Welcome to Welcome to Marshall UniversityMarshall University

www.marshall.edu

School of Physical Therapy

  An Integrated Case-Based An Integrated Case-Based

Learning Model to Enhance Learning Model to Enhance Teaching and LearningTeaching and Learning

Penny G Kroll, PT PhD

PurposePurpose

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 CasesApplication 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.

BackgroundBackgroundThis curricular strategy is expected to: • Help student develop and reinforce problem solving, abilities,

clinical decision-making abilities, legal and economic-psycho-social 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.

MethodsMethods• 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

MethodsMethodsGiven 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

MethodsMethods

• 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

MethodsMethods

• 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

MethodsMethods

• 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

MethodsMethods

• 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 TestingBeta 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 StepsFuture 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 ScenarioSample 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.)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:Primary Course Objectives Meet by This Case:

• History

• Recognition of red flags

• Musculoskeletal Screen

• Neuromuscular Screen

• Clinical judgment for PT appropriateness

• 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.

Primary Course Objectives Meet by This Primary Course Objectives Meet by This Case:Case:

Stimulus Questions Covering Major Aspects of This Topic: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 Stimulus Questions/Reviews Necessary to bring to bear in this case: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 InfoPatient 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: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/AHistory 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/AHistory 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• 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

ExaminationExamination• Functional Tool: Quick Dash – 52.3/100

• Inspection: Reverse Scapulohumeral Rhythm

• Pain: Current 8/10VAS, Best 4/10VAS, Worst 8/10VAS

ExaminationExamination

• 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

ExaminationExamination

• 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

ExaminationExamination

• 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

• Spurling’s – negative

• Quadrant – negative

• Hawkins-Kennedy – positive

• Cross over – positive

• Sulcus – negative

• Crank - positive

• O’Briens – positive

• Apprehension – positive

• Empty can – positive

• Drop arm – positive

• Lift off – negative

• Speeds – negative

• Yergason’s - negative

Special TestsSpecial Tests

Patient and Therapist Patient and Therapist Identified ProblemsIdentified 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: – Impaired ROM

– Rotator cuff weakness

– Impingement of subacromial tissues

– Rotator cuff inflammation

• Differential PT Diagnosis– Rotator cuff syndrome

GoalsGoals

• 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 LessonTake 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