PHYSICAL DIAGNOSIS

RATIONALIZING TREATMENT AND

CLINICAL DECISION MAKING IN
NEUROLOGICAL CONDITIONS

Faculty of Physiotherapy
M.Rajeswari
 Rationalization

➢ Justifying their action

➢ Justification of assessment (subjective and objective) and

management

➢ Appropriate use of history and physical examination is

essential to clinical practice
 Rationalization

• Prescribed interventions should be coherent and placed in

logical treatment sequence that best meet the rehabilitation

goals.

• This requires a good clinical decisions based on a clear

understanding of the condition and various factors that

influence rehabilitation.
COMMON PROGRESSIVE AND NON PROGRESSIVE CONDITIONS
SEQUELAE

• Sequelae is the term used to describe the secondary after effects of

the disease.

• Neurological conditions characterized by multiple sequelae

• These sequelae influence clinical decision making and

rehabilitation.

• Physiotherapist should identify, sort and prioritize treatment

COMMON SEQUELAE ASSOCIATED WITH
NEUROLOGICAL CONDITIONS
GOALS OF TREATMENT:

• As a result of multiple sequelae management of neurological

disorders require multiple goals.

• Initial treatment evaluation for a patient with CVA, MS,TBI include

goals that address ambulation, muscle tone, ADL, standing.

• Therapist should be able to clearly discern how the goals interact

with one another

• EX. Can ambulation training effectively proceed if muscle tone is

not addressed?
GOALS OF TREATMENT:

• Can a patient progressed to supervised transfer if interventions to address

unilateral neglect are not initiated?

• Can ADL improve if volitional movements is too heavily influenced by mass

patterns?

• Effective PT prioritize treatment goals in recognition of sequelae’s

cascading effects.

• Appropriate decisions include selection of interventions, sequence of

interventions and determination of self management strategies.
CASCADING EFFECTS OF COMMON SEQUELAE
REHABILITATION ENVIRONMENT

• Clinical management is rarely characterized by administration

of specific physical agents or exclusive sets of exercises

• Instead effective intervention is provided through eclectic and

imaginable clinical approaches that consider clinical goals,
patient needs and available resources
 UNDERSTANDING PATIENT FAMILY NEEDS

Understanding patient family specific needs and expectation is critical

in the management of clinical decision making in neurological
disorders.

For ex: Some patients may place greater importance on the ability to
transfer to and fro from the bed independently but others may place
importance on being able to perform simple kitchen duties.

Clinical decision making is heavily influenced by these needs.

PTs must foster patient cooperation by communicating rehabilitation

goals and discussing on how they relate to their needs.
 UTILIZATION AND ASSESSMENT OF OUTCOME MEASURE

• Unlike musculoskeletal conditions, sequelae associated with neurological

disorders are more cumbersome to objectively measure and monitor

• Patient progress should always express in objective rather than subjective

ways

• Ex: If gait or motor control is improving, the objective evidence that

supports the assessment must be provided

• Most appropriate objective tool is selected. Decision in selecting is based

on Reliability and validity, patient acuity, Rehabilitation setting, Treatment
emphasis etc
COMMON OBJECTIVE MEASURES USED
SOUND CLINICAL KNOWLEDGE AND EXPERTISE

Strong foundation of clinical knowledge is required

Components of the foundation include

- Clear understanding of neurological condition

- Appreciation of relationship between sequelae and function

- Receptivity to alternate or blended intervention strategies

- Ability to fashion interventions based on above foundation

components.

- PTs should be ready to receive, process and incorporate new

knowledge.
CLINICAL DECISION MAKING

Clinical Reasoning is the process by which a therapist interacts

with a patient, collecting information, generating and testing
hypotheses, and determining optimal diagnosis and
treatment based on the information obtained.

Multidimensional process that involves a wide range of cognitive

skills physical therapists use to process information, reach
decisions, and determine actions.
CLINICAL DECISION MAKING

It has been defined as “an inferential process used

by practitioners to collect and evaluate data and to make
judgments about the diagnosis and management of patient
problems“

Clinical reasoning is “the sum of the thinking and decision-

making processes associated with clinical practice”
 CLINICAL DECISION MAKING

• Decision making frameworks, such as algorithms, have been

developed by experienced practitioners to guide clinicians in their
reasoning processes.

• Rothstein and Echternach developed the Hypothesis-Oriented

Algorithm for Clinicians II (HOAC). An algorithm is a graphically
represented step-by-step guide designed to assist clinicians in
problem solving by considering several possible solutions.
CLINICAL DECISION MAKING

• During this process, the therapist analyses multiple variables

contributing to the patient’s limited physical capacity (the ability to
execute a task or action in a standard environment) and performance
(what the patient can do in his or her own current environment)

• The key elements of the process include generation of hypotheses of

factors assumed to underlie the limitations of physical capacity and
performance and postulation of the magnitude of those factors.

• Hypotheses are defined as the underlying reasons for the patient's

problems, representing the therapist's conjecture as to the cause.
CLINICAL DECISION MAKING

• The therapist interacts with the patient and other persons involved
in the patient care (family, other health care professionals) and
guides the patient in finding meaningful goals and health
management strategies.

• All decisions and actions need to be made in line with professional

ethics and community expectations.
CLINICAL DECISION MAKING
HYPOTHETICO-DEDUCTIVE REASONING.

• The most common form of clinical reasoning within the

physiotherapy profession is HYPOTHETICO-DEDUCTIVE
REASONING.

• The clinician gains initial clues in regards to the patients problem

(from the subjective assessment) which forms initial hypotheses in
the therapists mind.

• Further data is collected in the objective assessment which may

confirm or negate the hypotheses. Continual hypothesis generation
may occur during management and reassessment.
• Clinical reasoning should begin as soon as the therapist meets the
patient as their behaviour can inform the therapists clinical
reasoning.

• There should be ongoing data collection which should not stop at

the end of the assessment to aid this process.

• The therapist may be able to ascertain quickly that something is

wrong with the patient due to the subjective and objective
assessment along wither their subsequent clinical reasoning.
CLINICAL DECISION MAKING
HYPOTHETICO-DEDUCTIVE MODEL
CLINICAL DECISION MAKING
PATTERN RECOGNITION

• Knowledge is an important consideration.

• The newly qualified therapist is expected to have many more

potential hypotheses in comparison to a experienced therapist.

• There is suggested to be differences in novice and expert

therapists in the process of clinical reasoning.

• Although largely similar, novice physiotherapists have to go

through a longer process of clinical reasoning compared to expert
therapists due to lack of knowledge in comparison; and less
experience in pattern recognition.
 Clinical decision-making involves several stages:
➢ Cue recognition or Cue Acquisition: The initial encounter with the patient
– collation of clinical information about the patient.
➢ Hypothesis generation: :This may be undertaken shortly after the initial
encounter and may be case specific and developed in relation to previous
experience and education
➢ Cue interpretation: focus on the confirmation of cues that significantly
contribute to the original hypothesis or alternatively, the rejection of cues
unrelated to the original hypothesis.
➢ Hypothesis evaluation: Evaluated in relation to its relative merits,
advantages and disadvantages and possible contribution to the confirmation
or rejection of the original hypothesis.
CLINICAL DECISION MAKING
PATTERN RECOGNITION
 PATIENT INVOLVEMENT IN THE CLINICAL REASONING PROCESS

• The patient should be an integral part of the clinical reasoning

process as this can help the clinician to form hypotheses and lead
towards the review of the outcome post physiotherapy intervention
PATIENT INVOLVEMENT IN THE CLINICAL REASONING
PROCESS
Physical
Therapy,
Volume 91,
Issue 1, 1
January
2011,
THANK YOU