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?