L14 - CLINICAL REASONING 2 Flashcards
Definition OMPT
Definition
= specialized area of physiotherapy / physical therapy for management of neuro-musculoskeletal
conditions, based on clinical reasoning, using highly specific treatment approaches including manual
techniques & therapeutic exercises
- Encompasses & is driven by available scientific & clinical evidence & biopsychosocial framework
of each individual patient
2 principal parts of BPS
Reductionism & dispositional approach
Description reductionism
Reductionism
- Inadequate as it relies heavily on philosophy of interpreter to build bridges between
characteristics & meld biomedical, psychological, cognitive, behavioral, social & occupational
threads back together to make a whole
Remove boundaries between themes & their overlap to embrace dispositional quality
Description dispositional approach
Dispositional approach
= non-linear interaction & mutual manifestations
- Helix better symbolizes unique sequencing of themes of individual’s health & expressions o
individualized phenomena arising from complex interactions between integral characteristics
- Communication & therapeutic alliance are scaffold of helix, structure enables ingredients of
complex, unique human experience to be explored
Definition & components of therapeutic alliance
THERAPEUTIC ALLIANCE
= dynamic construct within clinical encounter & influenced reciprocally between person seeking care & PT
by biological, social & psychological contributing factors
- Communication acts as catalyst in operationalizing therapeutic alliance in PT context
Components
- Collaboration
- Communication
- Empathy
- Mutual respect
ICE clinical communication: description, goals
Communication technique should be part of normal conversation (no tick-box), by question something
patient has already told & asking open question
Goals
- Helps acquiring patient’s perspectives within healthcare assessment
- Promotes patient-centered care
- Reduce prescriptions, whilst improving shared decision making & patient satisfaction
Description of ideas, concerns & expectations
IDEAS = to acquire knowledge about situation, help clarify misconceptions, improving understanding &
gain rapport
CONCERNS = to address fears & anxieties about situation
EXPECTATIONS = to establish patients’ agenda also helping shared decision-making
Patient values in PT: 3 types & description
PATIENT VALUES IN PT PRACTICE
1. Values of one-self
- Uniqueness: personal recognition & wish to be seen as unique individual
- Autonomy: being well informed on order to make right decision by themselves
- Values of professional
- Technically skilled: competent, including communication skill
- Conscientious: moral in clinical decision-making process
- Compassionate: empathize with person & his/her unique history
- Responsive: able to adapt to patient’s need - Values of interaction
- Provide cooperation & open space for question
- Empowering patient & provide tips/tools to support self-care
Use the different components of therapeutic alliance: collaboration, communication, empathy & mutual
respect
Description of pain as multidimensional personal experience
N: MULTIDIMENSIONAL PERSONAL EXPERIENCE
- Multifactorial & highly personal nature of pain experience contributes to challenges of adequate
design & interpretation of RCTs
- Treating every patient only as supported by evidence drawn from one size fits all style comparing
group means risks under or over treatment of individual person
More logical & achievable approach would be:
1. Implement clinically rigorous yet feasible & personalized multidimensional assessment
2. Identify multisystem patterns in patient profile that may be driving pain experience
3. Intervene in targeted fashion based on results of that assessment
Description of prognosis profiling + different parts
Prognosis profiling
- Serious condition: require urgent medical evaluation or intervention
- Specific MSK pain disorder: pain & symptoms directly attributed to biological process associated
with MSK system
- Nonspecific condition: no identifiable pathology or weak correlation between symptoms &
underlying pathology
Non-specific spinal pain
- Biomedical diagnosis contested
- On one hand, having diagnosis of exclusion is reassuring but, on other diagnostic uncertainty
remains where cause of pain is unknown, which appears to lead to pain-related guilt, disability & depression
- Diagnosing conditions is regarded as essential element of medical practice & correspondingly
acquiring acceptable diagnosis is significant feature within patient’s illness experience
Diagnosis
Diagnosis is of exceptional importance:
- Diagnosis ascribes causal claim suggesting biomedical explanation of illness, whereby illness can be controlled & treated with potential for subsequent optimist & hope about future
- Diagnosis has legal & political implications giving individuals the opportunity to access welfare benefits
- Diagnosis provides psychological, reassurance & social acceptance by validating illness
Biopsychosocial model
- May have been misunderstood & therefore ineffectively applied, both in research & clinical
practice
- It fails to explain body/mind problem with clear theoretical link between them
- From patient’s viewpoint, body is at center at pre-reflective level & may not correspond to
healthcare practitioners’ categorical understanding
Definition + description of pain
n
= unpleasant sensory & emotional experience associated with or resembling that associated with, actual
or potential tissue damage
- Pain is individual experience & relationship between biological, lifestyle, psychological & social
domains on everyone is highly variable
- Consistent with this variability, multitude of potential factors can interact to produce & maintain
pain experience
Causal complexity of pain + description & implications of vector model
Causal complexity
All casual factors may coexist, are situational, context dependent, interact in non-linear fashion & can
only be seen as correlations
Cause as cluster of powers or dispositions orientated toward effect
Effect is reached when single or combination of dispositions exceed threshold
Vector model
Causal factors convey relative strengths of power indicated by vector’s length in relation to each other &
direction towards or away from manifestation of an effect or not
Overall tendency is composition of all powers mutually manifesting toward symptom generation in given context
This favor uniqueness, context sensitivity & holism, in contrast with traditional reductionist medical approach
Implications
People suffering with painful conditions wish to know & understand cause (diagnosis) of symptoms
Biomedical linear models are insufficient to provide adequate explanation as conditions & contextual
factors vary with time
BPS model has been criticized for ignoring patient’s experience as compartmentalizes condition into
biological, psychological & social phenomena
Utility of dispositions in clinical practice may avoid tension that classification systems create by being
noncategorical in so much that multidimensional causal mechanisms replace simplistic linear ones
Multidimensional profiling description + goals
MULTIDIMENSIONAL PROFILING
Individual profile established by including diagnosis together
with contributing factors weighted according to relative importance
Goal
To guide & prioritize targeted management
+ IMAGE
Different part of multidimensional profiling
Patient centered
Stage of disorder
Pain feature mechanism
Pain feature characteristics
Pain feature sensitization
Psychological consideration (yellow flags)
Lifestyle
General health
Functional behavior
Description of patient centered
Patient often report frustration in relation to perceived lack of
listening or hearing of what is said by healthcare professionals
Numerous benefits of competent listening skills:
- Individual’s perspective on problem
- Problem impact
- Goal & expectation
