5 Assessment of

Functional Outcomes

S
Bridget Hill electing an appropriate outcome measure is extremely challenging but central to
Andrea Bialocerkowski evidence-based practice. An appropriate outcome measure is essential to monitor
client progress, aid in clinical decision making, and evaluate the effectiveness of
treatment, but how do we decide when a measure is appropriate or right for our mea-
surement purposes? The renowned physicist William Thomson, better known as Lord
Kelvin, once said, ‘When you can measure what you are speaking about, and express it in
numbers, you know something about it; but when you cannot measure it, when you cannot
express it in numbers, your knowledge is of a meagre and unsatisfactory kind.’1 It is relatively
simple to use a measuring device such as a dynamometer to assign a number to grip
strength, or a goniometer to measure joint range of motion in degrees. These types of
devices produce scores that can be objectively evaluated,2 but can we assign a score to less
tangible constructs such as day-to-day use of the arm or a client’s participation in society?
And if this is possible, how do we ensure that the outcome measure is appropriate to
quantify these complex constructs?
Choosing an outcome measure to assess day-to-day use of the arm is complicated
for a variety of reasons. First, there are many different types of outcome measures, each
having different measurement properties and demands on the client and the clinician.
Second, the arm works in different ways throughout the day. We use the arm to stabilize,
reach, grasp, and manipulate objects when performing basic life tasks.3 In addition, each
arm or hand is used in a variety of different ways for any given activity.4 Activities may be
bimanual or unimanual. To perform bimanual activities, the two arms frequently adopt
different roles: (a) the arms and hands may work symmetrically, as when carrying a tray
or pushing an object with both hands; (b) the arms and hands may work asymmetri-
cally but cooperatively, as when pouring water from a jug to a glass; or (c) the arms and
hands may perform very separate diverse activities, as when holding a bag while opening
a door.5 Further, the dominant hand is used more often while the nondominant arm
and hand usually performs an orientation or stabilizing role when the two arms work
collaboratively.5
For these reasons, the impact of an injury may vary dependent on whether it involves
the dominant or nondominant arm. Evidence suggests that those with severe injury or
long-term disability may change their hand dominance over time or live primarily with
the use of only one arm.6,7 As a result, people with severe long-term injuries can become
so proficient at using compensatory techniques that they rate themselves as being the
same or less disabled as somebody with far less severe functional loss.8 For example,
Baltzer et al. demonstrated that unilateral arm amputees reported similar levels of disabil-
ity to people with Dupuytren’s contracture, thumb osteoarthritis, or finger amputation
when assessed by the Disability of the Arm, Shoulder and Hand (DASH).9 By the very
nature of these disparate conditions, greater disability would be expected in the amputee
group. However, while the DASH is a patient-reported outcome measure that evalu-
ates function and disability, it does not differentiate between the use of the affected or
unaffected arm. It is therefore more likely assessing compensation for people with severe
long-term injury.8
At times it can be useful to know how people manage day to day by whatever strate-
gies they normally use. However, results that assess change over time from outcome
measures that do not attribute responses to the affected arm cannot be attributed to
an intervention directed specifically at the injury.7,10 Moreover, it is biologically plau-
sible that a person can make significant functional improvements by learning to write
or becoming adept at washing their hair with the preinjury nondominant hand while
avoiding using the injured arm entirely.
All these factors mean that assessment of the arm requires a range of tools that target
different aspects of arm use. The clinician must have a clear understanding of what it is