Clinical Reasoning in Physiotherapy Practise

Overview

Clinical reasoning refers to the ‘thinking and decision-making processes which are integral to clinical practice’ (Higgs & Jones, 1995). This is a fundamental skill that physiotherapists incorporate into their clinical practice. Therapists typically reason within their own unique approach however when doing so effectively common characteristics are present. These characteristics can be explored through the use of diagnostic and narrative reasoning using the hypothesis categories framework. Clinicians are prone to errors in their clinical reasoning. Common errors can be identified and mitigated by using strategies for minimisation. These are skills that therapists may consider within the context of their practice.

Theoretical processes involved in clinical reasoning in physiotherapy practise

Several theoretical processes are involved in effective clinical reasoning. These can be broken down into components. To implement clinical reasoning effectively a three-step process can be utilised by therapists.

1. Selection and implementation of a clinical reasoning framework

2. Understanding the components of effective clinical reasoning

3. Understanding factors that influence effective clinical reasoning

The utilisation of a framework that can be used within a therapist’s clinical reasoning is paramount. This gives therapists the foundation to harness their reasoning and ensure some form of systematic methodology. There are three commonly accepted frameworks that facilitate this process in physiotherapy practice. There is a fluid interaction between these frameworks. They can be used in conjunction with one another or isolated within their own components.

The biopsychosocial approach is a holistic construct that allows a therapist to explore a patient’s physical, psychological, and social domains (Atkins & Ersser, 2008). Evidence supports this theory with the psychological and social components of a patients presentation now being recognised as important health determinants. In society, physiotherapists have historically been confined to the physical domain. This framework enables physiotherapists to have a greater appreciation of the entire health presentation whilst still working within their scope of practise.

Clinical reasoning strategies involves the selective use of different reasoning paradigms throughout a patient interaction. To do this effectively a therapist must be aware of the different forms of reasoning that can be applied and skillfully do so as clinically indicated. This is a more fluid framework that gives a therapist autonomy in its implementation. The types of reasoning that are included within this approach are (Jones, Edwards & Jenson, 2008):

• Diagnostic reasoning: The logic used for forming a patient's diagnosis.

• Narrative reasoning: Understanding of a patient's experiences.

• Reasoning about the procedure: How treatment is selected, implemented and progressed.

• Interactive reasoning: Building patient rapport and including the patient throughout a service

• Collaborative reasoning: Including a patient in the decision-making process

• Reasoning and reaching: Empowerment of patient through education

• Predictive reasoning: Skillful prediction of effect and prognosis

• Ethical reasoning: recognising, respecting and facilitation of an ethical service

Hypothesis category formation is the third clinical reasoning approach. It involves making clinical judgments based on gathering information throughout the examination. A minimum number of categories was proposed by Jones in 1989 as seen below. The theory behind hypothesis formation can be applied in other aspects of the clinical encounter however it can be used as a template for therapists when analysing their own clinical reasoning (Jones, Edwards & Jenson, 2008).

• Activity and participation capability/restriction

• Psychosocial

• Problem classification/physiotherapy diagnosis

• Impairments in body function or structure

• Contributing factors

• Precautions and contraindications

• Management and treatment

• Prognosis

To implement clinical reasoning into physiotherapy practice therapists should be aware of the key components that lead to its effective integration within the selected framework. Some of the components that enable effective clinical reasoning from therapists include:

• Critical thinking (Christensen, Jones, Higgs & Edwards, 2008)

• This skill involves “actively and skillfully conceptualising, applying, analysing, synthesising and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning or communication, as a guide to belief and action” (Christensen, Jones, Higgs & Edwards, 2008)

• Metacognition

• Is the ability of the therapist to self-monitor their performance, thinking and knowledge. Having such insight enables therapists to be critically self-aware of their performance and make the appropriate adjustments to enhance the efficacy when clinical reasoning

• Data collection and procedural skills (Jones, Edwards & Jenson, 2008)

• Without effective data collection and procedural skills, a therapist has insufficient information to analyse within their clinical reasoning.

• Knowledge organization (Boshuizen & Schmidt, 2008) (Higgs Jones & Titchen, 2008)

• Having well-structured knowledge has a clear association with successful performance when clinically reasoning. The structure of knowledge is a critical component as it needs to be readily accessible for the therapists to access. This component is regularly what separates expert and novice practitioners.

• Therapeutic alliance (Atkins & Ersser, 2008)

• This facet involves optimising the collaboration between therapist and patient. When done so effectively it correlates positively with increased patient motivation, self-efficacy and the sharing of all relevant information.

Clinical reasoning can be influenced by a variety of factors. When optimised therapists can use these factors to enhance their ability to reason. However, when neglected these elements will compromise a therapists reasoning process and make them vulnerable to error.

Interpersonal and communication skills are vital to the clinical reasoning process. These skills ensure that an interaction with the patient is optimised to extract all the necessary information to include in your reasoning (Jones, Edwards & Jenson, 2008). Being able to relate to patients enables them to feel at ease and share with you all relevant information. The ability of a therapist to educate and converse with patients is also a key element when considering favourable outcomes.

Practical skills present a new dimension of information into the therapists reasoning process. The better a therapist’s practical skills the more valuable this information will be when included within the reasoning process. This involves the integration of information from the hands-on assessment and treatment.

Individualization is a key element to clinical reasoning (Atkins & Ersser, 2008). This is the therapist’s ability to adapt their processes and tailor it to the individual. The method of reasoning in one circumstance may be suboptimal in another. This challenges the therapist to recognize and adapt accordingly to enhance their performance.

Organization and environmental factors are key elements to the reasoning process. The organisation can refer to variables such as how much time a therapist has with a patient and monetary constraints that a patient may have. Environmental influences may be elements such as access to equipment. These elements need to be considered in the reasoning process as they will affect performance and also patient outcomes.

The most important characteristics of effective clinical reasoning are the use of a clinical reasoning framework the therapist can skillfully implement into their practice. Optimising key components of the clinical reasoning process including critical thinking, metacognition, data collection, knowledge organisation and therapeutic alliance. Demonstrating the effective use of factors that influence clinical reasoning such as interpersonal skills, communication skills, practical skills and individualisation. These characteristics are indicative of effective clinical reasoning and therapists should refine their skills in these domains to optimise performance.

Common errors in clinical reasoning in physiotherapy practice

Clinical reasoning errors are common within clinical practice. It is important for clinicians to be aware of these errors so that they can identify them in their own practice and limit their influence on the reasoning processes.

Priming is when a therapist’s clinical reasoning is influenced by having prior information (Jones, Edwards & Jenson, 2008). This may be in the form of a referral from another health professional or imaging. Due to having this information, a therapist is prone to biasing their assessment based on preconceived ideas.

Example: In some forms of patient presentations imaging correlates poorly to pain and disability (lower back pain). Therefore, it is paramount that the patient examination is conducted in a manner that does not bias this pathology as the source of symptoms. To effectively manage this patient group the imaging needs to be correlated with an unbiased assessment to determine its relevance.

Strategy for minimisation: Follow a systematic process despite preexisting information. This can be done by implementing one of the clinical reasoning frameworks as discussed in section 1.

Confirmation bias/premature closure is when a therapist collects information from a patient that seeks to purely confirm their existing hypothesis (Gilliland & Wainwright, 2017). This error in reasoning neglects information that is relevant to their presentation that may be related to an alternate hypothesis (Gilliland & Wainwright, 2017). The therapist is then unable to disprove differential diagnoses secondary to a lack of information.

Example: A therapist is enquiring about the behaviour of symptoms and identifies a pattern of instability at the shoulder. They ask questions that confirm vulnerability in a specific direction (ie anterior shoulder instability). However, in some patient presentations, patients may have multidirectional instability and be vulnerable activities that stress the shoulder in the opposite direction also (ie anterior and posterior instability). This will cause the therapist to make a diagnostic error.

Strategy for minimization: Implement diagnostic reasoning. This is an ongoing process where the therapist considers all available information the confirms and negates a hypothesis.

Conservatism/stickiness occurs when a therapist fails to revise their hypothesis in the face of conflicting information (Jones, Edwards & Jenson, 2008). This occurs commonly in physiotherapy when clinicians fail to reflect on all the available information at their disposal and instead preference their initial hypothesis (Gilliland & Wainwright, 2017).

Example: A therapist determines a working diagnosis for their patient. They prescribe a relevant and appropriate exercise at the time. The patient comes back worse but the therapist persists. The therapist fails to investigate alternative hypotheses despite potentially conflicting information.

Strategy for minimisation: Continued use of diagnostic reasoning throughout the entirety of the patient interaction. This then needs to bed revisited and reflected on after each patient interaction.

Memory bias is a common phenomenon experienced by physiotherapists in clinical practice. This is the tendency to preface something that has been done previously with success to a patient (Jones, Edwards & Jenson, 2008). Although the experience of the therapist is one of the pillars of evidence-based practice, it needs used in consideration with the other elements.

Example: A therapist prescribes standing external rotation as their go-to exercise for subacromial impingement. This is done due to the therapist having success using it in the past. The therapist neglects to assess other exercises/positions to address the impairment.

Strategy for minimization: A therapist needs to individualise their encounter to meet the needs of each patient. Ongoing reassessment and objective comparisons between alternatives should be used to optimise performance.

Assumptions make therapists vulnerable to error as they lead to inaccurate judgements being made based on skewed knowledge (Higgs Jones & Titchen, 2008). Therapists need to be self-aware of the assumptions that they make and take this into consideration whilst reasoning.

Example: A patient describes the aggravating position for the lower back pain in sitting. The therapist makes the reasonable assumption that they have a flexion based impairment. They fail to assess the patients sitting positioning. The patient has an upright sitting position and uses lumbar support that is pushing them into excessive extension.

Strategy for minimization (Jones, Edwards & Jenson, 2008):

• Clarifying using skilled questions

• Screening for all available information (to both confirm and negate hypothesis)

• Test for contradictory hypothesis

• Compare reasoning to other therapists

• Reflect on reasoning (both effective and ineffective components)

Errors in reasoning are common within physiotherapy. The ability to recognise when making errors is a critical component of effective clinical reasoning. This enables therapists to put strategies in place to minimise these errors and enhance their ability to reason.

Conclusion

Effective clinical reasoning shares common characteristics. The ability of therapists to demonstrate these within their practice will enhance their reasoning processes. Errors are common within clinical reasoning however being self-aware and implementing minimisation strategies will assist in mitigating their effect. Clinical reasoning is a skill that all therapists use. It is something that should be rehearsed and refined on a regular basis to ensure optimal performance.

Dylan Barnaby (APA Titled Sports and Exercise Physiotherapist)

Advanced Clinical Physiotherapy

References

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