I attended the MPA Complex Clinical Reasoning lecture last night, presented by Andrew Dalwood, Specialist Musculoskeletal Physiotherapist. The night highlighted the change in my thinking since completing my Masters but also how much more there is to learn. One quote from Andrew stuck with me, “gap in my knowledge base”. It made me realise we will always come across new conditions or treatment techniques but rather than feeling inadequate, we should take the opportunity to learn more and expand this “knowledge base”.

Andrew began with a background on clinical reasoning, contrasting pattern recognition to hypothetico-deductive reasoning. Surprisingly, I had written an assignment on this topic last year. At the time, it appeared to be a long-winded, uneventful assignment but I was amazed to see how much this had moulded my clinical practice. Hypothetico-deductive reasoning is the most enduring clinical reasoning model, whereby a therapist proposes prioritised hypotheses which are then proved or disproved by the analysis of examination findings. This assumes that illness is objective and measurable which follows a clinical pattern and can be used to predict prognosis (Edwards et al, 2004). Pattern recognition occurs when a therapist notices similar attributes to another case/patient and uses the previous cases to extrapolate additional information (Edwards et al, 2004). For example, my last patient with left sided lumbar radiculopathy had poor left gluteal function, so I should check the gluteal function in this lumbar radiculopathy patient. Pattern recognition is generally used by experienced, expert physicians with hypothetico-deductive reasoning adopted by inexperienced clinicians. Hypothetico-deductive reasoning is also adopted by experienced therapists when treating challenging, complex conditions.

Problems arise when inexperienced clinicians adopt pattern recognition without the necessary experience or reasoning. Andrew touched on this last night, when stating the biggest problem he encounters with new graduates is their over or underweighting of certain features of a condition. A clinical diagnosis is based on multiple subjective and objective asterisk signs or measures, with all aspects forming the diagnosis. Inexperienced physiotherapists sometimes base their diagnosis on one or two features, trying to make the diagnosis fit the patient. The diagnosis comes from an overall appreciation of the condition, after assessing multiple areas, clearing or implicating all relevant structures, not just based on one or two “features” of a condition.

I can directly relate to this, when I assessed my brother’s knee pain while studying physiotherapy. We’d just covered knee injuries when my brother experienced lateral knee pain after running. I checked the symptoms and figured out my brother had ITB Friction Syndrome. I asked if he had pain running, pain on mid-range knee flexion and pain localised to the lateral knee. All positive, therefore ITB Friction Syndrome. I neglected to ask about traumatic onset, the pain occurred after turning a corner while running downhill, or pain getting into a car. When he didn’t get better from my ITB release, I accompanied him to a Sports Physiotherapist appointment. After open-ended questioning, taking notice of all aspects of the patient’s condition, the physiotherapist suspected a lateral meniscal tear. This was proven after clearing patellofemoral joint, ITB, patella tendon, ligamentous and soft tissue injuries. Looking back it appears obvious, but I was convinced a running injury was ITB Friction Syndrome, and overweighted pain on running, while missing other crucial factors.

Andrew presented five case studies, which were multi-faceted or slightly obscure cases. The first case study described a complex neuropathic and nociceptive lumbopelvic patient with associated leg pain and numbness. Although a complex patient, several things became clear.

Is the pattern adaptive or maladaptive? To assess this you must change the patient’s position and re-assess. If you are able to change symptoms with altering posture, activation patterns or loading, it appears more nociceptive.
Target your intervention to address the various asterisk signs, one treatment may not address all symptoms.
Be prepared to add or remove treatments as required.
Always focus on the patient’s function, while specific signs are crucial for re-assessment and patient compliance, ultimately you should attend to the patient’s functional goals.
Don’t treat the scans, you should always base your diagnosis and management on a complete clinical assessment.
Enlist help or adapt when conditions change.

Andrew’s other case studies were very enlightening, also focusing on complete assessment of a patient’s condition and being able to adapt when unexpected situations or symptoms arise. The previous dot points seemed to be repeated throughout the lecture, reinforcing the same key areas of physiotherapy. Another lecture on complex clinical reasoning is scheduled in Melbourne for October, through the Victorian MPA committee. I can highly recommend attending this.

I will conclude with another quote from Andrew Dalwood, “empathy...never underestimate the power of empathising with a patient”. Often we forget we are treating a person, not a condition. While thorough assessment is crucial, sometimes understanding and support is just as crucial.

A special thank you to Andrew Dalwood for his enlightening presentation which caused many discussions later that night.

Alicia

References:

Edwards, I., Jones, M., Carr, J., Braunack-Mayer, A., & Jensen, G. M. (2004). Clinical reasoning strategies in physical therapy. Physical therapy, 84(4), 312-330; discussion 331-315.