Centre for Education in Musculoskeletal Therapies SOMT, Amersoort, The Netherlands.
J Orthop Sports Phys Ther. 2011 Feb;41(2):108-17. doi: 10.2519/jospt.2011.3353. Epub 2010 Sep 17.
Resident's case problem.
This case report describes the diagnostic process, based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), and subsequent interventions in an elite athlete with subacute low back pain. It also demonstrates the clinical application of the HOAC II and shows how disablement terms, as used in the World Health Organization's International Classification of Functioning, Disability and Health model, can be integrated into patient management in a manner that we believe enhances clinical practice. It also demonstrates the practical use of validated questionnaires and how these can be used to gather necessary information for the algorithm.
A structured, evidence-based assessment led to a multifaceted, activity limitation-based diagnosis of being unable to (1) remain in a deep squat position during speed skating, (2) accelerate in turns while speed skating, and (3) rise from a slouched position without pain. We believed that these dysfunctions were due to local limited lumbar segmental mobility, concurrent with an inability to properly and functionally stabilize the lumbopelvic area.
The HOAC II requires the therapist to develop an evidence-based strategy for the examination that is based on initial hypotheses developed from the medical history and other data obtained prior to the examination. The examination was tailored to identify and quantify activity limitations and participation restrictions that we believed could help to explain why this patient had his health problem. The case demonstrates how all elements of the HOAC II can be used for what we consider to be relatively common types of patients. We believe that by applying the HOAC II on an individual-patient basis, therapists will be ideally positioned to apply evidence to patient care and to defend their interventions to colleagues and third-party payers.
Differential diagnosis, level 4.
住院医师病例问题。
本病例报告描述了基于临床医生定向假设算法 II（HOAC II）的诊断过程，以及随后对一名患有亚急性下腰痛的精英运动员的干预措施。它还展示了 HOAC II 的临床应用，并展示了如何将世界卫生组织国际功能、残疾和健康分类模型中使用的残疾术语以我们认为增强临床实践的方式纳入患者管理。它还展示了验证问卷的实际用途，以及如何使用这些问卷来收集算法所需的信息。
基于结构化、循证评估，对活动受限为特征的多方面诊断为：（1）无法在速滑中保持深蹲姿势，（2）在速滑中转弯时无法加速，（3）从俯身在不感到疼痛的情况下起身。我们认为这些功能障碍是由于局部腰椎节段活动度有限，同时无法正确和有效地稳定腰骶区。
HOAC II 要求治疗师根据病史和检查前获得的其他数据制定基于初始假设的基于证据的检查策略。检查旨在确定和量化活动受限和参与限制，我们认为这些受限和限制可以帮助解释为什么该患者存在健康问题。该病例展示了 HOAC II 的所有要素如何用于我们认为相对常见类型的患者。我们相信，通过在个体患者的基础上应用 HOAC II，治疗师将能够将证据应用于患者护理，并为同事和第三方支付者辩护他们的干预措施。
鉴别诊断，4 级。
