Clinical

Reasoning DPTI Mentoring Program

What is Clinical Reasoning?

Interaction of individuals in a

collaborative exchange to achieve a

mutual understanding of the problem and

negotiate a plan

Patient-centered

Deductive and inductive reasoning

Complex, non-linear, CYCLICAL

Critical role in reflective learning

Clinical Reasoning or

Evidence Based Practice?

Clinical Reasoning is a process that is used

and guides the clinicians where and

when good quality evidence does not

exist or cannot be applied due to a

variety of factors (time, resources, patient

values, etc.)

What is Clinical Reasoning?

Integration of best clinical research,

knowledge gained through clinical

practice, knowledge gained through

personal or like experience.

Clinical Reasoning and Expert Practice

Collaborative/ Patient centered

Clinical Pattern Development

Hypothetico-deductive reasoning

Diagnosis reasoning

Treatment reasoning

Errors in Clinical Reasoning

Failure to generate initial concept of the

problem

Wrong hypothesis/ inadequate testing

Confirmation Bias (tendency to look,

notice, remember what fits with pre-

existing expectations)

Outcome Bias- over reliance of the

outcome of the treatment intervention

Limiting Error

Awareness of clinical errors

Include screens/ examination questions

that would disprove your hypothesis

Clinical pattern recognition

Differential Diagnosis of

Soft Tissue Pathology: Muscle

History

Unaccustomed

activity

Repetitive

eccentric activity

Sudden/

unexpected strain

Direct trauma

Physical Examination Pain with

contraction Pain at endrange

stretch

Tender to palpation over muscle belly or trigger point

Imbalance length and strength

Swelling may be present

Differential Diagnosis of

Soft Tissue Pathology: Tendon

History

Recent repetitive activity

Midrange arc of pain with ROM

Direct trauma

Physical Examination Pain with isometric

contraction while joint is maintained in mid/ endrange or repetitive contraction

Weakness with mod-major pathology

Palpable tenderness

Muscle imbalance of length/ strength

Differential Diagnosis of

Soft Tissue Pathology: Bursa

History

Recent overuse

Unaccustomed

pressure

Acute:

Pain at rest

Pain with all

motions

Physical

Examination

Reproduces with

direct palpation

Differential Diagnosis of

Soft Tissue Pathology: Capsule

History

Acute

Trauma

Sudden,

unguarded mvtmt

Swelling

Pain with motion

Chronic

Stiffness

Physical Exam:

*Capsular Pattern

Pain at endrange

of motion

Worse in one

direction

Differential Diagnosis of

Soft Tissue Pathology: Ligament

History

Trauma

Postural: sustained

position

Physical Exam:

Acute

Swelling, compensatory

Partial tear: pn testing

Complete: Laxity

Postural: Pn with OP in one direction

Eased with movement in opposite direction

Differential Diagnosis of

Soft Tissue Pathology: Disc

History

Recurring episodes

Worse with flexion

25-45

Referred pain

Physical Exam

Location changes

with movement

Loss of lordosis

Peripheralization/

centralization

Lateral shift?

Reduced with

unloading

Differential Diagnosis of

Soft Tissue Pathology: Nerve

History

Paresthesia/

numbness

Lancinating pain

Pulling

Physical Exam

Positive Neuro

Screen

Sensation, reflex or

myotomal loss

Position nerve

tension test

Palpable nerve

tenderness

Differential Diagnosis of

Soft Tissue Pathology: Dura

History

Multisegmental

Pain

Pain/ Paresthesia

assoc

Headache,

“entire” spine,

extremities, ANR

Physical Exam

Positive Slump Test

Abnormal tension

testing

Differential Diagnosis of

Hard Tissue Pathology: Fracture History

Trauma

Minor if osteoporotic

Aching/ throbbing

Pain at rest

Pain worse with movement

Pain with stress

Unusual location of pain

Stress fracture: rapid increase in activity

Physical Exam

Deformity may be

present

Grinding or grating

Point tenderness

Confirm with

diagnostics

Differential Diagnosis of

Hard Tissue Pathology: Avulsion,

Tendon Rupture, Ligament Tear

History

Trauma

Pain, swelling

Loss of function

Bony deformation

Instability

Joint Locking

Physical Exam

Special tests

confirm

Surgical consult

Differential Diagnosis of

Hard Tissue Pathology: Subchondral

Articular cartilage, DJD/ OA

History

Gradual onset

Insidious

Pain/ stiffness

Increase with WB

Progressive

Physical Exam

ROM deficits

Mild

Pn with compression

Pn with endrange stress

Strength deficits

Biomechanic changes

Diagnostics confirm

Subjective Exam

“ The patient is the most valuable source

of information and our ability to extract

that information will determine our depth

of understanding, and subsequently our

ability to manage the patient’s problem.”

Subjective Exam

However, the patient will not know what is not important and cannot be expected to know what we do, and do not need to know. This is important as we need to be skilled in helping patients through accounts of their problems and virtually teach patients how to listen to their own bodies and inform us of relevant information.”

-Jones and Butler 1991

Subjective Exam

Nonverbal communication

Spontaneous information

Use patient’s words

Active listener

Never assume anything

Assume responsibility

Subjective Examination:

Inquiry Strategies

Open-ended questions

Directed questions

Forced choices

Repetition of the story

Subjective Examination:

Self Assessment

Communication

Clear and Concise?

Non-verbal behaviors interacting?

Rapport established?

Effectively perceiving, interpreting?

Spontaneous information?

Using patient’s words?

Assumptions?

Open ended questions?

Relevant observation?

Subjective Examination:

Self Assessment

Collaboration

Patient’s initial concept of problem?

Drawing information from patient’s frame of reference?

Learning promoted?

Explanations?

Self management?

Negotiation?

Goals?

Subjective Examination:

data gathering

Is all information useful?

Is all of the necessary information

gathered?

Was a search and scan method used?

Any confirmation bias?

Was an initial impressions/ concept of the

patient used?

Subjective Examination:

data gathering

Establish ‘kind’ of disorder

Site/ Area of symptoms

Behavior of symptoms

Special questions/ med history

Present episode

Related past history

Subjective Examination:

data gathering- body chart

Map out each component separately

Depth

Varying/ Non-varying

Constant/ Intermittent

Relate different areas

Paresthesias

Subjective Examination:

data gathering- body chart

Identify all structures in each location of pain that could be “possible” sources of pain

Remember….

somatic (local)

referred- any pain felt away from source

radicular- must have neurological loss

peripheral

vascular

visceral

latent- pain that does not occur immediately

Subjective Examination:

Completion- Can you answer?

Mechanical vs chemical

“Kind of disorder”

Body region primarily to be examined

Body regions to be cleared

Neurological exam

Degree of provocation

Severity, irritability, nature, stage, stability

Hypothesis

Subjective Examination: Completion- Have you developed?

Hypothesis

Nocioceptive

Central vs. Autonomic

Source

Precautions/ Contraindications

Contributing Factors

Management

Prognosis

Contraindications/ Precautions

Malignancy Cauda Equina Cord Lesion Active Inflammatory Process Recent Fracture Osteoporosis

Neurological Signs RA Spondylolisthesis Hypermobility Dizziness

Subjective Examination:

Completion- Can you answer?

Patient Severity: Clinician’s assessment of the intensity of patient’s complaint and influence on functional activities

Patient Irritability: Amount of aggravating activity provoke symptoms, intensity of symptoms provoked, amount of time for symptoms to settle to previous level, problems with sleeping

Nature of Problem: Clinicians assessment/ hypothesis of the structures or pathology responsible for producing the patient’s symptoms and any relevant contributing factors.

Subjective Examination:

Completion- Can you answer?

Nature: Progression of Symptoms,

progression overall of repeated episodes

Stability: Predictability, consistency of

symptoms, consistency of movement or

resting

Physical Examination: Purpose

Identify Potential Sources

Identify Contributing Factors

Goals:

Determine structure that is involved

Reproduce symptoms

Pattern of movement comparable with history

Refine, support or rule out hypothesis

Establish baseline

Physical Examination

Posture and Observation

Neurologic Screen

Active Range of Motion

Passive and Physiologic Motion

Palpation

Flexibility

Motor Function

Assessment

“Although a clinician must possess a skill in

the area of examination and treatment,

the most important skill of all is that of

assessment, and the skilled use of

assessment in the overall process of

analytical assessment and clinical

reasoning” -Maitland

Assessment Assessment at end of initial examination

Assessment during performance of technique

Assessment after application of forces

Assessment at the end of treatment session

Assessment at the beginning of the next treatment session

Retrospective assessment

Assessment at completion of treatment

Assessment: Communication

Perspective of Patient

Assume Nothing

Comparative/ Baseline

Spontaneous/ Open ended Questioning