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1
Introduction to
Clinical Reasoning
BPT First Year
Saurab Sharma, MPT
Lecturer, KUSMS
Contents
• Definition of Clinical Reasoning
• Decision Tree Process
• Models of Clinical Reasoning
• Types of Clinical Reasoning
• Hypothesis Categories
2
Objectives of the class
At the end of the class, students should be able to:
• Define clinical reasoning
• Explain “Decision Tree Process”
• Explain models of Clinical Reasoning
• List the types of clinical reasoning
• Elaborate the hypothesis categories
3
 How do we decide about the assessment and
management of the various problems of our
patients?
4
A case study
• A 37 year old female suffers right lateral elbow pain since
7 months which initially increased by squeezing and
gripping activities. She pain gradually increased and did
not have any history of injury. She is a house wife and
occasionally works in the fields. She is married and has a
child. She has a very supportive family. She was treated
by surgeon with corticosteroid injection twice causing
temporary symptom control for 3 months. Her pain is
increasing despite of treatment and rest. Now she cannot
perform most of her activity of daily living including eating,
brushing, bathing etc.
5
By an
internal thought process called
Clinical Reasoning
6
7
Clinical reasoning
 A process of thinking or reasoning which is used
by all the clinicians for the diagnosis and
management of their patients.
 Done knowingly or unknowingly
8
Clinical reasoning - Definition
• A thought process that guides practice.
• It is a cognitive process by which the
information contained in a clinical case or
situation is synthesized, integrated with the
clinician’s knowledge and experience and
used to diagnose and manage patient’s
problems
9
Decision Tree Process
Evaluation
Treatment planning
Re-evaluation
Test interpretation
The decision made at each
step influences the
decision made at each
subsequent step.
Mental Strategies During Decision Tree Process:
11
Cue acquisition
Hypothesis generation
Cue interpretation
Hypothesis evaluation
Assessment (History and
examination)
Provisional Diagnosis
Evaluating which cue is
important for particular
hypothesis
Selecting hypothesis
supported from above
steps
Models of clinical reasoning:
1. Hypothetico-deductive reasoning
2. Pattern recognition, and
3. Problem solving
12
Hypothetico-deductive Reasoning
 Backward reasoning
 Sequential reasoning, uses decision tree
1. collect information
2. form hypotheses about specific aspects of
the problems
3. confirm or reject the hypotheses
13
Pattern Recognition
 In familiar non-problematic situations
 Experts don’t always go through the decision
tree process
 Recognize familiar patterns without analyzing
the individual behaviors
14
Pattern Recognition
 Forward Reasoning
 Expert’s well structured clinical knowledge and
experience.
 Clinician compares current pattern with
previously seen pattern
 Eg: lateral elbow pain-> tennis elbow
15
Pattern Recognition
 In the case mentioned earlier, it is evident that
the problem the woman had was lateral
epicondylalgia because she has lateral elbow
pain with pain increasing with gripping
activities.
16
Problem Solving
 Is context-specific process requiring rules
and knowledge related to the task and
context.
 Different types of problem solving strategies
are used depending upon types of clinical
problems or cases.
17
Problem Solving
18
Which is the best model?
 No SINGLE answer
 Clinicians use all of these models, since no
single model would be appropriate in all
circumstances
19
Types of Clinical Reasoning
20
1. Procedural
2. Interactive
3. Conditional
21
Clinical Reasoning:
Hypothesis Categories
1. Dysfunction
2. Pathobiological mechanisms
3. Source and cause of the symptoms
4. Contributing factors
5. Precautions and contraindications
6. Prognosis
7. Management
22
Mark Jones and Darren Rivett, 2005
Hypothesis Categories
23
1. Dysfunction/ Impairment
Hypothesis Categories
24
2. Pathobiological mechanism
Hypothesis Categories
25
I
O
CP
2. Pathobiological mechanism
Case
• The pain was supposed to reduce after rest and
medication in a couple of weeks or more. But should have
lasted for 7 months as the tissue would have healed.
What is causing/ contributing the ongoing pain?
• Is she worrying about the pain? How stressful is she
because of pain?
• What has she been told about her problem?
• By family members
• By treating physicians
• By her inner self?
26
Case continued…
• ……As nothing seems to reduce her pain, she is very
worried that the pain will never resolve and cries most of
the time. Her family members, though are very supportive,
but they had experienced a family member on her
husband’s side had similar arm pain, and who eventually
had gangrenous limb, had to undergo amputation and
finally passed away. She is convinced by her family
members that she will have similar fate as the pain is
ongoing. Her surgeon suggested for surgery if the patient
does not respond after physiotherapy and corticosteroid
injections.
27
Case
Pain Mechanism
Input
Output
Central processing
28
29
30
31
32
33
Hypothesis Categories
34
3. Sources of symptoms
Hypothesis Categories
• Somatic local
• Somatic referred
• Neural
• Vascular
• Visceral
35
3. Sources of symptoms
Hypothesis Categories
36
4. Contributing factors
Hypothesis Categories
1. Physical/ biomechanical: muscle, joint etc
2. Ergonomics/ work
3. Emotional: anxiety, depression
4. Cognitive: attention, memory
5. Behavioral: fear avoidance, coping
6. Social: broken relation, family issues
7. Environmental: climate, surface of work
37
4. Contributing factors
Case ….
• … Her pain really seems to be contributed by the fear that
her family members have imposed on her and which is
strengthened by the advice of the surgeon. She is
affected emotionally, has social contribution to pain, she is
not working and constantly worrying about the pain.
38
Hypothesis Categories
39
5. Precautions and contraindications
Case…
• ….. As her family members suggested, it could be a
severe condition also e.g., tumor. The reason is, patient is
having constant pain, cannot sleep at night because of
night pain. The pain gradually developed and peaked over
time. The pain doesn’t seem to respond by conservative
treatment after months of treatment.
• Thus, assessing for any red flags is essential.
40
Case … clinical reasoning
• It is less likely to be tumor, because on further queries,
patient did not report of previous history of tumor, does
not have unexplained weight loss, no local swelling. She
has less pain when she protects her arm and more pain
when she moves.
• Ruling out the presence of flags or any precautions is
absolutely necessary for the safety of physiotherapy
assessment and treatment, and thus for the treatment and
outcome.
41
Hypothesis Categories
42
6. Prognosis
Hypothesis Categories
• Favorable prognosis:
• Young age
• Mechanical
• Non irritable
• Good general fitness
• Non stressful occupation
• Early treatment/ Acute stage
43
6. Prognosis
Case
• The prognosis can be better if provided the cognitive
factors, illness perception and family members’
understanding of her pain is changed.
• Relatively young age, supportive family, no other
comorbidities will help her improve faster.
• Chronicity of the problem, yellow flags, irritable problem
will delay her prognosis.
• Thus, good education, assurance, goal directed physical
therapy can help her problem, but it will take longer time.
44
Hypothesis Categories
45
7. Treatment
Hypothesis Categories
• Input/output dominant: hands on technique
• Central processing dominant: hands off
technique
• Ongoing analytical assessment
46
7. Treatment
Case
• As this person has dominant central contribution of pain,
she will need interventions to target her brain than her
elbow. Interventions such as assurance, explain pain,
cognitive behavioral therapy and graded motor imagery
may help.
• This can then be progressed to target the impairments
and activity limitations by graduated exercises, manual
therapy etc.
47
Take home message
• Assessment and management of a problem is not
constant.
• It involves complex thought processes and reasoning.
• Starting thinking about the patients problem:
• Why is it hurting? What are the factors contributing?
• What structures are involved?
• Is it because of severe problem: e.g., any flags?
• Will this patient improve?
• What treatment should I give? why? How much? How?
48
Objectives of class
At the end of the class, students should be able to:
• Define clinical reasoning
• Explain “Decision Tree Process”
• Explain models of Clinical Reasoning
• List the types of clinical reasoning
• Elaborate the hypothesis categories
49
Summary
References and further reading
• Mark Jones. Clinical Reasoning for Manual Therapists.
2005
• Lester E. Jones, Desmond F.P. O’Shaughnessy. The Pain
and Movement Reasoning Model: Introduction to a simple
tool for integrated pain assessment. Manual Therapy 19
(2014) 270e276.
• Hengeveld and Banks. Maitland's Peripheral
Manipulation. 4th Edition. 2005
50

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Clinical reasoning in physiotherapy

  • 1. 1 Introduction to Clinical Reasoning BPT First Year Saurab Sharma, MPT Lecturer, KUSMS
  • 2. Contents • Definition of Clinical Reasoning • Decision Tree Process • Models of Clinical Reasoning • Types of Clinical Reasoning • Hypothesis Categories 2
  • 3. Objectives of the class At the end of the class, students should be able to: • Define clinical reasoning • Explain “Decision Tree Process” • Explain models of Clinical Reasoning • List the types of clinical reasoning • Elaborate the hypothesis categories 3
  • 4.  How do we decide about the assessment and management of the various problems of our patients? 4
  • 5. A case study • A 37 year old female suffers right lateral elbow pain since 7 months which initially increased by squeezing and gripping activities. She pain gradually increased and did not have any history of injury. She is a house wife and occasionally works in the fields. She is married and has a child. She has a very supportive family. She was treated by surgeon with corticosteroid injection twice causing temporary symptom control for 3 months. Her pain is increasing despite of treatment and rest. Now she cannot perform most of her activity of daily living including eating, brushing, bathing etc. 5
  • 6. By an internal thought process called Clinical Reasoning 6
  • 8. Clinical reasoning  A process of thinking or reasoning which is used by all the clinicians for the diagnosis and management of their patients.  Done knowingly or unknowingly 8
  • 9. Clinical reasoning - Definition • A thought process that guides practice. • It is a cognitive process by which the information contained in a clinical case or situation is synthesized, integrated with the clinician’s knowledge and experience and used to diagnose and manage patient’s problems 9
  • 10. Decision Tree Process Evaluation Treatment planning Re-evaluation Test interpretation The decision made at each step influences the decision made at each subsequent step.
  • 11. Mental Strategies During Decision Tree Process: 11 Cue acquisition Hypothesis generation Cue interpretation Hypothesis evaluation Assessment (History and examination) Provisional Diagnosis Evaluating which cue is important for particular hypothesis Selecting hypothesis supported from above steps
  • 12. Models of clinical reasoning: 1. Hypothetico-deductive reasoning 2. Pattern recognition, and 3. Problem solving 12
  • 13. Hypothetico-deductive Reasoning  Backward reasoning  Sequential reasoning, uses decision tree 1. collect information 2. form hypotheses about specific aspects of the problems 3. confirm or reject the hypotheses 13
  • 14. Pattern Recognition  In familiar non-problematic situations  Experts don’t always go through the decision tree process  Recognize familiar patterns without analyzing the individual behaviors 14
  • 15. Pattern Recognition  Forward Reasoning  Expert’s well structured clinical knowledge and experience.  Clinician compares current pattern with previously seen pattern  Eg: lateral elbow pain-> tennis elbow 15
  • 16. Pattern Recognition  In the case mentioned earlier, it is evident that the problem the woman had was lateral epicondylalgia because she has lateral elbow pain with pain increasing with gripping activities. 16
  • 17. Problem Solving  Is context-specific process requiring rules and knowledge related to the task and context.  Different types of problem solving strategies are used depending upon types of clinical problems or cases. 17
  • 19. Which is the best model?  No SINGLE answer  Clinicians use all of these models, since no single model would be appropriate in all circumstances 19
  • 20. Types of Clinical Reasoning 20 1. Procedural 2. Interactive 3. Conditional
  • 21. 21
  • 22. Clinical Reasoning: Hypothesis Categories 1. Dysfunction 2. Pathobiological mechanisms 3. Source and cause of the symptoms 4. Contributing factors 5. Precautions and contraindications 6. Prognosis 7. Management 22 Mark Jones and Darren Rivett, 2005
  • 26. Case • The pain was supposed to reduce after rest and medication in a couple of weeks or more. But should have lasted for 7 months as the tissue would have healed. What is causing/ contributing the ongoing pain? • Is she worrying about the pain? How stressful is she because of pain? • What has she been told about her problem? • By family members • By treating physicians • By her inner self? 26
  • 27. Case continued… • ……As nothing seems to reduce her pain, she is very worried that the pain will never resolve and cries most of the time. Her family members, though are very supportive, but they had experienced a family member on her husband’s side had similar arm pain, and who eventually had gangrenous limb, had to undergo amputation and finally passed away. She is convinced by her family members that she will have similar fate as the pain is ongoing. Her surgeon suggested for surgery if the patient does not respond after physiotherapy and corticosteroid injections. 27
  • 29. 29
  • 30. 30
  • 31. 31
  • 32. 32
  • 33. 33
  • 35. Hypothesis Categories • Somatic local • Somatic referred • Neural • Vascular • Visceral 35 3. Sources of symptoms
  • 37. Hypothesis Categories 1. Physical/ biomechanical: muscle, joint etc 2. Ergonomics/ work 3. Emotional: anxiety, depression 4. Cognitive: attention, memory 5. Behavioral: fear avoidance, coping 6. Social: broken relation, family issues 7. Environmental: climate, surface of work 37 4. Contributing factors
  • 38. Case …. • … Her pain really seems to be contributed by the fear that her family members have imposed on her and which is strengthened by the advice of the surgeon. She is affected emotionally, has social contribution to pain, she is not working and constantly worrying about the pain. 38
  • 40. Case… • ….. As her family members suggested, it could be a severe condition also e.g., tumor. The reason is, patient is having constant pain, cannot sleep at night because of night pain. The pain gradually developed and peaked over time. The pain doesn’t seem to respond by conservative treatment after months of treatment. • Thus, assessing for any red flags is essential. 40
  • 41. Case … clinical reasoning • It is less likely to be tumor, because on further queries, patient did not report of previous history of tumor, does not have unexplained weight loss, no local swelling. She has less pain when she protects her arm and more pain when she moves. • Ruling out the presence of flags or any precautions is absolutely necessary for the safety of physiotherapy assessment and treatment, and thus for the treatment and outcome. 41
  • 43. Hypothesis Categories • Favorable prognosis: • Young age • Mechanical • Non irritable • Good general fitness • Non stressful occupation • Early treatment/ Acute stage 43 6. Prognosis
  • 44. Case • The prognosis can be better if provided the cognitive factors, illness perception and family members’ understanding of her pain is changed. • Relatively young age, supportive family, no other comorbidities will help her improve faster. • Chronicity of the problem, yellow flags, irritable problem will delay her prognosis. • Thus, good education, assurance, goal directed physical therapy can help her problem, but it will take longer time. 44
  • 46. Hypothesis Categories • Input/output dominant: hands on technique • Central processing dominant: hands off technique • Ongoing analytical assessment 46 7. Treatment
  • 47. Case • As this person has dominant central contribution of pain, she will need interventions to target her brain than her elbow. Interventions such as assurance, explain pain, cognitive behavioral therapy and graded motor imagery may help. • This can then be progressed to target the impairments and activity limitations by graduated exercises, manual therapy etc. 47
  • 48. Take home message • Assessment and management of a problem is not constant. • It involves complex thought processes and reasoning. • Starting thinking about the patients problem: • Why is it hurting? What are the factors contributing? • What structures are involved? • Is it because of severe problem: e.g., any flags? • Will this patient improve? • What treatment should I give? why? How much? How? 48
  • 49. Objectives of class At the end of the class, students should be able to: • Define clinical reasoning • Explain “Decision Tree Process” • Explain models of Clinical Reasoning • List the types of clinical reasoning • Elaborate the hypothesis categories 49 Summary
  • 50. References and further reading • Mark Jones. Clinical Reasoning for Manual Therapists. 2005 • Lester E. Jones, Desmond F.P. O’Shaughnessy. The Pain and Movement Reasoning Model: Introduction to a simple tool for integrated pain assessment. Manual Therapy 19 (2014) 270e276. • Hengeveld and Banks. Maitland's Peripheral Manipulation. 4th Edition. 2005 50

Editor's Notes

  1. Being physiotherapist, we come across many patients with variety of clinical conditions everyday and our job involves finding out their problems and making an appropriate treatment plan for them.
  2. Decision tree process is defined as a sequence of decisions involved in problem management that takes into account the uncertainty of events at each step. (Watts, 1985) The decision made at each step influences the decision made at each subsequent step.
  3. (Scadding, 1967; Barrows and Feltovich, 1987)
  4. (Scadding, 1967; Barrows and Feltovich, 1987)
  5. (Scadding, 1967; Barrows and Feltovich, 1987)
  6. Procedural- Like SOAP notes that students practice Interactive- considers patient as a whole- NOT just a disease (?ICF)- When therapists use interactive reasoning, they focus on how they should interact with the person rather than only dealing with the diagnosis & management of condition. Conditional- Conditional reasoning can be defined as the multidimensional process that involves complicated forms of thinking. Conditional reasoning creates an image of the patient that is provisional, holistic and conditional on patient participation.