Unit 1 - MSK Clinical Reasoning

What are the parts of CRAFTE (Clinical Reasoning Assessment for Thinking Effectively)?

1. patient history

2. physical examination

3. assessment

4. initial interventions

5. prognosis

6. education

7. plan of care

CRAFTE: Section1 (history)

• initial hypothesis is based on your review of the patient's chart and intake forms

• will list the possible diagnostic hypotheses for the patient's condition

  • including at least one nonmusculoskeletal condition or red flag hypothesis

• therapist-generated body chart

• subjective history, or patient interview

• ICF

• stage of change

• stage of healing

• symptoms

• SINSS model

initial hypotheses should be…

• plausible based on the information you have gathered from the patient's medical chart and intake forms

• Under each hypothesis, provide evidence from the intake forms that indicates the reasoning as to why the hypothesis should be included

• The three initial hypotheses will be labeled as

  • primary, most likely

  • secondary, less likely

  • remote, least likely

subjective exam

• one of the most important parts of your examination

• 80% of the information needed to determine the source of the patient's symptoms can be gathered from the patient's responses during the history-taking process

• Some key findings may include

  • demographics

  • occupation

  • role of mechanism of injury

  • current symptoms

  • past medical history

  • medications

  • prior activity level

  • self-identified functional impairments

  • prior treatments

  • 24-hour symptom pattern

  • notes about current motivation

  • movement

  • yellow flags

  • goals

ICF

• a framework to gain a holistic understanding of the patient's health condition in the broader context of their life

• primary activity limitation is often the thing the patient most wants to do, or is most limited in doing

• Participation restriction is how that activity limitation restricts the patient from engaging in social or environmental contexts

• describe how these factors may act as barriers or facilitators to recovery

  • list at least two barriers and two facilitators

  • identify how you plan to intervene for any modifiable barriers

• Personal factors include age, health and wellness, beliefs, education, occupational, motivational, or psychological factors

• Environmental factors may include the patient's living environment, level and type of social support, and level and type of accessibility

stage of change

• During the subjective interview, you will learn if the patient is in the precontemplation, contemplation, preparation, action, or maintenance stage

• you will identify the body systems primarily involved in the patient's condition, which pain mechanisms are predominant, and any evidence of tissue healing

Signs of tissue healing

• inflammatory phase

  • may include swelling, pain, redness, and/or warmth

• proliferation phase

  • there's pain, redness, and swelling, but they will all begin to decrease

• remodeling phase

  • the tissue will be in the final phase of healing with improved strength and durability

  • There should be little to no pain and no swelling present in this phase

Symptom sources

• may include joint and bony structures under areas of symptoms, muscles and tendons under in the area of symptoms, ligaments, nerves, and other soft tissues under and in the area of the symptoms, neurological or musculoskeletal structures which may
  refer to the area of the symptoms, or red flag conditions or visceral structures which may be screened.

• You may include up to three structures per region

SINSS model

• severity

• irritability

• nature

• stage

• stability

Severity (SINSS)

• the extent of the impact of symptoms on the patient's activity

• The highest NPRS is often used to quantify

Irritability (SINSS)

includes the assessment of the time frames and/or intensity of activity which brings on symptoms

Nature (SINSS)

includes a suspected involvement system, pain mechanisms, structures, and psychosocial factors

Stage (SINSS)

can be classified as acute, subacute, or chronic, and may be linked to severity and irritability

Stability (SINSS)

related to the predictability and progression over time of the symptom behavior

How do you use SINSS with CRAFTE?

• you will list each problem labeled as P within the form and justify your assessment of each using the SINSS model

• You will include a rationale for your decision

CRAFTE: Section 2 (physical exam)

• Which of your initial hypotheses were you able to roll down in likelihood from the subjective examination findings, and how?

• What evidence can you identify from your interaction with the patient thus far that would support any changes to your hypotheses list?

What do you do after the patient interview but before the physical examination?

• generate your revised working hypotheses

• You will list a primary hypothesis

A critical factor in your physical assessment?

intensity of your range of motion examination

examination vigor spectrum

• Most cautious

  • highly irritable patients, limit range of motion testing to first onset or change in symptoms, even if you suspect they have more available motion

  • This minimizes discomfort while still gathering useful information.

• Moderately cautious

  • For example, patients with moderate irritability, you may test active range of motion to its limit even if it reproduces their pain. You might also apply passive overpressure to assess and feel, accepting some symptom reproduction in exchange for deeper clinical insight.

• Least cautious

  • When working with low irritability patients, you can perform sustained, repeated, or combined movements without significant concern for symptom exacerbation

  • In these cases, you are confident that the vigorous examination will not provoke excessive discomfort

plan for the physical examination

• Which symptoms will you try to reproduce, and how?

• Do you expect it to be easy or hard to reproduce these symptoms?

• What is the anticipated vigor or limit of your range of motion examination?

CRAFTE: Section 3 (assessment)

• After your physical examination, you will assess your findings

• Using the SINSS principle, do you have to change your assessment, level of irritability, or pain mechanisms?

• One of the most important questions you will have to answer is if the patient is appropriate for physical therapy management

• Is your clinical management to treat, treat and refer, a nonurgent referral, or an urgent referral?

• If you are deciding to refer out, to whom will you refer?

• What is the clinical reasoning for this referral? What will you suggest for the referral, such as imaging or lab work?

If deemed appropriate for physical therapy management…

• you will list your baseline objective findings

• you will choose your primary hypothesis and describe the clinical evidence that supports this choice

• You will do the same thing for an alternative hypothesis

CRAFTE: Section 4 (initial interventions)

• What do you expect to primarily be treating initially?

• Pain and symptom modulation, range of motion, muscle performance, activity performance, or contextual factors?

• What evidence indicates that this treatment approach is appropriate for your patient?

• You will then list two specific interventions, the expected response for each, and choose a comparable sign to reassess after the treatment

• The comparable sign reassessment is crucial to determining if your treatment was effective

• At least one intervention should be active in nature

• Your home exercise program should include three interventions with listed frequency, intensity, and time.

• provide a rationale for your dosage selection.

CRAFTE: Section 5 (prognosis)

• You will start by describing any contrast between the individual's prior, current, and desired level of function

• You will justify your choice with evidence from the subjective and physical exams

• Is there any natural history of the disorder that can guide your prognosis?

  • List any positive or negative prognostic indicators, likelihood of recurrence, and the rationale.

• Overall, how would you rate this patient's prognosis? Is it poor, fair, good, or excellent?

• Finally, you will create short and long-term goals using the SMART goals concept and the ICF framework

CRAFTE: Section 6 (education)

• What's wrong with me?

  • most important

• How long will it take?

• What can you, the therapist, do about it?

• And what can I, the patient, do about it?

• These questions are designed to give the patient a clear and foundational understanding of their condition and the path forward.

• To answer them effectively, you'll need to integrate all the information from the CRAFTE form along with your clinical reasoning skills.

CRAFTE: Section 7 (plan of care)

• You will answer how you expect the condition to progress over time considering the patient's impairments, activity limitations, participation restrictions, and tissue healing.

• How many visits?

• Over what period of time do you expect to see the patient?

• you will use the targeted ICF framework to pull all of your clinical decision making together.

  • You will address the ICF components using specific interventions and describe the dosage for each.

  • Each ICF component will have an associated goal

CRAFTE body chart symbols

• circle

• X

• slash mark

• arrow

• check mark

• P_

Body chart: circle

dull or aching

Body chart: X

numbness

Body chart: slash

tingling

Body chart: arrow

shooting/radiating

Body chart: check mark

clear, noninvolved

Body chart: P_

each symptom

Using the Body Chart

• Can significantly improve your subjective examination by precisely identifying the patient's specific symptoms.

• The symptom investigation can include subcategories of:

  • Symptom location and descriptor of the pain

  • Onset of symptoms

  • Behavior or pattern of symptoms over time

Using the Body Chart: Ruling Out

• Noting the exact location of symptoms and descriptors of symptoms (e.g. ache, burning, shooting), paresthesia, numbness, and weakness can be extremely valuable.

• Note where the patient does not have symptoms with a check mark

• Overlap between pain location patterns associated with visceral disorders and common musculoskeletal disorders

Tell me, what brings you in today, and how can I help you?

• “Listen to your patient, he is telling you the diagnosis”

  • Sir William Osler, Physician, 1 of 4 founders of Johns Hopkins Hospital

• Start with OPEN-ENDED questions

• Clarify with CLOSE-ENDED questions

• “Patients spoke, uninterrupted, an average of 12 seconds” (Rhoades, D. et al. 2001)

• One of our greatest interventions begins with the first question: LISTEN

Can you show me exactly where your pain is?

• Identify through tracing with hand

• Pinpoint versus General

• Where did it start?

• Does it move up or down?

  • Spreading

  • Referral Pattern

• Are you having this pain right now?

  • If so, how would you rate this pain, 0 - 10?

  • Establish BASELINE

  • First indication of SEVERITY and IRRITABILITY

What does it feel like?

• Pain Descriptors

  • Sharp

  • Dull

  • Stiff

  • Achy

  • Tight

• Numbness or Tingling?

  • Dermatomal Pattern

  • Peripheral Entrapment Pattern

  • Strong indication of Neuropathic Mechanism

• Throbbing

  • Vascular Pattern

Have you noticed anything that aggravates your symptoms?

• BEHAVIOR: “Aggs”

• The factors that aggravate symptoms

  • Positional?

  • Activity-related?

  • Stress-related?

• time to aggravate

  • How quickly does this exacerbate symptoms?

    • Immediate

    • Gradual

• Intensity (NPRS)

  • Rate 0-10 at its Worst

• Persistence

  • How long does it last?

Have you noticed anything that makes your symptoms better?

• BEHAVIOR: “Eases”

• The factors that provoke or exacerbate symptoms

  • Positional?

  • Activity-related?

  • Stress-related?

  • Modalities?

• Time to Onset: How fast does it go away?

  • First indication of IRRITABILITY

    • Immediate

    • Gradual

• Intensity (NPRS)

  • Rate 0-10 at its Worst

• Persistence

  • How long does it last?

Behavior

• Symptom Presentation Characteristics

  • Constant?

  • Intermittent?

  • Consistent?

  • Variable?

• Helps to determine NATURE

  • Involved system and structures

  • Pain classification

• RED FLAG: Constant + Consistent

  • Non-mechanical

  • No easing factors

  • Refer

Is there anything this symptom is holding you back from doing?

• Strongest indicator of SEVERITY

• Activity?

  • ADLs

  • Work

  • Hobbies/Sport

  • Social

• Insight into Fear Avoidance Behaviors

• Best indication of patient-centered, functional Goal

Have you noticed any patterns in your symptoms based on the time of day?

24-Hour Pattern

• Worse in A.M., eases with movement?

• Good in A.M., worse as day progresses?

• Does this pain wake you up at night?

  • Can you change positions to ease?

  • Can you fall back asleep?

  • If no: potential RED FLAG:

    • Unrelenting

    • Wakes up at same time each night

Would you say this pain is getting worse, getting better, or staying the same?

• Strongest indication of STABILITY

• Is it following a predictable pattern?

  • Expected rate of healing for tissue injury

  • Factor in co-morbidities

  • Predictable Aggs and Eases

• Progression or Regression over time

When/How did this start?

• Was there a mechanism of injury?

  • Trauma

  • Insidious Onset

  • Gradual/Overloaded

• If tissue is injured, consider phases of tissue healing

  • Coagulation and Inflammatory

  • Migratory and Proliferative

  • Remodeling

Have you ever had anything like this before?

History of condition

• Previous Injury

• Previous Treatment

Have you / Are you participating in any other treatments?

• Co-treatment with other health professionals

  • May affect progression / regression

• Insight into beliefs around recovery

Are you taking any medications?

• Effects of pain relievers / anti-inflammatories / steroids

• Not just for present condition

  • Screening for compounding / non-conducive medications

  • Insight into co-morbidities

  • Insight into compliance

Have you had any imaging?

X-Ray, MRI, CT Scan —> Referral —> Discussing maladaptive beliefs

Review of Systems/Red Screening

Review of Systems: Have you considered all the systems?
1. Cardiovascular
2. Pulmonary
3. Endocrine
4. Eyes, Ears, Nose, or Throat
5. Gastrointestinal
6. Genitourinary/Reproductive
7. Hematologic/Lymphatic
8. Immune
9. Integumentary
10. Musculoskeletal
11. Neurologic

Currently I am experiencing: (please circle all that apply)

• Difficulty swallowing
  Nausea/vomiting
  Shortness of Breath
  Pulsing in abdomen
  Unexplained Weight Loss
  Change in bowel/bladder
  Changes in appetite
  Increase pain at night/rest
  Poor Balance/Falls/Dizziness
  Pain with eating
  Pain with menstruation
  Numbness/Tingling
  Headaches
  Depression
  Vision Changes

Tell me, what do YOU think is causing your symptoms?

• Insight into patient beliefs

  • Opportunity to break down fears, maladaptive beliefs

  • Opportunity for reassurance

• What do YOU think will help it get better?

What is your number one goal?

• Functional —> Activity —> Participation

• SMART

• Motivational

Recap

Review your findings to the patient

Is there anything else that I haven’t asked about or that you would like to tell me?

Open Opportunity for Patient

EXPLAIN: 4 Questions

• Hypothesis

  • 1) “What is wrong with me?”

  • Explanation of Objective Examination

• Potential Prognosis

  • 2) “How long will it take?”

• 3) “What can I do?”

• 4) “What can YOU do?”

• Informed Consen

Subjective exam Conclusion

• Allow your patient to tell THEIR story.

• INVEST in your patient by LISTENING.

• Explore the IMPACT on the patient’s life.

• Demonstrate EMPATHY.

• EDUCATE.

• “Honesty without COMPASSION is Cruelty” - unknown

Screening Tools

• “Brief triage instruments”

• Used to

  • Identify patients who may be at risk for poor clinical outcomes

  • Improve the efficiency and effectiveness of care

Outcome Measures

• Used to

  • assess a patient’s current status and ability

  • track functional changes over time

• Types

  • Performance-Based

    • Timed Up and Go (TUG)

  • Self-Reported

    • Oswestry Disability Index (ODI)

Patient Client Management Model

ICF Examples of Screening Tools/Outcome Measures

• Health Condition:

  • PHQ-2 and PHQ-9

• Body Structures/Impairments:

  • Beighton score

• Activity Limitations:

  • TUG, Dynamic Gait Index, Noyes Hop Testing, NDI

• Participation Restrictions:

  • PSFS, ODI, UEFS, LEFS

• Environmental Factors:

  • Health-Related Social Needs Screening Tool

• Personal Factors:

  • Tampa Scale of Kinesiophobia (TSK)

Which One Do I Choose?

• Red and Yellow Flag screening

  • Differential Diagnosis

• Map out the ICF Model for your patient

  • Which domain(s) do you need to assess?

• Review the Psychometric Properties of the Tools/Measures

  • Validity

  • Reliability

  • Population

The SINSS

• Characteristics of the patient’s presenting symptoms

• Purpose:

  • Guide clinical decision-making

  • Reduce clinical reasoning errors

    

How to use SINSS?

• Develop Hypotheses

• Plan for Objective Examination

  • Vigor

  • Volume

  • Precautions

• Plan for appropriate Intervention

  • Selection

  • Dosage

Application of SINSS

“The construct of SINSS appears in several textbooks and peer-reviewed articles. However, it has been inconsistently defined and applied in clinical practice”

Guidelines of SINSS

• Must be assessed for each individual symptom

  • P1 - right sided neck pain

  • P2 - pain medial to the right scapula

  • P3 - pain over the right lateral elbow

• Continually reassessed

SINSS: Severity

• “The clinician's assessment of the intensity of the patient's symptoms as they relate to functional activities."

• How the patient’s symptoms affect their activities of daily living (ADLs)

• ICF

  • Activity Limitation

  • Participation Restriction

SINSS: Severity —> pain

• The intensity of the patient’s pain

  • Numeric pain rating scale (0-10)

• Rating:

  • Low

  • Mod

  • High

• Also consider:

  • Medications used to control pain

  • Presence or absence of night pain

  • Impact of symptoms on sleep

• Pain and activity do not always correlate

SINSS: Severity —> impact

• Impact of pain on function

• Patient-specific Functional Scale

  • a self-report outcome measure of function (0-10)

• Identify ≥5 important activities and rate them

  • Total Score = sum of activity scores/number of activities

  • MDC = 2-point change

• Identify 1 activity

• MDC = 3-point change

SINSS: Severity —> rating: low

• 0-3/10 NPRS with 8-10/10 PSFS

• No limitation to ADL's, work or recreational activities

• Indications:

  • Verbal & nonverbal cues indicate minimal to no pain

  • Descriptors indicate intermittent low-grade symptoms

  • Not taking pain relieving medications

  • No impact on sleep

SINSS: Severity —> rating: moderate

• 4-7/10 NPRS with 4-7/10 PSFS

• Moderate limitation to regular ADL's, work, or recreational activities & avoidance of more demanding requirements

• Indications:

  • Verbal & nonverbal cues indicate the presence of moderate pain

  • Descriptors indicate constant but variable moderate intensity symptoms

  • Intermittent mild pain-relieving medications may be required to function & sleep

  • Sleep disturbance possible

SINSS: Severity —> rating: high

• 8-10/10 NPRS with 0-3/10 PSFS

• Maximal limitation to regular ADL's and may be avoiding work or recreational activities

• Indications:

  • Verbal & nonverbal cues indicate the presence of intense pain

  • Descriptors indicate constant high intensity symptoms

  • Frequent pain-relieving medications may be required to function & sleep

  • Sleep disturbance likely

SINSS: Irritability

• The behavior of the symptoms.

• Considerations
  1. Amount and type of activity to aggravate symptoms
  2. Amount and type of activity to ease symptoms
  3. Ratio of the magnitude of aggravating factors to easing factors

SINSS: Irritability —> Ask yourself

• “How easy will it be to reproduce the patient’s symptoms?”

• “How likely is it that I will exacerbate those symptoms?”

• “How long will it take and to what extent can the patient alleviate those symptoms?”

• Implications:

  • Plan for the physical examination

  • Plan for Interventions

SINSS: Irritability —> Criteria To Assess

• Aggravating Factors ("Aggs")

  • Intensity of the activity to agg

    • Sitting vs. walking vs. running

  • Time to onset or exacerbation

  • Intensity at onset – NPRS

  • Intensity at worst – NPRS

• Easing Factors ("Eases")

  • Activity or reduction of activity to ease

    • Walking to sitting vs. running to lying down

  • Time to Ease

  • Intensity at best – NPRS

• Constant vs. Intermittent?

• Consistent vs. Variable?

SINSS: Irritability —> Symptom Characteristics

• Constant vs. Intermittent?

• Consistent vs. Variable?

• Constant + Consistent

SINSS: Irritability —> rating: low

• High intensity activity to agg

  • running

• Minor reduction in activity to ease

  • walking

• Greater time to agg and less time to ease

  • 30 minutes to 2/10, 60 minutes to 6/10 // 10 minutes to 0/10

SINSS: Irritability —> rating: moderate

• Moderate intensity activity to agg

  • walking

• Moderate reduction in activity to ease

  • sitting

• Similar time to agg and ease

  • 60 minutes to 6/10 // 60 minutes to 0/10

SINSS: Irritability —> rating: high

• Low intensity activity to agg

  • standing

• Significant reduction in activity to ease

  • lying down

• Less time to agg and greater time to ease

  • 5 minutes 6/10 // 60 minutes to 0/10

SINSS: Nature

• "Broad, conceptual term

• Includes

  • the specific diagnosis or condition

  • the nature of the patients themselves

  • the nature of the pain itself."

• Each clinical presentation is unique

• All factors that should be considered as you are planning the physical exam

SINSS: Nature —> clinician’s assessment

• Hypotheses

  • involved systems

  • involved structures (if appropriate)

  • syndrome/classification

• Dominant mechanism of pain

  • e.g., nociceptive, neuropathic, nociplastic

• Psychological and social factors

• Precautions

What is Referred Pain?

• Pain that is perceived at a site adjacent to or at a distance from the site of origin or stimulation

• Multifactorial etiology

• Common structures that refer pain

  • Viscera

  • Muscle

  • Intervertebral disc

  • Joint

  • Trigger points

Types of Referred Pain

• visceral

• somatic

• neurological

Visceral pain

Pain referred from any visceral organ or peritoneum

Somatic pain

Pain referred from any innervated musculoskeletal structure of the body

Neurological pain

Pain referred from any neurological structure of the body

Cervicothoracic Referred Pain

• Facet joints

  • Most commonly symptomatic (Bogduk, 2007)

    • C2-3

    • C5-6

• Cervical disc

• Muscle

Cervicothoracic Referred Pain: C1-2 and C2-3

suboccipital region

Cervicothoracic Referred Pain: C3-4

posterolateral neck, levator scapulae

Cervicothoracic Referred Pain: C4-5

angle between the neck and shoulder girdle

Cervicothoracic Referred Pain: C5-6 and C6-7

lower neck and periscapular region, most commonly the medial scapular borders

Cervical Facet Joint Pain Patterns

Cervical Facet Joint Pain Patterns: C1-2

• Suboccipital region, can extend to occiput and vertex of head or into neck

• Upper forehead, ear, and orbit

Cervical Facet Joint Pain Patterns: C2-3

• Within a band from the occiput to the vertex

• Lateral occiput toward the mastoid region and above

• Occiput to parietal and upper temporal regions

Cervical Facet Joint Pain Patterns: C3-4

• Anywhere over the suboccipital and occipital regions, or cranially in the vertex or forehead

• Pain exclusively from this level is rare

Cervical Facet Joint Pain Patterns: C5-6

• Focal symptoms, centered over the lower posterior quadrant of the neck

• Can spread to proximal region of the shoulder girdle up to the occipital region

• No pain reported in the head

Cervical Facet Joint Pain Patterns: C6-7

• Centered over the junction of the base of the neck and top of the shoulder girdle to suboccipital region and lateral to the shoulder girdle and arm

• No pain in head

Cervical Facet Joint Pain Patterns: C7-8

• Junction of the neck and shoulder girdle

• Spreads inferiorly and medially into or around the scapular region

• Does not spread into the lateral arm or head

Craniofacial and Cervical Muscular Referral Patterns: Temporalis

Cheek area
TMJ
Maxillary Teeth

Craniofacial and Cervical Muscular Referral Patterns: Masseter

Mandibular
Teeth
Maxillary Teeth
Ear
Cheek Area
TMJ
Temple