CLINICAL REASONING TOOLS FRANK TUDINI PT, DSC,OCS,FAAOMPT MATT WALK PT, DPT,OCS, FAAOMPT Rothstein, Echternach and Riddle 2003 Hypothesis-Oriented Algorithm for Clinicians Patient-centered conceptual framework for guiding patient management 2 Parts Part 1: Clinical Decision Making from Medical History to Intervention Part 2: Re-assessment algorithm to identify deficiencies in treatment when patient response is less than optimal Acknowledges two types of problems Primary Complaint Linked to the ICF activity limitations and participation restrictions Contextual Factors > Biomechanical Judge whether key impairments leading to functional loss are important Scapular Dyskinesis Secondary: Anticipated problems, prevention, Risk Factors Only a potential event that may not occur Predictive criteria are observable and documented 1
This Photo by Unknown Author is licensed under CC BY-NC-ND Collect initial data Generate patient-identified problems (PIP) list Consultation if needed Formulate examination strategy Conduct the examination, analyze data, refine hypotheses, and carry out additional examination procedures needed to confirm or deny hypotheses Add nonpatient-identified problems (NPIPs) to the problem list For each existing problem For each anticipated problem Generate a hypothesis as to why the problem exists Identify the rationale for believing anticipated problems are likely to occur unless intervention is provided Consultation if needed Go to refine problem list Consultation if needed HOAC PART 1 STEP 1 Collect Data See Patient referral and subjective history HOAC PART 1 STEP 2 Make a Problem List Patient Identified Problems (PIP s) Activity Limitations Unable to sit for > 30 minutes without pain Unable to run Unable to stand 30 minutes without pain Unable to walk without limp Participation Restriction Unable to play soccer Unable to cycle without pain Unable to dance 2
HOAC PART 1 STEP 3 Examination Strategy Standing Observation and Posture Functional Tests: Squat, Step Down, SLS Lumbar AROM Thessaly Test Sitting MMT Knee Flexion and Extension McConnell Test HOAC PART 1 STEP 3 Examination Strategy Lying Hip and Ankle AROM with OP and Resistance Knee AROM and PROM Joint Mobility Girth Measurement Balottment Test Valgus Stress Test 0 and 30 degrees McMurray Test Lachman, Anterior Drawer, McConnell Test Palpation MCL, Medial joint line, Patella HOAC PART 1 STEP 4 Conduct Examination Measure Impairments and Activity Restrictions Impairments Activity Restriction Decreased SLS (10 sec) Step Down Decreased ROM (0-130) Squat Decreased Knee Strength Antalgic Gait Swelling (3 cm girth) Inability to run Decreased Med Patella Glide 3
Analyze Data HOAC PART 1 STEP 4 Limited ROM but tibiofemoral joint mobility WFL limitations due to swelling Playing soccer up until 3 days ago Non-contact injury with rotation Poor quality of movement with step down and squat Tenderness and Decreased patellar glide medial + McConnell Test Increased genu valgum + Lachman Refine Hypotheses Knee pain with mobility deficits Knee Stability with Movement Coordination Impairments ACL, PFPS Carry out additional Testing if necessary HOAC PART 1 STEP 5 Add Non-Patient Identified Problems (NPIP s) Increased Genu Valgum with squat Foot Pronation Altered running mechanics Pressure of quick return to soccer Female soccer player Increased Q-Angle HOAC PART 1 STEP 6 Generate Hypothesis for each Problem Swelling and pain are affecting knee ROM and strength, girth measurements Decreased strength, conditioning, and Neuromuscular control are affecting balance and quality of movement, gait, ability to run and play soccer, squat, SLS, and sit Increased tibial translation with Lachman due to ACL strain NPIPs including female, soccer player, large Q-angle are risk factors for ACL injury 4
Referral if needed Refine problem list For each problem: establish 1 or more goals For each existing problem Establish testing criteria Consultation if needed For each anticipated problem Establish predictive criteria Consultation if needed Plan intervention strategy based on hypotheses and anticipated problems Consultation if needed Plan tactics Implement tactics FIGURE 1. Hypothesis-Oriented Algorithm for Clinicians II, part 1. Adapted from Rothstein et al. 37 Establish Goals 1. Decrease mid-patellar swelling by 2 cm in 5 days HOAC PART 1 STEP 7 2. Patient to sit for 1 hour during class with knee pain </= 3/10 NPRS in 2 days 3. Improve Left Knee flexion and Extension to 5/5 MMT in 4 weeks 4. Patient to descend from 8-inch step with no pain and with controlled valgus independently in 4 weeks 5. Patient to return to soccer practice without restriction and with pain < 2/10 NPRS in 4 weeks 6. Patient to SLS left for 30 seconds with EC independently in 2 weeks 7. Patient to score < 5 on LESS test in 4 weeks Establish Plan of Care 2 x per week x 4 weeks HOAC PART 1 STEP 8 Manual Techniques including medial patellar mobilization to decrease pain and improve patellar mobility Therapeutic Exercise to improve knee flexion and extension strength and ROM Neuromuscular Re-education to control genu valgum during functional activities Modalities including ice PRN to control inflammation Functional Retraining and Optimization including agility drills for return to soccer Administer KOS ADL and Sport Scale outcome measure at IE and before return to play Administer LESS with score < 5 before return to play 5
HOAC PART 2 Reassessment At week 2 and 4 Goals met = Discharge Goals Not Met Are Hypotheses Correct? Are Testing Criteria Correct? Is the Treatment Correct? Are the goals viable? https://mm.tt/1019495290?t=1gkpdc50vs Systematic Clinical Reasoning in Physical Therapy (SCRIPT) Baker 2017 A tool to facilitate and assess reasoning in orthopedic residencies and fellowships Oriented specifically to manual therapy Clinical Reasoning Assessment For Thinking Effectively () A tool modified from the SCRIPT to facilitate and assess reasoning in entry level DPT students MSK content during PBL tutorials Oriented to general orthopedics and much more guided for entry level students Also used to structure the OSCE PART 1 ANATOMIC STRUCTURES AS SOURCES FOR PAIN INITIAL HYPOTHESES AND DIFFERENTIAL DIAGNOSIS 6
PART 2 INFLUENCE OF SYMPTOMS ON EXAM PART 2 INFLUENCE OF SYMPTOMS ON EXAM PART 2 REVISED HYPOTHESIS AFTER INTERVIEW 7
PART 3 PLANNED PHYSICAL EXAM PROCEDURES PART 4 ASSESSMENT PART 4 ASSESSMENT FINAL HYPOTHESIS 8
PART 5 CONTEXTUAL FACTORS PART 6 PROGNOSIS AND GOALS PART 7 PLAN OF CARE 9
PART 7 TREATMENT PROGRESSION SPECIFICS DOSAGE Easy to Link with ICF SUMMARY POINTS Later hypothesis generation - exhaustive reasoning potential -can be inefficient Allows Clear Communication Identifies both PIP s and NPIP s Includes Environmental Factors: Risk Factors, Prevention, and Anticipated Problems Emphasis on Deductive Reasoning Includes Reassessment algorithm if patient response is less than optimal Can be used with all patient populations SUMMARY POINTS Strong anatomical foundation with emphasis on pathoanatomic diagnosis and development of Pattern Recognition Incorporates all Domains of the ICF, but less identifiably than the Facilitates early hypothesis generation and testing and subsequent hypothesis revision confirmation bias must revise Does not preclude Inductive Reasoning and may facilitate it with repeated use Includes Assessment of Severity and Irritability in Examination, facilitating Reasoning about Procedure Specifies outcome measures and SMART goals Includes Narrative and Predictive Reasoning Specific to Musculoskeletal cases 10
This Photo by Unknown Author is licensed under CC BY QUESTIONS AND COMMENTS QUESTIONS AND COMMENTS CONTACT: TUDINI@CAMPBELL.EDU; WALK@UIWTX.EDU TWITTER: FTUDINIPT BIBLIOGRAPHY 1. Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (): a guide for patient management. Phys Ther. 2003;83(5):455-470. 2. Schenkman M, Deutsch JE, Gill-Body KM. An integrated framework for decision making in neurologic physical therapist practice. Phys Ther. 2006;86(12):1681-1702. 3. Thoomes EJ, Schmitt MS. Practical use of the for clinical decision making and subsequent therapeutic interventions in an elite athlete with low back pain. J Orthop Sports Phys Ther. 2011;41(2):108-117. 4. Thoomes EJ, Schmitt MS. Practical use of the for clinical decision making and subsequent therapeutic interventions in an elite athlete with low back pain. J Orthop Sports Phys Ther. 2011;41(2):108-117 5. Baker SE, Painter EE, Morgan BC, et al. Systematic Clinical Reasoning in Physical Therapy (SCRIPT): Tool for the Purposeful Practice of Clinical Reasoning in Orthopedic Manual Physical Therapy. Phys Ther. 2017;97(1):1-10. 6. Edwards I, Jones M, Carr J, et al. Clinical Reasoning Strategies in Physical Therapy. Phys Ther. 2004;84(4):312-330. 11