Introduction to Clinical Decision
Making, and Orthopedic
Examination and Evaluation
John Petrizzo, PT, DPT, CSCS
Clinical Decision-Making
• CDM requires the ability to assess the credibility of the
information presented to you
• Decisions generated based on observation, medical
records, letter of referral, etc…
Clinical Decision-Making Continued…
• Assess the patient
• Analyze the data
• Set goals
• Formulate a treatment plan
• Treat the patient
Assessment
• Gather subjective and objective data
• Signs vs. Symptoms
• Examples of subjective data?
• Examples of objective data?
• Stay on topic
Data Analysis
• Accuracy of data dependent on practitioner’s skill level
• Data must be reliable!
• Intra-rater reliability
• Reproducible when you repeat them
• Inter-rater reliability
• Reproducible between multiple clinicians
Data Analysis Continued…
• Once data is gathered:
• Organize a problem list
• Stage of making a diagnosis
• Disease process vs. Impairments
• Primary vs. Secondary problems
Making a Diagnosis…
• Diagnosis:
• A label encompassing a cluster of signs and symptoms
• Decision reached as a result of the diagnostic process
• Diagnosis should always be made within the scope of
the practitioner’s knowledge and expertise
• In PT, diagnosis are made based on impairments, not disease
processes!
Diagnostic Criteria
• Movement Dysfunction:
• Diagnosis should be related to movement
• Functional Ability:
• Must relate to function
Useful Definitions…Impairments and
Functional Limitations
• Impairments
• Any loss or abnormality of psychological, physiological or anatomical
structure or function
• Functional Limitations
• A restriction of the ability to perform, at the level of the whole person,
a physical action, activity, or task in an efficient, typically expected or
competent manner
Definitions Continued…Disability
• Disability
• Inability to engage in age-specific, gender-related, or sex-specific roles
in a particular social context or physical environment
Set Goals…
• Make a prognosis
• Goals must be measurable, observable, and functional
• Long-term goals:
• Ultimate level of functioning
• Short-term goals:
• Component skills to reach LTG
Formulate a Treatment Plan…
• Interventions
• Frequency
• Duration
• Potential D/C plans
• HEP
• What other factors should we consider when
formulating a treatment plan?
Treatment…
• Always re-assessing during treatment
• Modify treatment plans based on patient response
• Goals met?
• If not, why?
• If so, establish new STG
Psychological Adjustment to Injury or
Disability
• Factors
• Onset
• Change of lifestyle
• Change of income
• Ego
• Change of identity
• Positive or negative adjustment
• How people view injuries will have a major impact on how well they do with
treatment
Phases of Adjustment
• Traumatic reaction:
• Initial shock and anxiety
• Posttraumatic adjustment:
• Denial
• Grief
• Mourning
• Hostility
• Stabilization period:
• Adaptation
• Can be stable without being well-adjusted
Response
• Psych make-up is key to adjustment
• Disability is based on primary factors and secondary
factors
• Response may not be in direct proportion to the injury
What to Do?
• Listen
• Watch mannerisms
• Do not hesitate to refer out if necessary!
What’s the Difference Between
Examination and Evaluation?
• Examination
• Gathering information from the chart, other caregivers, the patient,
the patient’s family, caretakers, and friends in order to identify and
define the patient’s problems
• Evaluation
• The level of judgment necessary to make sense of the examination
findings in order to identify a relationship between the symptoms
reported and the signs of disturbed function
Purpose of the Examination
• The aims of the examination process include:
• Provide an efficient and effective exchange
• Develop a rapport between clinician and patient
• Successful clinicians are those who demonstrate:
• Effective communication
• Sound clinical reasoning and judgment
• Creative decision making
• Competence
Clinician’s Responsibility
• Primary responsibility is to make decisions that are in
the best interests of the patient
• Decisions are based on evaluation of the available
information gleaned from the examination
Principles for Clinical Success
• Utilize your resources
• All clinicians should be life-long learners
• Utilize the expertise of more experienced clinicians
• Be an effective communicator
• Verbal and non-verbal
• Body language
• Tone of voice
• Attitude
Examination Principles
• Make a complete and accurate functional diagnosis
• Not always possible!
• Should be performed in a predictable manner
• Patient history
• Systems review
• Tests and measures
• The examination is an ongoing process
• Always observe for changes in patient presentation
The Examination: History
• The overwhelming majority of the necessary
information to explain presenting patient problem can
be provided by a thorough history
• Start with general questions
• As examination proceeds, ask more specific questions
• Use neutral questions whenever possible!
• Examples?
Purpose of the History
• Develop a working relationship with the patient
• Elicit reports of potentially dangerous symptoms
• Determine the following:
• Chief complaint
• Mechanism of injury
• Impact on patient’s function
History Continued…
• Gather information on history of current condition as
well as past general medical and surgical history
• Social history
• Family history
• Living environment
• Occupation/Employment/School
• Functional status/Activity level
The Examination: Systems Review
• The systems review is the part of the examination that
identifies possible health problems that require consultation
with, or referral to, another health-care provider
• Consists of a limited examination of the anatomic and
physiologic status of all systems
• Musculoskeletal, neurological, cardiovascular, pulmonary, integumentary, GI,
urinary, reproductive
Systems Review Continued…
• Musculoskeletal
• Gross ROM, functional strength, symmetry
• Neuromuscular
• General movement patterns
• Integumentary
• Skin integrity, color, scar, temperature
• Communication Ability
• Consciousness, orientation, expected emotional and behavioral responses
The Examination: Tests and Measures
• Adjunct to the history and systems review
• Physical examination of the patient
• Goals of the physical exam:
• Determine the structure involved
• Reproduce the patient’s symptoms
• Confirm or refute the working hypothesis
• Establish an objective data baseline
Tests and Measures Continued…
• The focus of the physical examination should be to
identify physical impairments, functional limitations,
disabilities, change in physical function and health
status resulting from injury, disease, or other causes
• This information is then used to establish the
diagnosis and the prognosis and to determine the
intervention
What Tests?
• A good test must differentiate the target disorder from
other disorders, which it might otherwise be confused
• Ideally, the chosen tests used by the clinician are also
based to some degree on the patient’s history or
presentation
Evidence-Based Practice
• Involves the integration of best research evidence with clinical
expertise and patient values
• EBP process occurs in five steps:
• Formulate a clinical question
• Searching for best evidence
• Critical appraisal of the evidence
• Applying the evidence to the patient
• Evaluation of the outcome
Evidence-Based Practice Continued…
• Many tests and procedures used in PT, S&C, etc. are not, as of yet,
evidence-based
• Many special tests listed in orthopedic texts exhibit poor diagnostic
accuracy
• Our field is ever-changing, it is up to the practitioner to remain updated
with practice recommendations and decide the appropriateness of the
evidence for each of their own unique clinical settings
How to Approach the Evaluation
• Based on specific pathology
• PT identifies signs and symptoms which can be treated
• You don’t need to know the underlying pathology fully if you understand the
signs and symptoms
• If you do not feel comfortable with patient’s presentation, do not treat them!
Sequence of Exam
• People are coming to see you because they are in pain
• Order should be logical
• Do not make patients change position unnecessarily
• If you run your exams in the same order every time, you are less likely to
miss something
Subjective Exam
• Discussed earlier, should be done prior to objective
exam!
Objective Exam
• Screening exam
• Quick overview to rule-in or rule-out an area
• Not always necessary (but usually a good idea!)
• Posture
• AROM
• PROM (with and without over-pressure)
• MMT
• Appropriate neurologic tests and measures
Physical Exam
• Observation/Inspection
• General appearance, observation of specific area
• Selective Tissue Tension Testing/Resisted Movements
• AROM, PROM, Joint Play
• Differentiate between contractile and non-contractile tissue
• Neuromuscular Tests
• Palpation
Observation/Inspection
• Observation
• General appearance, walking, dressing, up/down, slim/obese, postural deviations
• Inspection of Specific Body-part
• Usually in conjunction with palpation
• Bony structure and alignment
• Soft tissue
• Skin
Bony Structure and Alignment
• Properly aligned?
• Assess in all three planes
• ID key landmarks and determine relationship to norm
and to each other bilaterally
Soft Tissues
• Swelling
• Extra/Intra-articular
• Atrophy/Hypertrophy
• Cysts/Nodules
• Anthropometric/Volumetric Measurements
Skin
• Changes in color
• Changes in texture and moisture
• Local scars, blemishes, abnormal hair patterns, open wounds
• Blood flow problems can cause distal hair loss
• Open wounds should be measured, take note of size, shape, color, smell,
discharge
AROM
• Provides general information:
• Willingness to move!
• Make note of:
• Onset of pain/painful arc
• ROM
• Crepitus
PROM
• Capsular vs. Non-capsular Patterns
• Capsular:
• problem with capsule itself
• Arthritis, tear, infection
• Non-capsular:
• Intra-articular blockage, muscular, tendon, fracture
End Feel
• Normal or • Always Abnormal:
Abnormal:
• Capsular • Muscle Spasm
• Bony • Boggy
• Soft Tissue • Empty
Joint Play
• Degree of mobility
• Assesses ligamentous support
• Presence of pain or muscle guarding
Joint Play Continued…
• 0: Ankylosed
• Normal mobility and painless • 1: Considerable
hypomobility
• Normal mobility and painful
• 2: Slight hypomobility
• Hypomobility and painless
• 3: Normal
• Hypomobility and painful
• Hypermobility and painless
• 4: Slight hypermobility
• Hypermobility and painful • 5: Considerable
hypermobility
• 6: Unstable
Resisted Tests
• Assesses musculotendinous unit
• Weak
• Neurologic or disuse?
• Painful
• Tendon or muscle belly?
• Muscle hurts on contraction and stretch
• Ligaments only hurt when stretched
• Held at midrange
• If you go through full ROM then the joint and ligaments come into play
Neuromuscular Tests
• Detect loss of neurologic function
• Compare dermatome and myotome
• Extent of lesion
• Strength tests
• Sensory tests
• Vibration loss first
• Decreases touch is more serious
• Also test coordination, tone, pathologic reflexes
Dermatomes and Myotomes
Neuromuscular Tests: DTRs
• Peripheral lesion
• Decreased DTR
• Central lesion
• Increased DTR
• Grading Scale
• 0: Absent Reflex
• 1+: Trace
• 2+: Normal
• 3+: Brisk
• 4+: Non-sustained clonus
• 5+: Sustained clonus
Palpation
• Skin
• Tenderness, moisture and texture, temperature, mobility
• Subcutaneous Soft Tissue
• Fat, fascia, muscles, tendons
• Tenderness, edema, mobility, pulse
• Bone
• Highly innervated
• Good innervation:
• Injury = Pain!
Specific Structures
• Bone
• Fractures, dislocations
• Articular Cartilage
• Degeneration, crepitus, loose body
• Intra-articular Fibrocartilage (labrum, menisci)
• Tearing, inflammation
• Joint Capsule
• Fibrosis or adhesion, tearing
Specific Structures Continued…
• Ligament
• Sprain
• Grade I: Minor, normal joint play
• Grade II: Hypermobility and painful
• Grade III: Hypermobility and painless
• Muscles, Tendons, Bursa
• Inflammation, tearing, strains
• Nerves
• Entrapment (lower cervical and lower lumbar)
Questions?
