Michael McMurray

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  • in reply to: Biopsychosocial Questions #8748
    Michael McMurray
    Keymaster

    Steven,

    I think all of those questions are really good and important to incorporate into not only the eval but throughout the POC as well. These are the types of questions that, unfortunately, I think get overlooked and may have a huge impact on their recovery both short and long term. These may be the key questions that may have been overlooked from other providers.

    It all depends on the patient but I usually ask similar questions throughout the evaluation especially when going through the SINSS and clarifying if it is pain or fear, or both which limits the movement. I again ask that throughout the objective section too if they are apprehensive. There is a fine line as well though, as it is important that they aren’t focusing too much on the pain itself.

    Another question that I tend to ask is do they notice their symptoms more while they are in the same scenario. For example, my clinic sees a lot of MVAs and I often ask if they are afraid to drive or if they feel their symptoms increased while driving. In certain instances I think there can potentially be PTSD related to injuries that often are over looked.

    in reply to: July Journal Club #8709
    Michael McMurray
    Keymaster

    – To find these articles, I use the following search string: “manual therapy AND cervicogenic headache AND cervicogenic dizziness”. Would you change anything regarding this search strategy?

    I think that if you are searching for articles about manual therapy in regards to cervicogenic headache and dizziness then it will be a good potential search strategy. I think it all depends on your PICO question. Also, your search may come up with minimal results due to searching for two different diagnoses in one article, cerviocgenic headache and dizziness.

    – Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?

    I really like using SNAGs as a treatment for patients with decreased cervical rotation, limited cervical joint mobility, cervical pain, and cervicogenic headaches. Overall, the patients seem to like this intervention after they get the hang of the form.

    – What do you make of the authors’ findings? And are there any glaring limitations?

    A glaring limitation that I noticed was the compliance in both groups but mainly of the placebo group. Could the the poor compliance be related to the lack of improvement or the lack of improvement be related to poor compliance?

    The study had a relatively small number of participants (16 in each group).

    The actual treatment itself interests me as it is described as “3 second sustained hold at pain free end range and performed for 2 repetitions.” I am not sure how much stock I place in this dosage.

    – Have you ever treated cervicogenic dizziness? If so, what techniques or interventions have you found helpful?

    Surprisingly enough, I have not actually treated any patients with cervicogenic dizziness. I have treated patients with cervicogenic headaches and there are a lot of different techniques that seem to be beneficial (STM to SCM and suboccipitals, MT including CPAs/UPAs, Exercises including laser for “joint repositioning training” and proprioception/kinesthesia and some gentle muscle energy techniques in various painfree ROM.

    in reply to: June Journal Club #8668
    Michael McMurray
    Keymaster

    She is a wizard, she came from the future! Just kidding, I’m assuming it started in 2019.

    1) Given that the systematic review says that there is not evidence to show any benefit for physical therapy with Bell’s Palsy, what treatment choices would you make going forward with this patient?

    The review showed that Wang 2004’s functional exercise group showed statistical differences compared to the control group in regards to fascial muscle function at 1 month using Potmann score which includes: frowning, eyes closing, and smiling which are all impairments for your patient.

    Like the others have mentioned, I think education is a huge proponent for this patient not only to educate her but to also ease her mind and potentially decrease any anxiety.

    2) Is a systematic review the most applicable level of evidence given this pathology?

    I think it may be a good place to start and then delve deeper into articles which may peak my interest based on chronicity and patient characteristics.

    3) Since there is weak evidence for interventions, what principles or concepts do you think apply from other body regions/practice in general that you would use to guide your treatment and POC?

    Since this is similar to a paresis, I would most likely treat this similar to patients post-stroke. I would have my the patient not only perform interventions on affected side but also on the unaffected side in order to promote potential overflow. As far as POC is concerned, maybe a f/u in a week or two. Like the others mentioned I think I would create a home-based approach.

    in reply to: May Journal Club #8631
    Michael McMurray
    Keymaster

    1. Do you feel like my search strategy was too narrow to start with? Why or why not?

    I don’t believe so, I think having a more narrow focus and then being able to broaden your “net” if need be is more efficient than having a huge amount of articles to choose from and have to try and narrow your focus.

    2. What are some strengths/weaknesses of this article?

    Strengths
    -RCT
    -blinded and concealment of allocation of participants
    -Methodology/consistency of treatment performed

    Weakness
    -relatively low sample size from one clinic
    -No formal inclusion criteria (aside from not being excluded) such as their definition of chronic or their minimum time frame for chronicity
    -Lower bound estimates of 95% CI did not meet MCID for pain, so it may not be as significant as the paper states.

    3. Do you feel like this article impacts or changes your clinical practice for an individual that “fits” into this category?
    -I prefer to utilize CTJ and thoracic manipulation over cervical manipulation in this population, so I think this paper helps to strengthen my bias. There isn’t anything that I read that makes me sway from one intervention to the other though.

    Do you feel as though this article answered your PICO question? Your PICO is querying thoracic manipulation vs CTJ manipulation, whereas this article is comparing isolated cervical manipulation to a combination of cervical, CTJ, and thoracic manipulation.

    in reply to: April Journal Club #8523
    Michael McMurray
    Keymaster
      ANNA

    1) Gotcha, thanks Anna. Seems like a similar strategy that I try to use.

    2) Very true, I was thinking the same thing. Even the control group of “general trunk strengthening interventions were strange, I am not sure the last time I have given a trunk curl as an exercise.

    3) I agree, I don’t trust it much either and obviously don’t utilize it in the clinic. I agree that it may be a stretch to correlate it to the outcomes directly.

    4) I agree, Anna, I think they used strong language about activation of deep musculature. They also speak about disturbances in mechanoreceptors and proprioception which may affect motor control and stability in the low back which I can get on board with a lot more than the direct correlation to pain and disability. The population was very narrow and I missed that with my first read through due to the inclusion criteria and lack of mention of population in the participant section.

      TAYLOR

    1) Interesting, I haven’t thought of doing it this way. That makes sense to make sure the study is well done before choosing it. I did this with this article but unfortunately did not delve deep enough. It looked good on the surface but there were a lot of things that fell through the cracks.

    2) I agree, I believe that a lot of “lumbar stabilization” interventions are not the most functional, especially the basic ones. I would have liked to see them use the basic interventions at first to try and “teach” the patients what to feel and then progress to utilizing that while performing more functional tasks.

    3) Awesome, thanks for that. That is really interesting, I did not know that and should have done some digging myself. Very true, I agree that clinically it isn’t worth assessing but I can see why they may have wanted to use it as a pre and post test to have some objective data for measuring their outcome.

    4) I agree, while the article seems to lean towards core strengthening and PNF compared to their general exercise group. I would argue your point.

      HELEN

    1) Gotcha, I’m glad to hear that what I did wasn’t totally off the wall. Unfortunately that strategy (especially focusing on the PEDro score and year) biased my opinion while first reading through this article.

    2) Those are all valid points and I am not sure why they had the participants resting after each rep, very confusing indeed.

    3) Very true, we don’t use those muscles in isolation during functional tasks. While it may not be great carry-over for function, I’m thinking the authors were more likely using this to help “support” their claim for activation of these muscles being a factor in reducing patient’s pain and disability. Objectively, how else can we measure for this specific impairment?

    4) Amen

      STEVEN

    1) That all makes perfect sense, thanks for sharing that. That is somewhat similar to what I did and relied to heavily on the PEDro scoring and the abstract, so we have to make sure to not let those bias our selections of articles.

    2) Very true, not functional or specific at all. I would be interested to see how the findings would have differed with more appropriate selections of interventions.

    3) Very true, I am not sure how they can state that they are isolating the muscles that they are looking for.

    4) I like your thought process here. Adding in the therapist involvement is definitely a factor not addressed in the paper.

      LAUREN

    1) Awesome, I like the idea of skimming through the references!

    2) I agree the selection of interventions and dosing was lacking

    3) Again, I agree with you and everyone on that. Clinically not relevant but for test, treat, retest it may help have some objective measures?

    4) Agreed, the article definitely stepped back in regards to treatment interventions.

      BARRETT

    1) Nice, sounds like a solid strategy.

    2) Very true, there isn’t much along the lines of clinical reasoning.

    3) I agree, very hard to use clinically. I am hoping it was more used for comparative reasons pre and post test.

    Michael McMurray
    Keymaster

    I have evaluated/treated a few patients with vertigo where I have assessed for VBI before performing the canal repositioning technique. I figure this is a good way to not only assess VBI but also take/talk them through most of the positions of the test before we perform it at a faster speed. While the CRT does not place the patient in to full rotation and extension, I prefer to test the positions before adding in the speed/velocity of CRT.

    In regards to assessing before cervical manipulation, I cannot say that I have evaluated for VBI as I have not performed any and feel more comfortable at this point focusing more on CTJ or thoracic manipulations.

    I think the subjective report from the patient is a huge part of screening for VBI as you can ascertain a lot of information by asking about specific symptomatic positions such as shaving ones face, looking up/overhead into cabinets, if they rest their head on the hands, etc. Along with that is their description of symptoms (“HA like no other”) and asking about dizziness, difficulty swallowing, speech difficulties, nausea, for example. in addition to the subjective report, increasing the stress gradually and providing progressive overload while assessing for symptoms is at this point the best way to objectively help rule out potential red flags and help guide us to perform or not perform manipulation to the cervical spine and be more cautious.

    The big take away from this article aside from the amazing citations and research is the ending of “no added value to the patient evaluation” section:

    “Screening for the effect of head movement on vascular haemodynamics and adequate collateral cerebral blood flow therefore may still be an important part of the evaluation of the patient (Blanpied et al., 2017) and relevant to physiotherapy management. In addition the tests can be quickly incorporated into an active movement assessment and do not add substantially to the assessment time.”

    While, at this point we can’t use these tests alone to rule in/rule out VBI, we can use these tests, in my opinion, to progressively overload the system. In doing so we can gather information in the evaluation, whether it be the patient becoming symptomatic and to avoid those movements and potentially refer or that the patient is able to tolerate specific loads, which we can use in our future treatment/interventions.

    I also think the authors provide a good point that positional testing is not unique to VBI and that there are other diagnoses which may be related to the positional testing such as vestibular or cervicogenic as well.

    Finally, the authors also did a good job of stating what needs to be done in order to better assess VBI testing. They not only talked about both sides of the argument to discard testing or leave it in the evaluation but they provided us with a potential groundwork in order to better research this topic:

    “…future studies must use appropriate dynamic imaging
    i.e. angiography or transcranial Doppler in different head positions,
    to capture the most informative images at the most relevant sites.
    The downstream effect of rotated head positions on blood supply to the
    brain needs to be evaluated in symptomatic rather than asymptomatic
    individuals and in those with confirmed vascular pathologies. In tandem
    there is a need for detailed characterisation of the timing and nature of
    symptom responses to the positional tests in those with vascular pathologies,
    healthy individuals, and those with other causes of dizziness,
    for a full understanding of their clinical interpretation and diagnostic
    utility.”

    in reply to: Running Medicine #8456
    Michael McMurray
    Keymaster

    1) Great review of anatomy of the foot including neural contributions/conditions. Will definitely think more about these neural contributions when evaluating the foot/ankle in the future — consider for differential.

    2) The S’s of treadmill running was really helpful, I like the breakdown of what is/isn’t important to look for. I also think what he said about “if it isn’t broken don’t fix it” was really important, so often as physical therapists I feel like we look for impairments when they do not always need to be fixed. I thought Chris’s thoughts on cadence were interesting as well as barefoot treadmill running analysis/drills (hopefully can carry this into practice when I am back in clinic).

    3) Clinical ultrasound lecture presented by Dr. Hryvniak was great as I was familiar with a lot of the patients he presented on — so helpful to hear his perspective and to be able to work with him. Gaining a better understanding of what he is looking for on ultrasound and where specifically he is injecting was helpful in terms of understanding nerve anatomy and pathological nerve anatomy. After working with him during my internship, I will definitely better consider referral to hydrodissection when deemed appropriate for my future patients.

    4) Physical performance and clearance considerations for distance runners presented and suggested by Chris Johnson was quite comprehensive. I would be worried about being efficient enough to look at all of these performance measures but do think they would be very beneficial when considering required performance characteristics for long distance running. I hope in the future to be able to select from this list in order to increase specificity of my examination for runners.

    in reply to: Weekend 6 Case Presentation #2 #8373
    Michael McMurray
    Keymaster

    Hey guys, thanks for the responses. Just a heads up, while reading your responses I noticed that I made an error copying over the cervical rotation ROM. He did indeed have about 20% limitation and 10% limitation with L and R cervical rotation respectively. I believe I got too in the zone while filling out the chart. Sorry for the mistake but overall, I like everyone’s thought process. See you this weekend.

    in reply to: Weekend 6 Case Presentation #8357
    Michael McMurray
    Keymaster

    1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?

    -Patellar tendinopathy
    -PFPS
    -Pes anserine tendinopathy

    2. With the subjective and objective information, does this patient fit a clinical pattern?

    From the subjective and objective information provided, I don’t see a specific pattern in which this fits. I would lean towards patellar tendinopathy d/t nature of repetitive action and tenderness to palpation.

    3. Do you feel like you need more subjective/objective information for this case, and if so, what?

      Subjective

    How long has she been running recreationally?
    Any training intensity/duration recently altered?
    Does the intensity continue to intensify as she continues to run?
    Has she changed shoe wear recently?
    What position of sitting (i.e knees straight, at 90 deg, doesn’t matter)?
    What part of the squat/stairs does her pain come (ascending/descending)?
    Previous knee/hip/ankle pains?
    Any other activities, hobbies outside of running?

      Objective

      Knee resisted testing
      Adductor resisted testing (testing in seated position or supine?)
      Patellar positioning (static/dynamic)
      Any core strengthening assessed?
      With SL squat, did patient have contralateral leg in front or behind?
      With the functional testing, anything noted in the sagittal plane?
      At what point did she experience the pain during the SL hop?

      4. What is your treatment for day 1 and what are you reassessing next visit?
      I would see if her mechanics would change with cuing during DL squat, if she can demonstrate decreased knee valgus and proper form, I would do STS or a mini-squat
      Bridging – While lower level, would help strengthen some of the hip musculature while placing some stress through the knee
      (Potentially challenging) Side plank + clam, target glute med and core musculature
      Reassess – squat mechanics, and SL hop after cuing

    in reply to: Reflection and Beliefs #8315
    Michael McMurray
    Keymaster

    The big thing that sticks out to me, which has been strengthened since starting the residency experience is the use of passive modalities, well rather not using them. I have never been a fan of them and I have had to defend my position on my beliefs over and over for the past 16 months or so that I have been working. My clinical director, area manager, and regional director continue to drill the idea of me using TENs on my patients and have started using the verbiage as “placebo is a strong treatment” and “If it makes them feel better, they will continue to come back” while at the same time telling me that my billing charges are too low (strange coincidence).

    I can’t think of a time where I have felt like a marionette being controlled by ideas that I have not fully fleshed out as of yet. The closest thing that I can think of is in PT school, diagnoses, while important, weren’t the major focus in comparison to impairments of the patient. I feel as though before this residency, I had an issue trying to identify patterns of diagnoses and therefore connecting the potential diagnoses and impairments in order to better create a treatment plan and improve outcomes for my patients.

    in reply to: Non Ossifying Fibromas #8314
    Michael McMurray
    Keymaster

    Very interesting, I have yet to encounter a case similar to this that I know of.

    Along the same lines as Helen, I would have asked a little more about the aggravating factors:
    -Does time of day affect her symptoms?
    -how long it took for symptoms to increase for each activity and
    -how long for the symptoms to dissipate once she was resting.

    -In the article it states that there are stages of the NOF, so I wonder which stage hers is as some of the stages are more prone to fx. It seems from the description that it is less likely stage A and probably late stage B or stage C.

    -Was the imaging taken prior to or after being immobilized?

    -I am sure you tested it but are there any changes with strength, motion, etc?

    -Has she ever had a previous injury of the leg or any imaging of the leg before?

    -Was the pain always localized to the medial aspect of the tibia or has the pain moved around (I only wonder because of the location of the NOF, could she have been compensating because of pain and then then the medial symptoms arose)?

    If all things point towards posterior tibialis tendinopathy and there are impairments to address, I would focus on those and keep the NOF in consideration when creating the program and tailor it towards the patient and how she presents to you.

    Good luck and thanks for sharing, hopefully this was somewhat helpful

    in reply to: January Journal Club #8307
    Michael McMurray
    Keymaster

    1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
    Primary: Labral Pathology
    Differentials: Rotator cuff tear, Impingement

    2) Are there any objective tests you feel would provide a clearer picture of this case?
    – APR of cervical spine and shoulder
    – Rotator cuff: palpation, painful arc, ER lag sign, jobe, drop arm
    – Impingement: HK, scapular assist, painful arc
    – Labral (rule in): apprehension/relocation, crank, speeds, load and shift

    3) Do the objective findings fit a clinical pattern? If so, of what?
    Pattern seems to fit with labral pathology, with positive special testing and subjective reporting of instability

    4) What impairment or limitation would you want to address first with this patient?
    Improving strength and NM activation of rotator cuff musculature to improve active stability of L shoulder joint.

    in reply to: A very interesting Facbook post that I stumbled upon #8194
    Michael McMurray
    Keymaster

    Dr. Kelley
    Maybe I should have placed a better follow up question at the end of my post, something along the lines of:

    “With a lot of clinicians using social media to promote physical therapy and their treatment philosophies/styles as well as informing people of different diagnoses, interventions, manual techniques, etc. How do you filter out those who you do not deem to be reputable and therefore find better clinicians that you would follow and possibly utilize their information?”

    With that being said, I think this post does indeed have a large learning moment. When searching the literature, we have to weed out poor quality articles. In the same light, as we search for fellow clinicians who are on social media, we should weed out those who are spreading poor quality information. I believe this also shows that, like you said, there is a lot of garbage out there and we need to be vigilant in promoting quality patient management and quality physical therapy while questioning and avoiding the promotion of said garbage.

    Finally, here is an article from the archives of internal Medicine called “Words That Harm, Words That Heal. The article discusses how the words that we use affect our patients. A quote that I found to be intriguing was the following:

    “Being ill inherently humbles and corrodes the sense of self, making patients vulnerable to the words of their physicians. Language reinforces the tendency of the patient to yield to the authority of the physician, and it is one way that physicians inadvertently distance themselves from patients. Rather than describe the complexity of a situation, physicians may use words that generate fear, anxiety, despair, or
    hopelessness, thus silencing all further discussions. As a result, patients have more difficulty making intelligent decisions and becoming active participants in their care. Such intense emotions also dissipate hope and aggravate symptoms, and may adversely affect healing.”

    The article talks about frightening metaphors, misunderstood jargon and technical language, reasons why physicians use words that may harm, and also language that heals. The article proposes four possible reasons why physicians may use words to harm and they are:
    1) Medicine’s inherent uncertainty may prompt the use of words that harm.
    2) Time pressure may also encourage physicians to curtail patients’ questions through use of words that harm.
    3) Sometimes a caring physician may reach for alarmist language in order to convey a sense of urgency, thus hoping to ensure that his or her patient will comply with lifesaving recommendations.
    4) It is also likely that physicians are so close to the language of medicine, to the specific words of their subspecialty, that they may no longer really hear the words that they use.

    The author describes words of healing as “clear, precise meaning and with connotations that do not evoke dread in the patient…Healing language avoids words that intensify these emotions or destroy hope and any prospect for rational self-determination…language that adapts and responds to a patient’s experience.” Reading this definition of words of healing is a nice way to create a framework and allow us to create our own words of healing for our patients.

    With that being said, I am going to leave one last quote found in this article about words that heal:

    The essential feature of language that heals is empathic communication, eloquently described by Coulehan et al as language that aides the process of healing by bolstering patient’s strengths, validating their perspective, and teaching them how to grow to be more self-reliant.

    in reply to: ACL rehab #8145
    Michael McMurray
    Keymaster

    1) What objective measures do you use throughout to track progress?
    -Quad strength (SLR – extensor lag/no lag), isometric strength (at end stages) and isokinetic (I don’t have the equipment though)
    -gait kinematics (I think normalizing gait and monitoring it throughout, especially at the start of weightbearing is important)
    -Functional: Squat (symmetry, depth, quality). I also read somewhere about being able to lunge with adding 1/2 body weight is a good indicator to begin running protocol. Other tests such as hop testing (single leg hop for distance, triple hop for distance, crossover hop for distance and 6-meter time hop. The general rule is to obtain an LSI ≥ 90% compared to the reference limb.)

    Below is a nice article by Mike Reinold which discusses this and has some good references added in.

    https://mikereinold.com/return-to-play-testing-after-acl-reconstruction/

    2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
    I tend to perform manual techniques (anterior tibiofemoral glides, superior patellar glides, etc.) first.

    Passive: The exercises I go to are heel/calf props, sitting in a chair with leg propped on another chair with a gap between and using either a weight or self-applied force (LLLD has worked well for my patients). More ac

    Active: SLR(can do active assist with PT, use NMES, or even march up/ecc SLR), retrowalking, sled push/pull, TKE (standing/prone), SLS, Marching.

    There was an Instagram post regarding knee extension posted by prehabguys that have videos and explanations on some of these.

    3) What does your HEP look like early on and as rehab progresses?

    Early – Understanding of weightbearing status, proper use of crutche(s) then get rid of them as early and safe as possible. Large emphasis on knee extension (more time the better, as long as they are doing it safely and to tolerance), quad strength, and gait kinematics. I also through some heel slides in to promote knee flexion. Scar mobilization, proper wrapping and cleaning of surgical site is also taught.

    *One really cool external cue that I use during squats to help equal weight shifting is to have them perform a mini-squat while standing on a wobble board with a box under the affected side. If they are weightshfiting properly the wobble board should remain relatively fixed. If they are placing more weight on the uninvolved side, the wobbleboard will..well..wobble and they will be able to see and feel the difference. A mirror works well but is not as effective through my experience.

    Mid – Same as early but focusing largely on functional strengthening (wall sits, squats, continued gait, glute strengthening, hamstring strengthening, etc.) Incorporating proprioception and kinesthetics into treatment by adding in some external perturbations and changing surfaces. I tend to try and make this phase a little more fun as the first phase is kind of boring for them. During wall sits or lateral walking I’ll give them a basketball or something to dribble (more so if they are a basketball player)

    Late – I make it more functional : if they are an athlete or are trying to get back into running and are ready, I may give them hopping drills, running intervals, resisted lunges, squats, etc. For other patients I may give a faster walking exercise, stairs, squats, etc.

    4) How often are you seeing these patients early on and as they progress through each stage of rehab?

    I think the first 2-3 weeks are crucial and if able, I like to see them 3x a week to help get the ball rolling and then drop them down to 2x a week. Once they are late enough into the game to perform activities safely in the gym (if an athlete), I may do once a week to focus on higher level activities to make sure they can perform them safely outside of the clinic.

    5) Thoughts on open chain kinetic exercises?

    I think they are okay for isolated strengthening when safe to perform but I think they aren’t the most functional and should be used as an adjunct more so than a main intervention.

    Graft selection

    I think this is very important to go over with your patient to help educate them on the graft that was utilized. I observed an ACLR and was able to watch the surgeon create the hamstring graft and talk me through the steps. One of the golden nuggets that the surgeon told me was that patients who have a hamstring graft will often describe discomfort in the medial aspect of their affected leg which may be related to the hamstring harvesting process (they really have to go up high in the leg in order to get a good amount of tendon). Knowing that has really helped me when patients have told me about their inner thigh pain and I am able to explain to them that it may be related to the graft and that it is a normal sensation to feel post-op.

    in reply to: The power or prediction, generation and elaboration #8144
    Michael McMurray
    Keymaster

    The slinky video was very interesting and made a lot of good points. One of the biggest take away was when he said “If you don’t make a prediction, what you learn from this will be no more than if you never saw this at all.” This resonates with me because, this reinforces an active learning style which is how I learn best. Another take home message was at the end when he was talking about having to believe it before you see it rather than the old saying, see it to believe it. I think this has major implications with clinical reasoning. For example, researching and being able to identify patterns for specific diagnoses can help identify and create PT diagnoses for future patients. Another way that this has implications to clinical reasoning is that if you can create a prediction, based on previous experience and knowledge before and during the evaluation, you will learn from the experience a lot more than if you were to just complete the evaluation and retroactively try and diagnose.

    The second video about predictions also had a lot of good points. Using contextual clues as well as clues from previous experiences is very important in clinical reasoning. As mentioned above, being able to use these clues is essential for not only creating but using the patterns to help with clinical reasoning.

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