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 or dysfunction is a complex cause of symptoms, impairments, funcitonal limitations and/or disability.
  

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

Mechanism of Injury (physical)

Physical injuries should be categorized according to the cause of their symtpoms in the following way:

1. Microtraumatic
2. Macrotraumatic
3. Microtraumatic and Microtraumatic

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.

Stage of the Condition

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 >6 weeks as chronic.

Acute: Early onset of symptoms. This patient is in the inflammatory phase of healing.

Subacute: The inflammatory phase of healing is subsiding and the patient should be in the reparative/proliferative phase of healing.

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

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.

Irritability

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.

Irritability

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.

Positive Patient Behaviors

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.

Negative Patient Behaviors

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

Phase of Healing

The phase of tissue healing is closely related to the prognosis of the patient.

Primary phases of healing include:

1. Inflammatory phase
   
2. Fibroblastic (Reparative or Proliferative) phase
   
3. Maturation (Remodeling) phase
   
4. Degenerative phase
   

Management

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

Slope of Recovery

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.

1. Static
2. Positive
3. Negative
4. Oscillating

Clinical Reasoning Forms

Clinical Reasoning - Post Subjective

Clinical Reasoning - Objective Planning

Clinical Reasoning - Post Objective

Recent Related Research (from Pubmed)

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