Measurement of the functional improvement in patients receiving [PDF]

questionnaire was then scored according to the instructions for both the Roland-Morris and the. Lower Extremity Function

0 downloads 6 Views 2MB Size

Recommend Stories


Functional outcome measurement in SMA
The beauty of a living thing is not the atoms that go into it, but the way those atoms are put together.

Performance Measurement: Accelerating Improvement
What we think, what we become. Buddha

Measurement for Improvement Curriculum
Never let your sense of morals prevent you from doing what is right. Isaac Asimov

Measurement Improvement Journey Process
Don't ruin a good today by thinking about a bad yesterday. Let it go. Anonymous

Dental management of patients receiving antiresorptive therapy
Never let your sense of morals prevent you from doing what is right. Isaac Asimov

Practical Management of Patients receiving Rivaroxaban
Silence is the language of God, all else is poor translation. Rumi

AIDS patients receiving highly active
I cannot do all the good that the world needs, but the world needs all the good that I can do. Jana

Adult patients Receiving Epidural Analgesia
The best time to plant a tree was 20 years ago. The second best time is now. Chinese Proverb

Prevention and treatment of oral mucositis in patients receiving chemotherapy
Knock, And He'll open the door. Vanish, And He'll make you shine like the sun. Fall, And He'll raise

Financial Analysis of CYP2C19 Genotyping in Patients Receiving
Knock, And He'll open the door. Vanish, And He'll make you shine like the sun. Fall, And He'll raise

Idea Transcript


Research Report

Measurement of the functional improvement in patients receiving physiotherapy for musculoskeletal conditions Celia Monk, DipPhys, DipMDT Physiotherapist, Northwest Physiotherapy Centre, Christchurch, New Zealand

Abstract

Purpose: In order to objectively assess whether a clinically significant improvement in a patient’s function has occurred, it is important that physiotherapists monitor change in their patients’ functional disability. Methods: This study assessed the difference between the functional disability score (FDS) during the initial assessment with the FDS recorded on discharge, for each patient presenting with low back pain or a lower extremity condition. Two validated FDSs were used: The Roland-Morris Disability Index and the Lower Extremity Functional Scale. Sixty-eight (68) consecutive participants with low back pain or lower extremity conditions completed a functional disability questionnaire on their initial assessment and again on discharge from the clinic following a course of physiotherapy treatment. Results: The patients’ functional disability was reduced by an average of 70%. The mean number of treatments given was 5.1. Conclusion: A statistically significant improvement was seen in the patients’ functional ability following a course of physiotherapy treatment for low back pain or lower extremity conditions. This process provides an objective measurement of functional improvement in individual patients, as well as average improvement across patients with varying presenting conditions. It is hoped this report will encourage other physiotherapists to perform similar studies within their own clinical settings. Monk C (2006): Measurement of the functional improvement in patients receiving physiotherapy for musculoskeletal conditions 34(2): 50-55. Key Words: Low back pain, Questionnaires, Function, Outcome, Lower Extremity Functional Scale, Roland-Morris Disability Index

Introduction

Improving functional ability is one of the main goals of providing physiotherapy treatment to patients with musculoskeletal conditions and injuries. “Successful physical therapy intervention is usually not reflected in simply better movement but in improvements in functioning” (Kane, 1994). In the clinical setting, the usual method of deciding a patient has improved enough to be discharged from treatment relies on verbal reporting by the patient, coupled with an improvement in objective findings found by the physiotherapist during the reassessment process. As patient reporting is subjective in its nature, functional outcome questionnaires have been developed to gain a more objective measurement of the patient’s interpretation of their improvement, or lack thereof, although these still rely on self-reporting by the patient. The use of validated Functional Outcome Measurement Tools to measure improvements in a patient’s functional ability is not widespread within physiotherapy clinics in New Zealand, or in several other countries around the world including England (May, 2003), Ireland (Caulfield & Reilly), Australia (Beattie & Maher, 1997), or Canada (Kirkness & Korner-Bitensky, 2002). A literature search revealed no studies have been published in New Zealand looking at the use of the functional outcome measurement tools within the physiotherapy clinical setting.  50

In this study we use a validated functional outcome measurement tool to assess whether there is a functional improvement in patients from the time of their first assessment to the time they are discharged. In this day of evidence-based medicine, it is vital that as a profession physiotherapists are able to objectively justify and measure the effect of the treatment provided (Caulfield & Reilly). It is suggested that the main reasons for physiotherapists not utilising functional outcome tools are pressures of time, lack of access to measurement instruments and a lack of knowledge of which instruments to use, the scoring methods, and how to interpret the results (Caulfield & Reilly). There are specific questionnaires that have been developed to apply to various parts of the musculoskeletal system. To be effective, they must have had their validity, reliability and sensitivity to change established by previous research. One functional outcome tool for the lumbar spine that has been well established in the literature is the Roland-Morris Disability Index,(Deyo et al., 1998; Roland & Morris, 1983; P. Stratford & Binkley, 1997). Another well established functional outcome tool is the Lower Extremity Functional Scale (LEFS) (Binkley et al., 1999). Its validity, reliability, sensitivity to change, and specificity have been reported (Binkley et al, 1999) and it is commonly utilised in the literature (Riddle et al., 2004; P. W. Stratford et al., 2003; White et al., 2004). NZ Journal of Physiotherapy – July 2006, Vol. 34 (2)

The main objective of this study is to demonstrate the use of functional outcome measurement tools in a typical New Zealand private physiotherapy practice, and to determine if there is a statistically significant functional improvement in patients receiving physiotherapy at our practice, for either low back pain or a lower extremity condition.

Method

Setting This study was performed in the Northwest Physiotherapy Centre in Christchurch, New Zealand. The Centre consists of two private Physiotherapy Clinics, and has two physiotherapists (including the author). Both Clinics are accredited by the New Zealand Physiotherapy Accreditation Scheme. Patient Selection All consecutive patients who presented to the Northwest Physiotherapy Centre between midMarch and mid-April 2005 for treatment of low back pain or a lower extremity condition who did not meet the exclusion criteria were invited to partake in the study. The exclusion criteria were: difficulty with the written English language, declined to give informed consent, a condition not involving the low back or lower extremity, and the presence of a condition that was not suitable for physiotherapy treatment. Patients are referred to Northwest Physiotherapy by general practitioners, the public hospital, the private after hours medical centre, orthopaedic specialists, or by themselves (self-referral). The conditions seen are usually caused as a result of an accident, and therefore the Accident Rehabilitation and Compensation Corporation (ACC) covers the treatment costs, with no charge to the patient. Each condition has been assigned an ACC Read Code by the initial treatment provider and a recommended maximum number of required treatments is indicated by the Treatment Profile (ACC, 2000). Interventions: Following consent being given, the patients were asked to complete either the Roland-Morris Disability Index if they presented with low back pain, with or without referred pain, or the Lower Extremity Functional Scale if they presented with a lower extremity condition. The completed initial questionnaire was then scored according to the instructions for both the Roland-Morris and the Lower Extremity Functional Scale (LEFS). The Roland-Morris Disability Index was scored out of 24, with the higher number equating to a higher level of functional disability. The LEFS was scored out of 80, with the lower number equating to a higher level of functional disability. The normal assessment and treatment procedures were then followed for each patient, according to the Northwest Physiotherapy Centre’s Policy and Procedure Manual. The treatment philosophy of Northwest Physiotherapy is predominately based on the NZ Journal of Physiotherapy – July 2006, Vol. 34 (2)

principles of Mechanical Diagnosis and Therapy as described by McKenzie (McKenzie & May, 2000, 2003). This philosophy places a strong emphasis on a thorough initial assessment with the aim to determine the effective self-treatment strategies, including exercises, that the patient can apply to recover from the present episode of pain and disability. Electrotherapy is rarely used at Northwest Physiotherapy, and manual therapy techniques are utilised as required. When the physiotherapist determined that the patient had improved and was ready for discharge the patient was asked to complete a repeat questionnaire. Again this was scored and the resultant data entered into the spreadsheet, along with the number of treatments given to achieve that functional outcome. Patients who had not attended the final treatment session were contacted by phone and either posted a repeat questionnaire or were asked to come into the clinic to complete one. When the last patient was discharged, the results were analysed using simple statistical methods.

Main Outcome Measures

The main outcome measures were the change in the functional outcome scores, the average number of treatments given to achieve that result, and the average length of the present episode prior to receiving physiotherapy treatment. The Roland-Morris Disability Index (Roland & Morris, 1983) is a 24-item questionnaire, where patients tick the appropriate statements for the pain and disability they are experiencing the day they are completing the questionnaire. The score is calculated by adding the statements ticked, giving a score out of 24. Typical analysis of the Roland-Morris Disability Index involves comparing the final score and the initial score for all patients. However, this process can introduce a bias if the patient population either has a very high or a very low initial score. For example, if the majority of patients presenting to the clinic have very low scores, there is little room for improvement and therefore the overall mean change in score of only one or two would reflect poorly on the treatment provided, called the floor effect. Conversely, if the average initial score is high, the resultant mean change could exaggerate the effectiveness of the treatment provided. It was therefore decided, for the purposes of this study, to introduce a method of analysing the proportion of change for each patient. To find the overall improvement, the following formula was utilised: Proportional Reduction = Initial score – Final Score First Score This formula was used in order to find the proportion of reduction in disability that had occurred in relation to the original amount of disability the patient was experiencing on their presentation to the clinic. For any given patient the best outcome we can expect is to reduce their disability to zero, which is considered to be 100% proportional reduction of disability regardless of the original level of disability.  51

The Lower Extremity Functional Scale (Binkley et al., 1999) is a 20-item questionnaire that requires the patients to score the level of difficulty they are experiencing with certain activities according to a scale from 0 for “extreme difficulty” to 4 for “no difficulty”. The resultant score is out of 80, with a high score reflecting a low level of functional disability. Some patients did not complete all aspects of the LEFS questionnaire because they felt the statements did not apply to them, or they could not answer them honestly. For example, some older patients were unable to state if the pain was causing difficulty running on uneven ground. For the purposes of statistical analysis, the percentage of answered questions was calculated and then prorated up to a total possible score of 80. The LFS is scored in the opposite manner to the Roland-Morris Disability Index, which has a low score for a low level of functional disability, which could introduce the ceiling effect. However, the proportion of reduction in disability was calculated enabling the two different groups to be compared to each other and to give an overall percentage of reduction of disability for all patients in the study. To achieve this the LEFS score was transformed to the same scale as the RMD by calculating (100 – x) for both the initial and final scores, and calculating the reduction in disability from the transformed values. Data Analysis The Data Analysis Toolpak® in Microsoft Excel ® was used to perform the data analysis. The mean and standard deviation of the raw scores were reported. The Analysis of Variance (ANOVA) single factor t -test was applied to determine the p value for the data collected. Statistical significance was set at 0.05 in all analyses.

Main Results

Over the four-week enrolment period for the study, 79 patients attended the clinic for treatment of low back pain or a lower extremity condition. Four patients were excluded from the study due to a lack of understanding of the written English language (n = 2) or refusal to give consent for personal reasons (n = 2). Of the 75 patients initially included in the study, 6 were later excluded when it was identified that their conditions were unsuitable for physiotherapy (Table 1). Of the 69 patients included in the full study, 68 patients (99% followup rate) completed both the initial and the final questionnaires. One patient did not return for the final follow-up questionnaire, despite several phone calls from the clinical staff. Characteristics of the participating patients are reported in Table 2. The average length of the present episode was 26.7 days (Table 2). 29 patients presented with Low Back Pain (with or without referred pain into the leg) and 39 presented with a condition of the Lower Extremity (Table 3). Overall, the average number of treatments given was 5.1  52

treatments. The low back pain patients received an average of 5.2 treatments, and the lower extremity patients received an average of 5.0 treatments. The ACC Treatment Profile for low back pain is 12 treatment sessions, and the average Treatment Profile for the lower extremity conditions seen in this study was 14.3 treatments. (Table 2) At discharge from treatment, the average improvement for the low back patients was a decrease in the Roland-Morris score by 7.2 points. When the proportional reduction was calculated, the average improvement in the low back patients was 71% (p value 7 weeks) Patients with Low Back Pain Patients with Lower Extremity Condition Number of treatments given: All Patients Low Back Patients Lower Extremity Patients

Mean Result (n=68) 47 years 41 patients 27 patients 26.7 days

±4.95 years SD ±0.71 days SD

3 patients 29 patients 30 patients 9 patients 29 (43%) 39 (57%) 5.1 ± 1.41 SD (ACC Profile = 13.2 treatments) 5.2 ± 1.41 SD (ACC Profile = 12 treatments) 5.0 ± 1.41 SD (ACC Profile = 14.3 treatments)

Note: “ACC” Accident Rehabilitation and Compensation Corporation, “QTF” Quebec Task Force

gathering the data for both the initial and final scores, with only 53% of the patients having a complete set of data. To overcome the potential for a similar low compliance in this present study, the involved physiotherapists were included in the design process and were highly motivated to ensure the optimal amount of data was collected over the limited timeframe resulting in a 99% complete data set. This present study has similar findings to May’s study with a 30 percentage point reduction in the functional score over an average of 5 treatments. One of the main strengths of the present study was the use of validated outcome measures: the Roland-Morris Disability Index (Roland & Morris, 1983) and the Lower Extremity Functional Scale (Binkley et al., 1999). Both these functional NZ Journal of Physiotherapy – July 2006, Vol. 34 (2)

measurement tools have been validated in the literature and proven to be specific, sensitive to change, and reliable. The study also had a very low drop out rate, which may reflect the effectiveness of the communication process used with the patients: the Study Information Sheet explained the reason and procedure for the study, and a follow-up phone call being made if they did not attend the clinic for a given appointment time. The short time frame over which this study was conducted (eight weeks: four weeks for enlisting patients into the study and another four weeks to finish their course of treatment) may have ensured a high compliance within the clinical setting. The physiotherapists involved had limited time for the gathering of information and to ensure the task  53

Table 3: Read Codes and conditions seen Read Code

ACC Definition

Number of Patients (n=68)

Number of Treatments (mean)

S572

Lumbar Spine

29

5.2

S53

Sprain Hip/thigh

2

2.5

S54

Sprain Knee

6

3.8

S54x1

Strain Gastrocnemius

4

6.0

S550

Sprain Ankle

11

4.8

S5504

Strain TA

5

5.0

S460

Medial Meniscus tear

1

4.0

SE41

Contusion knee/lower leg

1

5.0

S463

Dislocation patella

1

9.0

S33

Fracture Tibia and Fibula

2

9.5

S535

Strain hamstring

1

5.0

S551

Foot Sprain

2

3.5

S541

Sprain Med Ligt Knee

3

5.7

Read Code reference: (ACC, 2000) Table 4: Mean Change in Functional Questionnaire Scores Initial Score (Mean)

Final Score

Mean Change in Raw Score

P Value

Reduction in Disability Initial – final initial

Low Back Pain (From total of 24)

10.1 42%

2.9 12%

7.2

p

Smile Life

When life gives you a hundred reasons to cry, show life that you have a thousand reasons to smile

Get in touch

© Copyright 2015 - 2024 PDFFOX.COM - All rights reserved.