The Orthopedic PT Exam

hypothesis formation

• type of pain

• source of symtpoms

problem list

• screens or SFMA and objective data

• contributing factors

  • prioritize problem list

  • organization of data

PT diagnosis

• evaluate pertinent information, make a diagnosis

prognosis

• protocols - benchmarks/outcome measures

• red flags/comorbidities

• stages of tissue healing

aggressiveness

• reactivity base subjective and objective examination

hypothesis formation - pain

• type of pain

  • nociceptive

  • neuropathic

  • visceral

  • autonomic

• source of symptoms

  • specific structures

  • tissue types

hypothesis formation - pattern recognition

• evaluate problem list

• pathokinesiologic vs pathoanatomic

  • guide to goal setting and intervention selection

pathokinesiologic

• how the pt functions/moves

• compensations, movement as a whole

pathoanatomic

• issue with structure

• ex: joint assessment, ROM

pitfalls related to clinical decision making

• representative heuristic - (mental shortcut, judging probability of something happening based on results of something else)

• availability heuristic - how easily it comes to mind

• overconfidence - relying more on knowledge/experience than testing

• confirmation bias - choosing tests/measures you think will prove you right

• illusory correlation

how to avoid clinical decision-making errors

• how common is the condition? (prevalence in population)

• is data relevant vs recent?

• regular self assessment, and continuing education

• disprove your current hypothesis

• track all outcomes, not just the ones that support your belief

PT diagnosis

• classification scheme should be consistent with boundaries of a profession’s focus

• tests and measures utilized should fall within legal purview of profession

• label should describe problem in a way that implies or directs treatment

a pt presents with knee pain while squatting. which of the following is an example of a potential contributing factor?

• knee pain during knee extension resistance

• hip weakness during MMT

• knee pain during lumbar extension overpressure

• hip pain with hip external rotation overpressure

• hip weakness during MMT

• hip pain with hip external rotation overpressure

intrinsic contributing factors

• age

• BMI

• structure/biomechanics

• muscle function (strength/motor control)

• ROM/flexibility

• movement skill

• tissue quality

  • vascular inadequacy

  • 2-6 cm from musculotendinous junction

extrinsic contributing factors

• environment

• activity level (frequency, intensity, duration)

• technique/compensations

• equipment

• psychosocial factors (stress, fear)

modifiable factors

• BMI

• biomechanics

• muscle function (strneght/motor control)

• ROM/flexibility

• movement skill

• training technique

• nutrition

• psychosocial issues (pt education, motivation, active listening, referring)

non-modifiable factors

• age

• structural issues

  • anteversion/retroversion

  • tibial varum/valgum

• comorbidities

contributing factors assist with:

• goals

• diagnosis

• POC - interventions

• prognosis

problem list

• functional & specific list of pt’s problems

• developed early and refined

  • exam begins w/ subjective and is refined throughout exam

  • re-exam shows response to treatment, guides progress reports & priority list

• prioritized

  • contains contributing factors

• will drive intervention

prognosis - clinical prediction rules (CPRs)

• tools designed to assist clinicians in decision-making

• estimates of likelihood of a target diagnosis, prognosis, or treatment outcome

  • ex: return to sport, rates of re-tearing

prognosis - clinical practice guidelines (CPGs)

• used to direct treatment, guide best practice, and inform progress

prognosis

• predicted optimal level of function that a patient will attain within a certain timeframe

• helps guide intervention’s

  • intensity

  • duration

  • frequency

  • justify intervention progressions or regressions

prognosis is based on:

• understanding of pathology

• premorbid condition/issues

• status of surrounding tissues

• healing process

• PT experience

• examination findings

• pt’s age, social, emotional, and motivational status

less favorable outcome prognosis

• long standing

• challenging condition

• unwilling to change

• little ability to change

more favorable outcome prognosis

• early/first injury

• condition rehabs

• willing to change

• ability to change

identify the following topics that would most likely indicate a less aggressive assessment / treatment

• pain that is mechanical in nature

• pain that is inflammatory in nature

• acute symptoms

• chronic symptoms

• high reactivity

• low reactivity

• pain that is inflammatory in nature

• acute symptoms

• high reactivity

how aggressive to be?

• do no harm

• do no good

high reactivity

• easily irritated

• difficult to settle

• alters activity / participation

• treat less aggressive

low reactivity

• difficult to irritate

• easy to ease

• little to no activity or participation loss

• can treat more aggressive

reactivity - nerves are ______

highly irritable and tougher to settle

inflammatory pain

• resting pain

• treat less aggressive

chronic pain

• pain worse at onset of activity

• improves with movement (arthritic)

• moderate aggressiveness

mechanical pain

• worse with activity

• treat more aggressive

aggressiveness - severity

• potential harm/damage?

• make pathology worse?

• consider

  • health condition/disease

  • body structure/function

intervention

• utilize problem list

• prepare 2-3 interventions for each problem

• be purposeful with choices and order

rationale

• always need sound rationale for each exercise

• need to assess to appropriately treat

intervention summary

• HEP

• education - activity modification

• modalities

• soft tissue mob

• flexibility

• ther-ex

• joint mob

• neurodynamics

• re-education

• orthosis