It’s about Clinical Reasoning

Image

By: Brett Windsor PT, PhDc, MPA, OCS, FAAOMPT

It’s about clinical reasoning. Nothing less. Put simply, the key to PT success is knowing what’s really going on. Knowing exactly why a person is experiencing pain; knowing what structures are generating it and how each individual places symptoms into the context of their own lives. Directional preferences can work – sometimes. Clinical Prediction Rules can work – if you hit the patient jackpot. Bending a person this way or that way can work. But, there is simply no substitute for anatomy, biomechanics, and pathology. It’s hard, sure. But nothing in life worth having is easy. At some point, you have to rollup the sleeves and work out what’s really going on.

People say that the pathoanatomical diagnostic model is dead. No it’s not. It’s truly alive, and it always will be. Perhaps what’s dead is the willingness to really, really work at thinking. Maybe what’s dead is the desire to wade deeply into the anatomical literature, looking at the historical and contemporary pain literature, seeing the comparisons, looking for the contrasts. Is it possible that what’s passing away is taking the time necessary to perfect a craft, failing so often you want to quit, learning from others who are better than yourself, seeking with an truly open mind? The patho-anatomical may have been pronounced dead, but it’s alive and kicking.

The patho-anatomical ideal is not dead…Bogduk can show you that. The reams of literature (it’s medical) substantiating the production of pain from discs, from facet joints, can show you that. Working hard in collaboration with physicians to fill the gaps the clinical examination can’t get to can show you that. The satisfaction of a patient returning with imaging results that perfectly substantiate your in-depth clinical exam will prove that it still works. Seeing a patient’s eyes fill with tears when finally, someone takes the time to work all the way through a complex, chronic case and figure it out? Priceless.

The easy road is likely here to stay. But, we know there are people out there, hundreds every year, who want more, who want the hard road. We love those people. If you’ve been reading this for a while, you’re probably one of them. Deep down inside, you want to truly learn how to think and to reason and really get to the bottom of things. You can deal with ambiguity; you can accept that sometimes it’s ok to trust your intuition. Join us. We stick with what we know works. We cherish the past. We don’t try to explain it away. We’ll constantly seek to improve. But, we’re not going to apologize for taking the difficult road. Top left. Click it. Join us.

11 thoughts on “It’s about Clinical Reasoning

  1. “Diagnostic labels are important in the management of patients. Patients expect a name for their condition. A label shows that the doctor knows what is wrong. But such labels should not be incorrect or specious, lest they lead to therapeutic misadventure. Zygapophysial joint pain and discogenic pain can not be diagnosed clinically3,4 and are, at best, suppositions. Other labels, such as ‘segmental dysfunction’, are only metaphors, with no established biological correlates. Some labels are simply wrong and can have deleterious effects. ‘Degenerative disc disease’ conveys to patients that they are disintegrating, which they are not. Moreover, disc degeneration, spondylosis and spinal ostoearthrosis correlate poorly with pain and may be totally asymptomatic.5 They are age changes and do not constitute diagnoses. For this reason they were not admitted by the IASP.2 “Nominated treating doctors”, in recording a diagnosis for back and neck pain, can at least approach standardisation by avoiding these presumptive and specious labels.”
    –N. Bogduk, MD, Medical Journal of Australia, 2000; 173: 400-401.

    Like

    1. Excellent comments John. The larger focus here was not so much about ‘diagnostic labeling’ as it was about remembering that anatomy and pathology remain important in the full context of the evaluation and management of manual therapy patients. Signs and symptoms exist for a reason. The nature and properties of the tissues involved, where this can be known, play a significant role in the patients management process. Anatomy and pathology have been almost totally discarded in today’s physical therapy world – I think to the detriment of our overall ability to evaluate and manage patients. A sense of balance in approaches is called for.

      Like

    2. “All of the null hypotheses that have been raised against the concept of discogenic pain and its diagnosis have each been refuted by one or more studies. Although studies have raised concerns, none has sustained any null hypothesis. Discogenic pain can occur and can be diagnosed if strict operational criteria are used to reduce the likelihood of false-positive results”. Bogduk (2013)

      http://www.ncbi.nlm.nih.gov/pubmed/23566298

      Like

  2. In that review by Bogduk and colleagues, they are talking about employing very rigorous diagnostic criteria in provocative discography. How does this relate to manual assessment by a physical therapist? I don’t think Bogduk would agree that clinical assessment techniques used by a physical therapist in a spinal examination would be useful in identifying a patient whose internal disc disruption is a potential source of nociception.

    I think a very large and unwarranted conceptual leap is being made in the original post from provocative discography to the examination performed by a manual therapist. I consider myself to espouse a biopsychosocial approach to examination and treatment. Part of the “bio” is considering the possibility of as yet ill-defined pathology. If my patient fails to respond to a course of comprehensive treatment that includes all the potential inputs into the pain experience, then of course it’s time to consider other more invasive options.

    I don’t agree that pathology and anatomy have been discarded in “todays physical therapy world”; rather, I’m seeing a slow but growing effort to account for more of the variables that can contribute to the pain experience while acknowledging the lack of validity and reliability of many of the clinical tests used by OMPTs to identify “pathology”.

    Like

    1. Hi John, thanks for your excellent and thought-provoking comments. Please understand that nowhere did I refer to the ‘manual examination performed by a physical therapist’ as being diagnostic of all pathology. I’m not heading for that indefensible corner. No one piece of information helps very much diagnosing a disc as a source of nociception. Every piece of the subjective and objective presentation should be considered should it not? Pain presentations, symptomatic patterns, the knowledge of what types of disorders tend to present at different stages of a person’s life when stacked against the probabilities. Knowing what aggravates and relieves, knowing the patients contextual story – their daily work and recreations and positions and postures. It all counts. With all of this…perhaps it is possible for a PT to become reasonably sure that internal disc disruption is causing pain. At that point, we can work with physicians to focus on the disc as a possible cause. And you’re absolutely right; a lot of times you can’t do it…we end up with ill-defined pain that is what it is, and we have to educate patients, and modify activities and treat in different ways that take into the account the whole person. What we advocate is exactly what you said ‘it’s an effort to account for more of the variables’. Pathology and anatomy are two of those variables…I’d like to see them remain at the forefront…that, I guess, is for the readers to decide. Best regards. Brett.

      Like

  3. Hi Brett, great response to John’s comment. I think the ‘conceptual disc model’ first described by McKenzie remains as such, it is a concept. With all the scientific research on the intervertebral disc can be quite overwhelming for us – the consumers of literature, to really know if the IVD is the primary symptom generator. However, by means of mechanical loading of the spine – manual or exercise, one can evaluate the pain source’s response. The phenomenon of centralization still becomes our best prognostic indicator of patient’s early return to function. How do we potentially explain the centralization phenomenon? Hmm, it depends on which training ground. Is it the pumping effect of the vascular structures that surround the nerve root and vertebral end plate? or the movement of the NP brought by repeated extension? Does the NP actually move to the center of the disc as described by studies of earlier models? How about rotation and the concept of tissue repair and its effects on the annular fibers. How about the theory of disc migration towards the weaker part of the injured annulus? Experts will argue on these issues, but at the end of the day we do whatever it takes to make the patient better.
    The only thing I can share is this, by meticulously trying each model of assessment and treatment, the only valid test or measure of a primary disc pathology (combined with a thorough history taking) is the effect of repeated mechanical loading of the spine in flexion, e.g. for a postero-lateral disc protrusion. Taking into consideration that most of the research and evidence are seen in the lumbar IVD.
    I have also found NAIOMT’s “compression overload test” to have similar results.
    The next question is – how much lumbar extension is needed to facilitate centralization? That would be another discussion on another rainy day here in Florida. 🙂

    Kevin F. Spratt, PhD, quoted: The lowest form of evidence is when an advocate finds that their approach is better, and the highest form of evidence is when an advocate finds that a competing approach is better.

    Great posts. Andrei

    References on scientific research above is available upon request.

    Like

    1. Thanks for the comments Andrei…I think it’s a positive thing to realize that we all have to be able to step back and see that none of us has all the answers, but that all of us have some of the answers. That, and to realize that there are three pillars of evidence, each of which is able to contribute something important to the overall picture. We cannot rely on literature alone. Just one day in the clinic trying to support all decisions with literature would put paid to that idea. That doesn’t mean that we don’t pursue better evidence, but clinical evidence and theoretical models based on logical thought processes do have their place. The McKenzie system is a fantastic example of a great theoretical model supported by sound rationale that has been shown to be effective on the right patients. It doesn’t work on everyone (nothing does). I don’t think we know exactly why it works yet? We should continue to work on the why…but we don’t throw it out because we don’t know the why. As you’ve indicated, clinical evidence is important…as are patient preferences. It’s not just about rattling off another article….Thanks again Andrei…excellent contributions. Brett

      Like

  4. Thanks Brett. I think everyone should start looking at the “Revised Sackett Solution” (Chad Cook, AAOMPT Conference 2010) where clinical expertise and empirical data becomes top of the pyramid.. which clearly states your post on clinical reasoning.

    Cheers!
    Andrei

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s