January 31, 2017
In the clinic or at home?
Both clinic assessments and screening in the home have their part in practice, so what is the best tool to use to collect outcome measures?
While is it known we need to choose tools that are specific and sensitive to what we are attempting to measure, the debate surrounds what tools we need to use to ensure measurements collected are functional, appropriate and specific to our treatment and goals.
As if choosing the correct tool is complex enough, choosing the most appropriate location; home, clinic, workplace or vehicle is like a lucky dip. We will explore clinic assessments vs. screening in the home.
How would we assess?
36-year-old female, office worker, lives with two children aged 7 and 10.
Complex Regional Pain Syndrome (CRPS) in the hand from a fracture acquired from falling down the fire stairs during a drill.
How would we assess the client in the clinic:
It is difficult to speak for Allied Health as a whole, as we know each profession has its own way of looking at an injury but speaking broadly most Allied Health professionals would aim to identify any main impairment. Impairments are products that may cause activity or participation restrictions.
|Heightened sensation to pain/ allodynia (Sensory)||Light/ Sharp touch|
|Decreased sensation (Sensory)||Determone mapping|
|Reduce range of motion (Motor)||Goniometer|
|Decreased strength (Motor)||Manual Muscle Testing (MMT), grip strength, myotome testing|
|Reduced reflexes (Motor)||Reflexes|
|Skin changes (Vasomotor)||Look, feel|
|Temperature changes (Vasomotor)||Feel|
|Swelling/ Sweating (Sudomotor)||Patient reported, observation|
Table 1. Illustrates some impairment, how these relate to the Budapest diagnosis criteria and how Allied Health professionals would assess these impairments.
It is essential that all of these impairments are examined and tested:
2. Extent of condition
3. Collect outcome measures
4. Determine extent of impairments and how these impairments may effect activity or participation restrictions.
While these measures are essential and provide a clearer picture of the problem. These test lack function, we are unable to see how the individual is able to care for her children, cook dinner, wash herself, tie her hair up or return to work. These measures provide a lot of information regarding the extent of her CRPS, not an indication how this is affecting her life.
It is common, that Allied Health professionals may become too caught up with collecting information from highly specific and sensitive measures, but do not spend the time with the patient to discuss how these impairments are actually affecting their life.
Yes, outcome measures and data collection is an essential component of any assessment, consultation or treatment. However, without the clinical reasoning or knowledge of how these measures affect the client are these tests a waste of time?
Outcome measures in the clinic are essential and need to be collected, however the Allied Health professional needs to ensure these tests focus on what the Allied Health professional is trying to achieve. We have confirmed that this patient is suffering from CRPS, is there a need to test her sensation and range of motion every session? Probably not!
What is more important is how is the patient handling with activities of daily living (ADL) and her plan to return to work. Unfortunately, you would be unsure, you didn’t collect any appropriate measures. You may have used a questionnaire such are the OREBRO Musculoskeletal Pain Questionnaire, however this is client reported.
The patient displays yellow flags or does not enjoy her workplace due to workplace bullying (this is another issue). When you stand in front of a judge or insurance company, what will you, the allied health professional say? Mrs A has normal range, and adequate sensation, however is unable to return to work because she cannot hold a pen? The next question will be why can’t she hold a pen? Unfortunately a lack of strength or “motor control” is not the right answer.
The correct answer will be, I’m not sure I haven’t looked at it.
This is where some, not all Allied Health professionals fall short.
Screening in the home:
The public health system has established an excellent system, where a number of Allied Health professional visit clients in their home environment. This strategy enables the Allied Health professional to observe how the client is handling day to day life, something often neglected in the clinic.
Let’s look at a more “functional” approach; commonly a method used by Occupational Therapists (OT’s) the Assessment of Motor and Process Skills (APMS).
The AMPS is an observational assessment, used to evaluate people in the context of familiar and relevant tasks. A core concept in the AMPS is the importance of client choice, as engagement in chosen and meaningful activities is at the core of occupational therapy. Client motivation and performance is believed to be best when he or she can choose the activity.
An AMPS assessment begins, therefore, with an interview of the client so that the therapist can determine which standardised AMPS tasks are familiar, relevant and of sufficient challenge to the client. AMPS tasks include a variety of ADL tasks – personal ADL (eating, dressing, grooming, etc) and domestic ADL (simple to complex cooking, home maintenance, outdoor tasks, etc)
The AMP identifies:
- Performance skills – smallest units of observational action, the process of the task, sequence of actions;
- ADL motor skills- Observable, goal-directed actions the person enacts when interacting with and moving task objects, moving oneself around the task environment;
- Process skills- Selecting, interacting with, and using task tools and materials, carrying out individual task actions and steps, modifying task performance when problems are encountered.
The advantage of using a technique such as the AMP is we are looking at skills rather than body actions.
For example, when completing a task such as making a cup of tea with a hand with CRPS some of the motor skills examined include:
Obtaining & holding objects
The AMP uses a much more holistic approach to assessing outcome measures. While the therapist may also collect outcome measures such a range of motion (ROM), pain scores and sensation. The AMP enables the therapist to identify regular task that are of concern. These methods should be used especially for those patients who are suffering from chronic conditions.
CRPS is a condition that has high rates of depression and anxiety, a topic that will be discussed latter. A sense of accomplishment would assist in reduction of these physiological conditions.
In conclusion both methods have their part in practice. The practitioners in the clinic should consider how the client would manage if they were at home. Allied health professional’s should consider collecting more sensitive outcome measures, however ensuring patient satisfaction and achieving goals should be of top priority.
At Prudence Consulting we a team of experience personal injury specialists who provide evidence based and independent reports to the medico-legal industry. Contact us today to request a report for your client.