Selecting Measures for Balance and Mobility to Improve Assessment and Treatment of Individuals After Stroke Deb A. Kegelmeyer, DPT, MS, GCS,1 Anne D. Kloos, PT, PhD, NCS,1 and Amelia B. Siles, PT, DPT, NCS1 1
Division of Physical Therapy, The Ohio State University, College of Medicine, Columbus, Ohio
Assessment of individuals with stroke using reliable and valid outcome measures is a key component of the treatment planning process. Health care professionals may have difficulty selecting balance and mobility measures given the large number of measures to choose from. This article utilizes a case-based approach to describe the benefits of using a common set of outcome measures and a process for selecting optimal measures across body structure/function, activity, and participation domains of the International Classification of Functioning, Disability and Health (ICF) model and stages of stroke recovery. Specific measures for use in acute care, rehabilitation, outpatient, and home health care settings are discussed based on StrokEDGE task force recommendations by the Neurology Section of the American Physical Therapy Association. Key words: assessment, outcome measure, stroke, test(s)
he use of outcome measures allows health care professionals to assess the individual with stroke across the continuum of care and to guide interventions. Outcome measures that are valid and reliable provide a means of measuring and communicating progress from the acute through the chronic stage and from one care setting to the next. In the acute care setting, the use of well-recognized and accepted measures provides a means of establishing a patient’s baseline status and effectively communicating this with other professionals who work with the patient. They provide a common language for comparing outcomes related to different intervention approaches. Health care facilities can determine the effectiveness of stroke care by collectively comparing care across therapists and patients. The selection of outcome measures that meet all of these goals is challenging and requires a complicated decision-making process. The measures need to be appropriate to the stage of recovery, include items that are meaningful to the individual, and are relevant to the functional goals. The measures need to be valid and reliable
T
not only in the general population, but also in the stroke population. They must be responsive to change and avoid floor or ceiling effects for the individual. Ideally, clinicians should select outcome measures that assess body structure/ function, activity, and participation components of the International Classification of Functioning, Disability and Health (ICF) model (http://www. who.int/classifications/icf/en/). When choosing outcome measures, clinicians also must consider the time to administer the test, what equipment if any is needed, whether modifications can be made (ie, use of assistive devices or physical assistance) for individuals with limited ambulatory status, and whether specific training is needed to administer the test. To enhance continuity of care, clinicians should consider whether an assessment can be used across multiple settings. It takes time and an understanding of these parameters to determine which measures meet all of these criteria. Finding time to complete this type of assessment for every measure chosen for every patient would be impossible for any given clinician.
Corresponding author: Deb Kegelmeyer, DPT, MS, GCS, Associate Clinical Professor, Division of Physical Therapy, The Ohio State University, 453 West 10th Ave, Atwell Hall 516, Columbus OH 43210; Phone: 614-292-0610, Fax: 614-292-5921, Email: [email protected].
Top Stroke Rehabil 2014;21(4):303–315 © 2014 Thomas Land Publishers, Inc. www.strokejournal.com doi: 10.1310/tsr2104-303
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There are tools to help clinicians and facilities determine which measures would be appropriate to include in their decision-making process, thus making the task of outcome measure selection less daunting. The Rehabilitation Measures Database (www.rehabmeasures.org) was developed to help clinicians and researchers identify reliable and valid instruments through assessment of each measure’s psychometric properties. This Web site includes a description of the measure, a concise description of its psychometric properties, and, when possible, a link to the outcome measure itself. The American Physical Therapy Association (APTA) Neurology Section created a task force to review outcome measures for all major areas of neurology practice, calling these reviews EDGE tools. The outcome measures in stroke were the first to be examined by the section. This review resulted in the creation of the StrokEDGE recommendations, which are published on the Neurology Section of the APTA’s Web site (http://www.neuropt.org/professionalresources/neurology-section-outcome-measuresrecommendations/stroke). The StrokEDGE task force made recommendations for outcome measures to be used in acute care and inpatient and outpatient rehabilitation settings and measures to be taught in entry-level Table 1.
StrokEDGE recommended measures
Measure 6-minute walk test 10-meter walk test Action Research Arm Test Ashworth Motor Scale Berg Balance Scale Dynamic Gait Index FIM Fugl-Meyer (Motor Performance subscale) Functional reach Goal Attainment Scale Motor Activity Log Orpington Prognostic Scale Postural Assessment Scale for Stroke Patients Stroke Impact Scale Tardieu Spasticity Scale Timed Up and Go a
physical therapy programs. Each outcome measure was rated by task force members, and a modified Delphi method was used to reach consensus using the following ratings: 4 = highly recommended (the outcome measure has excellent psychometric properties and clinical utility); 3 = recommended (the outcome measure has good psychometric properties and good clinical utility); 2 = unable to recommend at this time (there is insufficient information to support a recommendation of this outcome measure); and 1 = not recommended (the outcome measure has poor psychometric properties and/or poor clinical utility). Table 1 gives a list of highly recommended (rating of 4) measures for each category. In addition, the therapist must choose a measure that fits the individual patient. It is important to look at the items on the measure and determine whether the individual will be able to perform at least some of the items. If an individual cannot perform the items or would score a zero, it is considered a floor effect – the individual’s level of performance is lower than the level that this particular tool measures. If the individual is able to do higher level activities than the measure includes or is performing with a near perfect score, this is considered a ceiling effect – the tool is measuring performance at a lower level than the performance of this individual and therefore is not adequately
Use in acute care
Use in inpatient and outpatieint rehabilitation
X X
X X
X
Teach in entry-level physical therapy programs X X X X X X
X* X
X X
X
FIM is only recommended for use in inpatient rehabilitation settings.
X X X X X X
X X
X X X X
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measuring his or her true capabilities. Ideally outcome measures selected for each individual should have neither a floor nor a ceiling effect. As part of the Middle Class Tax Relief Act of 2012, the Centers for Medicare & Medicaid Services (CMS) will be collecting data on functional outcomes of therapy services provided to their beneficiaries. This 5-year project is to support payment reform with outcome-based data. This is strictly a data collection effort, and no other uses beyond analysis have been published. To collect the data, CMS will be requiring that claims submission forms report functional limitations through a series of G-codes (Gxxx8) and modifiers (CX) at the outset of treatment, at least every 10 visits thereafter, and at discharge. StrokEDGE measures and their StrokEDGE ratings and G-code categories are listed in Table 2. The introduction of G-codes by the CMS indicates that it recognizes the importance of functional and participation level outcomes, and it will likely continue to base payment for therapies on improvements within these categories. Other payers are likely to follow suit. Now is the time for therapists to be proactive in choosing measures that best represent these G-codes and study the validity of these measures for determining progress in each of these areas. In support of the importance of using effective, consistent outcome measures, a recent clinical practice guideline1 found that stroke centers have better outcomes than other facilities due to (a)
Table 2.
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comprehensive assessment of medical problems, body structure/function, activity, and participation and (b) early assessment and planning for discharge needs. Clearly the use of appropriate outcome measures is warranted based on the impact they have on the outcome of care. Acute Care: Choosing the Outcome Measures Table 3 shows the history and short- and longterm physical therapy goals for 2 patients, Tom and Sarah, who recently experienced ischemic strokes and are in a hospital. In acute care settings, the time for evaluations may need to be shorter to accommodate the therapists’ and patients’ schedules and to avoid excessive physical demands on patients. Body structure/function and activity measures are typically prioritized, as they are more relevant to the patients’ rehabilitation goals. Due to the limited time that most patients spend in acute care, it is important that sensitive measures or measures with relatively low minimal detectable change scores be selected to detect small but meaningful changes in function. Clinicians should also consider using outcome measures that predict future function so that interventions can be planned accordingly. Patients in acute care may exhibit severity of impairments, so it is particularly important for a clinician to know whether a test can be performed with or without assistive devices (ADs) or physical assistance.
StrokEDGE measures by setting and acuity and their G-code categories Setting
Outcome measure 6-Minute Walk Test 10-Meter Walk Test Action Research Arm Test Berg Balance Test Dynamic Gait Index Functional reach Motor Activity Log Postural Assessment Scale for Stroke Patients Stroke Impact Scale Timed Up and Go
Acuity
G-code use
Outpatient
Subacute
Chronic
4 4 3 4 4 4 4 4
4 4 3 4 4 4 4 3
4 4 3 4 4 4 4 1
4 4
4 4
4 4
Mobility: walking & moving around
Changing & maintaining body position
Carrying, moving, & handling objects
Self-care
X X X X X X X
X
X
X
X
X
X
Note: 4 = highly recommended; 3 = recommended; 2 = unable to recommend at this time; 1 = not recommended.
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Table 3.
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Case studies for acute care settings
Tom
Sarah
Health condition: 67-year-old male 4 days status post ischemic stroke
Health condition: 32-year-old female 2 days status post ischemic stroke Body structures/functions: • Decreased balance • Mild right hemiparesis; full AROM right UE and LE; decreased coordination right UE • Shortness of breath with activity Activities: • Insufficient grasp to hold objects with right hand • Independent bed mobility • All transfer and ambulatory skills require min A for balance loss • Stairs mod A for balance loss
Body structures/functions: • Right hemiplegia, 1/5 MMT grades at hip, knee and shoulder • Poor trunk control • Poor attention and initiation Activities: • Bed mobility, max A of 2 • Sitting, max A • Slideboard transfers, max A • Standing, max A of 2 • Gait/stairs: unable Short-term goals: • Roll in bed and sit up on edge of bed • Reach in sitting for eye glasses or television remote without losing balance • Transfer from bed to chair and back Long-term goals: • Stand without holding on to anything • Reach for toothbrush or comb at sink without losing balance • Walk independently to be able to ambulate in home
Short-term goals: • Walk to the hospital cafeteria to have dinner with her family without feeling tired • Go up and down flight of stairs without holding on to rail for balance Long-term goals: • Go on long walks with her dog • Go up and down stairs carrying laundry basket • Go to all of her kids’ sports and school activities • Use right hand for writing, buttoning shirts, and tying shoes
Note: AROM = active range of motion; LE = lower extremity; max A = maximal assistance; min A = minimal A; mod A = moderate assistance; MMT = Manual Muscle Test; UE = upper extremity.
Tom
Based on Tom’s short-term goals to be able to roll in bed, reach in sitting, and transfer to his bed and back, it would be important to select assessments that can capture changes in his postural control and in basic functional mobility. Two scales that assess balance and postural control that are highly recommended by the StrokEDGE task force are the Postural Assessment Scale for Stroke Patients (PASS) and the Functional Reach Test (FRT). The PASS is a 12-item activity scale designed specifically for the stroke population that assesses the ability to maintain lying, sitting, or standing postures and to move between postures (ie, supine to sitting up on edge of bed and sit to stand and stand to sit).2 It has strong responsiveness to change when administered within the first 90 days poststroke.3 Testing time is short (~10 minutes); the total possible score is 36, with higher scores indicating better performance. The FRT is a test of dynamic balance that requires a person to reach as far forward as possible in standing without moving his or her feet.4 For individuals who are not able to stand independently such as Tom, the test can be
performed in sitting (modified FRT [mFRT]).5 The test takes approximately 5 minutes to perform, and normative values in healthy adults have been published.4 Additional outcome measures to consider for Tom that were recommended by the StrokEDGE task force include the Berg Balance Scale (BBS), the Five Times Sit-to-Stand (5TSTS), the FuglMeyer Assessment of Motor Recovery After Stroke lower extremity subscale (FMA-LE), the Trunk Impairment Scale, and the Stroke Rehabilitation Assessment of Movement (STREAM). The BBS is a test of static and dynamic balance that is commonly used in the stroke population.6 The FRT is included in the test. A major concern with the use of the BBS in acute care is a floor effect.3 Individuals are not allowed to use an AD or have manual assistance when performing this test; this would prevent use of the test with Tom at this point in his recovery. However, this test may be a good choice for Tom once he is able to stand independently. The 5TSTS is a test of lower extremity strength and dynamic balance.7,8 Although little is known about the psychometric properties of this test in the stroke
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population, it would provide a quantitative measure of Tom’s ability to arise from and sit down in a chair. The PASS is a good test for measuring his ability to maintain and change postures, but it does not measure recovery of voluntary movement in the hemiparetic limbs. To measure changes in the quality of Tom’s movements of his right leg or trunk over time, the clinician may choose to use the FMA-LE subscale or the Trunk Impairment Scale, respectively. Both of these tests take a short time to perform. The FMA-LE measures lower extremity reflexes and movements in supine, sitting, and standing.9 The total possible score is 34 and a minimal detectable change score of more than 5 points has been reported.10 The Trunk Impairment Scale11 was designed to assess the motor function of the trunk after stroke and predicts Barthel Index scores at 6 months.12 An assessment tool that combines assessment of upper and lower extremity voluntary movement control and mobility is the STREAM.13 A simplified version (S-STREAM) takes less than 10 minutes to perform, which makes it practical for use in acute care settings.14 Each S-STREAM limb subscale (upper and lower extremity) has a total possible score of 10, and the mobility subscale has a total possible score of 15, with higher scores being better. Tom’s long-term goals are the ability to stand and reach and to walk independently for short distances. As Tom’s postural stability in stance improves, the FRT can be used to assess his ability to reach forward that is necessary for him to brush his teeth and comb his hair standing at the sink. If Tom progresses to being able to walk short distances, the therapist should consider using the 10-Meter Walk Test (10MWT) or the Timed Up and Go (TUG) test.15 The 10MWT assesses gait speed and can be performed with ADs and orthotics as long as it is recorded. For individuals with acute stroke (0.8 m/s to support his long-term goal of less reliance on the wheelchair. Tom’s BBS score cannot be used to predict falls; however it is likely that due to his low score, this scale will be sensitive to his expected progress. His 5TSTS score can provide a baseline for comparison with future measures obtained in home health and outpatient settings and can be compared to reference values32 obtained for healthy elderly to set therapy goals. Sarah
Sarah’s goals for inpatient rehabilitation physical therapy include discharge to home with the least amount of assistance with her mobility,
Potential measures for use in the inpatient and outpatient health care settings
Tom
Sarah
Body structures/functions: • None Activities: • 6-Minute Walk Test • 10-Meter Walk Testa: 0.3 m/s • Berg Balance Scalea: 19/56 • FIM: 54 • Modified Functional Reach Test: 10.2 cm or 4 in. • Motor Activity Log • Postural Assessment Scale for Stroke Patients: 10/36 • Timed Up and Go • 5TSTSa : 75 seconds • Functional Ambulation Category: admission = 0; discharge = 3
Body structures/functions: • None Activities: • 6-Minute Walk Test: 400 m • 10-Meter Walk Test: 1.3 m/s (comfortable speed) • Berg Balance Scale: 50/56 • FIM: 87 • Functional Reach Test: >25 cm for Berg Balance Scale and measured at 33 cm or 13 in • Motor Activity Log • Postural Assessment Scale for Stroke Patients • Timed Up and Go • Dynamic Gait Index: 18/24 • 9-Hole Peg Test • Functional Ambulation Category: admission = 3; discharge = 4 Participation: • Goal Attainment Scale • Stroke Impact Scale Length of stay: 4 days
Participation: • Goal Attainment Scale • Stroke Impact Scale Length of stay: 3 weeks
Note: Items in bold are selected tools. 5TSTS = 5 Times Sit-to-Stand Test. Not completed at admission but during stay when the prerequisite skills were achieved.
a
Selecting Measures for Balance and Mobility
self-care, home management, and in her role as a mother. Sarah has prior scores from acute care for the BBS, 6MWT, 10MWT, and the DGI. These are indicated as repeat measures on examination in inpatient rehabilitation, along with the FIM, to assess her current status in the areas of balance, endurance, and walking speed, respectively. An additional measure to consider is the TUG. Ambulation skills, including speed and turning and the sit-to-stand transfer, are inherent criteria in the 10MWT and the DGI. The only reason for performing the TUG, then, is if dual task performance is of interest. In regard to the interpretation of the results of Sarah’s outcome measures, the following conclusions can be made. Sarah continues to have endurance, speed, and balance deficits, although improvement has been noted since acute care. She is still under the same age-normal value for gait speed and median value for distance in the 6MWT. The score of 4 on the FAC is predictive of Sarah becoming ambulatory in the community by 6 months (cutoff score is 4).29 The BBS performance can inform the therapist as to what types of activities are of greatest challenge to Sarah, so these can be integrated into balance interventions. Table 7.
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Length of stay for a patient after stroke in inpatient rehabilitation varies, and therefore outcome measures may be assessed at different frequencies for each patient. Sarah’s measures were completed at admission and discharge only, whereas Tom’s stay allowed for a weekly collection of data points. With each of these frequencies, appropriate and clear documentation, with qualifying information, such as use of an AD or need for external assistance, will guide the therapist in the next level of care. Outpatient and Home Health Care: Choosing the Outcome Measures Tom is now being seen in the home for his physical and occupational therapy sessions, whereas Sarah is receiving therapy at an outpatient clinic (Table 7). The decision to choose outcome measures for individuals who come to outpatient therapy or home health care after being seen for therapy in an inpatient setting must take into account both the individual’s goals and continuity of care issues. Measures are chosen based on the patients’ presentation when they enter care and the goals that they express during the initial interview.
Case studies for the outpatient and home health care settings
Tom (home health care)
Sarah (outpatient therapy)
Health condition: 30 days status post ischemic stroke Body structures/functions: • Right hemiplegia, 2/5 MMT at hip, knee, and shoulder • Decreased trunk control • Fair attention and initiation Activities: • Independent bed mobility and transfers to bed, toilet • Ambulation with assistance for home environment • Stairs with assistance and rail to enter home
Health condition: 7 days status post ischemic stroke Body structures/functions: • Decreased dynamic balance • Mild right hemiparesis; full AROM right UE and LE
Short-term goals: • Ambulate independently in home, level surfaces, and stairs • Ambulate independently over ground and down driveway • Ambulate 200 feet without becoming short of breath Long-term goals: • Return to traveling with wife, with modifications • Return to prior fitness activities 3 times per week at community center • Engage in activities with grandchildren Length of stay: 8 weeks
Activities: • Uses right hand in gross motor skills but slow and awkward for typing and fine motor activity • All transfer and ambulatory skills independent • Stairs independent • Unable to walk on uneven, hilly ground or to kick the soccer ball with her children Short-term goals: • Go to all of her kids’ sports and school activities
Long-term goals: • Perform fine motor tasks such as typing as she did previously • Play games such as soccer and baseball in the yard with her children Length of stay: 4 weeks
Note: AROM = active range of motion; LE = lower extremity; MMT = Manual Muscle Test; UE = upper extremity.
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In addition, the initial examination will include assessments at the body structure and function level of the ICF, such as manual muscle testing and sensory testing. The therapist uses this information to determine which areas are important to address in therapy and selects outcome measures within these areas. For example, Tom is expressing a desire to regain independence in the area of activities related to gait and transfers. The therapist will then choose a measure that incorporates this domain that is valid in stroke and does not have a ceiling or floor effect for Tom. Additionally the therapist will consider issues related to continuity of care. To build on the achievements made in previous therapy and demonstrate progress, whenever possible, the same outcome measures should be used across all levels of care. With the new rules regarding electronic documentation and the portable health record, it is possible to obtain this information. The ability to measure progress across all levels of care is important to establishing the long-term benefits of therapy and justifying therapeutic interventions to payers. The 10MWT is a key measure; we have been able to monitor Tom and Sarah on this measure from very early in their care right through to the end of their care. Tom was initially unable to ambulate; Sarah was able to walk at 1.2 m/s in acute care. At this time, Tom ambulates at .6 m/s on level surfaces and Sarah ambulates at 1.8 m/s. Tom’s velocity continues to be slow and at a level that is likely to limit his ability to perform community ambulation.33,34 The 10MWT is simple and easy to do in any setting, yet it provides powerful information to the treating therapist about a patient’s potential to ambulate functionally in the community. Treatments focused on increasing safe ambulation velocity are indicated to assist in achieving Tom’s short- and long-term goals. Sarah has achieved a functional gait speed but needs to keep up with children who are able to run. Her goals are quite different than Tom’s, but they are still strongly related to her gait speed. She will be working on increasing gait velocity through learning to run in order to participate in games and activities with her children. Tom and Sarah both have difficulty with activities and participation due to deficits in balance. The
BBS is recommended for all levels of care and will provide useful information about Tom and Sarah. For Tom, the BBS will provide a measure of balance and will also measure fall risk. For Sarah, the BBS will primarily be used to measure balance outcomes. The BBS becomes a means of measuring Sarah’s progress across the course of her therapy, as it was also utilized during her inpatient stay. Electronic documentation and the portable medical record provide health care professionals with a means to track care and progress over long periods of time; therapists can use this system to better address participation level goals and to demonstrate to payers the patients’ progress and achievement of return to important life activities such as work and care of the home. Previously, it was difficult for therapists to demonstrate that longer lengths of stay in therapy lead to longterm health benefits and lower financial burden to taxpayers. The use of evidence-based measures across levels of care will now allow these outcomes to be measured. Tom is beginning to return to his roles as husband and grandfather and is becoming aware of his limitations in fulfilling these roles. The use of the Stroke Impact Scale (SIS) provides therapists with information regarding the dimensions of healthrelated quality of life: emotion, communication, memory and thinking, and social role function.35 Use of the SIS provides an assessment at the participation level of the ICF of the activities that are difficult for Tom and Sarah and the importance of these activities for them. The SIS measures areas that most therapists strive to cover during the subjective interview, and therefore therapists may not consider it to be a necessary tool. It measures the aspects of stroke recovery that are found to be important to patients and caregivers as well as stroke experts and is valid for use in individuals with mild stroke. 36 It is recommended that therapists take the extra step of using this tool, as it ensures a more thorough review of information and cues both the client and the therapist to consider a wider range of activity and participation areas than would typically be addressed in an unstructured interview. It also provides a means to quantify this information and to measure the importance of each area to each specific client. Tom may feel that
Selecting Measures for Balance and Mobility
his inability to perform social activities and to walk a block are having the largest negative impact on his ability to participate in daily life, whereas Sarah may find difficulties in performing recreational activities and walking fast to be most disabling (see excerpt in Table 8). These differences are based on individual traits such as age and family role as well as traits that are more difficult to measure, such as personality. The SIS provides a quantifiable measure of progress for both Tom and Sarah’s activity and participation level goals. Tom continues to be profoundly impacted by his stroke and has ongoing strength deficits. The use of the 5TSTS test provides a measure of lower extremity strength and function that is quantifiable and reproducible across time and across different therapists. A goal for Tom would be to regain the ability to do the 5 times sit to stand within age-matched normed time, less than 13 seconds.37 This should translate to improvements in strength and motor control in the lower extremities and to improvements in function and participation, such as the ability to safely and easily sit in and rise from a folding chair at his grandchild’s soccer game. Sarah has indicated more difficulty with fine-motor hand function. This would likely be best handled by occupational therapy. Use of the 9-Hole Peg Test would provide the therapist with a good baseline Table 8.
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measure and may help to determine whether or not a referral to occupational therapy would be beneficial. Sarah should be able to perform the 9-Hole Peg Test in 16.7 seconds but is taking 32 seconds, indicating the need for continued occupational therapy.38 Sarah’s goals in outpatient therapy are primarily at the participation level. There are few good measures at this level. The Goal Attainment Scale provides a valid and reliable means to measure improvement at the individual level.40 Sarah and her therapist will set goals that are meaningful to Sarah, and they will determine how each of those goals will be measured. They will then measure progress toward her participation with these goals. Although this measure is not made up of a predetermined set of items, it has been shown to provide a valid measure of progress that has good inter- and intrarater reliability. 39 If the goal of therapy is to return each individual to their previous level of function at the participation level, then therapists and payers alike are going to need to adopt measures that are individualized while remaining valid and reliable, such as the Goal Attainment Scale. Acknowledgments The authors declare no conflicts of interest.
Potential measures for use in the outpatient and home health care settings
Tom
Sarah
Body structures/functions: • None Activity: • 6-Minute Walk Test • 10-Meter Walk Test: 0.6 m/s • Berg Balance Scale: 45/56 • Functional Reach Test • Motor Activity Log • Postural Assessment Scale for Stroke Patients • Timed Up and Go • 5 Times Sit-to-Stand Test: 60 seconds Participation: • Goal Attainment Scale • Stroke Impact Scale–Tom rates himself as having only a little strength and says he could not walk fast at all. He says that he has been able to do quiet recreational activities but could not participate in his role as a family member at all.
Body structures/functions: • None Activity: • 6 Minute Walk Test: 510 m • 10 Meter Walk Test: 1.8 m/s • Berg Balance Scale: 54/56 • Functional Reach Test • Motor Activity Log • Postural Assessment Scale for Stroke Patients • Timed Up and Go • 5 Times Sit-to-Stand Test Participation: • Goal Attainment Scale: goals for sports and running • Stroke Impact Scale–Sarah rates herself as having some strength and says it is not difficult at all to walk a block and do transfers. She rates participation in quiet recreation and social activities as being limited most of the time.
Note: Items in bold are selected tools.
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acute stroke. Arch Phys Med Rehabil. 2001; 82(9): 1204-1212. Kosak M, Smith T. Comparison of the 2-, 6-, and 12-minute walk tests in patients with stroke. J Rehabil Res Dev. 2005; 42(1):103-107. Kalra L, Crome P. The role of prognostic scores in targeting stroke rehabilitation in elderly patients. J Am Geriatr Soc. 1993;41(4):396-400. Pittock SJ, Meldrum D, Ni Dhuill C, Hardiman O, Moroney JT. The Orpington Prognostic Scale within the first 48 hours of admission as a predictor of outcome in ischemic stroke. J Stroke Cerebrovasc Dis. 2003;12:175-181. Enright PL. The six-minute walk test. Respir Care. 2003;48(8):783-785. Bowden MG, Balasubramanian CK, Behrman AL, Kautz SA. Validation of a speed-based classification system using quantitative measures of walking performance poststroke. Neurorehabil Neural Repair. 2008;22(6):672-675. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in communitydwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903. Wrisley DM, Walker ML, Echternach JL, Strasnick B. Reliability of the Dynamic Gait Index in people with vestibular disorders. Arch Phys Med Rehabil. 2003;84(10):1528-1533. Shumway-Cook A, Horak FB. Assessing the influence of sensory integration on balance. Suggestions from the field. Phys Ther. 1986;66:1548-1549. Bohannon RW. Comfortable and maximum walking speed of adults aged 20-79 years: Reference values and determinants. Age Ageing. 1997;26(1):15-19. Reistetter TA, Graham JE, Deutsch A, et al. Utility of functional status for classifying community versus institutional discharges after inpatient rehabilitation for stroke. Arch Phys Med Rehabil. 2010;91:345-350. Chumney D, Nollinger K, Shesko K, et al. Ability of functional independence measure to accurately predict functional outcome of stroke-specific population: Systematic review. J Rehabil Res Dev. 2010;47:17-30. Holden MK, Gill KM, Magliozzi MR. Gait assessment for neurologically impaired patients. Standards for outcome assessment. Phys Ther. 1986;66:1530-1539. Mehrholz J, Wagner K, Rutte K, et al. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007;88:1314-1319. Tur BS, Gursel YK, Yavuzer G, Kucukdeveci A, Arasil T. Rehabilitation outcome of Turkish stroke patients in a team approach setting. Int J Rehabil Res. 2003;26(4):271-277. Beninato M, Gill-Body KM, Salles S, Stark PC, Black-Schaffer RM, Stein J. Determination of the minimal clinically important difference in the FIM instrument in patients with stroke. Arch Phys Med Rehabil. 2006;87:32-39.
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32. Bohannon RW. Reference values for the fiverepetition sit-to-stand test: A descriptive metaanalysis of data from elders. Percept Mot Skills. 2006;103(1):215-222. 33. Schmid A, Duncan PW, Studenski S, et al. Improvements in speed-based gait classifications are meaningful. Stroke. 2007;38(7):2096-2100. 34. Bijleveld-Uitman M, van de Port I, Kwakkel G. Is gait speed or walking distance a better predictor for community walking after stroke? J Rehabil Med. 2013;45(6):535-540. 35. Duncan PW, Wallace D, Lai SM, Johnson D, Embretson S, Laster LJ. The Stroke Impact Scale version 2.0. Evaluation of reliability, validity, and sensitivity to change. Stroke. 1999;(30)10:2131-2140. 36. Lai SM, Studenski S, Duncan PW, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke. 2002;33(7):1840-1844. 37. Guralnik J, Simonsick E, Ferrucci L, et al. A short physical performance battery assessing
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lower extremity function: Association with selfreported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2): M85-M94. Grice K, Vogel KA, Le V, Mitchell A, Muniz S, Vollmer MA. Adult norms for a commercially available Nine Hole Peg Test for finger dexterity. Am J Occup Ther. 2003;57(5):570-573. Brock K, Black S, Cotton S, et al. Goal achievement in the six months after inpatient rehabilitation for stroke. Disabil Rehabil. 2009;31:880-886. Turner-Stokes L, Williams H, Johnson J. Goal attainment scaling: Does it provide added value as a person-centered measure for evaluation of outcome in neurorehabilitation following acquired brain injury? J Rehabil Med. 2009;41:528-535. Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998;158:1384–1387.
Division of Physical Therapy, The Ohio State University, College of Medicine, Columbus, Ohio
Assessment of individuals with stroke using reliable and valid outcome measures is a key component of the treatment planning process. Health care professionals may have difficulty selecting balance and mobility measures given the large number of measures to choose from. This article utilizes a case-based approach to describe the benefits of using a common set of outcome measures and a process for selecting optimal measures across body structure/function, activity, and participation domains of the International Classification of Functioning, Disability and Health (ICF) model and stages of stroke recovery. Specific measures for use in acute care, rehabilitation, outpatient, and home health care settings are discussed based on StrokEDGE task force recommendations by the Neurology Section of the American Physical Therapy Association. Key words: assessment, outcome measure, stroke, test(s)
he use of outcome measures allows health care professionals to assess the individual with stroke across the continuum of care and to guide interventions. Outcome measures that are valid and reliable provide a means of measuring and communicating progress from the acute through the chronic stage and from one care setting to the next. In the acute care setting, the use of well-recognized and accepted measures provides a means of establishing a patient’s baseline status and effectively communicating this with other professionals who work with the patient. They provide a common language for comparing outcomes related to different intervention approaches. Health care facilities can determine the effectiveness of stroke care by collectively comparing care across therapists and patients. The selection of outcome measures that meet all of these goals is challenging and requires a complicated decision-making process. The measures need to be appropriate to the stage of recovery, include items that are meaningful to the individual, and are relevant to the functional goals. The measures need to be valid and reliable
T
not only in the general population, but also in the stroke population. They must be responsive to change and avoid floor or ceiling effects for the individual. Ideally, clinicians should select outcome measures that assess body structure/ function, activity, and participation components of the International Classification of Functioning, Disability and Health (ICF) model (http://www. who.int/classifications/icf/en/). When choosing outcome measures, clinicians also must consider the time to administer the test, what equipment if any is needed, whether modifications can be made (ie, use of assistive devices or physical assistance) for individuals with limited ambulatory status, and whether specific training is needed to administer the test. To enhance continuity of care, clinicians should consider whether an assessment can be used across multiple settings. It takes time and an understanding of these parameters to determine which measures meet all of these criteria. Finding time to complete this type of assessment for every measure chosen for every patient would be impossible for any given clinician.
Corresponding author: Deb Kegelmeyer, DPT, MS, GCS, Associate Clinical Professor, Division of Physical Therapy, The Ohio State University, 453 West 10th Ave, Atwell Hall 516, Columbus OH 43210; Phone: 614-292-0610, Fax: 614-292-5921, Email: [email protected].
Top Stroke Rehabil 2014;21(4):303–315 © 2014 Thomas Land Publishers, Inc. www.strokejournal.com doi: 10.1310/tsr2104-303
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There are tools to help clinicians and facilities determine which measures would be appropriate to include in their decision-making process, thus making the task of outcome measure selection less daunting. The Rehabilitation Measures Database (www.rehabmeasures.org) was developed to help clinicians and researchers identify reliable and valid instruments through assessment of each measure’s psychometric properties. This Web site includes a description of the measure, a concise description of its psychometric properties, and, when possible, a link to the outcome measure itself. The American Physical Therapy Association (APTA) Neurology Section created a task force to review outcome measures for all major areas of neurology practice, calling these reviews EDGE tools. The outcome measures in stroke were the first to be examined by the section. This review resulted in the creation of the StrokEDGE recommendations, which are published on the Neurology Section of the APTA’s Web site (http://www.neuropt.org/professionalresources/neurology-section-outcome-measuresrecommendations/stroke). The StrokEDGE task force made recommendations for outcome measures to be used in acute care and inpatient and outpatient rehabilitation settings and measures to be taught in entry-level Table 1.
StrokEDGE recommended measures
Measure 6-minute walk test 10-meter walk test Action Research Arm Test Ashworth Motor Scale Berg Balance Scale Dynamic Gait Index FIM Fugl-Meyer (Motor Performance subscale) Functional reach Goal Attainment Scale Motor Activity Log Orpington Prognostic Scale Postural Assessment Scale for Stroke Patients Stroke Impact Scale Tardieu Spasticity Scale Timed Up and Go a
physical therapy programs. Each outcome measure was rated by task force members, and a modified Delphi method was used to reach consensus using the following ratings: 4 = highly recommended (the outcome measure has excellent psychometric properties and clinical utility); 3 = recommended (the outcome measure has good psychometric properties and good clinical utility); 2 = unable to recommend at this time (there is insufficient information to support a recommendation of this outcome measure); and 1 = not recommended (the outcome measure has poor psychometric properties and/or poor clinical utility). Table 1 gives a list of highly recommended (rating of 4) measures for each category. In addition, the therapist must choose a measure that fits the individual patient. It is important to look at the items on the measure and determine whether the individual will be able to perform at least some of the items. If an individual cannot perform the items or would score a zero, it is considered a floor effect – the individual’s level of performance is lower than the level that this particular tool measures. If the individual is able to do higher level activities than the measure includes or is performing with a near perfect score, this is considered a ceiling effect – the tool is measuring performance at a lower level than the performance of this individual and therefore is not adequately
Use in acute care
Use in inpatient and outpatieint rehabilitation
X X
X X
X
Teach in entry-level physical therapy programs X X X X X X
X* X
X X
X
FIM is only recommended for use in inpatient rehabilitation settings.
X X X X X X
X X
X X X X
Selecting Measures for Balance and Mobility
measuring his or her true capabilities. Ideally outcome measures selected for each individual should have neither a floor nor a ceiling effect. As part of the Middle Class Tax Relief Act of 2012, the Centers for Medicare & Medicaid Services (CMS) will be collecting data on functional outcomes of therapy services provided to their beneficiaries. This 5-year project is to support payment reform with outcome-based data. This is strictly a data collection effort, and no other uses beyond analysis have been published. To collect the data, CMS will be requiring that claims submission forms report functional limitations through a series of G-codes (Gxxx8) and modifiers (CX) at the outset of treatment, at least every 10 visits thereafter, and at discharge. StrokEDGE measures and their StrokEDGE ratings and G-code categories are listed in Table 2. The introduction of G-codes by the CMS indicates that it recognizes the importance of functional and participation level outcomes, and it will likely continue to base payment for therapies on improvements within these categories. Other payers are likely to follow suit. Now is the time for therapists to be proactive in choosing measures that best represent these G-codes and study the validity of these measures for determining progress in each of these areas. In support of the importance of using effective, consistent outcome measures, a recent clinical practice guideline1 found that stroke centers have better outcomes than other facilities due to (a)
Table 2.
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comprehensive assessment of medical problems, body structure/function, activity, and participation and (b) early assessment and planning for discharge needs. Clearly the use of appropriate outcome measures is warranted based on the impact they have on the outcome of care. Acute Care: Choosing the Outcome Measures Table 3 shows the history and short- and longterm physical therapy goals for 2 patients, Tom and Sarah, who recently experienced ischemic strokes and are in a hospital. In acute care settings, the time for evaluations may need to be shorter to accommodate the therapists’ and patients’ schedules and to avoid excessive physical demands on patients. Body structure/function and activity measures are typically prioritized, as they are more relevant to the patients’ rehabilitation goals. Due to the limited time that most patients spend in acute care, it is important that sensitive measures or measures with relatively low minimal detectable change scores be selected to detect small but meaningful changes in function. Clinicians should also consider using outcome measures that predict future function so that interventions can be planned accordingly. Patients in acute care may exhibit severity of impairments, so it is particularly important for a clinician to know whether a test can be performed with or without assistive devices (ADs) or physical assistance.
StrokEDGE measures by setting and acuity and their G-code categories Setting
Outcome measure 6-Minute Walk Test 10-Meter Walk Test Action Research Arm Test Berg Balance Test Dynamic Gait Index Functional reach Motor Activity Log Postural Assessment Scale for Stroke Patients Stroke Impact Scale Timed Up and Go
Acuity
G-code use
Outpatient
Subacute
Chronic
4 4 3 4 4 4 4 4
4 4 3 4 4 4 4 3
4 4 3 4 4 4 4 1
4 4
4 4
4 4
Mobility: walking & moving around
Changing & maintaining body position
Carrying, moving, & handling objects
Self-care
X X X X X X X
X
X
X
X
X
X
Note: 4 = highly recommended; 3 = recommended; 2 = unable to recommend at this time; 1 = not recommended.
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Table 3.
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Case studies for acute care settings
Tom
Sarah
Health condition: 67-year-old male 4 days status post ischemic stroke
Health condition: 32-year-old female 2 days status post ischemic stroke Body structures/functions: • Decreased balance • Mild right hemiparesis; full AROM right UE and LE; decreased coordination right UE • Shortness of breath with activity Activities: • Insufficient grasp to hold objects with right hand • Independent bed mobility • All transfer and ambulatory skills require min A for balance loss • Stairs mod A for balance loss
Body structures/functions: • Right hemiplegia, 1/5 MMT grades at hip, knee and shoulder • Poor trunk control • Poor attention and initiation Activities: • Bed mobility, max A of 2 • Sitting, max A • Slideboard transfers, max A • Standing, max A of 2 • Gait/stairs: unable Short-term goals: • Roll in bed and sit up on edge of bed • Reach in sitting for eye glasses or television remote without losing balance • Transfer from bed to chair and back Long-term goals: • Stand without holding on to anything • Reach for toothbrush or comb at sink without losing balance • Walk independently to be able to ambulate in home
Short-term goals: • Walk to the hospital cafeteria to have dinner with her family without feeling tired • Go up and down flight of stairs without holding on to rail for balance Long-term goals: • Go on long walks with her dog • Go up and down stairs carrying laundry basket • Go to all of her kids’ sports and school activities • Use right hand for writing, buttoning shirts, and tying shoes
Note: AROM = active range of motion; LE = lower extremity; max A = maximal assistance; min A = minimal A; mod A = moderate assistance; MMT = Manual Muscle Test; UE = upper extremity.
Tom
Based on Tom’s short-term goals to be able to roll in bed, reach in sitting, and transfer to his bed and back, it would be important to select assessments that can capture changes in his postural control and in basic functional mobility. Two scales that assess balance and postural control that are highly recommended by the StrokEDGE task force are the Postural Assessment Scale for Stroke Patients (PASS) and the Functional Reach Test (FRT). The PASS is a 12-item activity scale designed specifically for the stroke population that assesses the ability to maintain lying, sitting, or standing postures and to move between postures (ie, supine to sitting up on edge of bed and sit to stand and stand to sit).2 It has strong responsiveness to change when administered within the first 90 days poststroke.3 Testing time is short (~10 minutes); the total possible score is 36, with higher scores indicating better performance. The FRT is a test of dynamic balance that requires a person to reach as far forward as possible in standing without moving his or her feet.4 For individuals who are not able to stand independently such as Tom, the test can be
performed in sitting (modified FRT [mFRT]).5 The test takes approximately 5 minutes to perform, and normative values in healthy adults have been published.4 Additional outcome measures to consider for Tom that were recommended by the StrokEDGE task force include the Berg Balance Scale (BBS), the Five Times Sit-to-Stand (5TSTS), the FuglMeyer Assessment of Motor Recovery After Stroke lower extremity subscale (FMA-LE), the Trunk Impairment Scale, and the Stroke Rehabilitation Assessment of Movement (STREAM). The BBS is a test of static and dynamic balance that is commonly used in the stroke population.6 The FRT is included in the test. A major concern with the use of the BBS in acute care is a floor effect.3 Individuals are not allowed to use an AD or have manual assistance when performing this test; this would prevent use of the test with Tom at this point in his recovery. However, this test may be a good choice for Tom once he is able to stand independently. The 5TSTS is a test of lower extremity strength and dynamic balance.7,8 Although little is known about the psychometric properties of this test in the stroke
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population, it would provide a quantitative measure of Tom’s ability to arise from and sit down in a chair. The PASS is a good test for measuring his ability to maintain and change postures, but it does not measure recovery of voluntary movement in the hemiparetic limbs. To measure changes in the quality of Tom’s movements of his right leg or trunk over time, the clinician may choose to use the FMA-LE subscale or the Trunk Impairment Scale, respectively. Both of these tests take a short time to perform. The FMA-LE measures lower extremity reflexes and movements in supine, sitting, and standing.9 The total possible score is 34 and a minimal detectable change score of more than 5 points has been reported.10 The Trunk Impairment Scale11 was designed to assess the motor function of the trunk after stroke and predicts Barthel Index scores at 6 months.12 An assessment tool that combines assessment of upper and lower extremity voluntary movement control and mobility is the STREAM.13 A simplified version (S-STREAM) takes less than 10 minutes to perform, which makes it practical for use in acute care settings.14 Each S-STREAM limb subscale (upper and lower extremity) has a total possible score of 10, and the mobility subscale has a total possible score of 15, with higher scores being better. Tom’s long-term goals are the ability to stand and reach and to walk independently for short distances. As Tom’s postural stability in stance improves, the FRT can be used to assess his ability to reach forward that is necessary for him to brush his teeth and comb his hair standing at the sink. If Tom progresses to being able to walk short distances, the therapist should consider using the 10-Meter Walk Test (10MWT) or the Timed Up and Go (TUG) test.15 The 10MWT assesses gait speed and can be performed with ADs and orthotics as long as it is recorded. For individuals with acute stroke (0.8 m/s to support his long-term goal of less reliance on the wheelchair. Tom’s BBS score cannot be used to predict falls; however it is likely that due to his low score, this scale will be sensitive to his expected progress. His 5TSTS score can provide a baseline for comparison with future measures obtained in home health and outpatient settings and can be compared to reference values32 obtained for healthy elderly to set therapy goals. Sarah
Sarah’s goals for inpatient rehabilitation physical therapy include discharge to home with the least amount of assistance with her mobility,
Potential measures for use in the inpatient and outpatient health care settings
Tom
Sarah
Body structures/functions: • None Activities: • 6-Minute Walk Test • 10-Meter Walk Testa: 0.3 m/s • Berg Balance Scalea: 19/56 • FIM: 54 • Modified Functional Reach Test: 10.2 cm or 4 in. • Motor Activity Log • Postural Assessment Scale for Stroke Patients: 10/36 • Timed Up and Go • 5TSTSa : 75 seconds • Functional Ambulation Category: admission = 0; discharge = 3
Body structures/functions: • None Activities: • 6-Minute Walk Test: 400 m • 10-Meter Walk Test: 1.3 m/s (comfortable speed) • Berg Balance Scale: 50/56 • FIM: 87 • Functional Reach Test: >25 cm for Berg Balance Scale and measured at 33 cm or 13 in • Motor Activity Log • Postural Assessment Scale for Stroke Patients • Timed Up and Go • Dynamic Gait Index: 18/24 • 9-Hole Peg Test • Functional Ambulation Category: admission = 3; discharge = 4 Participation: • Goal Attainment Scale • Stroke Impact Scale Length of stay: 4 days
Participation: • Goal Attainment Scale • Stroke Impact Scale Length of stay: 3 weeks
Note: Items in bold are selected tools. 5TSTS = 5 Times Sit-to-Stand Test. Not completed at admission but during stay when the prerequisite skills were achieved.
a
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self-care, home management, and in her role as a mother. Sarah has prior scores from acute care for the BBS, 6MWT, 10MWT, and the DGI. These are indicated as repeat measures on examination in inpatient rehabilitation, along with the FIM, to assess her current status in the areas of balance, endurance, and walking speed, respectively. An additional measure to consider is the TUG. Ambulation skills, including speed and turning and the sit-to-stand transfer, are inherent criteria in the 10MWT and the DGI. The only reason for performing the TUG, then, is if dual task performance is of interest. In regard to the interpretation of the results of Sarah’s outcome measures, the following conclusions can be made. Sarah continues to have endurance, speed, and balance deficits, although improvement has been noted since acute care. She is still under the same age-normal value for gait speed and median value for distance in the 6MWT. The score of 4 on the FAC is predictive of Sarah becoming ambulatory in the community by 6 months (cutoff score is 4).29 The BBS performance can inform the therapist as to what types of activities are of greatest challenge to Sarah, so these can be integrated into balance interventions. Table 7.
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Length of stay for a patient after stroke in inpatient rehabilitation varies, and therefore outcome measures may be assessed at different frequencies for each patient. Sarah’s measures were completed at admission and discharge only, whereas Tom’s stay allowed for a weekly collection of data points. With each of these frequencies, appropriate and clear documentation, with qualifying information, such as use of an AD or need for external assistance, will guide the therapist in the next level of care. Outpatient and Home Health Care: Choosing the Outcome Measures Tom is now being seen in the home for his physical and occupational therapy sessions, whereas Sarah is receiving therapy at an outpatient clinic (Table 7). The decision to choose outcome measures for individuals who come to outpatient therapy or home health care after being seen for therapy in an inpatient setting must take into account both the individual’s goals and continuity of care issues. Measures are chosen based on the patients’ presentation when they enter care and the goals that they express during the initial interview.
Case studies for the outpatient and home health care settings
Tom (home health care)
Sarah (outpatient therapy)
Health condition: 30 days status post ischemic stroke Body structures/functions: • Right hemiplegia, 2/5 MMT at hip, knee, and shoulder • Decreased trunk control • Fair attention and initiation Activities: • Independent bed mobility and transfers to bed, toilet • Ambulation with assistance for home environment • Stairs with assistance and rail to enter home
Health condition: 7 days status post ischemic stroke Body structures/functions: • Decreased dynamic balance • Mild right hemiparesis; full AROM right UE and LE
Short-term goals: • Ambulate independently in home, level surfaces, and stairs • Ambulate independently over ground and down driveway • Ambulate 200 feet without becoming short of breath Long-term goals: • Return to traveling with wife, with modifications • Return to prior fitness activities 3 times per week at community center • Engage in activities with grandchildren Length of stay: 8 weeks
Activities: • Uses right hand in gross motor skills but slow and awkward for typing and fine motor activity • All transfer and ambulatory skills independent • Stairs independent • Unable to walk on uneven, hilly ground or to kick the soccer ball with her children Short-term goals: • Go to all of her kids’ sports and school activities
Long-term goals: • Perform fine motor tasks such as typing as she did previously • Play games such as soccer and baseball in the yard with her children Length of stay: 4 weeks
Note: AROM = active range of motion; LE = lower extremity; MMT = Manual Muscle Test; UE = upper extremity.
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In addition, the initial examination will include assessments at the body structure and function level of the ICF, such as manual muscle testing and sensory testing. The therapist uses this information to determine which areas are important to address in therapy and selects outcome measures within these areas. For example, Tom is expressing a desire to regain independence in the area of activities related to gait and transfers. The therapist will then choose a measure that incorporates this domain that is valid in stroke and does not have a ceiling or floor effect for Tom. Additionally the therapist will consider issues related to continuity of care. To build on the achievements made in previous therapy and demonstrate progress, whenever possible, the same outcome measures should be used across all levels of care. With the new rules regarding electronic documentation and the portable health record, it is possible to obtain this information. The ability to measure progress across all levels of care is important to establishing the long-term benefits of therapy and justifying therapeutic interventions to payers. The 10MWT is a key measure; we have been able to monitor Tom and Sarah on this measure from very early in their care right through to the end of their care. Tom was initially unable to ambulate; Sarah was able to walk at 1.2 m/s in acute care. At this time, Tom ambulates at .6 m/s on level surfaces and Sarah ambulates at 1.8 m/s. Tom’s velocity continues to be slow and at a level that is likely to limit his ability to perform community ambulation.33,34 The 10MWT is simple and easy to do in any setting, yet it provides powerful information to the treating therapist about a patient’s potential to ambulate functionally in the community. Treatments focused on increasing safe ambulation velocity are indicated to assist in achieving Tom’s short- and long-term goals. Sarah has achieved a functional gait speed but needs to keep up with children who are able to run. Her goals are quite different than Tom’s, but they are still strongly related to her gait speed. She will be working on increasing gait velocity through learning to run in order to participate in games and activities with her children. Tom and Sarah both have difficulty with activities and participation due to deficits in balance. The
BBS is recommended for all levels of care and will provide useful information about Tom and Sarah. For Tom, the BBS will provide a measure of balance and will also measure fall risk. For Sarah, the BBS will primarily be used to measure balance outcomes. The BBS becomes a means of measuring Sarah’s progress across the course of her therapy, as it was also utilized during her inpatient stay. Electronic documentation and the portable medical record provide health care professionals with a means to track care and progress over long periods of time; therapists can use this system to better address participation level goals and to demonstrate to payers the patients’ progress and achievement of return to important life activities such as work and care of the home. Previously, it was difficult for therapists to demonstrate that longer lengths of stay in therapy lead to longterm health benefits and lower financial burden to taxpayers. The use of evidence-based measures across levels of care will now allow these outcomes to be measured. Tom is beginning to return to his roles as husband and grandfather and is becoming aware of his limitations in fulfilling these roles. The use of the Stroke Impact Scale (SIS) provides therapists with information regarding the dimensions of healthrelated quality of life: emotion, communication, memory and thinking, and social role function.35 Use of the SIS provides an assessment at the participation level of the ICF of the activities that are difficult for Tom and Sarah and the importance of these activities for them. The SIS measures areas that most therapists strive to cover during the subjective interview, and therefore therapists may not consider it to be a necessary tool. It measures the aspects of stroke recovery that are found to be important to patients and caregivers as well as stroke experts and is valid for use in individuals with mild stroke. 36 It is recommended that therapists take the extra step of using this tool, as it ensures a more thorough review of information and cues both the client and the therapist to consider a wider range of activity and participation areas than would typically be addressed in an unstructured interview. It also provides a means to quantify this information and to measure the importance of each area to each specific client. Tom may feel that
Selecting Measures for Balance and Mobility
his inability to perform social activities and to walk a block are having the largest negative impact on his ability to participate in daily life, whereas Sarah may find difficulties in performing recreational activities and walking fast to be most disabling (see excerpt in Table 8). These differences are based on individual traits such as age and family role as well as traits that are more difficult to measure, such as personality. The SIS provides a quantifiable measure of progress for both Tom and Sarah’s activity and participation level goals. Tom continues to be profoundly impacted by his stroke and has ongoing strength deficits. The use of the 5TSTS test provides a measure of lower extremity strength and function that is quantifiable and reproducible across time and across different therapists. A goal for Tom would be to regain the ability to do the 5 times sit to stand within age-matched normed time, less than 13 seconds.37 This should translate to improvements in strength and motor control in the lower extremities and to improvements in function and participation, such as the ability to safely and easily sit in and rise from a folding chair at his grandchild’s soccer game. Sarah has indicated more difficulty with fine-motor hand function. This would likely be best handled by occupational therapy. Use of the 9-Hole Peg Test would provide the therapist with a good baseline Table 8.
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measure and may help to determine whether or not a referral to occupational therapy would be beneficial. Sarah should be able to perform the 9-Hole Peg Test in 16.7 seconds but is taking 32 seconds, indicating the need for continued occupational therapy.38 Sarah’s goals in outpatient therapy are primarily at the participation level. There are few good measures at this level. The Goal Attainment Scale provides a valid and reliable means to measure improvement at the individual level.40 Sarah and her therapist will set goals that are meaningful to Sarah, and they will determine how each of those goals will be measured. They will then measure progress toward her participation with these goals. Although this measure is not made up of a predetermined set of items, it has been shown to provide a valid measure of progress that has good inter- and intrarater reliability. 39 If the goal of therapy is to return each individual to their previous level of function at the participation level, then therapists and payers alike are going to need to adopt measures that are individualized while remaining valid and reliable, such as the Goal Attainment Scale. Acknowledgments The authors declare no conflicts of interest.
Potential measures for use in the outpatient and home health care settings
Tom
Sarah
Body structures/functions: • None Activity: • 6-Minute Walk Test • 10-Meter Walk Test: 0.6 m/s • Berg Balance Scale: 45/56 • Functional Reach Test • Motor Activity Log • Postural Assessment Scale for Stroke Patients • Timed Up and Go • 5 Times Sit-to-Stand Test: 60 seconds Participation: • Goal Attainment Scale • Stroke Impact Scale–Tom rates himself as having only a little strength and says he could not walk fast at all. He says that he has been able to do quiet recreational activities but could not participate in his role as a family member at all.
Body structures/functions: • None Activity: • 6 Minute Walk Test: 510 m • 10 Meter Walk Test: 1.8 m/s • Berg Balance Scale: 54/56 • Functional Reach Test • Motor Activity Log • Postural Assessment Scale for Stroke Patients • Timed Up and Go • 5 Times Sit-to-Stand Test Participation: • Goal Attainment Scale: goals for sports and running • Stroke Impact Scale–Sarah rates herself as having some strength and says it is not difficult at all to walk a block and do transfers. She rates participation in quiet recreation and social activities as being limited most of the time.
Note: Items in bold are selected tools.
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