Clinical reasoning

The Maitland concept requires open-mindedness, mental agility and mental discipline linked with a logical and methodical process of assessing cause and effect. The central theme demands a positive personal commitment (empathy) to understand what the person (patient) is enduring. The key issues of ‘the concept’ that require explanation are personal commitment, mode of thinking, techniques, examination and assessment.

(Maitland 1987, p. 136)

Clinical reasoning defined

More simply it is the thinking and decision making associated with clinical practice that enables therapists to take the best-judged action for individual patients. In this sense, clinical reasoning is the means to ‘wise’ action (Cervero 1988, Harris 1993).

• When we become critical thinkers we develop an awareness of the assumptions under which we, and others, think and act

• We learn to pay attention to the context in which our ideas and actions are generated

• We become sceptical of quick fix solutions, of single answers to problems, and of claims of universal truth

• We also become open to alternative ways of looking at and behaving in the world

• Critical thinking influences all aspects of our lives. For example, in our personal relationships we can learn to see our own actions through the eyes of others

• At our workplace we seek democracy and take initiative in forming new directions

• We become aware of the potential for distortion and bias in media depictions

• We value political freedom, we practice democracy, we encourage a tolerance of diversity, and we hold in check the demagogic tendencies of politicians.

• Improve lifelong learning

• Avoid misdirection in beliefs

• Discover alternative understandings and solutions and generate new ideas

• Optimize health care outcomes

• Improve social interactions

• Analyze arguments of others thereby making you less susceptible to manipulation by others

• Increase earning power; and

• Enrich your life aesthetically by becoming more observant.

No matter how much we may think we have an accurate sense of our practice, we are stymied by the fact that we are using our own interpretive filters to become aware of our own interpretive filters! … To some extent we are all prisoners trapped within the perceptual frameworks that determine how we view our experiences. A self-confirming cycle often develops whereby our uncritically accepted assumptions shape clinical actions which then serve only to confirm the truth of those assumptions. It is very difficult to stand outside ourselves and see how some of our most deeply held values and beliefs lead us into distorted and constrained ways of thinking and practicing.

• Experts excel in their own domains

• Experts possess large repertoire of well-developed profession specific patterns they recognize

• Experts solve problems fast with less error

• Experts see problems at a deeper level, spending more time analyzing problems qualitatively (i.e. more aware of contextual cues in the presentation)

• Experts have strong self-monitoring skills

• Experts possess the affective dispositions necessary to learn from their experiences including:

• Experts value participation of others (patients, family, other health professionals)

• Experts value different forms of knowledge in their reasoning (research and experienced based)

• Experts' theory, practice, reasoning and intuition are intertwined through practical experience

• Experts are patient-centred, collaborative with superior practice based knowledge. For example patients are viewed as active participants in therapy

• Primary goal of care is empowerment of patients through collaboration between patient and therapist

• Expert has a strong moral commitment to beneficence or doing what is in the patient's best interest

• Expert is willing to serve as a patient advocate or moral agent in helping them become successful

• Experts have good communication skills

• Experts use collaborative problem-solving to help patients learn how to resolve their problems on their own, fostering self-efficacy and empowering them to take responsibility

• Experts share their expertise to assist others; and

• Experts communicate their reasoning well at an appropriate level depending on who they are speaking to.

• Clinical reasoning is situated within a bio-psychosocial model of health

• Clinical reasoning is complex, non-linear and cyclical in nature involving both inductive and deductive reasoning

• Clinical reasoning is patient-centred involving a collaborative exchange to achieve a mutual understanding of the problem and to negotiate an agreed-upon plan for addressing that problem

• Clinical reasoning requires different foci of thinking, or ‘reasoning strategies’ within which expert physiotherapists make judgments

• Clinical reasoning plays a critical role in reflective learning from practice experiences and in the development of clinical expertise.

…dispenses with the scientifically archaic principles of dualism and reductionism and replaces the simple cause-and-effect explanations of linear causality with reciprocal causal models.

(Engel 1978, p. 175)

The physiotherapist's thinking

The therapist's reasoning is an ongoing hypothesis-oriented process of perception, interpretation and synthesis of information. Information about or from the patient must first be perceived as relevant and then interpreted. Both perception and interpretation are directly related to the therapist's knowledge base (e.g. novices often miss relevant information, struggle to identify and give weight to the most relevant information, and may interpret information incorrectly or superficially). Once identified and interpreted, information must then be synthesized with other information obtained. This is a higher order thinking skill, again directly related to the clinician's organization of knowledge. It is useful to conceptualize the working interpretations made throughout the patient examination and ongoing management as hypotheses as this discourages premature conclusions. Instead, further information obtained is interpreted and considered against existing hypotheses (i.e. tested) as either supporting or not-supporting. This process of hypothesis generation involves a combination of specific data interpretations or inductions (generalizing from the specific) and the synthesis of multiple clues or deductions (instancing from generalizations) that, taken together, has been characterized as hypothetico-deductive or ‘backward reasoning’ (Arocha et al. 1993, Patel & Groen 1991). In this sense clinical reasoning is a cyclic process of information perception and interpretation (i.e. hypothesis generation) followed by further information collection, interpretation and synthesis (i.e. hypothesis testing, modification and additional hypothesis generation). The reassessments following treatment interventions represent another example of hypothesis testing as reflected in the arrow in Figure 2.2 which runs from reassessment back up to the therapist's evolving understanding of the problem and person. It is important for student physiotherapists to learn to think on their feet. While examination routines are helpful to ensure a thorough and systematic assessment of the neuro-musculoskeletal system, examination by rote (i.e. simply following a protocol without reasoning) is inefficient and likely to lead to recipe treatments that are not tailored to the individual patient and so are less effective.

The hypothetico-deductive reasoning process portrayed in the left side of Figure 2.2 underpins the diagnostic process used in medicine and physiotherapy. While experts with extensive experience and superior knowledge are often able to use pattern recognition (discussed later) to circumvent extensive generation and testing of competing hypotheses when confronting familiar presentations (Elstein & Schwarz 2002, Kaufman et al. 2008, Patel & Groen 1986, Patel et al. 1986), the process of differential diagnosis still exists as typically the two or three most likely patterns are considered. However, where medical diagnosis normally has a disease or pathology focus, physiotherapy physical diagnostic reasoning tends to incorporate a broader analysis of the patient's functional capabilities and physical impairments along with their established or hypothesized pathology as they relate to the presenting activity and participation restrictions (APTA 2003, Jensen et al. 2007, Jones & Rivett 2004).

The patient's thinking

Understanding the patient as a person rather than simply their biomedical physical problems requires understanding their perspectives or their thoughts, feelings, self-efficacy and coping strategies as reflected in the boxes on the right side of Figure 2.2. Patients' beliefs and feelings which are counterproductive to their management and recovery can contribute to their lack of involvement in the management process, poor self-efficacy and ultimately a poor outcome. Patients acquire their own ideas and associated feelings regarding their health problems from their personal experiences including advice from medical practitioners, family and friends. While typically not thought of as such, these can be equated to their ‘hypotheses’ regarding what is going on with their body, how serious it is and what can and should be done about it. A brief summary of research findings demonstrating the potential influences of patients' perspectives on their clinical presentation, expectations and willingness to self-manage follows.

Patients' perspectives of their problem have been shown to impact on their levels of pain tolerance, attempts to adjust or cope, their mood and pain related disability and eventual outcome (Craig 2006, Flor & Turk 2006, Gottlieb et al. 2001, Jensen et al. 2003, King et al. 2002, Williams & Keefe 1991, Wilson et al. 1993). Levels of anxiety have been shown to influence pain severity, complications following surgery and days of hospitalization (DeGroot et al. 1997, Pavlin et al. 1998, Salkovskis 1996). Anxiety is most common when symptoms are unexplained, the future is uncertain and the patient is concerned about the perception of others. A reciprocal relationship exists so that negative thoughts elicit negative moods and negative feelings in turn adversely influence patients' appraisals of their problem. Reduction in pain-related anxiety has been demonstrated to predict improvement in functioning, affective distress, pain and activity levels (McCracken & Gross 1998). Patients' preoccupation with negative thoughts and self-statements about their circumstances and future prospects (i.e. ‘catastrophizing’) is a risk factor for pain-related fear and long-term disability (Pincus 2004, Vlaeyen & Linton 2000). Greater worry about pain is also associated with hypervigilance, or over-attention and misinterpretation of body sensations. Negative, unhelpful thoughts tend to relate to the meaning patients attribute to their problem or pain. Patients with low self-efficacy (i.e. low perception and confidence in ability to cope and make a change) tend to be convinced their own efforts will not be successful and tend to use less constructive coping strategies. This perceived helplessness has been related to pain level and disability (Gatchel et al. 2007).

Assessment, management and reassessment of patients' thoughts and feelings contribute to both the patient's and the therapist's evolving understanding of the significance these factors have to the clinical presentation. When unhelpful thoughts and feelings are successfully addressed patients gain a deeper understanding of their problem that includes recognition of the extent to which their incorrect and often excessively negative perspectives have been contributing to it. This new more constructive understanding enhances their self-efficacy and self-management. Assessing a patient's perspectives requires an understanding of what makes up a health perspective.

Health perspectives (pain, illness, self)

Research into patient's health and disability perspectives highlights important components that make up a patient's understanding/beliefs and concerns about their problem. The experience of pain is integrally associated with personal perceptions and social influences such that patients' pain perceptions, experiences and coping combine into a pain or disability experience lived as a whole (Kleinman et al. 1992, Sim & Smith 2004). As such, the various elements can never truly be isolated. However, greater understanding of the components of the pain experience and their interrelationships is important to guiding what information the physiotherapist listens for and seeks out (either through questionnaire or interview) when attempting to understand the person and any psychosocially related factors that may be contributing to their presentation. Research in medical anthropology, medical sociology and cognitive psychology has all contributed to the understanding of illness representations or schemas (e.g. Bishop 1991, Pincus & Morley 2001, Skelton & Croyle 1991, Sim & Smith 2004, Turk & Rudy 1992). Leventhal et al. (1980) put forward the notion that patients' mental representations of health threats determine how they respond to those threats. Illness schemata are defined as individuals' ‘implicit theories of illness’ that they use in order to interpret and respond to health threats. These illness (or pain) schemas are like imprints, or patterns of interconnected features, learned (consciously or unconsciously) through social and personal experiences. Skelton and Croyle (1991, p. 4) report on illness cognition research that demonstrates illness schemas comprise the following elements:

Research has also identified a number of dimensions that people use in evaluating their health problem including their perception of its seriousness, social desirability, personal responsibility, controllability and changeability (Bishop 1991). Therefore it is not only the person's existing beliefs and assumptions that make up their illness schema and contribute to determining their coping but also their appraisal of the threat their medical condition poses. This highlights the importance of assessing, and if necessary addressing through education, the patient's threat appraisal (Jones & Edwards 2006, Moseley 2004).

A person's understanding, expectations and concerns about different types of pain (e.g. needle injection pain, toothache pain, back pain, etc.) would make up their pain schema which Pincus and Morley (2001) suggest comprises beliefs regarding the immediate sensory-intensity, spatial and temporal features of pain along with the initial affective responses and self-protective behaviours that ensue. The pain schema would also likely include a similar appraisal as the illness schema regarding its seriousness and controllability/changeability.

Lastly, Pincus and Morley (2001) discuss a ‘self’ schema as a complex multifaceted construct that relates to who you are with reference to who you used to be (prior to your perceived change in self) and who you would like to be in the future. It includes an evaluative dimension that contributes to an individual's sense of self-worth. Pain and disability have the potential to disrupt aspects of the self, such that repeated failures to function ‘normally’ and the negative emotions that result can lead to changes in a person's self-image (Osborn & Smith 1998, Sim & Smith 2004, Steen & Haugli 2000).

Pincus and Morley (2001) also propose that these different schemas can be enmeshed so that a pain schema for example may enmesh with an illness schema and elicit interpretations of the pain as a marker or part of a larger illness or health problem. Similarly, perceptions of the threat a pain condition or illness may create can be enmeshed with the patient's self-worth as with the chronic back pain patient whose pain has not been adequately explained by the medical system who develops perceptions (real or imagined) that his family, employer and/or co-workers don't believe him, causing him to feel he is not a good work-mate, spouse, parent, etc.

The value of this concept of different pain, illness and self schemas to patients' presentations is not for physiotherapists to attempt to classify a patient's schemas or their theoretical schema enmeshment, instead the value is to our clinical reasoning and the scope of patient perspectives we listen for and seek out when attempting to assess psychosocial factors. Patients are clearly not homogeneous when you consider the different pathologies that can cause pain and disability, the continuum of any particular pathology (minor to extensive), the physical impairments that can predispose to the problem or be created by the problem, and the different perspectives (understandings, beliefs, fears, coping mechanisms, self-image, etc.) that exists in varying combinations. This is important to our clinical reasoning as it highlights theory we must understand (e.g. pain and disability associations with psychosocial factors), skills we must acquire in order to assess (e.g. questioning about psychosocial factors, questionnaires to use) and manage (e.g. education and cognitive-behavioural strategies, referral pathways) this dimension of our patients' presentations. Understanding patients' perspectives is also important as their understanding, attributions, feelings, etc., will influence other perspectives. For example, expectations of management such as the perspective ‘my disc is out’ causing the expectation that nothing can be done or perhaps physical/passive treatment is required; expectations regarding personal responsibility and self-management, such as the perspective/belief that ‘the problem is my degenerative spine’, without appreciating the physical (e.g. relative flexibility, motor control, fitness), lifestyle and environmental factors that may have predisposed the degenerative spine to become symptomatic and require a significant contribution of self-management; and expectations regarding the future as with the perspective ‘my back-knee-shoulder, etc. is stuffed and I will never be able to work-exercise-etc. again’. Understanding patients' problems diagnostically and understanding patients' perspectives require considerable bio-psychosocial research and practice knowledge.

The level of education physiotherapists receive in psychosocial assessment and management varies considerably. Jones and Edwards (2006) have suggested the following categories of information are screened when assessing patients' perspectives (i.e. psychosocial status):

As a measure of their ‘motivation’ the patient can then be asked: ‘On a scale of 0 to 100, how ready are you to make these changes? How important are these changes to you? How confident/ able are you to make these changes?’

There is now also a wide range of questionnaires available for screening patients' psychosocial related issues (see Table 2.1 for an example). While these questionnaires provide a helpful resource, on their own they are insufficient to guide the physiotherapist's management. They provide useful insight to a patient's thoughts, beliefs and feelings but they generally do not provide the basis of those thoughts and feelings. As such, physiotherapists need to review the completed questionnaire with the patient to explore further the patient's answers. That is, questionnaires such as these should not be seen as a replacement for the interview questions suggested above, rather they should be used as an adjunct and an objective means of documenting and scoring patients' psychosocial status.

It is beyond the scope of this chapter to extend this discussion to the physical and cognitive-behavioural management strategies needed to address patient perspectives judged as contributing to their disability and/or presenting as obstacles to their recovery. However, there is now very helpful physiotherapy literature providing suggestions on assessment and management strategies specifically targeting patients' unhelpful thoughts, feelings and behaviours (e.g. Harding 1998, Johnson & Moores 2006, Keefe, Scipio & Perri 2006, Kendall & Watson 2000, Main & Watson 2002, Main et al. 2008, Muncey 2002, Strong & Unruh 2002).

Clinical reasoning as collaboration between therapist and patient

Thinking of clinical reasoning through examination and management as a therapeutic alliance where collaboration, rather than simply compliance, is sought is important to encourage students and therapists to involve their patients in the decision making process (Edwards et al. 2004b, Higgs & Hunt 1999, Jensen et al. 2002, Payton et al. 1998, Trede & Higgs 2008). While obviously the patient has come to the physiotherapist seeking their expertise, treatment and advice, patients who have been given an opportunity to share in the decision making have been shown to take greater responsibility for their own management, are more satisfied with their health care (reducing risk of formal complaints) and have a greater likelihood of achieving better outcomes (Arnetz et al. 2004, Edwards et al. 2004b, Trede & Higgs 2008). Despite acknowledging the importance of being collaborative with their patients many physiotherapists do not respond to patients' life and treatment priorities or work with patients in collaboratively setting goals (Edwards et al. 2004b). Patient learning (i.e. altered understanding and improved health behaviour), improved self-efficacy and shared responsibility in management are primary outcomes sought in a collaborative reasoning approach.

Therapist learning also occurs through collaboration. That is, when patients are given the opportunity to tell their story rather than simply answer questions, reflective therapists, who attend to individual patient presentations noting features that appear to be linked (such as increased stress affecting one patient's symptoms but not another's), will learn the variety of ways in which patients' health, cognition, behaviour, movement and pain can interact. Specific strategies for involving patients in their health care, including when differences in opinion exist, are addressed by Edwards et al. (2004b) and Trede and Higgs (2008).

The box on the far left-hand side of Figure 2.2 highlights important variables influencing the therapist's clinical reasoning including their knowledge base, their cognitive, metacognitive (including critical thinking), and their data collection skills.

Socratic questioning

Thinking is driven by questions in that questions define or clarify issues being discussed. An open and questioning mind is a prerequisite to skilled critical thinking and reasoning which in turn cultivates deep learning. The art of asking questions and pursuing answers originated by Socrates (Athens, c. 469–399 BC), called ‘Socratic questioning’, is based on the notion that thinking (e.g. interpretations, opinions, analyses, conclusions) has a logic or structure that underpins it that typically is not evident in the initial expression (Paul & Elder 2007). The purpose of Socratic questioning is to clarify and understand the logic of someone's thought (including your own through critical reflection). Paul and Elder (2006, pp. 54–55) note that:

Through disciplined questioning complex ideas and concepts can be explored, truth can be sought, unrecognized issues and problems can be revealed, assumptions can be made apparent, what is known and not known can be made evident and the logical implications of thought can be highlighted. From an educator's perspective Paul and Elder (2006, p. 55) highlight the value of successful Socratic questioning discussions to:

Edited examples of different types of Socratic questions related to critical thinking in general (but also relevant to critical thinking in the clinic) as suggested by Paul and Elder (2006, pp. 5–7, 20–23) are highlighted in Box 2.1.

Clarification for precision

There are many situations where the patient makes a general statement that requires clarification to understand precisely their meaning. Examples include such things as constancy of symptoms (where clarification of ‘constant’ reveals daily symptoms but not every moment of the day); area of symptoms (where for example patient's perception of their ‘shoulder’ is clarified to actually be their supraspinous fossa); and aggravating factors (where for example ‘walking’ requires clarification regarding what aspect of the walking is a problem – time, speed, distance, surface, phase of gait, etc.?).

Clarification for accuracy

Patient responses are often generalizations where the lack of accuracy can lead to misinterpretations. Examples here include reassessments of previous treatment sessions (where the patient reports no benefit but clarification reveals symptoms significantly improved for a period of time before returning); and patient reports of what others have said or the attitude/support of others (e.g. doctors, employers, family) that reflect the patient's perspective but not always reality.

Clarification for relevance

While it is important to always give patients a voice and an opportunity to tell their story, it is also necessary to control the interview for time management. This requires considerable communication skills to establish the relevance of a particular tangent the patient seems to be taking and diplomacy to bring them back on track while still conveying interest.

Clarification for completeness

Completeness (thoroughness) of examination and reassessments is necessary to ensure nothing important is missed. This relates to another clinical reasoning tactic referred to as ‘screening questions’.

Screening questions

Patients will typically volunteer the information they feel is important and related to their main problem. However, they will often not appreciate the potential importance of other information they may feel is unrelated. Without thorough screening, information may be missed and as a result reasoning compromised. Important areas to use screening questions for completeness include mapping out the patient's symptoms, establishing their behaviour of symptoms and medical screening for precautions and contraindications to examination and treatment.

While the patient will obviously describe their main complaint they may not feel other symptoms and problems in other body areas are relevant. Clearing other body areas, as emphasized by Maitland, ensures the main complaint is considered in the context of the patient's broader health presentation. For example, when clarified a recent peripheral joint pain may turn out to be part of a broader systemic disorder, only recognized when further screening reveals involvement of other joints. Similarly, patients will report their main symptom(s) but may not consider other symptoms as relevant or may not even recognize other feelings as symptoms until questioned. Examples of common neuromusculoskeletal symptoms that should be screened for include:

As with mapping out the patient's symptoms, when questioning in order to determine aggravating factors, patients will often only mention what they remember or consider most significant. However, if the therapist is reasoning through the examination they should, based on the patient's area of symptoms, consider different structures that may be involved and with that knowledge direct further questions to ‘test’ those hypotheses. For example, a posterior buttock pain may be emanating from the hip, the sacroiliac joint, the buttock muscles/soft tissues, a neural source (e.g. sciatic or nerve root), or be referred from the lumbar spine. While no aggravating activity will affect a single joint or structure in isolation, questions about other potential aggravating factors that tend to affect one area more than another can assist the evolving picture. For example, if the buttock pain is worsened by crossing the legs and/or squatting, the hip and/or sacroiliac joint-associated tissues are incriminated. This can then be considered against other aggravating factors explicitly screened for which relate to spinal movements and neurodynamics; it may also highlight movements and structures that must be examined and differentiated. The third main area where it is important to screen for completeness, medical screening for precautions, and contraindications to examination and treatment will be discussed later within the section on Hypothesis Categories.

Effects of therapist's questioning/manner on the patient

While the patient interview is largely about gaining information to understand the patient and their problem, the nature and manner (i.e. tone, non-verbal behaviours) of the therapist's questions and responses to patient answers will influence the interest the patient perceives the therapist has in them, the confidence they have in the therapist and the success of the therapeutic relationship in general (Klaber et al. 1997). Maitland emphasized the importance of establishing patient rapport through the interest and belief conveyed in what they say and through the thoroughness of examination you demonstrate. Our questions and responses (verbal and non-verbal) are interpreted by patients as conveying our thoughts. Many patients report negative experiences with medical and other health professionals who they felt didn't listen or believe them. Without good rapport the patient is less likely to collaborate in providing the necessary information or participate in the management jeopardizing the eventual outcome.

Skilled questioning should be open but specific. The therapist should seek understanding of the person and their problem(s), be efficient while giving the patient a voice, and constantly clarify responses for precision, accuracy, relevance and completeness. The therapeutic relationship, reasoning and outcome are all enhanced when the therapist's listening and responding conveys interest, acknowledgement/empathy, respect, and collaboration while reserving judgment. While patients may need to be challenged at some stage regarding their beliefs, attitudes and health behaviours, argumentation should be avoided and where possible opportunities should be sought to support patient self-efficacy. Patients are unlikely to make the necessary lifestyle changes unless they believe they have the capacity to do so. Brief summaries of your understanding of the patient's story, including your assessment of their perspectives, are important to validate the patient's meaning. While physical impairments such as range of movement and strength are quantitative measures that can be judged against established normative data, patient perspectives represent qualitative data that does not lend itself to absolute interpretations of normality (i.e. adaptive versus maladaptive/unhelpful perspectives) and hence require validation with the patient (Edwards et al. 2004b, Stewart et al. 2011).

Clinical reasoning strategies

While clinical reasoning is often equated with diagnostic decision making, in reality that represents only a small portion of the reasoning that actually occurs in clinical practice. In a qualitative research study of clinical reasoning in physiotherapy, Edwards and colleagues (Edwards 2000, Edwards et al. 2004a) identified patterns in the focus of expert physiotherapists' clinical reasoning in three different fields of physiotherapy (musculoskeletal, neurological and domiciliary care). Individual expert therapists in all three fields employed a range of ‘clinical reasoning strategies’, despite the differing emphases of their examinations and management. The clinical reasoning strategies identified were each associated with a range of diverse clinical actions. While this was the first physiotherapy study to elucidate expert physiotherapists use of this full range of strategies, they have been identified previously either by research, by theoretical proposition or by an exposition of the relevant skills in the literature of medicine, nursing, occupational therapy and physiotherapy under the following names: diagnostic or procedural reasoning (Elstein et al. 1978, Fleming 1991); interactive reasoning (Fleming 1991); conditional or predictive reasoning (Fleming 1991, Hagedorn 1996); narrative reasoning (Benner et al. 1992, Mattingly 1991); ethical reasoning (Barnitt & Partridge 1997, Gordon et al. 1994, Neuhaus 1988); teaching as reasoning (Sluijs 1991); and collaborative decision making (Beeston and Simons 1996, Jensen et al. 2007, Mattingly & Fleming 1994). The clinical reasoning strategies identified by Edwards and colleagues (Edwards 2000, Edwards et al. 2004a) can be grouped broadly under a classification of ‘Diagnosis’ and ‘Management’ as follows:

Activity capability/restriction

Patients' activity capabilities and restrictions directly relate to the ICF framework of health and disability presented in Figure 2.1 and refer to the patient's functional abilities and restrictions (e.g. walking, lifting, sitting, etc.) that are volunteered and for which they are further screened. To gain a complete picture it is important the therapist identifies those activities the patient is capable of alongside those that are restricted.

Participation capability/restriction

Patients' participation capabilities and restrictions refer to the patient's abilities and restrictions to participate in life situations (e.g. work, recreation/sport, family, etc.). Again, determining participation capabilities, including modified participation (e.g. modified work duties) is important as this will contribute to other decisions such as prognosis and management. It is particularly important to pay attention to the proportionality of activity and participation restrictions and the physical pathology/impairments identified through examination. When activity and participation restrictions are out of proportion to identified pathology and physical impairments then it is likely the patient's perspectives on their experience (i.e. psychosocial factors) will be negatively contributing to their disability.

Patient perspectives on their experience

Patient perspectives on their experience relates to the patient's psychosocial status which the therapist tries to understand through their narrative reasoning (as discussed earlier in this chapter under ‘The patient’s thinking’). It incorporates such things as the patient's understanding of their problem (including attributions about the cause and beliefs about pain), their goals and expectations for management, the stressors in their life and any relationship these have with their clinical presentation, as well as the effects the problem and any stressors appear to have on their thoughts, feelings, motivations, their coping and self-efficacy.

Pathobiological mechanisms

The pathobiological mechanisms category incorporates hypotheses about pathology or tissue mechanisms and hypotheses about pain mechanisms. While neither of these can be validated on the basis of a clinical examination alone, biomedical knowledge of pathology and pain combined with clinical and research supported knowledge of typical clinical patterns enables therapists to hypothesize with reasonable confidence about the likely pathology and dominant pain mechanism, both of which have implications to other categories of decisions including precautions/contraindications, management and prognosis.

Pathology within the neuromusculoskeletal system can be considered at both the process and structure levels. For example, in some presentations the process (e.g. inflammatory, degenerative, ischaemic, infection, etc.) or syndrome (e.g. stenosis, impingement, instability) underpinning a person's pain and disability can be identified even when the exact structures or tissues cannot be confirmed. In other presentations the pathology can be confirmed through a combination of clinical and medical investigations (e.g. spondylolisthesis, muscle tears/tendinopathy, disc disease, etc.). Since pathology can be asymptomatic and clinical presentations within a symptomatic pathology will vary according to the extent of pathology and influence of both physical and psychological factors, skilled clinical reasoning necessitates that the therapist avoid simply administering prescribed pathology focused treatments. Rather, therapists must consider the safety and management implications of a hypothesized pathology and then strike a balance between treating the associated physical impairments and unhelpful patient perspectives while also utilizing research evidence and theory supporting pathology directed treatments (e.g. tendinopathy – Cook & Purdam 2009; intervertebral disc – Adams et al. 2010, exercise for tissue repair – Khan & Scott 2009; Van Wingerden 1995, etc.).

Pain mechanisms refer to the different input, processing and output mechanisms underlying the patients' activity/participation restrictions, unhelpful perspectives and physical impairments. These are explained more comprehensively elsewhere (e.g. Butler 2000, Fields et al. 2006, Gifford 1998a, 1998b, 1998c, Gifford et al. 2006, Meyer et al. 2006) but briefly the input mechanisms include the sensory and circulatory systems that inform the brain about the internal and external environment. Two input pain mechanisms relevant to physiotherapists are nociceptive mechanisms and peripheral neuropathic mechanisms (Butler 2000, Galea 2002, Gifford 1998a, Gifford 1998d, Meyer et al. 2006, Wright 2002). Technically all pain perception is an output from our central nervous system as nociceptive activity following a noxious stimuli will always be subjected to central modulation and it is this modulation that ultimately determines whether pain is perceived or not. However, clinically it is useful to recognize patterns of pain perception associated with nociceptive activity triggered by a peripheral stimulus such as tissue injury or overload. That is, nociceptive pain involving chemical and mechanical activation of nociceptors in somatic or visceral tissues such as joints, muscles, bone, meninges, peripheral nerve sheaths and the various viscera has a recognizable clinical pattern (Butler 2000, Smart et al. 2012a, Wolf 2011). While clinical patterns for different pain mechanisms are not fully validated, broadly nociceptive pain includes local symptoms plus or minus referral to areas of common segmental innervation (Bielefeldt & Gebhart 2006, Bogduk 1993, Schaible 2006, Smart et al. 2012a, Vicenzino et al. 2002) (chronic nociceptive pain may only present with referred symptoms), a predictable stimulus-response relationship with aggravating and easing factors (Butler 2000, Nijs, Van Houdenhove & Oostendorp 2010, Smart et al. 2012a), a history of either trauma or specific predisposing factors (e.g. overload, new activity, etc.), physical impairments that are proportional to the symptoms, activity and participation restrictions and a predictable response to treatment.

Peripheral neuropathic pain refers to symptoms with contributions from neural tissue outside the dorsal horn or cervicotrigeminal nucleus as occurs with spinal nerve root or peripheral nerve irritation/compression. Peripheral neuropathic pain can be less clear in its presentation (Butler 2000, Devor 2006, Gifford 1998d). Common features include: the type of symptoms (e.g. numbness, pins and needles, weakness, burning, itching, etc.); quality of symptoms (severe, shooting if acute); area of symptoms (distribution according to nerve although nerve root pain is typically not in classic dermatomes while paraesthesias are more dermatomal; Smart et al. 2012b); symptoms often worse at night; symptoms aggravated by movements and positions that compress or stretch the involved nerve (Smart et al. 2012b) or by situations that elicit stress or anxiety (possibly reflecting a component of central sensitization); symptoms eased by movements and positions that unload the nerve; physical impairments in neural conduction (i.e. positive neurological findings), neural mechansensitivity (i.e. positive neurodynamic and neural palpation findings) and in interfacing tissues that can compress or irritate neural tissue (e.g. structures forming borders of intervertebral foramina, adjacent muscles and fascia).

Central processing refers to the neural modulation of both input and output that occurs throughout the central nervous system/neuromatrix (e.g. Fields et al. 2006, Gatchel et al. 2007, Melzack 2005, Moseley 2003, Nijs et al. 2010, Wolf 2011) in response to internal and external sensory inputs including physical (e.g. overloaded tissues), cognitive and emotional input (e.g. thoughts, fears, anxiety, frustrations, self-efficacy, etc.). While the central nervous system is always processing input and generating output, maladaptive central processing is known to underpin some pain states causing increased responsiveness to a range of stimuli including emotional stressors, mechanical pressure, chemical substances, light, sound, cold and heat (Nijs et al. 2010). The increased sensitivity (or decreased load tolerance) can co-exist with somatic or visceral noxious stimulus nociception but can also be evoked or maintained without a peripheral noxious stimulus. Symptom provocation therefore occurs out of proportion to existing pathology and can even exist when overt pathology no longer exists. Wolf (2011) reports evidence that central sensitization has been demonstrated in a wide range of conditions commonly treated by physiotherapists including rheumatoid arthritis, osteoarthritis, temporomandibular disorders, fibromyalgia, chronic musculoskeletal disorders, headache, neuropathic pain, complex regional pain syndrome, post-surgical pain and visceral pain hypersensitivity syndromes. With central sensitization normally non-noxious stimuli and loads become provocative often creating false positive findings in the physical examination (i.e. physical testing is provocative despite the lack of overt pathology) leading to ineffective management when pain mechanisms are not understood (Butler 2000, Gifford 1998c).

Currently diagnostic criteria and biomarkers for central sensitization are lacking (Wolf 2011). However, contemporary thinking extrapolated from a broad range of research supports the observation that maladaptive central symptoms no longer follow the predictable pattern of pain with nociceptive and peripheral neuropathic contributions (Butler 2000, Nijs et al. 2010, Smart et al. 2012c, Wolf 2011). Instead, activity and participation restrictions and symptoms are typically out of proportion to the physical impairments and the symptom behaviour is less predictable with spontaneous pains, latent pains, inconsistent stimulus-response relationships to aggravating and easing factors and more pronounced associations with psychosocial stressors. Pain may be disproportionate to the nature and extent of injury or pathology with strong association to psychosocial factors and diffuse, non-anatomical areas of pain or tenderness to palpation (Smart et al. 2012c). Traditional nociceptively oriented therapies may produce short-term gains but are themselves ineffective in making lasting changes.

Melzack (2005) describes the neuroscience of patients' thoughts, feelings and pain as neurosignatures of a widely distributed neural network involving diverse areas of the brain he calls the ‘body-self neuromatrix’. Since these neurosignatures are related in part to our own subjective experiences or perceptions (e.g. pain and what it means, interpretation of what others' think, etc.) they are like our own ‘virtual reality’ of our experienced existence (Revonsuo 1995, 2006). That is our conscious experience is a construction of our brain. In this sense the chronic pain patient with significant central sensitization is trapped in their own representations/neurosignatures of their internal and external world. This is what cognitive-behavioural therapy attempts to change by firstly identifying unhelpful perspectives and then by assisting the patient to construct more adaptive perspectives, feelings and behaviours through a combination of providing convincing alternative understandings and through behavioural strategies that facilitate controlled reactivation (e.g. graded exposure, pacing, relaxation, flare-up management; e.g. Donaghy et al. 2008, Gatchel et al. 2007, Harding & Williams 1995, Keefe et al. 2006, Linton & Nordin 2006, Main et al. 2008, Muncey 2002, Strong & Unruh 2002, Turk & Flor 2006). There is now a convincing body of literature supporting the efficacy of neuroscience based pain education and cognitive-behavioural interventions for chronic low back pain patients and for preventing progression from acute to chronic pain. For example, Moseley (2004) demonstrated that individualized pain education to moderately disabled chronic low back pain patients successfully changed patients' pain cognitions (i.e. understanding) and physical performance (e.g. straight leg raise and forward bending). Vlaeyen et al. (2002) demonstrated an exposure in vivo (individually tailored practice tasks developed on the basis of graded hierarchy of fear-eliciting situations) intervention resulted in reductions in chronic low back pain patients' pain-related fear, pain catastrophizing, pain disability, pain vigilance while increasing their physical activity levels. Linton and Nordin (2006) reported on a 5-year follow-up of a randomized clinical trial investigating the efficacy of a cognitive-behavioural intervention for prevention of chronic back pain. The effects of six (2-hour) cognitive-behavioural sessions promoting patients' individualized problem solving, risk analysis, activity scheduling and other coping strategies were compared with an information comparison group who received standardized pamphlets emphasizing self-help, remaining active and ergonomic, ‘back school’ based information. The cognitive-behavioural group improvements demonstrated at an initial 1-year follow-up (Linton & Andersson 2000) were maintained at this 5-year follow-up including significantly less pain, greater activity levels, better quality of life, better general health and significantly fewer days off work due to illness.

Lastly the output mechanisms refer to the effects of central nervous system/neuromatrix modulation that produce, for example, our cognitions, emotions, learning, sleep and language as well as our motor, autonomic, endocrine and immune system functions, all of which can be adversely affected in some acute, and particularly chronic, pain conditions. In fact pain itself is an output in that it is a perception of our brain in response to the internal and external influences discussed above. While it is beyond the scope of this chapter to cover the neurophysiology and clinical presentations of these different systems, the reader is referred to a variety of resources that provide clinically relevant overviews with reference to the underlying basic science research (Butler 2000, Gifford 1998c, Jänig & Levine 2006, Mackinnon 1999, Martin 1997, Sapolsky 1998).

At present, contemporary thinking holds that if a patient presents with a ‘normal’ adaptive pain mechanism, wherein symptoms are the result of pathology or abnormal load to specific structures/tissues, it is appropriate to identify and treat relevant physical impairments while also addressing physical, environmental and psychosocial contributing factors. However, when ‘abnormal’ maladaptive central pain mechanisms are hypothesized to be present, management requires attention to stressors (physical and non-physical) thought to be sensitizing the nervous system and use of cognitive-behavioural strategies to promote increased activities, participation and general fitness. Making these judgments is not simple as often clinical features of several pain mechanisms will be present along with clear physical impairments that may or may not prove relevant. This is where skilled clinical reasoning to recognize the overlapping patterns combined with short-term treatments and re-assessments to identified relevant physical impairments will assist in establishing how much an apparent central sensitization is being driven by the symptomatic physical impairments or other co-existing cognitions, emotions and life stressors. In some cases physical impairments and disability will underpin the stress, frustrations, etc. that a patient is experiencing with resolution of the pain and the negative psyche following thorough assessment and skilled physical and environmental management. Here it is important to recognize that symptomatic physical pathology/impairment is also a source of stress that can affect neuromodulation and the neuromatrix (Melzack 2001) in order to avoid the erroneous assumption that all stress is necessary psychosocial in origin, requiring hands off therapy. In other cases sensitization is driven by both physical and cognitive/affective factors necessitating management of both. In contrast, extreme central sensitization driven primarily by psychosocial factors requires cognitive-behavioural management (Donaghy et al. 2008, Harding & Williams 1995, Muncy 2002, Strong & Unruh 2002, Turk & Flor 2006) and is unlikely to be helped by tissue-based approaches.

Physical impairments and associated structures/tissue sources

Clinical decisions identifying and judging the relevance of the patient's physical impairments combined with hypotheses regarding structures involved and potential sources of any symptoms provoked are based on findings obtained throughout the subjective and physical examination combined with re-assessments following targeted interventions to different impairments. The physical impairments are the specific regional neuromusculoskeletal abnormalities found through physical examination including impairments in posture, active and passive movement, soft tissue, neurodynamics and motor control/strength/etc. Physical impairments may be symptomatic and directly associated with the source of the patient's symptoms or asymptomatic but still contributing by altering stress/load elsewhere causing other structures to be symptomatic. Asymptomatic physical impairments must be analysed with regard to the structures responsible (e.g. restricted passive hip extension due to hip joint hypomobility, hip flexor tightness/tone or both) and whether the impairment is truly contributing to other structures being symptomatic. Again, this requires specific treatments, re-assessments and skilled reasoning to determine. Symptomatic physical impairments also have to be analysed as to the structures (and pathology) implicated and for their particular clinical presentation with respect to pain (e.g. minor to severe, non-irritable to irritable), mobility (e.g. stiff to hypermobile), dynamic control (e.g. weakness/inadequate stabilization to over-activity), and the relationship of pain provocation to passive movement (i.e. Maitland's passive movement diagram), all of which represent non-propositional craft knowledge that assists selection and progression of treatment. While clinical examination generally cannot confirm the actual source of a patient's symptoms, clues from the area and behaviour of symptoms, history, physical examination and treatments/re-assessments, combined with knowledge of common clinical patterns, will enable the therapist to hypothesize with confidence the likely structures at fault and possibly their pathology.

As an example of generating hypotheses regarding possible sources of the patient's symptoms based on the area of symptoms, consider the body chart in Table 2.2 depicting a common area of shoulder pain and the potential sources of that pain that should be considered.

Considering potential structures involved within the suggested columns assist a though generation of hypotheses that can then be tested with further questioning through the behaviour of symptoms (aggravating and easing factors), history, medical screening and physical examination–treatment– re-assessment. As alluded to earlier, hypotheses about specific sources of the patient's symptoms must be made with consideration of the dominant pain mechanisms hypothesized. Symptomatic local tissue impairment is likely an accurate reflection of structures involved in nociceptive dominant patterns where maladaptive central processing can create false positives causing ‘healthy’ structures/tissues to be symptomatic.

Contributing factors

Hypotheses regarding potential contributing factors represent the predisposing or associated factors involved in the development or maintenance of the patient's problem. These include environmental, psychosocial, behavioural, physical/biomechanical and hereditary factors.

The potential physical contributing factors that can create excessive strain causing another structure to be symptomatic are quite varied. Examples here include hip extension stiffness causing increased lumbar spine strain during walking and weakness of the scapular upward rotators causing increase subacromial strain during shoulder elevation. Just as physical impairments commonly exist without becoming symptomatic (i.e. sources of pain), physical impairments can also cause increased strain without those tissues becoming symptomatic. While these impairments still represent risk factors for musculoskeletal symptoms later (analogous to dietary risk factors for heart disease), establishing their relevance in a patient's current pain presentation requires systematic intervention to alter the impairment and reassessment of the effect. Often this can be established relatively quickly with procedures that immediately address the impairment (e.g. manual assistance or taping of the scapula) or brief trial treatments to assess their benefit.

Even with the same pathology different patients can have different physical, environmental and psychosocial contributing factors necessitating quite different management. For example, three patients can present with similar subacromial bursitis pathology causing subacromial pain but quite different predisposing contributing factors necessitating quite different management. Patient 1, for example, may present with a tight posterior glenohumeral joint capsule causing increased anterosuperior humeral head translation during overhead activities that result in bursal irritation. Patient 2 has good posterior capsule mobility, as reflected in their good range of humeral internal rotation and horizontal flexion, but this patient has poor control/strength of their scapular force couples which are required to upwardly rotate the scapula, resulting in inadequate rotation, a narrowed subacromial outlet during overhead activities and bursal irritation. Patient 3 also has a motor control/strength problem but not of the scapula, instead the rotator cuff force couples responsible for maintaining humeral head depression during elevation are ineffective resulting in increased superior translation and, again, bursal irritation. Knowledge of common contributing factors to different clinical problems combined with skilled reasoning to establish their relevance is essential. While treatment directed to the hypothesized source of the patient's symptoms is often effective in relieving symptoms, contributing factors must be addressed in order to minimize reoccurrence.

The scenario above of one pathology (subacromial bursitis) having three different clinical presentations requiring three different approaches to management is one example of the philosophical principle contained within the ‘Brick wall’ concept put forward by Maitland (Maitland 1986; also see Chapter 1). While research evidence provides some guidance to management of different pathologies/problems, variation in clinical presentations necessitates that the therapist's management decisions are based on consideration of the patient's unique clinical presentation combined with contemporary knowledge from the current body of research evidence.

Precautions and contraindications to physical examination and treatment

Patient safety is paramount and there are a range of decisions within this hypothesis category that therapists must consider including: whether a physical examination should be carried out at all (versus immediate referral for further medical consultation/investigation) and if so the extent of examination that can be safely performed that will minimize the risk of aggravating the patient's symptoms; whether specific safety tests are indicated (e.g. vertebra-basilar insufficiency testing, neurological, blood pressure/heart rate, instability tests); whether any treatment should be undertaken (versus referral for further consultation/investigation); and the appropriate dose/strength of any physical interventions planned. A number of factors will contribute to determining the extent of physical examination and treatment that is safe to perform, including the following:

Medical screening for other health problems requires knowledge of the body systems and common features of medical conditions, particularly those that overlap with neuromusculoskeletal problems. This form of screening is not for the purpose of assigning a medical diagnosis; rather medical screening by physiotherapists is for the purpose of identifying patients who may have medical conditions that require further investigation and medical consultation. It is particularly important to first contact practitioners who see patients that have not previously been evaluated by a medical practitioner but is it also important to physiotherapists practising under referral as non-musculoskeletal conditions may have been missed or developed since the patient last saw their doctor. Physiotherapists should be familiar with recognized ‘red flags’ which are signs and symptoms that may indicate the presence of more serious pathology and systemic or viscerogenic pathology/disease which should elicit consideration of referral for further consultation/investigation. There are different lists of ‘red flags’ available in the literature but two excellent resources written for physiotherapists are Boissonnault (2011) and Goodman and Snyder (2013). As an example of important medical screening to guide clinical reasoning regarding precautions and contraindications to physical examination and treatment, Goodman and Snyder (2013) provide the lists of ‘Guidelines for medical referral’ and ‘Precautions and contraindications to therapy’:

Readers are referred to Goodman and Snyder (2013) for additional lists of ‘red flags’ and ‘Guidelines for immediate medical attention’.

Physiotherapists need to develop a through yet efficient system of medical screening. The texts by Boissonnault (2011) and Goodman and Snyder (2013) provide a comprehensive Review of Systems that assist therapists to recognize combinations of symptoms and signs that may reflect non-musculoskeletal conditions requiring further medical consultation. Both texts also provide examples of information to include in a medical screening questionnaire which is an excellent way to thoroughly and efficiently screen a patient's medical health. Having completed the questionnaire the physiotherapist must then review the patient's responses and clarify conditions or symptoms/signs ticked to establish their history, medical management and relationship with the patient's current problem.

Management and treatment

Management in this context refers to the overall health management of the patient, including consultation and referral to other health professionals, health promotion interventions (e.g. fitness assessment and management) and patient advocacy as required (e.g. with insurers or employers). Treatment refers to the specific therapeutic interventions (physical and educational) carried out during an appointment and the underlying reasoning required to determine which impairments to address, which to address first, the strategy/procedure and dosage to use, the outcome measures to reassess and the self-management appropriate for optimizing change (in understanding, impairment, activity and participation).

Most important to skilled reasoning is that there are no recipes! Health care in general and physiotherapy care in particular are not an exact science. While clinical trials and theory extrapolated from basic science provide helpful guides to management for different problems, these should not be taken as prescriptions. Instead, therapists must judge how their patient matches the population in the research reported and then tailor their management to the individual patient's unique lifestyle, goals, activity and participation restrictions, perspectives, pathobiological mechanisms and physical impairments. Since research supported management efficacy is still lacking for most clinical problems, skilled reasoning is the therapist's best tool to minimize the risk of mismanagement and over servicing.

The bio-psychosocial model highlights the need for management to be holistic (i.e. addressing physical, environmental, psychosocial as required) with systematic and thorough re-assessments to determine inter-relationships between different physical impairments (e.g. presence of a neurodynamic impairment secondary to a soft tissue interface impairment) and between physical impairments and cognitive/affective factors (e.g. education to improve understanding leading to a decrease in patient fear and concurrent improvement in movement impairments). Management of contributing factors is essential to minimize risk of reoccurrence and patient understanding and active involvement is critical to promoting self-efficacy, self-management and long-term success.

As discussed earlier, much of the reasoning and practice knowledge associated with selection, delivery and progression of treatment falls within the area of professional craft knowledge. Since such knowledge typically lacks direct research validation therapists must be diligent in their personal reflection and critique to minimize the trap of falling into habits of practice. As discussed later, a good strategy to avoid this is to subject your reasoning and practice to critical appraisal from your peers through patient reviews and case study discussions.

Prognosis

Prognosis refers to the therapist's judgment regarding their ability to help their patient and an estimate of how long this will take. Broadly a patient's prognosis is determined by the nature and extent of patient's problem(s) and their ability and willingness to make the necessary changes (e.g. lifestyle, psychosocial contributing factors, physical contributing factors) to facilitate recovery or improved quality of life within a permanent disability. Clues will be available throughout the subjective and physical examination and the ongoing management including the:

While prognostic decisions also are not an exact science (Jeffreys 1991) it is helpful to consider a patient's prognosis by reflecting on the positives and negatives from the list above.

The decisions required in clinical practice will determine the information sought (e.g. safety information considered important necessitates safety oriented questions and physical tests). However, the hypothesis category framework is not intended to direct the order in which information is obtained or the precise inquiries and physical tests utilized to obtain that information. For example, musculoskeletal physiotherapists will typically follow a systematic subjective and physical examination as depicted in Table 2.3.

Clinical reasoning within the hypothesis category framework involves consideration of the different categories of decisions as information unfolds. While it is not possible or desirable to stipulate what hypothesis categories a therapist should be considering at any given point in time (e.g. it is not realistic or cognitively efficient to consider every hypothesis category after every new piece of information is obtained), equally the therapist should not simply be obtaining information without thinking. Mostly during the examination the therapist will be trying to understand the patient and their problem(s) in order to plan their management including judging how much physical examination can be safely performed and which physical examination procedures are most important to prioritize at the first appointment. For this focus the therapist would need to consider the patient's activity and participation capabilities and restrictions, the patient's perspectives, the pathobiological mechanisms, the structures/sources and contributing factors implicated from the subjective examination (hence requiring priority in examination), the precautions to physical examination and treatment, physical impairments found on physical testing and the structures/sources implicated, and management clues (emanating from both the subjective and physical examination). It is the therapist's ability to think on their feet through the examination and ongoing management that leads to their qualification of patient responses and the variations in examination routines. That is, all tests are not performed on every patient.

Interpreting information across different hypothesis categories

Patient information will inform several hypothesis categories at the same time. Just as the therapist may be asking a pathology/impairment oriented question but receive a patient answer that sheds light on their perspectives (i.e. psychosocial status), a question directed at understanding their activity capability and restrictions will often provide clues to other hypothesis categories at the same time. Consider for example a 72-year-old patient's response to a question regarding what aggravates their back and bilateral leg pains?

This one answer provides the following hypothesis categories information:

In the end the therapist gains clues to the different hypothesis categories throughout the whole examination and ongoing management that must be interpreted, weighed for significance and analyzed with other supporting and negating information. The knowledge that underpins the different clinical decisions comes from a broad range of both propositional and craft knowledge. Learning theory suggests that for knowledge to be clinically accessible it needs to be acquired within the conditions and constraints for which it will be used (Glaser 1984, Greeno 1998, Lave & Wenger 1991). This is typically achieved in physiotherapy education through the use of experiential/problem based teaching strategies. With the same aim, the hypothesis categories provide a bio-psychosocially oriented organizing framework to link academic knowledge to the clinical reasoning through the patient examination–treatment–re-assessment process facilitating the learning of clinical patterns.

• Therapist views biomedical and psychosocial as separate, assuming that their role as a physiotherapist is to manage only the biomedical, with the psychosocial exclusively the responsibility of psychologists and counsellors

• Therapist does not attempt to understand biomedical diagnosis in the context of patient's personal circumstances

• Therapist does not screen psychosocial factors or their psychosocial assessment is too superficial, leading to judgments based on insufficient assessment. Common examples here include:

Capability in clinical reasoning involves integration and effective application of thinking and learning skills to make sense of, learn collaboratively from and generate knowledge within familiar and unfamiliar clinical experiences.

Understanding clinical reasoning theory

Just as students are expected to learn basic and applied science theory from presentations and review of literature, they should also be presented with contemporary theory and research of clinical reasoning. Ideally they should read selected clinical reasoning literature with activities or assignments that require them to demonstrate their understanding and application of that theory to practice. Reading literature from medicine, physiotherapy and the other allied health professions (e.g. Higgs et al. 2008) provides students with a comprehensive overview that will assist construction of their own understanding while at the same time giving them insight to the reasoning of their colleagues in other health professions.

Facilitated clinical reasoning through case studies and real patients

Real or hypothetical clinical problems can be used in clinical reasoning learning activities presented as paper-based, computer-based, filmed or through the use of simulated patients (trained actors). The text Clinical reasoning for manual therapists (Jones & Rivett 2004) provides theory chapters on clinical reasoning, learning theory and improving clinical reasoning as well as 23 case study contributions from recognized musculoskeletal clinical experts around the world. Through their cases the experts are questioned about their evolving reasoning, with the case providing valuable resources for educators and practicing therapists to use in clinical reasoning learning activities. A recent monograph entitled Clinical reasoning and evidence-based practice, available as an independent study course through the American Physical Therapy Association (Christensen et al. 2011) also provides a good overview of clinical reasoning theory linked to three patient cases. Newer books also now commonly include case studies and associated clinical reasoning (e.g. see Lee 2011, Vicenzino et al. 2011). When using case studies drawn from published resources or your own clinical experiences it is important that the cases are selected with an appropriate level of complexity for the student group with strategically planned discussions around aspects of clinical reasoning, basic science and physiotherapy examination, clinical pattern and management theory all linked to EBP (including experience and research-based evidence). Clinical reasoning activities with real patients are essential for students to develop their clinical reasoning capability within the variability of clinical presentations (problems and people), variability of practice environments and variability of time constraints inherent in real life practice. It is often useful to bridge the learning between case studies/simulated patients and students' reasoning through real patients they examine and treat with opportunities for students to observe patient demonstrations (and discuss associated reasoning) by their educators.

Whether using case studies, simulated or real patients it is essential that educators access students' thoughts in order to understand the reasoning and knowledge on which they base their reasoning. Students' reflections on their reasoning can be encouraged before, during and after the patient case/encounter. While stopping part way through an examination or treatment of a real patient is time consuming, it is also invaluable in exploring the student's immediate perceptions, interpretations and synthesis of patient information. The educator clearly must provide feedback and share their own interpretations but at the same time allow students the opportunity to explore (within reason and without risk to patient safety) their own reasoning even if it proves to be less efficient/effective than that of the educator. A balance is required to shape the student's knowledge, skills and reasoning without necessarily forcing them to only think and do the same as you. Peer coaching involving demonstration, observation, collaborative practice, feedback and reasoning discussions between students has also been demonstrated to be effective in facilitating student reasoning (Ladyshewsky & Jones 2008).

Self-reflection worksheets and clinical pattern diaries

Often educator / student ratios and time constraints prohibit one-on-one discussion with all students on every case. Here, use of self-reflection worksheets completed by students following their patient encounter is effective in accessing students' reasoning and promoting their self-awareness. Two examples of clinical reasoning self-reflection forms (long and short versions) are provided in Appendix 2.1. These have evolved to their present form from Maitland's original ‘planning sheet’ and readers are invited to use or modify them according to your own teaching and learning needs. Students commonly find the forced reflection these forms require is itself illuminating in highlighting information they failed to obtain or areas of knowledge and reasoning where they need further work. This, combined with feedback from the clinical educator, makes them a useful teaching, self-reflection and assessment tool.

Requiring students to compile a diary of clinical patterns facilitates their knowledge organization around common clinical patterns for use in their clinical reasoning. While there are a variety of ways clinical patterns can be presented, two examples of templates for constructing a clinical pattern used in the Master of Musculoskeletal and Sports Physiotherapy program, University of South Australia (single pattern versus comparative pattern) are available in Appendix 2.2. The content for constructing the patterns will come from the literature, ideally with acknowledgment of the level of supporting evidence used. Importantly for these patterns to become meaningful, educators should encourage students to include summaries of real patients they have seen who fit a particular pattern as this instantiation promotes deeper learning and highlights that clinical presentations typically do not match textbook patterns perfectly, enabling students to learn common variations and recognition of overlap between different patterns.

Mind maps

Mind maps (Buzan 2009) (also called concept and cognitive maps, although some differences exist) are another teaching and assessment strategy useful for facilitating metacognition, knowledge organization and clinical reasoning. A mind map is a pictorial representation of a person's knowledge and organization of knowledge on a specified topic. As such, it externalizes for the learner and the assessor the breadth and depth of the learner's understanding with potential to reveal preconceptions, assumptions, misunderstandings and biases. Cahill and Fonteyn (2008) review the literature on mind mapping and attribute its theoretical basis to the learning theory espoused by Ausubel (1963) who is credited with identifying the importance of relationships between concepts to a person's understanding and thinking. Meaningful (i.e. deep as opposed to superficial or rote) learning occurs when new learning is related to existing concepts or knowledge structures resulting in some change in understanding. This may be revision of a previous concept and/or new insight to relationships with other concepts previously not appreciated. Buzan and Buzan (1996) draw parallels between the mind map and the associative nature of brain pathways and argue for the importance of learning associations to improving understanding and memory. A growing body of education research is now available supporting the efficacy of mind mapping for promoting meaningful learning (see Cahill & Fonteyn 2008).

There are different processes for creating mind maps described in the literature. In natural science education students are often given a group of related concepts accompanied by a lecture after which the students are asked to create a mind map depicting their understanding of the concepts and any relationships between concepts. Arrows are generally used to illustrate relationships and words may be written along the arrows to qualify the nature of the particular relationship (e.g. ‘leads to’, ‘causes’, etc.). Cahill and Fonteyn (2008) describe how they had student nurses complete mind maps representing their ‘thinking about a patient case’ including patient problems, assessments, interpretations and management. At the University of South Australia, Master of Musculoskeletal and Sports Physiotherapy programme we have used mind maps as both a teaching and assessment tool. We start by having the students brainstorm on a sheet of paper everything they know about a specified topic prior to reading or receiving a lecture on the topic (e.g. inflammation, subacromial impingement). The students are then asked to number the items they brainstormed by grouping related items (i.e. giving every item that they feel should be categorized together the same number, for example for a common clinical presentation such as ‘groin pain’ all symptoms might be given a ‘1’, signs a ‘2’, possible pathologies a ‘3’ and so on). After completing the categorization of items the students then transfer those category headings and items within categories to another paper. Lastly students are asked to illustrate the relationships between categories (or concepts) by their placement on the paper (e.g. predisposing factors may be above pathology and signs and symptoms) and by arrows between categories with words along the arrows to qualify the relationship. The process of constructing a mind map itself is often illuminating to the student highlighting gaps in their knowledge. When time allows for students to complete maps prior to another learning activity (reading, lecture, demonstration) the pre-mind map promotes self-awareness (i.e. metacognition) of what they know and do not know about the nominated topic. This alone is valuable as students are then more likely to engage in the learning activity with greater interest and interaction as they listen for and ask about the gaps in their knowledge. Ideally a post-mind map is completed after the learning activity which enables the student to review new information and revise previous understandings. The second map will almost always have greater breadth and depth of information and relationships represented reflecting the learning and knowledge reorganization that has occurred. We have used this formatively to facilitate deeper learning and we have used it as a summative assessment for a whole course on ‘Ethics and communication’ where students are required to complete pre-course and post-course mind maps illustrating their understanding of the constructs and relationships between clinical reasoning and ethical reasoning (Jones et al. 2013). In this case students also wrote a brief essay explaining their second map which provided further insight to their understanding and learning through the course.

Lateral/creative thinking

Logical (also called vertical) thinking is essential to inductively recognize clinical patterns and to deductively substantiate those patterns through hypothesis oriented questioning and physical assessment (i.e. differential diagnosis). While this hypothetico-deductive process is clearly important to diagnostic reasoning and to advances in knowledge through quantitative research, lateral thinking is also important to the generation of new insights and discoveries that enable the individual therapist and the profession to advance their knowledge and practice. In fact, Kuhn (1970), in his text The structure of scientific revolutions, points out that many of the major breakthroughs in science did not occur due to carefully controlled scientific research, rather they often emerged from accidents or the lone insight of an individual. As long as a student's or therapist's clinical reasoning is logical and safe, lateral thinking should be encouraged. If we only encourage logical thinking and practice within the realm of what is ‘known’ or substantiated by research evidence we limit the variability and creativity of thinking that is important to the generation of new ideas.

Logical and its associated scientific thinking typically discourage individual intuition (i.e. gut feelings). However, in reality both the frontal cortex (cognition) and limbic system (emotions) are involved in most decisions to varying degrees. Research investigating the effects of over analyzing (too much logic) versus insufficient analysis (relying too much on emotions/gut feelings) suggests both can lead to poor decisions (Lehrer 2009). That decision-making research was primarily conducted in the realm of day to day decisions (e.g. which wine or food product you prefer, which house to buy, on field sports decisions, etc.) rather than clinical decision making. However, given the reality that health and disability are not an absolute science where judgments are black and white, correct or incorrect, intuition and emotions will also be involved in clinical reasoning. It is easy to imagine the errors of clinical reasoning that might occur with relying completely on gut feelings but could being too analytical and resistant to intuition also lead to clinical judgment errors? This has not been investigated but at the very least personal intuition should be reflected on and even pursued (i.e. line of questioning, physical assessment, treatment intervention) as it may lead to a fruitful outcome (e.g. useful information, positive response to intervention) that would not have been discovered if obvious logical avenues are the only things pursued. That is, new ideas and new approaches can emerge from intuition as well as logic.

Teaching lateral thinking centres on helping students recognize their current thinking processes (e.g. interpretations of patient information, diagnostic and management decisions) and encouraging them to think more widely, outside what may seem obvious and logical to them (de Bono 1970, 1994). Lateral thinking is relative to each individual's perspectives. That is, what is logical to one person is not necessarily logical to another. De Bono characterizes vertical thinking as logical, sequential, predictable thinking where the thinker aims to systematically make sense of all information. In contrast lateral thinking involves restructuring and escape from old patterns, looking at things in different ways and avoidance of premature conclusions. The logical thinker attends only to what is obviously relevant where the lateral thinker recognizes that sometimes seemingly irrelevant information assists in viewing the problem from a different perspective. As a practical example of encouraging lateral thinking a student could be encouraged to conduct a review of patient progress and their reasoning (i.e. Maitland's ‘retrospective assessment’) where the student is explicitly asked to identify their dominant interpretation of the patient's diagnosis (e.g. pathology vs impairment, physical vs psychosocial, etc.) and the dominant approach they have been taking in their management to date (e.g. passive or dynamic bias, bias to treating source versus contributing factors, bias to physical impairments vs psychosocial factors, etc.). It is difficult to think laterally/creatively if you cannot first recognize how you have been thinking or approaching the problem thus far. Once recognized, the student can then be encouraged to think more laterally about alternative interpretations of the patient's presentation and alternative management approaches. Maitland's way of emphasizing this process was to physically turn around in a circle, take a deep breath and start again. If students and therapists always follow the same interpretations and always manage problems the same way they never learn the place for alternative interpretations or that other approaches may be equally or even more effective.

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