Skip to main content Skip to navigation

The outcome measure minefield

Derek Laidler, Physiotherapist
Wansbeck General Hospital, Northumberland

Way Ahead 2008;12(4):12
an exercise class

Health professionals in all fields of practice are coming under increasing pressure to 'validate' the services they provide. But while justifying the need for new or improved services in MS often comes easily, evaluating practice in relation to MS often proves challenging. Derek Laidler, a physiotherapist at Wansbeck General Hospital in Northumberland, describes the difficulties he encountered in identifying an appropriate outcome measure for a group-based physiotherapy intervention for people with MS.

Physiotherapists have an important role in the management of symptoms encountered by people with MS, and providing people with appropriate information and management strategies at an early stage can help prevent unnecessary problems as symptoms develop. With this in mind, I was in little doubt that the development of a group-based physiotherapy intervention would prove beneficial to people with MS who were minimally impaired.

The group exercise and education programme I devised consisted of six weekly sessions incorporating a stretching and balance programme and an educational session followed by a related practical session. Classes were held within the hospital physiotherapy department and delivered with the support of a number of colleagues within the Trust. With all the preparations for the first class in place, I was confident that the service came very close to meeting the standards required by the NICE guidelines and the National Service Framework for Long Term Conditions1-2. The one requirement that was yet to be addressed however was evaluation of the service provided.

I had initially intended to use a variety of physical outcome measures and evaluation questionnaires all tied in to EDSS. Yet I soon realised how significantly I had misjudged the practicality of this form of evaluation. With a team limited to one technical instructor and myself, the time required completing the necessary pre and post class balance, gait, and strength assessments for 10 participants would only leave enough class time to welcome them into the room. It also seemed likely that the positive feedback on evaluation questionnaires was more a reflection of gratitude for providing a service rather than a genuine reflection of the quality and relevance of the classes.

The problems I came up against forced me to re-examine what I was trying to achieve by providing the service and therefore to consider more rationally how to evaluate it. My initial ideas seemed more like an attempt to produce irrelevant information simply to proclaim that the service was being 'evaluated'.

Having decided what exactly I needed to evaluate, I was now faced with a new challenge - I had no idea what evaluation tool to use or whether a suitable one even existed. I was looking to evaluate the impact of a multidisciplinary and multifactorial service which hopefully impacted positively on numerous aspects of a person's life. Whilst I accepted that I was unlikely to find a 'perfect' measure, I didn't expect the exclusion process to prove so complicated.

The MS Trust information service helped to identify a number of potentially useful outcome measures: TOM, MSQOL-54, SF-36, FIM, MSIS-29, AI, RMI, LMSQoL - to name just a few. However, a closer investigation of the literature relating to the reliability and validity of these measures proved less than helpful when I came to realise that they all had their merits and very few could be ruled out as unsuitable for my needs.

I eventually settled on one outcome measure - one I believed to be sensitive enough and wide ranging enough to properly evaluate the impact of the six week programme. Which outcome measure I chose is not important; I could have picked one of many. The important thing that I learnt from the whole process was that in order to evaluate my practice, it was to vital to be clear in my own mind exactly what I was evaluating and what I wanted the service to achieve. These questions not only helped me to find a suitable evaluation tool, the reflection involved actually helped to shape and improve the service provided by my NHS Trust.

Acknowledgements

I would like to thanks Serena Hartley for her advice and assistance in setting up the classes.

References

  1. National Institute of Clinical Excellence.
    Multiple Sclerosis: management of multiple sclerosis in primary and secondary care. NICE Clinical Guideline 8.
    London: NICE; 2003
  2. Department of Health.
    National Service Framework for Long-term Conditions.
    London: DH; 2005.

Return