PRESENTEDATBLACKLIONHOSPITALAddisAbaba,EthiopiaJUNE2012BYMONIKAMANN,PTInaffiliationwithHEALTHVOLUNTEERSOVERSEASmonikamann@sbcglobal.net 2GOALS vUnderstandtheimportanceofclinicalreasoninginreferencetophysicaltherapyevaluationandtreatment.

vAbilitytodelineateandidentifytheprosandconsoffourbasicclinicalreasoningstrategies.

vBeabletoutilizethebasicconceptsoftheDisablementModelwhenformulatinggoalsforpatients.

vExplainwhatSINSareandthereimportancetotreatmentplanning.

vFilloutabodychartcorrectlyonasamplepatient.

vGiveexamplesofhowtoaskfollowupquestionstopatientsinordertoobtainspecificandquantitativesubjectiveinformation.

vEnumerateatleast5questionsonemaywanttoaskaboutpain.

vUnderstandComparablesignsandtheirimportance.

vPerformasystemsreviewwithanorthopedicpatient.

vPrioritizeandperformappropriateTestsandMeasuresonanorthopedicpatientbasedoninformationgleanedfromtheSubjectiveEvaluation,includingdiscussionofclinicalindicatorsanddatagenerated.

vFormulateasuitableassessmentforanorthopedicassessmentincludingfunctionallimitationsanddisabilities,measureablegoals,andatreatmentplan.

vDiscussandunderstandwhenandhowoftenapatientshouldbeassessed.

vUnderstandcriteriaforterminationofphysicaltherapyservices. 3INTRODUCTION Clinicalreasoningreferstothethinkinganddecision-makingprocessesthatareusedinclinicalpractice.(1)Itallowsusasphysicaltherapiststodeterminewhattotreatfirst,prioritizewhichtechniquestoselect,howvigorouslytoapplythem,andhowtoevaluatethepatientsresponsetotreatment.(2)Thiscoursewillemphasizehowwecanofferthemostefficientandeffectivecaretopatientsbyanalyzingandresolvingtheproblemstheypresentwith,usingasystematicclinicalreasoningapproach.HiggsandJones(3)havedefinedclinicalreasoningasthethinkingand/ordecision-makingprocessesusedinclinicalpractice.Morespecificallyitistheprocessbywhichthetherapist,interactingwiththepatientandothers(suchasfamilymembersorothersprovidingcare),helpspatientsstructuremeaninggoals,andhealthmanagementstrategiesbasedonclinicaldata,patientchoices,andprofessionaljudgmentandknowledge.

WHYISTHISIMPORTANT?Helpsassureadesirableoutcomeoftherehabilitationprocess.RaisesPhysicalTherapistsfrombeingmerelytechnicianstobeingprofessionals.

AccordingtoNitaMuir(4)inordertocompetentinassessingandevaluatingpatients,andestablishinganappropriatetreatmentprogam,oneneeds Asoundbaseofknowledgeandexperienceinformedby Clinicalstandardsandresearchevidence, Anabilitytoexercisesoundcriticalthinkingand Diagnosticreasoningskillsinadditionto Theabilitytodevelopatherapeuticrelationshipwiththepatient.

4Clinical Reasoning Strategies RecognitionorInductiveReasoningoThisisbasedonpastknowledgeandexperience:recognizingsimilarpatternsofsignsandsymptomsandthengroupingthemtogethertomakeahypothesisonthediagnosisandtreatmentthatwouldbeaffective.oPros:Fast,Conclusionscanbereachedwithimprecisedata(5)oCons:lackscertainty.Needexperiencetorecognizepattern(5)

Hypothetico-DeductiveReasoningoMakingdeterminationsaboutthepatientsproblemandcomingupwithahypothesisaboutitbasedonthedatapresentedintheevaluation.oPros:organized,ateachableskill(5)oCons:slow,canbedependentontoomuchdata(5)

Knowledge-ReasoningIntegrationoThisisacombinationofHypothetico-DeductiveReasoningandPatternRecognition/InductiveReasoningoNeedastrongknowledgebaseforthistobemostsuccessful.

IntegratedPatient-CenteredReasoningoIncorporatesmutualdecision-makingwiththepatientandoTakesintoaccountthecontextofthesituation.oUsescognitionandknowledge.Cognitionallowsyoutoprioritizeandrealizewhatinformationisrelevant.Itallowsyoutointerprettheinformationpresentedandformahypothesis.Thisisdifferentthanknowledge. 5Byusingacombinationofallofthesestrategiesoneachievesanimprovementintheaccuracyofdiagnosis.(6)Whenutilizingclinicaldecision-making,thetreatmentofpatientscanberepresentedwiththisdiagram:

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 6Withoutathoroughevaluation,itisntpossibletocompletetheremainingstepsandhavethemosteffectiverehabilitationoutcomeforyourpatients.Thisprocessofre-assessmentandmodificationoftheplanisntcompleteuntilthepatienthasreachedhis/herrehabilitationgoals.Howoftenshouldwere-assess?Whattoincludeonabodychart:Areasofpain(P1,P2...),radiatingpain,numbnessand/ortingling,painfreeareas.Goshisa33yearoldsalespersoninafurniturestore.Threeweeksagohewentaroundacornertoofastandcrashedhismotorcyclewhiledrivingtowork.

Xray(-)Painisconstantandvariable.Gettingbetter.Inlastweekworstpainis7/10whenliftingapieceoffurniture.Best2/10.Average4/10. 7AggravatingFactors:Liftingmorethan10pounds.Turningheadtolookoverleftshoulder.Sleepingonleftsidewakesseveraltimesanightandhasdifficultygettingbacktosleep.Deepbreathing.Beinguprightmorethanonehour.EasingFactors:Lyingonback.Massage.Rest.Vicodin.Other:Marriedwithtwochildrenunder3.Difficulttopickthemup.UsuallyplayssocceronSundaysandnowhecant.Offworknow.Patientisconcernedaboutnotbeingabletoworkandbringinincome.WhatotherinformationwouldyouliketoknowaboutGosh?Why?

Howcanyouapplythefollowingstrategiestotheevaluation:RecognitionorInductiveReasoning:

Hypothetico-DeductiveReasoning:

Knowledge-ReasoningIntegration:

IntegratedPatient-CenteredReasoning:

8DISABLEMENT MODEL & CLASSIFICATION (From CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST PRACTICE Part 3 Segment 1 and 2)

FUNDAMENTALCONCEPTS

GOALSOFAPPLYINGDISABLEMENTMODEL

PositionthebodyofknowledgeinphysicaltherapywithinatheoreticalframeworkrelevanttoclinicalpracticeDelineatethemajorpathways--fromdiseaseorinjurythroughtovariousfunctionalconsequences

MODELSOFABILITY/DISABLIITY

Modeltodelineateconsequencesofdisease&injuryastheyimpactatthelevelofaperson&societyBasedonworkofNagiandadoptedbytheWorldHealthOrganization(WHO)NationalCenterforMedicalRehabilitationResearchInstituteofMedicine

(8)

9PATHOLOGY(cellularlevel)

InterruptionofnormalcellularprocessesBiochemical,physiologic&anatomicabnormalitiesofthehumanorganismIMPAIRMENT(bodysystems)

Lossorabnormalityofphysiological,psychological,oranatomicalstructureorfunctionClassificationofabnormalitiesdiagnosisofimpairmentExamples:Aerobiccapacity/endurance;gait,locomotion&balance;integumentaryintegrity;jointintegrity&mobility;motorfunction;muscleperformance;ROM;pain;posture;ventilation&respiration/gasexchange

FUNCTIONALLIMITATION(wholeperson)

Restrictionoftheabilitytoperformanaction,task,oractivityinanefficient,typicallyexpected,orcompetentmannerClassificationofrestrictionsdiagnosisoffunctionallimitationsExamples: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-specificrolesinaparticularsocialcontextorphysicalenvironmentClassificationofinabilities-diagnosisofdisabilityExamples:Work(job,school,play),community,leisureintegrationorreintegration

WherewouldthesefitintotheDisablementModel?

Inabilitytoshopforfamilymyocardialinfarctionabilitytoambulateaerobiccapacityorendurance

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 12EXAMPLE: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 - _______________________________________ PLANIs this enough information to elaborate an effective plan ofcare? 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 13USE OF CLINICAL DECISION-MAKING IN AN EVALUATION Whyareevaluationsimportant?oClarifytheseverityandnatureoftheproblemoFindwhatfunctionaldeficitsapatienthasoTouncovertheprincipalproblemscontributingtofunctionaldeficits(pain,weakness,lackofROM,etc)oTotakeobjectivemeasurementsthatcanbereferredbacktolaterinordertoassessprogress.Whydoweneedtheaboveinformation?oInordertodesignthemosteffectiveandefficienttreatmentplanforeachpatientsothattheycanreachtheirrehabilitationgoalsasrapidlyaspossible.Wellgointothisinmoredetaillater,butisitappropriateforallpatientswiththesamediagnosistoreceivethesametreatment?Whataresomefactorsthatmightinfluenceyourchoiceoftreatment?

14WhyisitnecessarytoevaluateapatientifanMDhasalreadyexaminedthem?oTheprimarygoalofamedicalexamistoformulateadifferentialdiagnosisofthepatientsproblem.

oTheprimarygoalofaPTevaluationistogathersubjectiveandobjectiveinformationthatwillguidetheclinicaldecisionmakingregardingwhatPTtreatmentswillbemosteffectiveinreachingtherehabilitationgoalsforthept.Documentationisanessentialelementofevaluationandtreatment.AccordingtothePhysicalTherapyGuidetoClinicalPractice:

Asyouallknow,aphysicaltherapyevaluationconsistsof4parts:SubjectiveObjectiveAssessmentPlan Documentsshouldincludeappropriateevaluations&interventions,expectedoutcomes,&recommendedfrequency,intensity&durationofphysicaltherapyservices.Thespecificconditionsforwhichcareisdescribedcanbebasedondiagnoses,oronotherbases,suchasfunctionallimitationsordisabilities. 15Subjective Evaluation LISTEN!

OnsetofcurrentEpisode

16

(7)

AreaofSymptoms(bodychart)oDescriptors,typeofpain,relationshipofpainareas,numbness/tingling.

17

BehaviorofSymptomsoConstantorIntermittent

oAggravatingandeasingfactors

o24HourBehavior

18

(7)

oAskfollowupquestionstotrytoelicitanswersthatareasspecificandmeasurableaspossible.

oThinkaboutwhatthisistellingyouaboutwhichstructuresmaybeinvolved.

oMarksignificantfindingswithanasterisk

19PainscaleoCurrentoPastoWorstoBest

Functionallimitationsanddisabilities

SINSseverity,irritability,nature,stage

Severityoreferstotheintensityofthepainprovokingactivity.Cautionisnecessaryduringtheexaminationandtreatment.

Irritabilityoameasureofhoweasilythepatientssymptomsareaggravatedandhowquicklytheysubside.:Ifapatientssymptomscomeoneasilyanddontsubsidewithinafewminutesofstoppingtheaggravatingactivity,thentheconditionisconsideredirritable.

Natureoreferstothetypeofissuethatiscausingthesymptoms(i.e.:mechanical,inflammatory,etc.)

Stageoftheinjuryoacute-osubacute-ochronic 20LifestyleFactorsoWorkoRecreationalactivitiesoFamily/supportsystemoEnvironmentMedicalhistoryoothermedicalproblemswhichmayhaveaninfluence.oPrevioustreatmentsforthecurrentconditionandoutcomes.oPriorleveloffunction.

PatientsGoalsoItsveryimportanttoinquireastowhatthepatientsgoalsare.Attempttogatherfunctional/realisticgoalsfromthepatient.

Duringsubjectivequestioning,wewanttoassurethattheinformationwearereceivingisasspecificandquantitativeaspossible.Whydowewanttonotespecificandquantitativeinformationfromthepatient? 21

AFTERSUBJECTIVEEVAL:formhypothesisPRIORITIZEWHICHOBJECTIVETESTSYOUWILLPERFORM

PLANNING THE ORTHOPEDIC OBJECTIVE EVALUATION ThissectionisprimarilytakenfromtheworkofG.DMaitland.(7)oneofthegreatestphysicaltherapistsofourtime.Whenplanningtheorthopedicobjectiveevaluation,thefollowingshouldbetakenintoconsideration.Possiblesourcesofthesymptoms.(includejoints,muscles,neuralstructures,etc)

Arespecialtestsindicated?(neurologicalorcardiopulmonarytest,etc)

InfluenceofseverityandpathologyontheexaminationandtreatmentHerearesomethingsapatientmighttellyouandIwantyoutoletmeknowifyouthinktheywouldbegoodindicatorstomeasureprogressinthefuture.Ifyoudontthinktheywouldbegoodtouseformeasurementsofprogress,letmeknowhowthestatementscanbeimproved:Ihavepaininmyhip.IhavepaininmyhipwhenIwalk.(whatotherinformationdowewant?)Icanonlysitforonehour.Myleftarmisweak.Icantpickupmydaughterwithmyleftarm.(whatotherinformationdowewant?)Ihavealotofnumbnessinmyhand. 22

oIsthepain...SevereLatentoIsthedisorderirritable?oDoesthenatureofthedisorderindicatecaution?oAretherecontraindications?ThekindofExamoDoyouthinkyouwillneedtobegentleormoderatelyfirmwithyourexamination?

oDoyouexpectaCOMPARABLESIGNtobeeasyorhardtofind?

oWhatmovementsdoyouthinkwillbecomparable?

oWhatassociatedfactorsneedtobeexamined?

oAretherefactorsthatcouldcausetheproblemtoreoccur?(posture,muscleimbalance,instability,weakness,obesity,etc)

oDoyouthinkyouwillneedtofocusmostonweakness,stiffness,pain,orinstability?

23

Objective Evaluation ConsistsofSpecifictestsandmeasurementstodetermineinanobjectiveandquantitatemannertheseverityandtypeofproblemthatthepatientpresentswith.Also,themeasurementstakenintheobjectiveevaluationarenecessaryinordertodeterminetheextentofprogressinthefuture.

24Oneofthegoalsoftheorthopedicobjectiveevaluationistofindcomparablesigns.Thesearenecessaryinordertohelpusinthediagnosisofwhichtissuesareinvolved,andalsoinre-assessingprogressaftertreatment.

Systems Review

(See CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST PRACTICEPart 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)emphasizesthenecessityofelicitingComparableSignswhichrefertoanycombinationofpain,stiffnessand/orspasm,duringaspecificmovement,whichtheexaminerfindsonexaminationandconsiderstobecomparablewiththepatientssymptoms. 25Integumentary 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) 26TESTS & MEASURES (See CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST 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 SOBTests & Measures Aerobic capacity during standardized exercise protocols (see appendix A) Belowisanalphabeticallistofgeneralcategories oftestsandmeasuresthatpertaintoorthopedic evaluations,alongwithexamplesof clinical indicationsregardingwhenitmaybeadvisableto performthetest. 27 ClinicalIndicators TestsandMeasures DataGenerated

ANTHROPOMETRIC CHARACTERISTICS EXAMPLE Clinical Indications Abnormal fluid distribution Obesity /emaciatedTests & Measures Girth measurements BodyMassIndex(BMI) Data Generated Presence and severity of abnormal body fluid distribution Level of obesity and risk of disease 28CIRCULATION (ARTERIAL, VENOUS, LYMPHATIC) EXAMPLE Clinical Indications 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 orthostatichypotension. ClinicalIndicators TestsandMeasures DataGenerated

ENVIRONMENTAL, HOME & WORK BARRIERS EXAMPLE Clinical Indications Inability to enter building - no ramp is available Tests & Measures Current & potential barriers Data Generated Documentation and description of compliance with accepted standards ClinicalIndicators TestsandMeasures DataGenerated

29 ERGONOMICS & BODY MECHANICS EXAMPLE Clinical Indications 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 ClinicalIndicators TestsandMeasures DataGenerated

GAIT, LOCOMOTION & BALANCE EXAMPLE Clinical Indications 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 ClinicalIndicators TestsandMeasures DataGenerated

30INTEGUMENTARY INTEGRITY EXAMPLE Clinical Indications post- surgical scar/wound Tests & Measures Wound characteristics Data Generated Description and quantification of wound JOINT INTEGRITY & MOBILITY EXAMPLE Clinical Indications 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- orhyper- mobility ClinicalIndicators TestsandMeasures DataGenerated

MOTOR FUNCTION (CONTROL & LEARNING) EXAMPLE Clinical Indications Irregular movement pattern 31Tests & 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. ClinicalIndicators TestsandMeasures DataGenerated

MUSCLULO-TENDON PERFORMANCE EXAMPLE Clinical Indications 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 ClinicalIndicators TestsandMeasures DataGenerated

32NEUROLOGICAL TESTING EXAMPLEClinical Indications 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 Clinical Indications 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 Clinical Indications Difficulty eating because of jaw pain Tests & Measures Provocation tests find comparable sign(s) Data Generates Description and quantification of pain 33ClinicalIndicators TestsandMeasures DataGenerated

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 Clinical Indications 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. 34ClinicalIndicators TestsandMeasures DataGenerated

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 increasingROM What is limiting the ROM: pain, stiffness, anxiety Note the end feel Is there pain throughout the rangepainful arc 35Sometimes repeated tests are indicated.You should note if there is a change in pain and ROM with repetition. oWhat would help you determine whether repeated movement testing is indicated or not? EXAMPLE Clinical Indications 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 ClinicalIndicators TestsandMeasures DataGenerated

SELF-CARE & HOME MANAGEMENT EXAMPLE Clinical Indications Severe kyphosis Tests & Measures Ability to perform self- care and home management activities Data Generated Description and quantification of need for devices and equipment 36SOFT TISSUE EXAMPLE Clinical Indications 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 Clinical Indications 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

Assesstheinformationgatheredinthesubjectiveandobjectiveevaluationinordertolisttheproblemsthatyouaregoingtoaddressandsetupmeasureableandfunctionalgoalsinordertodecreasefunctionallimitationsanddisabilityasmuchaspossible.

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. 38OBJECTIVE: 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 GoalTreatment 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.) 40Posture: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 GoalTreatment Plan 1 2 3 4 41 TREATMENT (See CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST 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 42RE-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. 43APPENDIX 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. 443 Minute Step Test (Men) - Heart Rate Age18-2526-3536-4546-5556-6565+ Excellent130 3 Minute Step Test (Women) - Heart Rate Age18-2526-3536-4546-5556-6565+ Excellent134 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. 45Appendix B Geriatric Assessment !""#$%&' MU PT 8390 Tinetti Performance Oriented Mobility Assessment (POMA)`Description:The Tinetti assessment tool is an easily administered task-oriented test that measures an older adult`s gait and balance abilities. Equipment needed: Hard armless chair Stopwatch or wristwatch15 It walkway Completion: Time:10-15 minutes Scoring:A three-point ordinal scale, ranging Irom 0-2. '0 indicates thehighest level oI impairment and '2 the individuals independence.Total Balance Score 16 Total Gait Score 12 Total Test Score 28 Interpretation: 25-28 low Iall risk 19-24 medium Iall risk 19 high Iall risk* Tinetti ME. PerIormance-oriented assessment oI mobility problems in elderly patients. !"#$ 1986; 34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993) 46Tinetti Performance Oriented Mobility Assessment (POMA) - Balance Tests - Initial instructions: Subject is seated in hard, armless chair. The following maneuvers are tested. 1. Sitting BalanceLeans or slides in chair=0 Steady, safe=1_____ 2.ArisesUnable without help=0 Able, uses arms to help=1 Able without using arms=2_____ 3.Attempts to AriseUnable 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 DegreesDiscontinuous 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 47Tinetti 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; observeexcursion 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 orSpreads 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 48Bibliography 1.Ian Edwards, Mark Jones, Judi Carr, Annette Braunack-Mayer and Gail M JensenClinical Reasoning Strategies in Physical Therapy Physical Therapy April 2004 vol. 84 no. 4 312-330

2.Naber,RobertI,ORTHOPEDICEXAMINATION:FromSciencetoPractice(pdffileofcoursegiven) 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.pdf2008 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