Practical Clinical Measures
Donald G. Shurr, PT, CPO
ABSTRACT
When practitioners understand the components of the scientific process, meaningful clinical research can occur. This
process includes consistent, accurate
observation and reporting of both the
normal and pathological motions either
produced or allowed. A normal extension of the reporting process includes
comparing objective data with data
from similar cases to mark progress. Although thought to be less scientific, using subjective responses is important
when evaluating design and fitting.
Introduction
When the subject of research, and specifically clinical research, is introduced
to clinicians or practitioners, they often
respond by saying only academicians
and researchers should conduct studies. Unfortunately, this misconception
tends to stratify role delineation and
further separates patient care from
true clinical research. This leads to a
void in the literature with little relevant
clinical problem-solving ever published.
Attempts at rectifying the situation
have included books, articles and conferences working with subjects, methodologies, statistical analyses and various evaluative procedures.
In this issue, the authors attempt to
further educate clinical practitioners,
allowing them the opportunity to evaluate functional outcomes using a variety of methodologies, analyses and
evaluations. This article deals with the
concept of relevant, simple, clinical,
evaluative measures that can be recorded easily to provide useful, retrospective information about patient care in O&P.
Recording Methods
Campbell has properly identified the
need for healthcare professionals to be
adept and consistent reporters of what
is clinically normal and then pathological by comparison (1). She stresses the
proper use of measurement tools that
have proven valid and reliable by physicians. Since their invention, many of
these tools have had few improvements
or changes.
In a well-thought-out article on this
subject, Richard Bohannon described
what he calls the dichotomous responses to many clinical questions for physical therapists (2). Many of these questions are asked by orthotists and prosthetists. Since many practitioners understand the concept of the problem oriented record and the SOAP note,
subjective and objective responses are
relatively easy to develop and record
(see Figure 1
).
Objective records need not be extensive, sophisticated or collected using
support-driven computers. Remarks as
simple as "present" or "absent" may
suffice to record findings that may
serve a useful purpose in future analyses of the medical record.
Examples include a comment relative to the presence or absence of edema, redness, inflammation, infection,
range-of-motion, muscle strength,
tone, sensibility or gait. Although there may be very sophisticated means
of recording exact numbers relative to
each category, in many cases the mere
presence or absence of these conditions is enough to indicate a problem.
In any case, no fancy equipment is
needed to develop the clinical impression that may provide answers to the
problem.
Objective measures become very important in design. For example, the degree of ankle dorsiflexion or plantarflexion can determine the difference
between success and failure from a
functional perspective. Depending on
whether change is expected or encouraged, the exact degrees may be very
critical to positive outcomes.
Perhaps no goal is more important
than achieving normal locomotion. In
many cases, all O&P considerations revolve around gait. The basic O&P professional programs teach both normal
and pathological gait, but both are
taught from a visual point of view. In
other words, normal and abnormal
characteristics are observed and
changes recommended that may alter
design, alignment or materials. Little
consideration is given the contribution,
or lack of same, by the biological entity. Thus, there is a gap between this
approach and conventional teachings in medicine and allied heath.
This approach leads to a dichotomy
in understanding, and therefore, treatment approaches. This situation begs
for a new approach in O&P education
to include an understanding of gait
problems and solutions, combining a
multiplicity of treatment approaches.
This also presents the problem of how
and what to record.
One way the professional orthotist
and prosthetist can contribute to
O&P's body of knowledge and deliver
more complete patient care is by collecting basic objective gait information
and recording it in the patient record.
Some practitioners use videotape both
to record and to provide an instantaneous visual feedback to the amputee
or patient. This is satisfactory but does
not guarantee any hard thoughts will
be recorded in the patient record.
Gait Data
Clinicians should value measurements
concerning characteristics of gait to include both pre- and post-fitting, as well
as follow-up visits. These data can provide the medical rehabilitation team
with facts about each patient's care and
can differentiate among components,
designs and/or materials. Data also
may provide important information
about impending problems not sensitive to other measures.
Collective gait data need not be difficult or require sophisticated equipment. Most practitioners today are
aware of the dimensions of the halls of
their offices. They also wear digital
watches that often provide a stopwatch
function. By dividing the distance
walked in meters by the time required,
one may easily calculate the rate of
progression with 80 meters per minute
being near normal (3).
Additionally, recording pulse rate
information following four minutes of
constant walking allows the development of age-predicted maximum heart
rate information established by the cardiac medical community. The percentage of maximum age-predicted heart
rate may infer the level of effort, and
therefore efficiency, of the patient's
gait cycle while using a prosthesis or
orthosis and may be useful in documenting differentiation between designs or among components. Since
many patients using orthoses and prostheses have diseases of the heart, lungs
and circulatory system, clinical evidence of functional contribution plays
an important role in documenting and
justifying component selection.
Using and collecting subjective responses relative to research are often
considered secondary and, unfortunately to some, useless. There definitely is a place for subjective response,
especially as a birthplace for clinical
questions based on observations rooted in sound clinical judgment.
An example of a relevant clinical
question is Why does a below-knee amputee feel less tired at the end of a workday when wearing a Flex-Foot? as
compared to a conventional SACH
foot? This question forms the basis for
the methodology that allowed practitioners to prove there is an energy cost
difference seen at similar speeds of level walking. Had it not been for the clinical question the study may never have
been done. However, one must use
clinical opinions as such until scientific
inquiry proves them true or false.
Historically, the medical record has
been thought to contain information
about patient diagnosis and treatment
and was used by the attending medical
staff to document evaluation and treatment. Throughout the 1970s the number of practitioners involved in the care
of the multiple-system-involved patients grew rapidly. Accordingly, so
did the size of the medical record.
Although much talk and effort was
made to conceptualize the problem oriented approach, many source oriented records continued to be used,
particularly in institutions involving
multidisciplinary care. The advent of
computers has allowed an electronic
medical record to be developed. Prosthetists and orthotists have a legal as
well as a medical responsibility to document the effect of treatment using
these conventional record systems.
In the early 1980s, third parties and
auditors for self-insured and other insurance parties changed the focus of
medical records to one of documentation of services for justification of fees.
The current dilemma with Medicare proposed rules for funding O&P services reflects this philosophical change.
The Researcher's Responsibility
In a perfect world, prosthetists and orthotists would document function as
well as physiological efficiency and effectiveness of each design, material or
component. This documentation
would combine classic diagnosis and
treatment information as well as information about specific O&P services.
Professionals have a responsibility to
provide this information in an easily
understood and retrievable fashion.
Whose role is it to provide clinical
O&P research to the ever-evolving
medical communities of the world? It is
no doubt unrealistic to expect every orthotist and prosthetist to do meaningful clinical research since the tools, patience, motivation, time and equipment are uniformly not available. It is,
however, the responsibility of professional educational programs to enhance the awareness and appreciation
for the role that clinical research and
clinical researchers play in the evolving
field of orthotics and prosthetics.
In the medical model this research is
produced in institutions of higher
learning by tenured faculty. However,
it has been apparent for many years
that the accepted medical model for
not only physicians but many other allied health groups does not exist to any
large degree in O&P educational programs. Therefore, the database that
could provide documentation about
knowledge orthotists and prosthetists
use daily does not exist and is not being
enhanced by clinical researchers.
It remains the task of orthotists and
prosthetists to recognize this void and
to begin implementing meaningful
change. Accepting the notion that a
dedicated publication such as this
needs to be published is evidence of the
necessity for such an undertaking. The
clinician's role in the process includes a
better understanding of and working
relationship with clinical researchers
and a modeling of methods and techniques for developing the patient data
so vital for O&P's survival and our patients' care.
Donald G. Shurr, PT,CPO, is district manager of American Prosthetics Inc. in Iowa City, Iowa. He also serves on the editorial board of the JPO: Journal of Prosthetics and Orthotics, the task force of the National Center for Medical Rehabilitation Research, and the AOPA Functionality Subcommittee.
References:
- Campbell SK. On the importance of being earnest about measurement or how can
we be sure that what we know is true? Phys
Ther 1987;67:12:1831-3.
- Bohannon RW. Simple clinical measures. Phys Ther 1987;67:12:1845-50.
- Corcoran PJ. Energy expenditure during
ambulation. Editors: Downey JA, Darling
RC. Physiological basis for rehabilitation
medicine. Philadelphia:WB Saunders Co.,
1978.
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