also gave me another option for how patients can gain dorsiflexion... I always prefer a weightbearing kind of activity for improving dorsiflexion as a home exercise program, especially after fractures. What an easy idea to use a wall...



FLAOrthoPT -> Re: Impairment measure correlating to function (December 31, 2005 6:11:00 AM)

what if you don't have a wall? I mean those therapists in the keys and the islands must have a hard time working with ankles...



Andrew M. Ball PT PhD -> Re: Impairment measure correlating to function (January 2, 2006 12:51:00 AM)

"I haven't seen much literature on using impairments to assist with predicting outcomes."

It's depressing to see this kind of statement made by so many people in the field. Not only is it proclaimed by rank-and-file outpatient orthopedic PT's, but PhD PT's (generally focused on orthopedics) who really should know better. Our profession screams "evidence-based" but too many of us really don't know what that means, and are WOEFULLY inadequate at finding and becoming aware of the evidence-based information that DOES exist.

There is a wide-range of evidence-based literature linking impairment to function, especially in the adaptive physical education world, and in the pediatric physical therapy world. For some good evidence-based examples, I suggest taking a look at Palisano's work with the Gross Motor Functional Classification System (GMFCS), Haley's work with the Pediatric Evaluation of Disability Inventory (PEDI), and Coster's School Function Assessment (SFA). There are also studies that compare improvements in one or more of the impairment level tests (e.g. the Peabody) to a more functionaly oriented one (e.g. the PEDI) --- one just has to take the time to look.

Drew



SJBird55 -> Re: Impairment measure correlating to function (January 2, 2006 1:13:00 AM)

I am predominantly in the orthopaedic world and treat predominantly orthopaedic patients. As I had stated, there isn't much literature that utilizes physical impairments to PREDICT functional outcomes through the provision of our services. Physical impairments haven't been linked to predicting anything to my knowledge. Granted there are clinical prediction rules that do have some impairments involved in the rule itself, but the clinical prediction rules are more for providing guidance on treatment intervention. Physical impairments seem to always have the relevance of being measured to track changes and to basically justify that something is occurring with physical therapy intervention.

That research opens the mind to thinking about a lot of "what abouts." What about patients that have had a total knee arthroplasty - is there a certain period of time where if a certain amount of range of motion isn't gained that basically the patient won't be able to descend stairs normally. Is there some way to earlier predict those particular patients that won't improve to as high of a level? What are those factors that are involved with those patients - the component used? gender? post surgical knee alignment (maybe still has some valgus present)? calcaneal valgus present? obesity? the amount of mobility of the knee at 4-6 weeks post op?

That article is also important in regard to the type of communication we receive from physicians. "Ankle fracture" is nice to know and that is generally the type of diagnosis that I will see written - but via this particular article, it warrants that I don't just accept the patient's perception of what was fractured but instead make that extra phone call to the physician's office for the specifics of the fracture. After knowing the specifics, I can better communicate realistic goals and expectations to the patient.

Thanks for sharing your view, Drew. I appreciate the point you were making, but your point didn't seem to capture anything dealing with prediction, in that second paragraph. From reading your post, it seems to be focused more on tying impairment to function, maybe?

Edited by SJ



Andrew M. Ball PT PhD -> Re: Impairment measure correlating to function (January 2, 2006 1:15:00 PM)

SJ,

I see your point, and you are right about there not being too many objective tests that are predictive in nature. One that I would point to, however, is the Alberta Infant Motor Scale (AIMS) that is both functional and developmental, in addition to being norm-referenced and predictive.

That kind of test, in my opinion, might be a good model for attempting to make a jump from pediatric predictive tests to outpatient orthopedic predictive tests. The only problem, however, is that it's most likely to be useful for the post-surgical population --- hope that makes sense.

Drew



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