Clinical Reasoning. Clinical Reasoning. Objectives. What is an expert? THE EXPERT CLINICIAN CLINICAL REASONING. Characteristics of Experts

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1 Clinical Reasoning Jason Zafereo, PT, OCS, FAAOMPT Clinical Orthopedic Rehabilitation Education Objectives Define the characteristics that set an expert and novice clinician apart Discuss the use of hypothesis testing as a model for clinical reasoning Describe how the clinical reasoning process is carried out during a patient encounter Apply hypothesis testing to the differential diagnosis of lateral elbow pain Discuss factors affecting the healing and management of connective tissue What is an expert? THE EXPERT CLINICIAN CLINICAL REASONING A person with Special knowledge or ability who performs skillfully diagnosis and management planning on a consistent basis Characteristics of Experts Clinical Reasoning Maximize direct patient care time Use social interaction to elicit and provide information Handle environmental interruptions without disrupting treatment Accuracy in interpretation Reflection Clinical reasoning The cognitive process, or thinking, used in the evaluation and management of a patient Requires integration and organization of clinician s knowledge Is influenced heavily by clinician s experience Wainright

2 Integration of Knowledge Organization of Knowledge Sources of knowledge Anatomy/physiology Disease prevalence Clinical presentations of impairment/pathology Testing Treatment Experience Feedforward processing Logic applied for familiar presentations Expert-level reasoning Feedback processing Logic applied for uncertain presentations Application of Knowledge Pattern Recognition Develop initial concept of problem in first few minutes of encounter Forms Medical history/demographics Functional questionnaire Pain diagram FABQ Imaging Observation Subjective interview and physical examination should then attempt to Make the features fit Make the features fit Knowledge base of impairments Knowledge base of pathologies Confirmation of fit through inquiry and examination ~5 subjective and ~3 objective pieces to a pattern Hypothetico-Deductive Reasoning Analysis Consider best 2-3 hypotheses Hypothesis testing integral in examination, but is applied to prognosis and treatment planning as well The terminal process of selecting a specific diagnosis, prognosis, or treatment Decisions are based on the best information available at the time Decisions subject to change 2

3 Hypothesis Testing Every treatment should be a form of hypothesis testing Continual reassessment of patient improvement provides the evidence by which all hypotheses are accepted or rejected Reassessment Reject hypotheses Change treatment (error in management hypothesis) Re-examination (error in diagnostic hypothesis) Referral Accept hypotheses Errors in Clinical Reasoning Leading questions/testing Avoid pre-maturely looking at radiology or colleague dx Considering too few hypotheses Failure to sample enough information Not being open to change in hypothesis Analyze information that falls outside patient s pattern Summary of Clinical Reasoning Methodology Input Knowledge base Cognitive skills Metacognitive skills Output care Learning Ingenuity Summary of Expert Clinician Considerations Representation of the problem will influence the subsequent reasoning and search for a solution of hypotheses considered is the best indicator of correctness of diagnosis and management plan HYPOTHESIS TESTING IN PRACTICE 3

4 Hypothesis Categories Source of Symptoms or Dysfunction Diagnostic Source of Symptoms or dysfunction Contributing factors Evaluation and Management Prognosis Precautions and contraindications to physical examination and treatment Management Local or remote structure from which symptoms are emanating Musculoskeletal (somatic) Contractile tissue Non-contractile tissue Visceral Correlation to radiology Gathering Information Considering the Source of Remote Pain Source of Symptoms History Nature Aggravating/easing Timing testing Special testing Local pain always present with remote pain Pain connecting the two areas Remote pain provoked by movement or prolonged posturing of the local area Remote pain progressing with local pain Contributing Factors Gathering Information Factors responsible for the development or maintenance of patient s problem Environmental Behavioral Emotional Physical Biomechanical Contributing Factors History Aggravating/easing Timing Functional activities Co-morbidities FABQ testing Impairment testing 4

5 Contributing Factors (Biomechanical) Stiffness Joints at, above, or below pain site Mechanical interfaces along involved nerve Muscles at pain site Alignment Regional long bones Regional joints Instability/Weakness Joints at, above, or below pain site Facilitated segments responsible for innervation of pain site Muscles at pain site CASE PRACTICE Lateral Elbow Pain Common Extensor Origin (Local) Pathology pattern recognition Contractile tissue Non-contractile tissue Contributing factor pattern recognition Environmental Biomechanical Joint Nerve Common Extensor Origin (Local) Radiohumeral or Superior Radioulnar Joints (Local) Objective Exam Special Tests Muscle Provocation Tests 5

6 Radiohumeral or Superior Radioulnar Joints (Local) Posterior Interosseous Nerve (Local) Objective Exam Timing Posterior Interosseous Nerve (Local) C5-6 Nerve Root (Remote) Objective Exam Special Testing Muscle Provocation Tests Neurological exam C5-6 Nerve Root (Remote) Alternate Pathology Hypotheses Objective Exam Special Testing Fascia Bone Neurological exam Synovium 6

7 Contributing Environmental Factors Contributing Mechanical Factors Ergonomics Stiffness Instability/Weakness Common Extensor Origin (Local) Common Extensor Origin (Local) Repetitive microtrauma Local Weakness Gripping, Resisted wrist extension/rest Dull to sharp, poorly localized Lateral epicondyle Objective Exam Special Tests Active and Passive painful in opposite directions; Active more than 5deg limited compared to passive in the same direction + Mill s, Cozen s Muscle Provocation Tests Pain with resisted wrist extension Tenderness over ECRB/ECRL origin Radiohumeral or Superior Radioulnar Joints (Local) Radiohumeral or Superior Radioulnar Joints (Local) None Elbow/forearm or sustained positioning/rest Dull, aching, well localized Radio-capitellar joint, radial head Objective Exam Active and Passive equal and painful in same direction; Restricted motion in capsular or characteristic pattern Tenderness over Radio-capitellar joint, radial head 7

8 Posterior Interosseous Nerve (Local) Posterior Interosseous Nerve (Local) Objective Exam Timing microtrauma or macrotrauma Local Weakness Gripping, Resisted wrist extension/supination/rest Night pain is common Dull, aching, linear Radial head or radial tunnel Special Testing Muscle Provocation Tests Neurological exam Active and Passive of mechanical interface painful in opposite directions Positive ULTT 2b Pain with forearm supination or third finger extension Normal sensation, weakness may be present at wrist/digital extensors Tenderness over radial head or tunnel C5-6 Nerve Root (Remote) C5-6 Nerve Root (Remote) Objective Exam Dermatomal weakness and paresthesias Cervical/shoulder or sustained postures/ Hand on top of head Sharp, burning, linear, catching C5-6 dermatome Special Testing Neurological exam UE: Active and Passive equal and painful in same direction; Cervical spine rotation <60deg Positive Cervical distraction; positive Spurling s; Positive ULTT Sensation, strength, and reflex may be altered at C5/C6 key points Tenderness over nerve trunks Alternate Pathology Hypotheses Contributing Environmental Factors Fascia Anconeus compartment syndrome Bone Radial head fracture AVN of radial head or capitellum Synovium Posterolateral impingement Ergonomics A poor backhand technique in tennis A racket grip that is too small Strings that are too tight Playing with wet, heavy balls Repetitive activities such as using a screwdriver, painting or typing 8

9 Contributing Mechanical Factors Stiffness Radiocapitellar, Radioulnar, Ulnohumeral joints Radiocarpal joint C5-6/Radial nerve mechanical interfaces (double crush) Wrist flexors Instability/Weakness C5-6 facilitated segment Common wrist extensors EVALUATION AND MANAGEMENT PLANNING Prognosis Rate of Healing Exam findings Irritability Centralization/sensitization Chronicity Phases of healing Severity/Type of tissue involved Yellow flags Motivation/compliance Fear avoidance Systemic influences Co-morbidities Underlying disease/conditions Phase of Healing Inflammatory 4-6 days Healing and Repair 14-21days Maturation and Remodeling weeks Chronic Pain Persistent pain beyond 6 months Tissue Specific Considerations Tissue Specific Considerations Tendon and ligament insertion months to reach 80% of normal strength Ligament 8-9 weeks to reach 100% normal strength Muscle 6 weeks to 6 months to reach 90% normal strength Bone 12 weeks to reach 100% normal strength 9

10 Tissue Specific Considerations Positive Systemic Influences Cartilage 6 months articular cartilage is a combination of Type I & Type II calcified cartilage with normal appearance Protein (animal products) Fibroblastic proliferation Angiogenesis Collagen remodeling Phagocytosis Proteoglycan and collagen synthesis Vitamin A (liver, carrots, sweet potato, greens) Epithelialization Rate of collagen synthesis and cross-linking Vitamin B1 (tuna, beans, peas, seeds) Collagen formation Positive Systemic Influences Negative Systemic Influences Vitamin B5 (liver, mushrooms, avocado) Tensile strength of healed tissue Increased fibroblast number Vitamin C (fruits and veggies) Increased collagen synthesis by fibroblasts Zinc (liver, beef, oats) Epithelialization Collagen synthesis Tensile strength Magnesium (bran, beans, nuts) Collagen synthesis Copper (liver, beans, seeds, mushrooms) Tensile strength Food sensitivities Steroids Decreased GAG production Smoking Vasoconstriction Cellular hypoxia Demineralization of bone Delayed revascularization Alcohol Inhibited fibroblast proliferation Other Considerations Progressing to Treatment Underlying disease OA Auto-immune disease Infection Poor vascularity Identify precautions or contraindications Plan for management Frequency/duration Therapeutic procedures Education 10

11 Precautions and Contraindications Management Red flags to exam or treatment Fracture/instability Neoplasm Acute CNS/cardiac involvement Infection Pain/Irritability Yellow flags Age Pharmacology Psych/emotional impairment Co-morbidities Hypertension Pregnancy Osteoporosis Role of yellow flags/comorbidities Role of pain management Source of symptoms or contributing factors Role of mobilization versus stabilization Physiological or accessory movement Direction, amplitude, speed, duration of movement applied Role of education Goals of Treatment Planning for Treatment Pain reduction Reduction of impairments to function Education of patient for self management Findings from contributing factor and pathology hypotheses guide pain management Findings from contributing factor hypotheses guide impairment management 11