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Clinical Reasoning is the process by which a therapist interacts with a patient, collecting information, generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.  Treatment choice and patient management should be based on clinical reasoning using information gathered from the following categories.
<br>
Much of the clinical reasoning language utilized below has been modified from the Hypothesis-Oriented Algorithm for Clinicians 2nd Edition (HOAC II)<ref>Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003;83(5):455. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12718711</ref>
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=== Pathobiological Mechanisms  ===


*mechanisms relating to tissues - tissues injured, nature of injury, stage of healing<br>
*mechanisms relating to pain - input (nociceptive, neurogenic), processing (central, cognitive), output (motor, sympathetic).<br>


=== Nature (Biomechanical)<br> ===
== Introduction ==


There are 3 primary forces the human body must dissipate. The biomechanical nature of the condition helps the clinician to determine which of these forces may be the primary contributor to a patient's symptoms. For example: tension overload may be the primary biomechanical nature of a patient who is experiencing patellar tendonitis.  
Clinical Reasoning is the process by which a therapist interacts with a patient, collecting information, generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained. It has been defined as “an inferential process used by practitioners to collect and evaluate data and to make judgments about the diagnosis and management of patient problems"<ref name="Higgs">Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs J, Jones MA, Loftus S, Christensen N. Clinical reasoning in health professions. Amsterdam: Elsevier;2008. p. 4-19.</ref>. This clinical reasoning process sensitizes healthcare professionals to make the best judgment under specific circumstances, in relation to the patient and context.<ref>Gummesson C, Sundén A, Fex A. Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews. 2018 Jan 2;23(1):29-34.</ref>


*[[Compression]]
Clinical reasoning is “the sum of the thinking and decision-making processes associated with clinical practice”<ref name="Ed2004">Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. [http://ptjournal.apta.org/content/84/4/312 Clinical reasoning strategies in physical therapy]. Physical therapy. 2004;84(4):312-30.</ref><ref name="Higgs" />. During this process, the therapist analyses multiple variables contributing to the patient’s limited physical capacity (the ability to execute a task or action in a specific environment) and performance (what the patient can do in his or her own current environment). The key elements of the process include the generation of hypotheses of factors assumed to underlie the limitations of physical capacity and performance and the postulation of the magnitude of those factors. The therapist interacts with the patient and other persons involved in the patient's care (family, other health care professionals) and guides the patient in finding meaningful goals and health management strategies<ref name="Atkinson">Atkinson HL, Nixon-Cave K. [http://ptjournal.apta.org/content/91/3/416.full.pdf A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model]. Physical therapy. 2011;91(3):416-30.</ref>.
*[[Tension]]  
*[[Shear]]


=== [[Nature (Centrally Mediated)]]  ===
All decisions and actions need to be made in line with professional ethics and community expectations<ref name="Atkinson" />.


*Central symptoms or dysfunction is a complex cause of symptoms, impairments, funcitonal limitations and/or disability. <br>
The below 7-minute video is a good introduction to clinical reasoning
{{#ev:youtube|https://www.youtube.com/watch?v=6DzeF8hCNb8&app=desktop|width}}<ref>Rahul Patwari Clinical reasoning Available from:https://www.youtube.com/watch?v=6DzeF8hCNb8&app=desktop (last accessed 3.3.2020)</ref>  


=== Dysfunction/Impairment<br>  ===


Clinical manifestations of the pathobiological processes, these are the patients main problems at that time.<br>
== Clinical Reasoning  ==


*dysfunction - general physical dysfunction as described by the patient such as limitations in activity<br>restriction in participation
Clinical Reasoning is integral to physiotherapy practice. As a concept, clinical reasoning is quite a simple one; however in practice, it is difficult and fraught with errors. The aim of clinical reasoning is to prevent misdirection <ref name="Jones">Jones, M. Clinical reasoning and pain. Manual Therapy. 1995; 1:17-24.</ref> A robust clinical reasoning process is vital so the threshold of suspicion of serious pathology is at an appropriate level<ref name="G+S2008" />. The way a therapist clinically reasons their findings can strongly influence how the case is interpreted. This has implications as to how the clinician views the red flags and gives weight to any red herrings presented therein <ref name="G+S2004">Greenhalgh, S. and Selfe, J. [https://www.researchgate.net/publication/222425308_Margaret_A_tragic_case_of_spinal_Red_Flags_and_Red_Herrings Margaret: a tragic case of spinal Red Flags and Red Herrings]. Physiotherapy. 2004; 90:73-76.</ref>. It is done knowingly or unknowingly and is basically a cognitive process.
*impairment - specific impairments in body functions and structures identified on examination.<br>


=== Patho-Anatomic Hypothesis<br> ===
The most common form of clinical reasoning within the physiotherapy profession is hypothetico-deductive reasoning<ref name="Doody">Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy. 2002;88 (5): 258-268.</ref>. Within hypothetico-deductive reasoning, the clinician gains initial clues in regard to the patient's problem (from the subjective assessment), which forms the initial hypotheses in the therapist's mind. Further data is collected in the objective assessment, which may confirm or negate the hypotheses. Continual hypothesis generation may occur during management and reassessment<ref name="Ed2004" />. Identification and prioritization of pertinent clinical data to either support or negate the hypotheses form the basis of clinical reasoning.<ref>Richards JB, Hayes MM, Schwartzstein RM. Teaching clinical reasoning and critical thinking: from cognitive theory to practical application. Chest. 2020 Oct 1;158(4):1617-28.</ref>  


The actual anatomical location of the pathobiological mechanisms. What discrete anatomical structure is generating the primary complaint. [[More...]]<br>
Clinical reasoning consists of the following five dimensions:


=== Contributing Factors<br> ===
• cognition  


Any factor relating to the predisposition, development and maintenance of the problem<br>
• a discipline-specific knowledge base 


*physical - previous injury, nerve root involvement, pain provoked by multiple trunk movemements, reduced muscle control, reduced physical fitness
• metacognition, which means the individual’s awareness of his/her way of thinking 
*psychosocial - yellow flags determine a patients potential to proceed to chronicity.
*environmental
*emotional
*behavioural
*ergonomic
*cultural


==== Mechanism of Injury (physical) ====
• the role of the patient in the decision-making process  


Physical injuries should be categorized according to the cause of their symtpoms in the following way:
• contextual interaction<ref name="Higgs" />


#[[Microtraumatic]]  
[[Clinical Reflection|Reflection]] after the initial assessment and also after the subsequent sessions will help the therapist to recognise patterns and their clinical reasoning process will improve<ref name="Jones" /><ref name="G+S2008">Greenhalgh, S. Red Flags, and clinical Presentation Mapping. Available from: https://macpweb.org/home/index.php?m=file&amp;f=873. (accessed 21 October 2008)</ref>.
#[[Macrotraumatic]]
#[[Microtraumatic and Microtraumatic]]


<br>
== Process of Clinical Reasoning  ==


==== Problem List  ====
Clinical reasoning should begin as soon as the therapist meets the patient, as their behaviour can inform the therapist's clinical reasoning<ref name="G+S2008" />. There should be ongoing data collection which should not stop at the end of the assessment to aid this process. A hypothetico-deductive model of clinical reasoning can be seen in Figure 1.


===== [[Patient Identified Problems (PIP)]]<br>  =====
[[Image:Clinical reasoning.png|Figure 1: Hypothetico-deductive model of Clinical Reasoning  (Jones,1995).]]  


These are the patient identified problem(s), either in a symptom AND/OR functional limitation/disability level. <br>  
Figure 1: A Hypothetico-deductive model of Clinical Reasoning<ref name="Jones" />&nbsp;<br>  


===== [[Non Patient Identified Problems (NPIP)]]<br> =====
The therapist may be able to ascertain quickly that something is wrong with the patient due to the subjective and objective assessment along wither their subsequent clinical reasoning. The data gathered over sessions should be collated to best inform the therapist. This will contribute to the therapist's evolving concept of the patient's problem<ref name="G+S2008" /><ref name="Jones" />. The decision made at each step will influence the decision at the next step.


This is essentially a problem list generated by the clinician. This is an ongoing process of evaluation as the subjective examination and physical examination is taking place. <br>  
Another model used for clinical reasoning is the Dual process theory, i.e.,  the ability to balance intuition and analytical reasoning for a particular situation.<ref name=":0">Croskerry, P. (2015). Clinical Decision Making. In: Barach, P., Jacobs, J., Lipshultz, S., Laussen, P. (eds) Pediatric and Congenital Cardiac Care. Springer, London. <nowiki>https://doi.org/10.1007/978-1-4471-6566-8_33</nowiki></ref>It uses the concepts of deduction, induction and abduction for coming to a conclusion; however, developing this type of decision-making requires significant experience and exposure.<ref name=":0" />  


===== Anticipated Problems =====
== Pattern Recognition ==


These are problems that if they are not addressed, will lead to PIPs or NPIPs in the future. This is based on the clinicians utilization of best practice as well as there own prognostic skills. For example, research has shown that those wiht a BMI&nbsp;?25 kg/m<sup>2</sup> have an increased likliehood of disc degeneration, notably if this develops at an early age.<ref>Liuke M, Solovieva S, Lamminen A, et al. Disc degeneration of the lumbar spine in relation to overweight. International Journal of Obesity (2005). 2005;29(8):903-908. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15917859.</ref>  
Pattern recognition is an important part of clinical reasoning however, this will be limited in students and newly qualified physiotherapists<ref name="Jones" /><ref name="Doody" />.


=== Precautions<br> ===
Knowledge is also an important consideration. The newly qualified therapist is expected to have many more potential hypotheses in comparison to an experienced therapist<ref name="Jones" />. There are suggested to be differences between novice and expert therapists in the process of clinical reasoning<ref name="Doody" />. Although broadly similar, novice physiotherapists have to go through a long process of clinical reasoning compared to expert therapists due to a lack of knowledge comparison and less experience in pattern recognition. Figure 2 demonstrates the clinical reasoning process of expert therapists (with at least 3 years of experience) and novice therapists (with under three years of experience or students)<ref name="Doody" />.


*red flags - need referral on for appropriate medical intervention.<br>
[[Image:Diff in clinical reasoning.png]]
*yellow flags - highlight the need for a more detailed psychosocial assessment.<br>
*SIN factor - severity, irritability, nature.


=== Prognosis<br> ===
Figure 2: Difference in clinical reasoning between expert and novice therapists<ref name="Doody" />.


To predict potential improvement identify positive and negative prognostic indicators.&nbsp; Consider age, occupation, hobbies, previous treatment response, stage and stability od condition, general health, past medical history,&nbsp; pain mechanisms.<br>
== Problem solving ==
This approach is a content-specific process requiring rules and knowledge related to the text and context. The types vary according to different clinical cases or problems. It involves comparing, testing and analysing the case to determine what will be next in protocol and this keeps on going in a cycle till a desired result is achieved.


==== [[Stage of the Condition]] ====
== Patient Involvement in the Clinical Reasoning Process ==


The stage of the condition should closely follow the phases of healing. There is not a consistent language used across physical therapy literature on how to stage a condition. Some refer to symptoms lasting &gt;6 weeks as chronic.  
The patient should be an integral part of the clinical reasoning process, as this can help the clinician to form hypotheses and lead towards the review of the outcome post physiotherapy intervention<ref name="Jones" />(See Figure 3).  


Acute: Early onset of symptoms. This patient is in the inflammatory phase of healing.  
[[Image:Patient involve.png]]


Subacute: The inflammatory phase of healing is subsiding and the patient should be in the reparative/proliferative phase of healing.  
Figure 3: Patient involvement in the clinical reasoning process<ref name="Jones" />.  


Chronic: This patient should have completed the maturation stage of healing; however, there may be intrinsic or extrinisc factors limiting the complete recovery of this patient
Despite the desire of the physiotherapist to find logical connections between signs and symptoms that lead to specific functional diagnoses, this is not always readily achieved. In such instances, failure to get the pieces that will solve the puzzle may prove troubling and discomforting. But clear answers and ready explanations will not often be at hand, and becoming comfortable in the grey areas of clinical practice may be a prerequisite for compassionate and pathic practice in physiotherapy<ref>Chowdhury A, Bjorbækmo WS. Clinical reasoning—embodied meaning-making in physiotherapy. Physiotherapy Theory and Practice. 2017 Jul 3;33(7):550-9.</ref>.


Acute on Chronic: This patient has reinitiated the inflammatority phase of healing, on a previous chronic condition that may or may not have completed the maturation phase of healing.
== Approaches  ==


==== [[Severity|Irritability]]<br>  ====
[[Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)]]  


The irritiability also helps determine the vigorousness of your examination, the examination sequence and strategy, as well as the dosage of your intervention. The VAS (or audible pain scale of 0-10) is very helpful when determining the irritability. The average 24 hour VAS must be used in context. The presence or absence of pain at rest is helpful and over the course of the day. However, how easily pain is exacerbated and relieved may have just as much relevance. <br>
[[International Classification of Functioning, Disability and Health (ICF)]]


==== [[Irritability|Severity]]<br> ====
== Resources ==


This helps determine the vigorousness of the examination and the tactics of your intervention, notably the exact positions to avoid and dosage to control. Functional forms are primarily used to will help determine the severity of the condition. Pain scales (such as the VAS) may also be helpful in determining the severity, but these can be misleading at times as pain is a relative experience for each person. Therefore, how the symptoms affect function is a very helpful way to identify how severely this problem is affecting a persons function.<br>
[http://ptjournal.apta.org/content/91/3/416.full.pdf Physical Therapy Clinical&nbsp; Reasoning and Reflection&nbsp; Tool] - aims to integrate the ICF framework into the patient management model while incorporating the hypothesis-driven basis of CDM models


==== [[Positive Patient Behaviors]]<br>  ====
[http://getptsmart.com/ getPTsmart] - Tool to engage in the teaching and learning of clinical reasoning in a contemporary, time-independent environment that serves as a link between the classroom and clinical practice.<div class="research box"></div>  
 
These are behaviors that may improve a patient's prognosis. Example: active participant in plan of care, internal locust of control, trusts therapists judgement/rapport, compliant, respects therapists schedule.<br>
 
==== [[Negative Patient Behaviors]]<br>  ====
 
These are behaviors that may negatively affect a patient's prognosis. Example: fear avoider, kinesiophobia, passive participant in POC, non-compliant with recommendations, disrepect for therapists time, external locust of control<br>
 
=== Phase of Healing<br>  ===
 
The phase of tissue healing is closely related to the prognosis of the patient. <br>
 
Primary phases of healing include:<br>
 
#[[Inflammatory phase]][[Javascript:void(0);/*1315667019867*/|<br>]]
#[[Fibroblastic (Reparative) phase|Fibroblastic (Reparative or Proliferative) phase]]<br>
#[[Maturation (Remodeling) phase]]<br>
#[[Degenerative phase]]<br>
 
<br>
 
=== Management<br>  ===
 
Optimal management with a dynamic clinical working diagnosis should follow if all the above categories have been cosidered.
 
==== [[Strategy]] (of intervention)  ====
 
There are basic strategies of physical therapy intervention that may be employed.
 
#Stretch
#Soft Tissue Mobilization (STM)
#Joint Mobilization&nbsp;(JM)
#Strengthening/Stabilization
#Re-training/Re-education
#Education
#Offloading
#Pain inhibition
#Modalities/Physical Agents<br>
 
==== Tactics<br>  ====
 
*These are the detailed and specific elements of an intervention. Tactics specify the frequency, duration, and intensity of interventions.<br>
*In a direct access environment, the therapist decides the stategy and tactic(s) of the treatment, not the physician. In a non-direct access environment, the physician may at times request a specific strategy; however, they rarely dictate the tactics employed. Therefore, it is the therapists responsibility to prescribe and modify the tactics implemented. The strategy may be to strengthen, but the tactics will specificy: quadriceps eccentric load on single leg to maximimum tissue failure for 3 sets, 30 second rest between sets. 3 times per week. <br>
*The strategy to use ultrasound will need specific tactics to highlight the dosage. Example: 50% pulsed ultrasound, 1.0mhz, .5 w/cm^2, 8minutes, to insertion of extensor carpi radialis brevis, 1.5 ERA (effective radiating area).<br>
 
<br>
 
==== Post Test&nbsp;(Testing Criteria)<br>  ====
 
*These represent critical values that if attained, would suggest the hypothesis is correct and the associated problem/impairment are improving or has resolved.<br>
*Establishing valid post-test criteria is an important component of clinical reasoning as it helps to determine if the interventions are moving towards the goals. <br>
*This is different than goal setting as this is the specific testing employed to prove that your goals have been met, or that your goals are moving in a positive direction.<br>
*Example: You have a long term goal for a patient to have symmetrical quadriceps strength. Your post-test could look quite different.&nbsp;&nbsp; '''EXAMPLE''':&nbsp;hand-held maximum isometric strength in the 90 degree position of the knee VS. isokinetic strength throughout the entire range at a specific angular velocity to measure endurance over a 60 second period.<br><br>
 
==== [[Slope of Recovery]]<br>  ====
 
It is key to monitor the patients slope of recovery. Understanding the patients slope of symptoms and functions assists with case management, prognosis, as well as the dosage of interventions. These slopes can be categorized below.
 
#Static
#Positive
#Negative
#Oscillating
 
<br>
 
==== Discharge Criteria<br>  ====
 
When is the patient ready for discharge? When does optimal care end to address all key NPIP and PIP. You must also consider anticipated problems and the need for re-admittance to physical therapy secondary to inadequate rehabilitation. All patients must of course be discharged. There are some patients that will be discharged prior to the recommended time frame secondary to monetary constraints. Please assume that there are no significant monetary restraints (but be reasonable) and focus on what criteria is in the best interest of the patient as you complete this section. Someone with severe degeneration will be discharged with different criteria than an acute injury. Often, the patient will be ready for discharge because they are back to functioning normally but you are not pleased with their protective mechanisms and HEP intensity. To prevent reinjury, your D/C criteria may be very specific. For instance, normalized core ratios with McGill testing.<ref>McGill SM, Childs a, Liebenson C. Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Archives of physical medicine and rehabilitation. 1999;80(8):941-4. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10453772.</ref> Tolerating Core IV/V level exercises. Normal cervical ROM for a young neck. 110% of external rotation strength (per hand-held dynamometer) relative to the non-dominant throwing shoulder for a college pitcher. You may officially discharge this college pitcher 6—9 months after surgery. Consider the discharge criteria your absolute last patient encounter before they re-enter the general populace without limitations OR once they have reached their MMI (maximum medical improvement). <br> <br>
 
== Clinical Reasoning Forms  ==
 
{{pdf|ClinicalReasoning-PostSubjective.pdf|Clinical Reasoning - Post Subjective}}
 
{{pdf|ClinicalReasoning-ObjectivePlanning.pdf‎|Clinical Reasoning - Objective Planning}}
 
{{pdf|ClinicalReasoning-PostObjective.pdf‎|Clinical Reasoning - Post Objective}}
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1FMYHy0ufD8nUIKW849ycppSefJwaxCO9JIPBWnfknyDsepMfD|charset=UTF-8|short|max=10</rss></div>  
== References  ==
== References  ==


<references /><br>
<references />  
 
<br>  


[[Category:Articles]] [[Category:Assessment]]
[[Category:Assessment]]
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[[Category:Occupational Health]]
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Latest revision as of 14:47, 24 February 2023

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Introduction[edit | edit source]

Clinical Reasoning is the process by which a therapist interacts with a patient, collecting information, generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained. It has been defined as “an inferential process used by practitioners to collect and evaluate data and to make judgments about the diagnosis and management of patient problems"[1]. This clinical reasoning process sensitizes healthcare professionals to make the best judgment under specific circumstances, in relation to the patient and context.[2]

Clinical reasoning is “the sum of the thinking and decision-making processes associated with clinical practice”[3][1]. During this process, the therapist analyses multiple variables contributing to the patient’s limited physical capacity (the ability to execute a task or action in a specific environment) and performance (what the patient can do in his or her own current environment). The key elements of the process include the generation of hypotheses of factors assumed to underlie the limitations of physical capacity and performance and the postulation of the magnitude of those factors. The therapist interacts with the patient and other persons involved in the patient's care (family, other health care professionals) and guides the patient in finding meaningful goals and health management strategies[4].

All decisions and actions need to be made in line with professional ethics and community expectations[4].

The below 7-minute video is a good introduction to clinical reasoning

[5]


Clinical Reasoning[edit | edit source]

Clinical Reasoning is integral to physiotherapy practice. As a concept, clinical reasoning is quite a simple one; however in practice, it is difficult and fraught with errors. The aim of clinical reasoning is to prevent misdirection [6] A robust clinical reasoning process is vital so the threshold of suspicion of serious pathology is at an appropriate level[7]. The way a therapist clinically reasons their findings can strongly influence how the case is interpreted. This has implications as to how the clinician views the red flags and gives weight to any red herrings presented therein [8]. It is done knowingly or unknowingly and is basically a cognitive process.

The most common form of clinical reasoning within the physiotherapy profession is hypothetico-deductive reasoning[9]. Within hypothetico-deductive reasoning, the clinician gains initial clues in regard to the patient's problem (from the subjective assessment), which forms the initial hypotheses in the therapist's mind. Further data is collected in the objective assessment, which may confirm or negate the hypotheses. Continual hypothesis generation may occur during management and reassessment[3]. Identification and prioritization of pertinent clinical data to either support or negate the hypotheses form the basis of clinical reasoning.[10]

Clinical reasoning consists of the following five dimensions:

• cognition

• a discipline-specific knowledge base

• metacognition, which means the individual’s awareness of his/her way of thinking

• the role of the patient in the decision-making process

• contextual interaction[1]

Reflection after the initial assessment and also after the subsequent sessions will help the therapist to recognise patterns and their clinical reasoning process will improve[6][7].

Process of Clinical Reasoning[edit | edit source]

Clinical reasoning should begin as soon as the therapist meets the patient, as their behaviour can inform the therapist's clinical reasoning[7]. There should be ongoing data collection which should not stop at the end of the assessment to aid this process. A hypothetico-deductive model of clinical reasoning can be seen in Figure 1.

Figure 1: Hypothetico-deductive model of Clinical Reasoning (Jones,1995).

Figure 1: A Hypothetico-deductive model of Clinical Reasoning[6] 

The therapist may be able to ascertain quickly that something is wrong with the patient due to the subjective and objective assessment along wither their subsequent clinical reasoning. The data gathered over sessions should be collated to best inform the therapist. This will contribute to the therapist's evolving concept of the patient's problem[7][6]. The decision made at each step will influence the decision at the next step.

Another model used for clinical reasoning is the Dual process theory, i.e., the ability to balance intuition and analytical reasoning for a particular situation.[11]It uses the concepts of deduction, induction and abduction for coming to a conclusion; however, developing this type of decision-making requires significant experience and exposure.[11]

Pattern Recognition[edit | edit source]

Pattern recognition is an important part of clinical reasoning however, this will be limited in students and newly qualified physiotherapists[6][9].

Knowledge is also an important consideration. The newly qualified therapist is expected to have many more potential hypotheses in comparison to an experienced therapist[6]. There are suggested to be differences between novice and expert therapists in the process of clinical reasoning[9]. Although broadly similar, novice physiotherapists have to go through a long process of clinical reasoning compared to expert therapists due to a lack of knowledge comparison and less experience in pattern recognition. Figure 2 demonstrates the clinical reasoning process of expert therapists (with at least 3 years of experience) and novice therapists (with under three years of experience or students)[9].

Diff in clinical reasoning.png

Figure 2: Difference in clinical reasoning between expert and novice therapists[9].

Problem solving[edit | edit source]

This approach is a content-specific process requiring rules and knowledge related to the text and context. The types vary according to different clinical cases or problems. It involves comparing, testing and analysing the case to determine what will be next in protocol and this keeps on going in a cycle till a desired result is achieved.

Patient Involvement in the Clinical Reasoning Process[edit | edit source]

The patient should be an integral part of the clinical reasoning process, as this can help the clinician to form hypotheses and lead towards the review of the outcome post physiotherapy intervention[6](See Figure 3).

Patient involve.png

Figure 3: Patient involvement in the clinical reasoning process[6].

Despite the desire of the physiotherapist to find logical connections between signs and symptoms that lead to specific functional diagnoses, this is not always readily achieved. In such instances, failure to get the pieces that will solve the puzzle may prove troubling and discomforting. But clear answers and ready explanations will not often be at hand, and becoming comfortable in the grey areas of clinical practice may be a prerequisite for compassionate and pathic practice in physiotherapy[12].

Approaches[edit | edit source]

Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)

International Classification of Functioning, Disability and Health (ICF)

Resources[edit | edit source]

Physical Therapy Clinical  Reasoning and Reflection  Tool - aims to integrate the ICF framework into the patient management model while incorporating the hypothesis-driven basis of CDM models

getPTsmart - Tool to engage in the teaching and learning of clinical reasoning in a contemporary, time-independent environment that serves as a link between the classroom and clinical practice.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs J, Jones MA, Loftus S, Christensen N. Clinical reasoning in health professions. Amsterdam: Elsevier;2008. p. 4-19.
  2. ↑ Gummesson C, Sundén A, Fex A. Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews. 2018 Jan 2;23(1):29-34.
  3. ↑ 3.0 3.1 Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Physical therapy. 2004;84(4):312-30.
  4. ↑ 4.0 4.1 Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model. Physical therapy. 2011;91(3):416-30.
  5. ↑ Rahul Patwari Clinical reasoning Available from:https://www.youtube.com/watch?v=6DzeF8hCNb8&app=desktop (last accessed 3.3.2020)
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Jones, M. Clinical reasoning and pain. Manual Therapy. 1995; 1:17-24.
  7. ↑ 7.0 7.1 7.2 7.3 Greenhalgh, S. Red Flags, and clinical Presentation Mapping. Available from: https://macpweb.org/home/index.php?m=file&f=873. (accessed 21 October 2008)
  8. ↑ Greenhalgh, S. and Selfe, J. Margaret: a tragic case of spinal Red Flags and Red Herrings. Physiotherapy. 2004; 90:73-76.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy. 2002;88 (5): 258-268.
  10. ↑ Richards JB, Hayes MM, Schwartzstein RM. Teaching clinical reasoning and critical thinking: from cognitive theory to practical application. Chest. 2020 Oct 1;158(4):1617-28.
  11. ↑ 11.0 11.1 Croskerry, P. (2015). Clinical Decision Making. In: Barach, P., Jacobs, J., Lipshultz, S., Laussen, P. (eds) Pediatric and Congenital Cardiac Care. Springer, London. https://doi.org/10.1007/978-1-4471-6566-8_33
  12. ↑ Chowdhury A, Bjorbækmo WS. Clinical reasoning—embodied meaning-making in physiotherapy. Physiotherapy Theory and Practice. 2017 Jul 3;33(7):550-9.
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