WEEK 3 - clinical reasoning, pain, gait aids, postural assessment

Question 1

what is clinical reasoning?

Answer 1

• It is a way of thinking:
  - Hypothesis testing
  - Pattern recognition… comes with experience
  
  • It is a way of thinking to sort out and make sense of the information a client tells you (subject assessment) and information gathered form the objective assessment
  • “thought processes and decision making associated with a therapist’s examination and management of a patient”

Question 2

why is clinical reasoning important?

Answer 2

• Each person we assess/treat is unique
  
  • Research results, clinical guidelines and even anecdotes can only provide general guidelines to strategies of assessment and treatment
    Clinicians must then use their own clinical reasoning skills to determine how best to process with each patient

Question 3

what are the 2 ways of physiological thinking?

Answer 3

1. Deducto-hypothetico
   
   • Make decisions from the information gathered
   • Form and test hypotheses
   • Younger physiotherapists
   • Slow thinking -> hypothesis categories
     2. Pattern recognition
   • Recognise patterns
     
     • More experienced physiotherapists who have seen many patients

Question 4

what are the models of clinical reasoning?

Answer 4

1. WHO ICF
2. intervention process model
3. collaborative reassign model (Hypothesis categories)

Question 5

what is the intervention process model?

Answer 5

1. initial data collection
2. identity the concerns
3. identify relevant theory
4. assess body structure/ function activity paticipation
5. identify contextual factors
6. negotiate management plan
7. implement plan
8. evaluate outcomes
   - concerns resolved

Question 6

what is the collaborative reasoning model?

Answer 6

hypothesis categories
- activity and participation capability and restriction
- patients perspective on their experiences and social influences
- pain type
- sources of symptoms
- pathology
- impairments in body function or structure
- contributing factors to the development and maintenance of the problem
- pre-cautions and contraindications to physical exam and treatment
- management/ treatment selection and progression
- prognosis

Question 7

define nociceptive pain

Answer 7

with inflammation (Inflammation pattern) / without pain (mechanical pattern)
- pain that is associated with actual or threatened damage to non-neural tissue and involves the activation of peripheral nociceptors
- proportionate to injury
- clear aggravating and easing factors
- can be localised to area of pain

Question 8

define neuropathic pain

Answer 8

lesion or disease affecting the somatosenroy nervous system
- can affect the CNS or PNS
- sharp, shooting, boring, electric shock sensation
- can have pins and neediness, numbnesss or other dysthesia

Question 9

define nociplastic pain

Answer 9

pain that persists in the absence of overt tissue or nerve pathology
- dysfunctional nociceptive plasticity
- serves no protective benefit
- disproportionate to condition/ injury
- wide spread

Question 10

define FWB

Answer 10

no restriction with weight bearing status

Question 11

define NMW

Answer 11

no weight through the affected limb

Question 12

define PWB

Answer 12

0-50% weight through the affected limb

Question 13

define WBAT

Answer 13

50-100% weight through affected limb

Question 14

define PTWB

Answer 14

weight bearing as tolerates but gait aids are mandatory at all times until further follow-up with the surgeon

Question 15

define TWB

Answer 15

light touch for balance only (10%)

Question 16

what is the purpose of gait aids?

Answer 16

assist with:
- balance
- weight bearing/ protecting affected limb
- reduce fatigue or pain
- facilitate a safe walking pattern

purpose:
- increase BOS
- redistribute weight-bearing by reducing weight on the affected leg
- to compensate for weak muscles
- decrease pain
-improve pain

Question 17

sticks/ Cains

Answer 17

• Most common mobility aid
  
  • Usually made up of wood, steel or aluminium
  • Height adjustable
  • Transmits 20-25% of body weight
  • Elbow usually bent in 30 degree flexion
  • Held in hand opposite to the involved side
    The stick should be placed forward at the same time as the affected leg and then the unaffected leg follows

types:
- single point stick
- tripod
- quad stick

measurement:
- height of walking stick set at wrist crease
- base of stick placed 15cm from outside of foot
- elbow bent slightly

Question 18

walking frames

Answer 18

• Greatest stability
  
  • Good for elderly people with poor balance
  • Measure the height with the elbow 25-30degree bent while standing upright
    Many walkers have optional accessories such as baskets or bags, trays and oxygen bottle holders.

types:
- pick up frame
- two wheel frame
- four wheel frame
- gutter frame

sit to stand:
- place one hand (unaffected side) on the chair or bed and the other on the frame. push up fro the chair or bed through arm and stand

Question 19

crutches

Answer 19

1. Underarm (axilla) crutches:
   
   • Commonly used following an acute, short-term injury
   • Recommended for those who are only able to bear weight on one leg i.e. NMB on the affected leg
     2. Forearm (or elbow) crutches:
   • Commonly recommended for long term use
   • May not be quite as stable with a full load (NMB)
     Ideal for those who can bear weight on both legs, but who require the additional support (PWB, WBAT, PTWB)

measurement:
- handles to greater trchonater
- axillary: 2-3fingers between axilla and top of cruteches
- elbow: 20-30degree elbow flexion

Question 20

what is good posture?

Answer 20

• Neutral spine
  
  • 33 vertebrae in spine
  • 7 cervical (Cx) vertebrae - convex anteriorly
  • 12 thoracic (Tx) vertebra - convex posteriorly
  • 5 lumbar (Lx) vertebrae - convex anteriorly
  • 5 sacral bones - fused and sit in the pelvis
  • Curves in spine allow for the least amount of energy to be expended to maintain an upright position

Question 21

why is good posture important?

Answer 21

• Reduce the mechanical load on the spine and weightbearing surfaces of joints
  
  • Reduce stress/ strain in ligaments and joints
  • Good alignment of joints enabling muscles to work efficiently
  • We need good posture for using arms
  • Maintain balance
  • Prevent/ reduce pain and fatigue
  • To breath well assists with oxygenation and nutrition to internal organs (kyphotic or scoliosis)
  • Upright posture is required for eating and drinking

Question 22

what is the plumb line?

Answer 22

• Through apex of head
  
  • Middle of ear
  • Glenohumeral (GH) joint
  • Lx vertebra
  • Greater trochanter
  • Centre of knee joint
    Anterior to lateral malleoli

Question 23

what is a postural analysis?

Answer 23

• To assess standing posture, the client should standing upright with arms by side and looking forwards, knees ideally straight and all joints in a neutral position.
  
  • Assessment of posture needs to occur using 3 views: Anterior, posterior & lateral
    Assessment needs to be systematic and work down the body chain using the imaginary plumbline

Question 24

scoliosis

Answer 24

• In the frontal plane and looking posteriorly you can get lateral deviation of the spine
  
  • Spine no longer straight
  • Can be structural and fixed -> congenital / extra vertebrae or atypical vertebra/ neuromuscular
    Can be functional -> developed over time due to poor posture

Question 25

what do you assess in a postural assessment?

Answer 25

• leg length discrepancies -> pelvis, knee, achilles, creases
• posture of knees in standing - normal, genuine valgum, genuine vacuum
• posture of feet in standing - pronated, supinated
• sitting posture - head position, spinal curves, pelvis tilt, COG,