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Outcome Measures
55 Plays2 months ago
Dr. Kirsten Potter joins the podcast to talk about outcome measures! She discusses her experiences with outcome measures, from witnessing initial clinician resistance toward leading the charge as a change agent through her work in developing the core set of outcome measures and her role as MS Edge Chair. Dr. Potter and Dr. Powers highlight the evolution of evidence-based practice and data within neurologic physical therapy, including how the use of the core set measures leads to improved clinical decision-making and patient outcomes. After this episode, you will have added the core set measures into your toolkit while also appreciating the tremendous work (past and present!) being done to supply clinicians with the best available evidence in neurologic physical therapy!
References and Took Kit
- ANPT Core Set of Outcome Measures: https://www.neuropt.org/practice-resources/anpt-clinical-practice-guidelines/core-outcome-measure-cpg
- Core Set of Outcome Measures Clinical Practice Guideline: https://pmc.ncbi.nlm.nih.gov/articles/PMC6023606/
- Self-Report Measures of Fatigue for People with Multiple Sclerosis - A Systematic Review: https://journals.lww.com/jnpt/fulltext/2024/01000/self_report_measures_of_fatigue_for_people_with.2.aspx
- Modified Fatigue Impact Scale: https://www.sralab.org/rehabilitation-measures/modified-fatigue-impact-scale
- Fatigue Severity Scale: https://www.sralab.org/rehabilitation-measures/fatigue-severity-scale
All music courtesy of Free Music Archive and used via attribution 4.0 international license.
- Intro and Outro: Stylin' by JMHBM
- Transitional: Our Reality by Ketsa
Contact Dr. Powers
- Email: neuropowerhour@drmichaelpowers.com
- LinkedIn: https://www.linkedin.com/in/michael-powers-pt-dpt-edd/
Contact Dr. Potter:
- Email: kirsten.potter@tufts.edu
- LinkedIn: https://www.linkedin.com/in/kirstenpotter/
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Transcript
Introduction of Host and Guest
00:00:10
Speaker
Welcome to the NeuroPowerHour. I'm your host and neurological navigator, Michael Powers, physical therapist, board certified in clinical electrophysiology and neurologic physical therapy.
00:00:22
Speaker
Let's get started.
Dr. Potter's Background and Role
00:00:23
Speaker
I am thrilled today to be welcoming a special guest on the show today. Joining us is Dr. Kirsten Potter, PT, DPT, MS.
00:00:33
Speaker
She received her Bachelor Science in Physical Therapy from the University of Buffalo in 1985. her Master of Science in Physical Therapy with a focus on neurologic PT from Rosalind Franklin University of Science and Medicine in 1992, and her Doctor of Physical Therapy from the MGH Institute of Health in 2006. Since 1993, she has been a physical therapy educator and currently is professor and director of curriculum at Tufts University, Department of Rehabilitation, DPT Seattle,
00:01:05
Speaker
and a faculty member in the neurologic practice management courses in patient-centered care. Main reason
Journey into Outcome Measurement
00:01:11
Speaker
I really wanted to talk to her, well, there's multiple reasons, but her research focuses on outcome measures for adults with neurologic conditions, and that's what we'll be talking about today. Dr. Potter, thanks for coming on the show.
00:01:23
Speaker
Well, thank you for inviting me, Mike. I am thrilled to have an opportunity to talk to you and your listeners about outcome measurement. It's been a major focus of my career for almost my entire career. And so anytime I can talk to everyone about it and help share my thoughts and enthusiasm for it, I'm always pleased.
00:01:42
Speaker
We greatly appreciate that. And before we started recording, we talked a little bit about my love for outcome measures. And I just really want students to be excited as as we both are. So can
Shift to Quantitative Measures in PT
00:01:53
Speaker
you tell me, though, a little bit about what led you to become interested in the area of outcome measures and outcome measurement?
00:01:58
Speaker
Yeah, sure thing. So this all got started for me in the early nineteen ninety s I graduated with my bachelor's degree in PT in 1985. So that was certainly a while ago. And in the early nineteen ninety s I was working on an inpatient rehab unit in Chicago.
00:02:15
Speaker
And at that point in time, there were a lot of changes going on in physical therapy practice for adults with neurologic conditions, one of which was a move away from more descriptive or qualitative assessment of patients where we would describe their function or their movement pattern to something more quantitative. And at that point, it was the functional independence measure that was really the primary measure that was used across centers across the United States. And because of this change from more qualitative to quantitative measures, it was a big shift. And so there was a lot of resistance among clinicians at that point. And it was at that point that I actually went back to school and got my master's degree in specializing in neurologic physical therapy. And
Development of Stroke Gait Measure
00:02:57
Speaker
a lot of my courses and my research focused on outcome measurement. And so that's really what drove my interest and got the ball rolling for what has happened over the past few decades.
00:03:09
Speaker
When you talk about the resistance that you witnessed or experienced, and I don't want to go down to the rabbit hole of current resistance because we see changes in neuro PT all the time. And there's currently some some big shifts. Did you feel that you were part more interested in being part of the change? Did you feel like you were part of the resistance? Or where did you kind of fall along that spectrum?
00:03:30
Speaker
I would say I was more part of the change. Because of my master's degree, I really became familiar with measurement properties and the importance of quantitative data. And i actually developed an outcome measure for quantifying changes in patients with stroke in terms of their gait mechanics.
00:03:50
Speaker
Because
Importance of Data in PT Care
00:03:51
Speaker
typically we would describe the gait mechanics, but at that point we didn't have a way to quantify it, at least that was useful for clinical practice. So I developed an outcome measure to look at and to quantify performance in patients post-stroke as they were walking. I did a reliability study on that and some other psychometric properties. And that kind of gave me the skills and the knowledge to be able to continue my work.
00:04:13
Speaker
And I suppose I should have known where you fell on that side of the argument because I see on your shirt, I see the top of it saying without data. So I think there's a story behind the shirt you're wearing today.
00:04:24
Speaker
Yeah. so my shirt reads, a person without data is just another person with an opinion. So I thought this was a perfect day to wear this t-shirt. This is odd, but this was actually my favorite Christmas gift from my husband last year. And, you know, I think we've been married for a long time. It shows that he knows me well and knows my love of data. And for me, I think data is absolutely correct. You know, in today's healthcare care environment, we need to show evidence of a patient's baseline status to show the need for care. And
Overcoming Resistance to Outcome Measures
00:04:56
Speaker
without that data, we can't track progress, we can't necessarily get reimbursed. And so that is a major reason why clinicians need to be using objective measures in
00:05:07
Speaker
I want to, before moving on to talking about how you became more involved with the APTA and Academy of Neurologic PT, I was just wondering, as you got more involved in this process and you saw the power of data, did you eventually see some of the clinicians around you come around and decrease the resistance to change in terms of using outcome measures, or was that a more prolonged I don't want to say resistance, is not like it was a battle, but it kind of is in a way. Was it a prolonged effort to maybe encourage other clinicians to see the value? Good question. I think as with any change, when it is somewhat forced upon you, which it was in a way, there's always going to be some people who resist and other people who welcome the change. That said, the functional independence measure, as good as it was for doing what it does do, it wasn't meeting our needs clinically. And so there was a need for different types of outcome measures. That period was when new measures were starting to come out pretty rapidly. And as they came, as they were published and disseminated and available for clinical practice, I think that there was more of an interest. And over the years, I've seen a tremendous change towards acceptance of using measures and because of the recognition of the value of using them in practice.
00:06:24
Speaker
Those of us in clinical practice now have people like you to thank for sure for all the work that you've done research-wise and showing the benefits of some of these outcome measures. So could you speak a little bit more about how you were involved or how you got involved in outcome measurement research with the APTA and the Academy of Neurologic Physical Therapy?
Involvement with APTA and Task Forces
00:06:42
Speaker
Sure. Yeah. You know, it all started back in, gosh, I think it was 2007 when the neurology section now called the Academy of Neurologic Physical Therapy or ANPT put out a call for clinicians who were familiar with outcome measures to teach what to teach regional courses.
00:07:01
Speaker
on outcome measures. So these courses were taught across the country in different regions, and these were finally called the toolbox courses. The focus of these courses was to increase awareness and knowledge and skills in selecting, administering, and scoring a select group of outcome measures that were increasingly used in practice at that point in time. and I taught this with a group of colleagues that I continue, some of whom I continue to collaborate with today, which is awesome. But what we kept hearing from the attendees was that
00:07:32
Speaker
They appreciated the workshops. They were very helpful, but they really wanted to know what measures are best for patients with stroke, multiple sclerosis, Parkinson's disease, and other conditions. And this ultimately led to what are often called the EDGE task forces. And EDGE stands for Evidence Database to Guide Effectiveness Task Force. The EDGE task forces, there are six for the AMPT, stroke,
00:07:57
Speaker
MS, Parkinson's, vestibular brain injury and spinal cord injury. And I was actually invited to chair the MS EDGE task force, which was kind of the next step in the evolution.
00:08:09
Speaker
Can you tell me a little bit more about your work there? Yeah, so the original MS EDGE, we started working probably, i don't know, 2010 or so. We were charged with reviewing measures and making recommendations for patients with MS. And we ultimately
Reviewing and Standardizing Measures
00:08:25
Speaker
selected 63 measures across the ICF. So some were related to body function structure.
00:08:30
Speaker
others activity and then participation. In a similar way, the other task forces also reviewed dozens of measures. And so one of the problems that we encountered was that we reviewed collectively, i think it was 248 measures for use in practice and in for each We made recommendations for use patients at different acuity levels or functional levels, different healthcare settings. And then we even made recommendations for use in education and research. And because there were so many measures, our work was, we were well-intended. We wanted to help clinicians make better choices about measures. And we wanted to help educators and researchers as well. But with 248 measures reviewed, it was just too much. And so we probably inadvertently created
00:09:19
Speaker
more variability and less standardization, which was not our intent. So ultimately,
Creation of Core Set of Measures
00:09:25
Speaker
in reviewing 2,248 measures, we gave clinicians a lot of options for measures that they could use, but it really created a lot of confusion. And ultimately, I think we probably created a situation where there was more variability in measures used rather than increased standardization. That led some of us that were involved in the edges, and namely this was my colleagues, Jane Sullivan and Jenny Moore, to recognize the need for a core set of measures for adults with neurologic conditions. And a core set, we analogized it with what we what we see when we go to see our doctor, where our medical providers will take our heart rate, blood pressure, and respiratory rate. And we thought we need to have a similar core set for our patients
00:10:11
Speaker
with neurologic problems. This ultimately led to the Core set Clinical Practice Guideline that was published in 2018 in the Journal of Neurologic Physical Therapy. And the Core Set CPG was a project that Jane and Jenny and I led. took us about four years to get it done. It was a huge project. And we started with a survey to understand what clinicians and patients both thought was important. because we couldn't do a core set that covered everything that we assessed. It needed to be narrow or else we'd still be working on it today. So based on the feedback from clinicians and patients, we identified that our main focus was going to be on measures of gait balance and transfers.
00:10:54
Speaker
And that led to our six measures that comprise the core set, the Berg Balance Scale, the Functional Gait Assessment, activity-specific, balanced confidence scale, five times sit to stand, and then 10-meter walk tests and six-minute walk tests. And all of these met our criteria of having data, meaning reliability, validity data, responsiveness across patients with different neurologic conditions, and they were clinically feasible.
00:11:22
Speaker
So it was a big project. And today, the core set measures are pretty widely adopted in neurologic physical therapy.
00:11:36
Speaker
There's a lot. There's a tremendous amount to unpack there. And I'm just, again, so excited about outcome measures. want to acknowledge the amount of time that went into this. You said four-year project. And even before that, there must have been a tremendous amount of time investment. And I'd like listeners to consider starting out with 248 measures, doing just ridiculous amount of work, and then recognizing, well, we probably need to actually go back and revise this. And so you've just given yourself almost more work to do. The other reason I want to hone in on that a little bit is sometimes I feel students may not appreciate the history of where we're at as a profession. And it's easy to vector in or to think, well, just tell me what's best to use. And so understanding the work that went into this and possibly the tradeoffs that went on in developing a toolkit, what was accepted, what was not, helps to have a little more nuanced discussions, perhaps. So I just wanted to highlight those and just Also highlight, I think as educators, we talk about resilience or we talk about seeing projects through. and I just love that you've modeled that and put in that tremendous amount of work.
00:12:38
Speaker
I was just going I was going to add to that, you know, your your point about history is is an important one, I think, because it shows how far we've come. It also shows how long it takes for a lot of this work to get done. i think another thing that I didn't talk about yet was how advocacy was so important to these projects, to both the edges,
00:12:57
Speaker
and the course at CPG. When we were teaching the the toolbox courses, Jane Sullivan and i actually wrote a letter to the leaders of the NeuroAcademy and said, we need to do something to help clinicians select measures for patients that fall in certain diagnostic groups. That led to the EDGE Task Force. Then following all of the publications that
Impact of Core Set CPG on PT Practice
00:13:23
Speaker
came out of the EDGE Task Forces, such as our paper that was published in 2014 on the MS EDGE, we wrote another letter. Jenny Moore was now part of the team.
00:13:32
Speaker
And we said, we need to take the next step. We now need to do a core set. And in both cases, the academy leaders thought that was great and said, go do it. They knew we had the skill and the knowledge and we could pull it off. but they were also open to the ideas that we had. So a lot of this started out as service or volunteerism within the academy and ultimately became research and frankly has changed the face of the outcome measurement in in our profession, in neuro rehab at least.
00:14:03
Speaker
Absolutely. And I think that highlights the key consideration when you mentioned service and service that is kind of self-directed that you and your colleagues chose to lead. It's leading from the bottom up. Essentially, this was not dictated down. And we talked earlier about maybe resistance to change when something's forced. But here, this wasn't forced by any people in either elected or assumed leadership position. This is leadership at the ground level, seeing what needs to happen and then following through with it, which is, again, commendable. i I love that so much. I also wanted to point out for any students listening, the treasure trove of information that's available within ANPT. I think you and I both put a lot of the content into courses and sometimes it's easy to think, well, it's just, I'll go look at it later. There is an unbelievable amount of information that's actually going to make your clinical practice a little bit easier. So let's talk about maybe that. how What are the perceived benefits
Benefits and Challenges of Outcome Measures
00:14:58
Speaker
and barriers of using some of these measures in practice?
00:15:01
Speaker
Yeah, you know, I think the benefits really are to first and foremost, establish a baseline. If we don't have good data measuring the right things, the things that are important to patients, we're not going to be able to develop a plan of care that's going to be both effective and meaningful to our patients. So establishing that baseline is really, really important. I think these measures are also used to determine fall risk, which can help justify the need for care and to track change over time, which is instrumental in
00:15:33
Speaker
motivating patients and justifying care and seeking reimbursement. So there's a lot of different benefits to using measures in practice. I think there are also some challenges. When we did our survey of clinicians, we asked about challenges and there's been ample studies that have shown similar challenges and predominantly based on what I've read in the literature and heard at conferences and so forth, is that the major challenges to using measures are time and knowledge. Clinicians' knowledge these days is increasing because measures are more commonly pretty significant part of the education of future physical therapists and physical therapist assistants. But back in the days when they were first coming around, we didn't learn about measures in entry-level programs. I didn't do that until my master's degree. which was a graduate degree at that point in time. I think the barriers, and you talked about resources, and one of the things to to know, at least about the Neuroacademy, is that when the Neuroacademy sponsors CPGs, and they sponsor them along with APTA, there's a method to help translate that knowledge to clinical practice. Every CPG group in the Neuroacademy, at least to my knowledge, appoints a knowledge translation task force.
Role of Knowledge Translation Task Force
00:16:51
Speaker
And, you know, I'll be honest with you, when we finished with our CPG, we were out of steam, we didn't have kind of the bandwidth ourselves to dedicate towards putting together resources that clinicians could use to actually make good clinical decisions and implement these measures in practice. So we brought on a knowledge translation task force that we worked fairly closely with and their job was to create resources to help clinicians use these measures in practice. So if you go to neuropt.org, that's the ANPT website, you can look at the different resources that are available. And these resources are Knowledge Translation Task Force resources, I mean, but they're really helpful because they provide administration protocols, kind of a patient report tracking sheet, and materials that you can give to your patients about the measures that you're using. So they're super, super helpful. So
Maintaining Consistency in Outcome Measures
00:17:46
Speaker
as a clinician, i would encourage you to go to that website and look at those resources.
00:17:51
Speaker
And we'll link that in the show notes. And those, some of the information and the materials they have there is so user-friendly too. And that's what I just get so excited about the evidence, but that's what's so exciting too, is it's not abstract that some researchers were doing this. This was really designed to put into clinical practice. So there's maybe one page handouts on here's how you administer the outcome measure. Here's your little cheat sheet. How would I score it? How would I modify it? It even puts for many of the outcome measures, common maybe modifications or things you may need to consider. And maybe we could speak to that a little bit of what are your thoughts on, because I'll get this in class often, well, can we modify how we're doing the outcome measure? And that's, I try and pretend like I'm laid back, but I'm very type A, I'm a stickler. so I have certain thoughts, but I'd love to hear your thoughts on modifying outcome measures.
00:18:39
Speaker
Yeah, I can appreciate that. You know, I think there is a tendency on on behalf of a lot of people to want to modify them for various reasons that are understandable. You know, it may be that there are equipment barriers and limitations. There may be space limitations, especially for the six-minute walk test. You're supposed to have a long walkway and not all environments have that long walkway. You know, there's also a tendency sometimes for clinicians to say, well, I'm just going to do these items from the Berg balance scale or whatever. So my answer to that is i tend to be a stickler too. i tend to say, if you can avoid modifying, avoid it.
00:19:21
Speaker
Because whenever we modify the use of an outcome measure, we're going to have to remember that we modified it. And we're going to have to let our colleagues know who might be doing a repeat assessment on behalf of you know us And If we aren't consistent with how we're administering the measures, we're not going to get reliable results. So that's a problem. So we want to make sure that our testing method measures, processes rather, are consistent from one measurement to another measurement. So if you need to make a change, let's say, for example, that you don't have the recommended walkway length for to do the six minute walk test because you're in a home environment, for example. Use the walkway length that you can and then document that change. that your walkway length was 25 or 30 feet or whatever it was. If you need to modify the height of a chair or footstool for a given measure, again, document the height of the footstool or chair that you use. If you let your patient use their arms for the five times sit to stand, technically their arms should be crossed on their chest. Document that they use their arms.
00:20:28
Speaker
I just covered my eyes,
Scoring Incomplete Assessments
00:20:29
Speaker
sorry. i just You just gave me the heebie-jeebies. no, you can't use your arms.
00:20:36
Speaker
You did. i know I'm watching you. Exactly. I'm sorry. I know. i know. Well, okay. here's Here's another thing that we need to talk about is when do we say that the patient cannot complete the assessment now, but we'll be able to later and how do we do that? So let's say, for example, you want to administer the Berg balance scale and the five times sit to stand and maybe some of the other core set measures with a patient who just had a stroke. Okay.
00:21:05
Speaker
We know that a lot of patients with strokes gain, gain motor function, sensory function back. So they may not be able to walk today, but they might be able to walk down the road. So with the core set measures, our recommendations indicate your decision-making is based on two things. Does the patient have goals in the area? Meaning, is it important to them to walk, to transfer and so forth? And do they have the capacity?
00:21:33
Speaker
So for example, my patient post-stroke who right now can't walk and can't transfer independently. They may have goals. They probably do. Most patients come to us because they want to do those things. So they have goals, but they don't have the capacity now. So then the question you need to ask yourself is, do they have the capacity potentially later? If so, the answer is to that is that you will not administer the test because the patient can't do it, but you will score it as a zero and say patient is unable to complete at this time. That way your baselines
00:22:12
Speaker
is a zero. And that's what you're going to use to show change over time. And so then maybe a couple of weeks later, now they can go from sit to stand. And now maybe they can do some of the easier items on the Berg, do those items that they can do and score them. Every other item on the Berg might still get a zero, but you might have seen that they went from a zero out of 56 on the Berg to a seven out of 56. And that in
Using MDC and MCID for Goals
00:22:37
Speaker
all likelihood,
00:22:39
Speaker
exceeds minimal change, the minimal detectable change score to show that they actually had likely real improvement. That's a great consideration. And I think there's, I kind of have a two part follow up. One would be your decision making, just like what you described as how would you decide we've got six core ones, we don't have all the time in the world. And I love that you mentioned, well, if you think there's potential in the area, go ahead and do one, even if they score a zero. And then maybe we can spend a little bit of time talking about those measurement considerations, that that MDC, minimal detectable change, and MCID, minimal clinically important difference.
00:23:16
Speaker
And to me, and I
Prioritizing Outcome Measures
00:23:17
Speaker
really want to highlight this for students listening, if you know these numbers, you could have no clinical experience whatsoever, and you can still look at establishing meaningful goals. How powerful is that?
00:23:29
Speaker
Yes, exactly. Yeah. So, you know, I teach my students that they should use things such as minimal detectable change and minimal clinical important difference as as a benchmark for goal writing. There's no point in making up a number. Use those data points. So let's say that the MDC is, you know, four points for the functional gait assessment.
00:23:54
Speaker
your goal might be five points. That way you know that that patient exceeded error and the change that you're seeing is likely real change. Or if it's an MCID, that that change is meaningful to the patient.
00:24:07
Speaker
So those are things that you can use for goal writing, for tracking change, for justifying care to payers and so forth. So, you know, we refer to that scoring of zero as kind of the power of zero. in kind of the old days, what we would do is we would just say not applicable, the patient can't do it. And then we didn't do the Berg or whatever measure until they could move from sitting to standing and do some standing balance items. But we just lost an opportunity to show great improvement. That's really, really helpful as kind of that algorithm to to making those clinical decisions. It's really, really
Future of Outcome Measurement
00:24:42
Speaker
important and helpful.
00:24:44
Speaker
So in some ways, we've moved from when you said we used to do not applicable, we've almost in the profession adopted a growth mindset, because now we're saying, well, they can't do it yet. So we're scoring them a zero. But I think that's a fundamental shift in thinking that we're not thinking this is a waste of time. But again, clinicians need to come in with a good sense of what's the overall prognosis. And that is a whole separate discussion of where you land on that, but the person has goals and they have potential to improve in that area. So a zero might still give you great information in terms of a baseline starting point.
00:25:16
Speaker
Absolutely. And, you know, I think it's important to recognize that the core set measures aren't for every patient and that's okay. Not every patient has capacity to to move from sitting to standing, to walking, to doing standing balance activities. So for example, if you have a patient who has a complete cervical spinal cord injury, the course that measures aren't your best choices for measures. And that's where I would go back to the spinal cord injury edge documents and try to find other things that really relate more closely to what the patient's goals are. So they might be more related, for example, to wheelchair mobility.
00:25:55
Speaker
to basic mobility tasks, to quality of life. You know, for patients with fatigue who can't walk, maybe some of the sitting balance stuff on the bird might be doable, but we should also be looking at things such as fatigue. And in fact, the MS EDGE, we just did a systematic review that got published on self-reported measures for fatigue. And so this work is continuing at the level of the EDGE task forces and the academy, and that's a great thing as well. So, you know, I think there definitely has been a lot of progress in the last 30 years or so, and and I don't see it stopping. I think that this, that outcome measurement is going to continue to evolve and things are going to continue to need to be updated in the future.
00:26:37
Speaker
To me, that's exciting. And I would encourage people listening to approach this with some humility that we're always constantly learning. And so to the earlier thought about resistance, as as we change things, I think it can be easy to think, well, people that aren't staying up to date are completely wrong. And we want to welcome everyone in and try and move towards the evidence, but also understanding what we know is correct now may change down the road or may need to be revised. So we want to stay humble as we're moving through as well.
00:27:05
Speaker
Absolutely.
Case Example: Core Set and MS EDGE Integration
00:27:12
Speaker
So wanted to go back. You had mentioned the recent publication of the ms Edge. Can you kind of talk us through how you would integrate this with clinical practice? Sure. Yeah. So we updated the original MS Edge, which was published in 2018.
00:27:28
Speaker
fourteen By doing a systematic review, we were actually charged from the leadership in the Neuroacademy to do a systematic review on a construct or area of importance to people with MS. And because fatigue is oftentimes the most commonly reported disease. issue that patients face, and it's very difficult to assess and manage, we decided to to do our systematic review specifically on self-report measures. So meaning things that like questionnaires and surveys versus more objective measures such as a six-minute walk test. So we did a systematic review. And again, this was another lengthy process. It actually happened during COVID and it ended up taking us way more time than we would have envisioned, but it actually just got published in 2020. So that's great. So let me give you a a case example, and then I'll kind of talk you through how I would go about integrating CoreSET with the the MS Edge measures. So let's say that you're working with a patient with MS who recently had an exacerbation with sensory, gait, and balance issues, especially when walking in challenging environments. Patient reports decreased ability to complete grocery shopping due to endurance issues.
00:28:40
Speaker
And the goals are to resume her ability to complete daily activities in her home and community, including walking to complete her instrumental activities of daily living, as well as for exercise purposes. So let me start with the core set. I'll just kind of go down through each of the six core sets.
00:28:58
Speaker
give you my thoughts as to whether or not I would administer and score them. So we'll start with the Berg Balance Scale. My opinion is the Berg Balance Scale assesses sitting and standing balance, and the standing balance is related to static standing and anticipatory balance in standing. So it's pretty limited and it's better for patients who are at a somewhat lower level of function. I think for this patient, probably isn't going to get a perfect score, but she's going to score pretty high. In clinical practice, your time is limited. You have to make some choices. So in this case, I would choose to administer the functional gait assessment because the skills on the functional gait assessment are higher level and they are skills that are useful for community ambulations, such as walking around obstacles, walking and turning our heads, things like that. Five times sit to stand might have limited utility.
00:29:50
Speaker
An alternative to this, if you really wanted to look at the endurance factor of sit to stand might be a 30 second sit to stand. And actually that's oftentimes used in people with MS. 10 meter walk test.
00:30:02
Speaker
I would need to explore this a little bit more with the patient. I would wonder is speed a concern or goal of hers? If so, I'd probably administer it. It can't hurt to administer it. It's quick, it's easy. There's lots of data out there. And so chances are I would choose to do it.
00:30:19
Speaker
Six minute walk tests, I think it's worth the time. I think this is one where a lot of people think I don't have time for a six minute walk test. I'm going to do a two minute walk test. But a six minute walk test, even though it takes more time, can give you really good information about her goals to resume longer distance walking. So I would administer the six minute walk test as closely aligned to the protocols as possible. And the protocols are published in our CPG and our recommendations based on the literature are there. One of the things that I would do with this patient is look at how, what distance did she walk in the first minute? And what distance did she walk in the last minute? Because that gives you an idea of her endurance. So it's not really a modification. It's just looking at the data in a little bit deeper way. And then lastly, the activities balance specific confidence scale.
00:31:10
Speaker
Absolutely. This is something she could potentially take on her own time, which would be helpful from a time management perspective in the clinic. But it's really important because its items are very much related to higher level balance and gait activity. including things like walking and challenging environments.
00:31:27
Speaker
So in sum, i would do the FGA, six-minute walk tests and the ABC for sure, and probably the five-time sit-to-stand and 10-meter walk tests. Then the question is, what are we missing?
00:31:40
Speaker
You know, balance gait and transfers are really important. Our patients who completed our survey to inform the CPG told us that. But we also know that MS is so complex. Our patients with MS have so many different problems. And this patient has endurance problems, which suggests there are fatigue issues. So I would go to the recent fatigue systematic review that we just published in Just quick summary, we reviewed, ultimately there were 24 articles that met our full text criteria. We not only reviewed articles, but we reviewed measures to meet, see if they met our clinical utility criteria. That matched our methodology, by the way, for the CPG as well.
00:32:20
Speaker
Looking at, we looked at 24 articles and 17 different measures and our data ultimately pointed towards two measures that we could actually recommend. One is the fatigue severity scale.
00:32:32
Speaker
It is a screening assessment of physical fatigue. That is a fantastic measure. It's shorter than the other recommended measure, which is the Modified Fatigue Impact Scale. And the Fatigue Severity Scale focuses on physical fatigue, which has an an absolute relationship to what we as PTs are concerned with. The Modified Fatigue Impact Scale has three domains. means It's more comprehensive. It does include physical fatigue. I don't know that it would be all that important in this particular case.
00:33:00
Speaker
So I would probably choose the fatigue severity scale and administer that as baseline. And you can also administer that over time to look at changes. So those would be kind of the measures that I would choose and how I would integrate the course set CPG with the MS Edge updated systematic review.
00:33:19
Speaker
I love that. And I think
Aligning Measures with Patient Goals
00:33:20
Speaker
that's so helpful for people to hear your decision making as you go through there. The considerations of we don't have unlimited time. Here's what I would prioritize using the core set as kind of your central hub or home base and then branching out from there with considerations about fatigue or wondering, hey, what did I miss? I was also laughing a little bit when you talked about the six minute walk and clinician saying, I don't have time, which I get. I've been in that boat myself, but it's also six minutes.
00:33:48
Speaker
It's not as though it's a 15 or 20 minute treatment. What you might, in fact, be saying is I don't have the right setup. I don't want to spend six minutes. administering the test, but it's only six minutes. And for this patient, I completely agree. If we think about her participation, she's wanting to be out in the community. We don't want to constrain her to measurements that are just within the clinic. The other thing that struck me by what you were mentioning as you went through which measures you would use, is the discussion about five times it to stand, why you may use it, may not use it, or maybe look at 30 seconds.
00:34:23
Speaker
One thing I found within my teaching practice is students, as they are learning about the core outcome measures or as they're novices with outcome measures, will quickly vector into saying, I'm doing this test because this person is a fall risk and I'm getting a balanced number.
00:34:40
Speaker
On its surface, it's not wrong. You can quantify a fall risk, but I really appreciated how you went through your consideration of really tying more intentionally the outcome measure with the patient presentation and the patient goals. And that I would challenge students to become well-versed in the core outcome measures, but also really intentional about aligning them to your patient presentation and not hanging your hat on saying, well, this person's a fall risk and I have a fall risk number.
00:35:07
Speaker
Exactly. The number is really only one piece of the puzzle. It's ah it's a crucial piece, but it's one it's one data piece. And so we need to go beyond that. You know, we not only need to look at the numbers, we need to look at the data that tell us something about those numbers, that help us interpret them, that help us determine change. We also need to look at movement quality. So when someone's doing that six-minute walk test, what are we noticing between minute one and minute six? With someone with fatigue,
00:35:38
Speaker
It's not uncommon that the longer they walk, the more their gait deteriorates and the more their fall risk goes up. And that can helps us help us formulate a treatment plan to address those physical endurance
Technology in PT Outcomes
00:35:51
Speaker
limitations and educate the patient about when they might need to take a break and what things that they might notice about their walking that tells them that they might be more at risk of falling so that they can be more careful.
00:36:03
Speaker
There's one other point I want to make. You brought up the importance of participation. And that made me think about the difference between performance and capacity.
00:36:15
Speaker
And so, you know, a lot of times performance is considered to be sort of what does that patient do in the clinic? What are we seeing when they perform something? Capacity is really the concept of, well, what do they actually do when they're home and out in their community? And, you know, I'm sitting here and I've got my Apple watch on. And so it reminded me, you know, we can pull other data points from devices that our patients may be wearing, such as a Fitbit or an Apple watch. So for this particular patient, I might add in there, to a step counter. We can have the patient every day at the end of day, write down how many steps, report back to me next week when you come in. And that can be another really valuable measure because we know, and we've we've seen it for as long as I've been a PT and probably eons before, patients come into the clinic, they start, they look better as a result of our treatment. The next week they come back, they look the same.
00:37:06
Speaker
There's not always change that's long lasting that We really want to happen. And so these step counter device types of devices can be another good measure as well. I think that's a great point. And I'm a big fan of the optimal theory of motor learning and enhanced expectations, patient autonomy. The evidence I'm aware of points to patients want to be challenged or they want to meet goals. And so those step counters would go a long way. And it's another data point as well. And even now, as I'm seeing patients, anytime I get a data point, I'll share it with the patient and they will 99% of the time work to try and beat that data point. A final point, I wanted to talk about the technology, which is a great point. I think we're probably looking at in the near future, some interesting information coming out with heart rate variability. That's pretty big in the fitness world right now. But I'm i'm curious, and I've seen some exploratory studies looking at heart rate variability with MS and some correlations there with fatigue. So I think we're going to find interlocking or the use of technology in what we're doing is just very exciting.
00:38:10
Speaker
it It definitely is. And, you know, I think that the main barrier to using technology is the cost associated with it. But these days, you know, the number of steps we take per day does matter in terms of health and function. And so, and a lot of these devices don't cost a lot of money and a lot of our patients are already using them. There are low-ish tech type things that aren't very expensive that we can also use in ah in addition to the measures that are on the core set and the CPG and the the edge documents. And you know, regarding the corset, all of the measures that we selected for the original corset had to be low or no cost. And so those measures are really, they're they don't have a high cost associated with them. The measures themselves, the forms are free to use. So those are, that's a good thing. But I think that we
Updating Core Set CPG
00:39:01
Speaker
need to, we're moving forward towards using more technology as measures of physical functioning capability as well.
00:39:08
Speaker
Moving forward, was that a callback to the the white paper about moving forward? A little neuro, a little neuro pun in there are for people that are listening that may have caught that. That's funny. I hadn't picked up on that, but there you go.
00:39:20
Speaker
Yeah.
00:39:28
Speaker
So we've mentioned technology, kind of some thoughts about where we might be moving overall. Where do you see us as a profession moving in terms of outcome measures in PT practice over the next five to 10 years?
00:39:41
Speaker
Yeah, good question. um You know, let me let me go back to the course set. The course set was originally published in 2018. Ideally, CPG should be updated every five or so years. So we're obviously behind that because we didn't actually start updating it until just about a year ago. So if there's a group of us that are currently working to update the course at CPG, we are using methodology that aligns with what we did with our original four-set CPG. We're going to be updating it with new measures and new data and adding that into the data that we reported in our 2018 paper. So at this point, we we actually went back to, took a step back again, and we did two different things to inform the CPG, just to make sure we were kind of thinking correctly that we should stay with the constructs, balance gate and transfers that we chose before. We did another survey. We really wanted to ascertain
00:40:38
Speaker
clinician uptake of the CPG and barriers to use, because that can help us when we get to the knowledge translation piece to really be mindful of what what are clinicians now saying is the problem or challenges with administering measures and practice. We also did a citation analysis to identify how many times has the CPG been cited in the literature and how has it informed future studies. And it's amazing like that our CPG at the time of We did our citation analysis with cited over 200 and 200 studies. And now it's over, i think over 300 studies. It's incredible. It's just been, it really has been a game changer in terms of not only practice, but I think research. So that's been very, very rewarding for those of us that were involved in the original CPG. I would add that the one change that we are making to our methodology is we are considering step counters this time as ah as a measure. We did not do that before. They weren't widely used, if at all. We will see how things land in terms of the available data, whether or not there's data out right out there right now to actually write an action statement to make a recommendation will be determined. We hope we're now in the midst of the title abstract search. We actually had, believe it or not,
00:41:57
Speaker
over 48,000 title abstracts to review. we each reviewed over 16,000. So we're just finishing that up. Then we will go into our full text review and then we'll be doing, we have recruited ah article appraisers, which is a great way to get involved in research. If you're interested in contributing to a CPG, that's a good way to kind of dip your toes into into helping out is to be an article appraiser. And so we've recruited article appraisers. They're going to be doing the analysis using a standardized form for looking at methodological quality of outcome research studies. So we hope that that will be published here within the next couple of years. But that's kind of it to be determined. These things always take more time than you would envision, but they're worth it.
00:42:46
Speaker
I have a couple as as you were speaking, i have a couple thoughts. One, I hope you're getting enough sleep. That sounds like a lot of articles or abstracts to review. And then ah with the updates, supposed time frame, I think we had like a pandemic or something in the midst of between the when the initial ones were published and now. So I think any gaps in what the time frame should be to what they are is probably pretty understandable.
00:43:10
Speaker
Definitely.
Advancements and Accessibility in Neuro PT
00:43:11
Speaker
Yeah, I appreciate that, Mike, because, you know, the pandemic did play a part for sure. It's just the nature of these projects. They are very, very time consuming and it it takes a village. There are so many different people who are involved in so many different ways. You know, there's six of us now leading the effort, but then we have probably 30 to 40 other people who will contribute in some way as as we move forward with the project.
00:43:38
Speaker
As someone who's more on the consumer side of benefiting from the hard work that's being done, i just want to say a thanks not only to you, but also I just really appreciate to NeuroWorld, the Academy of NeuroPT. For a long time throughout my career, I felt like neuro was kind of second fiddle to MSK in terms of our use of evidence. And now we've got CPGs. We have really, in my opinion, minimized a lot of uncertainty and variability.
00:44:03
Speaker
at least about where we should start working with patients or establishing baselines. We're always going to individualize our treatments, but I really feel this has also made neuro a lot more accessible to more therapists. It's not just the hidden domain of some experts that have masterful handling. It is if you're a coach, if you're someone who can analyze movement, if you can apply evidence, come join us over in the neuro world. you
Dr. Potter's Path to Neuro PT
00:44:27
Speaker
You were essentially making a call for people to help out with the evidence. And I'm putting out a little call for it come, come join us in neuro. It's, it's fun over here.
00:44:35
Speaker
Definitely. Yeah. I, I actually went to PT school because I thought I wanted to be an orthopedic and sports PT. And I was so certain that one day I told my neuro instructor that that was exactly what I was going to do. And her response to me was, no you're going to end up in neuro. I wish at the time i had said, why, what do you see in me that tells you that?
00:44:56
Speaker
It didn't take me long after I graduated from PT school to realize that she was right. She saw something in me. And I think for me, my love of neuro PT has to do, I mean, it kind of starts with the brain and all the things that the brain does and what can happen when someone has some sort of insult or disease impacting the brain, patients are highly variable, which I like, I like to be challenged and have to use my critical thinking skills to help my patients. And I'll say, just say one more thing about that. I think the other thing that I love about neuro is that our patients are highly motivated. i very rarely have come across patients in my clinical career, where where I thought that they were not motivated. The harder thing for these patients is that they lost
00:45:44
Speaker
their ability to do some pretty basic functional skills that are important to their everyday lives. So they're they're highly motivated and really fun to work with and very appreciative of our help. So it's just a
Discussion Wrap-Up
00:45:55
Speaker
ah great population.
00:45:56
Speaker
Completely agree. So we're ending kind of in some ways with the sales pitch. As we're drawing down to a close, is there anything we didn't discuss about outcome measures or anything that we missed that you think we should add on here before we say goodbye?
00:46:09
Speaker
I, you know, I think we covered everything. I'll just let your listeners know that if you want to connect with me, I, you can find me on LinkedIn and you can also feel free to email me at Kirsten, K-I-R-S-T-E-N dot Potter. at tufts.edu. So thanks for having me on today, Mike. It's been fun talk to you about outcome measurement.
00:46:30
Speaker
Thank you for coming on. And one thing I didn't mention, and I was going to at the top of the interview, and I was like, no, I don't want to embarrass her is that in in addition to the introduction, I'm highly privileged and very grateful to have had the opportunity to teach with Kirsten for a period of four years. And more importantly than that, my life's better for being able to call her my friend. So thanks so much for being on the show. I want to thank everyone for listening and we hope to catch you in the next episode to continue learning.