Week 1 Study Pack Answers

Clinical Reasoning as an iterative process

Cognitive process by which clinician makes decisions regarding diagnoses and treatment

Imprecise - lacks a single right Answer

Iterative - continuously updated with new pieces of relevant data

Significance of MOI in MSK Physio Assessment

Develops clinical diagnosis, leading to specific provisional diagnoses

Guides objective testing - targeted assessment and treatment

Helps understand the presenting complaint

Key Domains of Subjective Ax

Encourages patient to tell story

MOI, SSx, Site, Intensity, Severity, Stability, Irritability, Progression, Expected, Symptom Behaviour

MHx, General health, Social Hx, PLOF, Special questions, Functional Questionnaires

Key domains of Objective Ax

General Observations, Functional tasks, clearing adjacent joints, Active movement test, Passive physiological and accessory movement, Palpation, Specific assessment

Non-structural influences affecting a patient’s msk presentation

Unhelpful or incorrect beliefs about pain, Cyberchondria, Expectations of poor treatment outcomes, Sickness behaviours

Emotional responses: Fear, low self-efficacy, catastrophizing, rumination, alexithymia, anxiety/depression

Pain behaviours: Hypervigiliance, social withdrawal, unsupportive workplace, Positive expectations of Passive treatments, health profressional shopping

Coping strategies: Medication cocktails, Alcohol/drugs, risky behaviours, suicidial ideations, binge eating/not eating

Environmental and Social Factors

Ax approach for Acute injury

Pain fire concept: acute episode follows clear progression

Focusing on MOI, SSx, and stage of healing

Expected pattern of symptoms

Treatment goals aimed at facilitating natural healing process and restoring function

Ax approach for chronic injuries

Pain fire concept: hypersensitive nervous system triggered by minor stimuli

Focus on: unhelpful beliefs, Certainty, psychological influences, yellow flags

Motivational interviewing - discuss Righting reflex, 4 processes, importance and confidence strategy

Treatment goals beyond structural recovery

Importance of Irritability in managing MSK injuries

Guides testing, informs treatment intensity, Safety, patient education

Importance of Progression and rate of change in managing MSK injuries

Monitoring effectiveness of treatment, prognosis and expectations, Identifying red flags, Treatment progression planning

Describe the difference between Change talk, Sustain Talk, and Ambivalence

Change: patient expresses desire to change and provides reasons for why

Sustain: resistance and reasons against change

Ambivalence: mixed feelings about change, reasons for and against change

Detail the 4 processes of MI

Engagement: Invite the patient to tell their story, help say what they want to

Focusing: help assess behaviours they want to focus on, finding direction, finding what is most relevant to them

Evoking: heart of MI, why and how they might change

Planning: plan developed must be the patient’s own goal, patient actively taking responsibility

6 key domains of patient behaviour that drive negative psychological beliefs

Catastrophizing

Rumination

unhelpful or incorrect beliefs about pain

Fear avoidance

Low self-efficacy

Sickness behaviours

Identifying the five densities in various X-rays

Air, fat, soft tissue, bone, metal

Interpreting post-surgical X-rays relative to what is bone and what is a prosthesis

Demonstrate an understanding of the systematic approach to X-ray interpretation ABCS

A - alignment Check for bone alignment

B - bones Fractures

C - Cartilage Joint space narrowing or destruction of cartilage

S - soft tissue Soft tissue breaks

Discuss the role and importance of identifying red flags during Ax, why is it cruicial to differentiate between msk and non-msk conditions

Red flags - clinical SSx or features indicating serious pathology

While 80% of people may have 1 or more, 1% have serious pathology

Screen - determines if it safe to work with patient, identify inappropriate or harmful interventions, Guides referral on, and ensures patient safety

Be able to discuss the clinical presentations of key red flags that you may see clinically

MSK red flags - unremitting LBP, cauda equina symptoms, Thoracic pain, night pain, unexplained weight loss

Non-msk red flags - Vascular (DVT), depression, suicidal ideation, unexplained weight loss

Show an understanding of the difference between red and yellow flags clinically

Yellow flags present more as warnings/indications of unhelpful psychological or psychosocial factors, pain beliefs, cyberchondria, kinesiophobia, anger, frustration

Red flags are clinical SSx or something from the patient’s history that may indicate more serious pathology - DVT, unexplained weight loss, cauda equina symptoms

Be able to define what a yellow flag is

Psychological or psychosocial factors that can negatively influence treatment outcomes and lead to more disability for the patient

Show clear understanding of the prevalence of mental health issues in australian society

Highly prevalent, affecting 1 in 5

Anxiety, depression, and substance use disorders

Associated disability and negative impact on QOL

What are the benefits of recognizing Yellow flags as such as negative pain behaviours

It leads to more consistent positive treatment outcomes if caught early

Understand the benefits and risks, differences and areas/regions impacted by general, spinal, peripheral block and local anaesthetic types (add wear off time)

General - 1-2 hours, watching for nausea dizziness, drowsiness,

Spinal - b/l limb assessment of strength and sensation, can last 12-24 hours after shot, single shot epidural will last 4-6, stoppage of catheter epidural last 2 hours

Peripheral block - Affected limb assessment of strength and sensation, can last 12-24 hours

Identify analgesic options for post-surgical inpatient

Local Anaesthetic

Cryotherapy

NSAIDs

Opioids

Key components of Subjective exam and goals for assessment

Patient demographics, HPCx, Surgery type, red/yellow flags, relevant MHx/SHx, Op record, post op orders

Goals: Mobilize as early as we can leads to better recovery

Obs Chart

HR 60-100bpm, RR 12-20 bpm, BP <130/85, SpO2 95-100%, Temp: 36.5-37.5, Blood glucose 4-7.8 mmol/L

What does the op record detail and why is it important

Deatils the surgery and anesthetic used, surgical approach for explaining precautions if need be, identifying drain wounds, and information about anesthetic allows of accurate mobilization

What are post op orders

Restrictions on weight bearing, goals for patient to be at

Key components of clinical handover

ISBAR

I - Identification (self and patient)

S -Situation (Reason for handover)

B - Background (MHx, investigations)

A - Assessment (Current status)

R - Recommendation (next steps)

Review main elements of orthopaedic Objective

General observation, Obs chart, respiratory assessment, DVT check, neuro assessment, ROM and Strength, Functional ADL assessment

What are the various definitions for patient mobility

1x Assist

2x assist

Stand by assist

Describe several problems a patient may present with post-surgery

Decreased Joint ROM (lack vs Lag)

Strength

Numbness/weakness

Mobility aid types and guidelines for selection

FASF, Crutches (axillary, canadian), pickup frame, 4WW

Weightbearing restrictions, discharge destination, cognition, patient preference

Weight bearing status definitions

Non-WB - 0% bw through limb

Touch WB - 5% bw

Partial WB 50%

WBAT - up to 100%

Gait patterns (Step to vs Step through)

Step to gait pattern - step with injured limb to crutches, other foot matches

Step through - use foot and crutch as normal gait

Discharge advice and education

Pain management, HEP, follow up physio if needed, how to use mobility aid

Lack vs Lag

Lack is the loss of passive ROM due to joint stifness

Lag is the loss of active ROM due to pain inhibition or weakness

Understand the distinct types of hip/knee arthroplasties

Knee (partial/UCR, TKR/TKA, revision)

Hip (THR/THA, Resurfacing, Revision)

Know main clinical indications and contraindications for arthroplasty

Indications - Pain, loss of function

Contraindications - active infection, sepsis, severe peripheral vascular disease, poor bone stock

Be familiar with general timeline/expectations for recovery in TKR/THR

THR - home 1-3 days, crutches 2-4 weeks, bruising/swelling 2-5 days, 2-6 weeks to settle

TKR - home 2-4 days, crutches 2-4 weeks, bruising/swelling 1-7 days, takes 2-6 weeks to settle, knee can be swollen for 6-9 months

Recognize importance of rehab prior and after surgery

Pre-op: Optimise physical condition, familiarise with post-op exercises, weight loss, mental readiness, can reduce hospital stay and improve early outcomes

Post-op: restore mobility and function, strengthen for support, reduce risk of complications (DVT), optimises prosthesis lifespan, support RTW/RTS

Post-op precautions for hip surgeries

Posterior: no hip flexion past 90deg, hip add, IR

Anterior: Hip extension, Hip ER

Understand importance of graded isometric force application in rehab, concept of ramping in isometric force application and how it is beneficial

Gradual increase in force in a held position,

Protects healing tissue, can modulate pain, prevents deocnditioning, facilitates progressive loading

Slow ramp or fast ramp