Pt Management Process - Clinical Reasoning Form-CRAFTE

CRAFTE Overview

  • Presentation on the Clinical Reasoning Assessment for Thinking Effectively (CRAFTE) tool for physical therapy evaluations.

  • Aim: Guide clinical decision making and improve thinking during examination processes.

Section I: Patient History

  • Initial Hypothesis

    • Initial hypothesis based on review of patient's chart and intake forms.

    • List possible diagnostic hypotheses including at least one nonmusculoskeletal condition or red flag hypothesis.

    • Classify initial hypotheses:

    • Primary: most likely

    • Secondary: less likely

    • Remote: least likely

    • Evidence should be provided for each hypothesis from intake forms.

  • Therapist-Generated Body Chart

    • Filled out during objective history.

    • Further details will be discussed in the next lecture.

  • Subjective History (Patient Interview)

    • Significance: 80% of information for determining patient's symptoms can be gathered from this.

    • Key components of subjective history:

    • Demographics

    • Occupation

    • Mechanism of injury

    • Current symptoms

    • Past medical history

    • Medications

    • Prior activity level

    • Self-identified functional impairments

    • Prior treatments

    • 24-hour symptom pattern

    • Notes about current motivation and movement

    • Yellow flags (psychosocial factors)

    • Goals

  • Baseline Symptom Findings

    • Understanding irritability level and examination tolerance.

    • Include:

    • Current intensity (numeric pain rating scale)

    • Aggravating factors

    • Time to onset and intensity at onset

    • Time to worst and intensity at worst

    • Easing factors and time to ease

    • Intensity at best

Section II: ICF Classification

  • ICF Framework

    • Provides holistic understanding of patients’ health conditions in the context of their life.

    • Activity Limitation: The most significant limitation for the patient.

    • Participation Restriction: How activity limitations prevent engagement in social or environmental contexts.

  • Barriers and Facilitators

    • List at least 2 barriers and 2 facilitators to recovery.

    • Identify intervention plans for modifiable barriers.

    • Personal Factors: Age, health and wellness, beliefs, education, occupation, motivation, psychological factors.

    • Environmental Factors: Social support, accessibility, living environment.

  • Stage of Change

    • Understand patient’s readiness for care: precontemplation, contemplation, preparation, action, maintenance.

  • Body Systems and Pain Mechanisms

    • Identify body systems involved and predominant pain mechanisms.

    • Signs of tissue healing based on phases:

    • Inflammatory Phase: Swelling, pain, redness, warmth.

    • Proliferation Phase: Decreasing pain, redness, swelling.

    • Remodeling Phase: Little/no pain, no swelling, improved strength/durability.

  • Possible Sources of Symptoms

    • Consider structures related to the patient's symptoms, including:

    • Joint and bony structures

    • Muscles and tendons

    • Ligaments, nerves, and other soft tissues

    • Neurological or musculoskeletal structures potentially referring pain

    • Red flag conditions or visceral structures to screen.

    • Up to three structures per region may be included.

Section III: SINSS Model

  • Symptom Behavior

    • Utilizes the SINSS model:

    • Severity: Impact of symptoms on activity, quantified using the NPRS.

    • Irritability: Timeframes/intensity of activity that invoke symptoms.

    • Nature: Suspected involved systems (pain mechanisms, structures, psychosocial factors).

    • Stage: Symptoms classified as acute, subacute, or chronic.

    • Stability: Predictability and progression of symptom behavior over time.

  • Assessment Labeling

    • Use CRAFTE tool to list problems in P form alongside justifications based on SINSS model.

Section IV: Physical Examination

  • Hypothesis Revision Post-Subjective Examination

    • Roll down hypotheses from subjective findings and provide evidence for any changes.

  • Range of Motion Examination Intensity

    • Appropriate level of vigor selection is crucial to maintain patient comfort while gathering diagnostic insights.

    • Intensity Spectrum:

    • Most Cautious: Highly irritable patients; limit testing to first onset/change in symptoms.

    • Moderately Cautious: Moderate irritability; assess active range to limits, accept some symptom reproduction.

    • Least Cautious: Low irritability; sustained, repeated, combined movements accepted without major concern.

  • Symptoms to Reproduce

    • Decide based on symptoms from subjective examination. Consider if it’s familiar symptom or clinically significant concern.

  • Planned Physical Examination

    • Document the physical examination tests and measures planned for confirmation of primary hypothesis, to rule out red flags, and nonmusculoskeletal hypotheses.

    • Anticipate and adjust findings if they do not support your hypothesis.

    • List expected findings based on primary working hypothesis.

Section V: Assessment

  • Post-Examination Assessment

    • Assess findings, considering SINSS principles.

    • Key decisions include appropriateness of patient for physical therapy: treat, treat and refer, nonurgent referral, or urgent referral.

    • Determine referral specifications: to whom, rationale, suggested imaging/lab work.

  • Objective Findings

    • List baseline objective findings if appropriate for physical therapy management.

    • Select primary and alternative hypotheses, provide evidence supporting each.

Section VI: Intervention Planning

  • Intervention Focus

    • Expected primary treatment: pain/symptom modulation, range of motion, muscle performance, activity performance, contextual factors.

    • Rationale for the treatment approach based on evidence.

  • Specific Interventions

    • List two interventions with anticipated responses and include a comparable sign for reassessment. One intervention must be active in nature.

    • Home exercise program must consist of three interventions specifying frequency, intensity, and time, rationalize dosage selection.

Section VII: Prognosis and Education

  • Prognosis Determination

    • Understand disparities between individual’s prior, current and desired functional levels. Justification through subjective & physical exams.

    • Consider natural history of disorder, list positive/negative prognostic indicators, recurrence likelihood, rationale, and overall prognosis rating.

    • Goals must be aligned with SMART framework and ICF guidelines.

  • Patient Education

    • Address four critical patient queries:

    • What’s wrong?

    • How long will it take?

    • What can therapists do about it?

    • What can patients do?

    • Foster trust, clear expectations, intervention strategies, and empower independent symptom management.

Conclusion

  • Plan of Care

    • Discuss expected progression over time regarding impairments, activity limitations, participation restrictions, and healing.

    • Duration of treatment, expected visits.

    • Utilize ICF framework for structured clinical decision-making, aligning interventions with specific goals across components.

  • Revisit the CRAFTE form throughout the course for reference.