The main purpose of the clinical examination is to gather information about the patient’s movement disorder and level of functional ability (Freeman 2002). Initially, observe the patient and try to draw conclusions about what they are able to do unaided. It is important to remember that at no point must the patient be put at risk. It is part of the physiotherapist’s role to ‘risk assess’ what is reasonable to allow the patient to attempt independently and what they need help with in order to be safe. Objective assessment should include assessment of active and passive range of movement and strength. This will guide observation of posture and movement analysis in sitting, lying to sitting, sit-to-stand, transferring from bed to chair, standing and walking, etc. The exact activities observed and/or assisted will depend on the level of ability of the patient. Once the patient has been given the opportunity to demonstrate what they can do unaided, assistance can then be given to ascertain what the person can achieve with help. This is where assessment and treatment begin to merge into one and the same thing. The assessment begins when initial contact is made. For instance, observing the person’s gait when they walk into the room often gives a more accurate picture of functional gait pattern than when the person is asked to walk while being watched.

International Classification of Functioning, Disability and Health

The WHO provides a useful framework and common terminology for describing and measuring the consequences of disease and the impact that rehabilitation may have on them (Edwards 2002). This is the International Classification of Functioning, Disability and Health, known more commonly as ICF, which provides a standard language and framework for the description of health and health-related states. This describes changes in body function and structure (impairment), what a person with a health condition can do (their level of ability), as well as what they actually do in their usual environment (their level of participation).

• ‘Body function’ considers the loss or abnormality of body structure, or of a physiological or psychological function.

• ‘Activity’ refers to the nature and extent of functioning at the level of the person. It may be limited in nature, duration or quality. It considers if a person can do a task and how well they do it.

• ‘Participation’ refers to the nature and extent of a person’s involvement in life situations in relation to impairment, activities, health conditions and contextual factors.

Research by the Greater Manchester Outcome Measures Project team identified the domains that physiotherapists need to measure during clinical assessment in neurological patients using the ICF as a framework. (Tyson et al. 2008). They suggested neurological assessments should include assessment of:

Impairments (problems in body functions or structures)

• ataxia/co-ordination

• balance impairment: postural sway

• oedema

• muscle tone/spasticity

• pain

• personal fatigue

• posture impairment: alignment, weight distribution

• range of movement/contracture

• sensation and proprioception

• subluxation

• walking impairment: speed, endurance, step length, cadence, etc.

• weakness

Activities (ability an individual has in executing activities)

• balance activity – sitting, standing, dynamic, supported, assisted

• mobility activity – bed mobility, sit-to-stand, transfers, walking, stairs/steps, etc.

• upper limb activity – grips/grasps, dexterity, activities of everyday life

• walking activity – in/outdoor, assistance, use of equipment, independence.

Ultimately, physiotherapy aims to improve an individual’s ability to undertake activities to improve function, participation and quality of life.

Outcome measures

Objective measurement of function is core within rehabilitation, with both clinical guidelines and professional bodies such as the Chartered Society of Physiotherapy (CSP) explicitly stating that standardised outcome measures should be used. Therefore, part of the objective assessment should include use of standardised outcome measures, which provide baseline information on individual’s ability and can be repeated to evaluate effectiveness of treatment. In the current climate of limited resources and financial cuts, it is vital that physiotherapists undertake robust, standardised measures to enable evaluation of the effectiveness of their treatment at an individual and service level. It is no longer acceptable to state physiotherapy treatment is effective – we need to be able to provide evidence to justify this.

CSP core standards of physiotherapy practice (2005) standard 6

Taking account of the patient’s problems, a published, standardised, valid, reliable and responsive outcome measure is used to evaluate change in the patient’s health status.

The outcome measure should be:

• applicable to the clinical setting;

• relevant to the patient’s problems;

• related to the aims of treatment;

• standardised, valid, reliable and responsive measure;

• used to evaluate change against the aims of treatment.

Physiotherapists should:

• have the necessary skill and experience to administer and interpret;

• ensure the instruction manual is followed to administer and score.

Measurement implies the quantification of data in either absolute or relative terms. Determining the effectiveness of an intervention by measuring its effect on an outcome provides the basis for evidence-based healthcare (Edwards 2002). Outcome measures take the guesswork and subjectivity out of evaluation and can assist the physiotherapist in proving clinical effectiveness.

Outcome measures also provide a method of communication. The importance of a language of universal use among clinicians must be promoted. The focus on multidisciplinary care and the blurring of traditional professional boundaries requires, at the very least, a system of measurement that can be understood by and utilised by the whole interdisciplinary team.

There are a wide range of outcome measures available and care is required when deciding which outcome measure to use and when. The general principles to follow when developing and/or considering the use of outcome measures are:

• deciding what needs to be measured;

• selecting the appropriate outcome measure;

• does it measure what you want it to measure (reliability, validity and sensitivity)?;

• ease of use on a day-to-day basis (clinical utility).

For a discussion of outcome measurement theory and properties in rehabilitation, we refer the reader to Finch et al. (2002).

CSP website

The CSP has provided a summary of the outcome measures currently available, which have relevance to physiotherapy care interventions. It can be found on the CSP website at www.csp.org.uk.

Outcome measures should be sensitive enough to allow for measurement of changes over time. The use of a suitable outcome measure for all physiotherapy interventions is an essential part of the treatment and management process, and the clinical area of neurology is no exception.

Outcome measures in context

Physiotherapy outcome measures should be considered in the wider context of rehabilitation. Rehabilitation can be considered a problem-solving and educational process aimed at reducing disability and enhancing function in people who are affected by disease (Wade 1992). Rehabilitation principles are based upon the enhancement of activity by restoring skills and capabilities through functional retraining and environmental adaptation. Rehabilitation promotes independence and aims to facilitate the fullest potential physically, psychologically, socially and vocationally for a patient. Rehabilitation involves the recovery or improvement of function, as well as prevention of disability and the maintenance of a social role.

Irrespective of the approach taken towards rehabilitation, the ability to quantify the function is the key to successful treatment. This process involves assessment, treatment-planning, goal-setting and evaluation of outcome. The WHO ICF classification and the process of rehabilitation together provide the context for which outcome measurement is used in physiotherapy.

Table 26.1 provides a summary of the outcome measures commonly used within neurology. It is not meant to be comprehensive and the reader is directed to the ‘Further reading’ list at the end of the chapter.

Table 26.1

Outcome measures frequently used within the clinical setting

Dimension	Outcome measure	References
Impairments
Muscle strength	Hand-held dynanometer	Bohannon et al. (1995)
	Medical Research Council (MRC) grades	MRC (1976)
Range of motion	Goniometry	Norkin and White (1975)
Tone	Modified Ashworth Scale	Bohannon and Smith (1987)
Sensation	Nottingham Sensory Assessment	Lincoln et al. (1998)
Fatigue	Fatigue Severity Scale	Petajan et al. (1996)
Activity
Global activity
Generic	Barthel Index	Mahoney and Barthel (1965)
	Functional Independence Measure	Granger et al. (1993)
Disease-specific	Motor Assessment Scale for Stroke	Carr et al. (1985)
Focal activity
Gait	Ten-metre timed walking test	Wade (1992)
	Rivermead Mobility Index	Collen et al. (1991)
Mobility	Rivermead Motor Assessment	Lincoln and Leadbitter (1979)
Balance	Brunel Balance Assessment Berg Balance Scale Functional Reach Test	Tyson & DeSouza (2004) Berg et al. (1989) Duncan et al. (1990)
	Timed get-up-and-go test	Podsialo and Richardson (1991)
Upper-limb function	Box and Block Test Nine-hole Peg Test	Mathiowetz et al. (1985) Mathiowetz et al. (1985)
	Action Research Arm Test	Crow et al. (1989)
Participation	London Handicap Scale	Harwood et al. (1997)
	Environmental Status Scale	Mellerup et al. (1981)
Quality of life
Generic	Thirty-six-item Short Form Health Survey	Ware et al. (1993)
	Nottingham Health Profile	Hunt et al. (1981)
Disease-specific	Thirty-nine-item Parkinson’s Disease
	Questionnaire	Peto et al. (1995)
	Functional Assessment of Multiple Sclerosis	Cella et al. (1996)

Goal-setting

Definition

Goal-setting refers to the identification and agreement of targets that the patient, therapist and team will work towards over a specified period of time (Wade 1999a, 1999b).

Once the assessment is complete, key problems need to be identified by using clinical reasoning processes. Goals of treatment, with appropriate timescales, can be formulated with the patient and the family. Goals need to be negotiated and discussed with all parties, including the rehabilitation team, so that there is a clear understanding of what is involved in achieving them. Failure to go through this process can lead to frustration and misunderstanding for all parties, particularly the patient and the family.

The planning of goals is necessary to ensure that the rehabilitation effort is as effective and efficient as possible (Elsworth et al. 1999). Outcome is better if the goals involve the patient, are challenging and are set at different levels.

The evidence relating to goal-setting is limited, but there is a general trend towards the inclusion of goal-setting in the rehabilitation process (Wade 1999c). With the emphasis on patient-centred care and inclusion of the patient in the decision-making processes, a formal process of goal planning will help to improve the co-ordination and co-operation of all those people involved. Co-operative goal setting makes the process of rehabilitation more patient-focussed and helps to motivate the patient through the long period of rehabilitation and beyond. In other words the effects of treatment will be long-lasting and continue to be evident when treatment has ceased.

Good rehabilitation practice should involve SMART goals (specific, measurable, achievable, realistic, time-framed).

1. Set meaningful and challenging but achievable goals.

2. Involve the patient and carers.

3. Include short- and long-term goals.

4. Set goals both at a team and an individual professional level.

It is common practice to set goals for the long, medium and short term. In summary, the terms commonly used to document goals are:

• long-term goals = aims;

• medium-term goals = objectives;

• short-term goals = targets.

Wade (1999a) defines these terms as given in Table 26.2.

Table 26.2

Aims, objectives and targets

	Describes a state
Aim	Is for the patient and family
	Is in terms of a social role or functioning or well-being
Objective	Is set within the medium term
	Involves direction of change as much as achieving a specific state
	Is framed in terms of patient behaviour and environment
Target	Is set within the short term
	Is specific and often involves only one named person/profession
	May be set at any level or in terms of the rehabilitation process

Adapted from Wade (1999b).

In summary, goal-setting allows for the alignment of patient and professional goals. It is a method of ensuring that the rehabilitation team focusses on the needs of an individual patient and can help to motivate patients. It should lead to an overall improvement in treatment effectiveness and provide a method of measuring the effectiveness of treatment interventions (McGrath and Adams 1999; Edwards 2002).

List of problems and goals

Now the assessment is complete, a problem and goals list needs to be formulated. It is important to bring the problems identified as a physiotherapist together with the patient’s/carer’s perceived problems. Problems and goals need to be agreed with the patient and family. At the end of the day it is important to remember that the goals should be the patient’s, not the physiotherapist’s (Table 26.3).

Table 26.3

Problems and goals

Problem list (with date set in order of priority)

Reason for problems

Agreed goals (in order of priority)

Review date

Treatment plan

Date goal achieved, signature and job title. If not achieved state reason why

Interventions

Task-specific practice

Ultimately, the majority of treatment aims to increase ability at a task or activity, and, consequently, one approach to treatment is simply to practise the task itself. Task-specific practice – repeated practice of tasks similar to those commonly performed in daily life – is a component of current approaches to stroke rehabilitation. In the past the focus of treatment was on reducing impairments in the expectation that activities would naturally improve.

Systematic reviews of treatment interventions suggest that participants benefit from exercise programmes in which functional tasks are directly trained, with less benefit if the intervention is impairment-focussed (Van Peppen 2004). Examples of task-specific practice include practising sit-to-stand, walking and reaching activities, and are often mixed with other components, including strengthening and treadmill training.

How the intervention might work

Many aspects of rehabilitation involve repetition of movement. Repeated motor practice has been hypothesised to reduce muscle weakness and spasticity (Feys 1998, Nuyens 2002), and to form the physiological basis of motor learning (Butefisch 1995), while sensorimotor coupling contributes to the adaptation and recovery of neuronal pathways (Bruce and Dobkin 2004). Active cognitive involvement, functional relevance and knowledge of performance are hypothesised to enhance learning (Carr and Shepherd 1987).

Evidence

Most research has been undertaken on patients with stroke. A Cochrane review, acknowledged as the best single source of evidence about the effects of healthcare interventions, has been undertaken on repetitive task training for improving functional ability after stroke (French et al. 2007). This showed repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. An evidence-based review of upper limb interventions found repetitive task-specific training may improve arm function (EBRSR 2009).

UK stroke guidelines

Emerging evidence suggests that giving the patients the opportunity to practise functional activities (task-specific training) may be important in improving outcomes. The UK clinical guidelines (Intercollegiate Stroke Working Party 2008) for stroke state:

Task-specific training should be used to improve activities of daily living and mobility:

• Standing up and sitting down

• Gait speed and gait endurance

Exercise

Exercise (as covered in Chapter 13) includes stretching, strengthening and aerobic types of activities. If performed regularly with enough repetitions and appropriate duration these activities can develop into an exercise programme that will improve an individual’s range of movement, muscle strength and physical fitness.

Current literature reviewing the effectiveness of these types of exercise now shows that strengthening exercises are beneficial to many types of neurological patients in the acute, rehabilitation and community settings (Weiss et al. 2000; Romberg et al. 2004). A Cochrane review suggested that aerobic exercise to develop physical fitness in stroke patients can improve their walking speed, tolerance and level of mobility (Saunders et al. 2009).

Any activity that seeks to enhance or maintain a function or movement can be classed as exercise. Task-specific training is one such form of exercise that has been proven to improve function in neurological rehabilitation (see above).

In summary, exercise should be considered a key part of the rehabilitation programme in the acute, rehabilitation and community settings. The exact number of repetitions, intensity, how often and content are currently being looked into. The reader should review the emerging evidence base to identify what will work best.