Intro to diagnosis/managment Flashcards
The process of clinical reasoning is: Collaborative Reflective Conscious Unconscious All of the above
All of the above
Clinical reasoning is based on what aspects (3)?
- Clinical findings
- Patient choices
- The clinician’s judgment (knowledge, experience, evidence)
Pattern Recognition (system 1) of problem-solving methods -
- “Forward reasoning”
- Faster
- More efficient
- Developed “scripts” or prototypes
Hypothetico-Deductive (System II) of problem-solving methods -
- “Backward reasoning”
- Heavy Reliance in Novice Practice
- Utilized by experts when faced with unfamiliar presentations
Mixed (diagnostic reasoning) of problem-solving methods most common in what level of clinicians?
Most common among expert clinicians
Probabilistic reasoning -
ex: Hx of ACL injury ->
- Assessing likelihood of a clinical hypothesis
- Statistic
- Approximated
ex: high probability of degenerative ACL
Causal reasoning uses inferences from _____ findings to reason a _____ relationship of variables.
- Inferences from clinical findings
- Cause and effect relationships of variables
- Based on normal/abnormal physiology
Case-based reasoning -
- Knowledge stored in a symbolic “script”
2. “Script” recalled in subsequent encounters with similar circumstances
Narrative reasoning -
Concerns the understanding of patients’ stories in order to gain insight into their:
- Experiences of disability or pain
- Their subsequent beliefs, feelings, and health behaviors
Strategy of seeking data to reduce suspicion of unlikely hypothesis
Elimination strategy
Negative likelihood ratio -
What values are of importance?
ex: Canadian c-spine rules
how many times more likely a negative test will be seen in those with the disorder than those without the disorder
Values <0.2 of importance
Values < 0.1 of significant importance
ex: Canadian c-spine rules - if test in negative then we can rule out need for x-rays
T/F Low negative likelihood ratio is good earlier in examination.
True rule out serious or other health conditions
Strategy seeking data to support a highly likely hypotheses
Confirmation strategy
positive likelihood ratio -
What values are of importance?
ex: Wainner’s Test Item Cluster for cervical Radiculopathy
how many times more likely a positive test will be seen in those with the disorder than those without the disorder
Values >5 of importance
Values >10 of significant importance
ex: Wainner’s Test Item Cluster for cervical Radiculopathy - if positive, will likely have diagnoses
T/F High positive likelihood ratio is good earlier in examination.
False, high positive is good but administered later in examination
What type of tests aids in narrowing hypothesis and therefore examination procedures?
Special tests
Tests with low (-) Likelihood Ratio (-LR) good to -
refute a diagnostic hypothesis
Tests with high + Likelihood Ratio (+LR) good to
confirm a diagnostic hypothesis
Discrimination Strategy -
- seeking information to discriminate between likely hypotheses
- We will have strategies that help us be confident with one diagnosis over another
Ockham’s Razor
the simplest solution may be the best
Hickam’s Dictum
Patients can have as many diseases as they d[ar]n well please
What are the steps of Diagnosis: the differential process to come to a diagnostic hypothesis?
- Chart review/patient interview
- visual inspection
- systems review
- elimination tests
- structural stress testing
- palpation and joint mobility tests
- confirmation tests
What are the steps after the diagnostic hypothesis?
- Performance measures/functional improvement
- Continued testing
- Response to interventions
- Clinical progress
T/F In many cases, special clinical tests are also used early to rule out the presence of red flags or conditions
True
In the examination sequence, after the screening/sensitive testing we make our first order decision. What does that mean?
If we will treat, treat and refer, or just refer
T/F In the examination sequence, after the physical performance measures we have a high suspicion of impaired driven treatment
True
What elements do we look at for our initial hypothesis generation? (4)
- Non-Musculoskeletal Health Conditions & Serious Musculoskeletal Conditions
- Potential radicular & referral sources
- Nerve root
- Peripheral nerve injury/ entrapment
- Somatic referred pain - Screening adjacent joint regions (commonly described as joint above and below)
- Differentiating local MSK conditions
Test-retest model -
- Continuous throughout services
- Apply intervention and assess response to intervention
- Determine the implications on continued services (test further, continue with intervention, continue with complementary intervention, reassess at next visit, discontinued intervention)
Patient Specific Functional Scale (PSFS) -
Individualized measure intended to reflect functional status
1. pt identifies activities for which performance has been limited
2. pt rates performance for each task 0-10
0 = inability to perform activity
10 = ability to perform activity at same level as before injury or problem
What is the minimal detectable change for the Patient Specific Functional Scale (PSFS)?
Average score = 2 points
Single activity = 3 points
The Patient Specific Functional Scale (PSFS) is validated for individuals with health conditions that include:
- neck pain
- cervical radiculopathy
- knee pain
- LBP
Signs and symptoms consistent with a non-musculoskeletal origin or serious musculoskeletal health condition that requires referral to another clinician -
red flags
Indicate need for more extensive examination or cautions/ contraindications to certain tests/ interventions
yellow flags
Screening questions for patient interview (
- Hx cancer
- Hx smoking
- Hx Infection
- Hx Trauma
- Wt loss
- Sexual dysfunction
- LE dysesthesia/ motor impairments (bilateral v. unilateral)
- Fever
- Phoresis
- DM
- Immunocompromisation
- Fatigue
- Bowel/bladder dysfunction
Category 1 factors that require immediate medical attention:
- Blood in sputum
- Loss of consciousness
- Neuro deficit not explained by monoradiculopathy
- Numbness/paresthesia in perianal region
- Path changes to bowel/bladder
- Pulsatile abdominal masses
Category 2 factors that require subjective questioning and precautionary examination and treatment procedures
- Age > 50
- Clonus
- Fever
- Gait deficits
- Hx of infection/hemorrhage
- Hx of metabolic bone disorder
- Hx of cancer
- Impairment precipitated by recent trauma
- Long term corticosteroid use
- Non healing sores or wounds
- Writhing pain
- Unexplained recent wt loss
Category 3 factors that require physical testing and differentiation analysis (UM Neuron tests)
- Abnormal reflexes
- Radiculopathy or paresthesia (uni/bilateral)
- Unexplained referred pain
- Unexplained UE LE weakness
If category 3 factors present and UM neuron tests (babinski, clonus, increased DTRs) are positive, what should you do?
consider neurosurgical/orthopedic consultation
If category 3 factors present and differentiation of referred pain what are three possibilities?
- Myelopathy (category 1) - refer out
- Somatic referred pain - treat
- Radiculopathy - Treat with caution
What aspects do you visually inspect for during physical examination? (5)
- Affect
- Anthropometrics
- Preferred positions
- Integumentary
- Posture (Symmetry, Bony/ soft contours, Resting posture vs ability to correct)
In the systems review you will test what components and defer what procedures?
- Test components that you do not plan to assess further
- Defer other procedures that you plan to test more thoroughly
Goal of a systems review?
Identify impairments for continued tests and measures:
- Cardiopulmonary
- Integumentary
- Neuromuscular (Cognition/ Affect)
- MSK
What is the difference between SYSTEMS REVIEW vs. ELIMINATION TESTS?
Ex: ULTT
- > The intent
1. Systems review - Testing body systems to determine need for further examination in “tests and measures”
2. Elimination tests - Part of “tests and measures” - Screening for health conditions commonly associated with the diagnostic hypotheses to aid in the differential process
- ex: ULTT to identify patient with UE pain of radicular origin
ELIMINATION TESTS: QUARTER SCREENING -
- Upper and lower quarter structures stressed to determine need for more specific regional examination
- Overpressure is often applied at the end of AROM (if motion is full and painless) to stress structures for clearance
- Strength grossly assessed to identify force production capacity
ELIMINATION TESTS: Neurologic Screening Tests What tests for: Sensation? Motor Function? Reflexes? Considerations?
- Sensation (Light Touch, Pin Prick, Proprioception)
- Motor Function (Myotome vs. peripheral nerve, Coordination)
- Reflexes (DTR, Pathologic Reflexes (present or absent))
- Considerations (Symmetry, Normal/ Diminished/ Absent)
ELIMINATION TESTS: Special Tests
Implication for performing test?
- safety (wouldn’t apply pressure to possible rotator cuff tear)
- information provided
- role in differential
Evidence based application of special tests (what are you looking for in the evidence)?
- Available body of evidence
- Utility of test per diagnostic research properties
- Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool (Cook, 2013)
- Sufficient Score >/= 10/14
5 aspects of the beigton’s scale?
- Hands flat on floor with knees straight?
- Bend elbow backwards?
- Bend knee backwards?
- Bend thumb back on to front of forearm?
- Bend little finger up at 90 to back of hand?
Process of inductive reasoning in which particular tissues are stressed during different types of testing procedures, and then the results of the tests are compared to narrow down a likely lesion/ tissue type -
Structural stress testing (AROM, PROM, Resistive training)
provocation testing -
tension on specific structures with testing procedures
Structural stress testing provides info about:
- Quantification and Qualification(ROM, performance symptoms)
- Willingness to perform movement
Concordant vs discordant symptoms -
Concordant: consistent with pt’s complaints
Discordant: not consistent with patient’s complaint(s)
Contractile unit structures stress testing:
What structures?
What offers greatest provocation with testing?
Contractile Unit Structures: muscle, tendon, bony insertion
- Resistive Testing > Active Contraction and passive stretch
- Passive shortening non-provocative
Inert structures -
Joint Capsule, ligament, bursa, fascia, dura mater, nerve, bone, disc
palpation -
- Find bony landmarks, bony structure abnormalities
- Identify relevant soft tissue structures
When palpating, assess what?
- Joint congruence, tenderness, stability
- Superficial temperature, inflammation
- Dryness or excessive moisture of skin
- Sensation
- Pulses, tremors, fasiculations, creptius
- Tension, thickness, texture of soft tissue (spasm, turgor, flexibility, pliability, fibrosis)
- Pain in various structures
At what position of joint do you perform joint mobility testing?
Resting position
Stabilize (distal/proximal) segment when testing joint mobility?
Proximal (unless using indirect technique)
When performing joint mobility testing, asses what?
- Symptom Provocation
- Quality (“Normal”, Mechanical block, Guarded)
- Quantity (Joint Integrity, Hypermobile, Hypomobile, “normal”)
- Willingness
What type of mechanical loading would you expect at: Articular surfaces? Inert joint stabilizers (capsule/lig)? Guarding contractile units? Point of contact?
Articular surfaces? shear loading
Inert joint stabilizers (capsule/lig)? tensile loading
Guarding contractile units? Tensile loading
Point of contact? Local compression
Once hypothesis has been narrowed, can use what type of tests?
Confirmation tests
What type of likelihood ratio do you want confirmation tests to have?
high Positive with high specificity (if test is positive, helps rule in health condition
Ex: Suspected labral lesion
+ LR = infinite
- LR = .009
QUADAS score 3/14
Excellent to rule in if test is positive and out if test is negative, however, QUADAS score is insufficient so not good quality research
Common (general) impairments patient’s will present with -
- Pain
- Tissue Damage
- Range of Motion (ROM)
- Joint mobility (hypermobility v. hypomobility)
- Posture (Impairment vs. sum of impairments and environmental/ personal factors)
- Muscle Guarding
- Muscle performance (Coordination, Endurance, Strength)
Tensile tissue loading -
forces in opposite directions
Compression tissue loading -
forces toward each other
Shear tissue loading -
2 surfaces rubbing against in opposite directions (can be problematic for discs)
Distribution of loading -
if all forces in one area -> excessive loading at point of contact and can lead to break down
Collagen stress-strain curve: Toe Region - Elastic Deformation Region - Plastic Deformation Region - Tissue Failure -
- Toe Region - straightening out wavy fibers
- Elastic Deformation Region - slight stretch on structure but not enough to deform (will resume original shape w/o stress)
- Plastic Deformation Region - (microscopic tears) lead to permanent stretch
- Tissue Failure - broken fibers (macroscopic failure)
Repetitive Stress injuries -
ex:
Low intensity of loading, High frequency and/or duration
Examples: Spondylolysthesis, or Tennis Elbow (lateral epicondylopathy)
Trauma injuries -
ex:
High Intensity of loading, Low frequency
Example: Fractured vertebrae related to a fall from a ladder
Injury classification:
Acute -
Subacute -
Chronic -
- Acute: typically 7-10 days
- Subacute: subsequent 5-10 days
- Chronic: Injury lasting longer than expected under “normal” healing conditions
General expected tissue healing:
Phase 1
Phase 2
Phase 3/4
PHASE I: acute inflammatory response
PHASE II: repair and regeneration
PHASE III (/ IV): remodeling and maturation
What are two general tissue healing requirements?
- Controlled forces necessary to facilitate tissue synthesis
- Protection from excessive and harmful stresses on tissues
Phase 1 of expected tissue healing for ligaments?
Acute Inflammation and Reaction (First 3 days)
- Acute inflammatory response & hematoma formation
Phase 2 of expected tissue healing for ligaments?
Repair & Regeneration (2-3 days post-injury to ~6 weeks)
- Fibroblasts produce collagen
- Matrix disorganized
Phase 3 of expected tissue healing for ligaments?
Remodeling and Maturation (>/= 12 months post injury)
- Collagen fibers become more parallel/ organized
- Increased tissue contraction and tensile strength
Healing requirements for ligaments:
- Disrupted tissue must remain in continuity
- Controlled forces necessary to facilitate collagen synthesis (tensile loading)
- Protection from harmful stresses on tissues
Phase 1 of expected tissue healing for tendons?
Inflammatory
- First 3 days
Phase 2 of expected tissue healing for tendons?
Reparative/ Collagen Productive
- Begins within first week
- Increased fibroblasts/ fibroblastic activity through week 4
- Collagen fibers initially formed disorganized and at random
- Cells and collagen become more aligned more perpendicular to long axis over time
Phase 3 of expected tissue healing for tendons?
Remodeling
- Collagen/ cells re-alignment typically complete by ~2 months
After initial tendon healing, why is controlled tensile loading necessary?
- Parallel organization associated with improved tissue strength
- Motion (eccentric) can aid in prevention of cross-linkage between tendon tissue and sheath tissue
T/F For a more extreme tendon injury, you don’t want to use tensile loading.
True
Describe the organization of ligaments and what type of loading?
Less parallel = multidirectional loading
Describe the organization of tendons and what type of loading?
More parallel and organized = loads in one direction
Tendonitis -
Inflammation of tendon
Tenosynovitis -
inflammation of synovial sheath surrounding tendon
Tendinosis
Is there an inflammatory process and healing response?
- Degeneration of the collagen tissue in tendons due to aging, microtrauma, or vascular compromise
- Disorganization of tissue
- No active inflammatory process
- Failed healing response
If you have loss of proteoglycans in the articular cartilage, what can you expect of the matrix?
Loss of proteoglycans: matrix reaches certain amount of loss that is irreversible (matrix unable to replenish)
The healing of articular cartilage depends on what?
Healing depends on:
- extent of injury: (chondral, chondral/ subchondral, subchondral, cystic)
- Injury type (Blunt trauma, penetrating Injury, frictional abrasion, sharp concentration of joint forces)
What to expect with a mechanical injury to the chondral level of articular cartilage?
Limited response per no inflammatory response
What to expect with a mechanical injury to the subchondral level of articular cartilage?
- Extends to blood supply
- Fills in with tissue more like fibrocartilage
- Fibrin clot at 48 hours
- 2 months: resembles “normal” cartilage
- Erosive changes observed around 6 months
Common immobilization/ protection timelines for bone healing - (by age)
Common immobilization/ protection timelines: 6-8 weeks for adults, 4-6 weeks for children
Immobilization based on:
- prevention of excessive shear - early excessive loading: risk for pseudoarthrosis (false joint - cartilaginous)
- Insufficient loading may be detrimental
Pathophysiology of stress fractures:
- Repetitive microtrauma
- Osteoblastic activity lags in comparison to osteoclastic activity
- Stress reaction (early in progression) may progress to cortical disruption (clear Frx line), then complete Frx
Fatigue Fractures -
ex:
Normal bone, abnormal stress
ex: couch potato to marathon runner
Insufficiency Fractures -
ex:
Normal stress, abnormal bone
ex: walking with older age
What type of onset for stress fractures?
Insidious onset, progressive
At what point do stress fractures affect ADLs/performance?
Progression
Risk factors of stress fractures?
- Female >
- Amenorrhea
- Smoking
- Prolonged steroid use
Symptomology of stress fractures - (3)
- Focal pain
- Exercise-induced pain
- Night pain
Physical examination of stress fractures - (5)
- Local tenderness
- Limited ROM at joint area (guarded vs. painful end feel)
- Palpable guarding
- Possible local swelling
- MRI, bone scan findings
Arthrogenic Muscle Inhibition (AMI)
- continued reflex inhibition of musculature surrounding a joint following injury or joint effusion
- Compensation strategies may cause damage to joint structures by resulting in abnormal joint loading during activity performance
Increase in the resting activity level of a muscle related to a protective response from painful stimuli -
guarding
Ectopic calcification -
accumulation of osteoid material in soft tissue
Secondary responses to injury:
- AMI
- Guarding
- Ectopic calcification
- Atrophy\
- Contracture
- Anxiety/fear
What are the two types of instability?
- Neuromuscular (functional) instability
2. Structural instability
Neuromuscular (Functional) Instability -
- Poor neuromuscular control, typically thought to be secondary to an injury, resulting in aberrant movement patterns and subsequent harm to involved structures (e.g. deep neck flexors & paraspinals following trauma)
- Typically what PTs think when instability is used
Structural Instability -
- Disruption in the continuity of an anatomic structure that limits the structure’s ability to accept loading (fracture, ligament rupture or laxity, etc.)
- Typically what the rest of the health care world thinks when this term is used
