Panel Discussion: What Reassessment (outcome measures) do you use?
Much attention has been given to assessment, but what about re-assessment? What reassessments (outcome measures) do you use to ensure that your interventions are successful, you are improving as a practitioner and you are continuing to provide optimal care?
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
This Panel Discussion was originally posted on my facebook page –https://www.facebook.com/brent.brookbush – on July 25th, 2015
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Erik Korzen DC Outcome assessments like Oswestry and NDI? Or are we talking about movement assessments?
Outcome measures for my office are usually repeating the tests/movements/assessments that yielded significant results at the previous assessment. For movements I always consider each exercise as a test. Thoughts?
Scott Hoar in the clinical setting, I try to find the dysfunctional movement pattern during the initial visit, then re-assess that at the beginning and at the end of every visit
Brent Brookbush Great stuff Erik Korzen DC… sure outcome measures like the Oswestry can be great tools (and mandated by 3rd party payers), but what do they really tell us about our intervention. I think you make a great point about using the same tests that you used in your assessment that yielded a significant result. So, maybe you are not repeating your entire evaluation, but you are repeating all provocative tests. In my practice, I am generally performing those tests over-and-over, throughout treatment, as a way of keeping track of which interventions produced the best results.
Brent Brookbush I think that is a great practice Scott Hoar, do you take notes after re-assessment for use at the next session?
Scott Hoar My notes reflect if a movement was dysfunctional or not, then the regional assessment. It'd honestly be much better if I took pictures to include in the notes for the pre/post and re-assessments. But that's not happening at the moment
Brent Brookbush I was actually just talking to Joe Ferrantelli about his product Posture Analysis… really cool app for your phone or tablet - Scott Hoar.
We may be doing some work with them at the Brookbush Institute
Leon Chaitow Assessment of movement patterns and palpated dysfunction are notoriously subjective. They do satisfy me up to a point, but reassessment based on those type of criteria are unlikely to be convincing/satisfying unless outcome measures correlate with these. I was looking yesterday at the recommendations of the International Headache Society.
They suggest that clinical trials should focus on outcomes (e.g. frequency of headaches) as a primary end-point, with duration and intensity as secondary end-points.
I think as individuals we should take account of what is desirable in research studies…and outcomes that are objective (at least to a degree) are most desirable.
Ref: Chaibi A Russell MB 2014 Manual therapies for primary chronic headaches. . Journal of Headache and Pain 2014, 15:67
I am absenting myself from the discussion after this brief contribution…. there's just too much pressing stuff to do.
Brent Brookbush Always appreciate your interaction, and respect your schedule Leon Chaitow!
Erik Korzen DC Some outcome assessments can be beneficial regardless if insurance co requires it. Sometimes it's just another form for a patient to fill out.
Brent Brookbush I do the same thing with tests throughout a session with a patient, provides great insight.
Scott Hoar, taking photos or videos would be very beneficial to add to notes. I'm not currently doing this either.
Brent Brookbush For the record, neither am I Erik Korzen DC, hence I was talking with Joe Ferrantelli. It's pretty easy to use.
I agree that some outcome assessments are inherently useful, I just don't want this to become a conversation that revolves around "evidence-based practice, 3rd party payers, and what outcome measures are mandated". There is still the whole movement thing, or muscle activity thing, or fascial thing that dominates our interventions and should be subject to reliable measures… if for no other reason than to grade our own progress as clinicians.
Steve Middleton I do 2-3 minutes of reassessment at the start of a session to determine what I will do: is PROM still limited? If it is, is it soft tissue or joint restriction? Then I have address that 1st, if PROM is acceptable, then I can progress with movement re-education. If they have appropriate motor control on AROM, then I can start with strengthening.
I think if you just do the same thing each session, you aren't meeting the patient at their current level of ability.
Brent Brookbush Great point Steve Middleton… as we grow as professionals it is important that we not only add to our arsenal of interventions and exercises, but to our arsenal of assessments as well.
Rob Fluegel Sorry Brent, no real time to chime in on this one this weekend. Hopefully, I can post about this on Monday.
Brent Brookbush Always love to hear from you brother, chime in when you can!
Tony Susnjara Brent, the question made me realise why I don't always get involved in your discussions which is because I'm not a physical therapist and most of my hands on work came from teaching yoga and often in large groups.
One of my yoga teachers was a physical therapist. I'd also studied remedial yoga, remedial massage and corrective exercise because I was more scared of hurting people than wanting to provide a 'yoga therapy' service.
Having said all of that, I would say that having awareness of the body as a biotensegrity system with particular connections or lines or chains or pathways of force transfer, I found that watching the body in a series of yoga postures gave me a good overall global assessment of what was going on for a particular client. If you think of the yoga postures like a downward facing dog or an extended right angle pose and so on, they are global activators from finger nails to toe nails. Some work the anterior / posterior sagittal plane, some on the frontal some the transverse and many on the integration of multiple planes.
So since 'the exercises' themselves give diagnostic information and then they are the 'intervention' there is not really a need to do formal testing because you can simple see the evolution of a persons practice over time. What I would do was give more focus to parts of the body that were lacking either ROM or stability or strength or control in an isolated manner and feed that back into the whole body integrated postures.
The other thing is that because of the time of the day, the season, the fact that we are trying to transform the entire body over time, particular stresses that people are going through and so on…progress seems to occur in a non-linear fashion. I also know from practicing yoga for years that it often 'feels' like one is going nowhere or even backwards but then suddenly, there is a breakthrough and from then on, you seem to be on another plateau where you might stay for some time until the next breakthrough comes about.
Brent Brookbush I would never say that you need to be a physical therapist to participate the discussion, and I am always happy to meet a professional where they are at Tony Susnjara. I would say that understanding of any movement patter could relay information about "best intervention" and as long as you return to that exercise to note improvements (or not), that does qualify as an assessment. It's simply about having a plan or system in which you can rate the effectiveness of the intervention, honestly, so that you continue to improve and enhance the lives of those you work with.
Tony Susnjara Thanks Brent. As a quick afterthought, I would say that every session (at least with the 1:1 clients) was for me a constant feedback loop of 'assessment' and 'intervention' so instead of saying that I did not undertake 'formal assessment' I would say that I never stopped assessing and then adjusting my instruction based on what was unfolding right in front of me. If something 'was not happening' on a particular day then I adjusted what I was doing as required.
Tony Susnjara You should get my friend Angelo Castiglione in on this discussion. He runs workshops where he takes videos of movements before and after each intervention and works through the body quite systematically in this process.
Brent Brookbush Angelo Castiglione, you are welcome to join our discussion and I would be happy to add you to our list of experts who are tagged for each discussion. We only do one discussion a month to ensure that these discussion are continuous enjoyment for those who participate and do not add any significant workload (we respect that everyone is super busy).
Kenneth E. Hoover This is one of those times when I'm thankful for how simple and straightforward my job is. Metabolic assessment is very easy to revisit. Whether it's VO2, submax or RMR testing, we just retest at an appropriate timeline. Outcomes are easy to compare.
Brent Brookbush Nice Kenneth E. Hoover - What equipment and software do you use for VO2, submax and RMR tests, and do you have any experience with other equipment and software that you could share?
Maurice D. Williams I use scale, body fat, circumference measurements, pictures, client's own thoughts about how things are going (verbal & written) dynamic & static postural assessments. This works for me as my target market is women around ages 50-55 who want 2 lose some weight, improve flexibility/posture & have more energy.
Kenneth E. Hoover Good question Brent Brookbush. Several changes in those areas over the last couple of decades. Even 15 years ago, the choices were limited and not as well verified as today. Assessment choices in this area usually depend on goal and ability. Assuming able bodies and athletic or fitness improvement as a goal, VO2 and AT are usually done on a treadmill. (cyclists and others may prefer cycling based tests.) In that case, most of my testing over the last 20 years has been done with Korr Cardio Coach or CC2 and either a treadmill or a cycle. Woodway has been a big part of my process and still is today. The current software that interfaces with their products is probably the most valuable yet and is simple to use. That software is CosMed (HPCosmos.) They also make a great treadmill (Quasar) if it works with your budget. One of my mentors in this area, Paul Robbins, helped develop the Korr products and has been a resource for my decision making concerning equipment since before he was the Metabolic Assessment Specialist with Athletes Performance. RMR Testing is much less intrusive, in terms of what is necessary to get actionable data. In this case, Korr's Cardio Coach II and ReeVue are easy to use and well verified. The majority of my RMR testing over the last 15 years has been done with MedGem and BodyGem. Formerly HealtheTech and now Microlife manufactures them. Over the last 8-9 years I have used armband devices because of the ease of use and clients willingness to use them. It's nice to have data in real time. My favorite example of changes in this area are related to the current "wearable tech" craze. The best (and only medically approved) armband, that Ive used for 8-9 years, was from a company called Body Media. The company was bought by Jawbone. They discontinued the armband, apparently to eliminate their advantage, not a new business tactic. Good for business, bad for consumers.
Brent Brookbush Nice Kenneth E. Hoover, I am sure you could create one heck of a spread sheet on cardiovascular assessments, pro's, con's, price range, etc. I do love the Woodway treadmills, and have never had the chance try the Quasar products. Really appreciate your input.
Brent Brookbush Hey Maurice D. Williams,
How often do you re-assess using the evaluations listed?
Maurice D. Williams Brent Brookbush: depends on each client, some every week, others every month. On Avg., every 4-6 weeks.
Brent Brookbush I realized I had not actually chimed in about the assessments and re-assessment I use.
Generally I try to make note of the "behavior of pain" from session to session based on the subjective exam.
During the objective exam, I am noting provocative tests as I work my way through special tests, dynamic postural assessment (overhead squat), cyriax/maitland style joint exam, nerve tests (when necessary), goniometry, muscle length tests and manual muscle tests. I generally follow that up with "What movement hurt's during your daily activity?" and essentially create a patient specific special test (for example, shoulder pain while getting their arm in the sleeve of a particular coat). This sounds like a ton of stuff, but remember I said, "I note provocative tests"… what this means is I only re-assess those tests that replicate the patient symptoms, or those tests that I hypothesize are highly correlated with the patient symptoms. This usually results in a quick battery of 3 - 5 tests that we can use over and over as we add interventions and exercises to their program.
I believe this is very similar to the way Dr Erik Korzen DC was eluding to re-assessing and is certainly not unique.
As a personal trainer, I would generally re-assess in a similar fashion but rely heavily on the overhead squat assessment and a couple of specific movement patterns the client wanted to see results on (for example, pull-ups, push-ups, vertical jump, etc.)
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