Clinical Reasoning for Classification and Diagnosis

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Examination and Evaluation

Use a table to show differences:

Examination – the process of collecting or obtaining data and information about a patient’s condition through various methods such as observation, measurements and specific tests to collect information about the patient’s impairments, activity limitations and participation restrictions.

Why is clinical reasoning needed in an examination?

Clinical reasoning is necessary to select useful questions and measures based on the patient’s problems

Evaluation – the process of interpreting and integrating the data collected during the examination to make sense of all the information as a whole. It helps the rehabilitation professional draw conclusions about the patient’s condition, identify goals and to develop the treatment plan. Evaluation involves making judgements about the significance of the data, identifying patterns and relationships and determine the implications for rehabilitations

Why is clinical reasoning needed in evaluation?

Clinical reasoning is necessary to identify relationships between the patient’s primary problems, impairments, activity limitation and participation

Examination is about collecting data, while evaluation is about making sense of the data and using it to make informed decisions

At end of evaluation = diagnosis

Diagnosis helps to guide the treatment plan

Clinical Reasoning Strategies for Examination and Evaluation

Hypothetical deductive reasoning

Yazdani S, Hosseinzadeh M, Hosseini F. Models of clinical reasoning with a focus on general practice: a critical review. Journal of advances in medical education & professionalism. 2017 Oct;5(4):177.

Patient cues serve as key elements in creating multiple hypothesis

Hypothesis are continuously updated and refined as new information is included

Schaaf RC. Creating evidence for practice using data-driven decision-making. The American Journal of Occupational Therapy. 2015 Mar 1;69(2):6902360010p1-6.

Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003 May 1;83(5):455-70.

Narrative reasoning

Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991 Nov 1;45(11):998-1005.

Mattingly C. In search of the good: Narrative reasoning in clinical practice. Medical anthropology quarterly. 1998 Sep;12(3):273-97.

Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine as a medical education tool: a systematic review. Medical teacher. 2019 Jul 3;41(7):802-10.

Haines D, Wright J. Thinking in stories: Narrative reasoning of an occupational therapist supporting people with profound intellectual disabilities’ engagement in occupation. Occupational Therapy In Health Care. 2023 Jan 3;37(1):177-96.

Utilises stories to depict clinical encounters, incorporating conditions,  consequences, motivation and interaction  Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991 Nov 1;45(11):998-1005.

Helps clinicians gain insight into the patient experience and foster empathy skills Cruz EB, Caeiro C, Pereira C. A narrative reasoning course to promote patient-centred practice in a physiotherapy undergraduate programme: a qualitative study of final year students. Physiotherapy Theory and Practice. 2014 May 1;30(4):254-60.

In an educational contect, narrative reasoning involves sharing a story, individual reflection and the collaborative exchange of perspectives Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine as a medical education tool: a systematic review. Medical teacher. 2019 Jul 3;41(7):802-10.

In clinical practice rehabilitation providers use both to organise an examination and evaluate data

Hypothetico-deductive reasoning in Rehabilitation

In medicine diagnostic characteristics are more apparent – the medical diagnosis is the final step of the hypothetic deductive model.

For example, a patient presenting to the emergency room after waking up with left arm and leg feeling weak and heavy and a loss of balance. Facial drooping is noticed and the patient is unable to speak. The emergency care provider recognises the stroke-like symptoms (as noted by the Stroke Association’s warning signs – FAST) and identifies measures to rule in the hypothesis of a stroke and requests a CT scan to distinguish between ischemic and haemorrhagic strokes. The medical intervention will be different based on the outcome of the scan.

In rehabilitation, the final step of diagnosis or categorisation is not always that obvious. There may be diverse categories such as functional deficits, dysphagia or aphasia, and movement deviations.

Consider the following example:

A patient with left hemiplegia after stroke. The patient is unable to perform activities of daily living involving self-care. She has difficulty dressing and grooming. The patient experiences difficulty with swallowing and talking. She also has a foot drop on the left side affecting her gait and increasing her risk of falling. She has a multidisciplinary team of rehabilitation professionals working collaboratively to provide the best possible care.

ICF

Example of ICF Model

Using the ICF model and Hypothetic-deductive reasoning

Example:

A 12-year old female patient with spastic cerebral palsy has difficulty with mobility, fine motor skills and self-care tasks. She also has difficulties with speech and communication. A multidisciplinary rehabilitation team, consisting of a physiotherapist, occupational therapist, prosthetist and speech and language therapist is working collaboratively to address her needs.

Classification of problems according to the ICF Framework

Body structures and functions

Increased muscle tone in lower limbs

Limited range of motion in hip and knee joints

Reduced lower limb strength and coordination

Limited articulation of words

Difficulty in forming coherent sentences

Reduced ability to be understood by unfamiliar listeners

Activities

Limitations

Difficulty walking independently

Challenges with fine motor skills (such as writing, buttoning clothes)

Impaired speech affects communication

Participation

Difficulty with activities of daily living (ADLs) such as dressing and eating

Limited participation in physical activities at school

Social interactions affected by speech difficulties

Environmental factors

The patient has a supportive family environment and an accessible home with the necessary modifications. Her school provides an inclusive setting with support services.

Personal factors

The patient is highly motivated and cooperative. She enjoys drawing and participating in creative activities.

Hypothetico-deductive reasoning process

Physiotherapist

During the examination the physiotherapist observes that the patient is walking with a pronounced limp and requires the use of a walker. Spasticity and limited range of motion in the lower limbs are observed.

Hypothesis: Spasticity and muscle weakness in the lower limbs can impair the patient’s ability to walk independently. The limited range of motion in joints can affect the patient’s mobility.  Possible outcome measures that the physiotherapist can use as part of the evaluation to test their hypothesis are the GMFM scale to assess the patient’s gross motor scales and changes in function over time. The FMS may be used to measure her mobility in different environments. If the patient scores low on the GMFM on the FMS this may indicate limitations in gross motor functions and mobility.

These findings will help with goal setting and the treatment plan. Goals may include: improving lower limb strength, reducing spasticity and improving walking ability. Interventions may include strengthening exercises, stretching routines and gait training.

Occupational therapist

During the examination the occupational therapist notes that the patient has difficulties with buttoning her shirt, writing and using utensils when eating.

Hypothesis: Spasticity in the upper limbs may affect the patient’s fine motor skills. A lack of adaptive tools may hinder her ability to perform daily tasks independently. Possible tests may include the PEDI to evaluate the patient’s capabilities and performance in daily tasks.

Goals may include: improve ADL performance of the patient with fine motor skill exercises (e.g. play-based therapy, hand exercises) and recommendation of adaptive tools to help with daily activities (e.g., writing aids, modified utensils)

Prosthetist

During the examination, the patient’s gait is observed and with the assessment of her current orthoses, it is clear that the current orthotic devices are worn out and causing discomfort.

Hypothesis: The current orthotic devices may not provide adequate support and may need adjustment. Custom orthoses could improve the patient’s stability and walking ability.

Goals may include: better orthotic support for lower limbs and collaborate with physiotherapist to integrate orthoses into gait training

Speech and language therapist

The speech therapists observes the patient’s speech during their interactions.

Hypothesis: Muscle tone issues may contribute to articulation difficulties. The patient’s limited vocabulary and comprehension are affecting communication. The GTFA and PPVT can be used to evaluate the patient’s speech and language.

Goals may include enhanced speech clarity, improve sentence formation and increase overall communication effectiveness by interventions such as articulation therapy, language development activities and the use of augmentative and alternative communication devices

HOAC-II and hypothetico-deductive reasoning

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