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Clinical reasoning is the thinking process that escorts clinical practice, it is a multifaceted skill. The aim of this report is to use clinical reasoning to comment on a case of medial compartment one-sided knee osteoarthritis. Using clinical reasoning, an outline of management and manual therapy are designed.
Mendez and Neufeld (2003) defined clinical reasoning as a cognitive process aiming to understand the implications of patient data. It also aims to recognize and diagnose present concrete or latent patient problems, to make clinical well-judged choices to help in problem solving, and to result in encouraging patient outcomes.
Factors affecting the outcomes of clinical reasoning can be internal factors linked to health professionals (knowledge, acquaintance with a particular case and their reasoning skills). Patient factors need skills to transfer facts, and explanation of disease condition and treatment alternatives. External factors include health institution potentials, profession-specific structure of treatment, and intricacy of the case (Mendez and Neufeld, 2003).
Edwards and others (2004) suggested the following practices of clinical reasoning for a physiotherapist. Diagnostic reasoning, developing a diagnosis based on disability and its impact considering accompanying pain, pathological changes, and contributing factors to the disease. Descriptive reasoning is to understand the patient's description and experiences about the disease. Procedural reasoning involves treatment decision making, while communication collaborative reasoning involves setting up a patient-therapist relationship and setting goals for treatment based on interpretation of investigations results. Predictive reasoning is foreseeing the treatment results, and ethical reasoning which needs understanding of the ethical questions about the conduct and goals of treatment.
Possible causes and processes of the patient's recent complaint:
Based on the patient's occupation, and history, knee Joint injury herald osteoarthritis in individuals who are in their 30s or 40s, osteoarthritis becomes obvious nearly in every other subject with a previous history of knee injury. A proper interpretation of the existing data infers that at 10 years after suffering an injury to the knee, an average of one third of patients display joint space narrowing on x-ray examination. Twenty years post injury, about half the individuals with history of injury shows similar changes (Roos, 2005).
Arthroscopic procedures may cause postoperative knee pain and swelling enough to delay rehabilitative physiotherapy. This should not persist more than two weeks otherwise the patient will be at risk of complications mainly prolonged knee stiffness. (Reuben and Sklar, 2000).
Many believe that changes in the knee joint in osteoarthritis reproduce the collective effects of mechanical stress rather than senile degeneration alone. Therefore, it is an occupational disease (Radin, 2004). Patient's occupation activities are aggravating factors to develop knee osteoarthritis (Loomis, 2008).
Based on the patient's symptoms and physical examination findings, the patient may have had a cruciate ligament rupture or added meniscal injury. Because of negative ligament tests, tenderness over medial TFJ joint line, no tenderness of patella tendon, quads tendon, hams tendons insertions, MCL attachments or LCL attachments, and data suggesting positive McMurray manoeuvre. Besides the presence of mild effusion, it is most likely the patient suffers a meniscal injury (Dascola, 2005).
Roos (2005) provided a model for the processes responsible for pain and development of osteoarthritis. He assumed the disease needs, being mechanically determined, increased or altered joint load as a precondition to its development. Therefore, joint injury, occupation and aging lead to development and progression of osteoarthritis in one of two possible pathways. First, deconditioning of the musculoskeletal, increased joint loads occur with pain and progression of osteoarthritis. Alternatively, joint instability, misalignment and defective proprioception result joint related changes leading to increased joint loads with pain and disease progression.
The patient's irritability:
At this point, the patient anxiety is because of worsening of pain and movement limitation and worry that he will not be able to continue working or doing everyday activities without significant discomfort. Jinks and others (2007) suggested that a therapist should look at the first onset of joint pain as sign to try preventing future disability.
Reasoned identification of need for caution and need for adjustments:
Three cardinal patient's findings call for caution and adjustment of assessment as they may need change in the plan of manual therapy. These are persistent pain for four months, reduced right knee extension in standing with slight varus deformity. Besides pain limiting knee movement in active and passive flexion and extension with pain and stiffness limiting lateral rotation and stiffness without pain limiting medial rotation. Plain radiography was done following Ottawa knee rules (Jackson and others, 2003) and showed the same findings as the one done two years earlier. The use of MRI in addition provides better prediction of the need for added treatment. Indication of MRI, in this case, is to evaluate pain as it persisted for more than 3-6 weeks (Oel and others 2005). In case MRI is not available, or not covered by insurance, knee ultrasonography can be helpful to assess knee effusion, integrity of tendon and MCL injuries and to rule out minimally displaced patellar cracks (Lin and others, 2000).
Arthroscopy can be diagnostic and therapeutic for meniscal or ligaments injuries, removal of loose pieces of cartilage or bone. Besides intra-articular steroid injection can be given to manage pain, viscous supplementation, and arthroscopic debridement and washout can ease the mechanical symptoms (Gidwani and Fairbank, 2004).
Factors that may be contributing to the patient's presenting problems:
The slowly developing knee swelling is matching with meniscal injury however, the therapist must consider associated mild ligament sprain. The absence of locking is against meniscal injury, but the giving way points to possible ligament injury or patellar sublaxation. The presence of anterior crepitus may point to ligament injury or patellar problems, however, the active and passive limited range of movement suggest an intra-articular problem (Smith, 2004). This calls to consider the possibility of having combined lesions on top of osteoarthritis.
Three more points need communication with the patient, adjusting occupational activities (Loomis, 2008), return to swimming sport practice or perform water exercise being a low knee load exercise (Grainger and Cicuttini, 2004). Also, tell the patient with the potential side effects of NSAID and advice to use topical preparations with safer analgesics as paracetamol (Derbyshire County NHS, 2008).
Developing a working hypothesis:
According to the patient's current situation, expectations, worries and good general health, and knowing the case is most likely to be knee medial compartment osteoarthritis the objectives of manual therapy should be (Technical Committee Physiotherapy Profession, 2003):
- Minimize pain
- Decrease disability and enhance functional ability, muscle strength, joint flexibility.
- Patient education to encourage better work activities, and regain interest in swimming sport.
When to start manual treatment and what is the plane:
Manual therapy portrays the physical therapist applying passive movements aiming to enhance joint motion and minimize stiffness. It includes passive range of movements, and muscle stretching techniques (Fitzgerald and Oatis, 2004).As this particular case needs a multidisciplinary approach that may involve surgery, manual therapy should start once the process of diagnosis and possible surgical interference finish. It may start in conjunction with pain relief physical therapies as thermotherapy, cryotherapy and transcutaneous electrical nerve stimulation. The general rules of static stretching range of motion manual therapy are (Technical Committee Physiotherapy Profession, 2003):
- Twice weekly when pain and stiffness are least in 20-30 minutes sessions (Hoeksma and others, 2005).
- Better to be preceded by warm compresses.
- To be performed slowly and the range of motion extended to the limit of least subjective pain and resistance.
- Advice the patient to breath slowly during passive exercise.
- Hold the terminal stretch for 10-30 seconds.
- Passive exercises are continuously adjusted according to pain and the duration of holding the static position.
Measuring the outcome:
The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) test is a self-report specific measure to assess pain and physical function. Validity of the test was investigated in many studies and showed high levels of consistency and test-retest reliability consistent with clinical practice (Stratford and Kennedy, 2004). The 6-minutes walk test is primarily endurance test originally developed to measure exercise capacity in cardiac and pulmonary patients. Test-retest reliability and responsiveness index (measures improvement after therapy) have been examined and found highly reliable (King and others, 2000). Patients perform these tests at baseline, on the 5th week, and later every 12 weeks of therapy (Hoeksma and others, 2005).
Prognosis and expected improvement rate:
Jinks and others (2007) stated the outcomes of osteoarthritis are poor quality of life, limited daily activities and disability. However, we know little about the primary influence of joint pain on disability in the older population; also we know little about if such influence is reversible if the pain improves. According to their results, Jinks and others (2007) inferred that decreased physical functions among knee osteoarthritis patients with pain shows how important this symptom is as a possible launching cause to decline of physical activities. Even those whose pain improves are occasionally able to regain their experienced levels of physical activities.
The Ottawa Panel (2005) advised the combination of manual therapy and therapeutic exercises especially muscle strengthening exercises to achieve better improvement of pain and function in patients with osteoarthritis knee.
Clinical reasoning is on of the methods of applying evidence based practice in physiotherapy. A case of medial compartment right knee osteoarthritis presented with pain after minor exercise is subjected to clinical reasoning critical thinking. The case turned to be a multidisciplinary case that needs further investigation and possibly orthopaedic surgeon interference before manual physiotherapy begins. Using clinical reasoning skills and principles, the patient's history and clinical findings were analysed, designing principles of a plane of manual therapy, measuring the outcome, and foreseeing prognosis and improvement rate were explained.
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