MSK 1: MSK clinical reasoning

when is radiological imaging not discouraged

serious pathology is suspected

there is an unsatisfactory response to care or unexplained progression of S/S

it is likely to change management

how should manual therapy be applied in care

as an adjunct to other evidence based treatments

what should be done before surgical intervention

evidence informed non surgical care

what is clinical reasoning

a cognitive assessment to evaluate and manage pts that is an ongoing process to guide present and future decisions

what is the foundational approach to evaluation and treatment in PT

impairment based approach

what are the challenges to clinical reasoning

time

experience

knowledge

what impairments should be focused on in treatment

the primary impairments linked to activity and participation limitations within the context of personal and environmental factors

what is the CRAFTE

clinical reasoning assessment for thinking effectively

aimed to organize and guide clinical reasoning and decision making

how can clinical reasoning be improved

reflection

foundational background understanding

organizing and planning

what are examples of forms of reflection

peer review and discussion

self reflection

what are the barriers to professional development

limited mentorship

time

access to technology

CEU opportunities

personal values

what is the PT management process

examination

evaluation

diagnosis

prognosis

intervention

outcomes

what are medical intake forms used for

used to get background info from the pt but a subjective exam still needs to completed after

what are the pros of a medical intake form

provides background info on conditions, chief complaint, symptoms behaviors, and review of systems/red flag/yellow flag screens

allows the pt to think about details that will be asked about

what are some cons of a medical intake form

information needs to be directly verified from pt

can be lengthy or confusing for some pts

needs to be referenced during subjective exam

what is included in a subjective exam

pt demographics

history of condition such as chief complaint, S/S

past history of condition

current and prior function

regional clearning

review of systems

contextual factors

medical tests/imaging

general past medical/surgical history

pt goals

summarize/review

in what setting should the subjective exam be performed

a quiet private room with the seats at same eye height about 3 feet apart

what communication strategies should be used in the subjective exam

open ended questions

funneling

active listening

why do we take a history

form hypotheses

establishes etiology and risk factors

guides objective exam

guides intervention

gather activity/participation limitations

establish SINSS

establishes rapport

sets tone for collaboration

what is narrative reasoning

allowing the pt to talk about why they are there to help guide the conversation

what pt demographics are collected in the subjective exam

age

gender

occupation

hand/LE dominance

confirm medical orders

what is the chief complaint

the primary reason the pt is seeking PT care

what information about the chief complain should be obtained in the subjective exam

MOI

date of injury/onset

how has their condition evolved

what is the body chart and symptom behavior portion of the subjective exam

pinpoint of exact location of symptoms

symptom feeling

determine of there are multiple pain locations

pain descriptors

numbness or tingling

throbbing

what is P1

P1 is the primary pain location

what is regional clearing

clearing locations that are not painful

what is collected from symptom and symptom behavior of the subjective exam

pain intensity (baseline, at worst, at best)

aggravating factors

easing factors

time to onset/ease

mechanical pattern

constant vs intermittent

24 hr pattern

limitations

clearing red flags

what does symptom behavior help to establish

helps to determine the nature of the injury/pain

what are pain red flags

constant and consistent

non mechanical

no easing factors

what is the strongest indicator of severity of symptoms

activity limitations

what is the strongest indicator of symptom stability

if the pain is getting worse, getting better, or remaining the same

why do we establish symptom behaviors

activity/participation limitations

pt education

SINSS

tissue of origin

guides interventions

activity modification

tracking response

what information should be obtained regarding the history of the present condition

if they are participating in other treatments

any medications for this or other conditions

why is obtaining a past history of current condition

can give insight of successful or non successful intervention

prior treatments

what is the purpose of the review of systems

to document the presence or absence of common symptoms related to each of the major body systems

ensures pt is appropriate for PT

what is the 14 point ROS

constitutional symptoms

eyes

ears, nose, throat

cardiovascular

respiratory

gastrointestinal

genitourinary

MSK

integumentary

neurological

psychiatric

endocrine

hematologic/lymphatic

allergic/immunologic

what is the main focus of the ROS

determine if the pt symptoms are MSK in nature or something else requiring referral

what is looked at for CV ROS

chest pain

pain with walk/exercise

edema

palpitations

what is looked at in the respiratory system in a ROS

cough

SOB

wheezing

what is looked at in the endocrine system in a ROS

cold or heat intolerance

excessive thirst

excessive hunger

what is looked at in the ears, eyes, nose or throat in a ROS

hearing loss

sinus pressure

vision changes

what is looked at in the GI system in a ROS

abdominal pain

blood in stool

constipation

diarrhea

heartburn

loss of appetite

nausea

vomiting

what is looked at in the GU system in a ROS

pain with urination

excessive urine

difficulty voiding

urinary frequency changes

what is looked at in the hematologic/lymphatic system in a ROS

easy bleeding

easy bruising

lymphedema

blood clots

what is looked at in the integumentary system in a ROS

rashes

moles

skin color changes

skin texture changes

body hair changes

what is looked at in the neurological system in a ROS

dizziness

numbness

weakness

headaches

seizures

tremors

what is a hypothesis

a proposed explanation made on the basis of evidence

what is considered when forming a hypothesis for MSK PT

tissue specific (active, passive, nerve, non MSK)

ICF framework

what should be able to be generated from a quality history/subjective exam

about 3-4 hypotheses to guide the plan

what are some areas of caution for forming hypotheses

confirmation bias

diagnosis chasing

only trying to establish diagnosis without examination of contributing factors

what are screening tools used for

identify pt who may be at risk for poor clinical outcomes

identify yellow or red flags

identify appropriate treatment

identify if referral is indicated

what is the purpose of outcome measures

assess a pt current status and activity

track functional changes over time

what are the types of outcome measures

performance based

self reported

what is an example of a performance based outcome measure

TUG

what is an example of a self reported outcome measure

oswestry disability index

what is SINSS

severity

irritability

nature

stage

stability

what is SINSS used for

developing hypotheses

develop a plan for objective exam

plan for appropriate intervention

what is the severity in SINSS

rating of the extend the symptoms are impacting the persons ADLs incorporating activity limitations, participation restrictions, symptom intensity

what are things to consider for the severity in SINSS

impact of meds to control pain

night pain

impact of symptoms on sleep

pain and activity are not always correlated

what is the rating for severity ofSINSS

low (0-3 NPRS with 8-10 PSFS)

moderate (4-7 NPRS with 4-7/10 PSFS)

high (8-10 NPRS with 0-3/10 PSFS)

what is seen in low severity

no ADL limitations

verbal and nonverbal cues indicate minimal or no pain

intermittent low grade symptoms

no pain meds

no sleep impact

what is seen in moderate severity

mod limitation for ADLs, work, or recreation

avoiding more demanding activity

verbal and nonverbal cues indicate mod pain

constant but variable moderate intensity symptoms

intermittent mild pain relief

what is seen in high severity

max limitation to activity

avoiding activity

verbal and nonverbal cues indicate intense pain

constant high intensity symptoms

frequent pain relieving meds required for sleep and function

sleep disturbances

what is irritability in SINSS

the behavior of the symptoms (how easily are they aggravated or eased)

what are the 3 components of irritability

the type of activity and amount needed to provoke symptoms

the intensity of symptoms once provoked

the type of activity and the amount of time needed for symptoms to subside

what is low irritability

greater time to agg and less time to ease (2:1 ratio of agg:ease)

high intensity activity to agg with minor reduction in activity to ease

what is mod irritability

similar time to agg to ease (1:1)

mod intense activity to agg with mod reduction to ease

what is high irritability

less time to agg and greater time to ease (1:2)

low intensity activity to agg and significant reduction in activity to ease

what is nature in SINSS

broad term including all things that should be considered when planning the physical exam including:

specific diagnosis or condition

mechanism

body system

affected structure

special cautions

nature of the pt factors themselves

what is stage in SINSS

phase of tissue healing should be considered in the presence of know tissue damage/injury (trauma, surgery)

what cells are involved in the acute/inflammatory healing phase

vascular changes

clot formation

exudation of cells and chemicals

phagocytosis

what is the estimated time of the acute/inflammatory healing phase

days to 2 weeks

what subjective reportings are common in the acute/inflammatory phase of healing

pain before tissue resistance during movement

what is the treatment in the inflammatory phase of healing

POLICE: Protect, optimally load, Ice, compress, elevate

control the effects of inflammation

prevent excessive rest

what occurs in the subacute/proliferation phase of healing

growth of capillary beds

removal of noxious stimulus

collagen formation

granulation tissue growth

how long is the subacute/proliferation phase of healing

can last up to 6 weeks of tissue lacks adequate blood supply

what is typically reported from pts in the subacute/proliferative stage of healing

pt typically reports pain at the same time of tissue resistance

what treatment occurs in the subacute/proliferation phase of healing

gradually load tissues as tissue is fragile

ROM

reduce inflammation

gradually increase functional activity

mobilize scar tissue

what occurs in the chronic/maturation phase of healing

collagen aligns with he direction of stress

how long is the chronic/maturation phase of healing

can last months to years

what is reported in the chronic/maturation phase of healing

pt reports pain after tissue resistance is felt allowing more aggressive ROM and stretching

what treatments are done in the chronic/maturation phase of healing

progressive loading and controlled motion to allow collagen to appropriately align and strengthen

what is the coagulation and inflammatory phase of soft tissue healing

the body's immediate response to trauma characterized by pain at rest, pain with movement/stress

what is the acute/protective stage of condition

a highly irritable, highly sever state of pt symptoms where the goal is symptom modulation

what is the subacute/controlled motion stage of condition

a stable, moderately irritable, moderately severe state of pts symptoms where the goal is movement control

what is the chronic (stable) stage of condition

a stable state of low severity and low irritability of the pts symptoms where the goal is optimizing return to function/sport/recreation

what is the chronic (unstable) stage of consition

a state of variable. unpredictable severity and irritability of the pts symptoms where the goal is functional optimization

what pain typically occurs on the chronic unstable stage of condition

nociplastic mechanism of pain and maladaptive beliefs/personal factors

what is the stability of SINSS

current status of the condition when considering progression or regression over time

what are the two sets of criteria for stability

progression/regression

predictability

what is improving stability

decreased intensity, frequency, and/or location

sleep patterns uninterrupted or restored

less meds

return to regular function

what is worsening stability

increased intensity, frequency, and/or location

sleep patterns disrupted

more meds

regression of function

what is unchanging stability

no overall change

what is waxing and waning stability

sometimes improving, sometimes worsening

may be dependent on external factors

what is pain

an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage

how is pain multidimensional

it involves biological factors, psychological factors, and social factors

what kind of experience is pain

personal

how are pain and nociception different

pain is not inferred only from activity of sensory neurons

how do individuals learn the concept of pain

through life experiences

what is allodynia

pain provoked by a stimulus that is not usually painful

pain in response to previously innocuous stimulus