Transcript Slide 1

Welcome to
Marshall University
School of Physical
Therapy
www.marshall.edu
An Integrated Case-Based
Learning Model to Enhance
Teaching and Learning
Penny G Kroll, PT PhD
Purpose
The purpose of this project was to develop
a series of cases to be utilized as a
curricular strategy to help students
• Discover
• Reinforcement
• Integration
didactic material presented in courses taught in
the first year Doctor of Physical Therapy
curriculum.
Application of Cases
• These cases will be presented and completed by students in
faculty-facilitated sessions of the Clinical Application Seminar and
Experiences (CASE) courses arrayed throughout the DPT
curriculum.
– Week 1: Case scenario and stimulus questions/areas of suggested
review will be provided to students
– Week 2: 5 students and a faculty facilitator will participate a small
group seminar/practice session to work through the case
– Week 3: The entire class will meet to review the case to assure that
the students attained/retained the salient points/objectives the case
was designed to deliver
• At the end of this class session, the next case scenario will be
distributed.
Background
This curricular strategy is expected to:
• Help student develop and reinforce problem solving, abilities,
clinical decision-making abilities, legal and economic-psychosocial knowledge, skill, attitudes and behavior necessary to meet
a number of our program objectives and accreditation criteria.
• Encourage applied learning, and building of clinical knowledge
and skills upon well founded basic science knowledge
• Decrease course isolation and the "silo" mentality that often
occurs in professional programs.
Wood DF, 2003.
Demarco R, Hayward LM, Lynch M, 2002.
Thomas MD, O’Connor FW, Albert MI, Boutain D, Prandt PA, 2001.
Loghmani MT, Bayliss AJ, Strunk V, Altenburger, P, 2011.
Methods
• Ten area physical therapy clinicians were recruited to
attend a ½ day preliminary Case Writing Workshop to
develop a core series of cases for the first year Case
Application Seminar and Experiences courses
• Clinicians were given course descriptions and objectives
for courses being delivered in the first year of the DPT
curriculum and asked to construct cases that would
reinforce any number of the course objectives from the
courses
• Clinical faculty worked in pair with an academic faculty
rotating between pair to assist as necessary
Methods
Given those materials, each clinicians pair:
• Developed a case scenario to be given to the students
• Developed a list of assigned readings
• Designed stimulus questions and/or gave suggestions for areas to be
reviewed by the student prior to the facilitated application session,
to guide the student to:
• Review/recall the relevant basic science and clinical science
(anatomy, physiology, pathophysiology) behind the
pathology/dysfunction described in the scenario
• Review/recall the knowledge, skills, attitudes and behaviors
acquired in current and prior semesters that can be brought to bare
on the case being presented
• Research/obtain any new information necessary to better
understand the case
Methods
• In addition, they developed:
– Mock patient data that the students can use in working
through the case, and that facilitating faculty can use to
guide the student through the case, including:
• Interview results
• Examination data results, including functional outcome
tests and measures to be applied
• Prior completed medical tests and measure that might
inform the therapist regarding the patients status
• Evaluation results
Methods
• Also included:
• Differential diagnosis (primary hypothesis and alternative hypotheses
that should be considered)
• Assessment (i.e. therapist and patient identified problem lists, short
and long term goals)
• Treatment intervention including home programs for the
patient/family
• Follow-up/reevaluation data
• Outcome measures that might be used to assess success of the
intervention
Methods
• Within the 3 hour session, clinicians completed the
greater bulk of 5 cases
• The cases were then posted on a Google Docs website
for 6 weeks so that clinical faculty could continue to
develop the cases to completion with a February 29,
“due date” for completing additions to the cases
Methods
• Cases will now be distributed to academic faculty so
they may:
– Review information for inconsistencies
– Add information, stimulus questions, etc. to maximize
integration of didactic and clinical learning supported by
the cases.
• The reviewing academic faculty will work with the
clinical faculty who developed/finalize the case
Beta Testing
• Similar to the beta testing of software/games, etc.
– The case in question will then be distributed to academic
and clinical faculty who participated in the workshop, but
were not involved in design of the specific case
– A questionnaire/form is presently being designed to solicit
feedback on the cases
– Once feedback is obtain, changes, as might be indicated,
will be incorporated into the final case designs
Future Steps
• A survey will be designed to be administered to students prior
to and after participation in the case to assess the perceived
effectiveness of this case methodology in achieving/supporting
the stated objectives of:
• Helping student develop and reinforce the problem solving, clinical
decision-making, and knowledge, skill, attitudes and behaviors required
for clinical patient care
• Encouraging applied learning
• Building of clinical knowledge upon well founded basic science
knowledge
• Decreasing course isolation and the "silo" mentality that often occurs in
professional programs.
Sample Case Scenario
• 49 y/o male, self employed auto mechanic
referred to PT with persistent left shoulder
pain after fall while at work 4 months ago.
Presently complaining of being unable to work
without pain.
• Evaluate and treat.
Assigned Readings (articles, chapters, videos, etc.)
• Moffat M, Rosen E, Eusnak-Smith S. Musculoskeletal Essentials:
Applying the Preferred Physical Therapist Practice Patterns. P335-337.
• Goodman C, Snyder T, Differential Diagnosis in Physical Therapy:
Overview of Cardiovascular Signs and Symptoms: 88-144.
• Medical Screening for Physical Therapist; Independent Study Course
14.1.1
• Jette et al: Decision-Making Ability of Physical Therapists: Physical
Therapy Intervention or Medical Referral, Phys Ther 86(12): 1619-1629,
2006.
Primary Course Objectives Meet by This Case:
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History
Recognition of red flags
Musculoskeletal Screen
Neuromuscular Screen
Clinical judgment for PT appropriateness
Primary Course Objectives Meet by This
Case:
• Formulate and conduct and efficient physical therapy interview and
physical Examination of mock patients/cases who exhibit movement and/or
related dysfunctions. (CC-5.28, 5.29, 5.30)
• Articulate, verbally and in writing, the finds obtained form examination of
patients with movement and/or related dysfunctions (CC05.31, 5.27)
• Collect appropriate health care information from a patient or client’s
medical record, subjective history, and date from quantitative and
qualitative tests/measures necessary to formulate a complete physical
therapy evaluation, diagnosis and prognosis. (CC. 5.28-5.34)
• Practice basic neurological and musculoskeletal screening examinations
• Recognize “red flag” issues that will alter decision to treat, or refer.
• Formulate appropriate clinical questions to guide physical therapy practice
decisions such as appropriateness for treatment, need to refer, or treat and
refer.
Stimulus Questions Covering Major Aspects of This Topic:
• What differential diagnosis would present for this case?
• What are the distinguishing characteristics between cardiomyopathy, cervical
radiculopathy, rotator cuff syndrome, brachial plexopathy, tumor etc.
• What appropriate physical therapy test and measures should be considered
for this case?
• What imaging may be warranted to further evaluate the left shoulder?
• If this patient is not suitable for physical therapy what referral may be
warranted?
Stimulus Questions/Reviews Necessary to
bring to bear in this case:
• Review the anatomy and biomechanics of the shoulder
• Consider what possible clinical hypotheses may be considered in the case?
• Review the pathophysiology of inflammation/stages of the inflammatory
process.
• How does the patients age, and occupation influence what hypotheses you
consider?
• What test and measures might be employed to help test the clinical
hypothesis?
• (What are the distinguishing signs and symptoms between cardiomyopathy,
• cervical radiculopathy, rotator cuff syndrome, brachial plexopathy, tumor
etc.)
Patient Info
• General Demographics:
– Male, 49 y/o, Caucasian, Right handed, self
employed auto mechanic, High school education,
Height 6’5, Weight 240 (BMI 28.46)
• Social History:
– Married, Drinking (negative), Smoking (negative).
History of Current Condition:
• Fall directly onto left shoulder 4 months ago while at work (secondary to
tripping per patient)
• Immediate pain to superiolateral shoulder extending into upper arm and
lateral aspect of c-spine
• Cervical pain and stiffness with left rotation and extension
• Paresthesia lateral shoulder
• Unable to elevate left shoulder through full arc motion
• Persistent night pain and unable to sleep
• Shoulder pain improves with immobilization
• Evaluated by PCP within week of fall
• Prescribed NSAIDs, rest, orthopedic referral
• Referred MRI, but refused by patient due to inability to pay (10,000 dollar
deductible)
• X-rays negative
• Referred to PT 4 months later for persistent shoulder pain
History Q/A
• Review of Systems Questionnaire: Quick Dash 52.3/100, sharp pain
superiolateral left shoulder
• Current Condition: Pain with active elevation or external rotation
• History of Current Condition: Fall onto left shoulder with immediate
pain and loss of function
• General Demographics: 49 y/o white male, self employed, right handed
• Past Medical History: Unremarkable
• Past Surgeries: Unremarkable
• Family Medical History: Father CHF
• Medications: OTC NSAID, Lortab 7.5
• Psycho/Social/Economic Status: Self employed auto mechanic, high
school education
• Social Habits: Church, enjoys working on cars
• Social History: Married, Non-smoker, Non-drinker
History Q/A
• Growth and Development: NA
• Living Environment: Normal
• Occupational/Employment/School: Auto mechanic
• Functional Status/Activity Level: Impaired with all overhead activities
of left shoulder
• Any other significant information:
– Pain: Superiolateral shoulder and left UT
– Pattern: Sharp and paresthesia lateral shoulder
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Rating: Current – 8/10VAS, Best – 4/10VAS, Worst 8/10VAS
• Health Status (Self-Report): Good
• Patient Goals: Improved mobility and decrease pain
• Medial Test/Procedures Results that might have bearing on the case (i.e.
lab values, medical imaging reports, EMG results, etc.: X-rays negative
Examination
• Functional Tool: Quick Dash – 52.3/100
• Inspection: Reverse Scapulohumeral Rhythm
• Pain: Current 8/10VAS, Best 4/10VAS, Worst 8/10VAS
Examination
• Cardiopulmonary Screen
– Blood Pressure: 141/98
– Heart rate: 98
– Respiration Rate: 14 bpm
– Edema: negative
• Neuromuscular Screen
– Myotomes – Normal
– Dermatomes – Decreased C5, otherwise normal
• Integumentary: Unremarkable
Examination
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Anthropometric Characteristics: 6’5, 240lbs
Arousal, Attention and Cognition: Alert and oriented x 3
Vital Signs: BP 141/98; 98bpm
Observation/Posture: Forward head/Rounded Shoulders
Integumentary Intergrity: Unremarkable
Range of Motion:
– Left Shld
• AROM: flex – 130d, Abd – 90d, ER – 45d, IR – 75d
• PROM: flex – 134d, Abd – 140d, ER – 30d, IR – 90d
• Sensory Testing/Neurological Testing: C5 impaired, left
Examination
• Muscle Performance:
– Left Shld MMT: Ant Deltoid – 4/5, Middle Deltoid – 5/5,
Supraspinatus – 2+/5, Infra/Teres Minor – 4+/5, Subscapularis –
5/5, Biceps – 5/5, Triceps – 5/5
• Orthotics, Prosthetic, Protective, Support Devices: NA
• Bed Mobility: NA
• Transfers: NA
• Balance: NA
• Gait/Locomotion: NA
• Endurance: NA
• Self-Care Unimpaired
Special Tests
• Spurling’s – negative
• Quadrant – negative
• Hawkins-Kennedy –
positive
• Cross over – positive
• Sulcus – negative
• Crank - positive
• O’Briens – positive
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Apprehension – positive
Empty can – positive
Drop arm – positive
Lift off – negative
Speeds – negative
Yergason’s - negative
Patient and Therapist
Identified Problems
• Macroeconomic Issues:
– Self employed, only source of income, Insurance deductable of
$10,000 dollars
– Lost day wage if not at work
• Patient Identified Problems:
– Shoulder pain, unable to raise arm overhead
– Unable to work without pain
• Therapist Identified Problems:
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Impaired ROM
Rotator cuff weakness
Impingement of subacromial tissues
Rotator cuff inflammation
• Differential PT Diagnosis
– Rotator cuff syndrome
Goals
• Short-Term Goals:
– Independent with HEP involving AAROM and muscle setting
– PROM will be normal throughout
– Pain levels will be 2/10 or less at worst
• Long-Term Goals:
– Rotator cuff exams will be negative
– Left shoulder strength will be 5/5 throughout to improve
performance of daily activities
– Left shoulder active range of motion will be functional for daily
activities.
Take Home Lesson
• Clinicians have a wealth of knowledge that
they can call upon the design these cases
• Though they know what they want to the
student to learn, they are unpracticed in writing
a learning objective
• The workshop experience led to on-the-spot
learning for the clinicians