Getting a Good Outcome…

 

Individuals experiencing persistent pain often report how pain can impact on their physical, social, and emotional well-being. To truly appreciate this, a thorough, interdisciplinary assessment is required, using a biopsychosocial framework to understand their current situation. As part of the assessment process, outcome measures can be a useful way to establish baselines from which the basis of rehabilitation can occur.

But many questions arise regarding outcome measures, including:

 

    • What are outcome measures?

    • Why do we use them?

    • Are they of value or just a tick box exercise?

    • Who are the outcome measures for?

 

What are outcome measures?

An outcome measure is a tool used by clinicians to identify an individual’s level within a given domain at any one point in time. This may be assessing someone’s level of physical functioning, including the ability to perform tasks in everyday life, it may be ascertaining a level of psychological well-being, including levels of depression or anxiety, or it may be exploring a person’s ability to engage in social interactions.

Outcome measures used can be patient reported (PROMs), in which the individuals complete self-reported questionnaires at any moment in time, or clinician reported measures (CROMs), which are measures completed by clinicians often displaying objective findings.

Whilst outcome measures are performed at the time of assessment, providing a baseline, they can also be repeated throughout courses of rehabilitation, in order to obtain a greater insight into whether meaningful change has occurred and to what level.

 

Why do we use outcome measures?

A question often asked is why we use outcome measures. In fact, there are many reasons why outcome measures are used, and should be celebrated opposed to diminished.

Outcome measures are a great way of understanding where an individual is at any one point in time, whether at the beginning of their rehabilitation journey, mid-way through, or coming towards the end. As this process is repeated throughout their rehabilitation, meaningful change can be identified, whether this is in a positive or negative way. This in turn can then be used to celebrate successes and reinforce changes that have been implemented by the individual, or it can be a helpful way of identifying when, why, and how people may be struggling in order to facilitate and support in a way that is personalised to that individual at that particular time.

Our professional guidelines also recommend we use outcome measures, for example, NICE guidance (NG211) states the following:

“Monitor the person’s progress after starting rehabilitation. Use tools such as patient reported outcome measures (PROMs) and clinician reported outcome measures (CROMs)”.

Goal setting, is a useful strategy and a key component of rehabilitation; however, people can often find it challenging to set goals. Outcome measures can be instrumental in identifying a domain in which someone is experiencing difficulties, and can therefore be used to facilitate the conversation around goal setting. For those individuals that feel stuck, whether with achieving their goals or whether with rehabilitation in general, outcome measures can be a tool to highlight potential barriers to both the individual and the clinician, allowing the conversation to open up about the current direction of rehabilitation.

Many people living with persistent pain report previous failed treatments, often losing hope and motivation. Outcome measures when used in a collaborative manner, can be both a motivational tool and can provide hope, demonstrating that things can change.

Outcome measure data does not only provide vital information to the individual experiencing pain and the clinicians involved in their care, but also to the referring parties. Subjective feedback is always helpful, however, quantitative and qualitative data, can provide much more meaningful context.

Finally, as HCPC registered clinicians specialising in rehabilitation, it is our duty and responsibility to undertake the completion of outcome measures in keeping with professional standards.

 

Chartered Society of Physiotherapy

“Using standardised, validated outcome measures in clinical practise is an explicit requirement of the CSP’s Quality Assurance Standards”.

 

HCPC Standards of Proficiency for Physiotherapy (2023)

“Gather and use feedback and information, including qualitative and quantitative data, to evaluate the response of service users to their care”.

 

Who are outcome measures for?

As clinicians, the answer appears fairly simple, the individual in pain. However, the desired outcomes can present very differently between the individual, the clinician, and the referring party (where applicable). Understandably, the individual in pain often wants to get better, be fixed, return to normal or even a new normal. The clinician would like to reduce or resolve the pain, reduce the emotional impact, reduce or resolve trauma symptoms, help improve physical conditioning and re-engage with meaningful activity. The referrer is aiming for the best possible outcome for their client, to receive appropriate treatment, and help the individual to return to pre-injury status.

Whilst there may be similarities in desired outcomes, there can often be differences, which may present conflicts and less optimal outcomes. This is why a collaborative, person-centred approach is vital in achieving the desired outcome for the individual experiencing pain.

 

Reflections

In my experience, specialising in musculoskeletal and pain rehabilitation for over 20 years, there are many common themes that often arise. One is the distinct lack of use of outcome measures. Two, the improper use of outcome measures, such as, incomplete or partially completed measures and failure to repeat measures making it difficult to draw conclusions, and thirdly, the lack of collaboration with how the measures relate to rehabilitation.

Unfortunately, outcome measures are commonly undervalued and often disregarded by clinicians, which in turn can impact on rehabilitation and overall outcomes.

Conversely, outcome measures can be repeated too frequently, with some clinicians assessing every session, almost ‘death by outcome measure’. This can present difficulties identifying meaningful change when little therapeutic time is obtained between measures, and with the risk of frustrating the individual having to complete on such a frequent basis.

When using measures, it is important to consider the tool’s validity and reliability. Is it measuring what it is supposed to be and is the tool stable when tested over a period of time. Utilising a reliable and valid measure with respective statistics and norms provides greater scope for measuring change.

As discussed above, the use of outcome measures is not only useful for everyone involved, it allows for a collaborative approach to be facilitated, demonstrates the effectiveness of rehabilitation, but also assists with those that present being “stuck”. Recommendations for the use of clinicians in the area of rehabilitation would therefore strongly advocate for those that consistently use outcome measures and involve them in the rehabilitation process.

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