sample icf chart – 6 year old male health condition...sample icf chart – 6 year old male health...

Sample ICF Chart – 6 year old male

HEALTH CONDITION

L3 Myelomeningocele (Spina Bifida)– 6 years old male Arnold Chiari II Malformation with hydrocephalus with VP Shunt placement Bilateral club feet (congenital talipes equinovarus) Bilateral Hip Dysplasia

ACTIVITY (TASKS)

Abilities Limitations

1. Walks independently on level surfaces with HKAFO and forearm crutches.

2. Climbs in/out of tub with supervision

3. Transfers and transitions independently

a. With HKAFOs braces - floor to standing and sit to

standing with upper extremity assistance

b. Without HKAFOs braces- transfers in and out bed and chair as well as to/from the

tub chair c. Car transfers –transfers in and out of the car with supervision from w/c to/from the car.

1. Can’t climb steps independently with HKAFO and crutches.

2. Difficulty keeping up with peers due to slow ambulatory speed.

BODY STRUCTURES/FUNCTION (IMPAIRMENTS)

1. Brain and CNS a. Arnold Chiari II Malformation

with Impaired cognitive functions impacting motor planning abilities

b. Peripheral nerve involvement of lower extremities.

1. Lower extremity paralysis 2. Impaired sensation in

both lower extremities 2. Musculoskeletal involvement of

lower extremity- legs and feet a. Bilateral Hip Dislocation due to

Hip dysplasia b. Impaired lower extremity ROM

and joint contractures with bilateral hip flexion contractures

PARTICIPATION

Abilities Restrictions 1. Attends school with same age peers 2. Plays recreational adaptive soccer with peers 3. Participates in all family activities and outings

1. Limited ability to interact with peers due to difficulty with long distance mobility, speed and endurance.

ENVIRONMENTAL

Internal External +

1. Above average intelligence motivated to learn and move

2. Very motivated to learn, move and engage with his

- 1. Impaired cognitive function due to hydrocephalus resulting in motor planning impairment. 2. Limited LE function

+ 1. Supportive and

motivated parents 2. Supportive school

system 3. Followed in a

multidisciplinary clinic.

- Limitation due to structural and environmental access.

a. school bus access is not available to due not owning a wheelchair which is required to ride the

peers. 3. Has a very social

personality

4. Support from 3rd party payers including private insurance and state Medicaid.

bus. b. Structural barriers

due to building, etc. not being accessible.

A Tool for Clinical Reasoning andReflection Using the InternationalClassification of Functioning, Disabilityand Health (ICF) Framework andPatient Management ModelHeather L. Atkinson, Kim Nixon-Cave

Background and Purpose. Professional development is a cornerstone ofphysical therapist practice. As the profession moves toward the ideals of Vision 2020,more emphasis is being placed on the process of clinical decision making. Althoughreflection and mentorship are widely regarded as important instruments to facilitatethe progression of clinical reasoning skills, little guidance exists in the postprofes-sional arena to assist clinicians with these essential needs. As more organizationsdevelop formal mentoring programs, a need arises for a tool that will engage mentors,proteges, and clinicians of all abilities in thoughtful reflection and discussion that willhelp develop clinical reasoning skills.

Case Description. The process of developing reflective clinical decision-makingskills in physical therapist practitioners is described, and how this process was usedat one institution is illustrated. A tool for clinical reasoning and reflection is proposedthat incorporates the existing conceptual frameworks of the Guide to PhysicalTherapist Practice and the International Classification of Functioning, Disabilityand Health (ICF).

Outcomes. This case report discusses how the tool was implemented by staffwith varying levels of expertise, their outcomes in regard to the development of theirclinical reasoning skills, and how the tool facilitated mentoring sessions aroundpatient cases to improve care.

Discussion. This case report describes a practical application of a post-professional educational process designed to develop reflective and patient-centeredclinical reasoning skills. Although this process has shown some preliminary success,more research is warranted. By cultivating reflective thinking and critical inquiry, thephysical therapy profession can help develop autonomous practitioners of physicaltherapy and promote the ideals of Vision 2020.

H.L. Atkinson, PT, DPT, NCS, isa clinical specialist in the De-partment of Physical Therapy,The Children’s Hospital of Phila-delphia, 34th and Civic CenterBlvd, Philadelphia, PA 19104-4399 (USA). Address all corre-spondence to Dr Atkinson at:[email protected].

K. Nixon-Cave, PT, PhD, PCS, isManager of Physical Therapy,Department of Physical Therapy,The Children’s Hospital ofPhiladelphia.

[Atkinson HL, Nixon-Cave K. Atool for clinical reasoning andreflection using the InternationalClassification of Functioning, Dis-ability and Health (ICF) frameworkand patient management model.Phys Ther. 2011;91:416–430.]

© 2011 American Physical TherapyAssociation

Case Report

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416 f Physical Therapy Volume 91 Number 3 March 2011

Vision 2020, as set forth by theAmerican Physical TherapyAssociation (APTA), highlights

the following elements: autonomousphysical therapist practice, directaccess, the doctor of physical ther-apy degree and lifelong education,evidence-based practice, practitio-ner of choice, and professionalism.1

As the physical therapy professionstrives to reach these goals, moreemphasis is being placed on the pro-cess of clinical decision making(CDM) and professional develop-ment, while using evidence andreflection to guide clinical decisions.

Common types of clinical decisionsinclude:

• Who needs treatment and why?• What are the expected outcomes of

intervention?• How should outcomes be mea-

sured and documented?• What intervention, instructions,

services, and number of visits arenecessary to meet these outcomes?

• How should the patient and care-givers be included in the decision-making process?

• How should the success of theintervention and cost-effectivenessbe evaluated?

• Are referrals needed for otherhealth care services and screen-ings?

Clinical decision making is a verycomplex, uncertain, evaluative, sci-entific process2 that can be costly,with a lot of intuition, in an effort toprovide best practice. Physical ther-apists strive to make decisions thatinclude all aspects of expert prac-tice, including knowledge, core val-ues, clear clinical reasoning, andexcellent clinical practice skillsfocused on providing high-quality,patient-centered care.

In making clinical decisions, physicaltherapists rely on a conceptualframework that includes theories of

practice, CDM models, clinical rea-soning approaches, and a model ofdisablement and functioning. Thephysical therapy profession has useda variety of conceptual frameworks,most recently the APTA’s Guide toPhysical Therapist Practice3 andthe International Classification ofFunctioning, Disability and Health(ICF) as set forth by the WorldHealth Organization.4

Clinical reflection and mentorshipare routinely recognized as impor-tant components of professionaldevelopment5,6; however, littlestructure exists to guide cliniciansthrough this complex process. Whilein the development stage of launch-ing a pediatric residency program,we recognized the need for a clinicalreasoning and reflection tool thatcould serve not only as a reflectionguide for the resident but also tofacilitate mentoring sessions. Whilepilot testing the tool with the resi-dent, it became apparent that it alsocould benefit clinicians of all abilitiesin their journey from novice toexpert practitioners, as great empha-sis is placed on using reflection andexisting clinical models to make bet-ter decisions about patient care.

The purpose of this case report is todescribe the process of developingreflective CDM skills for physicaltherapist practice within the contextof the Guide to Physical TherapistPractice and the ICF framework.This report illustrates case examplesin which this process was used inour institution. Finally, this articleproposes the use of a tool that can beused in any setting to facilitate thefollowing goals:

1. Assist in the development of CDMskills of physical therapistpractitioners.

2. Facilitate a reflective process inCDM that includes critical inquiryand the use of evidence.

3. Develop a guide or process forclinical mentoring of clinicians atall levels.

4. Integrate the ICF framework intothe CDM process using the Guideto Physical Therapist Practice asa structural base.

Target SettingThis tool was developed for use in alarge academic hospital networkproviding physical therapy through-out the continuum of care includingacute care, inpatient rehabilitation,general outpatient rehabilitation,and sports medicine. Our staff com-prises more than 65 full-time andpart-time therapists with a range ofexperience, from new professionalsto those in later career practice withmore than 30 years of experience.We currently employ more than 30board-certified specialists recog-nized by the American Board of Phys-ical Therapy Specialties (ABPTS) incardiopulmonary, pediatrics, neurol-ogy, orthopedics, and sports medi-cine specialties and have recentlydeveloped a pediatric residency pro-gram. As part of our department’svision for professional development,this clinical reflection tool was initi-ated to help novice and master clini-cians alike in their personal questfor professional development andto facilitate a formalized mentorshipprogram.

Development of theProcessIn preparing for the development ofour residency and mentoring pro-

Available WithThis Article atptjournal.apta.org

• Audio Abstracts Podcast

This article was published ahead ofprint on January 27, 2011, atptjournal.apta.org.

Clinical Reasoning and Reflection

March 2011 Volume 91 Number 3 Physical Therapy f 417

http://ptjournal.apta.org/content/91/3/suppl/DC1

gram, a literature search was per-formed and important conceptswere realized regarding the topics ofclinical reasoning, models of CDM inphysical therapy, reflection, mentor-ship, and expert physical therapistpractice. A common element thatcontinually arose was that althoughstructure or a concrete approach isregarded as very important in boththe clinical reflection and mentoringprocess, little exists in the profes-sional community in the way of aguiding tool or worksheet to facili-tate this process.

Clinical Reasoning andModels of Decision MakingClinical reasoning has been definedas “an inferential process used bypractitioners to collect and evaluatedata and to make judgments aboutthe diagnosis and management ofpatient problems.”7(p101) Clinical rea-soning includes the application ofcognitive and psychomotor skillsbased on theory and evidence, aswell as the reflective thought pro-cess, to direct individual changesand modifications called for in spe-cific patient situations.8 Currentresearch in clinical reasoning sug-gests that the process of applyingknowledge and skill, integrated withthe intuitive ability to vary an exam-ination or treatment based on reflec-tion and interaction to achieve a suc-cessful outcome for an individualpatient, is what separates expertsfrom novices as it relates to the cli-nician’s approach to reasoning.8–10

Jensen and colleagues9 described indetail the attributes of both noviceand master clinicians and proposed 4dimensions to characterize expertphysical therapist practice: (1) mul-tidimensional and patient-centeredknowledge; (2) collaborative andreflective clinical reasoning; (3)observational and manual skill inmovement, with a focus on function;and (4) consistent virtues. Theauthors illustrated the connectionbetween these realms and high-

lighted the interplay between knowl-edge and reasoning.9

In 2003, APTA put forth the Guide toPhysical Therapist Practice (2nd edi-tion), which offers the patient man-agement model as a conceptualframework for clinical decision mak-ing and includes all elements of phys-ical therapist practice, includingexamination, evaluation, interven-tion, and outcomes.3 This model pro-vides an overall concept map forpractice in any setting and with anypatient population. The Guide toPhysical Therapist Practice also usesthe Nagi model of disablement,3

which centers on the concepts ofpathology, impairment, functionallimitation, and disability, as a founda-tion. By using the Nagi model withthe patient management model, cli-nicians are able to prioritize prob-lems in a patient-centered methodand to better understand what prob-lems are most important to thepatient.

More recently, the profession hasadopted the ICF as a framework toapproach patient care that shifts theconceptual emphasis away from neg-ative connotations such as disabilityand places focus on the positive abil-ities of the individual at the patientlevel rather than the systems lev-el.4,11 The ICF framework is a classi-fication of the health componentsof functioning and disability andfocuses on 3 perspectives: body,individual, and societal.4 These 3perspectives underscore the impor-tance of the interplay and influenceof both internal and external factorsto each individual’s condition ofhealth.4

Since the introduction of the ICFas a conceptual framework, physicaltherapists in the United States havebeen slow to fully adopt it as anapproach to patient care.12 To facil-itate using the ICF in practice, sev-eral practitioners have proposed

conceptual models and case exam-ples that utilize the ICF as a basis fordecision making.13–17 Recently,Escorpizo and colleagues12 sug-gested a method to integrate the ICFinto clinical practice documentation.As the profession and the Guide toPhysical Therapist Practice evolveand seek new ways to integrate theICF, it becomes important for theclinician to have a practical tool thatuses both the ICF and the Guide toPhysical Therapist Practice in anintegrative manner to probe reflec-tion and reasoning in order to pro-mote best patient outcomes.

Clinical ReasoningStrategies Used in thePatient ManagementModelKnowledge garnered from researchin the field of clinical reasoning anddecision making can be directlyapplied to the patient managementmodel in a way that integrates theICF. Clinical reasoning strategiesmay differ in the various domains ofthe model, depending upon the spe-cific situation and the knowledgeand expertise of the clinician. Clini-cians also may use dialectical reason-ing, an ability to use a variety of rea-soning strategies for a singlesituation.18

ExaminationForward reasoning, or pattern recog-nition, often is used when identify-ing salient qualitative information.19

In the medical field, much attentionhas been afforded to the speed andaccuracy with which expert practi-tioners can recognize patterns andformulate hypotheses.18,20 Cliniciansalso may use backward reasoning, orhypothesis-guided inquiry, whichassists the practitioner in systemati-cally negating or supporting gener-ated hypotheses.19 This concept iscentral to the science and skill ofdifferential diagnosis. McGinnis etal21 suggested that a nonlinear



thought process is involved in select-ing specific tests and measures forbalance assessment. They described3 stages of clinical reasoning: (1) ini-tial impressions and movementobservation, (2) data gathering, and(3) diagnosis and treatment plan-ning. Interestingly, the therapistsinvolved in their study frequentlylooked ahead to their possible diag-noses and treatment plans whenselecting tests and measures duringthe examination, all while consider-ing patients’ values and beliefs andbeing guided by ethical and legalaspects of professional practice.21

EvaluationThe clinician next synthesizes quali-tative and quantitative information,considers all of the factors describedby the ICF framework, and generatesa diagnosis, prognosis, and plan ofcare. Prioritizing patient problemsand linking them to the ICF frame-work are essential in determining ifand how physical therapy may ben-efit the patient. Developing a flow-chart or concept map may help toorganize information in a meaningfulway.19 Conceptual mapping also canhelp illuminate which prob-lems are most important to thepatient, which problems are the larg-est barrier to the next level of func-tion, and which problems may bemost affected by physical therapyintervention.

InterventionSelection and progression of specificprocedural interventions are part ofa systematic clinical reasoning pro-cess.19 Physical therapists must uti-lize competent clinical decision-making skills when appraising theavailable evidence in the effort toselect the most appropriate treat-ment. Although scientific evidence isemphasized in guiding decisions, cli-nicians also must make decisionswhen receiving guidance from col-leagues or mentors or relying on pastexperience. Possessing the clinical

reasoning skills to effectivelyappraise and integrate evidence intopractice is essentially linked toVision 2020.

OutcomesA key component of the clinical rea-soning process in generating suc-cessful outcomes is collaborationwith the patient.9,22 Resnik andHart23 ascertained that physical ther-apy expertise is not based on yearsof experience and is rather moreclosely linked with health-relatedquality-of-life outcomes and patientsatisfaction. Emphasizing patientempowerment through active partici-pation, education, and collaborativereasoning is the hallmark of expertphysical therapist practice.22

Specialty-certified physical therapistsalso are more likely to use standard-ized outcome measures to makedecisions about practice.24 Jette andcolleagues24 found that althoughmany physical therapists routinelyrecognize the importance of measur-ing outcomes, standardized outcomemeasures are significantly under-used. They suggested that focusededucation, for both students andpracticing professionals, may be nec-essary to enculturate the standarduse of outcome measures inpractice.24

Physical therapists utilize a variety ofCDM strategies that incorporate aclassification system such as the ICFthroughout the various elements ofphysical therapist practice. Knowl-edge and psychomotor ability,including observational analysis, areimportant in the development ofhigher-level skill demonstrative ofexpert practice. Prospective or for-ward reasoning, deductive or back-ward reasoning, concept mapping,evidence appraisal, and interactivecollaboration with the patient andfamily are important strategies forCDM, and greater proficiency inthese skills frequently leads to anelevated level of practice and

improved quality of care. Further-more, it may not be necessarily yearsof experience that lead to clinicianbecoming an expert, but rather it isthe development of advanced CDMthat leads to the expertise associatedwith improved patient outcomes andquality of life.23

ReflectionClinical reflection is a powerful toolin developing clinical reasoningskills and professional growth.5,6,18,19

Reflection is a necessary skill inlearning and metacognition.25 Meta-cognition is defined as an “aware-ness or analysis of one’s own learn-ing or thinking processes.”26 This“thinking about thinking” has beenlinked to the cultivation of clinicalreasoning strategies.5,25 Schondescribed reflection as occurringeither “in action,” during the event,or “on action” after the event.27 Bothprocesses require metacognitivethinking and can be enhanced byspecial instructive techniques. Aunique strategy to augment reflec-tion in action is the “think-aloud”approach for either the learner orthe mentor in a given situation.25,28

Having a novice clinician think aloudduring a clinical encounter can helpthe mentor identify areas where rea-soning strategies may be improved.25

In addition, the articulation of clini-cal reasoning can facilitate the meta-cognitive process.25 The mentor alsomay choose to think aloud during aclinical encounter to give novice cli-nicians insight into his or her reason-ing strategies.28

After the clinical encounter, strate-gies to enhance learning and reason-ing include both internal focusedreflection and external reflectivearticulation, either orally or in writ-ing.29 External guided writing that isreflective on action may take theform of portfolios or journalentries.5,29 A critical aspect of theseinstructive techniques designed topromote reflection and improved



clinical reasoning is the use of struc-ture.5 Although structured reflectivelearning experiences are common inphysical therapy clinical educationfor students, little is known abouttheir use in the common workplacefor practicing clinicians. Wainwrightand colleagues6 studied differencesin how novice and experienced cli-nicians use reflection in the CDMprocess. They observed thatalthough novice clinicians are morelikely to reflect on the specific situa-tion in front of them, experiencedclinicians often reflect on a broader,deeper scale, bringing in past expe-rience and thinking about the widerscope of physical therapist practice.6

The authors suggested that this infor-mation can be helpful in designingmentorship experiences that facili-tate professional development.6

MentorshipMentorship is a cornerstone of pro-fessional development. In the prac-tice of health care, many disciplineshave written about the importanceof the mentoring relationship inprofessional growth and develop-ment.30,31 Likewise, from a physicaltherapy perspective, mentorship is akey element in the advancement ofCDM skills, the promotion of bothreflection in and on action, and pro-fessional development. The multidi-mensional relationship betweenmentor and protege has beenrevered as a crucial component offostering professional growth.32

Much has been published about thekey attributes of both mentors andproteges and expected outcomes ofthe relationship.30–32 A key elementof a successful mentoring relation-ship and program is structure.19

The development of physical ther-apy residency and fellowship pro-grams have allowed for structuredmentorship experiences.19,33 In resi-dency or fellowship programs, prac-ticing clinicians receive a plannedlearning experience designed to sig-

nificantly advance their preparationto provide patient care in a definedarea of practice.34 Planned postpro-fessional clinical education programssuch as these may more quicklydevelop an advanced practitionerand can potentially accelerate theprocess of developing from a noviceto a master clinician.33,35 Structuredreflection and mentorship are funda-mental to the success of these pro-grams and ultimately support theVision 2020 goal of physical thera-pist as practitioner of choice.

Although residency and fellowshipprograms seek to advance profes-sional and clinical reasoning skills tothe realm of expertise, access andavailability are relatively limited. As aresult, clinicians may seek structuredmentorship programs outside of res-idencies and fellowships, with thegoal of entering into either a mentoror protege role to promote profes-sional development. From a nursingperspective, Block and colleagues36

discussed that formal mentoring pro-grams are important not only for per-sonal growth and development butalso for staff retention and overallorganizational success. They advo-cated that organizations embrace theimportance of formal mentorshipprograms and encouraged allocationof the necessary financial and humanresources to ensure their success.36

Clinical reflection, supported bymentorship, is a key element indeveloping CDM skills. Reflectionand mentorship may take placeeither during or after a clinicalencounter and may include internalreasoning processes or externalarticulation. Reflection and mentor-ship that are structured and plannedlend themselves to a more compre-hensive and thoughtful learningexperience. Clinicians may use mul-tiple reasoning strategies at onetime, or use different strategies for agiven situation. Despite this knowl-edge, little exists in the way of a

clinical reflection guide to probe rea-soning throughout the various stagesof physical therapist practice. Fur-thermore, although training work-shops are available to educate clini-cians in the art of mentorship, littlespecific direction is available tohelp mentors generate questions forproteges regarding patient caseexamples.

Physical Therapy ClinicalReasoning and ReflectionToolThe Physical Therapy Clinical Rea-soning and Reflection Tool (PT-CRT)(Appendix) was developed and isproposed for use as a clinical reflec-tion tool and a guide for mentors,proteges, and clinical discussion.The PT-CRT seeks to integrate theICF framework into the patient man-agement model while incorporatingthe hypothesis-driven basis of CDMmodels.13–15,37 Its design aims toprobe reflection and discussion forboth the novice and master clinicianand may be used as a mentoring toolfor specific patient cases. Cliniciansmay choose pertinent sections andquestions to guide critical thinkingor may select to complete the work-sheet in its entirety. The shadedboxes include suggestions to furtherpromote reflection or discussionwith a mentor. They also may help toidentify further potential inquiries toexplore, either by a review of theevidence or by designing a new andimportant clinical question.

Application of the ProcessThe PT-CRT was pilot tested in thePediatric Residency Program of theChildren’s Hospital of Philadelphia.The resident reported that the toolhelped to organize individual patientproblems. By going through thereflection questions with her men-tor, she felt she was making betterclinical decisions and developing adeeper understanding of the role ofphysical therapy for her patients. Fig-ure 1 illustrates how the resident uti-



lized the evaluation section of thePT-CRT for a 17-year-old boy withleukemia and methotrexate toxicity.By using the structure provided bythe tool and identifying patient prob-lems within the context of the ICF,the resident was able to reflect onthe factors that were most importantto the patient, formulate a plan ofcare, and identify other resources(ie, psychology, social work) to helpmanage some of the factors outsideof the typical scope of physical ther-apy. The resident also was able toidentify environmental factors thatcould be a facilitator or barrier to thepatient’s overall progress. By doingthis, she accentuated the facilitators(high motivation) and the barriers

(delayed cognitive processing) tohelp the patient achieve his goals asquickly as possible. When designingthe intervention plan (Fig. 2), theresident initially was overwhelmedby the multitude of procedural inter-ventions she wanted to implementwith this complex patient. However,by using the reflective questions inthe intervention section of thePT-CRT and having a dialogue withher mentor, the resident was able tofocus on and prioritize an evidence-based intervention approach rootedin motor learning strategies such astask-specific training. The residentused the primary problem areas iden-tified using the ICF and interactionwith the patient to individualize the

treatment plan and advance thepatient toward his goals. Finally, theemphasis on outcomes and measure-ment guided the resident in selectingappropriate outcome measures thatevaluated progress across alldomains of the ICF, allowing her toevaluate the value of the interven-tions from a holistic and patient-centered perspective.

After pilot testing the PT-CRT in ourresidency program, the instrumentwas further trial tested with staffmembers as part of the department’sprofessional development program.Mentors received training through aworkshop led by experienced clini-cians and other mentors who dis-

Figure 1.Illustration of how the evaluation section of the Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) was utilized for a17-year-old boy with leukemia and methotrexate toxicity. ADLs�activities of daily living.



cussed general concepts of mentor-ship, created role play opportunities,and introduced the PT-CRT as amechanism to guide mentoring ses-sions. Both mentors and protegeswelcomed the concept of a work-sheet to facilitate clinical reasoningand have reported success in usingthe PT-CRT for mentoring discus-sions as well as their own clinicalreflection.

OutcomeAlthough the PT-CRT is still in theearly stages of implementation, thereare some promising outcomes toreport. The PT-CRT catalyzed ourfirst department resident to present acase study at the 2010 APTA Com-bined Sections Meeting and to pub-lish a Clinical Bottom Line.38,39 Oursecond resident expressed a signifi-cant shift in CDM and credited both

her mentor and the tool; thisadvancement in skills was confirmedby the residency committee duringher last practical live patient exami-nation. She submitted a case study atthe 2011 APTA Combined SectionsMeeting using the examplesdescribed in Figures 1 and 2.

The PT-CRT has received positivefeedback from the rest of staff,

VI. Interventions

a. Describe how you are using evidence to guide your practice• Researched methotrexate toxicity to determine what to expect in terms of neurologic recovery• Performed literature search for physical therapy interventions with leukemia• Used articles and textbooks to guide motor learning strategy

b. Identify overall approach/strategy• Will use motor learning theory; emphasize task-specific practice. Will consider:

• Feedback (intrinsic vs extrinsic, immediate vs delayed, knowledge of results vs knowledge of performance)• Practice (whole vs part, random vs blocked, massed vs distributed, constant vs variable)• Environment

• Recovery vs compensation• Due to good potential for neurologic recovery from methotrexate toxicity, will emphasize recovery in interventions rather

than compensatory techniques

c. Describe and prioritize specific procedural interventions• Task-specific practice

• Transfer training, bed mobility, ambulation• Massed practice

• Increase number of steps by using body-weight support for locomotor training• Strength training

• Progressive resistive exercises and proprioceptive neuromuscular facilitation techniques• Use of neuromuscular electric stimulation on hip abductors/extensors in standing as an adjunct

• Aquatic therapy• Use of water properties (buoyancy, resistance) to support and challenge return of neuromuscular motor control

d. Describe your plan for progression• Will utilize concept of the “challenge point”; will continually reassess and progress activities so that as the patient achieves

success, he will be challenged further• Will periodically reassess patient status with outcome measures across various levels of the ICF to help determine which areas

to prioritize during sessions:• Body structures/function: Balance scale, Functional Reach Test, isometric strength testing• Activities: Functional Improvement Measure, Dynamic Gait Index, Timed “Up & Go” Test• Participation: Six-Minute Walk Test, quality-of-life self-assessment

• Will consider patient and caregiver goals, response to intervention, and positive and negative internal and external environ-mental factors (what is most motivating, what is most important)

• Will perform brief systems review at beginning of each session to consider how various medical factors (blood counts, pain,fatigue, avascular necrosis) may affect or be affected by physical therapy intervention

Figure 2.Illustration of how the intervention section of the Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) was utilized fora 17-year-old boy with leukemia and methotrexate toxicity. ICF�International Classification of Functioning, Disability and Health.



including mentors, proteges, anddepartment leadership. No negativeconsequences or potential threatshave been identified. Differentaspects of the tool seem to be impor-tant based on therapist experienceand comfort with the patient case.For example, the hypothesis compo-nents of sections I and II helped toadvance reflection in a novice clini-cian by prompting anticipation ofthe patient’s problems, and thenprobed further analysis of the accu-racy of her predictions. Another cli-nician reported difficulty in generat-ing a prognosis; he stated thatexamining the prognosis questionsof the tool with his mentor improvedhis formulation of positive and neg-ative prognostic indicators andhelped him better understand therelationship between the medicalprognosis and physical therapist’sprognosis. Finally, experienced staffmembers have found the tool to behelpful in recognizing their biases incertain patient cases. They also havereported that the PT-CRT can beextremely helpful when guiding amentoring session.

DiscussionThe PT-CRT seeks to combine avail-able resources in the profession intoa user-friendly and thought-provoking worksheet that fully inte-grates the ICF into the CDM process.Physical therapists may use this toolnot only as a conduit to make deci-sions about patient care but also as avehicle for professional develop-ment through guided reflection andto stimulate discussions with a men-tor or among colleagues. Cliniciansalso may use the PT-CRT to identifyimportant clinical questions thatwarrant study and that, ultimately,may add to the literature. By activelyreflecting and making thoughtful,deliberate clinical decisions, physicaltherapists can further their profes-sional development, help promotethe elements of Vision 2020, and,

ultimately, improve outcomes forthe patients and clients they serve.

Although the initial data in this casereport are promising, more researchis warranted. Collaboration amongresidency and fellowship trainingsites to implement the PT-CRT anddocument outcomes through qualita-tive methods could provide furtherinformation about the helpfulness ofthe tool and the clinical reasoningprocess being developed in theseprograms. Additionally, moreresearch is needed to evaluate thePT-CRT’s effectiveness in differentsettings and how it may influencethe CDM process for physical ther-apists with different levels ofexpertise. Understanding how thePT-CRT relates to the advancementof CDM skills in the journey fromnovice to expert clinician couldprovide further insight into thedevelopment of the autonomous,reflective practitioner.

Dr Atkinson and Dr Nixon-Cave providedconcept/idea/project design and writing.

Part of the manuscript, including the PT-CRTTool, was presented by both authors at aneducational session at the Combined Sec-tions Meeting of the American Physical Ther-apy Association; February 11, 2011; NewOrleans, Louisiana.

This article was submitted July 7, 2009, andwas accepted November 11, 2010.

DOI: 10.2522/ptj.20090226

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Appendix.The Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT)a

I. Initial Data Gathering/Interviewa. History and present function

REFLECTION POINTS:

➢ Assess how the patient’s medical diagnosis affects your interview.

➢ How might your personal biases/assumptions affect your interview?

➢ Assessing the information you gathered, what do you see as a pattern or connection between thesymptoms?

➢ What is the value of the data you gathered?

➢ What are some of the judgments you can draw from the data? Are there alternative solutions?

➢ What is your assessment of the patient’s/caregiver’s knowledge and understanding of their diagnosisand need for PT?

➢ Have you verified the patient’s goals and what resources are available?

➢ Based on the information gathered, are you able to assess a need for a referral to another health careprofessional?

II. Generation of Initial Hypothesis

a. Body structures/functions

b. Impairments

c. Activity limitations

d. Participation restrictions

REFLECTION POINTS:

➢ Can you construct a hypothesis based on the information gathered?

➢ What is that based on (biases, experiences)?

➢ How did you arrive at the hypothesis? How can you explain your rationale?

➢ What about this patient and the information you have gathered might support your hypothesis?

➢ What do you anticipate could be an outcome for this patient (prognosis)?

➢ Based on your hypothesis, how might your strategy for the examination be influenced?

➢ What is your approach/planned sequence/strategy for the examination?

➢ How might the environmental factors affect your examination?

➢ How might other diagnostic information affect your examination?

(Continued)



Appendix.Continued

III. Examinationa. Tests and Measures

RELECTION POINTS:

➢ Appraising the tests and measures you selected for your examination, how and why did you selectthem?

➢ Reflecting on these tests, how might they support/negate your hypothesis?

➢ Can the identified tests and measures help you determine a change in status? Are they able to detect aminimum clinically important difference?

➢ How did you organize the examination? What might you do differently?

➢ Describe considerations for the psychometric properties of tests and measures used.

➢ Discuss other systems not tested that may be affecting the patient’s problem.

➢ Compare your examination findings for this patient with another patient with a similar medicaldiagnosis.

➢ How does your selection of tests and measures relate to the patient’s goals?

(Continued)



Appendix.Continued

IV. Evaluation

HEALTH CONDITION

BODY STRUCTURES/FUNCTION(IMPAIRMENTS)

ACTIVITY (TASKS)

Abilities LimitationsPARTICIPATION

Abilities Restrictions

ENVIRONMENTAL

Internal External

� � � �

(Continued)



Appendix.Continued

IV. Evaluation (continued)a. Diagnosis

b. Prognosis

REFLECTION POINTS:

➢ How did you determine your diagnosis? What about this patient suggested your diagnosis?

➢ How did your examination findings support or negate your initial hypothesis?

➢ What is your appraisal of the most important issues to work on?

➢ How do these relate to the patient’s goals and identified issues?

➢ What factors might support or interfere with the patient’s prognosis?

➢ How might other factors such as bodily functions and environmental and societal factors affect thepatient?

➢ What is your rationale for the prognosis, and what are the positive and negative prognostic indicators?

➢ How will you go about developing a therapeutic relationship?

➢ How might any cultural factors influence your care of the patient?

➢ What are your considerations for behavior, motivation, and readiness?

➢ How can you determine capacity for progress toward goals?

V. Plan of Carea. Identify short-term and long-term goals

b. Identify outcome measures

c. PT prescription (frequency/intensity of service, include key elements)

REFLECTION POINTS:

➢ How have you incorporated the patient’s and family’s goals?

➢ How do the goals reflect your examination and evaluation (ICF framework)?

➢ How did you determine the PT prescription or plan of care (frequency, intensity, anticipated length ofservice)?

➢ How do key elements of the PT plan of care relate back to primary diagnosis?

➢ How do the patient’s personal and environmental factors affect the PT plan of care?

(Continued)



Appendix.Continued

VI. Interventionsa. Describe how you are using evidence to guide your practice

b. Identify overall approach/strategy

c. Describe and prioritize specific procedural interventions

d. Describe your plan for progression

REFLECTION POINTS:

➢ Discuss your overall PT approach or strategies (eg, motor learning, strengthening).

y How will you modify principles for this patient?

y Are there specific aspects about this particular patient to keep in mind?

y How does your approach relate to theory and current evidence?

➢ As you designed your intervention plan, how did you select specific strategies?

➢ What is your rationale for those intervention strategies?

➢ How do the interventions relate to the primary problem areas identified using the ICF?

➢ How might you need to modify your interventions for this particular patient and caregiver? What areyour criteria for doing so?

➢ What are the coordination of care aspects?

➢ What are the communication needs with other team members?

➢ What are the documentation aspects?

➢ How will you ensure safety?

➢ Patient/caregiver education:

y What are your overall strategies for teaching?

y Describe learning styles/barriers and any possible accommodations for the patient and caregiver.

y How can you ensure understanding and buy-in?

y What communication strategies (verbal and nonverbal) will be most successful?

(Continued)



Appendix.Continued

VII. Reexaminationa. When and how often

REFLECTION POINTS:

➢ Evaluate the effectiveness of your interventions. Do you need to modify anything?

➢ What have you learned about the patient/caregiver that you did not know before?

➢ Using the ICF, how does this patient’s progress toward goals compare with that of other patients with asimilar diagnosis?

➢ Is there anything that you overlooked, misinterpreted, overvalued, or undervalued, and what might youdo differently? Will this address any potential errors you have made?

➢ How has your interaction with the patient/caregiver changed?

➢ How has your therapeutic relationship changed?

➢ How might any new factors affect the patient outcome?

➢ How do the characteristics of the patient’s progress affect your goals, prognosis, and anticipatedoutcome?

➢ How can you determine the patient’s views (satisfaction/frustration) about his or her progress towardgoals? How might that affect your plan of care?

➢ How has PT affected the patient’s life?

VIII. Outcomesa. Discharge plan (include follow-up, equipment, school/work/community re-entry, etc)

REFLECTION POINTS:

➢ Was PT effective, and what outcome measures did you use to assess the outcome? Was there aminimum clinically important difference?

➢ Why or why not?

➢ What criteria did you or will you use to determine whether the patient has met his or her goals?

➢ How do you determine the patient is ready to return to home/community/work/school/sports?

➢ What barriers (physical, personal, environmental), if any, are there to discharge?

➢ What are the anticipated life-span needs, and what are they based on?

➢ What might the role of PT be in the future?

➢ What are the patient’s/caregiver’s views of future PT needs?

➢ How can you and the patient/caregiver partner together for a lifetime plan for wellness?

IX. Mentor Feedback:Strengths:

Opportunities for development:

a PT�physical therapy, ICF�International Classification of Functioning, Disability and Health.



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