FOTO Rehab Outcomes

Aug 03, 2017 | Selena Horner

Patient Reported Outcome Measures are a Stethoscope for Patient History

Patient reported outcome measures are being used more and more frequently. In rehabilitation, I have a feeling the main reason the majority initially begin using a measure is to be compliant with regulations. I mean, we need to report functional limitations, so the easy button is to incorporate patient reported outcome measures.

I took time to read the below perspective published in Annals of Surgery.  Although I don't agree with a stethoscope analogy, I definitely agree that patient reported outcome measures can be used to drive clinical decision making. FOTO has really led in the outcome world by tackling two things: 1) making each patient's report easily understood by the clinician so that clinical decisions may be more easily determined and 2) immediately sharing results with the patient who just completed the patient reported outcome measure. 

 What are patient seeking when they enter the rehabilitation world? I have a feeling, most want to improve either in function or in reducing pain level. Patient reported outcome measures are far more than a score. The score translates into a picture of  their functional life. I can be immediately transported into a glimpse of what it is like to live in their shoes. I can see that when they begin services how much different they are from individuals who are similar. And, due to a large database, I can even learn how much improvement is typical and what that means in how function will change.

I use the functional limitation portion of the report only for patients who have insurance requirements to report functional limitation. I really don't see value in the functional limitation codes and modifiers. If I only used that portion of the report, I know that I would be missing a great opportunity to converse with the the patient about what matters to them most.

Below you will find a quick view of the abstract.

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Aug 01, 2017 | Selena Horner

What are Considered Social Determinants of Health?

Recently National Quality Forum released findings from a two-year trial to determine if social risk factors should be risk adjusted when determining outcomes. It appears that it may not be easy to obtain social factors.

A recent article highlights not only the social determinants of health, but also the ways in which these factors can be captured within electronic health records.

The risk adjustment process is a fairly new concept when it comes to predicting health outcomes. Although the social risk factors may seem to intuitively impact outcomes, the fact is, until various statistics are performed on a very large dataset, no one will really know the amount of impact each factor may or may not have on outcomes.  Health care providers want as many variables as possible considered and included in a risk adjustment process to help level the playing field in upcoming alternative payment models focused on value.

FOTO recently analyzed an enormous amount of data to assess its risk adjustment process. The analysis led to improvement in its risk adjustment process. You can see how FOTO uses its risk adjustment process to compare and predict outcomes of care.

Below you will find a quick view of the abstract.

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Jul 31, 2017 | Selena Horner

Can Aquatic Exercises Effectively Strengthen Lower Extremities?

Short answer, "No."

If we apply what we know about specific adaptation to imposed demands, it is doubtful that the lower extremities will be challenged enough in the aquatic environment. The buoyancy of the water reduces weightbearing through the joints. Specialized pools with jets and aquatic equipment that attaches to extremities to increase resistance will provide a bit more challenge if the goal is to increase strength.

To increase strength, it is important to know the patient's one repetition maximum. After knowing that, you can then calculate the appropriate intensity the patient needs to be challenged to increase strength.

The aquatic environment can be an excellent choice for exercise. It just may not be the best environment for increasing lower extremity strength.

Below you will find a quick view of the abstract.

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Jul 30, 2017 | Selena Horner

You Can't Have Good Outcomes if Clinicians are Injured: Safe Patient Handling Strategy

I know the weight limits of all my equipment. I'm thankful that FOTO's patient specific initial intake reports provide body mass index. Patients are more obese now than they were 20 years ago. Equipment tends to have a 350 pound limit. 

I'm in the outpatient world in a private practice. The majority of my patients walk in with at most the aid of an assistive device. Lucky for me, I'm typically not lifting or transferring patients.

My heart goes out to each of you in rehabilitation settings. It can't be easy. You have patients who are less healthy than mine and will have far less functional ability. In the blink of an eye, your life can change with the lack of a patient responding with the anticipated movement pattern or due to the patient's inability to assist you.

In all honesty, you can't help your patients if you are injured. Maybe the below abstract will help some of you stay safe.

Below you will find a quick view of the abstract.

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Jul 27, 2017 | Selena Horner

Does Shared Decision Making Matter?

For me, shared decision making is somewhat of an odd concept for rehabilitation professionals. First of all, the patient has 100% control in the decision making process. They either participate or refuse to participate. They either attend their visits or cancel or no show. If what is being provided doesn't meet a patient's expectations, how often will the patient continue to attend sessions?

I don't know about you all, but if I said, "would you like to lie on this table as I massage your leg OR would you like to do some squats?" the majority of the patients would love to lie around on the table, right? I'm pretty sure that even if I chose to explain the difference in outcomes, there'd be patients that would prefer to lie on the table. 

Patients already have an idea of what they want. Take for example yesterday. Yesterday I had a 75 year old female who was a previous patient. She really, really wanted kinesiotaping of her knee, back and ankle. I was pretty confident that she was dead set on this being the answer for her. She was willing to pay out of pocket just for the taping technique. I chose to assist her with her endeavor and found a therapist with a reputable company who would provide what this lady desired.  I wasn't going to make her happy OR meet her expectations. Was it a shared decision to assist her to find what she wanted? 

In order to truly have a shared decision making process, clinicians need data that contains both a predicted outcome and the processes and interventions involved in attaining the outcome.  Clinicians don't have all the data required for a full shared decision making process.

Looking at the parameters that needed to be met, I believe it is good that they found zero studies to evaluate. I'm not sure logistically how treatment decision making AND randomized controlled trial design could realistically happen in the real world. Patients are either included in the decision making or are not. And then, if they are... if they received the interventions they agreed upon, they'd know it - the flip side: not receiving the expected intervention would also be known.

Maybe in the rehabilitation world the shared decision is the patient chose to see a rehabilitation professional versus other options?

Below you will find a quick view of the abstract.

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Jul 24, 2017 | Selena Horner

The Downside of Generic Quality of Life Assessments

I am always intrigued reading research that focuses on quality-adjusted life year and the comparative effectiveness studies.  I think it is great to  know when comparing interventions if one has a higher mortality rate or higher costs due to complications. 

The problem I have with most of these studies is the tool used to determine "quality." As the research below indicates, EQ-5D-5L is one of the patient reported outcome measures often used. Have you seen the EQ-5D-5L? The static measurement looks at 6 things.  I don't know about you, but I tend to believe my quality of life is more than just being able to walk, wipe my butt, do my usual activities, my level of pain and my level of anxiety and depression. The generic tools are just that - generic. It feels more like a screening tool.  The scoring system really isn't a score.  It's a description. A 13311 means that the person can walk around without any problem, has moderate problems with washing oneself and dressing, has moderate problems with usual activities, has no pain and has no anxiety or depression.  I don't understand how a description can be changed to an index value.  

The problem I've always had with a generic tool like the EQ-5D-5L is the generic aspect of it. Disease-specific or condition specific or region specific tools provide a far better picture of just how well a patient is functioning. There will be less ceiling and floor effects compared to the generic tool. The responsiveness  of specific tools is much greater.  

Anyways, it's good to see researchers contemplating generic versus specific patient reported outcome measures.

Below you will find a quick view of the abstract.

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Jul 23, 2017 | Selena Horner

Should Exercise Be Painful When Managing a Patient with Persistent Pain?

The pain sciences suggest graded exposure and activity pacing, along with education as part of the treatment program for individuals who have persistent pain. There are researchers who specifically study the structures in the periphery (such as tendons) and suggest for tendinopathies that the structures should be loaded. Eccentric strengthening has a bit of a painful quality to it.  It's kind of confusing, isn't it? Should the prescribed activities be painful?

I'll point out that for most patients who have persistent pain there is a high likelihood that these individuals probably do have neurological changes within their brains and may have some amount of central sensitization.  At the same time, it seems that many individuals who have an Achilles tendinopathy (as an example) have peripheral changes in their neovascular structure.  If tendinopathy is addressed via eccentric loading leading to increased discomfort is that perpetuating central sensitization within that the patient and increasing the intensity of the pain experience?

The below study attempted to address the question of whether experiencing pain during the prescribed exercises is detrimental for the patient. I don't know about some of you, but I have been known to offhandedly say with a joking inflection, "you know, I don't feel it."  It seems that the results of this study seem to indicate that it's fine for patients to experience pain.

I think what may be more relevant is defining the expectations. Think of the words patients will use to describe what they feel. If we provide the expectation of the sensations that are reasonable and expected, then the patient probably has a reduction in their level of fear. If we provide the expectation of sensations that are not reasonable, then we allow the patient to communicate that what is being experienced is not reasonable.  

Below you will find a quick view of the abstract.

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Jul 21, 2017 | Selena Horner

Quick-DASH Requires Caution with Use

The first reference I can find about the Quick-DASH is in 2001. This patient reported outcome measure is favored by many because the DASH is familiar and the Quick-DASH is shorter. Like the DASH it was was originally created as a paper and pencil tool. 

The Quick-DASH has problems.  Even though it is faster to complete, it does not meet Rasch model analysis. Of the 11 items to respond, 2 of the items have a floor effect. Most of the items have a response bias. You can trust the Quick-DASH score.

FOTO has research supporting its shoulder functional status items and computer adaptive testing.  In 2006, the number of items originally tested was 60.  Factor analysis only supported 42 of the items.  The item pool was decreased to 37 items to fit the item response theory model.  

Below you will find a quick view of the abstract about the Quick-DASH.

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Jul 19, 2017 | Selena Horner

Post Op Total Knee Arthroplasty Home Exercise Program

I realize this particular abstract outlines a future study and has no results yet. As I read the abstract it really made me wonder.

So, here in the States, most individuals are discharged from the hospital after a total knee athroplasty day 2 or 3.  In the Netherlands, it appears discharge happens day 3 or 5 post operatively.

The proposed exercise program would begin day 4 or day 6 post operatively.  I don't know about what happens across the country, but I'm amazed at the progression. In my area, if a patient has home health services, the physical therapists won't utilize or even have a patient utilize their stationary bikes or recumbent bikes. So much time and energy is spent on standing on the non-surgical side and doing marches and kick backs and hip abduction with the surgical side.  Patients will typically bring in a booklet of exercises that take the majority of their time to perform.

I need to rethink my progression. I begin to push patients to begin a walking program at the 4 week point and pushing themselves doing stairs. I suppose I'm typically worried about joint swelling. I worry about motion not occurring due to joint swelling. I need to think like the Dutch and begin to be a bit more aggressive in pushing the two activities that I have feared my whole career!

Oh... I appreciated the accelerometer-based activity sensor.  I have a feeling it will help patients be more accountable. When we can find something that gives feedback on their stretches and their progress in that area, that will be hugely helpful also.

Below you will find a quick view of the abstract.

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Jul 17, 2017 | Selena Horner

Persistent Low Back Pain: Case Study 6 visits over 3 months

The beauty of a case study lies in the description of the story.

Although case studies fall low on the evidence scale, there is so much value to be had in the description of the story. We've learned that there is a risk of glaring bias in a case study. Granted, this is a factor to keep in the back of our minds while at the same time appreciating the story and the thought processes shared.

Rehabilitation professionals are going to be challenged about the frequency of patient visits. How is the frequency determined? Because it's just that way or because certain aspects of the individual patient dictates the provided frequency of care.

What I immediately found interesting about this case study was frequency of care. Providing 6 sessions over a 3 month duration is not something typical here in the States. What I find missing is knowing the patient's ability to function prior to initiating services compared to the 3 month. Did the patient's function change?

The study highlights how fear level reduced. The Orebro Musculoskeletal Pain Questionnaire is a tool designed to predict disability and return to work.  I will presume the study used the short form Orebro.  A score of 1-50 indicates a lower risk for work disability where as 51-100 indicates a higher risk.

The take home in this study is in the methods used to address the psychosocial factors and beliefs to reduce fear level and change the risk category for work disability. Based on this case study, it doesn't appear many visits are required for the cognitive changes. Although few visits are required, the patient needs time for change to happen.  It would have been nice to see if function changed. 

Below you will find a quick view of the abstract.

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