As medical SLPs treating individuals with cognitive impairments, we rely heavily on data and measurable outcomes to guide treatment. We must identify and quantify sources of impairment in a valid, reliable fashion, and measure therapy progress in a way that is objective, sensitive and meaningful to patients. This mandate is a tall order. Measurement is much more than just selecting the right test or questionnaire.
Measurement Types and Goals
Although treatment measurement is highly important and complex, we often fail to pause and plan it. A critical first (and quick!) step is to simply clarify the purpose of an evaluation. If we know the purpose, we are more likely to choose effective tools and assessment processes. Here are three reasons why we engage in clinical measurement:
- Initial Evaluation– The goal may be to identify and quantify the sources of difficulties and select the most appropriate therapy approach.
- Session Data– Measuring client performance may be needed to gauge when to continue, modify, or terminate therapy.
- Outcome Measures – These may aid in determining overall therapy effectiveness.
While these assessment categories appear to follow a chronological sequence, we often conduct them cyclically as patient needs and clinical questions change. A variety of assessment methods can be used to answer our questions, including:
- Standardized cognitive tests
- Clinician conducted performance measures and behavioral observations
- Validated client-centered questionnaires and self-reported outcome measures
Consider a patient with attention and memory issues following a traumatic brain injury. An initial evaluation may be warranted to understand the type of memory impairment and plan how to effectively teach the client compensatory strategies and tools. Here are three different situations in which different assessment methods may apply:
Situation A: Modality Specific Impairment
Based on a clinical interview, you may want to determine if the patient has a modality specific impairment with a difference between auditory and visual memory and new learning. Perhaps the patient wants to resume reading and writing activities and you need to know the best way to support this goal. As a result, you may select standardized cognitive tests that would help discern the nature of the cognitive impairment.
Situation B: Determining Baseline Performance
Another priority may be to establish baseline performance in order to track recovery in response to the medical team’s need for prognostic indicators. You would then want to select tests with high sensitivity to your patient’s issues that also have strong validity and reliability.
Situation C: Functional Goal
Frequently, the reason for your initial evaluation is to identify a functional goal area and treatment. Perhaps your patient wants to optimize her performance at her volunteer position and mitigate the effects of her attention and memory challenge. You will want to conduct a needs assessment to jointly determine what supports work best in that setting. You would likely choose patient-centered goal selection.
In each situation, your evaluation questions direct your assessment activities.
Similarly, you should plan how your session data will inform your intervention.
For example, if the initial evaluation process leads you and your client to a task organization app for her smartphone, then your sessions will be devoted to teaching her to use the app. You will need to measure her progress toward learning the app in order to know what to practice and reinforce in therapy. You will also want to measure generalization of use to determine the contextual supports needed to encourage use in a real environment.
Hence, session data often includes measures of learning the target device (or behaviors, strategies etc.) and measures of generalization. When you plan your measurements, you can use therapy data to target your interventions.
Outcome measurement must match the therapy rationale. You would likely not expect changes on a standardized test administered to a post-acute patient with whom you are working on compensatory strategies and not addressing underlying impairments. Instead, if you are teaching them to use a device, you will want to measure the patient’s progress with the target device and the impact of such learning.
Even if a patient met therapy goals for learning to use a device, this does not mean that functional goals were achieved. A task organization app is only successful if that patient’s task completion rate or efficiency increased. Patient-centered goal attainment scaling can help measure the impact of therapy. The ultimate outcome data is an improvement in the client’s daily functioning. Measurement is more than documentation — it is an active ingredient that guides the therapy.