1023 Physio Foundations

Unilateral vs bilateral

Unilateral - involving one side of the body

Bilateral - involving both sides of the body

Ipsilateral vs Contralateral

Ipsilateral - on the same side of the body

Contralateral - on different sides of the body

Clinical reasoning cycle

Consider the patient information

Collective cues/information

• gather

• review

• recall

process information

• interpret

• discriminate

• relate

• infer

• match

• predict

identify problems/issues

• synthesise

establish goals

• describe

take action

• select

evaluate outcomes

• evaluate

reflect on processes and new learning

• contemplate

Clinical reasoning

• develops with experience

• process of collecting ang and interpreting information

• formulate predictions about outcomes

known as:

• decision making

• problem solving

• critical judgements

• critical thinking

what is clinical reasoning influenced by

• Clinician knowledge base

  • Scientific & professional
    Personal experiences

• Beliefs

• Values

• Skills

Clinical reasoning pathway just the steps

Clinical reasoning pathway 5 step summary

Interview - subjective assessment

• Diagnostic hypotheses

• Plan Physical/Objective assessment (how to test/measure/identify/characterise results - notice symptoms/dysfunctions)

• Develop patient goals and a Treatment plan

observation/tests of body function - PHYSICAL/OBJECTIVEASSESSMENT

• Process to establish:

  • Individual's specific diagnosis and prognosis

  • can i treat this with physiotherapy

short/long term goals and treatment plan - treatment plan

• Judgments about diagnoses and prognoses

• Consider an individual's goals and resources

Gathering information clinical reasoning steps

Subjective assessment

• interview

objective assessment

• observation

• tests of body function

  • eg: Observation, Functional tests, Range of movement, Muscle strength etc

subjective assessment sample form

objective assessment sample

what things to consider when developing a hypothesis and processing information

how to target these impairments in physiotherapy? - also guide goals for treatment

Synthesise - ICF framework

clinical reasoning cycle

1. gather

2. interpret

3. sythesise

4. describe

5. select

6. evaluate (may go back between select and evaluate if chosen treatment is not

7. contemplate

GISDSEC

GuIdeS and SEleCts

diagnosis vs prognosis

diagnosis:

• reason for symptoms etc - causes of issue

Prognosis:

• suggested response - decision on how to address issue

what are heuristics?

• Generalisations/ rules of thumb/ educated guess

• Efficient and automatic so decrease cognitive load

types of heuristics

• availability heuristic

• Pattern heuristic

• Recognition heuristic:

explain availability heuristics

• Tendency to rely on information that is easy to recall when making decisions.

• Conversely, something that is hard to remember doesn’t get fed into the decision-making process as much.

eg: “I recently saw two disc herniations → this is probably another.”

explain pattern heuristics

• It involves making judgments by comparing things to concepts/patterns we already have in mind.

• Healthcare professionals may make diagnostic and treatment decisions based on how well a patient and their symptoms match an existing pattern/protoype.

• Focuses on clinical features

• matching up symptoms to a patter - thus subconsciously/consciously ask questions which suit that pattern

eg: “Young athlete and ankle swelling = lateral sprain”

explain recognition heuristics

• mental shortcut in which a person judges that an option or explanation is more likely to be correct simply because it is familiar or recognised.

• judgement is driven by recognition, not yet by formal testing.

eg: “I’ve seen this shoulder presentation many times before it looks like frozen shoulder.”

what is Hypothetico-deductive reasoning

• Use heuristics and inductive/deductive/abductive/ rule based/ reasoning to make hypothesis

• Iterative

• Hypothesis modification

what is dual process thinking

Type 1 thinking

• ‘intuitive’

• Fast

• Automatic

• Effortless

• Experience based

• Pattern recognition

Type 2 thinking

• Analytic

• Slow

• Systematic

• Logical

• Effortful

what is effective clinical reasoning?

• Good clinical skills

• Use and interpret clinical tests

• Understand cognitive biases and human factors

• Meta-cognition (thinking about thinking)

• Patient centred evidence-based therapy

• Shared decision making

what is a cognitive bias

• Thinking error

• a predictable tendency in thinking to favour one perspective over others.

• Not related to intelligence

• Subconscious deviations in judgement which lead to :

  • Perceptual distortions

  • Inaccurate judgement

  • Illogical interpretation

Types of cognitive biasse

1. Blind spot bias - able to see others biases but neglecting our own

2. Anchoring/Primacy - rely more heavily to an initial piece of information, failing to adjust with new info

3. Premature closure - prematurely decide on hypothesis before propper/full exploration

4. Diagnostic momentum - attached to one diagnostic label which gathers momentum with each revision - blinding to new possibilities

5. Confirmation bias - give more attention/focus on information that fits with our existing beliefs - less critical reflection

6. Ascertainment bias - thinking is shaped by previous expectations - what we expect

7. Halo effect/horns effect - A positive/negative impression of a person in one area affects how we think of them in others - eg: attractive = nicer/successful/intellegent obese=lazy look healthy=think they are

8. Visceral bias - influence of negative or positive feeling towards a patient

biases to watch for in the dual process theory

type 1

• Blind spot bias

• Anchoring

• Ascertainment

• belief bias

• Visceral bias

• Diagnostic momentum

• Halo/horns effect

Type 2:

• Premature closure

• Confirmation bias

internal vs external factors which influence clinical reasoning

Internal

• Knowledge

• Training

• Confidence

• Emotions

• Fatigue

• Stress

• Illness

External

• Workload

• Interruptions

• Patient factors

• Team factors

• Insufficient data

also may be influenced by the time of day

what is metacognition

• Ability to pull back and think about the thinking underlying our clinical reasoning

• Can use it to reduce the impact of biases

  • Not easy and needs multiple strategies and ongoing maintenance

  • Easier with outside input

Experts in clinical reasoning

• Use heuristics frequently

• Errors occur when heuristics dominate without analytical checking (deductive/rule-based reasoning)

• So Good/Expert clinicians:

  • Use heuristics to generate hypotheses

  • then use deductive + rule-based reasoning to test and safeguard decisions.

Methods to counteract cognitive biases

1. learn cognitive biases to recognise and counteract them

2. Question question decision making process where biases may have influenced decisions

3. collaborate a diverse group of contributors from varying experitise areas may be able to spot areas overlooked - identify biases

4. remain blind to avoid being influenced by gender, race, or other easily stereotyped considerations

5. Use checklists, algorithms or other objective measures to focus on relevent factors and no overlook processes

GALS screen view purpose

designed fro the routine assessment of a patient

starts with 3 questions which should be included in routine systemic inquirey

• identify common problems in the usculo skeletal system

• identify significant abnormalities in the upper and lower limb function

3 starting gal question

1. do you have any pain or stiffness in your muscles, joints or back

2. can you dress yourself completely without any difficulty

3. can you walk up and down stairs without any difficulty

order of things assess in GALS

1. GAIT

   • smoothness symmetry and ability to turn quickly

   • “can you take a few steps for me please?”

2. EXAMINE MUSCLE BULK

   • shoulder muscle bulk + symetry

   • spinal alignment

   • gluteal muscle bulk

   • politeal swelling or abnormalities

   • hindfoot abnormality or swelling

3. EXAMINE SPINE

   • from side:

     • normal cervical lordosis

     • normal thoracic kyphosis

     • normal lumber lordosis

   • “can you bend forwards and try touch your toes and come back up”

     • as they rise your fingers on lower back should mover back together

     • indicates movement isn’t purely from the hips

4. EXAMINE ARMS

   • stand in anatomical position

     • shows normal elbow extension

   • ask for cervicle spine lateral flexion

   • ask to open jaw wide - move it side to side

     • assess for temporal mandibular joint pain

   • hands behind head

     • creates humeral movement allows for elbow flexion to be examined and assesses arm function

   • pronation and flex elbows so hands face down

     • assess composite range of movement of elbow range of rotaion and wrist movement

     • can inspect patient hand for any swelling or deformity in the fingers

   • look and palms of the hands

     • examine muscle bulk, look for tendon thickening or abnormality

   • make a fist

     • test function

   • touch fingers together

     • test function smoothness and concentration

   • grip strength test

   • gently squeezing across the metacarpal phalangeal joints

     • screens for inflammatory joint disease

5. EXAMINE LEGS

   • assess knee flexion

   • hip flexion

   • internal rotation of the hip

   • patella tap

     • checks for fluid or knee effusion

   • cross fluctuation or bulge test

   • check feet for callus formation on soles

   • squeeze gently across the metatarsal phalangeal joints while watching patients face for signs of discomfort

If no abnormalities are found this should be recorded as GALS NAD

WHEN is the History taken by the Physiotherapist?

• Initial consultation

• During treatments (reassessment with reference to the initial history).

• Signs and symptoms can vary rapidly

• Following each treatment

• objective and subjective reassessment

• Reassessment at the start of each subsequent session

things to remember as a physio when taking history/notes

• Allocate enough time

• Be attentive and a good listener

• Be aware of your body language & tone of voice

• Be prepared eg: How are you taking notes?

• empathy

• insight

• active listening

• understanding

Where do phyios take a history

inpatient

• general ward

• high dependency

• icu

• transitional care

rehab/outpatients

Structure of taking a history - 7 Categories, each relating to one part of the problem

1. Area and type of the symptoms (Body Chart)

2. Current history (CHx)

3. Past history (PHx)

4. Behaviour of symptoms (24/24 hrs, Aggs/eases)

5. Irritability of symptoms (how easily aggravated)

6. Contraindications and precautions (‘special questions’)

7. Social history (SHx) and Goals

what information to gather on current presentation of symptoms

Spatial distribution

• Exact area (site of pathology?)

• referral patterns (somatic/visceral)

• # of areas, check unaffected areas (✓)

Type of symptoms

• pain, paraesthesia, anaesthesia, stiffness, weakness

Quality

• dull ache, burning, sharp, stabbing, maybe noises.

Intensity: (use scale /10)

Depth

Constant or intermittent

Establish relationship of symptoms

what to ask initially to a patient?

• what brings you in today?

• tell me where your experiencing pain or discomfort?

• pain threshold?

• constant or intimitent

Suspected structure and pain quality

how to take a current history? and potential questions?

aka: History of Present Condition

• Determine details of the incident/onset

potential qs:

• when did symptoms begin

• which symptoms - chronological onset

• mechanism of injury - how did they start (trauma, gradual onset?) - (any lifestyle changes?)

• progress of symptoms? worse/ better/ same since onset of episode?

• treatment since this episode began? effect?

Past history potential questions

First episode?

• when did it occur?

• how did it occur?

• previous treatment and effect?

Subsequent episodes?

• are they changing in frequency, intensity and duration?

behaviour of symtoms can be used for?

used to?

• hypothesise structure affected

• Indicate functional impairment

• Gain information re:

  • Severity

  • Irritability

  • Nature of condition

Examples of Aggravating factors

Aggravating factors

• Knee - squat / stairs

• Hip - squat

• Ankle - stairs / tipee-toes

• Foot – walking on uneven ground / barefoot

• Shoulder - overhead/ HBB

• Lx Sp - sitting/ standing

• Tx Sp - deep inspiration/ cough

• Cx Sp - sustained flexion

examples of easing factors

• Positions

  • eg. avoid putting much weight through leg, sitting rather than standing, walking not running, changing how put a bra on)

• Heat / cold / massage

• Exercises

patient assessment and outcome measures

1. history

2. physical assessment

3. goals

4. plant treatment

what is a subjective assessment/history

In a subjective assessment/history, we are gathering data through patient interview to:

• Generate diagnostic hypotheses

• Plan the physical assessment including selecting specific tests and measures to identify and characterize signs, symptoms, and risk of movement dysfunctions

• Determining irritability

what is an objective/ physical examination entail

Objective Assessment; an evaluation process to establish:

• Individual's specific diagnosis

• Individual's specific prognosis

• Whether the potential or existing disorders can be managed within the scope of physiotherapy practice.

what does assessing goals entail?

• Plan of care based on patients goals

• Consider short term and long-term goals

• SMART goals

• Goal setting keeps the focus of rehabilitation patient-centred.

• Goal setting helps health professionals plan their interventions for what is best or most meaningful for the patient.

What does establishing a treatment plan entail?

The treatment plan is based on:

• Your subsequent judgments about diagnoses and prognoses and patient goals

Physiotherapists manage an individual by:

• Making referrals

• Providing interventions

• Conducting re-assessments

• Modifying interventions to achieve the individual's goals and outcomes

• Determine a conclusion to the plan of care

the purpose and three aspects to determine in an irritability of symptoms assessment

Purpose:

• Plan an appropriate amount of examination & treatment

• Avoid making symptoms worse from too much examination or treatment

Three aspects:

1. Ease of onset

   • What activity (and/or how much) aggravates symptoms?

2. Intensity of symptoms

   • How severe are the symptoms?

3. Duration of symptoms

   • Continuation of symptoms after cessation of activity?

assessing symptoms behaviour across 24 hours?

night?

• Symptoms prevents from getting to sleep?

• Wakens?

• Best / worst positions?

Morning?

• pain

• stiffness

• when you first wake up in the morning what is the bodies position like?

During the day and at the end of day?

Purpose?

• Determine whether symptoms are caused by a mechanical disorder or a specific disease process.

  • Systemic Inflammation

  • Mechanical

• use as an indication of progress

how to distinguish between a mechanical or inflammatory problem?

A spectrum: not always this black and white

Mechanical:

• Better in the morning

• Worse at the end of day

• Worse with activity

• Obvious aggravating activity causes symptoms

Inflammatory?

• Worse in the morning

• Improvement with movement

• Stiffness >30 minutes in the morning

• Night pain

• Better with activity

• No obvious aggravating activity

what are Contraindications and precautions (‘red flags’)

• Certain pathologies may contraindicate all or selected treatment strategies and

  may require further medical investigation

• Usually identified by asking “Special questions”

purpose:

• To alert of possible serious pathology

• To alert of possible precautions or contraindications to examination or

  treatment

does my patient belong here?

Types of questions (A.K.A. “Special questions”) - which could reveal or answers that indicated red flags

• General health

• Recent unexplained weight loss

• Presence or history of:

  • Inflammatory disorders

  • Cancer

  • Osteoporosis

• X-rays and other investigations

• Medications

• Steroid use

• All spinal conditions

  • Cord signs

    • Bilateral, non-dermatomal symptoms and ataxia

• Lumbar spine disorders

  • Cauda equina

    • Disturbed bladder or bowel function, saddle anaesthesia

• Cervical spine disorders

  • Dizziness

    • Vertebrobasilar insufficiency

what are some yellow flags?

• psychosocial and other risk factors that are likely to delay recovery

• include:

  • Unhelpful attitudes and beliefs about pain, resulting in fear/avoidance behaviour

  • Unhelpful behaviours. eg. use of extended rest and disproportionate downtime

  • Compensation issues (off work due to injury/pain > 12 weeks)

  • Inappropriate diagnosis and treatment

  • Catastrophising and fear (eg. of ending up in a wheelchair and never being able to walk again)

  • Unhelpful emotions eg. feeling under stress and unable to maintain sense of self control

  • Inappropriate family response. eg,. Overprotective or socially punitive responses from spouse

  • Work issues eg. belief that work is harmful or poor job satisfaction

purpose of assessing yellow flags

• Decide if more detailed assessment required or if a referral is needed

• Identify if more important factors should be addressed & intervened

AIM:

• change management to prevent development of chronicity

Some questionnaires to identify unhelpful attitudes & beliefs:

• Tampa scale for kinesiophobia

• Fear-avoidance beliefs questionnaire (FABQ)

things to assess when observing social history?

• age and gender

• employments

  • status and type

• domestic role

  • self care

  • dependants

• leisure activities / plater profile (sports, level, comp, training, equipment, surfaces)

• goals of treatment

what are outcome measures?

Outcome measures? - Tools used to evaluate the effectiveness and

impact of healthcare interventions, treatments, or services. - are important to provide credible and reliable

justification for treatment and measure how people look feel and function

• The baseline function of a patient at the beginning of treatment

• The changes over time

• The progress and treatment efficacy, once treatment has commenced

what are outcome measures aiming to measure?

Patient (or self) reported measures (PROMS) - for outcome measures

a measurement based on a report that comes directly from an

individual regarding the status of a particular aspect of their

health.

• examples

  • KOOS

  • Orebro Musculoskeletal Pain Questionnaire

  • Fear Avoidance Beliefs Questionnaire (FABQ)

  • Assessment of Quality of Life (AQoL)

  • Nordic Musculoskeletal Questionnaire

what are some performance related outcome measures

a measure based on an individual’s performance of a defined task that is quantified in a specified way and does not rely on judgement to determine the measure or score.

what are Clinician reported outcome measures

measure based on clinical judgement or interpretation of observations made by trained healthcare professionals

what re Observer-reported outcome measure

• a measurement based on observations made by someone other than a healthcare professional such as a family member or carer, when the patient is unable to self-report.

• are reported by a parent, caregiver, or someone who observes the patient in daily life e.g., decline in cognition

• Does not include medical judgement or interpretation.

what are some examples of questions to ask before choosing an outcome measure

• Is the Outcome Measure Reliable?

• is the Outcome Measure Valid?

• Is the Outcome Measure Responsive to Change?

• Are there any financial considerations?

• Are there any limitations in outcome measure implementation for the therapist?

• Are there any limitations in outcome measure implementation for the client?

• What are resource considerations?

some things in the physical assessment kit bag

• observation

• palpation

• active movement

• passive movements

• passive accessory

• muscle strength

• muscle length

• neurological

• neurodynamic

• endurance

• functional

reliability vs validity in physio

reliability

• When using an outcome measure, the results should be the same (or similar)

  regardless of who administers the test or when it is administered

validity

• Validity is defined as the degree to which an instrument measures what it

  intends to measure. hat we need.

what is layman language

simple, easy-to-understand language that avoids technical jargon, specialized jargon, or complex terminology

Explain kinematics in physio

Motion:

• Translation (linear), eg knee movement forward

• Rotation (angular), eg ankle dorsiflexion

explain torque in movement

force (ma) x distance from axis of rotation

• causes a rotaion

• action on joints in the body

to reduce torque

• reduce moment arm (distance from axis of rotation)

• or reduce mass of load

internal vs external forces on the body?

External forces:

• Ground reaction force: reactive force from ground or object against body

• external loads

• active bodies

• passive resistance (wind)

Internal Forces:

• Muscle Activity

• ligaments

• friction in muscles/joints

examples of points of observation of normal movements? (4)

• bed mobility

• sit to stand

• standing

• walking

Different ways of Bed mobility?

• Supine to sitting up over the side of bed

  • flexion and rotation of trunk and head

  • Flexion of hips and knees to swing legs and clear bed

  • Push up with hand closest to the side of the bed you are movingtowards

• Moving across the bed (bridging)

  • Flexion of hip and knee

  • Push through feet to lift hip from the bed

  • Move hips to the side

  • Move feet and head to straighten body alignment

• Supine to side lying (rolling)

  • Rotation and flexion of the neck

  • Flexion and protraction of shoulder

  • Rotation within the trunk

  • Hip and knee flexion

• Side lying to sitting over the edge of bed

  • Lateral flexion of neck

  • Lateral flexion of trunk and abduction of lower arm

  • Legs lifted and lowered over side of bed

important components of sitting up from a chair

Initial alignment (reduce thigh support)

• Feet placement (feet apart & pointing forward, knees directly

  over feet, ankles dorsiflexion (~75%))

Pre-extension phase:

• feet placed back so that ankles behind knees

• inclination of trunk forward by flexion at the hips with an

  extended trunk

Transition between 2 phases = “thighs off” (occurs at 30% of movement duration - 150% of body weight on occurs during this time)

Extension Phase:

• dorsiflexion of ankle to bring the knees forward

• sequence of lower limb extensions at knees, hips and ankles

what are the important components of standing posture (4)

Alignment of body segments

• Head balanced on level shoulders

• Hips in front of ankles

• Feet approx. hip width apart

• Weight evenly distributed

Posture and movement are interrelated

Normal stance posture is somewhat variable among individuals

• influenced by size, age, sex and body type - though share some characteristics - guidlines in performing an individual postural assessment

Antigravity Muscles that maintain upward posture

• neck and trunk extensors

• neck extensors

• trunk extensors

• hip extensors

• knee extensors

Forces required to maintain Upright Stance

Line of gravity passes either anterior or posterior to the joint axis and as a result gravity creates a moment arm that applies a rotational force to the joint

what does centre of mass COM mean?

a point that corresponds to the centre of the total body mass. The point at which the body is in perfect equilibrium

what does centre of gravity COG mean?

the vertical projection of the COM to the ground.

what does centre of pressure COP mean?

the point on the ground that represents the average position of the forces that a person exerts on the ground

what does base of support mean BOS?

defined as the perimeter of the

contact area between the body and it’s support

surface.

what do limits of stability LOS to mean?

refers to the

sway boundaries in which an

individual can maintain

equilibrium without changing

his/her BOS

what are stability considerations?

Base of support

• stability increases as area of BOS increases

Height of centre of mass

• Lower centre of mass = COM more stable

Motion of projection of CoM with respect to BoS

• stability increases as projection of COM moves closer to perimeter of base of support.

• as COM closer towards limits of stability less stable

what is balance? - definition

Defined as the ability to control the body mass relative to the base of support

Static:

• COM is maintained within the BOS

Dynamic:

• COM is maintained while in motion or switching between positions

explain balance as a complex motor control task

• Involves the detection and integration of sensory information to assess the position and motion of the body in space.

• Involves the execution of appropriate musculoskeletal responses to control body position within the context of the environment and task.

Involves:

• musculoskeletal system

• nervous system

• contextual effects

Explain the role of the sensory system in balance control

Visual:

• information on position which allows for appropriate postural adjustments

• most important in a static environment

• can be easily altered or eliminated in a clinical setting

Vestibular (labyrinth):

• information regarding the position of head

• detect positional changes of head

• allows for postural correction

Proprioceptive (muscle/joint/skin):

• information on bodies position relative to other body parts

• enables one to make postural adaptions eg: change base of support or surface stability

postural adjustments?

postural adjustments:

• are the muscle activity and segmental movements concerned with the preservation of balance

• are:

  • anticipatory

  • ongoing

  • specific

  • movements not just muscle activity

postural sway:

• horizontal movement of the COG

ankle strategy to maintain balance

Shifts CoG by maintaining placement of the feet by rotating body as a rigid mass about the ankle joints

• Muscles are activated on the side contralateral to direction that COG is shifted or perturbed

when effective:

• Slow CoG movements when BOS is firm and CoG is well

  within LOS perimeter

• When maintaining a static posture with the COG offset

  from the center.

• Appears only if somatosensory reception intact

how does the hip strategy maintain balance

Helps control motion of the CoG through initiation of large and rapid motions at the hip with anti-phase rotation of ankles

• Muscles are activated on the side toward which COG is shifted or perturbed

Effective when:

• COG is near LOS perimeter

• LOS boundaries are contracted by narrower base of

  support

explain stepping strategy

• Utilised when COG is displaced beyond LOS

• Step or stumble is the only strategy to prevent a fall