OUTCOME MEASURES

used at the Bobath Centre

Virginia Knox MSc PGCE MCSPConsultant Physiotherapist and Bobath

tutor April 2013

Outcome measures at the Bobath Centre Outcome measures are used at the Bobath

Centre

This presentation explains what outcome measures are, which ones we use and how we use them

Outcomes ‘Hard’ outcomes typically refer to data that can be quantified (i.e.

put into numbers) e.g. a child shows improved motor function on an outcome

measure; quality of life of child and/or family improved as demonstrated by improved scores on a standardised CP quality of life measure

‘Soft’ outcomes often intangible and hard to measure directly like improved self esteem or confidence or belief you could do something better, or may represent intermediary stages on the way to achieving ‘hard’ outcomes, e.g. a family wrote saying that the visit meant a lot to them and

was very supportive, and they understood their child’s difficulties better

At the Bobath Centre, we focus on ‘hard’ outcomes to show quantifiable change, but also record ‘soft’ outcomes as these can give helpful feedback from families and children on our services

Outcome measures - definitions ‘a measure of change, the difference from one point in time

usually before an intervention, to another point in time usually

following an intervention’

Kendall, 1997

‘a test or scale administered and interpreted by therapists that has been shown to measure accurately a particular attribute of interest to patients and therapists and is expected to be influenced by intervention’ Mayo et al, 1994

How do we use Outcome measures at the Bobath Centre?

‘Occasional’ children attending for 2 weeks of therapy If it is possible to find a relevant outcome measure which will be sensitive

enough to show change in a short period, we administer a test or one part of a test, at the beginning and end of the 2 weeks

If this is not possible, we use Goal attainment scaling to set GAS goals

Children attending on a more regular basis, e.g. once a week over several months Administer an outcome measure once a year or at the beginning

and end of their block of therapy Outcome measures may be used more frequently if we want to

record progress before and after other interventions such as surgery or Botulinum toxin injections

Clinical Audit of Outcome Measures Each year we record how many outcome measures were

used and how many children showed improved scores

This information is compared against pre-set targets to ensure we are continuing to use measures frequently, and to see if we are increasing the frequency of use

Therapists receive specific training on an annual basis to help them further develop their skills in using outcome measures, and the clinical audit can help us determine where training is particularly needed

Examples of outcome measures used at the Bobath Centre

Canadian Occupational Performance Measure COPM Purpose? To detect change in a client’s self-perception of

occupational performance over time How? An interview with the parent, carer or child to:

Identify activities that are difficult to do, or to do wellThen to rate these activities on 10 point scales: Importance (priority) How well the activity is being performed How satisfied the client/parent is with the activityThe rating is repeated after intervention, e.g. 2 week block of therapy

Who do we use it with? Often with teenagers to help them engage in therapy and set their own

goals Or to help set goals with parents of children with more severe limitations in

their activity and monitor their progress

Goal Attainment Scaling Kiresuk, Smith & Cardillo, 1994 Purpose: A structured way to measure change using individualised

goals

How? Goals are identified after discussion with parents and families. The goal is put onto a scale with five possible outcomes:

0 = expected level of attainment – what the therapist is aiming for the child to achieve at the end of the therapy

-1 and -2 are two levels which are less favourable but still an improvement from where the child started

+1 and +2 are two levels which are more favourable than the expected level of achievement at the end of therapy

Example of GAS goalGoal Score Score at end

of therapy

To stand still and put jacket on and zip it up himself

+2

To stand still while jacket is put on by parent and then zip up jacket himself

+1 To stand still while jacket is put on by parent

0

To stand still for 30 seconds -1

To stand still for 15 seconds -2

Gross Motor Function Measure Russell et al, 1989 Purpose: to evaluate change in gross motor function in children

with cerebral palsy aged 5 months to 16 years

How? The child is observed attempting lots of different gross motor activities within 5 areas:

1. Lying & rolling 4. Standing

2. Sitting 5. Walk, run & jump

3. Crawling & kneeling

Who do we use it with? Any child with cerebral palsy where we are working on improving gross motor

skills It is slightly less sensitive with children either with very mild or very severe

limitations in their activity so might not be used with those children

Assisting Hand Assessment AHA

Purpose: This measures how effective a child makes use of the assisting hand during two-handed activities. It is used with children with hemiplegia (cerebral palsy affecting one side of the body), aged 18m to 12 years.

How? A video is taken of a play session using specific toys which would

typically require the use of two hands The child is not instructed to use their affected hand – the test looks

at their spontaneous typical use of that hand

Who do we use it with? Any child with hemiplegia where therapy is aiming to improve hand function

Melbourne Assessment Purpose: To measure quality of upper limb function in one arm, in

children with cerebral palsy aged 2-15 years

How? A video is taken of the child performing different tasks, such as

reaching and pointing, grasping different objects, manipulating objects and a variety of functional tasks, like taking a biscuit to their mouth.

This is then scored for different aspects like range of movement, accuracy, smoothness of the movement and speed

Who do we use it with? Children where therapy is aimed at improving hand and arm function or sometimes to see if wearing a splint or lycra garment changes the level of hand function

Spinal Alignment & Range of Motion Measure SAROMM

Purpose: to give an overall score of spinal posture (alignment) and range of movement in upper and lower limbs

How? Spinal alignment (posture) is observed and compared to photographs

and rated on a 4 point scale Range of motion (ROM) for lower limb joints and upper limbs are

measured with a goniometer according to specific instructions and the ranges recorded on a 4 point scale

Total spinal & ROM scores and an overall total score are calculated

Who do we use it with? Children and teenagers where improving mobility is a focus of therapy, e.g. an adolescent child who has recently been getting significantly stiffer

Spinal Alignment and Range of Motion Measure SAROMM

0 = Full ROM (i.e. neutral hip ext.) and no hip flexion posture

Hip flexion posture

1 = Full PROM (ie. >0 hip ext.)

Limitation of hip extension

2 = Mild (Neutral to 15°)

3 = Moderate (15° – 30°)

4 = Severe (>30°)

Thomas Test

SAROMM0 = No alignment limitations

2 = Mild

1 = Scoliosis and/or rib hump observed butcan be corrected passively

Non reducible scoliosis & rib hump

3 = Moderate 4 = Severe

Chailey levels of Ability Purpose: assesses level of postural ability in children with cerebral palsy for

lying, sitting and standing. They can also be used to determine which type of equipment, e.g. seating, helps the child achieve the highest level of posture, e.g. Can the child only be placed in sitting, or can they get in and out of

sitting for themselves; can the child lie on their back and use their hands for play

How? The child is observed in different postures, looking at the posture they adopt, how they move, which parts of the body are taking weight, etc.

Who do we use it with? Children with more severe limitations to their posture to monitor progress in their postural ability, and sometimes to determine if different equipment or a lycra garment influence their postural ability

Pediatric Evaluation of Disability Inventory PEDI Haley et al, 1992

Purpose: To measure functional skills (what the child can do) and also the amount of assistance a parent/caregiver typically has to give a child in everyday activities in three areas: Self care, e.g. eating, bathing, dressing Mobility, e.g. moving around indoors, transfers Social function, e.g. play, problem solving

How? The parent/carer completes a questionnaire with a therapist or completes a computerised assessment

Who do we use it with? Children attending the Centre on a regular more long term basis to measure change particularly in self care and level of mobility

Caregiver Priorities and Child Health Index of Life with Disabilities CPCHILD Narayanan et al, 2006

Purpose? To measure health related quality of life including the child’s health and how functional activities are affected like personal care, positioning, transferring, mobility, communication and comfort, and how much the caregiver has to help the child with these activities

How? A questionnaire for the caregivers of children, at the beginning of a block of therapy and then repeated a few weeks after returning home.

Who do we use it with? Children with more severe limitations in their activity (GMFCS IV & V)

Care & Comfort Hypertonicity Questionnaire CCHQ Nemer McCoy et al, 2006

Purpose? To assess the degree of difficulty in carrying out specific personal care activities and whether there is any discomfort or pain during such activities, e.g. Is there pain or discomfort during nappy changes? Ease of getting in/out of wheelchair

How? A questionnaire with a rating scale for parents/carers

Who do we use it with? Parents/carers of children with more stiffness, pain or discomfort which we think may change with therapy

Pediatric Pain Profile Hunt et al, 2004

Purpose? To identify the frequency of behaviours that might indicate a child is in pain, where they cannot easily communicate this for themselves e.g. had disturbed sleep, difficult to feed, bit self,

pulled away when touched, etc.

How? A 20 item rating scale completed by parents or carers.

Who do we use it with? Parents/carers of children where pain and discomfort are an important issue e.g. monitoring of ongoing musculoskeletal or other conditions likely to

result in pain, e.g. a hip which is disclocating and where we think a child’s level of pain may be influenced and reduced by

therapy