Clinical Reasoning

Clinical Reasoning for Exercise Physiology Interventions

Introduction

• Speaker: Dr. Jen Fleeton from the University of Sydney, Discipline of Exercise and Sport Science

• Focus on clinical reasoning in exercise physiology (EP) interventions.

ESSA Elements

• 1.2.1: Practice with integrity within the scope of practice for Accredited Exercise Physiologists (AEPs) according to the ESSA Code of Professional Conduct and Ethical Practice and jurisdictional Codes of Conduct.

• 1.2.2: Compliance with ethically relevant legislation, regulations, and standards such as privacy, confidentiality, data security, informed consent, and record-keeping.

• 1.2.5: Commitment to culturally safe, inclusive, respectful, and responsive care, following person-centred care principles.

• 2.2.1: Integration of knowledge in anatomy, physiology, and pathophysiology to inform safe and effective exercise interventions.

• 2.2.2: Application of biopsychosocial and value-based care principles to promote health and well-being for clients and populations.

• 2.2.5: Addressing health needs through exercise prescription based on research findings and recommendations tailored to optimize health statuses, recovery, independence, and participation.

• 2.2.6: Application of clinical, ethical, and evidence-based decision-making to formulate interventions and expected outcomes.

• 3.2.1: Evaluation and risk stratification for client participation in assessments and interventions, including client-centered service modalities.

• 3.2.2: Safe and culturally sensitive assessments to gather relevant client information and needs.

• 3.2.7: Identification when client needs exceed the scope of practice, ensuring timely actions.

• 4.2.1 & 4.2.3: Development of evidence-based exercise prescriptions and management strategies that adapt based on individual client needs, preferences, and measured outcomes.

• 4.2.4: Creation of inclusive communication strategies that educate and engage clients regarding their interventions.

Problem-Based Learning Task

• Task 1: Review a case study and apply the ICF framework to the client's condition and context.

• Key considerations include identifying AEP scope and integrating AEP treatment into client care plans, communication strategies, and timing.

Client Case Information: Arthur

• Profile:

  • Age: 65, male

  • Conditions: Moderate intellectual disability, schizophrenia (stable), high blood pressure, type 2 diabetes, obesity.

  • Living conditions: Supported accommodation, NDIS funding, no family contact.

  • Recent history: Hospital admission for hip surgery, prolonged recovery, insulin-dependent diabetes, delayed mobility and instability.

  • Recovery issues included delirium and aggression, managed by psychiatric team.

  • Recommendations for discharge included temporary rehabilitation for therapy and implementation of accessibility enhancements (e.g., ramps, grab rails).

• Multi-disciplinary conference included a range of health professionals discussing a coordinated discharge and follow-up plan.

International Classification of Functioning, Disability and Health (ICF)

• ICF Framework serves as a standard for describing functioning and disability.

• Framework emphasizes dynamic interactions between health conditions and contextual factors affecting functioning.

Clinical Reasoning for EP Interventions

• Definition: Clinical reasoning described as "a way of thinking and taking action within clinical practice" (Edwards et. al. 2004).

• Structure: A systematic approach to identify problems, develop assessment plans, and implement evidence-based interventions focused on patient-centeredness.

• Key Points:

  • Merge evidence with clinical experience and patient-specific factors.

  • Identify patterns and use algorithmic reasoning (if-then logic).

  • Novice practitioners develop skills through in-depth engagement with processes; experienced practitioners utilize automaticity in decision-making.

ESS EMP Clinical Reasoning Process

• Part 1: Decision-Making Process

  • Evaluate whether treatment is possible within AEP scope; refer to other professionals when necessary.

  • Understand health concerns and context: Identify primary conditions and comorbidities, physical, social, and psychological factors affecting treatment.

  • Assess the urgency of the condition; consider psychosocial factors including barriers or facilitators.

  • Review exercise evidence: What interventions exist and what assessments are necessary?

  • Reflect on functional outcomes, context, and modifications needed for treatment.

  • Develop a critical evaluation plan: safety, integration with broader healthcare context, therapeutic relationship maintenance.

Evidence-Based Practice: Levels and Quality of Evidence

• Levels of Evidence:

  • Systematic reviews

  • Randomized Controlled Trials (RCTs)

  • Cohort studies

  • Case-controlled studies

  • Background information/expert opinion

• Quality of Evidence: Contextual approach necessary to interpret and apply these findings effectively.

Patient Communication and Care Strategies

• Importance of shared decision-making and meeting clients’ self-determined goals.

• Implement culturally responsive and adaptive communication methods to ensure understanding and engagement.

• Consider accessibility needs and personal preferences in planning exercise interventions.

Risk Screening and Management

• Use of screening tools for risk evaluation (e.g., Adult Pre-exercise Screening System).

• Maintain a comprehensive history of client's medical and lifestyle aspects through effective communication.

• Understanding and addressing yellow flags (potential confounding factors) and red flags (requirements for immediate attention) during assessments to ensure client safety.

Implementation of Patient-Centered Care

• Focus on client empowerment, preference acknowledgment, and adaptability to their unique health and lifestyle context.

• Utilize patient-reported outcomes measures (PROMs) and experiences (PREMs) to assess treatment effectiveness and satisfaction.

Conclusion

• Effective clinical reasoning in exercise physiology combines systematic decision-making, adherence to ethical guidelines, and patient-centered interventions.

• Continuous reflection and adaptation are crucial in delivering optimal exercise care for diverse client needs and contexts.