Introduction
An Outcome Measure is a test used to objectively determine baseline function of an individual at the beginning of treatment. Once treatment has commenced, the same instrument can be used to determine progress and treatment efficacy. With the move towards Evidence Based Practice (EBP), objective measures of outcome are important to provide credible and reliable justification for treatment. The instrument should also be convenient to apply for the therapist and comfortable for the individual.
Measuring the effectiveness of interventions is accepted as being central to good practice. An integral part of evaluating clinical practice is to objectively assess the intervention and measure it against a set of outcomes to determine its efficacy. For results to be meaningful, it is imperative that any measures used to assess outcomes in any health care context cover domains (for example pain, physical function, perceived independence) that are relatively specific and appropriate to both the particular context and population that you are working with and have acceptable measurement properties, including: reliability, validity, responsiveness, acceptability and feasibility specific to that population. [1][2]
There has been an increased focus on outcome measurement in the field of spinal cord injury, with creation of common definitions and data sets to ensure that information being collected is both valid and accurate with consistent recording of both clinical and research information. Despite increased use of validated outcome and more frequent assessment, there is still a broad range of outcome measures being used that limits the ability to compare findings from centre to centre or client to client, which has an impact on identification and implementation of best practice. This page presents the best available information on how outcome measures for spinal cord injury might be classified and selected for use, based upon their measurement qualities incorporating the most recent consensus recommendations. [3][4]
SCI EDGE Task Force Recommended Outcome Measures
The SCI EDGE Task Force reviewed 63 outcome measures covering the range of body structure and function, activities and participation evaluating each for psychometrics and clinical utility for individuals with a Spinal Cord Injury. Through literature review, analysis, and a modified Delphi Procedure, recommendations were formulated for outcome measures that are highly recommended for use in individuals with Spinal Cord Injury during each phase of treatment and for each type of injury, with a summary for each of these outcome measures updated or added to the [4]
- 20 measures were recommended or highly recommended for both complete and incomplete spinal cord injury
- 14 measures were recommended or highly recommended for at least 2 levels of acuity
- 23 measures were recommended for use in physiotherapy education
- 32 measures were recommended for use in spinal cord injury research
Results also revealed a number of underrepresented areas. In the Body Structure and Function Domain of the International Classification of Functioning, Disability, and Health, none of the measures for tone or cardiovascular function could be recommended secondary to insufficient research specific to the spinal cord injury population to support a stronger recommendation. Similarly in the Activity Domain, balance, upper limb function, and wheelchair skills were also underrepresented with only 1 of 7 balance measures (ie, Berg Balance Scale) and 2 of 9 upper limb function measures (ie, the Capabilities of Upper Extremity Functioning and the Graded and Redefined Assessment of Sensibility, Strength, and Prehension) receiving a “Recommended” rating. Finally in the Participation Domain, all measures that achieved a “Recommended” or “Highly Recommended” rating in at least 3 of the 5 categories were patient- reported outcomes measuring domains of quality of life, community function, health and wellness, and environmental factors, which all displayed extensive psychometric data available in the chronic spinal cord injury population, but only one recommended in the acute spinal cord injury population, (the Needs Assessment Check-list), as such the Participation-level Outcome Measures are most appropriate to be used in the chronic spinal cord injury population. [4]
Phase of Treatment
Overall 14 measures were recommended or highly recommended for at least 2 levels of acuity providing the ability to compare progress over a longer period of time and covering a number of domains of the International Classification of Functioning, Disability, and Health. The acute spinal cord injury category had a total of 6 “Highly Recommended” Outcome Measures and 7 “Recommended” Outcome Measures in comparison with the chronic spinal cord injury category, which had a total of 6 “Highly Recommended” Outcome Measures and 19 “Recommended” Outcome Measures. Limited research in acute spinal cord injury (0 – 3 months) meant fewer measures could be recommended during this phase of injury. In particular in relation to quality of life and upper limb function were areas in which no recommendations could be made, despite the importance of both areas and have been identified as a need for further research and development. [4]
ASIA Impairment Scale Level
Overall 20 measures were given a rating of “Recommended” or “Highly Recommended” in both incomplete and complete spinal cord injury categories including measures covering the Body Structure and Function, Activity, Participation and Environment Domains of the International Classification of Functioning, Disability, and Health. [4]
SCIRE Spinal Cord Injury Outcome Measures Toolkit
Specific and validated outcome measures data is central to understanding the needs of clients, their level of care, and the services that will enhance their rehabilitation. Developed in 2017 specifically for clinicians working in spinal cord injury rehabilitation, the [3]
One hundred and forty-eight outcome measures were initially considered for inclusion with consensus reached for 23 out of 30 clinical areas. In the remaining seven clinical areas, more than one outcome measure was recommended. The final toolkit comprises 33 Outcome Measures across 30 Clinical Areas with sufficient measurement properties for use with a spinal cord injury population. It was highlighted that many of the other measures not selected were missing clinically important measurement properties, such as responsiveness, that assist the most in documenting a client’s progress in rehabilitation. As such further research is recommended to establish the clinical suitability of the other measures for later inclusion in the toolkit. [3]
International Classification of Functioning, Disability, and Health Component
Conclusion
Spinal cord injury is a medically complex and life-disrupting condition with a high likelihood that secondary health complications, such as pressure ulcers, fractures, or circulatory dysfunction, will develop. Clinicians who work with individuals with a spinal cord injury share a commitment toward providing the best interventions to produce successful out- comes for those that they work with. [3]
The most meaningful determinant of treatment efficacy from the perspective of the individual with a spinal cord injury generally relates to improvements in their ability to function in everyday activities and must be forefront in our minds as health care professionals throughout all stages of treatment and rehabilitation. While there will never be a perfect questionnaire or measure of outcome, choosing the right measure to use involves identifying the most appropriate measure for the chosen population group, context and purpose, where evidence exists to show that the questionnaire has exhibited adequate measurement properties pertaining to that group and/or context. [1][3]
Prior to determining any intervention, careful choice of treatment goals and aims is essential in individuals with a spinal cord injury in order to identify and determine the most appropriate outcome measures to use. This means the therapist can ensure they are providing the most appropriate intervention that meets the treatment goals and expectations of the individual with a spinal cord injury. Use of an outcome measures toolkit, specifically validated for spinal cord injury, should lead to improved identification of best practice and enable clinicians to more effectively monitor client progress. [2][3]
Resources
References
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