Clinmical Reasoning

8/3/2019 Clinmical Reasoning

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Dr Masharawi Y. [email protected]

:תוכנית

מבוא לחשיבה קלינית.1

ראיון המטופל האמבולטורי.2

בדיקה פיזיקאלית.3

המנואליעקרונות הטיפול.4



Clinical reasoning in physiotherapy

2Dr Masharawi Y. [email protected]



הרבה טעויות היינו מונעים מבני"

אילו לימדנו אותם כיצד לחשוב,אדם"ולא מה עליהם לחשוב

גיאורג כריסטוף ליכטנברג•


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Clinical reasoning - Introduction

• The thought process

• Importance of knowledge and theorganization of knowledge

• There are many types of knowledge

• We must be critical of knowledge




Cognitive skills include:

• Relevant / irrelevant information

• Interpretation of information

• Hypothesis generation

• Hypothesis testing







METACOGNITION

THINK ABOUT YOUR THINKING

By:

Reflection in action

Reflection about action




• A clinicalreasoning

model for

therapists

(Barrows and Tamblyn1980)




…Organization of thinking

1. Mechanism of Symptoms (Sx.)2. Sources of symptoms (Sx).

3. Contributing factors.

4. Precautions and contraindications.

5. Prognosis.

6. Management.




..1MECHANISMS OF THE SYMPTOMS

a. Peripherally Nociceptionb. Peripherally Neurogenic Nociception

c. Centrally Activated Nociception

d. Autonomice. Affective


Aff ih ilP i h lP i h l



AffectiveSympatheticCentralPeripheralNeurogenic

Peripheralnociceptive

EmotionalItchingBizzar SxP & NIntermittent

EnvironmentalBurningLatencyNerve lineSharp

Non-mechanicalstimulus

SweatingSpontaneousLatencyMech.Relationship

Over-responseColor changesBuilds-upBurningThrough range

PersonalityTemp. changesAllodyniaSharp/acheLocal ache

Work loadTrophic changesHyperalgesiaNasty/nagging

TensionPupils reactionNegativestim./response

Weakness

Financial stressHeart rateCyclicNumbness

Stiffness,

patching,wheezing

HormonalGiving way




. SOURCES OF THE SYMPTOMS2

)ות הסימפטומים/מקור(Local Vs Non-local source




Source-cont.

Always consider the followings:

Joint/ Ligaments

NeuralMuscle/Soft tissue

Bone

Vascular

Visceral




Source-cont.

• Non-local sources:

– Projected pain )כאב מוקרן( : nerve irritation (eg.

nerve root/radicular pain, CTS, Thoracic outlet

Synd.)

– Referred pain )כאב מושלך( : segmental

enervation

(muscle, soft tissue, bone, visceral)




Source-cont.

depth, character)detailed area,(Site.1

constancy, type)(Characteristics.2

hour pattern)24aggravating, easing,(Behavior.3

type of onset, progression, previous(History.4treatment(




CONTRIBUTING FACTORS.3

)גורמים תורמים(

Physical

BiomechanicalEnvironmental

Psychological

Cultural influences




PRECAUTIONS AND CONTRAINDICATIONS.4

a. Precautionary questions

b. Severity/irritability

c. Progression

d. Stability of the disorder




Prognosis.5

Mechanical/inflammatory balance

Irritability

24 hour pattern

Degree of traumaPatient’s expectations

lifestyle

Personal profileHealing potential




Management.6

Remember!!!

- Asking open questions

- Do not assume things

- Do not become locked into rigidthinking




- THE INTERVIEWןויאירה

(Subjective examination)

1. Main complain (C/O)

2. Body Chart

3. Behavior of Symptoms (Sx)4. History and Past-history (Hx & PHx)




SEQUENCE OF THE INTERVIEW

יתרונות הריאיון המובנה

- Speed of questioning

- Concentrate on the implication

- Ensures that all relevant areas are covered

- Encourages logical progressive thinkingDr Masharawi Y. [email protected]



SEQUENCE OF THE INTERVIEW

(cont.)

חסרונות הריאיון המובנה

- No interpretation of information received

- Less personal communication with each

patient




MAIN COMPLAIN

• Establish the patient’s main problem by

asking an open question like:

” What is your main problem at this stage?”




BODY-CHART

Site (area and depth) of all symptoms

Type of symptoms

Constant or intermittent (Cte. or Int.)

Relationship between symptoms


B d h t ( t )



Body-chart (cont.)

a) Questions common to all patients

-General health (GH):-medical condition, recent surgery (OP), Tablets (Tab.)

Recent weight loss (WL)how much? reason e.g. dieting

- Special investigations

X-rays, blood tests (?patient knows the result, look at later)




Body-chart (cont.)

b) Questions specific to area of symptoms:

Upper quarter Vs. Lower quarter




Body chart (cont.) -Special questions

A. Upper quarter:iplopia,Disarthria,Disphagia,Dizziness,Ds:’D5

attacks.-ropD

B. Lower quarter:

Cauda-equina, incontinence

C. Both:

Cord signsDr Masharawi Y. [email protected]



Stop!!!

look at the recorded symptoms and

convert them into the initial hypotheses (all six categories)




Interview (cont.)

Proceed to behavior of symptoms or history

How to choose?Chronic → Behavior

Acute → History




Behavior of symptoms (Sx)

What do we want to know?

a) mechanical/non-mechanical

b) inflammatory component

c) behavior (activities/postures)




c) Behavior (activities/postures) help to…

- incriminate certain sources

- confirm relationship of Sx.

- identify contributing factors

- severity

- irritability




Behavior of Sx (cont.)

Severity of Sx/disorder:

- On a scale of 1 (mini.) to 10 (maxi.)

- Functional limitation

- Constancy of Sx.





elements):3Irritability of Sx/disorder (

1. Determining the painful activity (repetitive orisolated movement)

2. How painful it becomes (i.e. severity)

3. The length of time the increased Sx takes to recover





How best to obtain this information?

What aggravates the symptom1.

2. What eases the symptoms


Behavior of Sx (cont )




hour pattern24

Symptoms during the day


http://www.risk.state.ut.us/Lbtran/lbtwist.gif

http://www.risk.state.ut.us/Lbtran/lbtwist.gif



History: present and past

From the History, we should know:

-The status of the disorder !!!

-Whether the disorder is mechanically stable !!!

-The likely prognosis !!!




Present history

Of local and referred symptoms:

When did it start?

How did it start?


History



History (cont.)

SpontaneousTrauma

What was noticed first?What happened? What wasnoticed first?(pain/stiffness/etc)

predisposing factorsExtent of damage,

Activity - unusual/heavySustained posturesUnwell/virus Overtired,others

Degree of immediate pain,swelling

Treatment and its effectPredisposing factorsTreatment and its effect

Progress sinceProgress since


P t hi t (PH )



Past-history (PHx)

“When did you first have any trouble with your”.....”?”

Details of first episode

“Between then and now, how many times have you had

trouble?”

“How long has each bout lasted? Do they require

treatment?”

“Are the bouts regular/irregular? what causes them?”


Past history (PHx) (cont )



Past-history (PHx) (cont.)

“Are they getting worse, same or better? (in frequency,

severity, duration, area of symptoms)

“How does this bout compare with the first one?”

“How does this bout compare with the last one?”

“What has been the effect of previous management?”




Remember !!!

- Asking open questions

- Do not assume things

- Do not become locked into rigid thinking







PHYSICAL EXAMINATION (P/E)

Dr Yousssf Masharawi



Clinical reasoning of the P/E

as an extension of the S/E

- Clues to P/E structures, extent and precautionsrequired will arise throughout S/E

- What structures/systems must be examined?

- How much P/E is indicated (precautions, time)?- Is a neurological examination indicated?

- What special tests (e.g. VBI, instability) areindicated?



Must examine all potential sources

(structures) and contributing factors:

Structures (e.g. joints , muscles, soft tissues, nerves)the area of symptomswhich underlie

to the area of symptomswhich can referStructures

Structures contributing to symptom production



How much physical examination is indicated on

day 1?

Divide patient’s into two broad categories:

1. Limited examination

2. Full examination



Limited examination

- Caution with production of Sx

- Limited procedure



Limited examination (Cont.)

Decision based on:

- Severity of the disorder

- Irritability of the disorder

- Whether disorder is progressive

- Rate of progression

- Stability of the disorder

- Known pathology (e.g. RA, Osteoporosis)

- Indicators of more sinister pathology

(e.g. GH, WL, Cord, VBI)



Limited examination (Cont.)

Examination without aggravation of

symptoms makes it possible to treat the

disorder effectively at the firstconsultation



Full examination

Full extent of examination without risk of aggravationof symptoms if the disorder is non-irritable, not

severe, and the nature, history and progression of

the disorder do not indicate the need for caution.

P/E (C )



P/E (Cont.)

What P/E findings implicate

a structure’s potential involvement?

Abnormal appearance (asymmetry, swelling,wasting, discoloration etc.)

2. Abnormal movement (range, active, quality,passive quality, resistive quality)

/



P/E (Cont.)

The potential involvement of a structure is

strengthened if:

- Altering the abnormality affects the patient’ssymptoms

- Directly or indirectly stressing a structure reproducesthe patient’s symptoms or symptoms that aredifferent than “normal”.



TESTS FOR DIFFERENT STRUCTURES

Tests of intervertebral joints- Physiological movements (singly or

combined)

- Palpation- Passive accessory inter-vertebral

movements (PAIVM’s)

- Passive physiological inter-vertebralmovements (PPIVM’s)



TESTS FOR DIFFERENT STRUCTURES (CONT.)

Tests of peripheral joints- physiological movements (singly or

combined)

- Palpation

- Accessory movements from differentpositions




Tests for musclesSource

-palpation

-contraction

-passive stretch

Contributing factors

-length

-functional and isolated performance(strength, endurance, power,

etc.)




Tests for vascular involvement

- VBI protocol

- Arterial pulses

- Thoracic outlet tests




”nervous system involvement“Tests for

- Passive neck flexion (PNF)

- Slump

- Straight leg raise (SLR)

- Prone knee bend

- Upper limb tension tests (ULTT’s)

- Combined tests and variations- Nerve palpation

- Neurological function (CNS, nerve root,peripheral, autonomic)



INDICATIONS FOR NEUROLOGICAL EXAMINTATION

- Symptoms which are neural in character

- Symptoms in the limb

- History of trauma

- Worsening conditioning



what are we looking for ? –Posture

Asymmetry’s

Altered positions/angles

Under/over development etc.

Dynamic versus static



where and how should we look ? –Posture

- Note when patient unaware

- Note in patient’s relaxed posture

- Note from different views



Posture - How can we assess the significance ?

Alter the posture and note ease of correction

and effect on symptoms

(clue to source but doesn’t rule as contributing factor)



Posture - associated factors

Altered muscle length

Altered muscle performance

Altered joint, neural and soft tissue mobility



Assessing functional aggravating factor

- Posture or movement

- Provides useful initial clue to

structure(s)/components involved

- Provides meaningful reassessment for patient



FUNCTIONAL DIFFERENTIATION

ST RU CT UR A L R EGI ON A L

nerves Joint

joint (intra/extraarticular)

movement

muscle



Physiological and Accessory Movements

to simply note gross range andInsufficient

production of symptoms !

and itsquality of movementMust assess

relationship to behavior of symptoms

through range

i h i l i l



Active Physiological Movements

- Clear patient instructions

- Observe quality of movement and notebehavior of symptoms

- Continually re-establish status of symptoms

- Often requires different views of focus- Correct asymmetry’s to assess effect

- Overpressure to establish end feel and effect onsymptoms (local and refereed)

- Normal Mvt.=√√ (Full range , no pain withoverpressure)

i h i l i l



Active Physiological Movements(cont.)

If local/referred symptoms not reproduced (and notirritable)-refine tests:

-repeated movements

-sustained movements

-movements under loads

-movements at different speeds

-movements under compression

-combined movements

-pre-sensitize the area

Passive Peripheral Physiological and Accessory



Passive Peripheral Physiological and Accessory

Movements

Clear patients instructions

Effective control of movement (eg. hand holds,

thumb, pressure, body mechanics,etc.)

Establish relationship between quality of movementand behavior of symptoms(i.e. Movement

Diagram)

PPIVVM’s & PAIVM’s



PPIVVM’s & PAIVM’s

Passive Physiological Inter-vertebral

Movements (PPIVM’s)

Passive Accessory Inter-vertebral Movements

(PAIVM’s)

Grades of Passive Movements:



Grades of Passive Movements:

accessory and physiological

Grade I: small amplitude, no resistance

Grade II: large amplitude, no resistance

Grade III: large amplitude, into 50% of resistance (R.)

G. III+: into 75% of R.

G. III++: into 100% of R.

Grade IV: small amplitude, into 50% of R.

G. IV+: into 75% of R.

G. IV++: into 100% of R.

Grade V: Manipulation.

high velocity, slow amplitude at end of range

Palpation



Palpation

- Patient communication

- Bony position (eg. position of one

vertebrae relative to adjacent, patellar

position)

- Soft tissue changes (thickening old/new

spasm)

- Effect on symptoms

- Care with interpretation



Dr.Youssef Masharawi (PhD, BPT)72

אסטרטגיות לבחירת הטיפול הפיסיותרפי

כווני הגבלות תנועה•

סוגי ניתוחים ספציפיים•

סוגי פתולוגיות המערכת התנועה•

כרוניים / מצבים אקוטיים•

טווח ארוך / טווח קצר•

הרגלי חיים•




Relevant patterns in understanding a patient’s

problem (s) can be categorized as follows:

. mechanisms of the symptoms1.

2. Sources of symptoms (Sx).3. Contributing factors.

4. Precautions and contraindications.

5. Prognosis.6. Management.




Sources of Symptoms

• Local sources

• Non-local sources:

– Projected pain: nerve irritation (eg. nerve root,

CTS, Thoracic outlet Synd.)

– Referred pain: segmental enervation

(muscle, soft tissue, bone, visceral

Must treat all sources/structures and




Must treat all sources/structures and

contributing factors:

Structures (e.g. joints , muscles, soft tissues, nerves)

the area of symptomswhich underlie

to the area of symptomswhich can referStructures

Structures contributing to symptom production

The potential involvement of a structure




The potential involvement of a structure

is strengthened if:

- Altering the abnormality affects the patient’ssymptoms

- Directly or indirectly stressing a structurereproduces the patient’s symptoms or

symptoms that are different than “normal”.

PRINCIPLES OF TREATMENT




BY PASSIVE MOVEMENT

Types of passive movement which can be used in

treatment:

- Physiological within range- Physiological at end of range

- Accessory within range

- Accessory at end of range

Factors determining the choice of




Factors determining the choice of

technique and method of application

• Pathology

• Kind of disorder




1. Pathology

Specific diagnosis can:

- limit the strength of the technique

e.g. Rheumatoid Arthritis

- Guide the choice of technique

e.g. locked P.I.V. or knee joint

Often it is not possible to make a specificdiagnosis

1. Pathology (cont.)




gy ( )

A Particular “diagnostic title” can present

different patterns of Signs and SymptomsExamples:

- L4/5 discogenic pathology

- Sprained medial collateral ligament of theknee

- O.A. of the hip

In these cases, the choice and method of applying passive movement is based on thepresenting symptoms and signs

2. Kind of disorder




Patients present with a disorder that is:

only symptom, no underlying stiffnessPain:-

: pain = dominantPain and Stiffness-

only, no pain or other symptomStiffness:-

stiffness = dominantStiffness and Pain:-




Treatment of PAIN only

Example:

Patient with constant deep ache within the

shoulder, movement grossly limited by pain

f l d d



Dr.Youssef Masharawi (PhD, BPT)

83

Painful disorder: Day 1

Small amplitude of movement, rhythmical, slow,

no discomfort,

Dosage (time, amount of movement) depends

on irritability, ease/difficulty of finding a

painfree, position and ability to perform

movement short of pain

i f l di d i




84

Painful disorder: Progression

- Treat daily, or alternate days

- Increase amplitude of movement (still short

of discomfort) I→II-→II

- Perform technique into slight discomfort

II→III-→III

- Increase speed of movement / alter rhythm

from smooth to staccato (joint no longer in

neutral)




85

http://www.1backpain.com/images/piriformisstretch.jpg

http://www.1backpain.com/images/glutstretch.jpg




86

http://www.1backpain.com/images/Quadstretch.jpg

http://www.1backpain.com/images/groinstretch.jpg

http://www.1backpain.com/images/calfstretch.jpg

http://www.1backpain.com/images/TFLstretch.jpg

http://www.1backpain.com/images/piriformisstretch.jpg

http://www.1backpain.com/images/glutstretch.jpg

http://www.1backpain.com/images/hamstringsit.jpg




87




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Clinmical Reasoning

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