Clinical Reasoning/EBP/Scientific Method

Question 1

What is deductive reasoning?

Answer 1

“top down” logic
-creates a linear relationship between pt’s restrictions/impairments etc and their pathology of body structures, personal factors, environment, etc

Question 2

What is narrative reasoning?

Answer 2

using specific observations to draw conclusions
-achieved throughout open ended questions and active listening to gather info about the pt’s personal and environmental factors

Question 3

What is Bayesian reasoning?

Answer 3

basically involves application of probability as data is gathered to identify if something is more or less likely or the probability that something is true or not true

Question 4

What is the cluster of findings for nociplastic pain(central sensitization)

Answer 4

characterized by pain that is disproportionate, non-mechanical, unpredictable, and diffuse

-in the absence of red flag findings

Question 5

Sensitivity and Specificity of nociplastic pain cluster?

Answer 5

sensitivity 91.8%

specificity 97.7%

Question 6

What is the cluster of findings for peripheral neuropathic pain(radicular or referred)

Answer 6

-symptoms that are referred in a dermatomal (radicular) or cutaneous (referred) distribution
-history of nerve injury, pathology, or mechanical compromise of the nerve w/ symptom provocation via mechanical testing

Question 7

Sensitivity and speficifity of peripheral neuropathic pain cluster?

Answer 7

sensitivity 86.3%

specificity 96%

Question 8

What is the cluster of findings for nociceptive pain?

Answer 8

-symptoms localized to an area of injury or dysfunction
-provocation and/or alleviation are clearly identifiable and proportionate
-match known mechanical and anatomical distributions
-symptoms usually intermittent and start w/ onset movement or mechanical provocation
-quality of symptoms may be a constant dull ache or a throb at rest

Question 9

Sensitivity

Answer 9

the ability to identify a condition when it truly exists
-find true positives
-higher sensitivity means you will catch it if it’s there
-most people with the condition will test positive
-lower sensitivity means you will get some false positives

SnNOUT
-negative result rules it out
-only people without the condition get ruled out, but you may have false positives

Question 10

Specificity

Answer 10

the ability to identify when a condition is not present
-find true negatives
-higher specificity means that when the test is negative, you are confident that the condition is not present
-most people with the condition will test positive, but anyone who DOES NOT have it will test negative
-lower specificity means that when test is negative, you are less confident it is a true negative. might be a false negative

SpPIN
-positive result rules it in
-only people WITH the condition will test positive

Question 11

Type 1 error

Answer 11

“backing a loser”

FALSE POSITIVE

concluding that there IS a significant difference when there actually ISNT

-set a stricter alpha level for statistical significant difference to reduce likelihood
-larger sample size also helps
-well defined hypothesis
-replication studies with different samples can help validate findings

Question 12

Type 2 error

Answer 12

“missing a winner”

FALSE NEGATIVE

concluding that there ISNT a significant difference when there actually IS

-increase # of subjects in the study to reduce likelihood of this

Question 13

Large effect size

Answer 13

0.8 and up

Question 14

Moderate effect size

Answer 14

0.5-0.7999

Question 15

Small effect size

Answer 15

0.2-0.4999

Question 16

Trivial effect size

Answer 16

<0.2

Question 17

Cohen’s kappa (k)

Answer 17

describes how reliable something is

0 = no reliability(no better than chance)
1= perfect reliability

0 no better than chance
<0.4 poor
0.4-0.6 fair
0.6-0.75 good
>0.75 excellent
1 perfect reliability

Question 18

positive likelihood ratio

Answer 18

these will be >1

> 10 large shift in probaiblity
5-10 moderate shift
<5 small shift
1 = no change

Question 19

negative likelihood ratio

Answer 19

these will be <1

<0.1 large shift
0.1-0.2 moderate shift
>0.2 small shift
1.0 no change

Question 20

Placebo effect

Answer 20

individual believes in positive effect, even though no therapeutic value

good research should have placebo group so that test group improves MORE than placebo group

good research should have placebos that look like the real treatment
-placebo group needs to have belief that they actually had real treatment

placebo effect most powerful on outcomes mediated by the brain

Question 21

Nocebo effect

Answer 21

negative beliefs about a treatment
-exaggerated when subjects expect negative side effects or negative experiences with treatments in the past

research groups example
-good to have exclusion criteria
-in a research study on spinal manipulation this would exclude those who have positive or negative expectations about it
-randomization also helps reduce this effect

Question 22

Hawthorne effect

Answer 22

subjects who know they are observed as part of a research study tend to work harder than they would otherwise
-we find that people change their behavior(positive or negative) due to being observed

Question 23

Observer effect

Answer 23

people work harder when being watched
-more improvement in response to more attention

-control for this by making sure all treatment groups get about the same amount of attention from clinician

group that receives more attention likely to improve more

example:
group 1: 30 mins manual
group 2: 30 mins exercise
group 3: 30 mins manual + 30 mins exercise
-60 total minutes, they are likely to improve the most

Question 24

John Henry effect

Answer 24

“legend of john henry outcompeting the machine”

control group perceives that they are disadvantaged compared to experimental group
-they seek out additional treatment/help because they think they aren/t getting enough care otherwise

best way to reduce
-blind subjects so that they don’t know if they are in control or experimental group

Question 25

Pygmalion effect

Answer 25

AKA “rosenthal effect”

expectations of those in authority shape results of their subjects
-high expectations lead to improved performance
-low expectations lead to poor performance

best way to reduce
-blind clinicians who treat the group and those who assess the group

Question 26

Level 1 evidence

Answer 26

high quality diagnostic studies, prospective studies, RCTs, or systematic reviews

Question 27

Level 2 evidence

Answer 27

comes from lesser quality diagnostic studies, prospective studies, RCTs, or systematic reviews
-weaker diagnostic criteria
-weaker reference standards
-improper randomization
-no blinding
- <80% follow up

Question 28

Level 3 evidence

Answer 28

case control studies or retrospective studies

Question 29

Level 4 evidence

Answer 29

case series
-has no control compared to case control study

Question 30

Level 5 evidence

Answer 30

expert opinion

Question 31

Grade A recommendation

Answer 31

STRONG
-preponderance of level 1 and/or level 2 studies support the recommendation
-includes AT LEAST 1 level 1 study

Obligation
“Should”

Question 32

Grade B recommendation

Answer 32

MODERATE
-a single high quality RCT or a preponderance of level 2 studies support the recommendation
-includes studies w/ only short term follow up
(less than 3 months) or small sample size (less 100 subjects)

Obligation
“May”

Question 33

Grade C recommendation

Answer 33

WEAK
-single level 2 study supports the recommendation

Obligation
“Can”

Question 34

Grade D recommendation

Answer 34

CONFLICTING OR NO EVIDENCE
-level 1 and level 2 studies disagree with respect to their conclusions or provide no evidence of benefit

Obligation
“Should NOT”

Question 35

Incidence vs prevalence

Answer 35

incidence = # of NEW cases during a period of time
“10 of 100” people develop LBP during 2024

prevalence = # of cases at a specific point in time
“10 of 100” people have LBP on 12/10/2024
-prevalence includes ALL cases, including new and pre-existing

Question 36

MDC

Answer 36

smallest change detected that is not attributed to measurement error

example: moving from 2/10 to 1/10 on VAS, however MCID may be 2 full points

Question 37

MCID

Answer 37

smallest change in condition that either pt or clinician may consider important