1. OVERVIEW AND DESCRIPTION
Definition of the assessment/treatment procedure
Physical Medicine & Rehabilitation (PM&R) manages prevention, diagnosis and treatment of conditions and syndromes that result in impairment, leading to functional disability and impacting quality of life. Some of these disorders may include pathology of the nerves, muscles, bones and brain.1 The specialty of PM&R moves from a general disease-oriented approach, to a comprehensive detailed approach, incorporating medical factors, physical impairment and barriers, and the person’s goals, which together leads to the planning and achievement of functional goals and improved quality of life.
In order to objectively understand the functional changes attained through methodic treatment interventions, the rehabilitation team will use assessment instruments which will allow a systematic evaluation permitting later comparison of clinical changes in an objective manner. The use of instruments and outcome measures may contribute to improved clinical decision making and evidence-based-practice.2
There are numerous assessment instruments available. In order to improve selection, it is important that clinicians determine what he/she wants to measure, the population under study, and the reliability and validity of the instrument being applied. Most importantly, the physiatrist must comprehend that objective assessment tools should not be placed over the clinical care, but should only serve to enhance therapeutic recommendations.
The rehabilitation field uses a biopsychosocial model of care; this implies that as specialists, we do not limit our practice to diagnosing and treating a pathology (biomedical model), but we expand into understanding and treating the secondary effects of injury and illness. To successfully address this, the physiatrist will see the whole patient, incorporating motor, cognitive and emotional dimensions to the assessment so that a full picture of goals and barriers can be identified early in the planning of the rehabilitation program.3 These components, or dimensions, will be incorporated into the assessment tools.
The International Classification of Functioning, Disability and Health (ICF) endorsed by the World Health Organization (WHO) supports assessment tools, and presents recommendations on which tools to use and how to use them. The framework is divided into: (1) Functioning and Disability, which is subdivided in body function and body structures, and (2) Contextual Factors. The first one considers the individual and the societal perspective, and his/her ability to perform. The second one considers personal, attitudinal, environmental, physical and social factors.4
Range of Procedures and Settings:
The practice of PMR includes in-patient and outpatient settings. The setting where the evaluation is taking place will impact the extent and format followed to assess our patients. Traditionally, the inpatient scenario includes an inter-professional team that allows for a comprehensive evaluation and treatment recommendations. The family takes a huge role in this setting, particularly with the purpose of understanding the psychosocial context of the patient. This setting is highly influenced by third party medical insurers who will dictate costs and the limit/length of stay.3
The specialty of PMR makes use of a series of procedures that allows the diagnosis and treatment of patients with functional disability. Electromyography has complemented the physical exam impression by allowing the study of muscles and nerves through electrophysiology principles. This study uses a combination of superficial and intramuscular electrodes to study the nerve and muscle physiologic behavior, allowing the qualification and quantification of pathology, its localization, and the establishment of prognosis. Electrodiagnostic studies are not a substitute for radiologic imaging, but a complement to understanding anatomic findings. Specialized training is required to master a comprehensive interpretation of pathology identified by the study.5
Interventional procedures in PMR have expanded with time from peripheral joint and trigger point injections to the interventional pain management of spine and deeper joints under fluoroscopy guidance. Although interventional procedures in pain management can be done by other medical subspecialties, the physiatrist’s intervention incorporates not only the expertise of pain management, but the component of function and rehabilitation after the procedure is completed. This creates an impact in wellness and quality of life.6,7
Diagnostic ultrasound is another tool that is taking an important place in musculoskeletal medicine. This technology allows for easy portability, low cost and safe application in the clinical practice, allowing functional evaluation and diagnosis of a musculoskeletal complaint. At the care site, the physiatrist can make immediate decisions about therapeutic interventions, particularly when applied to guided injections. 8
Assessment tools allow measuring and comparing clinical outcomes based on expected milestones. Observations on time permit determining if functional progress goes along with the expected prognosis.
Specific features of clinical applications of the assessment /treatment procedures:
In rehabilitation medicine, a detailed history is initially obtained by the physiatrist, complemented by a comprehensive approach with inter-professional contribution of collaborative disciplines like the speech pathologist, the occupational therapist, the physical therapist, and the rehabilitation nurse, among others. The history includes the present illness, past medical history, and functional limitations. Although this information is obtained from the patient, the spouse and family play a key role in understanding the contextual dimension. A functional history allows for an understanding of the resulting disability, the remaining capabilities, and the compensatory techniques used by the patient. There are several activities of daily living evaluated; some of these are communication, transfers/mobility, self-care ability, and household chores. Functional limitations in each area may vary; therefore, treatment goals are specific and adapted to improve them. 3
Specific diagnostic criteria that justify use of the assessment/treatment procedure: 9,10,11
Once a subjective evaluation is completed, the physiatrist will establish a diagnosis and rehabilitation goals. He/she will use objective instruments to quantify the disability and later compare the functional changes obtained after therapeutic interventions. These instruments are called assessment tools, which can be generic or specific. Specific tools can either be disease-specific or region specific. Generic tools are designed to measure and improve quality of life; for said reason, they are considered broad-ranged and generic and very sensitive to any health change. It can include concepts like physical health, psychological state, and level of independence, social relationships, and the relation to the patient’s environment. They are applicable to different disease and cultural groups.
Assessment tools to be used will be based on the diagnosis established and the specific treatment goals that are aspired to attain and measure. Some examples of assessment tools available are:
- Arthritis Impact Measurement Scale: multidimensional health status index used in arthritis patients. It consists of 9 areas of evaluation: mobility, physical activity, dexterity, household activities, activities of daily living, social activities, anxiety, depression, and pain.
- Fibromyalgia Impact Questionnaire: is an assessment and outcome instrument developed to assess health components affected by this condition. Items include physical function, pain and fatigue, among others.
- Neck Disability Index: consists of items that evaluate pain function and clinical signs/symptoms.
- Oswestry Disability Questionnaire: evaluates pain intensity and its effect on daily activities, including recreation.
- Barthel Index: it allows measuring activities of daily living with chronically disabled patients; it includes 10 items, among those, bowel and bladder assessment scores.
- Katz Index of Independence: developed to study results of treatment and prognosis in the elderly and in chronic illness, this tool includes activities of self care.
- Functional Independence Measure: this tool includes 18 items in a 7-level scale that is used to uniformly assess the severity of patient disability and medical rehabilitation functional outcomes.
- Visual Analog Scale: pain intensity scale
Other factors that my influence clinical decision making when applying the assessment/treatment procedures:
A comprehensive rehabilitation treatment plan takes into account the environment and social support system to which the individual will be exposed. Consideration of structural and social barriers is crucial, especially when the individual presents with impairments that might restrict him/her (wheel chair accessible, elevators, ramps). Prior to making certain treatment decisions, it is imperative to explore the involvement of support systems, evaluate for a safe environment, the need for assistance with ADL/mobility, need of supervision, home modifications and the cost that these challenges involve.
Formal guidelines for using the assessment / treatment procedures: translation into practice: clinical pearls or potential performance improvement in practice
Evidence-based medicine (EBM) has been considered the backbone of high-quality medical practice. It is the process of systematically reviewing, appraising and using clinical research findings to aid the delivery of optimum clinical care to patients.12 It is estimated that less than 20% of medicine is based on scientific evidence. However, upon the integration of EBM with clinical expertise and patient values, clinical practice guidelines are developed to assist practitioners and patient decisions about appropriate health care for specific circumstances.13These guidelines are meant to provide a tool which complements the clinician’s evaluation, assessment and treatment plan, always acknowledging that individual needs of patients must be considered.
The AAPM&R has established the Clinical Practice Guideline Committee (CPGC) through which practice guidelines critical for the field of PM&R are developed and endorsed. Guidelines endorsed by the Academy require peer-reviewed evidence, classification of the evidence based on quality of study design, systematic review of the literature and recommendations based on the strength of the supporting evidence. The Committee also evaluates the quality guidelines established by other organizations that may benefit the practice of PM&R. The quality of the process through which each guideline is developed is key to the final decision of the Committee. Proposed guidelines are either endorsed (fully complying with the AAPM&R standards), accepted (information beneficial for members but recommendations endorsed only partially), affirmed (considered as educational tool but not endorsed) or denied.14
AAPM&R is one of the multiple worldwide organizations active in the Physician Consortium for Performance Improvement (PCPI), identifying within established guidelines aspects of care from which evidence-based, statistically valid, and reliable performance measures are developed.15
2. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
Physiatric practice has been expanding with emerging diagnostic and treatment technologies. Among them is the growing use of ultrasonography as a diagnostic tool as well as treatment modality. As a diagnostic tool ultrasonography has led to increased efficiency regarding timeliness and decreased cost, substituting other forms of diagnostic imaging such as CT and MRI for the diagnosis of multiple musculoskeletal conditions. Ultra-sound guided injections have also improved the efficacy in the treatment of these conditions. A treatment modality rapidly emerging is the use of Proliferative Therapy including PRP (Platelet-Rich Plasma) and Prolotherapy; both are promising but lack sufficient scientific evidence to confirm efficacy. Prosthetic rehabilitation has expanded with the use of high technology, including Microprocessor Knees and the inclusion of Artificial Intelligence in lower extremity prosthesis substituting the function of human muscle. Targeted nerve regeneration has also expanded the possibilities in the rehabilitation of both upper and lower extremity amputations. Newer technologies are emerging and still in research phase, such as Osseointegration, a technique which incorporates a pylon in the amputated lower extremity residual bone, eliminating the need of a socket. Treatment incorporating higher technology such as the use of robotics, is rapidly growing, and although few, upper extremity transplants are examples of cutting edge technologies which research needs to address.
3. GAPS IN KNOWLEDGE/ EVIDENCE BASE
Outcome measures are key to the establishment of performance improvement measures and health care. However, are we measuring the correct outcomes? Do the outcomes measure all consequences related to disease, including parameters related to quality of life? The development of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) provides a classification method which includes consequences at the organ, person, and society level as well as the influence of environment.16 How we translate ICF to the ICD-10 (International Statistical Classification of Diseases and Related Health Problems)?
Relevant outcomes in PM&R deal with multiple health conditions across several specialty boundaries, and as such, it assimilates practice guidelines non-specific for PM&R, gap which must be addressed in order to identify and develop best practice standards.
Even when functional assessments are key to rehabilitation medicine, clinicians are challenged with incorporating them in their day-to-day clinical practice. On one hand, the patients may not understand the importance of measuring functional milestones; on the other hand, medical insurers may not pay for services if the need for care is not demonstrated through objective measures. Using outcome tools can be time consuming for the provider and the patient, and this may interfere with its regular use.
Even when outcomes measures can allow following up on the clinical course of a disorder, its ability will depend on the instrument used, specificity to the pathology being observed, sensitivity to clinical changes, population studied, and by the coinciding co-morbidities suffered by the patient. Clinical improvement can be subtle enough as to not allow a significant measurable improvement by the tool. Medical documentation will play a role in justifying therapeutic interventions. Third party payers more and more exert an immense influence on the care offered to patients based on the established outcome measures. Clinicians will have to assess the benefits of care, costs, and the patient’s and the family’s desires and preferences.
Another area that can be affected by not having the right outcome measure for a specific intervention is clinical research. New expensive instruments and/or technology could be developed by the industry seeking to enhance sensitive identification of clinical changes.17
- Am Acad of Physical Medicine & Rehabilitation. https://www.aapmr.org/patients/aboutpmr/Pages/default.aspx 2015.
- Barat M, Franchiognoni F. Advances in Rehabilitation: Aggiornamenti in Medicina Reabilitativa. Assessment in Physical Medicine & Rehabilitation: Views and Perspectives. Maugeri Foundation Books and PI-ME, Via Vigentina, Italy, 2004; Vol 16: Chapter2.
- Ganter BK, Erickson RP, Butters MA, Takata JH, Noll SF. Delisa’s Physical Medicine & Rehabilitation, Principles and Practice. Chapter 1: Clinical Evaluation. Wolters Kluwer, Lippincont Williams @ Wilkins, Philadelphia, PA, 4th Edition.
- Peterson DB. International Classification of Functioning, Disability, and Health: An Introduction for Rehabilitation Psychologists. Rehabilitation Psychology. 2005 (50) 2; 105-112.
- Cole JL, Goldberg G. Delisa’s Physical Medicine & Rehabilitation, Principles and Practice. 4th Edition. Chapter 4: Central nervous system electrophysiology.
- Mukai A, Kancherla V. Interventional procedures for cervical pain. Phy Med Rehabil Clin N Am. 2011 Aug;22 (3):539-49.
- Pauza KJ. Educational Guidelines for Interventional Spinal Procedures. AAPMR. 2001.
- Patil P, Dasgupta B. Role of diagnostic ultrasound in the assessment of musculoskeletal disease. Ther Adv Musculoskelet Dis. 2012 Oct 4(5); 341-355.
- Franchiognoni F. Assessment in Physical Medicine & Rehabilitation: Views and Perspectives. Chapter 3: Generic and Specific Measures for outcome assessment in orthopedic and rheumatologic rehabilitation. 2004 (16).
- Christiansen CH. Delisa’s Physical Medicine & Rehabilitation, Principles and Practice. Chapter 43: Functional evaluation and management of self-care and other activities of daily living. 4th Edition.
- Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure. Scandinavian Journal of Rehabilitation Medicine. 1994. 26 (3): 115-119.
- Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ 1995; 310: 1122–1126.
- Institute of Medicine 1990.
- AAPM&R: “The Physiatrist”- October, 2008; Vol 24, #8 – www.aapmr.org
- Tenant, A. in Barat, M, Franchignoni, F. Advances in Rehabilitation: Assessment in Physical Medicine & Rehabilitation. Maugeri Foundation Books and PI-ME Press. Vol. 16, 2004
- Carl V Granger, MD; Chief Editor: Rene Cailliet, MD. Quality and Outcome Measures for Rehabilitation Programs. August 2013. http://emedicine.medscape.com/article/317865-overview#a30
Maricarmen Cruz, MD
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Isabel Borras-Fernandez MD
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Ana V. Cintron, MD
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