Clinical

reasoning
For musculoskeletal physical therapists
 Clinical reasoning has been defined as a process in which the
therapist, interacting with the patient and significant others (e.g.
family and other health-care team members), structures meaning,
goals and health management strategies based on clinical data,
client choices and professional judgment and knowledge (Higgs and
Jones, 2000).

It is this thinking and decision making associated with clinical

What is practice that enables therapists to take the best-judged action for
individual patients. In this sense, clinical reasoning is the means to
clinical 'wise' action (Cervero, 1988; Harris, 1993).
reasoning? Over the last decade, clinical reasoning has come to prominence as
a subject for study. This has occurred, in part, because of the skills
expected of physical therapists and development of the profession
in a changing health care climate that requires increasing
Mark A. accountability in decision making as part of the process of providing
Jones and Darren A. Rivett
desirable outcomes.
In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Boston, Mass:
Butterworth-Heinemann; 2000:3–14
In this model. clinical reasoning
is seen as a process of
reflective enquiry comprising
three core elements

Cognition.
Metacognition and
Knowledge

carried out in a collaborative

framework with the relevant
parties (e.g. the patient. carers,
other health-care providers,
the workplace and funding
bodies)
(Edwards and Jones,
Understanding both the
'problem’ and the 'person'
determine
management 1996: Jones et
al.. 2000)

Patient-centred model of clinical reasoning (Edwards and Jones. unpublished assignment).

 Attributes of the therapist (e.g. breadth, depth and organization of
Numerous knowledge , familiarity and experience with the type of case being
managed.
variables
influence the
Reasoning proficiency, communication and teaching and
success of this professional craft skills)
collaborative
therapist-patient Attributes of the patient (e.g. needs, beliefs/attitudes and individual
reasoning physical and psychosocial circumstances, including their capacity
and willingness to participate in shared decision making and man-
process. agement) attributes of the environment (e.g. resources. time.
including: funding, and any externally imposed professional or regulatory
requirements).
 The clinicians attend to initial cues (information) from or about the
patient. From these cues, tentative hypotheses are generated.

This generation of hypotheses is followed by ongoing analysis of

patient information in which further data are collected and interpreted.
Continued hypothesis creation and evaluation take place as
examination and management are continued and the various
Hypothetico- hypotheses are confirmed or negated.
deductive
model of is also known as the scientific or positivist paradigm, holds that truth or
reality (ie, knowledge) is objective and measurable, thereby utilizing
reasoning observation and experiment to produce a result that, in turn, can be
generalized and also leads to prediction.

derived from cognitive For example, randomized controlled trials are carried out within this
science, has its roots in paradigm of research. In clinical practice in physical therapy (as in
the medicine), hypothetico-deductive reasoning aims, within the limitations
empirico-analytical of available standards, to validate information or data acquired from the
research paradigm
patient through measurement in a reliable fashion.
 Other models of clinical reasoning from this same cognitive science
(empirico-analytical) perspective have focused less on the
processes and more on the organization and accessibility of
knowledge stored in the clinician’s memory.

• In making use of illness scripts or pattern recognition, the clinician

“illness scripts” recognizes certain features of a case almost instantly, and this
and recognition leads to the use of other relevant information, including
“if-then” rules of production, in the clinician’s stored knowledge
“pattern network.
➢ This form of reasoning moves from a set of specific observations
recognition toward a generalization and is known as “forward reasoning.”
➢ Forward reasoning contrasts with hypotheticodeductive reasoning
where a person moves from a generalization (multiple hypotheses)
toward a specific conclusion.
Both forms of ➢ Pattern recognition is faster and more efficient and is
this used by expert and experienced practitioners in their
domain.
cognitively
oriented ➢ Hypothetico-deductive reasoning is used by more
inexperienced practitioners and by experts when
reasoning are faced with an unfamiliar problem or a more complex
presentation.
used at
different These 2 cognitively oriented methods taken together
are often referred to as “diagnostic reasoning.”
times.
 Through a process of enquiry. examination and reflective
management. the therapist attempts to understand the patient's
problem, while at the same time trying to understand the patient's
personal story/narrative or the context of the problem beyond the
mere chronological sequence of events. Understanding the context.
Also called 'narrative reasoning
Narrative
reasoning
Understand the patient as a person. including their perspective of
the problem

their experiences (e.g. understanding, beliefs, desires.

motivations, emotions),

the basis of their perspectives and how the problem is affecting

their life (i.e. their pain or illness experience).
 A distinction can then be made between understanding and managing
the problem to effect change (requiring biomedically driven cause and
effect thinking and action: diagnostic reasoning and procedural
management) versus understanding and interacting with the person to
effect change (requiring biopsychosocially driven narrative reasoning
Diagnostic and communicative management).

versus A comprehensive diagnosis should encompass what is learned from

both the diagnostic reasoning regarding the physical problem and the
narrative narrative reasoning regarding the person. All forms of reasoning and
reasoning management should be carried out collaboratively.

The therapist's hypothesis oriented diagnostic and narrative

reasoning continues until sufficient understanding (of the person
and the problem) is reached by both therapist and patient to enable
joint determination of a plan of management.
 • Activity capability/restriction (abilities and difficulties an individual may
have in executing activities) and

• Participation capability/restriction (abilities and problems an individual

may be involved in life situations)
Hypothesis
categories of • Patients' perspectives on their experience
judgments • Pathobiological mechanisms (tissue healing mechanisms and pain
that assist in mechanisms)
understanding
• Physical impairments and associated structure/tissue sources
the patient as a
person and • Contributing factors to the development and maintenance of the
problem
their problem(s)
• Precautions and contraindications to physical examination and
treatment

• Management and treatment

• Prognosis
 Patient
centered
CR
 IASP Announces Revised Definition of Pain
Jul 16, 2020
Pain
“An unpleasant sensory and emotional experience associated
with, or resembling that associated with, actual or potential
tissue damage,”

is expanded upon by the addition of six key Notes and the

Basic pain etymology of the word pain for further valuable context.
terms and 1) Pain is always a personal experience that is influenced to varying degrees by
definitions biological, psychological, and social factors.
2) Pain and nociception are different phenomena. Pain cannot be inferred solely
from activity in sensory neurons.
3) Through their life experiences, individuals learn the concept of pain.
4) A person’s report of an experience as pain should be respected.
5) Although pain usually serves an adaptive role, it may have adverse effects on
function and social and psychological well-being.
6) Verbal description is only one of several behaviors to express pain; inability to
communicate does not negate the possibility that a human or a nonhuman
animal experiences pain.
 Nociception*
The neural process of encoding noxious stimuli.

Note: Consequences of encoding may be autonomic (e. g. elevated blood pressure) or

behavioral (motor withdrawal reflex or more complex nocifensive behavior).
Painsensation is not necessarilyimplied.
Nociceptivepain*
Pain that arises from actual or threatened damage to non-neural tissue and is due to
Basic pain the activation of nociceptors.

terms and Note: This term is designedtocontrastwithneuropathicpain.

The term is used to describe pain occurring with a normally functioning
definitions somatosensory nervous system to contrast with the abnormal function seen in
neuropathicpain.
Neuropathicpain*
Pain caused by a lesion or disease of the somatosensory nervoussystem.
Note: Neuropathic pain is a clinical description (and not a diagnosis) which requires a
demonstrable lesion or a disease that satisfies established neurological diagnostic criteria
Basic pain
terms and
definitions
Inflammatory  Inflammatory pain = dull, burn not well orientated
usually felt continuous
VS
Mechanically  Mechanically induced pain = usually intermittent , well
induced described orientated
referred pain is pain
perceived at a location other
than the site of the painful
stimulus/ origin.
It is the result of a network
of interconnecting sensory
nerves, that supplies many
different tissues. When
there is an injury at one site
in the network it is possible
that when the signal is
interpreted in the brain
signals are experienced in
the surrounding nervous •Convergence-projection theory
tissue.
This is the most acceptable explanation in which the pain is
caused by convergence of afferent information of the visceral
organs and those of somatic origin on the same segment. This
causes hyperreactivity of the dorsal horn neurons which is
interpreted as coming from the same dermatome.
 Radicular pain occurs when pain
radiates from an inflamed or
compressed nerve root. As an
example, an inflamed nerve root in
the neck may radiate pain into the
arm or hand.

 Radiculopathy occurs when a

compressed or inflamed nerve root
results in neurological deficits, such
as problems with reflexes,
numbness, and/or weakness.
 Radicular pain and
radiculopathy can occur separately
(one without the other) or together
 1. Differences in pain descriptors (Radicular = sharp, electric like
Possible follows usually a dermatome trajectory / Referred = dull, spread
differential NOT in dermatomal trajectory.

approach for 2. Neurological examination for radicular pain usually positive

=sensory testing , myotome , Neurodynamics.
Radicular VS
Referred pain 3. Referred pain = if the tissue involved is not of neural origin
neurological testing usually negative.
Examination algorithm
 Patient History / Assessment Form
Name Profession
Address Other
Date of birth Demographic
Tel Data

1. Pain characteristics (Quality- Quantity)

Intermittent / or Continuous
Spread / or Well orientated
Superficial / Deep
Like …Knife, Stubbing, throbbing, burning, acute,
sharp, dull (pain descriptors)
P1 P2
Neural involvement
Pins and needles, paresthesia, hypoesthesia,
 Patient History / Assessment Form

2. Modifying Pain activities Aggravate factors Alleviate factors

3. 24-hour behavior Morning / as the day progress / night
Related to what ?
4. Available imaging Xray's , MRI , Ultrasound , etc

1-4 disciplines are referred to symptoms in the last 2-3 days

For this event

5. Previous history
P1 P2
For previous
events

When / where / how often / how ? Suddenly / Gradually ?

 Patient History / Assessment Form
6. Previous treatments? what where the results
Drug related / other health professionals / others ?

7. General health / systemic or autoimmune diseases / previous surgeries

8. Special red flag signs? Investigate the flag system

9. Physical assessment
• AROM / functional demo
• Neurological examination / dermatomes /myotomes/Neurodynamics
• Manual testing PPIVM or passive movements
• Manual testing PAIVM or accessory movements
P1 P2 • Manual testing PREM

10. Investigate psychosocial factors interfering with the problem. ex.

Is the magnitude of pain experience related to your stress levels?
Personal approach to pain (severity*) or any other contextual factors
beliefs attitudes related to the problem
 Patient History / Assessment Form
Usual questions
1. Describe exactly where you have been hurting in the last 2-3 days. 11. How does your pain get worse? If you are in pain in more than
2. If zero means no pain and 10 the worst pain you can imagine, one place or area, report separately for each.
what degree would you put into your own pain? 12. What do you do on your own to relieve symptoms?
3. Do you have pain in some other parts of your body and where 13. Does your pain wake up at night? Do you wake up without
exactly? changing position or when you turn?
4. Do you have numbness somewhere in your body, feeling like 14. How many times do you wake up?
electricity, do you have less sensation of a part of your skin? Like this 15. Can you go back to sleep?
part doesn’t belong to you? Describe the area you do not feel good 16. Do you hurt in the morning when you get out of bed? Do you
about. have stiffness?
5. Is your pain constant or are there even a few moments in the day 17. If so, how long does it take and how long?
when you don't hurt? 18. How does pain behave during the day?
6. What does your pain look like? With nail, stab, bite, pulse, 19. Did it start suddenly or gradually? Do you remember how?
tightness, pinch some combination of the above or something not 20. Did you get any treatment for this episode? What treatment?
listed? 21. Have you had any more tests? What kind?
7. Is your pain in one place or in an area? Can you point a finger at 22. What other health problems do you have? (diseases in the past,
him? interventions, etc.)
8. Is your pain deep or superficial? 23. What medications do you take on a regular basis? Are you taking
9. Can you do your daily chores, hobbies, and obligations? anticoagulant drugs or cortisone?
10. If you are in pain in more than one place or area, write starting 24. Do you have problems with urination, with emptiness, bleeding,
from the area with the worst pain what are these and with what fainting episodes, instability in walking, vertigo, weight loss without
intensity does it hurt from 1 to 10 each? dieting, pains at night, anesthesia on your skin between the legs,
numbness in the tongue? State in detail what exactly.
 Reading material

GUIDELINES FOR
PATIENT HISTORY
TAKING
It is highly recommended
to follow the steps as
presented
 1. Mapping = Body chart (pick your own)
• Area of symptom (s) distribution
Were? Directions of pain distribution
Does the pain radiate from the Cervical Spine to the hand? Is it referred to the arm?
Does the pain radiate from the Lumbar Spine to the foot? Is it referred to the leg?
Check with “” the pain free areas
• Which is your worst pain? (Mark with Ρ1 = the worst, Ρ2 = second “worse”, Ρ3 = third etc )
• VAS the last 2 days?
• Area (s) of sensory dysfunction
“Do you have pins and needles, numbness , feeling of “dead skin” etc?
Show me exactly were
• Behavior
Is it always present, or does it come and go?

If the patient says “constant” ask: There is no single moment that you pain goes away? Not even when you relax, or
sleep?
 What Kind of pain?
nail, pinching, biting, burning, grip like.
Depth
Is it deep , or superficial? Can you show the pain with a finger, or with
your palm? Is is more widespread - diffuse?
• Severity
How severe is this for you?
How much does this stop you from doing………

Intermittent Pain Constant Pain

• “ When you have P1 do you have P2 at “If P1 worsens does P2 worsen
the simultaneously?”
same time?”
“ if P1 worsens does numbness in P2
• If not “When P1 increases does P2 worsen simultaneously?”
increase simultaneously?”
“Do you have pain all day without a single
• “Can P1 be without P2 or vice versa?” moment without pain?”
 2. Questions about aggravating activities – factors

“Which position / movement increases your symptoms?”

“What do yo do to improve your symptoms?”
“How fast do they improve?”

Intermittent pain Constant pain

➢ How long can you perform your given ➢ How long can you do your given activity
activity before your pain starts? before your pain gets wore?
➢ Does it make you stop this activity, or you ➢ Do you have to stop your given activity, or
can continue? can you still do what you started to do?
➢ How long do you need till your pain is ➢How long do you need for your pain to be
reduced / dissapear? reduced to its initial level?
3. Diurnal Behavior Questions

• Sleeping time (night)

➢ Do you wake up because of your symptom ?(pain etc)
➢ Do you wake up automatically, or only when you change position?
because you change your position?
➢ How many times do you wake up in the night?
➢ Can you sleep again easily?
➢ What is your sleeping position?
➢ Do you normally change it often?
➢ What kind of mattress / pillow do you have?
 3. Diurnal Behavior Questions

• Morning

Do you have pain immediately when you stand up from your

bed?

Worse in the morning

- What is the intensity of your pain? VAS

- How long do you need till your pain subsides/dissapears ?
-Do you have morning stiffness?
- How long does it need to subside /disappear?
• Day
- How is the behavior of your pain during the rest of the day?
- Is your pain “activity depended” or “time of the day
depended”?
Constant pain Intermittent pain
• Does your pain increase when • Does your pain begin when you
you sit or stand? sit or stand?
• How long can you keep this • How long can you keep this
position before your pain position before your pain begins?
increases? • If you change this position how
• If you change this position fast does your pain improves /
how fast does your pain disappear?
change / reach the previous • How long can you walk pain free?
level • What do you do to relieve your
• Can you walk ?How long can pain?
you walk pain free? • Do you have pain in coughing /
• What do you do to reduce sneezing?
your pain to the initial level?
• Do you have pain in coughing
/ sneezing?
• Evening
When do you feel better? During the day, or in the evening?
• Previous treatments
❖ Did you do?
❖ What kind (chiro, osteo, physio …)
❖ How helpful was it?
 5. Imaging
What kind of imaging?
What are you told about it?

6. Previous health history

➢ Did you have similar symptoms previously?
➢ If yes, when was it initially? ( Area of the body, how did it
start, duration, severity, treatment, results)
➢ How often do you have it since then?
➢ Does it relapse more often?
➢ Is it getting more serious ?
➢ Does it last longer?
7. Special questions
• How is your health generally?
General • Were you hospitilized / operated
health • Diabetes, RA, Neural diseases in the family?

• Burning feelings in the hands or legs?

Spinal cord / • Problems with walking?
Cauda Equina • Loss of feeling between the legs?
• Incontinence?
• Dizziness?
Vertebral
• Blur vision, double vision?
artery • Pins and needles in the tongue, mouth or face?
• Dysphagia, Dizzines, Drop attacks, Diplopia, Dysarthria

Weight loss Without diet

 Useful terms

Irritability (depends on)

• The VAS score
• the vigor of activity required to provoke the familiar symptoms
• the intensity of those symptoms
• the time it takes for the symptoms to disappear or drop to the
initial level before being aggravated
Severity

• Pain is considered severe if the intensity is sufficient to

interrupt a Patient’s activity.
• Severity is used to determine the level of the patient’s ability
to live his/her life with a certain VAS score
• Describes how disable the patient feels in relation with a vas
score
 Classification
Severity – Irritability- Nature – Stage
It will determine how detailed the examination can be and how
“aggressive” the treatment can be.

• Severity: How severe the pain is for a given patient? How severe
is your pain for you? What daily activities are hindered
• Irritability: How quickly do symptoms come – which activity?
How fast do symptoms subside / disappear?
• Nature: Artho, Myo, Neuro, Central, Affective etc
• Stage : Acute, Subacute, Chronic, Chronic improving etc

39
Hellenic OMT Diploma 2018
 SINS
• Severity Biopsychosocial, how severe for me is my VAS
• Irritability VAS easily provoked ,time to subside
• Nature Muscle injury etc
• Stage Acute, subacute, chronic

Beliefs
 SINS
• Severity Is NOT related directly to the VAS ➔ I can perform a
thorough examination and if needed go over the
resistance*(depending on fear response)
• Irritability It is ONLY related to the VAS and the time for
provoked symptoms to subside➔ if high I am very
• Nature careful with my testing and treatment
• Stage Muscle injury etc
Acute, subacute, chronic
Beliefs
 Procedure

Comparable
sign-
Listen Provoke Alleviate Reassess
trial
treatment
 In case of increased Irritability

• Avoid “thorough” examination

• Do the necessary
• Usually not many movements are tolerated
• Be extremely careful with passive movements
• PREM is very useful
• Take a good history to detect serious pathology

43
 Classification in Diagnosis

1. Movement dysfunction
2. Structural instability
3. Compromised motor control
4. Neural tissue response
5. Serious pathology (Red flag, systematic disease, Circulatory problem)
6. Biopsychosocial mechanism – centrally maintained pain
 Classification in Diagnosis

▪ Musculoskeletal  Non musculoskeletal

– Acute (inflamattory, ▪ Functional (Chronic)
ischemic,nociceptive) Pain
– Sub acute ▪ Neuropathic Pain
– Chronic
• Improving
• Not improving but
stable
• Not improving but
relapsing
 Treatment

• Physical Therapy  Management

❖ Manual Therapy ? % ❖ can I do it alone?
❖ must I send the patient
❖ Electrotherapy ? %
to a multidisciplinary
❖ Exercise ? %
team?
▪ When do we chose each ❖ or to a specialist
one of them? (which one?) in
absence of the
multidisciplinary team
 Algorithm

Red flags, Neural tissue, Cauda equina, Vertebrobasilar system

Musculoskeletal or functional pain?

•Musculoskeletal Functional pain

• Pathology
• Disturbed function

Management

•Evaluation form

• Explain pain
• Electrotherapy ?
Manual therapy examination and treatment • Exercise
•Massage
• Placebo Manual Therapy etc
That was for now