Application Of Clinical Reasoning Model In Clinical Practice
Clinical reasoning is the decision-making processes, and the reasoning behind them, associated with clinical practice. This process is vital for a physiotherapist to be able to create, evaluate and justify an effective assessment and treatment plan. This essay will use the Jones clinical reasoning model (1995) to create and evaluate an effective assessment, diagnosis and possible treatment plan for Ms Southfield using the subjective information given. The source of symptoms, according to Jones (1995), refers to the tissues of which the patients symptoms are deriving from. Ms Southfield is experiencing intermittent pain in the lateral aspect of her right shoulder, P(a), rated 7/10 on the pain scale. Patient reports that P(a) is radiating down her upper arm when aggravated; the patients aggravating activities, all with immediate onset of symptoms, include lifting a hairdryer, reaching high shelves, and removing clothing over her head, thus suggesting the movements which aggravate P(a) are shoulder flexion past 90 degrees; and shoulder flexion combined with abduction and movement from medial to lateral rotation. The onset of P(a) is immediate once aggravating activities are carried out and eases after two minutes of stopping the activity; this indicates involvement of contractile tissues suggesting a myogenic source of symptom. Ms Southfield suggests that P(a) is linked to decorating rooms and she is also a hairdresser; both activities require repetitive movements of the shoulder suggesting the onset of P(a) is due to degeneration of myogenic fibres. Myogenic fibres likely to cause pain in that area include lateral deltoid; and the muscles of the rotator cuff - subscapularis, suprascapularis, infrascapularis and teres minor.
The muscles of the rotator cuff are a likely source of symptom due to Ms Southfields gradual onset of P(a) she describes it as ‘worsening’. This gradual onset of symptoms is suggestive of a rotator cuff injury as rotator cuff injuries are more commonly due to repetitive, mechanical overuse injuries and are more common in those over the age of 40 – Ms Southfield is 54, so this would be a likely diagnosis. P(a) is unlikely to have any arthrogenic source of symptom as the patient has not described P(a) as a nagging or deep pain, and she has had an X-ray which the GP has reported as ‘normal’. Jones (1995) states that pain mechanisms refer to how pain messages from the nervous system are being initiated and maintained. The three main nociceptive mechanisms of pain are: mechanical, inflammatory and ischaemic. P(a) is unlikely to be neuropathic in origin as there are no clinical presentations of paraesthesia, dysesthesia or numbness. Mechanical pain causes stress on injured tissue due to certain movements, thus meaning that with mechanical pain there will be particular movements that will aggravate the injured tissue, and other movements that will ease the pain. Ms Southfield has clear movements which aggravate P(a) as well as movements that ease it, suggesting mechanical pain mechanisms. Although pain on movement may also be a characteristic of inflammatory pain it appears more likely that Ms Southfields symptoms are as a result of mechanical pain as she also experiences pain which she describes as ‘intermittent’, another characteristic of mechanical pain. Inflammatory pain mechanism is amplified pain occurring in response to injury of tissue of inflammation and the patients symptoms should ease with non-steroidal anti-inflammatory drugs. Clinical symptoms of inflammatory pain may include redness, heat and oedema of which Ms Southfield does not present with, suggestive that her pain is not inflammatory.
The patient does, however, present with pain worse in the evenings, characteristic of all three mechanisms, however she is not experiencing any pain or stiffness in the mornings, which implies a mechanical source of pain, more likely to be presenting due to the use of her shoulder during the day. P(a) is likely related to injury of the tendon, as this will not present clinically as inflammatory, but more so mechanical pain mechanisms. Ischaemic nociceptive pain is caused by nociceptive activity in tissues stimulated due to a drop in pH of tissues. Clinical symptoms would include symptoms produced after prolonged or unusual activities; ease of symptoms quickly after a change in posture and symptoms worsen in the evening. P(a) eases quickly with a change in posture, which could be suggestive of ischaemic pain, however the pain seems to follow a pattern in which when the affected tissues are contracted, the pain arises, and when the tissues are relaxed, the pain eases, more suggestive of mechanical pain. P(a) also arises immediately after carrying out particular movements and, if it were to be nociceptive ischaemic pain, it would be expected that P(a) would take a prolonged period of time to arise. According to these categories devised by Jones (1995), a likely primary hypothesis would be rotator cuff tendinopathy. According to Jones, 1995 contributing factors are pre-existing factors that may contribute to the development and continuation of the problem. Ms Southfield has reported that she is ‘worried that she is damaging the shoulder’, which will result in her not using her shoulder as frequently – for example she has stopped going to the gym. Narici, 2017, states muscle atrophy begins within 3 days of muscle disuse, therefore Ms Southfield avoidance of use of her shoulder will result in deconditioning, as well as stiffness, which will worsen her problem. This belief may also mediate central sensitisation. Central sensitisation is modification of the way the central nervous system works due to the presenting pain, which causes more pain with less aggravation. P(a) may become amplified due to the patients emotional response to the pain. As the patient is experiencing pain, and is fearful of it, she may become anxious and therefore the pain is amplified. Ms Southfield is a hairdresser, and her shoulder is meaning that she is having to work less, however she is also a single mother with two teenage children, which may amplify her pain due to increased stress. P(a) is 7/10 on visual analogue scale, which suggests a high severity, however P(a) is aggravated immediately and eases within 2 minutes, suggesting a low irritability.
Precautions and contraindications to physiotherapy must be considered before the assessment and treatment of any patient; this is to ensure the safety of both the patient and the physiotherapist. The patient doesn’t present with any red flags, which is a symptom that may suggest a serious or life threatening condition that requires immediate escalation. The patient has relatively high severity, which must be considered a precaution (Banks and Hengeveld, 2010), however due to the low irritability of P(a) means that treatment can still be carried out within patient’s pain tolerability. P(a) is also worsening, which is also a precaution in order to prevent further injury, however, physiotherapy can still be carried out if P(a) is constantly monitored and ensure that the pain remains tolerable for the patient. Prognosis can be used to predict the probability of the outcome of physiotherapy being positive. Ms Southfield has a fairly good prognosis, as she is generally in good health; she is keen to return to previous level of function; has no previous rotator cuff problems and has previous physiotherapy which completely resolved her symptoms, suggesting she has a positive view of physiotherapy. Although factors suggesting a poor prognosis are few, there are some which include Ms Southfield’s age as it predisposes her to rotator cuff tendinopathy and she is also unmarried, according to Magee, 2016 unmarried people are less likely to adhere to an exercise programme. Her presentation is chronic, and she has had a long duration of complaints of P(a) which may suggest a poor outcome. The physical assessment of a patient aims to determine what structures are causing their symptoms. Using the subjective information the physiotherapist can plan an assessment, based on priority, in the form of a must, should and could list.
The physiotherapist must include observation, both formal and informal. Informal observation would be carried out throughout the assessment and includes noting the patients quality of movement, postural characteristics and facial expression. Findings which would be likely for Ms Southfield in informal observation include poor quality of movements that include flexion, abduction, internal or external rotation as these movements are primary actions of the rotator cuff muscles (Palastanga, 2017). For the formal observation of Ms Southfield, she will be observed from anterior, lateral and posterior views. The patient is likely to present with poor posture, as this is often a predisposition to rotator cuff injuries; particularly a kyphotic posture with protracted scapulae. Palpation must also be carried out, taking particular notice to things such as colour and texture of the skin; swelling; skin creases and temperature. It may also be useful to palpate along the tendons of the rotator cuff muscles to examine for tenderness, heat or swelling. Both active and passive range of motion must be assessed in all planes of movement in order to understand if the problem is muscular or joint related. As the primary hypothesis for Ms Southfield is rotator cuff tendinopathy, it would be expected that she would present with a deficit of active range of motion, limited due to pain, particularly in flexion, abduction, external and internal rotation, but it would not be expected to have a deficit in passive range of motion. Manual muscle testing must also be carried out in all planes of movement in order to understand if there are any particularly weak muscles, which allows isolation of the problem to particular muscle groups. If the primary hypothesis is correct, then the patient will present with strong but painful movement as this is characteristic of minor lesions of muscle or tendon. The movements will be particularly painful into flexion, abduction, internal and external rotation. Shoulder symptom modification procedure (SSMP) must be carried out, which will assist in treatment plan for the patient as if the modification of the shoulder relieves P(a), then it can be used as a treatment option for Ms Southfield. Suitable aspects of SSMP for assessment of Ms Southfield includes modification of scapula position and thoracic kyphosis modification as Kibler, 2003 states that excessive protraction of shoulders can decrease rotator cuff strength by up to 23%, so it is important to modify any protraction of Ms Southfield’s shoulders and then reassess strength, noting any improvement. Accessory glides of the shoulder should be assessed, however are not compulsory as, from the subjective assessment, the patient isn’t presenting with any symptoms characteristic of joint pathologies. Therefore, it is unnecessary to test for pain or abnormalities within accessory movements. The cervical spine should also be cleared, as pain may be referred into to shoulder for the cervical and thoracic region, however Ms Southfield is not presenting with any symptoms that suggest injury in the cervical or thoracic region area. This is the same with a neurological assessment, it could be carried out however there are no symptoms characteristic of neurological conditions. The physiotherapist can devise a treatment plan based on findings from both the subjective and objective assessment. The principles of rehabilitation for include co-contraction, scapular stabilization and functional exercise prescription. Initially it would be appropriate to give advice and guidance on the injury, as well as advice on pain management including heat and ice, and suitable analgesia.
For an initial exercise programme, range of movement exercises must be included; in which the patient must be laying supine and use a stick to carry out active assisted flexion, abduction, external and internal rotation within Ms Southfield’s pain tolerability. These exercises can be progressed by carrying them out in standing, without the assistance of gravity. It is also appropriate to include stretching exercises, focusing on decreasing internal rotation tightness, as this can predispose scapula protraction, therefore decreasing range of movement in the shoulder. SSMP must also be included throughout treatment, using the assessment techniques that relieved the patient’s symptoms. It is likely that thoracic kyphosis modification procedure will help to ease the symptoms and scapula assistance, which can be reinforced by verbal or physical prompts or, if necessary, taping of the shoulder. Once Ms Southfields symptoms have started to improve and pain is decreasing, her exercise programme can be progressed to include eccentric exercises without pain as there is significant evidence to suggest that this is a beneficial management technique for tendinopathy’s. The tendon should be passively placed into its shortest position, and then actively contracted eccentrically; the speed of the contraction and the load can progressively increased in order to progress the exercise. In conclusion, using the six categories from the Jones 1995 and devising a suitable assessment plan, prioritised using a must, should and could list, it is possible to conclude that Ms Southfield is presenting with rotator cuff tendinopathy in the right arm. Using this information, a suitable treatment plan can be devised.
