Functional Outcome Measures

purpose of outcome measures

- objectively identify and measure a patient's deficits

- objectively measure progress over time

- write meaningful goals

challenges of outcome measures

- reimbursement requirements

- time

- productivity requirements

- documentation to support skilled care

- increased patient participation in their own health goals

benefits of outcome measures

- assist in determining patient's specific impairment

- patient education

- track functional progress objectively (tracks changes, motivates patients)

- common language between health care providers

- evidence based practice (valid, reliable)

APTA EDGE Taskforce recommendations

stroke, TBI, SCI, MS, Parkinson's, Vestibular

ICF WHO model

factors to consider when selecting an outcome measure

- purpose of measure (discriminative vs predictive vs evaluative)

- referral diagnosis

- clinic factors

- acuity level (acute, IPR, OP)

- observation (AD use, posture, movement quality and speed)

- patient's history

discriminative outcome measure

differentiates between patient groups and identifies meaningful differences in patients' abilities (no criteria reference)

predictive outcome measure

used to predict outcome (prognostic) or diagnosis (criteria referenced)

evaluative outcome measure

measures longitudinal change in an individual

minimal detectable change (MDC)

- smallest amount of change outside of error that reflects true change by a patient between two points in time (acuity, diagnosis specific)

- may not be meaningful

minimally clinically important difference (MCID)

- smallest amount of change in an outcome that a patient would perceive as clinically meaningful (acuity, diagnosis specific)

- meaningful change

cut-off scores

scores on an assessment that research has shown to have predictive value (fall risk, dysfunction)

normative data

what is usual in a defined population at a specific point or period of time (age, gender)

factors to consider when interpreting outcome measures

- scoring interpretation

- psychometric factors

reliability

consistency of the measure; repeatability

validity

is it testing what it is supposed to test; accuracy

specificity

how well a test can identify a true negative; rule in

sensitivity

how well a test can identify a true positive; rule out

ANPT core measures for all adults with neurologic disorders

- 6MWT

- 10 Meter Walk Test

- Berg Balance Scale

- Functional Gait Assessment

- Activities-Specific Balance Confidence Scale

- 5 Time Sit to Stand Test

neurological outcome measures

- gait measures

- balance measures

- tone measures

- cognitive screening assessments

- diagnosis specific

list the gait outcome measures

- 6MWT

- 10 meter walk test

- dynamic gait index

- functional gait assessment

- time up and go (TUG)

what do timed walk tests assess

aerobic capacity and gait

6MWT predictive value for patients with heart disease

<1000 ft in 6 minutes is a strong predictor of morbidity and mortality within 3-12 months

each 0.10 m/s (INCREASE/REDUCTION) in baseline walking speed over 1 year was associated with poorer health status, poorer physical functioning, more disabilities, additional rehab visits, longer hospital stays, and higher costs

reduction

each 0.10 m/s (INCREASE/REDUCTION) in baseline walking speed over 1 year resulted in improved health status, improved physical functioning, fewer basic disability and instrumental disabilities, fewer hospital stays, 2 fewer rehab visits, 3 fewer med-surg visits, and 1 year cost reduction of $1,188

increase

slow gait speed is the single best predictor of

functional decline and disability

older adults without impairments can increase walking speed from what percent over comfortable pace

22-56%

what gait speed is sufficient for most community mobility

0.5 m/s (1.1 mph)

what is the usual adult walking speed

1.2-1.3 m/s (2.67-2.9 mph)

gait speed of household ambulators (severe gait impairment)

0.23-0.27 m/s

gait speed of limited community ambulators (moderate gait impairments)

0.4-0.8 m/s

gait speed of full community ambulators (mild gait impairments)

>0.8 m/s

what gait speed requires intervention to reduce fall risk

<1 m/s

what percent of people who walked <0.6 m/s were hospitalized at least once

41%

what percent of intermediate walkers (0.6-1.0 m/s) were hospitalized

26%

what percent of fast walkers (>1.0 m/s_ were hospitalized

11%

what gait speed in acute stroke patients is indicative of the need for inpatient rehab

10 meter walk test measures the time it takes a patient to walk how many meters

6 meters (2 meter 'buffer' on each end)

dynamic gait index assesses

an individual's ability to modify balance while walking in the presence of external demands

dynamic gait index rundown

- uses 8 tasks of gait to assess a person's ability to accommodate to changes in gait speed, walking with head turns, stepping over obstacles, and changes in environment

- assessment may be performed with or without an AD

8 tasks included in dynamic gait index

1. gait level surface

2. change in gait speed

3. gait with horizontal head turns

4. gait with vertical head turns

5. gait and pivot turn

6. step over obstacle

7. step around obstacle

8. steps

0 on dynamic gait index

severe impairment

1 on dynamic gait index

moderate impairment

2 on dynamic gait index

mild impairment

3 on dynamic gait index

no gait dysfunction

what score does a patient automatically receive when using an AD on the dynamic gait index test

2

dynamic gait index cutoff score for fall risk

<19/24

functional gait assessment assesses

postural stability during walking tasks

functional gait assessment rundown

- modification of the DGI developed to improved reliability and decrease ceiling effect

- uses 10 items to assess gait (uses 7 items from DGI)

- max score of 30

- AD permitted where scoring indicates

10 tasks included in functional gait assessment

1. gait level surface

2. change in gait surface

3. gait with horizontal head turns

4. gait with vertical head turns

5. gait and pivot turn

6. step over obstacle

7. gait with narrow base of support

8. gait with eyes closed

9. ambulating backwards

10. steps (up and down)

0 on functional gait assessment

severe impairment

1 on functional gait assessment

moderate impairment

2 on functional gait assessment

mild impairment

3 on functional gait assessment

normal

functional gait assessment cutoff score for fall risk

<23/30

TUG assesses

mobility, balance, walking ability, and fall risk in older adults

TUG rundown

- on the command "go" the patient rises from the chair, walks 3 meters at a comfortable safe pace, turns, walks back to the chair and sits down

- patient needs to start with their back against the chair

- one practice trial

- be consistent with AD used

- standard chair height 46 cm (not supported against wall)

- no physical assistance

TUG cutoff score for fall risk

>13.5 seconds

30-50 year old TUG norm

4.4-4.9 sec

60 year old TUG norm

5.6 sec

70 year old TUG norm

6.7 sec

80 year old TUG norm

7.8 sec

TUG score indicative of impaired functional mobility

>20 sec

TUG score indicative of need for assistance with transfers and inability to climb stairs

>30 sec

the slower the TUG, the (MORE/LESS) variability with times

more

cognitive dual-task TUG

patients will complete the test while counting backward by 3s from a randomly selected number 20-100

manual dual-task TUG

patients will complete the test while carrying a full cup of water (filled 5 cm from the top)

cognitive dual task TUG cutoff score for fall risk

>15 sec

list the balance outcome measures

- functional reach test

- berg balance scale

- mini BESTest

- 5 rep sit to stand

- 4 square step test

- ABC scale

- modified CTSIB

purpose of functional reach test

measure maximum forward reach in standing

what functional reach test score indicates a significant increased risk for falls

what functional reach test score indicates a moderate risk for falls

6-10

purpose of berg balance scale

assess static balance and fall risk

berg balance scale rundown

- can be used in all settings

- takes about 15-20 minutes

- max score of 56

- patient cannot use AD for this test but is allowed to wear AFO

- items should be graded on the first attempt

berg balance test cutoff score for fall risk

<45/56

purpose of BESTest test (balance evaluation systems test)

assesses balance impairments across different contexts

mini-BESTest rundown

- balance evaluation systems test

- best all inclusive test of functional measure

contexts included in mini-BESTest test

- anticipatory postural adjustments

- reactive postural control

- sensory orientation

- dynamic gait

- dual tasking

mini BESTest cutoff score for fall risk

<21/32

purpose of modified clinical test of sensory integration and balance (MCTSIB)

quantify postural control under various sensory conditions

MCTSIB rundown

- patient stands on 4" foam (memory foam best) in a corner for safety

- stand 30 seconds, feet together, arms crossed

- if 30 seconds is not achieved on 1st trial, perform 3 trials and average scores

- useful in determining treatment strategies

MCTSIB sensory conditions

- eyes open, firm surface

- eyes closed, firm surface

- eyes open, compliant surface

- eyes closed, compliant surface

Activities-Specific Balance Confidence (ABC) Scale rundown

- subjective measure in which a patient rates their confidence in performing 16 different activities ("how confident are you that you will not lose your balance and become unsteady when you...")

- patient rates each item 0-100% confidence

- total ratings and divide by number of items completed

- 12/16 items must be answered to get a score

ABC Scale normative value for community dwelling older adults

79.89%

purpose of 5 time sit to stand test

- measure functional LE muscle strength (particularly quads)

- also useful in quantifying functional change of transitional movements

- correlates better to walking independence than MMT or handheld dynamometry

5 time sit to stand test rundown

- consistent chair height (17-18") that is unsecured (not up agaisnt a wall)

- patient sits with arms folded across chest

- patient trials 1-2 reps before being tested

- timing starts when you say go, stop timer when patient's buttocks hit the seat on the 5th repetition

sit to stand variations

- 10x STS

- single leg

- 30 second

- 60 second

5 time sit to stand cutoff score for fall risk

>12-15 seconds (dependent on source/dx)

purpose of four square step test

assesses a person's ability to step over objects in different directions

four square step test rundown

- both feet must make contact with the floor in each square

- patient stays facing forward

- timing starts when the right foot contact the floor in square 2

- PT demonstrates

- patient has 2 timed trails, best time is demonstrated

scales used to measure tone/spasticity

- modified ashworth scale

- tardieu scale

purpose of modified ashworth scale

measures spasticity in patients with CNS lesions

0 on modified ashworth scale

no increase in muscle tone

1 on modified ashworth scale

slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of ROM when the affected part(s) is moved in flexion or extension

1+ on modified ashworth scale

slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout less than half of the ROM

2 on modified ashworth scale

more marked increase in muscle tone throughout most ROM, but affected part(s) easily moved

3 on modified ashworth scale

considerable increase in muscle tone, passive movement difficult

4 on modified ashworth scale

affected part(s) rigid in flexion or extension

purpose of Tardieu Scale

measures spasticity in patients with CNS lesion at different velocities

V1 speed on Tardieu Scale

as slow as possible (minimizing stretch reflex)