The future of functional outcome measures in musculoskeletal physiotherapy practice.
Article Type: Report
Subject: Physical therapy (Health aspects)
Physical therapy (Patient outcomes)
Therapeutics, Physiological (Health aspects)
Therapeutics, Physiological (Patient outcomes)
Musculoskeletal diseases (Care and treatment)
Physical therapists (Practice)
Author: McLean, Kendra
Pub Date: 11/01/2008
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: Nov, 2008 Source Volume: 36 Source Issue: 3
Topic: Event Code: 200 Management dynamics
Product: Product Code: 8043600 Physical Therapists NAICS Code: 62134 Offices of Physical, Occupational and Speech Therapists, and Audiologists SIC Code: 8049 Offices of health practitioners, not elsewhere classified
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 207945643
Full Text: Musculoskeletal physiotherapists have traditionally not focused on the use of functional, activity related outcome measures in everyday practice. (Abrams et al 2006) However, as healthcare moves towards a more patient-centred system (Institute of Medicine 2001) physiotherapists need to adapt their routine practice to incorporate the measurement of these dimensions. After all, patients seek our services primarily because of impairments of function and activity. (Sykes 2008) It was therefore disappointing to read in the recently published study by Hefford et al (2008) that the compliance rate for use of an activity based outcome measure in musculoskeletal clinical practice was as low as 70%. This is particularly disappointing given that the participating practices were the School of Physiotherapy Clinics where the primary purpose is clinical education, and evidence-based practice would be expected.

In 2003 the Australian Physiotherapy Association (APA) adopted a national position statement to support the use of standardised measures of activity and participation, and the Transport Accident Commission (TAC) in Victoria made it mandatory for practitioners to submit such measures with their proposed treatment notification. (Abrams et al 2006) Ultimately, funding agencies and patients are more interested in performance indicators related to function and activity levels, than more traditional musculoskeletal physiotherapy outcomes such as range of movement or muscle strength. As mentioned by Hefford et al (2008) the Accident Compensation Corporation (ACC) in New Zealand has previously attempted to introduce benchmark reporting to clinicians according to number of treatments provided. It may only be a matter of time before physiotherapists' performance in relation to activity-based indicators is also subject to a report card.

Inconsistency and variation in domains amongst existing functional outcome measures, including those utilised by Hefford et al (2008) means that it is not possible to compare their data. (Sykes 2008) In order to make intra or inter profession comparisons, and benchmark nationally or internationally we need to use a common language. The International Classification of Functioning (ICF) endorsed by The World Health Organization (2001), has great potential for providing this universal language. The ICF is consistent with the new patient-centered approach to healthcare, classifying dysfunction as impairments, activity limitations and participation restrictions. In Australia ICF dimensions already underpin several national data collections. (Sykes 2008) The Australian Therapy Outcome Measures (AusTOMs) have also been developed for use by physiotherapy, occupational therapy and speech therapy to measure outcomes in relation to the ICF domains of patient function. (Unsworth et al 2004) Similar to those used by Hefford et al (2008) this measure takes 5 minutes to complete, however it has the advantage of using a framework which has more potential to allow comparisons of physiotherapy outcomes nationally, internationally and to other disciplines.

With costs of healthcare rising, administrators and clinicians are under growing pressure to demonstrate effectiveness of therapy by using functional, activity related outcome measures. (Unsworth et al 2004) I commend the efforts of Hefford et al (2008) in attempting to establish the use of such outcome measures in routine musculoskeletal physiotherapy practice. Although, to maximise the benefit of collecting this information, it is worth considering measures such as AusTOMs, which are referenced to a common framework, the ICF. It is then possible to make more meaningful comparisons nationally, internationally and even across disciplines. Of course before this can take place musculoskeletal physiotherapists need to make a commitment to incorporating functional, activity related outcome measures into routine practice, and require the technology infrastructure to make it happen.

Kendra McLean, B App Sci (Physio)

Physiotherapist

Melbourne, Australia

Abrams D, Davidson M, Harrick J, Harcourt P, Zylinski M, Clancy J (2006): Monitoring the change: current trends in outcome measure usage in physiotherapy. Man Ther 11: 46-53.

Hefford C, Lodge S, Elliott K, Abbott JH (2008): Measuring patient-specific outcomes in musculoskeletal practice: a pilot study. NZ Journal of Physiotherapy 36: 41-46.

Institute of Medicine (2001): Crossing the Quality Chasm: A new health system for the 21st century. http://www.iom.edu/file.

asp?id=27184 [Accessed August 30, 2008].

World Health Organization (2001): International Classification of Functioning, Disability and Health. Geneva: WHO.

Sykes C (2008): The International Classification of Functioning, Disability and Health: Relevance and applicability to physiotherapy. Advances in Physiotherapy 10: 110-118.

Unsworth CA, Duckett SJ, Duncombe D, Perry A, Skeat J, Taylor N (2004): Validity of the AusTOM scales: a comparison of the AusTOMs and EuroQol-5D. Health Qual Life Outcomes 2: 64.

Response to: The future of functional outcome measures in musculoskeletal physiotherapy practice

We would like to thank Kendra McLean for her comments and feedback on our article. We agree that it is important for physiotherapists to develop standardized ways of measuring functional outcomes that can be used and compared across comparable patient groups. In order to do this, McLean quite rightly points out that we need to make a commitment to incorporating functional, activity related outcome measures into routine practice, and ensure the technology infrastructure to make it happen.

McLean expresses her disappointment at our compliance rate of 70%. In retrospect, 'compliance' may not have been the best word choice: 'complete data', would have reflected these data better, as they included patients who only came for one treatment session, patients who failed to attend their final session, and patients whose final session fell outside of the sampling timeframe for the research--all of which resulted in missing follow-up data. Nevertheless, they did include a small proportion of patients for which therapists forgot to administer either baseline or final outcome measures for a variety of reasons and some patients who complained of pain but did not identify any functional limitations. Naturally, we would prefer this proportion to be better, but it is the reality of the everyday clinic situation. Should, as McLean suggests, legislation arise that includes mandatory outcome measures, it may improve the physiotherapists' compliance rate for gathering outcome measures, however we found there were a variety of patient-related reasons for non-compliance, in addition to therapist-related compliance. We are sure that the increasing use of electronic notes that give automatic reminders and prompts will assist the improvement of compliance rates.

The question about which outcome measures are the most appropriate for use in clinical practice is still being debated. There is growing consensus for the adoption of the International Classification of Functioning (ICF) framework. However the ICF is, of course, a framework, not an actual outcome measure itself, so therapists should consider the extent to which this framework is reflected in various outcome measures.

McLean is correct in stating that the wide variety of existing outcome measures mean that it is not possible to compare the outcomes of patients on a uniform scale. McLean places the Patient Specific Functional Scale (PSFS) alongside other existing functional outcome measures in this inconsistency and variation in domains that make them unable to be compared. We would argue that the patient-specific nature of the PSFS may make it ideally suited to comparing across a wide variety of musculoskeletal disorders that traditionally are assessed with a wide variety of outcome measures. It may also be ideally suited to fit within the ICF framework. Further research into the types of limitation in functional activities, impairments and restrictions in participation chosen by the patients when completing the PSFS would be valuable in this regard.

McLean advocates the Australian Therapy Outcomes Measures (AusTOMs) on the basis that it is referenced to the ICF framework. It should be noted that the AusTOMs differs in format from the PSFS, in that AusTOMs is clinician-generated and assessed (Perry et al 2004), while the items on the PSFS are generated by each individual patient and self-assessed. Which perspective and format is superior is yet to be established, and may never be. McLean states that the AusTOMs tool may enable "more meaningful comparisons", however studies providing comparative evidence are required to support this opinion. The debate as to which is the most appropriate outcome measure for musculoskeletal clinical practice must take into account the pros and cons of various perspectives, formats and frameworks, as well as validity, reliability, responsiveness to change, generalisability, and practical efficiency. Much more research is required into outcome measures in clinical practice, including the PSFS and AusTOMS, before we can be sure which outcome measure is the best for what purpose(s).

We thank Kendra McLean for her commendation of our initial attempt to establish the routine use of functional outcome measures in clinical practice.

Cheryl Hefford, DipPhty, DipEd, DipMDT

Clinic Coordinator, University of Otago Victoria

Physiotherapy Clinic

J. Haxby Abbott, PhD, MScPT, FNZCP

Senior Research Fellow, Centre for Physiotherapy

Research, School of Physiotherapy, University of

Otago

Perry A, Morris M, Unsworth C, Duckett S, Skeat J, Dodd K, Taylor N, Riley K. (2004). Therapy Outcome Measures for Allied Health Practitioners in Australia: The AusTOMs. International Journal for quality in Health Care, 16 (4), 285-291.
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