Implementing outcome measures—The military physical therapist’s perspective

Abstract

Outcome measures are a necessary part of rehabilitation. Various methods and measures have been used to assess patient progress and as criteria for discharge from inpatient care, routine outpatient care, and long-term rehabilitation in a variety of patient populations for many years. In the sports medicine setting, outcome measures become especially important in determining when injured athletes are able to return to the playing field. In a military setting, similar to sports medicine, the use of outcome measures is necessary to help determine when the patient is able to return to duty or deploy. In the case of servicemembers with traumatic limb loss, the ultimate goal for many is to return to Active Duty as a tactical athlete and member of today's Army, Navy, Air Force, Marine Corps, or Coast Guard. Determining the functional level and ability to meet the demands they may face is a challenge for the military healthcare system (MHCS) and more specifically for the providers rehabilitating servicemembers with major limb loss. The Armed Forces Amputee Patient Care Program is composed of three distinct centers: the Military Advanced Training Center (MATC) located at Walter Reed National Medical Center, the Center for the Intrepid (CFI) at Brooke Army Medical Center, and the Comprehensive Combat and Complex Casualty Care (C5) program center at the Naval Medical Center San Diego. Physical therapists caring for servicemembers with amputation at all three centers are particularly invested in making sure that the outcome measures we use systematically are appropriate. One of the challenges we faced early on was that most of the outcome measures used for people with amputation did not adequately measure the higher level of that servicemembers with amputation need to return to duty. The majority of combat-related amputations occur in relatively healthy males under the age of 35, a very different population from the civilian population with amputation, in which the vast majority are older and have comorbidities such as diabetes mellitus, peripheral vascular disease, and cardiovascular conditions. The outcome measures used in the civilian amputee population suffer from a ceiling effect when used to assess the typical young, physically active servicemember with amputation. A new paradigm and approach to testing high-level in people with amputation was needed for use in the military environment. In practice, there are already many sophisticated and instrumented outcome measures in use in the Armed Forces Amputee Patient Care Program. These measures include those obtained in the motion analysis/gait laboratories and the Computer Assisted Rehabilitation Environment virtual reality (VR) systems. Motion analysis is a proven technology, and the use of VR with patients with amputation appears to be useful in both patient treatment and research activities. The benefit to the patients in both of these systems is the real-time feedback they receive relative to weight bearing, lateral weight shifting, agility, pelvic obliquity, and shoulder symmetry. The learning that occurs with regard to agility, base of support, center of gravity, and proprioception is hidden underneath the facade of a video game. Biomechanical testing provides very detailed information on kinetics and kinematics of motion, but requires sophisticated equipment and expertise. These systems do not provide a relatively easy-to-administer test that culminates in a usable summary of abilities similar to the Amputee Mobility Predictor. Self-report measures can be used and are easier to administer than either biomechanical testing or performance-based tests. However, self-report measures, while they can be useful, are generally not strongly associated with actual performance-based measures. Many researchers feel that self-report measures alone do not adequately assess the broad concept of function and that performance-based measures are needed to capture the whole picture. …