Geriatric Functional Performance Measures

This text-based course is an edited transcript of the webinar Geriatric Functional Performance Measures, presented by Sally Stillings, MA, PT, MPT, CHT

Learner Outcomes

Background

Focus on Function

We have all heard so much in our lives as physical therapists that it's all about function. We focus on function from the time that we start PT/PTA school and we learn that creating good programs to help with function is absolutely key to helping our patients improve and meet their goals. In fact, if you look at the APTA definition of the Physical Therapist Scope of Practice, you see that word function multiple times.

"Physical therapy is a dynamic profession with an established theoretical and scientific base and widespread clinical applications in the restoration maintenance and promotion of optimal physical function. Physical therapists are healthcare professionals who help individuals maintain, restore, and improve movement, activity, (and", guess what)? functioning, thereby enabling optimal performance and enhancing health, well-being, and quality of life.  Their services prevent, minimize or eliminate impairments of body functions and structures, activity limitations, and participation restrictions" - American Physical Therapy Association

Of course, we know that those goals of enhancing health, well-being, and quality of life is basically why we're all PT practitioners. Understanding function and how to address it are both essential to being good therapists and this is especially important as a component of therapy for older adults, those who are age 65 or more. As we age, some decline in functional abilities is normal but major declines in function can lead to hospitalization, a need for long-term care, and even increased mortality rates. In older age groups, we know that even relatively small improvements in function can have a major impact on the patient's independence, quality of life, and health care utilization. This is just one of the many reasons that functional performance measures are essential elements in the clinical toolbox of every therapist who works with older adults. 

Okay, so we agree that understanding and addressing function is really essential to providing good therapy, especially with older adults, but why do we need standardized functional performance measures? Why can't we just measure all those things we learned about in school, range of motion, strength, and so on and work from there? Well, let's take a little closer look at that.

Why Do We Measure Functional Performance?

There are four main reasons. Those reasons include:

• Screening- You may use the geriatric depression scale to screen a patient who's come to you for therapy but is not doing well and suspect he or she has some depressive symptoms
• Description- It helps us understand where that patient is functionally today
• Prediction- Where might that patient be functionally in the future if we help him or her? 
• Outcome evaluation-To see what difference our interventions made to that particular patient and is extremely important in today's climate  

So why do we measure functional or why do we use functional performance measures to measure function as opposed to simply using measures like goniometer and manual muscle testing and so on? Well, the main reasons are because functional performance measures can provide an accurate and objective record of patient performance, they allow comparison with normative data, in other words, they give us the ability to compare a patient's performance with age and sometimes gender related peers. They provide prognostic indicators, that is they give us objective data to predict possible outcomes for that patient, such as fall risk.  Functional performance measures can help identify specific impairments so that we can develop an appropriate PT plan of care. And finally, functional performance measures support the development of appropriate patient-centered goals. Patient-centered goals are goals that focus on change that is meaningful to that particular patient.

History

The use of standardized tools to assess function is actually a fairly recent innovation in rehabilitation medicine. The first broad-based functional performance measures were not introduced until the last three decades of the 20th century. Before that time therapists had to use observation and subjective assessment to try to determine each pain level of function and then to understand how specific therapy interventions affected that patient's function. Therapy was based mostly on a good understanding of anatomy and physiology combined with a common-sense approach as to what seemed logical for a given situation. This kind of subjective approach was especially difficult with older adults because we know they often have a more complex medical history than younger adults as well as age-related physical changes that directly affect their function. Good therapists during those early eras developed a knack or a sort of intuitive sense of what worked and what didn't in rehabilitating their patients. We also know that common sense and intuition may sometimes be wrong because they are based on limited human understanding within a given social and cultural environment. Just as one example, before the germ theory of disease became accepted in the late 19th century, physicians felt that bad air or unbalanced body humours were what caused illness, which led to all kinds of inappropriate treatments that had seemed perfectly logical to them at the time. 

Prior to the mid 20th century, there was very limited scientific or research evidence to support the role of function within therapy assessments, interventions, and outcomes. Therefore there was little standardization in how function was measured. In 1971, the first definition of functional assessment was published by a gerontologist, MP Lawton. He said that functional assessment was "any systematic attempt to objectively measure the level at which a person is functioning in a variety of domains." His article, which is listed in your references also discussed various techniques for assessing the function of elderly individuals in several different areas including physical health, physical self-care, instrumental activities of daily living, mental and psychiatric status, social roles and activities, attitudes, moral and life satisfaction. 

He wanted to cover all of the bases. Those first functional performance measures that were created during the 1970s were still very subjective and they didn't have much research supporting them. So for this reasoning, in the early 1980s, most clinicians still thought of functional assessment as an attempt to measure something that really was essentially unmeasurable. Throughout the 1980s and 1990s that finally began to change. Research had been expanding exponentially across all medical disciplines, including therapy. There became a major focus in the rehab world on developing better functional assessment tools. So many of the instruments that we are familiar with now were first introduced during those decades of the late 1980s and the 1990s.

Theoretical Background 

There were several important reasons for this change that I just mentioned to you. Dale Avers describes two of the primary drivers behind the use of performance measures. These were evidence-based practice and globalization, in particular the universal perspective of health. This Universal perspective of health that she mentions is represented in the World Health Organization's 2001 International Classification of Functioning, Disability, and Health.

We are all familiar with that model that we can see in Figure 1. The ICF model is a conceptual framework to understand human disability. It's widely used in both physical therapy and occupational therapy to help structure and support the rehab evaluation process. Instead of focusing solely on physical contributors to a disability, this model began to look at the whole person within their environment. The ICF model looks at the relationships between various domains that include an individual's health condition and any diseases or disorders he or she may have and how that's related to body functions and structures. The individual's ability to complete activities, the person's level of participation in family, work, community, and so on, all of that within the context of environmental and personal factors.