L7 - CLINICAL REASONING Flashcards
Definition of clinical reasoning
- Reasoning skills encompass ability to think critically, analyze info & make sound judgments
based on evidence & logic - In PT:
o Critical thinking
o Decision making
Different reasoning approach
Backward reasoning
Pattern recognition (forward reasoning)
Bayesian reasoning
Description of backward reasoning
- Involves starting with hypothesis about potential causes of patient’s symptoms & working
backward to gather evidence that either supports or refutes hypothesis
1. Backward reasoning
a. Clinician starts with patient’s reported symptoms or clinical findings (pain, stiffness,
weakness…) & hypothesizes potential underlying causes
b. Process involves reasoning backward from observed clinical presentation to determine
possible origins of issue
2. Hypothetical-deductive process
a. Set of potential hypotheses (clinical diagnoses or differential diagnoses) is generated
early in assessment
b. Hypotheses are tested & refined through
▪ History taking
▪ Physical examination
▪ Functional tests
▪ Imaging or other diagnostic tools if needed
3. Iterative process
a. Clinician continually revisits & adjusts hypotheses as new info is gathered during
examination
Advantages of backward reasoning
- Systematic approach: ensures that all potential causes considered, reducing risk of misdiagnosis
- Adaptable: hypotheses can be updated as new evidence emerges, allowing flexibility in treatment
planning - Efficient problem solving prioritizes testing of most probable or impactful diagnoses first
- Evidence-based: grounded in clinical findings & validated by patient’s response to treatment
Disadvantages of backward reasoning
- time
- validity
- multiple pathos
Description of pattern recognition
- Pattern recognition approach = form of clinical reasoning that relies on clinician’s ability to
identify & match patient’s presentation to known pattern of symptoms or dysfunctions based on
prior experience & knowledge
1. Rapid diagnosis
o Clinician identifies familiar cluster of symptoms or signs that match known condition
o Approach bypasses hypothesis generation & testing steps of hypothetical-deductive
method
2. Experience-driven
o Relies heavily on clinician’s expertise, prior clinical encounters & patterns recall
3. Efficient
o Particularly useful in common on straightforward conditions where established patterns
are well-documented
Advantages of pattern recognition
- Speed: reduced time required for diagnosis in straightforward cases
- Effective for common conditions: very useful in MSK PT, where patterns like rotator cuff
tendinopathy, PFPS, or low back strain are frequent - Low cognitive load: relies on intuition & recall rather than methodical analysis
Limitations of pattern recognition
- Not ideal for atypical presentations: if patient’s symptoms don’t fit known pattern, this approach
may fail - Dependent on experience: novice therapists may lack clinical knowledge required to recognize
patterns accurately - Bias risk: over-reliance on past cases can lead to premature conclusions or diagnostic errors
Description of Bayesian reasoning
= involves applying probability-based reasoning to refine diagnoses by integrating prior knowledge (pretest probability) with new clinical findings (likelihood ratios).
- More methodical & evidence-based compared to other approaches
1. Probability-based:
o Uses statistical probabilities to refine diagnoses
o Involves calculating pos-test probability of diagnosis based on presence or absence of
clinical signs
2. Dynamic updating:
o Continually revises likelihood of different diagnoses as more info is gathered
3. Evidence-driven:
o Combines clinical data with research-derived probabilities
Advantages of Bayesian reasoning
- Highly accurate: reduced diagnostic of uncertainty by combining clinical expertise with research
evidence - Systematic & logical: particularly useful in complex or ambiguous cases
- Evidence-based: encourages clinicians to use research data to inform decisions
Limitations of Bayesian reasoning
- Time-consuming: requires tome to calculate probabilities & use diagnostic test effectively
- Data dependency: relies on availability of accurate likelihood ratios & pre-test probabilities
- Complex for novices: requires solid understanding of statistics & clinical reasoning
Description of right kind of reasoning
RIGHT KIND OF REASONING
- Rare for clinician to rely on single type of reasoning
- Backward & forward reasoning: comes with experience
- Apply knowledge
- Varies examination
- Reflection & interaction
Purpose of clinical reasoning
- t to obtain diagnostic certainty but rather to reduce level of uncertainty until treatment
threshold is reached - Clinical tests & measures can never absolutely confirm or exclude presence of specific disease
- Comprehensive diagnosis should encompass what is learned from both diagnostic reasoning
regarding physical problem & narrative reasoning regarding person
Description of data collection of BPS model
a collection
- Ability of clinician to obtain full data base depends on relationship with patient
- Difference between hearing & listening. Most patients actually give you aggravating factors &
facilitating factors during S/E which in turn can give you clues on physiopathology
- Connection must be made between existing knowledge & data obtained: initial phase of
reasoning
Novice: matching patients’ symptoms to concepts
Expert: experimental knowledge within evidence-based framework
- Keeping control
- Recognizing & responding to relevant info
- Specifying symptoms
- Asking specific questions that point to pathophysiological thinking
- Placing questions in logical order, being able to replace patient information in logical order
- Checking agreement with patients
- Summarizing & body language
End goal of BPS model
- Relevant clinical facts / elements
- Predisposing factors (remote + family history)
- Correlations
- Etiologies
- Cautionary situations (flag system)
- Diagnostic hypotheses
Description of critical thinking
- Self-reflection
- Ruminating
- Self-assess
Best practice steps of assessment
History
Red flags
Psychosocial factors
Physical examination
Outcome measures
Education
Physical activity
Manual therapy
Non-surgical care
Resumption of work
Description of history
History: patient centered (individual context, effective communication). Hearing is not enough,
you have to listen
o Mechanism of injury
o Severity & irritability
o Easing / aggravating factors
o Markers of yellow factors
o Socio-economic status
o Previous treatment (type of approach already tested)
o Emotional component
Description of red flags
- Red flags / serious condition screening: possible referral
o Description of CAD, fracture, infection, cancer
o Specific condition based on symptoms, mechanism of injury & pattern:
▪ Neuro: quality of pain, dermatome, myotome
▪ MSK: unexplained behavior of symptoms
▪ C-R: symptoms progression, external factors
Description of psychosocial factors
Psychosocial factors
a. Pain in psychological distress
o Pain catastrophizing Scale (PCS)
▪ Measures catastrophizing thoughts related to pain
▪ Focuses on rumination, magnification & helplessness
o Tampa scale for Kinesiophobia (TSK)
▪ Assesses fear of movement & re-injury
▪ Common in patients with chronic MSK pain
o Hospital Anxiety & Depression Scale (HADS)
▪ Screens for anxiety & depression in non-psychiatric populations
▪ Useful for identifying psychological distress impacting MSK conditions
b. Functional & work-related beliefs
o Fear-avoidance beliefs questionnaire (FABQ)
▪ Assess beliefs about how physical activity & work contribute to pain
▪ Particularly relevant in low back pain & work related MSK conditions
o Orebro MSK pain screening question (OMPSQ)
▪ Predicts risk of chronicity in patients with acute MSK pain
▪ Includes items on psychological & functional risk factors
c. Psychological readiness for rehabilitation
o Patient Health Questionnaire-9 (PHQ-9)
▪ Screens for depression severity
▪ Helps in assessing readiness for MSK rehabilitation
Definition red flags
Red flags are clinical indicators suggesting possibility of serious pathology requiring urgent investigation
or referral. They often present in combination rather than as isolated findings
6 examples of red flags & description of them
- Fracture
o Recent significant trauma
o Minor trauma in elderly or osteoporotic patients
o Pain with weight-bearing, localized tenderness or deformity - Infection
o Fever, chills or recent infection
o Immune suppression
o Persistent night pain not relieved by rest or position changes
o History of recent surgery or invasive procedure - Cancer
o Unexplained weight loss
o Pat history of cancer
o Persistent pain at night or at rest
o Age > 50 yo or < 20 yo with unexplained symptoms
o Failure to improve with standard treatment - Neurological deficits
o Saddle anesthesia
o New-onset bladder or bowel dysfunction
o Severe or progressive low limb weakness
o Bilateral sciatica - Vascular conditions
o Pulsatile abdominal mass
o Unilateral swelling, redness & pain in LL
o History of smoking or cardiovascular disease - Inflammatory disorders
o Morning stiffness lasting > 30 min
o Night pain or alternating buttock pain
o Improvement of symptoms with movement
o Onset < 40 yo
Definition of specific MSK conditions
Involve identifiable structural or pathological causes, which may require targeted management. Screening
involves history taking, physical examination and sometimes special tests
Characteristics of specific conditions
Characteristics of Specific conditions
- Identifiable pathology
o Presence of clear pathological process, as inflammation, infection or structural damage
- Consistent clinical presentation
o Symptoms & signs aligning with known patterns of specific disorders
o Predictable responses to certain movements or activities
- Diagnostic confirmation
o Positive findings on imaging
o Laboratory tests indicating infection or autoimmune processes
o Positive results from special clinical tests
Defining specific conditions in clinical practice
Defining specific conditions in clinical practice
- History taking
o Detailed patient history to identify patterns consistent with specific conditions
- Physical examination
o Special tests targeting specific structures
- Diagnostic imaging & tests
o Utilizing X-rays, MRI, CT scans & laboratory tests to confirm suspected diagnosis
3 main pathos of LBP, clinical features, screening tests & imaging
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2 main pathos of shoulder pain, clinical features, screening tests & imaging
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2 main pathos of hip pain, clinical features, screening tests & imaging
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3 main pathos of knee pain, clinical features, screening tests & imaging
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2 main pathos of neck pain, clinical features, screening tests & imaging
2 main pathos of systemic conditions with MSK manifestations , clinical features, screening tests & imaging
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