Clinical reasoning intro: upper limb
Introductory lecture upper limb
dr. Valentien Spanhove
Purpose of this presentation
Interaction by the use of Wooclap!
Purpose of this presentation
1. Introduction course clinical reasoning upper limb
2. Looking beyond the shoulder
3. Oral examination
Purpose of this presentation
1. Introduction course clinical reasoning upper limb
2. Looking beyond the shoulder
3. Oral examination
Introduction
2nd BACH 3nd BACH 1st MASTER
• Kinesitherapeutisch handelen: Revalidatie en kinesitherapie van Clinical Reasoning in
bovenste en onderste lidmaat het musculoskeletale stelsel: Rehabilitation and Physiotherapy:
• Kinesitherapeutisch bovenste lidmaat upper limb
onderzoek: bovenste lidmaat
Introduction
2nd BACH 3nd BACH 1st MASTER
• Kinesitherapeutisch handelen: Revalidatie en kinesitherapie van Clinical Reasoning in
bovenste en onderste lidmaat het musculoskeletale stelsel: Rehabilitation and Physiotherapy:
• Kinesitherapeutisch bovenste lidmaat upper limb
onderzoek: bovenste lidmaat
Introduction final competences
• 1 The student is able to formulate relevant treatment goals, based on relevant information from history taking and clinical
examination within all major physiotherapy areas.
• 2 The student is able to design an adequate rehabilitation program, based on the treatment goals
• 3 The student is able to adequately select the treatment techniques and is able to adapt the treatment strategy to patient progression
• 4 The student (within a group) is able to search for scientific literature in a systematic way (related to the pathology and the treatment
of the patient case), and is able to critically evaluate these articles, to summarize the information and to integrate it in the treatment of
the patient
• 5 The student is able to communicate with colleagues with respect to issues relevant for the patient case within
a multidisciplinary context
• 6 The student listens to the vision and expertise of the other and also accepts the relativity of his / her own vision and ideas.
• 7 The student deals constructively with the difficulties and negative feelings that can accompany intercultural encounters.
• 8 The student understands longer speeches and lectures, spoken in English and related to the field of study, and can present the
main thoughts of them.
• 9 The student can apply the formal procedure of screening and intake after registration in accordance with the guidelines / advice of
the KNGF (= Federal Council for physiotherapy on direct access to physiotherapy / physiotherapy (DTF / DTK)
Introduction final competences
• 1 The student is able to formulate relevant treatment goals, based on relevant information from history taking and clinical
examination within all major physiotherapy areas.
• 2 The student is able to design an adequate rehabilitation program, based on the treatment goals
• 3 The student is able to adequately select the treatment techniques and is able to adapt the treatment strategy to patient progression
• 4 The student (within a group) is able to search for scientific literature in a systematic way (related to the pathology and the treatment
of the patient case), and is able to critically evaluate these articles, to summarize the information and to integrate it in the treatment of
the patient
• 5 The student is able to communicate with colleagues with respect to issues relevant for the patient case within
a multidisciplinary context
• 6 The student listens to the vision and expertise of the other and also accepts the relativity of his / her own vision and ideas.
• 7 The student deals constructively with the difficulties and negative feelings that can accompany intercultural encounters.
• 8 The student understands longer speeches and lectures, spoken in English and related to the field of study, and can present the
main thoughts of them.
• 9 The student can apply the formal procedure of screening and intake after registration in accordance with the guidelines / advice of
the KNGF (= Federal Council for physiotherapy on direct access to physiotherapy / physiotherapy (DTF / DTK)
Introduction overview
Prof. Dr. A. Maenhout Introduction+ EBP assignment Lecture
F. Lanszweert Direct Access Lecture
Prof. Dr. T. Matheve Clinical Reasoning MSS Lecture
Dr. V. Spanhove Upper limb Theory Lecture
Dr. D. Borms – K. Berckmans Upper limb Case Practicum
Prof. Dr. Cools Upper limb Response (recording) Lecture
Dr. A. Van Bladel Neurology Theory Lecture
J. De Waele – W. De Wilde Neurology Case Practicum
Dr. A. Van Bladel Neurology Response Lecture
Prof. Dr. L. Bar-On Pediatrics Theory Lecture
N. Vens – B. De Mey – N. De Bruyn Pediatrics Case Practicum
Prof. Dr. L. Bar-On Pediatrics Response Lecture
Introduction
• Focus = clinical reasoning process!
• Upper limb cases: disorders of the
shoulder
Introduction learning path
• Ufora: Clinical Reasoning in Rehabilitation and Physiotherapy < 1. Upper Limb
Introduction
• Learning path: 4 cases
o Case 1: shoulder instability
o Case 2: postoperative rehab after RC repair
o Case 3: biceps pathology
o Case 4: rotator cuff tendinopathy
Introduction
• Learning path: 4 cases
o Case 1: shoulder instability
o Case 2: postoperative rehabilitation after RC repair
o Case 3: biceps pathology
o Case 4: rotator cuff tendinopathy
Learning path + practical course
Introduction
Please bring your answers to the
• Learning path: 4 cases questions on the learning path, as
these will be discussed in the practical
o Case 1: shoulder instability course!!
⇾ practical course 1
o Case 2: postoperative rehabilitation after RC repair
⇾ practical course 2
Learning path + practical course
→ overview tasks clinical reasoning
Introduction
• Learning path: 4 cases
o Case 1: shoulder instability
o Case 2: postoperative rehabilitation after RC repair
o Case 3: biceps pathology
o Case 4: rotator cuff tendinopathy
Learning path (self study)
Introduction
• Learning path: 4 cases
o Case 1: shoulder instability
o Case 2: postoperative rehabilitation after RC repair
o Case 3: biceps pathology
o Case 4: rotator cuff tendinopathy
Questions? Ask them in the practical courses or mail to
[Link]@[Link] before 15/3 17h.
Introduction
• Each learning path contains submodules You can only go through the entire
module if you have fully covered all
o 1. Introduction items in the previous module!
o 2. Anamnesis
o 3. Inspection
o 4. Clinical examination
o 5. Physiotherapeutic diagnosis
o 6. Goal setting and therapy
Introduction
Introduction EBP assignment
D-GROUPS: UPPER LIMB REHABILITATION
Persistent shoulder pain is prevalent and commonly related to substantial disability. Furthermore, the response to
physiotherapy is variable. While some shoulder pain patients completely recover or improve, a minority of patients report
no change or even a worsening of symptoms after physiotherapy. In this view, not only biomedical but also psychosocial
aspects need to be considered. Several influential factors have been identified that affect a patient’s outcome. Some factors,
such as a high self-efficacy, can be associated with a better outcome, while other factors, including high baseline pain levels
or low expectations of physiotherapy, increase the risk of persistent pain and disability. These psychosocial factors may also
influence exercise adherence and other health behaviors such as physical activity. Therefore, knowledge about these factors
seems crucial in order to improve patient outcomes.
In this assignment, we would like you to:
1) Look into the scientific literature to search for the influence of psychosocial and other patient related factors that could
(positively or negatively) influence therapy outcome in patients with MSS shoulder pain
2) Conduct field research on the perceptions and attitudes of a) physiotherapists b) MSS shoulder pain patients regarding
the effect of psychosocial and patient-related factors on shoulder rehabilitation outcome.
3) Create an infographic summarizing the most relevant aspects of 1) & 2)
Questions?
Purpose of this presentation
1. Introduction course clinical reasoning upper limb
2. Looking beyond the shoulder
3. Oral examination
Looking beyond the shoulder
Evidence-based Patient-based
Integrate research findings Pay attention to the beliefs,
in your clinical practice expectations and individual needs of
your patient.
Tissue irritability
Take into account tissue fragility! What is the
stage of irritability (STAR-shoulder)?
Looking beyond the shoulder
• Response to physiotherapy is variable in patients with shoulder pain
• Biological, biomechanical, and psychosocial factors
Looking beyond the shoulder
• Response to physiotherapy is variable in patients with shoulder pain
• Biological, biomechanical, and psychosocial factors
o Negative pain beliefs: potential barriers to achieve results
o Positive pain beliefs: facilitate adherence, better outcomes
Looking beyond the shoulder
Jim was referred to the physiotherapist with the diagnosis of ‘shoulder
instability’, confirmed by clinical examination. He visited the
physiotherapist 1x/week and was asked to perform some home exercises
3x/week. The physiotherapist searched in scientific literature for the latest
evidence regarding exercise therapy for shoulder instability and integrated
these exercises into his treatment plan. Despite the evidence-based
approach, Jim did not get better.
Looking beyond the shoulder
Kinesiophobia
• Pain-related fear of movement
• Hypervigilance or avoidance behaviour
• Higher levels of kinesiophobia → more shoulder pain and disability, poor quality
of life (Luque-Suarez et al. 2018)
• Tampa Scale for Kinesiophobia ??
Looking beyond the shoulder
Pain catastrophizing
• Irrational and negative predictions about pain/future events
• Higher levels of pain catastrophizing → higher shoulder pain and disability,
increasing risk of chronic shoulder pain (Javier Martinez-Calderon et al. 2018, Hirata et al. 2021)
Looking beyond the shoulder
Self-efficacy
• An individual’s own beliefs about the ability to perform activities, even in the
presence of difficulties
• Pain self-efficacy: performing activities and tasks despite pain
• Higher levels of self-efficacy → lower levels of shoulder pain/disability and better
physical functioning (Martinez-Calderon et al. 2018)
Looking beyond the shoulder
Patient expectations
• The belief that a specific outcome will occur
• E.g.: completely recover, much improve, slightly improve, no change, worse
• Higher levels of expectations of recovery → lower levels of shoulder pain and
disability (Martinez-Calderon et al. 2018)
• Reinforcement of positive patient expectation by clinicians
Looking beyond the shoulder
Jim was referred to the physiotherapist with the diagnosis of ‘shoulder instability’, confirmed on clinical examination.
He visited the physiotherapist 1x/week and was asked to perform some home exercises 3x/week. The physiotherapist
searched in scientific literature for the latest evidence regarding exercise therapy for shoulder instability and
integrated these exercises into his treatment plan. Despite the evidence-based approach, Jim did not get better.
The physiotherapist wondered why and started to ask Jim some specific questions. In his answers, Jim mentions that
he is very afraid of moving his shoulder, since he is afraid that the shoulder will dislocate again due to exercise therapy.
Because he is afraid, he never performed the home exercises that were prescribed, as he believed that he would not be
able to perform them due to his shoulder pain and he thought that exercising would only make it worse.
Looking beyond the shoulder
The physiotherapist wondered why and started to ask Jim some specific questions. In his answers, Jim mentions that
he is very afraid of moving his shoulder, since he is afraid that the shoulder will dislocate again due to exercise therapy.
Because he is afraid, he never performed the home exercises that were prescribed, as he believed that he would not be
able to perform them due to his shoulder pain and he thought that exercising would only make it worse.
Looking beyond the shoulder
The physiotherapist wondered why and started to ask Jim some specific questions. In his answers, Jim mentions that
he is very afraid of moving his shoulder, since he is afraid that the shoulder will dislocate again due to exercise therapy.
Because he is afraid, he never performed the home exercises that were prescribed, as he believed that he would not be
able to perform them due to his shoulder pain and he thought that exercising would only make it worse.
Which pain beliefs can you identify in this case?
Looking beyond the shoulder
• Psychosocial factors are important outcome predictors
• They should be formally assessed in all patients with MSS pain
o Anamnesis
o Likert scale, PSEQ…
Looking beyond the shoulder
Evidence-based Patient-based
Integrate research findings Pay attention to the beliefs,
in your clinical practice expectations and individual needs of
your patient.
Tissue irritability
Take into account tissue fragility! What is the
stage of irritability (STAR-shoulder)?
Looking beyond the shoulder
Looking beyond the shoulder
Looking beyond the shoulder
Looking beyond the shoulder
Jim was referred to the physiotherapist with the diagnosis of ‘shoulder instability’, confirmed on clinical examination.
He visited the physiotherapist 1x/week and was asked to perform some home exercises 3x/week. The physiotherapist
searched in scientific literature for the latest evidence regarding exercise therapy for shoulder instability and
integrated these exercises into his treatment plan. Despite the evidence-based approach, Jim did not get better.
The physiotherapist wondered why and started to ask Jim some specific questions. In his answers, Jim mentions that
he has a lot of shoulder pain (VAS 7/10) that doesn’t decrease overnight or in rest. He experiences a high amount of
disability and can’t perform all shoulder movements.
Looking beyond the shoulder
The physiotherapist wondered why and started to ask Jim some specific questions. In his answers, Jim mentions that
he has a lot of shoulder pain (VAS 7/10) that doesn’t decreases at night or in rest. He experiences a high amount of
disability and can’t perform all shoulder movements.
Questions?
Purpose of this presentation
1. Introduction course clinical reasoning upper limb
2. Looking beyond the shoulder
3. Oral examination
Oral examination
• Oral exam with written presentation
• Draw a lot → 1/6 domains
• Focus of this examination = clinical reasoning process!
• Upper limb: disorders of the shoulder (conservative + post-operative)
• Comorbidities in the upper limb kinetic chain?
Oral examination
Questions?
Enjoy the (practical) course!