By Bronwyn Spira, PT
Measurement is the cornerstone of evaluation. In Healthcare, objective metrics help us assess treatment protocols and relative outcomes. From this process we establish standards that serve as guidelines to help us recognize shortfalls in a procedure and make necessary changes. Measurement guides our decision-making and provides benchmarks for optimal outcomes.
Performance measures give providers a way to assess themselves as well as their patients. In a recent article entitled The ABCs of Measurement, the National Quality Forum (NQF) discusses the use of performance measures in evaluating optimal care and how they can improve quality and safety for patients (1). The NQF offers guidelines, derived from providers and patients, that health professionals should incorporate into their care regimens. This allows for astandardized, yet comprehensive review of the system and incorporates every endpoint of care. “Measures light the way, showing where systems are breaking down and where they are succeeding to help patients get and stay well” (1).
Further, measurement drives improvement, informs consumers and influences payment (1). Measures drive improvement through review of processes and adjustment of care. One example of this can be seen in physical therapy practices, ongoing measurement of a patient’s strength, range of motion and functional ability allow a physical therapist to evaluate effectiveness of treatment being applied and make necessary adjustments to subsequent treatment. Measures educate consumers, allowing them to better understand their condition, assess the quality of care being provided make informed decisions. Finally,measures also allow payors to accurately and fairly evaluate caregivers and patient progress.
What are the key components of measurement? Communication and monitoring. A continuous feedback loop where patients and providers can actively engage ensures improvement in quality of care. This also allows patients to report errors and potential mishaps in their care. For example, North Shore-Long Island Jewish Hospital uses performance measures of patient care and public reporting of results (1). A database has been created to track all patient feedback, which is then used to prioritize improvement initiatives. Communication ensures that patients “get better and stay better.” A rural hospital in northern California’s Humboldt County has significantly improved outcomes through new models of patient monitoring. The hospital discovered, through measurement, that patients needed “more follow up: more education, more explicit linking back to primary care, and more help managing their chronic conditions” (1).
Clinics leverage technology to become better informed. The NQF endorses wider use of electronic health records (EHRs) suggesting that, “EHRs will also make measurement and performance data available on a real-time basis, making healthcare much more responsive to patient needs.”
So how do we apply health care measurement in physical therapy? What tools do we have at our disposal to document patient performance and drive better care? Best practices dictate that we start the rehabilitation process by gathering baseline data against a set of standardized objective scales i.e. strength, range of motion and balance. Ongoing tracking of these metrics keep therapists and patients focused on specific, measurable goals. Engaging the patient in this process will allow providers to constantly re-evaluate care and make necessary adjustments. Available technology like the FORCE TherEx platform facilitates a continuous feedback loop between patient and provider. The NQF has made it a priority to endorse the use of performance measures to improve the healthcare system and it is imperative that we apply these standards the arena of physical therapy“Measures can best succeed when they are backed by all involved in healthcare, reported to the public, and used for continuous improvement.”
In the wellness arena, measurement devices and applications like ‘fitbit’ and ‘runkeeper’ have demonstrated traction with consumers. It seems that people manage what they measure, in which case, including patients in monitoring their physical progress should improve their participation in rehab programs and their resultant outcomes.
1. Robert Wood Johnson Foundation (RWJF). 2010 . The ABCs of Measurement, National Quality Forum, www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx.
By Tejal Ramaiya, DPT, CSCS
Patellofemoral Pain Syndrome (PFPS) is one of the most common conditions physical therapist’s encounter and yet one of the most challenging to treat. Hip weakness, quadricep weakness, and poor flexibility are just some of the factors that can contribute to PFPS, not to mention sub-par footwear, sport technique, joint arthrokinematics and/or foot abnormalities. Flexibilty exercises for psoas, quadricep, hamstrings, and gastroc-soleus are staple protocol when treating PFPS, however when it comes to strengthening, what is the most effective approach for the early stages of rehabilitation? Is there a difference between an early stage quadricep versus hip musculature strengthening approach?
A recent study published in Journal of Orthopedic and Sports Physical Therapy studied the effects of isolated hip strengthening compared to isolated quadricep strengthening prior to initiating a functional weight-bearing strengthening program in women with PFPS. This study included exclusively females due to their epidemiologically higher incidence of PFPS. The study was a randomized clinical trial where 33 women were randomly assigned to either a hip strengthening group or a quadricep strengthening group. The hip group performed exclusively hip abduction and external rotation strengthening for 4 weeks while the quadricep group performed only quadricep strengthening exercises for 4 week. At 4 weeks, both groups initiated a weight-bearing strengthening program.
Treatment was as follows: both groups performed stretching of the quadriceps, hamstrings, and triceps surae (3 times for 30 seconds each) throughout the 8-week program in addition to their respective strengthening programs (hip vs. quadricep).
Measures taken at baseline and at 8 weeks:
- Pain (Visual Analog Scale)
- Step-down Test
- Lower Extremely Functional Scale (LEFS).
Hip group exercises (weeks 0-4):
- Standing hip abduction
- Sidelying combination hip abduction and external rotation (clams)
- Seated hip external rotation
Quadricep group exercises (weeks 0-4):
- Quad sets
- Short-arc quads
- Terminal knee extensions
- Straight leg raises
Weight-bearing strengthening exercises (weeks 4-8):
- Single leg balance with front pull
- Wall slides with resistance
- Lateral step-downs
- Calf raises
The results of this study found that both groups experienced an overall increase in strength and improved function over the 8-week period, however, the hip group had a significant decrease in pain during the first 4 weeks of treatment whereas as the quadricep group reported no change in pain. The results of this study suggests that isolated hip strengthening in the early stages of treating patients with PFPS may be the more clinically efficient way of reducing pain and increasing function.
Click on the video below to see the correct technique for performing sidelying combination hip abduction and external rotation (clams). For videos of all other exercises mentioned in this post, please visit the FORCE Therapeutics online store.
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1. Dolak, K. et. al. Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. J Ortho Sports Phys Ther 2011; 41(8): 560-571.
Tejal Ramaiya is National Client Representative at Force Therapeutics. Force Therapeutics provides a web and mobile application that extends physical therapy patient care beyond the office visit. The application provides physical therapists with clinically tested platform to manage patients, track compliance and effortlessly assign exercise videos. Tejal owns a private practice in NJ where she uses the Force Therapeutics platform to prescribe video based exercise programs to her patients. Please visit www.forcetherex.com for more information.