: 1. 2. 3. 4.

1 Dr Masharawi Y. yossefm@post.tau.ac.il

Clinical reasoning in physiotherapy

Dr Masharawi Y. yossefm@post.tau.ac.il

" , "

Dr Masharawi Y. yossefm@post.tau.ac.il

Clinical reasoning - Introduction

The thought process Importance of knowledge and the organization of knowledge There are many types of knowledge We must be critical of knowledge

Dr Masharawi Y. yossefm@post.tau.ac.il

Cognitive skills include:

Relevant / irrelevant information Interpretation of information Hypothesis generation Hypothesis testing

5 Dr Masharawi Y. yossefm@post.tau.ac.il

Dr Masharawi Y. yossefm@post.tau.ac.il

METACOGNITION
THINK ABOUT YOUR THINKING By:

Reflection in action Reflection about action

Dr Masharawi Y. yossefm@post.tau.ac.il

 A clinical
reasoning model for therapists
(Barrows and Tamblyn 1980)

Dr Masharawi Y. yossefm@post.tau.ac.il

Organization of thinking
1. 2. 3. 4. 5. 6. Mechanism of Symptoms (Sx.) Sources of symptoms (Sx). Contributing factors. Precautions and contraindications. Prognosis. Management.

Dr Masharawi Y. yossefm@post.tau.ac.il

MECHANISMS OF THE SYMPTOMS1. . a. Peripherally Nociception b. Peripherally Neurogenic Nociception c. Centrally Activated Nociception d. Autonomic e. Affective

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Dr Masharawi Y. yossefm@post.tau.ac.il

Peripheral nociceptive Intermittent Sharp Mech. Relationship Through range Local ache

Peripheral Neurogenic P&N Nerve line Latency

Central Bizzar Sx Latency Spontaneous

Sympathetic Itching Burning Sweating

Affective Emotional
Environmental

Nonmechanical stimulus Over-response Personality Work load Tension Financial stress

Burning Sharp/ache
Nasty/nagging

Builds-up Allodynia Hyperalgesia

Negative stim./response

Color changes Temp. changes Trophic changes Pupils reaction Heart rate Stiffness, patching, wheezing

Weakness Numbness Giving way

Cyclic Hormonal

Dr Masharawi Y. yossefm@post.tau.ac.il

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2. SOURCES OF THE SYMPTOMS ()/

Local Vs Non-local source

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Dr Masharawi Y. yossefm@post.tau.ac.il

Source-cont.
Always consider the followings: Joint/ Ligaments Neural Muscle/Soft tissue Bone Vascular Visceral
13 Dr Masharawi Y. yossefm@post.tau.ac.il

Source-cont.
Non-local sources:
Projected pain ( :) nerve irritation (eg. nerve root/radicular pain, CTS, Thoracic outlet Synd.) Referred pain ( :) segmental enervation (muscle, soft tissue, bone, visceral)
14 Dr Masharawi Y. yossefm@post.tau.ac.il

Source-cont.
1. Site (detailed area, depth, character) 2. Characteristics (constancy, type) 3. Behavior (aggravating, easing, 24 hour pattern) 4. History (type of onset, progression, previous
(treatment
15 Dr Masharawi Y. yossefm@post.tau.ac.il

3. CONTRIBUTING FACTORS () Physical Biomechanical Environmental Psychological Cultural influences

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Dr Masharawi Y. yossefm@post.tau.ac.il

4.PRECAUTIONS AND CONTRAINDICATIONS

a. Precautionary questions b. Severity/irritability c. Progression d. Stability of the disorder

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Dr Masharawi Y. yossefm@post.tau.ac.il

5. Prognosis
Mechanical/inflammatory balance Irritability 24 hour pattern Degree of trauma Patients expectations lifestyle Personal profile Healing potential
18 Dr Masharawi Y. yossefm@post.tau.ac.il

6. Management
Remember!!! - Asking open questions - Do not assume things thinking - Do not become locked into rigid

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Dr Masharawi Y. yossefm@post.tau.ac.il

1. 2. 3. 4.

-THE INTERVIEW (Subjective examination) Main complain (C/O) Body Chart Behavior of Symptoms (Sx) History and Past-history (Hx & PHx)

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Dr Masharawi Y. yossefm@post.tau.ac.il

SEQUENCE OF THE INTERVIEW

- Speed of questioning - Concentrate on the implication - Ensures that all relevant areas are covered - Encourages logical progressive thinking
21 Dr Masharawi Y. yossefm@post.tau.ac.il

SEQUENCE OF THE INTERVIEW (cont.)

- No interpretation of information received - Less personal communication with each patient

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Dr Masharawi Y. yossefm@post.tau.ac.il

MAIN COMPLAIN
Establish the patients main problem by asking an open question like: What is your main problem at this stage?

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Dr Masharawi Y. yossefm@post.tau.ac.il

BODY-CHART
Site (area and depth) of all symptoms Type of symptoms Constant or intermittent (Cte. or Int.) Relationship between symptoms
24 Dr Masharawi Y. yossefm@post.tau.ac.il

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)

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Dr Masharawi Y. yossefm@post.tau.ac.il

Body-chart (cont.)
b) Questions specific to area of symptoms: Upper quarter Vs. Lower quarter

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Dr Masharawi Y. yossefm@post.tau.ac.il

Body chart (cont.) -Special questions A. Upper quarter: 5 Ds: Dizziness, Disphagia, Disarthria, Diplopia, Drop-attacks. B. Lower quarter: Cauda-equina, incontinence C. Both: Cord signs
27 Dr Masharawi Y. yossefm@post.tau.ac.il

Stop!!!
look at the recorded symptoms and convert them into the initial hypotheses ( all six categories)

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Dr Masharawi Y. yossefm@post.tau.ac.il

Interview (cont.)
Proceed to behavior of symptoms or history How to choose? Chronic Behavior Acute History

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Dr Masharawi Y. yossefm@post.tau.ac.il

Behavior of symptoms (Sx)

What do we want to know? a) mechanical/non-mechanical b) inflammatory component c) behavior (activities/postures)

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Dr Masharawi Y. yossefm@post.tau.ac.il

c) Behavior (activities/postures) help to - incriminate certain sources - confirm relationship of Sx. - identify contributing factors - severity - irritability
31 Dr Masharawi Y. yossefm@post.tau.ac.il

Behavior of Sx (cont.)

Severity of Sx/disorder:
- On a scale of 1 (mini.) to 10 (maxi.) - Functional limitation - Constancy of Sx.

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Dr Masharawi Y. yossefm@post.tau.ac.il

Behavior of Sx (cont.) Irritability of Sx/disorder (3 elements):

1. Determining the painful activity (repetitive or isolated movement) 2. How painful it becomes (i.e. severity) 3. The length of time the increased Sx takes to recover

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Dr Masharawi Y. yossefm@post.tau.ac.il

Behavior of Sx (cont.)
How best to obtain this information? What aggravates the symptom1. 2. What eases the symptoms

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Dr Masharawi Y. yossefm@post.tau.ac.il

Behavior of Sx (cont.)

24 hour pattern

Symptoms during the day

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Dr Masharawi Y. yossefm@post.tau.ac.il

History: present and past

From the History, we should know: -The status of the disorder !!!

-Whether the disorder is mechanically stable !!! -The likely prognosis !!!
36 Dr Masharawi Y. yossefm@post.tau.ac.il

Present history
Of local and referred symptoms:

When did it start? How did it start?

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Dr Masharawi Y. yossefm@post.tau.ac.il

History (cont.)
Trauma Spontaneous What happened? What was What was noticed first? noticed first? (pain/stiffness/etc) Extent of damage, Degree of immediate pain, swelling predisposing factors Activity - unusual/heavy Sustained postures Unwell/virus Overtired, others Treatment and its effect Progress since
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Predisposing factors Treatment and its effect Progress since

Dr Masharawi Y. yossefm@post.tau.ac.il

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?
39 Dr Masharawi Y. yossefm@post.tau.ac.il

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?

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Dr Masharawi Y. yossefm@post.tau.ac.il

Remember !!!
- Asking open questions - Do not assume things - Do not become locked into rigid thinking

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Dr Masharawi Y. yossefm@post.tau.ac.il

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Dr Masharawi Y. yossefm@post.tau.ac.il

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 precautions required 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) are indicated?

Must examine all potential sources (structures) and contributing factors:

Structures (e.g. joints , muscles, soft tissues, nerves) which underlie the area of symptoms Structures which can refer to the area of symptoms Structures contributing to symptom production

How much physical examination is indicated on day 1? Divide patients 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 first consultation

Full examination
Full extent of examination without risk of aggravation of 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 (Cont.)
What P/E findings implicate a structures 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 patients symptoms - Directly or indirectly stressing a structure reproduces the patients symptoms or symptoms that are different than normal.

TESTS FOR DIFFERENT STRUCTURES Tests of intervertebral joints - Physiological movements (singly or combined) - Palpation - Passive accessory inter-vertebral movements (PAIVMs) - Passive physiological inter-vertebral movements (PPIVMs)

TESTS FOR DIFFERENT STRUCTURES (CONT.)

Tests of peripheral joints - physiological movements (singly or combined) - Palpation - Accessory movements from different positions

TESTS FOR DIFFERENT STRUCTURES (CONT.)

Tests for muscles

Source -palpation -contraction -passive stretch Contributing factors -length -functional and isolated performance (strength, endurance, power, etc.)

TESTS FOR DIFFERENT STRUCTURES (CONT.) Tests for vascular involvement - VBI protocol - Arterial pulses - Thoracic outlet tests

TESTS FOR DIFFERENT STRUCTURES (CONT.)

Tests for nervous system involvement - Passive neck flexion (PNF) - Slump - Straight leg raise (SLR) - Prone knee bend - Upper limb tension tests (ULTTs) - 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

Posture what are we looking for ?

Asymmetrys Altered positions/angles Under/over development etc. Dynamic versus static

Posture where and how should we look ?

- Note when patient unaware - Note in patients 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 doesnt 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
STRUCTURAL REGIONAL
nerves joint (intra/extra articular) muscle Joint movement

Physiological and Accessory Movements

Insufficient to simply note gross range and production of symptoms ! Must assess quality of movement and its symptoms relationship to behavior of through range

Active Physiological Movements

- Clear patient instructions - Observe quality of movement and note behavior of symptoms - Continually re-establish status of symptoms - Often requires different views of focus - Correct asymmetrys to assess effect - Overpressure to establish end feel and effect on symptoms (local and refereed) - Normal Mvt.= (Full range , no pain with overpressure)

Active Physiological Movements

(cont.)

If local/referred symptoms not reproduced (and not irritable)-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 Movements

Clear patients instructions Effective control of movement (eg. hand holds, thumb, pressure, body mechanics, etc.) Establish relationship between quality of movement (i.e. Movement and behavior of symptoms Diagram)

PPIVVMs & PAIVMs Passive Physiological Inter-vertebral Movements (PPIVMs) Passive Accessory Inter-vertebral Movements (PAIVMs)

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 - 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


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)Dr.Youssef Masharawi (PhD, BPT

Relevant patterns in understanding a patients 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.
73 Dr.Youssef Masharawi (PhD, BPT)

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
74 Dr.Youssef Masharawi (PhD, BPT)

Must treat all sources/structures and contributing factors:

Structures (e.g. joints , muscles, soft tissues, nerves) which underlie the area of symptoms Structures which can refer to the area of symptoms Structures contributing to symptom production

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Dr.Youssef Masharawi (PhD, BPT)

The potential involvement of a structure is strengthened if: - Altering the abnormality affects the patients - Directly or indirectly stressing a structure

symptoms

reproduces the patients symptoms or symptoms that are different than normal.

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Dr.Youssef Masharawi (PhD, BPT)

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

Dr.Youssef Masharawi (PhD, BPT)

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Factors determining the choice of technique and method of application

Pathology Kind of disorder

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Dr.Youssef Masharawi (PhD, BPT)

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 specific diagnosis
79 Dr.Youssef Masharawi (PhD, BPT)

1. Pathology (cont.)
A Particular diagnostic title can present different patterns of Signs and Symptoms Examples: - L4/5 discogenic pathology - Sprained medial collateral ligament of the knee - O.A. of the hip In these cases, the choice and method of applying passive movement is based on the presenting symptoms and signs
80 Dr.Youssef Masharawi (PhD, BPT)

2. Kind of disorder
Patients present with a disorder that is: - Pain: only symptom, no underlying stiffness - Pain and Stiffness: pain = dominant - Stiffness: only, no pain or other symptom - Stiffness and Pain: stiffness = dominant

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Dr.Youssef Masharawi (PhD, BPT)

Treatment of PAIN only

Example: Patient with constant deep ache within the shoulder, movement grossly limited by pain

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Dr.Youssef Masharawi (PhD, BPT)

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

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Dr.Youssef Masharawi (PhD, BPT)

Painful disorder: Progression

- Treat daily, or alternate days - Increase amplitude of movement (still short of discomfort) I II-II - Perform technique into slight discomfort IIIII-III - Increase speed of movement / alter rhythm from smooth to staccato (joint no longer in neutral)
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Dr.Youssef Masharawi (PhD, BPT)