Clinical Reasoning in The Evaluating and Treating Orthopedic Patients

PRESENTEDATBLACKLIONHOSPITAL
AddisAbaba,Ethiopia
JUNE2012
BY
MONIKAMANN,PT
Inaffiliationwith
HEALTHVOLUNTEERSOVERSEAS
monikamann@sbcglobal.net
2
GOALS
v Understandtheimportanceofclinicalreasoninginreferencetophysicaltherapyevaluation
andtreatment.
v Abilitytodelineateandidentifytheprosandconsoffourbasicclinicalreasoningstrategies.
v BeabletoutilizethebasicconceptsoftheDisablementModelwhenformulatinggoalsfor
patients.
v ExplainwhatSINSareandthereimportancetotreatmentplanning.
v Filloutabodychartcorrectlyonasamplepatient.
v Giveexamplesofhowtoaskfollowupquestionstopatientsinordertoobtainspecificand
quantitativesubjectiveinformation.
v Enumerateatleast5questionsonemaywanttoaskaboutpain.
v UnderstandComparablesignsandtheirimportance.
v Performasystemsreviewwithanorthopedicpatient.
v PrioritizeandperformappropriateTestsandMeasuresonanorthopedicpatientbasedon
informationgleanedfromtheSubjectiveEvaluation,includingdiscussionofclinical
indicatorsanddatagenerated.
v Formulateasuitableassessmentforanorthopedicassessmentincludingfunctional
limitationsanddisabilities,measureablegoals,andatreatmentplan.
v Discussandunderstandwhenandhowoftenapatientshouldbeassessed.
v Understandcriteriaforterminationofphysicaltherapyservices.
3
INTRODUCTION

Clinicalreasoningreferstothethinkinganddecision-makingprocesses
thatareusedinclinicalpractice.(1)Itallowsusasphysicaltherapiststo
determinewhattotreatfirst,prioritizewhichtechniquestoselect,how
vigorouslytoapplythem,andhowtoevaluatethepatientsresponseto
treatment.(2)
Thiscoursewillemphasizehowwecanofferthemostefficientand
effectivecaretopatientsbyanalyzingandresolvingtheproblemsthey
presentwith,usingasystematicclinicalreasoningapproach.
HiggsandJones(3)havedefinedclinicalreasoningasthethinkingand/or
decision-makingprocessesusedinclinicalpractice.
Morespecificallyitistheprocessbywhichthetherapist,interactingwith
thepatientandothers(suchasfamilymembersorothersprovidingcare),
helpspatientsstructuremeaninggoals,andhealthmanagement
strategiesbasedonclinicaldata,patientchoices,andprofessional
judgmentandknowledge.
WHYISTHISIMPORTANT?
Helpsassureadesirableoutcomeoftherehabilitationprocess.
RaisesPhysicalTherapistsfrombeingmerelytechnicianstobeing
professionals.
AccordingtoNitaMuir(4)inordertocompetentinassessingand
evaluatingpatients,andestablishinganappropriatetreatmentprogam,
oneneeds
Asoundbaseofknowledgeandexperienceinformedby
Clinicalstandardsandresearchevidence,
Anabilitytoexercisesoundcriticalthinkingand
Diagnosticreasoningskillsinadditionto
Theabilitytodevelopatherapeuticrelationshipwiththepatient.
4
Clinical Reasoning Strategies

RecognitionorInductiveReasoning
o Thisisbasedonpastknowledgeandexperience:
recognizingsimilarpatternsofsignsandsymptomsand
thengroupingthemtogethertomakeahypothesisonthe
diagnosisandtreatmentthatwouldbeaffective.
o Pros:Fast,Conclusionscanbereachedwithimprecise
data(5)
o Cons:lackscertainty.Needexperiencetorecognize
pattern(5)
Hypothetico-DeductiveReasoning
o Makingdeterminationsaboutthepatientsproblemand
comingupwithahypothesisaboutitbasedonthedata
presentedintheevaluation.
o Pros:organized,ateachableskill(5)
o Cons:slow,canbedependentontoomuchdata(5)
Knowledge-ReasoningIntegration
o ThisisacombinationofHypothetico-DeductiveReasoningand
PatternRecognition/InductiveReasoning
o Needastrongknowledgebaseforthistobemostsuccessful.
IntegratedPatient-CenteredReasoning
o Incorporatesmutualdecision-makingwiththepatient
and
o Takesintoaccountthecontextofthesituation.
o Usescognitionandknowledge.
Cognitionallowsyoutoprioritizeandrealizewhat
informationisrelevant.Itallowsyoutointerpret
theinformationpresentedandformahypothesis.
Thisisdifferentthanknowledge.
5
Byusingacombinationofallofthesestrategiesoneachievesan
improvementintheaccuracyofdiagnosis.(6)
Whenutilizingclinicaldecision-making,thetreatmentofpatientscanbe
representedwiththisdiagram:
Perform a thorough evaluation

Analyze the objective and subjective
findings to come up with a PT diagnosis.

Develop objective measurable goals (with patients
input)

Delineate a plan of treatment to reach your goals

Carry out the plan

Re-evaluate the important subjective and objective
findings

Assess the plan

Modify the plan as needed
6
Withoutathoroughevaluation,itisntpossibletocompletetheremaining
stepsandhavethemosteffectiverehabilitationoutcomeforyourpatients.
Thisprocessofre-assessmentandmodificationoftheplanisntcomplete
untilthepatienthasreachedhis/herrehabilitationgoals.
Howoftenshouldwere-assess?
Whattoincludeonabodychart:Areasofpain(P1,P2...),radiatingpain,
numbnessand/ortingling,painfreeareas.
Goshisa33yearoldsalespersoninafurniturestore.
Threeweeksagohewentaroundacornertoofastandcrashed
hismotorcyclewhiledrivingtowork.
Xray(-)
Painisconstantandvariable.Gettingbetter.
Inlastweekworstpainis7/10whenliftingapieceoffurniture.
Best2/10.Average4/10.
7
AggravatingFactors:Liftingmorethan10pounds.Turninghead
tolookoverleftshoulder.Sleepingonleftsidewakesseveral
timesanightandhasdifficultygettingbacktosleep.Deep
breathing.Beinguprightmorethanonehour.
EasingFactors:Lyingonback.Massage.Rest.Vicodin.
Other:Marriedwithtwochildrenunder3.Difficulttopickthem
up.UsuallyplayssocceronSundaysandnowhecant.Offwork
now.Patientisconcernedaboutnotbeingabletoworkandbring
inincome.
WhatotherinformationwouldyouliketoknowaboutGosh?Why?
Howcanyouapplythefollowingstrategiestotheevaluation:
RecognitionorInductiveReasoning:
Hypothetico-DeductiveReasoning:
Knowledge-ReasoningIntegration:
IntegratedPatient-CenteredReasoning:

8
DISABLEMENT MODEL & CLASSIFICATION

(From CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST
PRACTICE Part 3 Segment 1 and 2)
FUNDAMENTALCONCEPTS
GOALSOFAPPLYINGDISABLEMENTMODEL
Positionthebodyofknowledgeinphysicaltherapywithinatheoreticalframework
relevanttoclinicalpractice
Delineatethemajorpathways--fromdiseaseorinjurythroughtovariousfunctional
consequences
MODELSOFABILITY/DISABLIITY
Modeltodelineateconsequencesofdisease&injuryastheyimpactatthelevelofa
person&society
BasedonworkofNagiandadoptedbythe
WorldHealthOrganization(WHO)NationalCenterforMedicalRehabilitation
ResearchInstituteofMedicine
(8)
9
PATHOLOGY(cellularlevel)
Interruptionofnormalcellularprocesses
Biochemical,physiologic&anatomicabnormalitiesofthehumanorganism
IMPAIRMENT(bodysystems)
Lossorabnormalityofphysiological,psychological,oranatomicalstructureorfunction
Classificationofabnormalitiesdiagnosisofimpairment
Examples:Aerobiccapacity/endurance;gait,locomotion&balance;integumentary
integrity;jointintegrity&mobility;motorfunction;muscleperformance;ROM;pain;
posture;ventilation&respiration/gasexchange
FUNCTIONALLIMITATION(wholeperson)
Restrictionoftheabilitytoperformanaction,task,oractivityinanefficient,typically
expected,orcompetentmanner
Classificationofrestrictionsdiagnosisoffunctionallimitations
Examples:Rolling,crawling,sitting,standing,walking,climbing,carrying,pulling,lifting,
bending,turning,twisting,doingbuttons,tyingshoelaces,bathing,dressing,grooming,
shopping,shoveling,vacuuming
DISABILITY(personsrelationtosociety)
Inabilitytoengageinage-specific,sex-specific,orgender-specificrolesinaparticular
socialcontextorphysicalenvironment
Classificationofinabilities-diagnosisofdisability
Examples:Work(job,school,play),community,leisureintegrationorreintegration
WherewouldthesefitintotheDisablementModel?
Inabilitytoshopforfamily
myocardialinfarction
abilitytoambulate
aerobiccapacityorendurance

Management Models

MEDICAL PATIENT MANAGEMENT MODEL
FOCUS ON DISEASE / INJURY
History / Physical Exam
10
Invasive Tests & Measures
Diagnosis: Cellular / System Level
Intervention: Pharmacology or Surgery
Outcome: Cure / Repair of Tissue or System

REHABILITATION PATIENT MANAGEMENT MODEL

FOCUS ON DYSFUNCTION
History / Physical Exam
Noninvasive Tests & Measures
Diagnosis: System / Person Level
Intervention: Improve Movement Performance
Outcome: Remediate impairments/optimize function

DISABLEMENT CRITERIA

Based on established expected norms for age, sex, anthropometrics, social
contexts, work standards
Norms used to:
Hypothesize regarding effects of disease or injury on systems, function & roles
Measure impact of risk factors & interventions on outcomes

IMPACT ON DISABLEMENT

RISK FACTORS
Predisposing Characteristics: Biological Congenital Demographic
Psychological Behavioral Lifestyle Social Environmental
INTRA-INDIVIDUAL FACTORS
Habits, Lifestyle & Behaviors Psychosocial Attributes / Coping Activity
Accommodations & Adaptations
EXTRA-INDIVIDUAL FACTORS
Medical care & rehabilitation Medications & other therapy Physical & social
environment External supports

APPLICATIONS OF DISABLEMENT MODEL

Standardize clinical practice in classification group
Open collegial discussion for peer review & quality improvement
Generate questions for clinical research

11

RELATIONSHIP OF Health-Related Quality of Life (HRQOL) TO DISABLEMENT CONCEPTS

PATHOLOGY

IMPAIRMENT

Adapted from Jette, 1994

The effect on the health-related quality of life takes place when there are functional
limitations and disabilities.

DISABLEMENT IMPACT
Health-related QOL: Total well-being
Self-perceived health
Physical status
Intellectual functioning
Performance of social roles
Social interactions
Economic status
Satisfaction

EMPHASIS & GOALS OF PHYSICAL THERAPY

Physical therapy is a health profession that emphasizes the sciences of
pathokinesiology & the application of therapeutic exercise for the prevention,
evaluation & treatment of disorders of human motion.
(Hislop, 1976)

FUNCTIONAL LIMITATION

DISABILITY
12
EXAMPLE: A patient presents to you with her L leg in a cast stating she was in a
car accident and fractured her femur and pelvis. She was NWB for 6 wks and
now is in a cast and using crutches. She states that her prior level of function
incudes caring for her family and home including, shopping and preparing food.

Pathology _______________________________________

Impairments - ______________________________________

Functional Limitations - _____________________________

Disabilities - _______________________________________

PLAN
Is this enough information to elaborate an effective plan of care?

What else do we need to consider?

General Demographics Social History Employment/Work Growth &
Development Living Environment General Health Status Social/Health
Habits Family History
Medical/Surgical History
Current Condition)(s))/Chief Complaint(s)
Functional Status and Activity Level
Medications Other Clinical Tests

Functional
problem/disability
Measurable
Goal
Treatment Plan
1
2
3
4

13
USE OF CLINICAL DECISION-MAKING
IN AN EVALUATION
Whyareevaluationsimportant?
o Clarifytheseverityandnatureoftheproblem
o Findwhatfunctionaldeficitsapatienthas
o Touncovertheprincipalproblemscontributingtofunctional
deficits(pain,weakness,lackofROM,etc)
o Totakeobjectivemeasurementsthatcanbereferredbacktolaterin
ordertoassessprogress.
Whydoweneedtheaboveinformation?
o Inordertodesignthemosteffectiveandefficienttreatment
planforeachpatientsothattheycanreachtheirrehabilitation
goalsasrapidlyaspossible.Wellgointothisinmoredetail
later,butisitappropriateforallpatientswiththesame
diagnosistoreceivethesametreatment?
Whataresomefactorsthatmightinfluenceyourchoiceof
treatment?
14
WhyisitnecessarytoevaluateapatientifanMDhasalready
examinedthem?
o Theprimarygoalofamedicalexamistoformulatea
differentialdiagnosisofthepatientsproblem.
o TheprimarygoalofaPTevaluationistogathersubjectiveand
objectiveinformationthatwillguidetheclinicaldecision
makingregardingwhatPTtreatmentswillbemosteffectivein
reachingtherehabilitationgoalsforthept.
Documentationisanessentialelementofevaluationandtreatment.
AccordingtothePhysicalTherapyGuidetoClinicalPractice:
Asyouallknow,aphysicaltherapyevaluationconsistsof4parts:
Subjective
Objective
Assessment
Plan

Documentsshouldincludeappropriateevaluations&
interventions,expectedoutcomes,&recommended
frequency,intensity&durationofphysicaltherapy
services.Thespecificconditionsforwhichcareis
describedcanbebasedondiagnoses,oronotherbases,
suchasfunctionallimitationsordisabilities.
15
Subjective Evaluation
LISTEN!
OnsetofcurrentEpisode
16
(7)
AreaofSymptoms(bodychart)
o Descriptors,typeofpain,relationshipofpainareas,
numbness/tingling.
17
BehaviorofSymptoms
o ConstantorIntermittent
o Aggravatingandeasingfactors
o 24HourBehavior
18
(7)
o Askfollowupquestionstotrytoelicitanswersthatareas
specificandmeasurableaspossible.
o Thinkaboutwhatthisistellingyouaboutwhich
structuresmaybeinvolved.
o Marksignificantfindingswithanasterisk
19
Painscale
o Current
o Past
o Worst
o Best
Functionallimitationsanddisabilities
SINSseverity,irritability,nature,stage
Severity
o referstotheintensityofthepainprovokingactivity.
Cautionisnecessaryduringtheexaminationand
treatment.
Irritability
o ameasureofhoweasilythepatientssymptomsare
aggravatedandhowquicklytheysubside.:Ifapatients
symptomscomeoneasilyanddontsubsidewithinafew
minutesofstoppingtheaggravatingactivity,thenthe
conditionisconsideredirritable.
Nature
o referstothetypeofissuethatiscausingthesymptoms
(i.e.:mechanical,inflammatory,etc.)
Stageoftheinjury
o acute-
o subacute-
o chronic
20
LifestyleFactors
o Work
o Recreationalactivities
o Family/supportsystem
o Environment
Medicalhistory
o othermedicalproblemswhichmayhaveaninfluence.
o Previoustreatmentsforthecurrentconditionand
outcomes.
o Priorleveloffunction.
PatientsGoals
o Itsveryimportanttoinquireastowhatthepatients
goalsare.
Attempttogatherfunctional/realisticgoalsfromthe
patient.
Duringsubjectivequestioning,wewanttoassurethattheinformationwe
arereceivingisasspecificandquantitativeaspossible.
Whydowewanttonotespecificandquantitativeinformation
fromthepatient?

21
AFTERSUBJECTIVEEVAL:formhypothesis
PRIORITIZEWHICHOBJECTIVETESTSYOUWILLPERFORM
PLANNING THE ORTHOPEDIC

OBJECTIVE EVALUATION
ThissectionisprimarilytakenfromtheworkofG.DMaitland.(7)oneofthe
greatestphysicaltherapistsofourtime.
Whenplanningtheorthopedicobjectiveevaluation,thefollowingshouldbetaken
intoconsideration.
Possiblesourcesofthesymptoms.(includejoints,muscles,neuralstructures,
etc)
Arespecialtestsindicated?(neurologicalorcardiopulmonarytest,etc)
Influenceofseverityandpathologyontheexaminationandtreatment
HerearesomethingsapatientmighttellyouandIwantyoutoletme
knowifyouthinktheywouldbegoodindicatorstomeasureprogress
inthefuture.Ifyoudontthinktheywouldbegoodtousefor
measurementsofprogress,letmeknowhowthestatementscanbe
improved:
Ihavepaininmyhip.
IhavepaininmyhipwhenIwalk.(whatotherinformationdowe
want?)
Icanonlysitforonehour.
Myleftarmisweak.
Icantpickupmydaughterwithmyleftarm.(whatotherinformation
dowewant?)
Ihavealotofnumbnessinmyhand.
22
o Isthepain...
Severe
Latent
o Isthedisorderirritable?
o Doesthenatureofthedisorderindicatecaution?
o Aretherecontraindications?
ThekindofExam
o Doyouthinkyouwillneedtobegentleormoderatelyfirmwithyour
examination?
o DoyouexpectaCOMPARABLESIGNtobeeasyorhardtofind?
o Whatmovementsdoyouthinkwillbecomparable?
o Whatassociatedfactorsneedtobeexamined?
o Aretherefactorsthatcouldcausetheproblemtoreoccur?(posture,
muscleimbalance,instability,weakness,obesity,etc)
o Doyouthinkyouwillneedtofocusmostonweakness,stiffness,pain,
orinstability?
23
Objective Evaluation
ConsistsofSpecifictestsandmeasurementstodetermineinan
objectiveandquantitatemannertheseverityandtypeofproblemthat
thepatientpresentswith.Also,themeasurementstakenintheobjective
evaluationarenecessaryinordertodeterminetheextentofprogressin
thefuture.
24
Oneofthegoalsoftheorthopedicobjectiveevaluationistofind
comparablesigns.Thesearenecessaryinordertohelpusinthe
diagnosisofwhichtissuesareinvolved,andalsoinre-assessingprogress
aftertreatment.
Systems Review
(See CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST

PRACTICE Part 5 Segment 2)

Part of your objective evaluation should be a brief Systems Review. You may
not need to go into depth with all of these systems, but should prioritize and
screen the ones relevant to your patient.

Purpose
A brief, limited systems screen provides additional information to assist in formulating
diagnosis, prognosis & plan of care and identifies possible health problems requiring
consultation or referral to another provider.

Cardiovascular/Pulmonary

Blood pressure
Edema
Heart rate/rhythm
Respiratory rate/rhythm

Maitland(7)emphasizesthenecessityofelicitingComparableSigns
whichrefertoanycombinationofpain,stiffnessand/orspasm,during
aspecificmovement,whichtheexaminerfindsonexaminationand
considerstobecomparablewiththepatientssymptoms.
25
Integumentary

Pliability (texture)
Presence of scar formation
Skin color
Skin integrity

Neuromuscular

Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Motor function (motor control and learning)
Musculoskeletal
Gross ROM

Gross strength
Gross symmetry
Height
Weight
Body Mass Index
Communication, Affect, Cognition, Learning Style
Ability to make needs known
Consciousness
Expected emotional/behavioral responses
Learning preferences (eg, educational needs, learning barriers)
Orientation (person, place, time)

26
TESTS & MEASURES

PRACTICE Part 5 - Segment 3)

Tests should be prioritized for the patient you are seeing.

More than one test can be performed simultaneously.
Examples________________________________________________

Results should be documented and as specific and reproducible as possible._

Results give us information on SINS and can be used later for re-testing ,
reassessment, research.

AEROBIC CAPACITY & ENDURANCE

EXAMPLE
Clinical Indications
Example: Inability to ambulate due to SOB
Tests & Measures
Aerobic capacity during standardized exercise protocols (see appendix A)

Below is an alphabetical list of general categories
of tests and measures that pertain to orthopedic
evaluations, along with examples of clinical
indications regarding when it may be advisable to
perform the test.
27

ClinicalIndicators TestsandMeasures DataGenerated

ANTHROPOMETRIC CHARACTERISTICS

EXAMPLE
Abnormal fluid distribution
Obesity /emaciated
Tests & Measures
Girth measurements
BodyMassIndex(BMI)
Data Generated
Presence and severity of abnormal body fluid distribution
Level of obesity and risk of disease
28
CIRCULATION (ARTERIAL, VENOUS, LYMPHATIC)

EXAMPLE
Example: Dizziness rising from sit to stand
Tests & Measures
Cardiovascular signs such as BP, HR, orthostatic hypotension testing.
(take BP supine and then immediately upon standing. If systolic blood pressure
falls >20 mmHg and diastolic blood pressure falls >10 mmHg within 3 minutes of
standing upright, then test is (+)
Data Generated
Quantification of cardiovascular demand and risk of orthostatic
hypotension.


ENVIRONMENTAL, HOME & WORK BARRIERS

EXAMPLE
Inability to enter building - no ramp is available
Tests & Measures
Current & potential barriers
Data Generated
Documentation and description of compliance with accepted standards


29

ERGONOMICS & BODY MECHANICS

EXAMPLE
Inability to rotate trunk at assembly line due to pain
Tests & Measures
Job simulation
Data Generated
Description and quantification of repetition and work/rest cycles in work
actions


GAIT, LOCOMOTION & BALANCE

EXAMPLE
Inability to go shopping because of decreased power
Tests & Measures
Gait during functional activities

Data Generated
Description and quantification of characteristics and safety of gait in different
physical environments

What are some balance tests you could perform? See Appendix B


30
INTEGUMENTARY INTEGRITY

EXAMPLE
post- surgical scar/wound
Tests & Measures
Wound characteristics
Data Generated
Description and quantification of wound

JOINT INTEGRITY & MOBILITY

EXAMPLE
Inability to stack boxes overhead at work because of shoulder pain
Tests & Measures
Joint integrity and mobility: accessory joint movement testing, ligamentous
laxity tests

Data Generated
Description and quantification of joint hypo- or
hyper- mobility


MOTOR FUNCTION (CONTROL & LEARNING)

EXAMPLE
Irregular movement pattern

31
Tests & Measures
Initiation, modification, and control of movement patterns.
Substitutions

If there is pain with an active movement along with a faulty movement
pattern, try to change the movement manually and see if that changes
the symptoms. (Sahrmann technique)

Data Generated
Observation and description of atypical movements, changes in Sxs
with correction of pattern.


MUSCLULO-TENDON PERFORMANCE

EXAMPLE
Decreased gross strength and reactivity.
Tests & Measures
MMT, Isometric, Tests, power, & endurance during functional activities

Isometric Tests if they are positive they implicate a lesion in the muscle or
tendon.

Data Generated
Presence and severity of specific weakness


32
NEUROLOGICAL TESTING

EXAMPLE
complaints of paresthesias or anesthesia.
Tests & Measures
sharp/dull, deep pressure, light touch, temperature testing. Also
reflex testing and selective strength testing.
Data Generated
Description and quantification of areas of decreased sensation

Always do a neurological screening exam on patients with spinal involvement if
there are complaints of symptoms below the neck, or below the gluteal fold.

ORTHOTIC, PROTECTIVE & SUPPORTIVE DEVICES

EXAMPLE
Inability to walk on uneven surfaces due to ankle instability
Tests & Measures
Remediation of functional limitations with use of orthotic device
Data Generated
Description and quantification of remediation of functional limitation with device

PAIN

EXAMPLE
Difficulty eating because of jaw pain
Tests & Measures
Provocation tests find comparable sign(s)
Data Generates
Description and quantification of pain

33

POSTURE

Remember to look at posture in sitting, standing and recumbent; paying special
attention to posture in pain-provoking positions. If an abnormality is found, correct
it immediately and then note the results.

EXAMPLE
complains of pain when sitting at desk.
Tests & Measures
Postural alignment and position, ergonomic set-up
Data Generated
Quantification of sitting posture and ergonomic set up.

34

RANGE OF MOTION

Remember: Always note the relationship of pain and range of motion.
Pain before resistance acute, severe, need to treat pain first
Pain and resistance at the same time Less acute
Pain after resistance - can work more aggressively on increasing
ROM

What is limiting the ROM: pain, stiffness, anxiety

Note the end feel
Is there pain throughout the range painful arc

35
Sometimes repeated tests are indicated. You should note if there is a change in pain
and ROM with repetition.

o What would help you determine whether repeated movement
testing is indicated or not?

EXAMPLE
Inability to wash clothes because of difficulty bending
Tests & Measures
Functional ROM, AROM, PROM.

Data Generated
Description and quantification of functional or multi-segmental movement


SELF-CARE & HOME MANAGEMENT

EXAMPLE
Severe kyphosis
Tests & Measures
Ability to perform self- care and home management activities
Data Generated
Description and quantification of need for devices and equipment

36
SOFT TISSUE
EXAMPLE
Muscle spasm limiting ability to turn head when driving to change lanes
safely.
Tests & Measures
soft tissue palpation superficial to deep
Data Generated
Description and quantification of palpable soft tissue abnormality

WORK, COMMUNITY, & LEISURE INTEGRATION / REINTEGRATION

EXAMPLE
Inability to board a bus because of muscle weakness
Tests & Measures
Ability to gain access to work, community, leisure environments
Data Generated
Description and quantification of ability to participate in a variety of
environments.

37

ASSESSMENT AND TREATMENT PLANNING

Assesstheinformationgatheredinthesubjectiveandobjective
evaluationinordertolisttheproblemsthatyouaregoingtoaddressand
setupmeasureableandfunctionalgoalsinordertodecrease
functionallimitationsanddisabilityasmuchaspossible.
Here is an example of some findings from two similar patients. Fill in the charts
below for each of them.
SUBJECTIVE: Ayana is a 53 year old woman who complains of pain in her right
arm when she puts on a sweater, lies on her right side, lifts a pot of tea, or
reaches up to put dishes away in a high shelf. She states that these problems
have come on slowly over the past couple of years. She says that the shoulder
doesnt hurt when she isnt moving it but when she reaches up high or reaches
back to put on her sweater the pain can reach a level 8 on a 1 10 scale. Pain
gets worse through the day.
38
OBJECTIVE:
PROM: Fl limited at 140 by pain and stiffness
ABD limited at 95 degrees by stiffness
ER limited at 20 degrees by pain and stiffness
IR limited at 55 degrees by stiffness
Isometric Tests to the Shoulder: All negative
AROM: FL limited at 120 by pain and stiffness (substitutes by elevating
scapula)
ABD limited at 90 by stiffness
ER limited at 10 degrees by pain.
IR limited at 60 by stiffness (substitutes with anterior rotation of
the scapula.
Accessory Movements of the GH and AC joints generally limited.
Posture: Forward rounded shoulders with abducted scapulae.
Work: Sits at a desk through the day.
What else do you want to know?

SINS
Severity___________________________________________________

Irritability___________________________________________________

Nature____________________________________________________

Stage_____________________________________________________
39

Functional
Problproblem/disability
Measurable Goal Treatment Plan
1
2
3
4

SUBJECTIVE: Hakim is a 25 year old male. He works in construction and has
been having pain in his right shoulder for the past three weeks after lifting a 100
pound crate overhead. He complains of pain (6/10) when taking a shirt off
overhead, turning the steering wheel of the car, lying on his right side, and lifting
anything over five pounds. The pain wakes him 1 2 times a night and it can be
difficult to get back to sleep.
OBJECTIVE:
PROM: Fl limited at 140 by pain and stiffness
ABD limited at 95 degrees by pain
ER limited at 20 degrees by pain and stiffness
IR limited at 55 degrees by pain
Isometric Tests to the Shoulder: + to ABD and ER with ABD eliciting more pain
than ER. After isometric tests, pt continues to have increased pain in shoulder
throughout the rest of the evaluation.
AROM: FL limited at 120 by pain and stiffness (substitutes by elevating
scapula)
ABD limited at 90 by pain
ER limited at 10 degrees by pain.
IR limited at 60 by pain (substitutes with anterior rotation of
the scapula.)
40
Posture: UEs in IR with tight pecs and over-developed upper trap.

What else do you want to know?

SINS
Severity___________________________________________________

Irritability___________________________________________________

Nature____________________________________________________

Stage_____________________________________________________

Functional
problem/disability
Measurable Goal Treatment Plan
1
2
3
4

41

TREATMENT

PRACTICE Part 6)

PLAN OF CARE
Integrates data from evaluation
Specifies:
Goals & outcomes
Direct interventions
Frequency of visits
Duration of episode of care
Discharge plan

42
RE-ASSESSMENT OF PLAN

Evaluate progress
Modify or redirect intervention
Respond to new clinical findings
Address failure to respond to current interventions

CRITERIA FOR TERMINATION OF PT SERVICES
Discharge
Goals and outcomes achieved

Discontinuation
Continued intervention declined
Unable to progress due to medical, psychosocial, or financial
limitations
Lack of benefit from further intervention determined

Key subjective findings and objective comparable signs should be re-
assessed at every visit.

Specific comparable signs should also be checked and re-checked
before and after a specific treatment.
43
APPENDIX A
Step Test for Aerobic Capacity

Equipment
1. a 12 inch high bench (or a similar sized stair or sturdy box), watch for
timing minutes.
Procedure
Step on and off the box for three minutes. Step up with one foot and then the
other. Step down with one foot followed by the other foot. Try to maintain a
steady four beat cycle. It's easy to maintain if you say "up, up, down, down".
Go at a steady and consistent pace. This is a basic step test procedure - see
also other step tests.
Measurement
At the end of 3 minutes, immediately check the patients HR while they are still
standing.

Results
This step test is based loosely on the Canadian Home Fitness Test and the
results below are also based from data collected from performing this test.
44
3 Minute Step Test (Men) - Heart Rate
Age 18-25 26-35 36-45 46-55 56-65 65+
Excellent <79 <81 <83 <87 <86 <88
Good 79-89 81-89 83-96 87-97 86-97 88-96
Above
Average
90-99 90-99 97-103 98-105 98-103 97-103
Average 100-105 100-
107
104-
112
106-
116
104-
112
104-
113
Below Average 106-116 108-
117
113-
119
117-
122
113-
120
114-
120
Poor 117-128 118-
128
120-
130
123-
132
121-
129
121-
130
Very Poor >128 >128 >130 >132 >129 >130
3 Minute Step Test (Women) - Heart Rate
Age 18-25 26-35 36-45 46-55 56-65 65+
Excellent <85 <88 <90 <94 <95 <90
Good 85-98 88-99 90-102 94-104 95-104 90-102
Above Average 99-108 100-111 103-110 105-115 105-112 103-115
Average 109-117 112-119 111-118 116-120 113-118 116-122
Below Average 118-126 120-126 119-128 121-129 119-128 123-128
Poor 127-140 127-138 129-140 130-135 129-139 129-134
Very Poor >140 >138 >140 >135 >139 >134
Source: Canadian Public Health Association Project (see Canadian Home Fitness
Test)

Also can use 6 minute walk test: Average healthy adult can ambulate 400
600 meters in 6 minutes.

45
Appendix B

Geriatric Assessment !""#$%&' MU PT 8390
Tinetti Performance Oriented Mobility Assessment
(POMA)`
Description:
The Tinetti assessment tool is an easily administered task-oriented test that measures an older adult`s
gait and balance abilities.
Equipment needed: Hard armless chair
Stopwatch or wristwatch
15 It walkway
Completion:
Time: 10-15 minutes
Scoring: A three-point ordinal scale, ranging Irom 0-2. '0 indicates the
highest level oI impairment and '2 the individuals independence.
Total Balance Score 16
Total Gait Score 12
Total Test Score 28
Interpretation: 25-28 low Iall risk
19-24 medium Iall risk
19 high Iall risk
* Tinetti ME. PerIormance-oriented assessment oI mobility problems in elderly patients. !"#$ 1986;
34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)
46
Tinetti Performance Oriented Mobility Assessment (POMA)
- Balance Tests -

Initial instructions: Subject is seated in hard, armless chair. The following maneuvers are tested.

1. Sitting Balance Leans or slides in chair =0
Steady, safe =1 _____

2. Arises Unable without help =0
Able, uses arms to help =1
Able without using arms =2 _____

3. Attempts to Arise Unable without help =0
Able, requires > 1 attempt =1
Able to rise, 1 attempt =2 _____
4. Immediate Standing Balance (first 5 seconds)
Unsteady (swaggers, moves feet, trunk sway) =0
Steady but uses walker or other support =1
Steady without walker or other support =2 _____
5. Standing Balance
Unsteady =0
Steady but wide stance( medial heals > 4 inches
apart) and uses cane or other support =1
Narrow stance without support =2 _____
6. Nudged (subject at maximum position with feet as close
together as possible, examiner pushes lightly on subjects
sternum with palm of hand 3 times)
Begins to fall =0
Staggers, grabs, catches self =1
Steady 2 _____
7. Eyes Closed (at maximum position of item 6)
Unsteady =0
Steady =1 _____

8. Turing 360 Degrees Discontinuous steps =0
Continuous steps =1 _____
Unsteady (grabs, staggers) =0
Steady =1 _____
9. Sitting Down
Unsafe (misjudged distance, falls into chair) =0
Uses arms or not a smooth motion =1
Safe, smooth motion =2 _____

BALANCE SCORE: _____/16

47
Tinetti Performance Oriented Mobility Assessment (POMA)
- Gait Tests -
Initial Instructions: Subject stands with examiner, walks down hallway or across room, first at usual pace, then back
at rapid, but safe pace (using usual walking aids)

10. Initiation of Gait (immediately after told to go
Any hesitancy or multiple attempts to start =0
No hesitancy =1 _____
11. Step Length and Height
Right swing foot
Does not pass left stance foot with step =0
Passes left stance foot =1 _____
Right foot does not clear floor completely
With step =0
Right foot completely clears floor =1 _____
Left swing foot
Does not pass right stance foot with step =0
Passes right stance foot =1 _____
Left foot does not clear floor completely
With step =0
Left foot completely clears floor =1 _____
12. Step Symmetry
Right and left step length not equal (estimate) =0
Right and left step length appear equal =1 _____
13. Step Continuity
Stopping or discontinuity between steps =0
Steps appear continuous =1 _____
14. Path (estimated in relation to floor tiles, 12-inch diameter;
observe excursion of 1 foot over about 10 ft. of the course)
Marked deviation =0
Mild/moderate deviation or uses walking aid =1
Straight without walking aid =2 _____
15. Trunk
Marked sway or uses walking aid =0
No sway but flexion of knees or back or
Spreads arms out while walking =1
No sway, no flexion, no use of arms, and no
Use of walking aid =2 _____
16. Walking Stance
Heels apart =0
Heels almost touching while walking =1 _____

GAIT SCORE = _____/12
BALANCE SCORE = _____/16
TOTAL SCORE (Gait + Balance ) = _____/28

48
Bibliography

1. Ian Edwards, Mark Jones, Judi Carr, Annette Braunack-Mayer and Gail M
Jensen Clinical Reasoning Strategies in Physical Therapy Physical Therapy April 2004 vol.
84 no. 4 312-330
2.Naber,RobertI,ORTHOPEDICEXAMINATION:FromSciencetoPractice(pdffileof
coursegiven)

3.Higgs J, Jones MA. Clinical reasoning in the health professions. In: Higgs J,
Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Boston,
Mass: Butterworth-Heinemann;2000 :314.

4. Muir N 2004, Clinical decision making: theory and practice Nursing Standard vol.18, no 36,
pp 47-52.

5. Davies, Robyn http://142.150.171.198/Oreg/Clinical%20Reasoning-FINALno%20ic.pdf
2008

6.Eva, KW What every teacher needs to know about clinical
reasoning.www.ncbi.nlm.nih.gov/pubmed/15612906 2005

7. Maitland GD. Maitland's Vertebral Manipulation. 7th ed. Philadelphia, PA.
Elsevier. 2005.

8. Snyder, AR Using Disablement Models and Clinical Outcomes
Assessment to ...
www.ncbi.nlm.nih.gov ... J Athl Train v.43(4); Jul-Aug 2008

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