Clinical Justification & Outcome Measures

The progressive evaluation of physiotherapy treatment outcomes is an integral part of professional accountability and is a requirement of the Australian Physiotherapy Competency Standards 1994-2002.  The Australian Physiotherapy Competency Standards make specific reference to the principles and practice of physiotherapy assessment and evaluation.

Outcome measures are tools that enable the treating physiotherapist to undertake an evaluation of physiotherapy treatment.  Outcome measures include, but are not limited to, an evaluation of the change in patient impairments, activity limitations (disability), participation restrictions (handicaps), or quality of life.  Some of the more common outcome measures are available to download at the bottom of this page.

The treating physiotherapist should select one or more valid, reliable and sensitive outcome measures relevant to a client’s individual clinical needs and treatment goals.  Where relevant, it is preferable to measure physiotherapy outcomes in the domains of activity limitation and/or participation restriction.  It is not appropriate to restrict the measurement of physiotherapy outcomes to the impairment domain alone, because the treating physiotherapist can not accurately predict dysfunction from the exclusive measurement of impairments.

As part of a clinical justification for physiotherapy, outcome measures should be used to:

• Evaluate and document the demonstrable benefits of physiotherapy in relation to treatment goals
• Evaluate the need for continued physiotherapy to maintain or improve patient status
• Help evaluate the cost benefits of physiotherapy in relation to treatment goals
• Identify, document and act on factors that may compromise treatment outcomes or predict poor outcomes
• Determine and document when physiotherapy treatment should cease or where relevant, to determine and document when the client should be referred to another professional within the multidisciplinary health care team

Selecting and utilising outcome measures

Outcome measures that have been formally validated in the scientific literature are preferable to those that have not been validated.  However, where there are no validated outcome measures that are relevant to the needs and treatment goals of a client, or where the treating physiotherapist deems it more appropriate, the physiotherapist should use customised outcome measures that are directly related to the client’s treatment goals.

In general, the treating physiotherapist should:

a) Set treatment goals in consultation with the client
b) Take appropriate baseline outcome measure(s)
c) Use (an) outcome measure(s) to evaluate the physiotherapy treatment against the baseline measure(s) and the treatment goal(s)
d) Communicate the treatment evaluation process and outcomes to the client and, where relevant, to a third party service purchaser

Evaluating physiotherapy outcomes

Any evaluation of physiotherapy treatment provided to a client should measure outcomes directly linked to the physiotherapy intervention ie evaluate the outcomes over which the treating physiotherapist has had significant influence. 

Conversely, if the treating physiotherapist has not had a significant influence over particular outcomes, such as return to work or the utilisation rate for home services, then any third party evaluation of physiotherapy treatment provided to a client should not be related to outcome measures that effectively measure the outcome of a total rehabilitation program. Instead it should relate to specific measures used by the physiotherapist to evaluate the client’s progress towards treatment goals. 

Best practice checklist for clinical justification

The APA believes it is useful for treatment documentation to include a ‘quality checklist’ to encourage treating physiotherapists to use outcome measures to optimal effect.  For example:

• Have you set treatment goals?
• Have you taken baseline outcome measures?
• Have you selected an outcome measure that is relevant, reliable and sensitive?
• Have you measured treatment outcomes against the baseline and against treatment goals?
• Have you identified any other factors that may compromise treatment outcomes or predict poor outcomes and, if so, have you taken action to ensure appropriate service provision?
• If you have not achieved your treatment goals within the treatment program you envisaged, have you considered referral to another physiotherapist or another professional within the multidisciplinary health care team?

The Lower Extremity Functional Scale Binkley et al (1999)	Measures the degree of difficulty experienced by patients with lower limb problems whilst carrying out 20 common activities.
The Upper Limb Functional Index Gabel et al (2006)	Provides information on how upper limb problems affect the patient's ability to manage aspects of everyday life.
Oswestry Disability Questionnaire Fairbank & Pynsent (2000)	Provides information on how back or leg pain affects the patient's ability to manage aspects of everyday life.
SF-36	The SF-36 is a copyright questionnaire. There is an annual license and registration fee for the use of SF-36 and SF-12 materials including the questionnaires and scoring manuals. Information is available from: Australian Health Outcomes Collaboration: http://chsd.uow.edu.au/ahoc/