Section 1: Foundations of Examination

INTRODUCTION

Clinicians use history questions during a clinical examination to explore how the patient's condition affects their quality of life. Does it limit their activities and, if so, how? Following the history portion of the examination, clinicians may use outcome-measure instruments to determine the patient's current functional status, the effect their condition has on their life, and the extent to which an intervention is helpful at minimizing their symptoms. Initially, outcome measures were primarily administered for research, but their use has expanded into clinical practice. Functional outcome measures and disability questionnaires are now completed at regular intervals to document a patient's progress over time. When collectively examined, outcome measures form the basis of data used to determine the effectiveness of an intervention. Both generic and condition-specific patient-rated outcome measures capture the effects of a condition across the disability spectrum.¹

USE OF OUTCOME MEASURES

The integration of patient-based outcome measures into the examination process is central to patientcentered care. Patient-rated outcome measures provide a standardized, objective means of quantifying a patient's impairments and determining how to best tailor an intervention to a specific patient. For example, a patient who complains of knee pain that limits their ability to run more than 20 miles would likely benefit from a different series of interventions than a patient whose knee pain prevents them from walking less than 100 yards.

Interpreting the results of a patient-based outcome measure requires a basic understanding of the instrument, its target population, and what change in the score is meaningful. Many outcome measures have been validated on nonathletic populations and therefore are not adequately responsive to assess change or disability in an athletic population. Consider, for example, a basketball player who fully participates in practice, yet reports lingering effects from an ankle sprain. This person may score the highest possible total on a patient-rated outcome measure but still may not be at their preinjury performance level. Some outcome measures incorporate a sports subscale to avoid this ceiling effect, that is, the point at which the instrument's score is no longer meaningful.

Using the same outcome measure on the same patient for the same condition provides information regarding the patient's progress. Two values, the minimal detectable change (MDC) and minimally clinically important difference (MCID), are important to interpreting results. The MDC describes a change that exceeds the boundaries of measurement error. For example, if a goniometric measurement has an error of plus or minus 5 degrees, a daily change of 4 degrees in a patient's ROM does not constitute a detectable change. A detectable change, however, may not be important to the patient. The MCID value represents the smallest amount of change that is perceived as beneficial to the patient, which should influence clinical decision-making about injury care.¹ (Refer to Chapter 3 for more discussion on these values.)

Quantifying the extent of ...