Ask Mike Reinold Show

Outcome Measures in Physical Therapy

Outcomes measures in physical therapy are often seen as helpful for some and a huge burden for others.

There are limitations. And while insurance companies tend to love them (maybe for the wrong reason), they aren’t always helpful for us determining our treatment approach.

Here are our thoughts on the pros and cons of outcome measures in physical therapy.

To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 244: Outcome Measures in Physical Therapy

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Show Notes



Transcript

Student Katie Stone:
All right. We got JD from Minnesota. He says, “Hello, Champion PTs. Do you find outcome measures to be helpful in your reasoning for patient progress? I don’t find them as helpful from a decision-making perspective. How often is it useful versus necessary for insurance? PS, who is the best arm wrestler of your staff?”

Mike Reinold:
Ooh, wow.

Lenny Macrina:
Dan Pope, Dan Pope.

Mike Scaduto:
Dan Pope.

Lenny Macrina:
Pope.

Mike Reinold:
I know. If you had to put money, I feel like we should do a NCAA bracket, right because it’s not fair to just say Dan Pope maybe. But maybe he gets taken down at some point. But [crosstalk 00:02:12]-

Lenny Macrina:
He’s probably done this before.

Mike Scaduto:
Yeah. He’s probably competed in some weird New Jersey arm wrestling competition.

Mike Reinold:
That’s probably true.

Dan Pope:
Big in elementary school, I tell you what.

Diwesh Poudyal:
Jersey’s wild.

Mike Reinold:
Has anybody here actually participated in an officiated arm wrestling event?

Mike Scaduto:
Absolutely not but Dan Pope, I promise I’m coming for you.

Mike Reinold:
Awesome. All right. Good question, JD. So outcome scales and what I like what JD said for outcome measures here is that, is it helpful… He’s asking from a decision-making perspective, meaning is he going to do something different, is he going to treat differently? Is he going to change his treatment progression based on an outcome of a subjective scale? Or is this just something to document progress for insurance? So who wants to start with this one? I think this is a good question. Dan yeah, you got some thoughts on this?

Dan Pope:
Yeah, I understand what you’re saying. I mean if someone has an Achilles rupture and you use them in a lower extremity functional scale, which maybe insurance company wants, there’s maybe two questions on that whole list that are relevant to their injury. It may look like they’re making no progress whatsoever. They get cut off by insurance it’s a huge pain in the butt. Right? So often times we’re trying to find that right outcome measure for the insurance companies. Specifically, what I find is really helpful for my decision-making and my progress is that patient-specific functional scale. So it’s that whole pick an activity. The athlete wants to get better. The individual wants to get better at and rate it on a scale of zero to 10. How good are you doing this movement with your injury in mind? So someone that has a shoulder pain, a bench press might be a five out of 10, right?

Dan Pope:
But someone who has shoulder pain, a jump rope might be a 10 out of 10. The jump rope doesn’t affect their pain whatsoever. I will write down all the movements that that individual wants to get better at. And they just rate it on a scale of zero to 10 and I can see exactly where they’re at and I can see how they progress along a period of time. The other thing that’s really helpful with this is that based on the number that they give me, I can get an understanding of how much I have to modify their training. Right? So if bench press is a five out of 10 and they’re not tolerating it very well, I need to come up with some sort of modification for that, but let’s say someone’s overhead press an eight out of 10. Okay. Overhead press, probably doesn’t need to be modified as much.

Dan Pope:
We have to be a little careful with the volume that the person is being thrown into. Let’s say, they’re going to CrossFit class. And the shoulder feels decent with overhead press, but there’s a thousand overhead presses in a given workout. We still probably need to modify that. And I actually use that information to send to the individual’s coach or personal trainer so that they have an idea of how they need to modify. And over the course of time, we run it again and see if they’ve made progress. We change modifications based on that. So it’s very much an outcome measure that helps me make decisions and also helps the people that my client is working with as well.

Mike Reinold:
Love it. And man, I like how you broke the mold a little bit and said, I’m going to come up with my own outcome scales to an extent, which I think is kind of really cool way of doing it because you’re right. Sometimes it’s like trying to fit, what is it, a square peg in a round hole. Sometimes you kind of figure out a better way to do it. And then heck man, I don’t know. You know what I thought of right there, somebody graded themselves as a six out of 10 with let’s say an overhead press or something. That’s what they want. I mean, I’d have no problem documenting that they have a 40% deficit in subjective function of their overhead press. I mean, what a cool way to document it. I like that. So Len how about you? I mean, obviously you deal with a lot of post-op, post-op knees, that sort of thing. What are we using with that? And what’s your experience been lately?

Lenny Macrina:
Yeah, I’ve tried with some of the subjective scoring, cause they’re out there they’re validated and they’re reliable. So I was like, okay, let me see if I can incorporate this because it’s something I never did. And I’m doing this, understanding that we don’t take insurance directly. So I’m doing this for my own thought process in the person’s ability to assess themselves. I don’t have to submit anything to an insurance company. Unlike what the question asked. And my experience with using these is I treat a lot of high school guys and girls, females, and they just completely lie about their scores. I mean, just like they are ready to get back to their sport at four or five, six months after surgery, mentally. Now I put this on social media recently. I think it was on Twitter and people, we went back and forth in a nice discussion.

Lenny Macrina:
And they said, well, give them these quizzes. Give them these questionnaires after they do some kind of specific functional tests, a hop test, something like that and see if they still rate themselves. And that’s a good point. Maybe I give it to them at the wrong time. I don’t know, but I still see a lot of my athletes are rating themselves much higher than what I would perceive them at. So whether it’s a Tampa scale, an RSI scale, any kind of ACL outcome scale, looking for kinesiophobia of their movement. They just rate themselves so much higher than I’m observing because they just want to get back to their sport.

Lenny Macrina:
So maybe for somebody who I’m observing is fearful of getting back. Maybe they are showing signs. Maybe they are still walking with a limp. Maybe I want them to do something. And they look at me like deer in headlights. Like they are afraid to do it. And maybe that would pull that out, but I’m observing it clinically. So I don’t know what the questionnaire is going to tell me much more. So I’ve kind of gotten away from using them because I still feel like I can read my athlete, observing them doing stuff better than almost any questionnaire I give them, but that’s [crosstalk 00:07:42] going against, yeah, yeah.

Mike Reinold:
Well, I was going to say, so going with JD, you kind of agree with JD a little bit where he’s not sure how much it does. So, I guess insurance is real. I mean, you have to keep that in mind. So I don’t know, Lisa, Dan, are these pretty big, insurance companies put a lot of credibility in these outcome scales?

Lisa Russel:
Yeah [crosstalk 00:08:07].

Mike Reinold:
Dang it.

Lisa Russel:
Way way way too much. And it’s everything Lenny was saying, or in what Dan pointed out, with the Achilles example, you choose your best outcome measure, but it doesn’t always help you. So then I feel like it creates more work for you because then you’re having to over extra triple justify elsewhere in your paperwork, why that patient needs to continue to come to therapy. And in an insurance-based practice, there’s so much paperwork anyway. So my goodness, if you just removed that piece, which they require, they a hundred percent require an outcome measure of some sort. But if you’re almost having to just fight against it half the time, but yeah, it’s not easy.

Dan Pope:
Yeah. I have a lot of thoughts about this. Just arguing with a whole bunch of insurance companies, what’s really tough is that insurance companies like specific outcome measures and these specific outcome measures don’t always capture function, right? Like I said before, if you have someone with an Achilles rupture and you give them an LEFS, right, which insurance companies generally like, it’s not going to show much progress, but they still have big-time functional deficits, even though the LEFS looks awesome. And then the insurance company is going to utilize that information to cut that person off because it looks like they’re doing great. When in reality, you’re not capturing the problem. And if you use an appropriate outcome measure, it might not be validated. The insurance company might not reimburse just because they don’t understand that outcome measure. So you’re playing this game, right.

Dan Pope:
It’s very challenging to try to find that right outcome measure they actually will utilize, and the other thing that’s really challenging, like Lenny’s saying is that people don’t always understand how to fill out the outcome measures. Right? They’re supposed to be honest, but often times they’re going to say they’re doing terrible because they want more insurance reimbursement. They keep on saying they’re doing terrible. They show that they have a problem, but the insurance company says, “Hey, you’re not making progress. We’ll cut you off.” Right. That comes to this aim where you’re trying to tell people how to fill out outcome measure. And now you’re skewing the results. All clinics are doing this because they want their patients to get the care they need. Right. So it’s just a very challenging system. Right. And I understand why they’re trying to do it. I mean, PT can very easily just work with someone forever and do something that’s not helpful for them. But the other side of the equation is that it’s an imperfect system and it’s very frustrating and it creates a lot more work for the physical therapist.

Mike Reinold:
Yeah. Super gameable it seems, right too. And I think we talked about that with the students yesterday. I think Katie said that, or somebody brought that up too, is it’s super gameable. I mean, you can just lie or you’re confused, you don’t understand the question. Well, you know what I mean? Super interesting. So I think that’s a good summary. I mean, Mike, you want to add anything? I mean…

Mike Scaduto:
Oh, I was just going to say from a purely clinical perspective, taking insurance companies out of it, you’re constantly assessing. So if you’re introducing a new exercise, say you’re going from a bilateral landing drill to a unilateral landing drill, the unilateral landing drill is your outcome measure for how effective your bilateral landing drill was. If you prepared them for that drill, you’re going to be able to tell, so I’m just constantly assessing. And that’s what kind of guides my decision making process.

Mike Reinold:
So, yeah, I think we agree with JD. I mean, we don’t feel like these outcome measures, especially the subjective ones, that are mostly subjective-based ones. Right. Really probably guide us enough. Right. So I’ll give a little credit to outcome measures for maybe one thing. If you’re trying to justify to somebody their lack of progress or that they’re not quite ready or something like that, and you want to pull that out and show them that their score is too low or they don’t meet criteria to start something, as long as you have an honest conversation, maybe you can use it for that sort of thing. Or you could use it to monitor progress.

Mike Reinold:
There are a couple of potential positive reasons why you do it, but it’s going to make a big difference on our treatment approach? Probably not. And yeah, it’s a super gameable thing. So, I think we’re in a jam a little bit as a profession. If insurance companies are putting so much credence into it, that’s an annoying thing. Right. But they probably are because they know all the same reasons we do, and they they’re using it as a reason to be negative. Either like Lisa said, annoy us. Right. So that way we just stop. Right. Or like Dan said to either justify stopping, because they’re either doing too good or too bad. That’s crazy.

Mike Reinold:
Like that they have a tool that they’re making us use to justify these things. So anyway, whatever, insurance is evil, right. We’ll end on that. How about that? But awesome. So good question, JD. Hopefully that was helpful. I think we agree with you that there’s some issues. So, I don’t know if we shed much light on that, but at least a little bit from our perspective, some of the pros and cons of these things. So, great question. If you have more like that, head to mikereinold.com, please click on that podcast link, ask away and be sure to subscribe to us on iTunes and Spotify so we keep doing this. Thank you so much. See you guys next episode.