Intro to Clinical Reasoning PDF

Clinical Reasoning Adam Squires PT, DPT, Cert SMT, Cert DN Board Certified Specialist in Orthopedic Physical Therapy  Objectives Define clinical reasoning and understand its importance in clinical practice. Understand and apply the SINSS model of clinical reasoning...

Clinical Reasoning Adam Squires PT, DPT, Cert SMT, Cert DN Board Certified Specialist in Orthopedic Physical Therapy  Objectives Define clinical reasoning and understand its importance in clinical practice. Understand and apply the SINSS model of clinical reasoning. Understand the Symptom Behavior Model of clinical reasoning. Apply SINSS to patient cases. Definition  Clinical Reasoning Definition “A complex cognitive process that is essential to evaluate and manage a patient’s medical problem” Includes “diagnosis of patient problem” “making a therapeutic decision” “estimating the prognosis for the patient” The most important skill Separates you from a personal trainer SINSS Model  SINSS Useful model for systematic clinical reasoning To determine diagnosis Assist in treat/refer decision Make intervention decisions Educate patient on prognosis Severity Irritability Nature Stage Stability  Severity High, moderate, low Impact on activities (daily living, work, recreation, etc.) 0-10 verbal scale (Numeric Pain Rating Scale) https://www.santephysique.com/blog/pain-types/  Irritability “Ratio of the magnitude of aggravating factors to easing factors” How much aggravating factor does it take to increase pain? How long does it take to calm back down when aggravating factor is removed or relieving factor is applied? One of the most important factors in determining aggressiveness of exam or intervention techniques. Don’t want to over examine/treat a high irritability Don’t want to under examine/treat a low irritability High, moderate, low Irritability Irritability  Nature “…includes the specific diagnosis or condition the patient is experiencing, [and] the nature of the pain itself.” Types of pain Nociceptive – mechanical or inflammatory Neuropathic Central Viscerogenic Autonomic https://samarpanphysioclinic.com/types-of-pain-physiotherapy/  Nature Mechanical Back Pain Inflammatory Back Pain Occurs at any age Age of onset < 45 years More acute onset Pain duration > 3 months Onset is variable - may be caused by a specific event Insidious onset May worsen with movement / exercise Improves with movement / exercise Improves with rest Does not improve with rest Little or no morning stiffness Early morning stiffness which lasts > 30 minutes Pain at night, which may wake the patient  Nature Pain Descriptions and Related Structures Type of Pain Structure Cramping, dull, aching Muscle Dull, aching Ligament, joint capsule Sharp, shooting Nerve root Sharp, bright, lightning-like Nerve Burning, pressure-like, stinging, aching Sympathetic nerve Deep, nagging, dull Bone Sharp, severe, intolerable Fracture Throbbing, diffuse Vasculature  Stage Time the symptoms have been present Acute Less than 3 weeks Subacute More than 3 weeks but less than 6 weeks Chronic Greater than 6 weeks Will affect interventions based on tissue healing timeframes  Stability Progression of symptoms over time Improving Symptoms decrease intensity, frequency, or location Less pain medication Worsening Symptoms increase intensity, frequency, or location No change Neither better or worse intensity, frequency, or location Inconsistent Sometimes better, sometimes worse Symptom Behavior Model  Definition Framework for testing hypothesis list developed through SINSS clinical reasoning Test-Treat-Retest is the hallmark “It is not your patient’s job to know if they are getting better, it’s your job to show them” – Institute of Clinical Excellence Cervical Spine Management  Symptom Behavior Model Asterisk signs Activities or movements that reproduce patient’s symptoms “Comparable signs” Defined values that can be tracked! E.g. Walking for 5 minutes vs Walking E.g. Cervical rotation: 46 degrees vs limited Subjective – Information reported by the patient (e.g. aggravating factors) Objective – data collected during examination (ROM, strength, outcomes measures, etc.)  Symptom Behavior Model Based on your hypothesis list (SINSS and asterisk signs), perform an intervention Retest asterisk sign Usually objective asterisk in-session Ask about subjective asterisk(s) at next session Show the patient how much improvement and WHY it is important to his/her life! Be like Costco Application  Patient Case Patient is a 37 year old male with acute low back pain after squatting at the gym 2 days ago. He reports his pain was 7/10 right after the incident, but has lessened in the last 24 hours to 5/10 at its worst. Describes it as a deep ache with sharp stabs of pain intermittently. States he cannot sit for more than 10 minutes before his pain is 5/10 and he has to stand and walk around for 15 or more minutes before it calms down. When bending, he can reach to his knees before pain stops him. Rotation is extremely limited bilaterally.  SINSS Determine SINSS for this patient with justification. Determine subjective and objective asterisk(s). Discuss as a class.  Objectives Define clinical reasoning and understand its importance in clinical practice. Understand and apply the SINSS model of clinical reasoning. Understand the Symptom Behavior Model of clinical reasoning. Apply SINSS to patient cases. Questions