Clinical Reasoning Framework/Examination Framework/ Management Framework

biomedical model

model that focuses solely on biological factors; illness/pain caused by factors including injury, physiological state, pathogens (factors outside of patient control)

diagnostic tests, medical diagnosis, medical treatment

3 biomedical model clinical phases

diagnostic

during phase 1 of the biomedical model, _____ tests are ordered to identify cause of symptoms (low specificity --> some findings are common and do not necessarily mean pathology/pain.)

diagnosis

during phase 2 of the biomedical model, a ____ is provided based on diagnostic test results (overdiagnosis, personify, psychological/existential burden)

treatment

during phase 3 of the biomedical model, _____ is provided based on medical diagnosis (fix it narrative, overmedicalization)

biopsychosocial

model that focuses making clinical decisions holistic. Includes biological, psychological, and social component

Bio

part of biopsychosocial model that describes the cause of symptoms stemming from the functioning of the person's body (physiological pathology, biology, anatomy

psycho

Part of biopsychosocial model that describes the thoughts, emotions, and behaviors that lead to disease. (lack of self control, emotional turmoil, negative thinking)

Social

Part of biopsychosocial model that describes how different social factors influence health (socioeconomic status, culture, poverty, technology, religion)

80

____% of factors affecting MSK recovery are outside of clinical care including environmental factors, health behaviors, and social/economical factors

Social Determinants of Health

nonmedical factors that influence health; directly contribute to well-being, health behaviors, and lifestyle --> most powerful factors that influence recovery and prognosis

severity

part of SINSS model; intensity of symptoms

low

a pain rating of 0-3/10 is ____ severity

moderate

a pain rating of 4-7/10 is ____ severity

high

a pain rating of 8-10/10 is ____ severity

irritability

part of SINSS model; amount of time or type of activity required to aggravate symptoms, amount/time or type of action it takes to ease symptoms, relationship between aggravating and easing factors

nature

part of SINSS model; type of tissue involvement, mechanical basis for symptoms; includes hypothesis list, type of diagnosis (region specific, region non-specific, persisting pain, or red flag), pain mechanism, PDDM

stage

part of SINSS model; duration of symptoms

acute

stage of symptoms; <1 month

subacute

stage of symptoms; 1-3 months

chronic

stage of symptoms; >3 months

acute on chronic

stage of symptoms; acute episode with chronic history of same symptoms

subacute on chronic

stage of symptoms; subacute episode with chronic history of same symptoms

stability

part of SINSS model; change in symptoms over time (getting better, getting worse, stable)

hypothesis list, diagnosis type, pain mechanism, PDDM

What are the four components of nature in the SINSS model

primary hypothesis

Hypothesis list; most likely diagnosis (never a red flag)

secondary hypothesis

Hypothesis list; second most likely diagnosis, can be multiple (never a red flag)

red flag hypothesis

Hypothesis list; can be multiple, ALWAYS prioritized (rule out first)

clinical diagnosis

process of determining the CAUSE of a patient's symptoms; typically does NOT guide treatment

classification system

process of organizing data into named categories; assists with making clinical decisions regarding patient management

region specific, region non-specific, persisting pain, red flags

4 different types of diagnoses

region specific disorder

type of diagnosis; <15% of patients present with this. There is a definitive mechanism of injury. Majority of clinical tests are designed to assess for this type of diagnosis (tendon strain/tear, ligament strain/tear, fracture, radiculopathy)

region non-specific disorder

type of diagnosis; approx 65-80% of patients presenting to outpatient PT, mechanical symptoms that have no biological explanation (also called somatization) (non-specific low back pain, rotator cuff related shoulder pain, patellofemoral pain, intra-articular hip pain, somatic referred pain)

persisting pain

type of diagnosis; not very common and difficult to treat; change in central nervous system due to prolonged pain (central sensitization, nociplastic pain, fibromyalgia, chronic regional pain syndrome

nociceptive, neuropathic, nociplastic

3 pain mechanisms

nociceptive pain

pain mechanism; results from stimulation of nociceptors, clear stimulus-response relationship, usually felt at or near the site of injury

neuropathic pain

pain mechanism; lesion, disease, or irritation affecting the peripheral nervous system --> history of nerve injury, trauma, compression, inflammation or ischemia. Increases with activities that compress or stretch involved structures, patients report more persistent and severe symptoms

nociplastic pain

pain from altered nociception despite no clear anatomical coorelation. Increased responsiveness of nociceptive neurons in the CNS. Persistent, spreading, worsening, unpredictable pain without a clear cause. Psychological factors are common (fear of pain/movement, pain catastrophizing)

3 regional hypersensitivity

For something to be considered Nociplastic pain, patients should report pain of at least ___ months duration, report ____ pain rather than discrete pain distribution, pain that cannot be explained by nociceptive/neuropathic mechanisms, clinical signs of ______

nociceptive, nervous system, comorbidity, cognitive-emotional, contextual

5 drivers of pain

nociceptive

driver of pain; non-specific deconditioning, structural stability deficits (assess symptom modulation, movement control, mobility and pain)

Nervous system

driver of pain; neurogenic or neuropathic; hyperalgesia, allodynia, central sensitization (test radicular pain pattern, signs of radiculopathy, signs of myelopathy

comorbidity

driver of pain; co-morbid mental health disorders, sleep disturbances, DIAGNOSED mental health (test co-occuring painful MSK pathologies)

cognitive-emotional

driver of pain; pain avoidance-behaviors like fear avoidance, mood, beliefs, undiagnosed mental health (test negative affect/mood, expectations, pain-related beliefs and cognitions, illness perception, self-efficacy, coping)

contextual

driver of pain; poor attitudes of employer, family or health care professionals, low/non-access to care (test low RTW expectations, low job satisfaction/high job stress, perceptions of heavy work, high occupational demands)

pain mechanism

What is primarily responsible for the patient's current pain presentation

PDDM

what factors will primarily be driving this patients prognosis

what is wrong with me, what can you do for me, what can I do for me, how long will this take

4 questions for patient education

specific

Many PT interventions have non-_____ effects

what are my options, what are possible benefits/harms, how likely are benefits/harms of each option to occur

three questions for shared decision making; after these, provide recommendation but ultimately allow patient to make final decision

patient centered care, guideline concordant, patient experience/outcomes, cost effectiveness

4 components to value based care

guideline concordant, integrated care

Implementation of clinical practice guidelines into practice

best research evidence, clinical expertise, patient values/preferences

Three parts to EBP