Incorporation of
Quantitative Tools and Instrumentation
Evidence Based Practice
Objectives
List six tools from the clinical tool box
Define the functional measure for each tool
Integrate measures into existing service delivery model
Compare and contrast low, medium and high tech tools
Research vs. Ritual
Practice
EBP
Dr. Lee Kirby, RESNA 2006
Current Assessment is based on RITUAL:
Subjective observation of the client
Rehabilitation knowledge or history with similar clients
Funding perceptions
Supplier / Manufacturer recommendations
“We used it once, let’s try it again.”
It Should be a Synergy
Research Evidence Based
Practice
Product Development
One Great Example:
Smartwheel User Group
Clinicians Deserve
“SMART” Tools….
Provide objective assessment of interventions
Compare clients to an evidence based body of research
The SmartWheel User Group
Formed in April of 2004 to:
Create a Standard Clinical Protocol
Create a Central Database
Shared among all SmartWheel users
Only Standard Clinical Protocol data files
Write Clinical Pathway and Protocol Guidelines for applications
Provide feedback to Three Rivers on how to improve the SmartWheel
There are now over 100 members
User Group Functions
Collection and contribution of protocol data into a central data base
Recent PVA grant to make the data base accessible to clinicians and researchers
Maintenance of the data base
Development of clinical pathways and application protocols
Provide information on utilization of quantitative data in clinical practice
Recommendations for software improvements
Grant funded clinical education on Guidelines for Upper Limb Preservation and the Smartwheel
Categories of Evidence-Based Practice
External Evidence
What are published outcomes for similar clients with similar requirements?
Knowledge and Skill of Rehabilitation Professional
What has worked well for similar clients?
Did we document it?
Individual Evidence
What are the characteristics of the Human, Assistive Technology, Activity, Context?
Evidence Based Practice: Ideal
External Evidence
Practitioner Experience
Individual Evidence
Knowledge Translation
Evidence Based Practice: Reality?
External Evidence
Practitioner Experience
Individual Evidence
Knowledge Translation?
Why quantitative data are important…
Demands from third party payers and government funding agencies
Limited time for assessment and reassessment
Disconnect between assessment and implementation
Need to validate clinical practice and product development
Support / documentation for subjective clinical findings
Provides information for justification
Strengthens the profession!
Database Development
Standards of Practice
Developed to :
Define a profession
Address scope of practice and methods
Provide a guide for conduct and a code of ethics
APTA/AOTA
RESNA
ARATA
NRRTS
Others?
Clinical Practice Guidelines
Focused on specific clinical practice related to one area
Multidisciplinary
Collaboration with clinic, research, product development
Becomes relevant to standards of practice
Therapists and Engineers – Working Together
Therapist: Human Evaluation and how the person interacts with the AT
Engineer: AT analysis as it relates to the Human Evaluation
Same process, different perspectives:
Overlap between professions
Final focus on environment and the task
Steps to Equipment Selection
Analysis: describing in quantitative terms the current situation (Gathering data)
Synthesis
Brainstorming, incorporating objective and subjective information
Evaluation: Which brainstorm is best?!
Service Delivery Process
Referral and Intake
Recommendations and Report Implementation
Follow-up Follow-along Based on Cook
& Hussey
Assessment
Requires Quantitative Tools
Analysis Describe in qualitative & quantitative (via tools) terms the current situation
Synthesis Brainstorming
Evaluation Which “Brainstorm” is best based on new qualitative & quantitative (tools) information?
Does “Brainstorm meet qualitative & quantitative goals defined in Analysis?
NO: Re-analyze using new qualitative &
quantitative goals
YES: Continue to Recommendation
& Report
Expanded View of Assessment
Unable to answer questions
without tools &
instrumentation
Opening the
Toolbox:
Types of Tools
Low Tech: Analog in nature, low cost, portable and relatively low precision. (goniometer, tape measure, bathroom scale)
Medium Tech: Digital in nature, do not require
external power, low to medium cost, portable, and medium to high precision. (camera, laser distance meter)
High Tech: digital and application specific,
medium to high cost, transportable or stationary, medium to high precision; requires more training to utilize (SmartWheel, pressure imaging, Balance Master)
Low Tech – Tape Measure/Measuring Wheel
$2.00-$50.00
Available for purchase at any local store or in a catalog
No special training required
Most people are familiar with use
Other Low Tech Tools
Analog angle finder
Goniometer
Stopwatch
Bathroom scale
Fish scale
Hand tools
Goniometer
Measure angles
Part of physical evaluation:
Set practice guidelines
Specific landmarks
Specific to position
Understand the basics
There are Accepted Guidelines for Measurements
Norkin and White; Measurement of Joint Motion:
A Guide to Goniometry, 3rd Edition, FA Davis, 2003.
Green and Heckman; The Clinical Measurement of Joint Motion, 1st Edition, American Academy of Othropedic Surgeons, 1994.
Magee, David J; Orthopedic Physical
Assessment, 4th Edition, Elsevier Health Sciences, 2005.
Norkin and Levangie; Joint Structure and Function, 3rd Edition, FA Davis, 2001
Axle Position
Know what your are looking for:
Position relative to the axis of the shoulder?
Measurement relative to the frame of the chair?
Dependent on order form
Most common – eyeball axle position in relation to the client
Using tools is more precise:
Plumb bob
Laser distance meter
Laser Distance Meter
Medium Tech – Laser Distance Meter
$200-600
Available for purchase and any major hardware store
30 minutes of training and 15 minutes of use
Reading manual, hands on trials
Easy to use once trained
Other Medium Tech Tools
Digital caliper
Digital inclinometer
Digital force gauge
COMPASS software
Language Activity Monitor (LAM)
Camera
Power tools
Digital Camera
Digital cameras – what shots should we take?
Side view (l and r):, front, back,
Kneeling and fill the frame; level camera angle
Digital Camera
Quickie LXI - Forward Axle Position Quickie LXI - Rearward Axle Position
Compass Software
Compass Switch Press Results
Correct Trials
Avg. Trial Time (s)
Avg. Press Time (s)
Avg.
Release Time (s)
Head Right 5/5 8.5 7.8 0.64
Head Left 5/5 9.0 8.5 0.57
Head Right - Embedded
4/5 17.4 11.1 6.32
Right Hand 2/5 19.4 15.6 3.8
Right Finger 4/5 11.2 8.6 2.5
NOTE Average Release Time
High Tech – SmartWheel
$22,500
44 clinical wheels in use throughout the world
Basic knowledge of computer applications and windows programs required
Multiple training sessions may be required implement clinical use
Easy to use once trained; interpretation tricky; may require tech support (internal)
SmartWheel
Other High Tech Tools
Wheelchair scale
Motion analysis
Force plate
Pressure imaging
SmartWheel
(WC propulsion)
Data Logger
Accelerometers
Motion Analysis
Applying the Tool Box
Case Examples
Alignment Laser Tool
Digital inclinometer
Seating
Caster housing
Ramps
Smart Wheel
Wheelchair Comparison
Aluminum Titanium
Data Analysis - Tile Floor
Al Ti
Peak Torque (N-m) 12.2 9.7
Avg Torque (N-m) 4.9 4.4
Stoke Smoothness - Peak/Avg
2.5 2.2
Ease of Propulsion - deceleration (m/s2)
0.19 0.11
*controlled conditions
How to use this information
Develop your own tool box
Always have them with you
Learn to use them correctly
Be consistent within your facility/program
Have a variety of options
Look at facilitating multiple visits
Be efficient!
Be open minded about changes
Keep up to date with your professional organizations
Research
Guidelines and practice standards
New tools
Limitations of the tools
Cost and availability
Limitation to expectations….
Requires clinical judgment calls
Doesn’t always answer our questions
Inter and intra-rater reliability
Translation to practical application
If you don’t use it…
If you don’t know when to use it…
Your not sure of the value of using it…
Tools don’t always lead us down the
right path….
Future applications
What tools can we use that are already developed?
What tools do we need?
