Musculoskeletal Physiotherapy Consultants

Measuring Effect – is this treatment really working?

By on February 2, 2016 in General with 0 Comments

outlcome measuresThe WorkCover WA-endorsed Clinical Framework  that we discussed in our previous blog, identifies as a guiding principle the need to measure and demonstrate the effectiveness of treatment. Demonstrating the benefit of treatment is critical to determining if the most appropriate or effective approach is being used. Often it is assumed by both physiotherapist and patient alike that just because symptoms are improved, even temporarily, after treatment that it is doing them good and therefore worth continuing. This may not always be the case and using validated outcome measures is the best way of objectively quantifying, or measuring, an effect.

Which questionnaire is right?

A reliable, validated outcome measure is one that has been tested, and proven, to be an accurate measure of what it is attempting to measure e.g. how much function one has in their upper limb or how much their problem is affecting their lifestyle or work. That’s simple enough but there are so many different ones – how do we know which is the right one to use for any given patient?. Some focus on just one aspect, others might combine several such as physical and psychosocial or both pain and impact on work.

Choosing the right measure should be based on answering questions most relevant for that person, these questions can best be determined after thorough examination and sometimes are not apparent initially. Considerations would be:

  • The stage of the condition – some questionnaires are best used early after injury and are helpful in identifying those that are at risk of becoming chronic or not getting back to work e.g. Orebro Musculoskeletal Pain Questionnaire or StarT Back
  • Assessing contributing factors – these may be aspects of the condition that are major barriers to progress such as the degree that psychosocial factors or fear avoidance are influencing or inhibiting recovery e.g. Fear Avoidance Belief Questionnaire or Depression Anxiety and Stress Scale
  • Diagnosis – certain conditions such as neuropathic pain can be identified with the use of questionnaires, this is important to ensure the best treatment is given and the most appropriate medical specialists are engaged e.g. Leeds Assessment for Neuropathic Symptoms and Signs or DN4
  • Prognosis – what is realistic to expect for this person individually in terms of goals? e.g. should they be back at work in 6 weeks or 6 months? e.g Patient Specific Functional Scale. Knowing what to expect is critical to knowing if progress is satisfactory
  • How much is this injury or condition limiting or ‘disabling’ this person? e.g. Oswestry Disability Index or Neck Disability Index

Establishing a baseline measure is important so that change can be monitored as soon as possible. Validated outcome measures are also very useful in determining if treatment is helping to maintain a level of functional capacity, but that’s another blog!

How much change is good?

It is one thing to show that there has been a change for the better by repeating an outcome measure but this then begs the question – is this sufficient change to indicate real improvement?.

Most validated outcome measures have also defined what is referred to as the “Minimum Clinically Important Difference” or MCID. This is the smallest change in score that represents a meaningful difference. This is what really matters to patients. MCID varies between measures and even within the same measure may vary depending on the nature of the problem e.g. the Disabilities of the Arm, Shoulder and Hand (DASH)  questionnaire has different MCIDs depending on which area is affected. While they do vary the MCID is often defined as a 15-20% change in the score.

Validated outcome measures are enormously helpful to patients, health professionals, injury managers and third party funders alike and as such they should be encouraged and embraced as an important tool to help inform decision making.

Follow this link for a good, and very comprehensive resource, for validated outcome measures of all kinds including MCIDs. www.rehabmeasures.org/rehabweb/allmeasures

Watch out for our next blog examining the current strong trend towards focussing on the psychosocial aspects of back pain.

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