Ah, day 3 of 3 of the Combined Sections Meeting of the APTA 2014 in Las Vegas.  The last morning to get up for an 8am class and sit through a 3-5pm session…I’m kidding…the courses are all great!

For me, today was spent in two courses, a mid-day workout (much needed!) and an awesome time on the exhibition floor.  Hope you enjoy the post.

The morning session was entitled, “Clinical Reasoning as a Learning Trajectory: Intentional Integration from Entry-Level to Residency Education”.  The following are the presenters:

Nicole Christensen, PT, PhD, MAppsSc
Lisa Black, PT, DPT
Daniel Dore, PT, DPT, MPA
Jan Gwyer, PT, PhD
Gail Jensen, PT, PhD, FAPTA

So basically this course was presented to aid in clinicians / educators to provide clinical reasoning as the focal point in internships/residencies/fellowships and even entry-level academics.  Any clinician out there can tell you—>clinical reasoning is hard to define! The speakers brought this up today too, so we all know if a phrase/term is hard to define, then it is hard to deliver.  It is difficult to define in simple words, but images / models help.

Dr. Gail Jensen, a renowned researcher and PT, spoke initially on “Clinical Reasoning: A Bridge Concept”.  The following are some highlights.  Without a powerpoint to go by, hopefully you can pull out a few phrases to assist you in bringing clinical reasoning to yourself, or even your students.  I am NOT  subject matter in this, even though I truly believe in clinical reasoning, so sorry in advance for not distributing this information in the context that it SHOULD be:

-Use frameworks to enhance ways of “seeing” clinical reasoning in order to more effectively & intentionally facilitate development throughout professional education at all levels.

-Making a connection between thinking and decision making

-You want to get engaged learners. Thinking will take care of itself.

-Get away from dichotomies: we need to bring our worlds together.

-If you don’t have a learner engaged, you can forget about learning.

-Critical thinking is insufficient: How do you understand context

-Theory is our friend.

-Theories of expertise: Context/Practice–>most important

–Thinking, Reasoning, Practice Knowledge, Skills, Interactions, Person/actions

-When students memorize, they hit a wall. Experts have ways to organize knowledge and scaffold information. We need to help students build their structure.

Critical self-reflection is a key piece. Need a metacognitive approach: reflect back on action and within your action. You learn from reflection on experience, just not experience itself. It is not 1 year x 10.

Bring context and connection earlier in formal education

META-COGNITION: Ability to monitor your own problem solving.
If you go down routine path, you do not engage your learning and facilitate lifelong learning.

Experts do the following:
Metacognitive strategies, self-monitor own level of understanding, recognize their limits of knowledge and take steps to remedy

You need to be concerned with learners who are OVER confident. They miss listening.

What are ways to help facilitate thinking skills?
Clinical reasoning is a phenomenon. It is hard to study and not just what is in the clinician’s head. Clinical reasoning needs to be patient-centered.

Residencies should be more than technique centered, but reflection centered.

CR as the context vs a separate “part” of the curriculum. It needs to always fit in our thought process. It can’t be taught in a simplistic way.
How can we facilitate thinking on our feet in clinical practice? Experts do this, but we need novices to.

Learning how to actively learn from experiences is key!

Learners who are FOCUSED on improving their learning skills. Recognize your WEAKNESSES is a key to clinical reasoning.

Intermediate conceptual reasoning: should be able to know what they should have done differently as this shows ability to reflect on action.
Entry-level conceptual reasoning: They can modify through accordingly, struggles include having expectations but KNOWING when it does not go right. You can modify your hypothesis.
Residency education: Proficient–reflect prior to action, not a routine expectation (moving beyond this), able to modify, and reasoning is a fluid, efficient, seamless process (demonstrates “reflection in action”)

No evidence of learning = no evidence of teaching

Conceptual knowledge: interrelationships among the basic elements within a larger structure that insures they function together (knowledge of classifications and categories; principles and generalizations, knowledge of theories, models and structures).

We don’t do a good job at conceptual knowledge, but we are good at factual knowledge. Can you use a concept and pull it down to make an application?
We are good at procedural knowledge, but not at metacognitive knowledge (this takes a lot of self-knowledge, strategic knowledge)

Mindful presence and avoid premature judgment. Skills go beyond psychomotor, but you need active listening and observing.

Dr. Daniel Dore from Duke spoke passionately and personally (paraphrased):
It is a lifelong journey to always reflect on what you do each day, challenge ourselves to do better, and what we could have done differently to help that patients. Assumptions may have flaws in them, but wisdom and compassion. Easy to say, very difficult to achieve. Some students may not “need” residency or fellowship, but thought it would make them a better person.

Clinical Reasoning 360
We know we can do this medically, but should we? This type of reflection & thinking is important.

Always ask, “What could I have done differently”

Allow the learner to teach.

Make a clinical reasoning learning diagnosis

The following 4 questions should be asked to your students and even to yourself to question your clinical reasoning.  THIS is what I’ll take back to work next week to help my current intern.

Sample Framework to include Clinical Reasoning

1. What conclusions have you come to? (content reflection).
We are already good at this.
2. How did you come to these conclusions? (process reflection).
This is usually left off. Ask how did you get there? Students may not have gotten ‘there’ in a systematic way. You should understand the patient’s perspective and
3. Did you make any assumptions that influenced/guided your thinking or actions? (premise reflection)
Pattern recognition can be found here. It is not all that bad, but you need to compare to competing hypothesis. Avoid confirmation bias though! What are your assumptions about this “type” of patient? Are you jumping to conclusions or do you have valid evidence?
4. What have you learned from this experience?
A higher level thinking student will be able to perform this. They should identify errors and strengths, while understanding their thinking level.

The afternoon session was entitled, “Evaluation and Treatment of the Injured Runner: A Movement System Approach”

The speakers were:

Ryan DeGeeter, PT, DPT, CSCS
Judy Gelber, PT, DPT, OCS, CSCS
Gregory Holztman, DPT

Basically this group of intelligent and obviously successful PTs described how they approach running injuries through a movement approach.  What I wanted to get from this session is how to they assess, if any differently, than myself. I will bullet highlights:

Running is the perfect example of an activity in which movement patterns can be highly variable. We need to look at optimizing movement patterns to decrease physical stress, pain and time off from running.

We need to look at Cause vs Source. Source can be treated quite easily (modalities, manual therapy, etc), but you have to look beyond the Source and examine the Cause (mechanical factors and altered movement patterns).

Functional education: A high emphasis as prolonged postures and repeated movements throughout the day influence movement strategies (including running). This is a KEY concept in a Movement Systems Approach to injured runners. Continued use of faulty movement strategies contributes to changes in movement system elements (muscle strength/length, recruitment, etc).

Running is associated with high levels of physical stress.

Key tests of Movement Quality:
1. Single Leg Stance: Snapshot of mid-stance
2. Partial squat: Check for pain, quality of movement and then you can correct immediately. Progress to single leg and even hopping too.
3. Step Down–anterior–(if tolerable) and can be THE key test test to see loading response in single leg.
4. Heel Raise: What goes on at push-off

Can also look at standing lumbar movements, sitting knee extension, prone knee flexion, prone hip extension with knee extension. Then, hip flexor length, ITB (Ober), Hamstrings (90/90), Ankle DF, Toe Ext, Hip IR/ER. Then, MMT of applicable groups based on your assessment. Then, get the patient on TM.  

The key tests of movement quality are very important and to me, are the highlights of breaking down running into a few movement patterns.  Yes, it is applicable to look at every muscle group and joint ROM, but for a more detailed and functional assessment, you should perform the 4 above.

The speakers then went on to describe atypical patterns that are usually seen. These include:
Hip Adduction / Femoral Rotation
Hamstring Dominance
Tibiofemoral Rotation
Decreased knee flexion during landing
Excessive Rearfoot Landing
Excessive Forefoot Landing
Excessive Pronation
Excessive Supination
Lumbar Rotation

Per respect of the speakers and not giving away the slides, I am not going to go through each one of these, but I will give you a screen shot of what the instructors would do with a common complaint you are will want to know: Excessive Pronation



Okay, my wife and I had an awesome time in the exhibition hall today and hope you enjoy the following pictures!

Vibration therapy: Actually felt quite good! More noise into the system though? Either way, it is called “targeted high speed vibration therapy” by Rapid Release Technology
http://www.drcoolrecovery.com This is a great concept and honestly surprised it has not been developed until now! Basically compression (which we know is best for swelling) combined with ice that can be applied easily. Would work best for ATCs IMO out on the field. May just have to get one for myself in the clinic too (especially for ankles).
Dr. Michael Wong and team at http://www.clinicalpatternrecognition.com gave me a thorough introduction to their Clinical Pattern Recognition App. I will check this out more on my own but through his description, it is quite useful! Especially, for students and other therapists who are trying to have a smoother assessment to treatment approach. May be a good app for review at MedicalAppJournal.com
Art was a great guy and has a very functional product here, at AbleTripod.com For a patient, or a therapist to recommend, you attach the bottom piece (the tripod) to a standard cane instead of a patient having to buy a new cane with broader support. Only $15-20.
I met Dr. Duvall this weekend and what a gentleman! I have to give he and Chris, and others @NxtGenInstitute a shout-out as I won the Boiance float. I’m sure more blog posts on this device will come. http://www.nxtgeninstitute.com/home.html
Remember the Acuball on Dr. Oz that brought publicity, however good or bad, to us several months back? If not, here is the youtube page: http://www.youtube.com/watch?v=Wi-6B81dTH0
Surprised this vendor was here, but the acuball was warm.
My wife and I trying out the Acuball…I look quite uncomfortable here!
To start, I do have to disclose that I write for MedBridge (on my blog) but in all reality, this doesn’t matter! This is a great online education tool and could not have been in touch in the past with as good of a team as I met personally this weekend. The picture is a bit dark, but its me, Andrew to the left, and Natalie to the right.
I’ll leave our other fun pictures to my personal library, but my wife and I enjoyed crepe’s while we were supposed to be in a class one day 🙂 Can’t get these anywhere, and they were delicious!

I wish I could have had pictures with all the vendors from this weekend and honestly, the ones I took pictures with above (besides MedBridge and NxtGenInstitute), I stumbled across.  That is the beauty of the CSM if you weren’t able to make it…you will see products and devices that keep you involved in the larger scheme of things.  It is relaxing to walk through the exhibition hall and see others at work!

It has been a pleasure to write for the APTA on In Touch PT Blog for this week’s events.  I appreciate all the re-tweets and favorites through my handle @intouchpt , but also those who read this blog. As with any activity, getting more experience in writing for 6 hours of courses and 4 other hours of events takes practice!  It is tough to put together quick blurps of the vast amount of courses.  Be sure to check back on #CSM2014 and #CSMTwitterPanel for more information in 140 characters or less.

Signing off.  Now to blackjack table.  I just hope I don’t bet my plane tickets home though.




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