Clinical Reasoning

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.

Original Editor - Rachael Lowe

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Pathobiological Mechanisms

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

Nature (Biomechanical)

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.

• Compression
• Tension
• Shear

Nature (Centrally Mediated)

• Central symptoms are often mediated by kinesiophobia, or fear of movement, or secondary gain issues (as seen with positive Waddel’s signs).
• This may be do to severe pain or often associated with fear that is mediated by past pain.
• Some conditions such as traumatic brain injury, spinal cord injury, phantom limb pain, and complex regional pain syndrome lead to neuropathic pain and may have a component of centrally mediated symptoms. Additionally, there may be a disruption of osteokinematics or tissue lengthening secondary to centrally mediated protective mechanisms.
• Some studies have shown that spinal ROM and even a SLR can be improved by simply helping the patient understand their symptoms.
  

References

Dysfunction/Impairment

Clinical manifestations of the pathobiological processes, these are the patients main problems at that time.

• dysfunction - general physical dysfunction as described by the patient such as limitations in activity
  restriction in participation
• impairment - specific impairments in body functions and structures identified on examination.
  

Patho-Anatomic Hypothesis

The actual anatomical location of the pathobiological mechanisms. What discrete anatomical structure is generating the primary complaint. More...

Contributing Factors

Any factor relating to the predisposition, development and maintenance of the problem

• physical - previous injury, nerve root involvement, pain provoked by multiple trunk movemements, reduced muscle control, reduced physical fitness
• psychosocial - yellow flags determine a patients potential to proceed to chronicity.
• environmental
• emotional
• behavioural
• ergonomic
• cultural
  

Patient Identified Problems (PIP)

These are the patient identified problem(s), either in a symptom AND/OR functional limitation/disability level.

Non Patient Identified Problems (NPIP)

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.

Precautions

• red flags - need referral on for appropriate medical intervention.
  
• yellow flags - highlight the need for a more detailed psychosocial assessment.
  
• SIN factor - severity, irritability, nature.

Prognosis

To predict potential improvement identify positive and negative prognostic indicators.  Consider age, occupation, hobbies, previous treatment response, stage and stability od condition, general health, past medical history,  pain mechanisms.

Management

Optimal management with a dynamic clinical working diagnosis should follow if all the above categories have been cosidered.

Clinical Reasoning Forms

Clinical Reasoning - Post Subjective

Clinical Reasoning - Objective Planning

Clinical Reasoning - Post Objective

Recent Related Research (from Pubmed)

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