Suk / Hanson / Norvell Musculoskeletal Outcomes Measures and Instruments

Vol1: Selection and Assessment Upper Extremity, Vol.2: Lower Extremity
2. Auflage 2009
ISBN: 978-3-13-258183-8
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 880 Seiten, ePub

Reihe: AO-Publishing

What outcomes are important to patients and clinicians? How is a specific instrument scored? Has it undergone reliability testing? In what population was it validated, and how did it perform? This pocket-sized handbook, covering all the major musculoskeletal outcomes instruments in use today, answers these questions and more. Key concepts like reliability, validity, and responsiveness form the framework of the book, which features more than 300 commonly used outcomes instruments for the shoulder, elbow, hand and wrist, hip, knee, ankle, and calcaneus. Each instrument is numerically rated based on clinical relevance and ease-of-use. Research results summarized in table form eliminate the need for looking up original studies. And, the book is organized and color-coded by anatomic region to save you time in locating desired content. Essential for orthopedic surgeons, rheumatologists, physical and occupational therapists, and others who manage musculoskeletal problems, this compact handbook is critical for deciding on an appropriate course of treatment based on validated outcomes.

Michael Suk, Beate P. Hanson, Daniel C. Norvell, David L. Helfet

Zielgruppe

Ärzte

Autoren/Hrsg.

Suk, Michael

Hanson, Beate

Norvell, Daniel C.

Helfet, David L.

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Orthopädie- und Unfallchirurgie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Muskuloskelettales System, Bewegungsapparat

Inhaltsverzeichnis

Volume 1
1 Introduction
2 Why appropriate selection is important
3 What makes a quality outcomes instrument?
4 Clinician-based outcomes measures
5 The purpose of patient-reported outcomes
6 Recommendations
7 Patient expectations of outcomes
8 Identifying and evaluating musculoskeletal outcomes instruments
9 Generic and upper extremity outcomes measures and instruments
Volume 2
10 Lower extremity outcomes measures and instruments

Leseproben

4      Clinician-based outcomes measures

1     Introduction

In evaluating an intervention or particular treatment protocol, students, physicians and researchers involved in musculoskeletal care have traditionally utilized several clinical parameters. Specifically, did the intervention or treatment protocol result in:

•    An increased longevity?

•    The prevention of deformity?

•    Improved pain relief?

•    The restoration or improvement of musculoskeletal function?

•    The prevention of future functional decline?

Typically, outcomes that can be simply determined, such as increased longevity and deformity prevention are among the easiest to evaluate. Often, these outcomes do not require a written instrument to derive a conclusion. For example, a comparison of survival rates between elderly patients who sustain a hip fracture and undergo a particular intervention versus those who do not can be directly assessed and quantified. On the other hand, evaluations of pain relief, functional improvement and the prevention of future functional decline is often more difficult to assess. However, these outcomes are frequently of greatest concern to the patient. Historically, clinicians have attempted to determine a patient's outcome by measuring attributes believed to be associated with well-being. We refer to these as clinician-based outcomes (CBO).

2     What are clinician-based outcomes measures?

Clinician-based outcomes measures refer to an array of tests and measures that assess the result of healthcare interventions from the perspective of the clinician. They are often physiologic and may include muscle strength, joint range of motion, gait abnormalities, bony alignment, edema, wound repair, response to provocative maneuvers, and inventories of physical/psychological/social function. They stand in contradistinction to patient-reported outcome (PRO) measures; those outcomes measures that reflect the patients' perception of their symptoms, functional ability, and quality of life.

3     Are CBO measures more objective than PRO measures?

Previously, many clinician-based outcomes measures were considered “objective”. After all, in most cases, the clinician was documenting the patient's progress directly, measuring motion, strength or other parameters that were deemed important. Outcome objectivity, however, is not determined by whether a clinician measures a parameter directly, but rather, objectivity is dependent on the or of a finding, among patients and clinicians alike [1,2]. There remains substantial variability in many CBOs. For example, interobserver agreement in determining motion of the spine [3,4] or extremities [5–8] is often poor. Muscle strength can be difficult to reproduce, particularly manually [9], but also in some cases when a dynamometer is used [10–12]. Variability for simple imaging tests has also been documented [13,14].

In short, one must not assume that CBOs are necessarily more objective than PROs simply because they are quantifiable. Objectivity is related to reliability, and measures of clinician-based outcomes should be tested for this metric before the measure is accepted as such.

Clinician-based outcomes

Patient-reported outcomes

•    Clinician-based outcomes are often physiologic and can be measured directly by the clinician. •    Examples of clinician-based or physiologic outcomes include muscle strength, joint range of motion, gait abnormalities, limb length, and bony alignment. •    These physiologic measures, often considered “hard” or “objective”, frequently serve to infer functional ability.

•    Patient-reported outcomes are concerned with the patient's perception of their symptoms, functional ability, and quality-of-life. •    They have been considered “soft” or “subjective”, and there has been some reluctance in the past to place a high value on these determinations. •    It is now generally agreed that a patient's symptoms, functional ability, and quality-of-life are important outcomes that also require direct assessment.

Table 4.1: Differences between clinician-based outcomes and patient-reported outcomes

4     Do clinician-based outcomes accurately measure patient function?

Historically, clinician-based outcomes have enjoyed widespread use because of the fundamental assumption that physiologic outcomes and patient well-being are highly correlated. We now recognize however that this is not always true [15–18]. For example, it has been shown that only a weak association exists between radiographic severity of knee osteoarthritis and patient quality of life. This was illustrated in a study where neither the measurement of mean joint space width (MJSW) nor the narrowest joint space point (NJSP) significantly correlated with pain, stiffness or function derived from a patient-reported outcome measure, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) [19]. In another example, 18 nonrheumatoid patients who underwent limited wrist fusion had wrist scores based on range of motion and grip strength that did not correlate highly with patient satisfaction or self-assessment of wrist performance [20]. These examples reinforce that, with respect to patient function, it is better measured directly rather than deduced from surrogate measures.

Clinician-based outcomes are often characterized by artificial categories of well-being. Simple designations such as “excellent, good, fair, or poor” are commonly used. This simple rating scale is based in part on physical findings assessed by the clinician. Assessments using these scales often presuppose a high correlation between clinician-based physiologic outcomes with patient-reported symptoms and functional status. For example, the Hospital for Special Surgery (HSS) knee scale combines pain, function, range of motion, strength, deformity and instability into a single score and classifies patients into one of four categories mentioned above. In a direct comparison between the HSS knee scale and the Cincinnati knee ligament rating, Sgaglione et al [21] found that each would rate the same patients differently. The proportion of subjects rated as excellent ranged from 23% (Cincinnati) to 76% (HSS knee scale).

The Thompson and Epstein score [22] for hip evaluation combines clinical and radiographic scores. Their clinical score identifies the following grades:

This scale again classifies patients into four categories that only identify gross differences in function. Furthermore, the rating system combines symptoms, gait, motion and hip dislocation within a single rating, despite the fact that these outcomes may vary independently. For example, what is the grade if the patient has no pain but marked limitation of hip motion and does not dislocate? Unfortunately, vague ordinal classifications such as these lack consistent definition.

In summary, clinician-based outcomes are not necessarily more objective than patient-reported outcomes, nor are they necessarily related to a patient's relief of symptoms, functional ability, and quality of life. These should be measured directly using patient-reported outcomes measures. Older clinician-based scales that combine clinical measures and patient symptoms can cause confusion, especially when simple designations such as excellent, good, fair and poor are used to summarize the patient's status.

5     References

[1]     Feinstein AR (1977) Clinical biostatistics. XLI. Hard science, soft data, and the challenges of choosing clinical variables in research. 22:485–498.

[2]     Deyo RA (1998) Using outcomes to improve quality of research and quality of care. 11:465–473.

[3]     Nelson MA, Allen P, Clamp SE, et al (1979) Reliability and reproducibility of clinical findings in low-back pain. 4:97–101.

[4]     Miller SA, Mayer T, Cox R, et al (1992) Reliability problems associated with the modified Schober technique for true lumbar flexion measurement. 17:345–348.

[5]     Edwards TB, Bostick RD, Greene CC, et al (2002) Interobserver and intraobserver reliability of the measurement of shoulder internal rotation by vertebral level. 11:40–42.

[6]     Hoving JL,...

Über Autor(innen)

Michael Suk, Beate P. Hanson, Daniel C. Norvell, David L. Helfet