clinmical reasoning
TRANSCRIPT
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Dr Masharawi Y. [email protected]
:תוכנית
מבוא לחשיבה קלינית.1
ראיון המטופל האמבולטורי.2
בדיקה פיזיקאלית.3
המנואליעקרונות הטיפול.4
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Clinical reasoning in physiotherapy
2Dr Masharawi Y. [email protected]
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הרבה טעויות היינו מונעים מבני"
אילו לימדנו אותם כיצד לחשוב,אדם"ולא מה עליהם לחשוב
גיאורג כריסטוף ליכטנברג•
Dr Masharawi Y. [email protected]
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Clinical reasoning - Introduction
• The thought process
• Importance of knowledge and theorganization of knowledge
• There are many types of knowledge
• We must be critical of knowledge
Dr Masharawi Y. [email protected]
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Cognitive skills include:
• Relevant / irrelevant information
• Interpretation of information
• Hypothesis generation
• Hypothesis testing
Dr Masharawi Y. [email protected]
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Dr Masharawi Y. [email protected]
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METACOGNITION
THINK ABOUT YOUR THINKING
By:
Reflection in action
Reflection about action
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• A clinicalreasoning
model for
therapists
(Barrows and Tamblyn1980)
8Dr Masharawi Y. [email protected]
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…Organization of thinking
1. Mechanism of Symptoms (Sx.)2. Sources of symptoms (Sx).
3. Contributing factors.
4. Precautions and contraindications.
5. Prognosis.
6. Management.
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..1MECHANISMS OF THE SYMPTOMS
a. Peripherally Nociceptionb. Peripherally Neurogenic Nociception
c. Centrally Activated Nociception
d. Autonomice. Affective
Dr Masharawi Y. [email protected]
Aff ih ilP i h lP i h l
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AffectiveSympatheticCentralPeripheralNeurogenic
Peripheralnociceptive
EmotionalItchingBizzar SxP & NIntermittent
EnvironmentalBurningLatencyNerve lineSharp
Non-mechanicalstimulus
SweatingSpontaneousLatencyMech.Relationship
Over-responseColor changesBuilds-upBurningThrough range
PersonalityTemp. changesAllodyniaSharp/acheLocal ache
Work loadTrophic changesHyperalgesiaNasty/nagging
TensionPupils reactionNegativestim./response
Weakness
Financial stressHeart rateCyclicNumbness
Stiffness,
patching,wheezing
HormonalGiving way
11Dr Masharawi Y. [email protected]
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. SOURCES OF THE SYMPTOMS2
)ות הסימפטומים/מקור(Local Vs Non-local source
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Source-cont.
Always consider the followings:
Joint/ Ligaments
NeuralMuscle/Soft tissue
Bone
Vascular
Visceral
Dr Masharawi Y. [email protected]
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Source-cont.
• Non-local sources:
– Projected pain )כאב מוקרן( : nerve irritation (eg.
nerve root/radicular pain, CTS, Thoracic outlet
Synd.)
– Referred pain )כאב מושלך( : segmental
enervation
(muscle, soft tissue, bone, visceral)
Dr Masharawi Y. [email protected]
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Source-cont.
depth, character)detailed area,(Site.1
constancy, type)(Characteristics.2
hour pattern)24aggravating, easing,(Behavior.3
type of onset, progression, previous(History.4treatment(
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CONTRIBUTING FACTORS.3
)גורמים תורמים(
Physical
BiomechanicalEnvironmental
Psychological
Cultural influences
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PRECAUTIONS AND CONTRAINDICATIONS.4
a. Precautionary questions
b. Severity/irritability
c. Progression
d. Stability of the disorder
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Prognosis.5
Mechanical/inflammatory balance
Irritability
24 hour pattern
Degree of traumaPatient’s expectations
lifestyle
Personal profileHealing potential
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Management.6
Remember!!!
- Asking open questions
- Do not assume things
- Do not become locked into rigidthinking
Dr Masharawi Y. [email protected]
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- THE INTERVIEWןויאירה
(Subjective examination)
1. Main complain (C/O)
2. Body Chart
3. Behavior of Symptoms (Sx)4. History and Past-history (Hx & PHx)
Dr Masharawi Y. [email protected]
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SEQUENCE OF THE INTERVIEW
יתרונות הריאיון המובנה
- Speed of questioning
- Concentrate on the implication
- Ensures that all relevant areas are covered
- Encourages logical progressive thinkingDr Masharawi Y. [email protected]
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SEQUENCE OF THE INTERVIEW
(cont.)
חסרונות הריאיון המובנה
- No interpretation of information received
- Less personal communication with each
patient
Dr Masharawi Y. [email protected]
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MAIN COMPLAIN
• Establish the patient’s main problem by
asking an open question like:
” What is your main problem at this stage?”
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BODY-CHART
Site (area and depth) of all symptoms
Type of symptoms
Constant or intermittent (Cte. or Int.)
Relationship between symptoms
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B d h t ( t )
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Body-chart (cont.)
a) Questions common to all patients
-General health (GH):-medical condition, recent surgery (OP), Tablets (Tab.)
Recent weight loss (WL)how much? reason e.g. dieting
- Special investigations
X-rays, blood tests (?patient knows the result, look at later)
Dr Masharawi Y. [email protected]
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Body-chart (cont.)
b) Questions specific to area of symptoms:
Upper quarter Vs. Lower quarter
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Body chart (cont.) -Special questions
A. Upper quarter:iplopia,Disarthria,Disphagia,Dizziness,Ds:’D5
attacks.-ropD
B. Lower quarter:
Cauda-equina, incontinence
C. Both:
Cord signsDr Masharawi Y. [email protected]
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Stop!!!
look at the recorded symptoms and
convert them into the initial hypotheses (all six categories)
Dr Masharawi Y. [email protected]
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Interview (cont.)
Proceed to behavior of symptoms or history
How to choose?Chronic → Behavior
Acute → History
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Behavior of symptoms (Sx)
What do we want to know?
a) mechanical/non-mechanical
b) inflammatory component
c) behavior (activities/postures)
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c) Behavior (activities/postures) help to…
- incriminate certain sources
- confirm relationship of Sx.
- identify contributing factors
- severity
- irritability
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Behavior of Sx (cont.)
Severity of Sx/disorder:
- On a scale of 1 (mini.) to 10 (maxi.)
- Functional limitation
- Constancy of Sx.
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Behavior of Sx (cont.)
elements):3Irritability of Sx/disorder (
1. Determining the painful activity (repetitive orisolated movement)
2. How painful it becomes (i.e. severity)
3. The length of time the increased Sx takes to recover
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Behavior of Sx (cont.)
How best to obtain this information?
What aggravates the symptom1.
2. What eases the symptoms
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Behavior of Sx (cont )
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Behavior of Sx (cont.)
hour pattern24
Symptoms during the day
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History: present and past
From the History, we should know:
-The status of the disorder !!!
-Whether the disorder is mechanically stable !!!
-The likely prognosis !!!
Dr Masharawi Y. [email protected]
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Present history
Of local and referred symptoms:
When did it start?
How did it start?
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History
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History (cont.)
SpontaneousTrauma
What was noticed first?What happened? What wasnoticed first?(pain/stiffness/etc)
predisposing factorsExtent of damage,
Activity - unusual/heavySustained posturesUnwell/virus Overtired,others
Degree of immediate pain,swelling
Treatment and its effectPredisposing factorsTreatment and its effect
Progress sinceProgress since
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P t hi t (PH )
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Past-history (PHx)
“When did you first have any trouble with your”.....”?”
Details of first episode
“Between then and now, how many times have you had
trouble?”
“How long has each bout lasted? Do they require
treatment?”
“Are the bouts regular/irregular? what causes them?”
Dr Masharawi Y. [email protected]
Past history (PHx) (cont )
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Past-history (PHx) (cont.)
“Are they getting worse, same or better? (in frequency,
severity, duration, area of symptoms)
“How does this bout compare with the first one?”
“How does this bout compare with the last one?”
“What has been the effect of previous management?”
Dr Masharawi Y. [email protected]
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Remember !!!
- Asking open questions
- Do not assume things
- Do not become locked into rigid thinking
Dr Masharawi Y. [email protected]
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Dr Masharawi Y. [email protected]
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PHYSICAL EXAMINATION (P/E)
Dr Yousssf Masharawi
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Clinical reasoning of the P/E
as an extension of the S/E
- Clues to P/E structures, extent and precautionsrequired will arise throughout S/E
- What structures/systems must be examined?
- How much P/E is indicated (precautions, time)?- Is a neurological examination indicated?
- What special tests (e.g. VBI, instability) areindicated?
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Must examine all potential sources
(structures) and contributing factors:
Structures (e.g. joints , muscles, soft tissues, nerves)the area of symptomswhich underlie
to the area of symptomswhich can referStructures
Structures contributing to symptom production
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How much physical examination is indicated on
day 1?
Divide patient’s into two broad categories:
1. Limited examination
2. Full examination
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Limited examination
- Caution with production of Sx
- Limited procedure
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Limited examination (Cont.)
Decision based on:
- Severity of the disorder
- Irritability of the disorder
- Whether disorder is progressive
- Rate of progression
- Stability of the disorder
- Known pathology (e.g. RA, Osteoporosis)
- Indicators of more sinister pathology
(e.g. GH, WL, Cord, VBI)
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Limited examination (Cont.)
Examination without aggravation of
symptoms makes it possible to treat the
disorder effectively at the firstconsultation
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Full examination
Full extent of examination without risk of aggravationof symptoms if the disorder is non-irritable, not
severe, and the nature, history and progression of
the disorder do not indicate the need for caution.
P/E (C )
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P/E (Cont.)
What P/E findings implicate
a structure’s potential involvement?
Abnormal appearance (asymmetry, swelling,wasting, discoloration etc.)
2. Abnormal movement (range, active, quality,passive quality, resistive quality)
/
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P/E (Cont.)
The potential involvement of a structure is
strengthened if:
- Altering the abnormality affects the patient’ssymptoms
- Directly or indirectly stressing a structure reproducesthe patient’s symptoms or symptoms that aredifferent than “normal”.
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TESTS FOR DIFFERENT STRUCTURES
Tests of intervertebral joints- Physiological movements (singly or
combined)
- Palpation- Passive accessory inter-vertebral
movements (PAIVM’s)
- Passive physiological inter-vertebralmovements (PPIVM’s)
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TESTS FOR DIFFERENT STRUCTURES (CONT.)
Tests of peripheral joints- physiological movements (singly or
combined)
- Palpation
- Accessory movements from differentpositions
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TESTS FOR DIFFERENT STRUCTURES (CONT.)
Tests for musclesSource
-palpation
-contraction
-passive stretch
Contributing factors
-length
-functional and isolated performance(strength, endurance, power,
etc.)
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TESTS FOR DIFFERENT STRUCTURES (CONT.)
Tests for vascular involvement
- VBI protocol
- Arterial pulses
- Thoracic outlet tests
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TESTS FOR DIFFERENT STRUCTURES (CONT.)
”nervous system involvement“Tests for
- Passive neck flexion (PNF)
- Slump
- Straight leg raise (SLR)
- Prone knee bend
- Upper limb tension tests (ULTT’s)
- Combined tests and variations- Nerve palpation
- Neurological function (CNS, nerve root,peripheral, autonomic)
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INDICATIONS FOR NEUROLOGICAL EXAMINTATION
- Symptoms which are neural in character
- Symptoms in the limb
- History of trauma
- Worsening conditioning
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what are we looking for ? –Posture
Asymmetry’s
Altered positions/angles
Under/over development etc.
Dynamic versus static
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where and how should we look ? –Posture
- Note when patient unaware
- Note in patient’s relaxed posture
- Note from different views
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Posture - How can we assess the significance ?
Alter the posture and note ease of correction
and effect on symptoms
(clue to source but doesn’t rule as contributing factor)
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Posture - associated factors
Altered muscle length
Altered muscle performance
Altered joint, neural and soft tissue mobility
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Assessing functional aggravating factor
- Posture or movement
- Provides useful initial clue to
structure(s)/components involved
- Provides meaningful reassessment for patient
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FUNCTIONAL DIFFERENTIATION
ST RU CT UR A L R EGI ON A L
nerves Joint
joint (intra/extraarticular)
movement
muscle
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Physiological and Accessory Movements
to simply note gross range andInsufficient
production of symptoms !
and itsquality of movementMust assess
relationship to behavior of symptoms
through range
i h i l i l
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Active Physiological Movements
- Clear patient instructions
- Observe quality of movement and notebehavior of symptoms
- Continually re-establish status of symptoms
- Often requires different views of focus- Correct asymmetry’s to assess effect
- Overpressure to establish end feel and effect onsymptoms (local and refereed)
- Normal Mvt.=√√ (Full range , no pain withoverpressure)
i h i l i l
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Active Physiological Movements(cont.)
If local/referred symptoms not reproduced (and notirritable)-refine tests:
-repeated movements
-sustained movements
-movements under loads
-movements at different speeds
-movements under compression
-combined movements
-pre-sensitize the area
Passive Peripheral Physiological and Accessory
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Passive Peripheral Physiological and Accessory
Movements
Clear patients instructions
Effective control of movement (eg. hand holds,
thumb, pressure, body mechanics,etc.)
Establish relationship between quality of movementand behavior of symptoms(i.e. Movement
Diagram)
PPIVVM’s & PAIVM’s
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PPIVVM’s & PAIVM’s
Passive Physiological Inter-vertebral
Movements (PPIVM’s)
Passive Accessory Inter-vertebral Movements
(PAIVM’s)
Grades of Passive Movements:
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Grades of Passive Movements:
accessory and physiological
Grade I: small amplitude, no resistance
Grade II: large amplitude, no resistance
Grade III: large amplitude, into 50% of resistance (R.)
G. III+: into 75% of R.
G. III++: into 100% of R.
Grade IV: small amplitude, into 50% of R.
G. IV+: into 75% of R.
G. IV++: into 100% of R.
Grade V: Manipulation.
high velocity, slow amplitude at end of range
Palpation
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Palpation
- Patient communication
- Bony position (eg. position of one
vertebrae relative to adjacent, patellar
position)
- Soft tissue changes (thickening old/new
spasm)
- Effect on symptoms
- Care with interpretation
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Dr.Youssef Masharawi (PhD, BPT)72
אסטרטגיות לבחירת הטיפול הפיסיותרפי
כווני הגבלות תנועה•
סוגי ניתוחים ספציפיים•
סוגי פתולוגיות המערכת התנועה•
כרוניים / מצבים אקוטיים•
טווח ארוך / טווח קצר•
הרגלי חיים•
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Dr.Youssef Masharawi (PhD, BPT)73
Relevant patterns in understanding a patient’s
problem (s) can be categorized as follows:
. mechanisms of the symptoms1.
2. Sources of symptoms (Sx).3. Contributing factors.
4. Precautions and contraindications.
5. Prognosis.6. Management.
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Dr.Youssef Masharawi (PhD, BPT)74
Sources of Symptoms
• Local sources
• Non-local sources:
– Projected pain: nerve irritation (eg. nerve root,
CTS, Thoracic outlet Synd.)
– Referred pain: segmental enervation
(muscle, soft tissue, bone, visceral
Must treat all sources/structures and
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Dr.Youssef Masharawi (PhD, BPT)75
Must treat all sources/structures and
contributing factors:
Structures (e.g. joints , muscles, soft tissues, nerves)
the area of symptomswhich underlie
to the area of symptomswhich can referStructures
Structures contributing to symptom production
The potential involvement of a structure
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The potential involvement of a structure
is strengthened if:
- Altering the abnormality affects the patient’ssymptoms
- Directly or indirectly stressing a structurereproduces the patient’s symptoms or
symptoms that are different than “normal”.
PRINCIPLES OF TREATMENT
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Dr.Youssef Masharawi (PhD, BPT)77
BY PASSIVE MOVEMENT
Types of passive movement which can be used in
treatment:
- Physiological within range- Physiological at end of range
- Accessory within range
- Accessory at end of range
Factors determining the choice of
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Dr.Youssef Masharawi (PhD, BPT)78
Factors determining the choice of
technique and method of application
• Pathology
• Kind of disorder
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Dr.Youssef Masharawi (PhD, BPT)79
1. Pathology
Specific diagnosis can:
- limit the strength of the technique
e.g. Rheumatoid Arthritis
- Guide the choice of technique
e.g. locked P.I.V. or knee joint
Often it is not possible to make a specificdiagnosis
1. Pathology (cont.)
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Dr.Youssef Masharawi (PhD, BPT)80
gy ( )
A Particular “diagnostic title” can present
different patterns of Signs and SymptomsExamples:
- L4/5 discogenic pathology
- Sprained medial collateral ligament of theknee
- O.A. of the hip
In these cases, the choice and method of applying passive movement is based on thepresenting symptoms and signs
2. Kind of disorder
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Dr.Youssef Masharawi (PhD, BPT)81
Patients present with a disorder that is:
only symptom, no underlying stiffnessPain:-
: pain = dominantPain and Stiffness-
only, no pain or other symptomStiffness:-
stiffness = dominantStiffness and Pain:-
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Dr.Youssef Masharawi (PhD, BPT)82
Treatment of PAIN only
Example:
Patient with constant deep ache within the
shoulder, movement grossly limited by pain
f l d d
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83
Painful disorder: Day 1
Small amplitude of movement, rhythmical, slow,
no discomfort,
Dosage (time, amount of movement) depends
on irritability, ease/difficulty of finding a
painfree, position and ability to perform
movement short of pain
i f l di d i
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Painful disorder: Progression
- Treat daily, or alternate days
- Increase amplitude of movement (still short
of discomfort) I→II-→II
- Perform technique into slight discomfort
II→III-→III
- Increase speed of movement / alter rhythm
from smooth to staccato (joint no longer in
neutral)
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