理学療法の臨床におけるクリニカル・リーズニング

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CliRgcal

Reasoriting

EnPhysical

Therapy

Practice

,*

Helen

M.Jones"'

Continuing

to

learn

and

improx,e

clinical skill$

i$

a challenge '.,o

al] _{practicing physiothcrapists,} In addi'Lion to rhe obviou,s

benefits

to patients,

con-tiriued

learning

anc]

iinprox,ed

patient ouLcomes

he]ps maintain professional satisfaction 1'rom c]ini-ca] work. A]1 ot'us con'ipare, cLassit'y, order, esti-mate, forTnhypotheses, weigh evidence, draw

con-ciusions and engage iunurnerous activities thatare t},'picallyclassi.fied as thinkjng or reasoning.

Btit

Lhisisnot tosa'y that we do these thingswe[[ {na]1 circumstanccs. or thtvi/we couldinTt Eearntodo them

better. Physiothei'apist'swith _good cliriica}

re?ison-ing sk"]$ are able to learn from each in{livi[lual

patient'sphysiological and emotive response to

in.iuryand dyslunction. They use the c}inical

rea-soni"g process to buildon the feundation they

ac-quirecl in scliool anci in time develop a broacler

siore of c]jnical patterns and management

strategles.

Clinicaldeci$ioe$in manual therapy are strong'ly

inl'luencedby the bias taught inour formal

educa-t/'Lon,tisca,n be seen inthe dilferentmanual therapy

pii.ilosophles uf Kagtenborii,

]vlaitla"d

and

Paris,

CUnical reasoning is not about changing the tnanual skills you presently utilise inphysical ther-apy. However, as the nature o['critlcal t.hinkingis

to

be

epenly skeptical ot' any _person or approach

that professesabsolute truth,skilted reasonin.v wil!

assist _you to broaden y,our ouLlook, to chalLenge

'

_{V[l'1{:as?'Sia)Et,,:taieltslt6V} b)

-=

h Jle D rJ

-

_{zr;- 7} a' "' _{Bayside JVlanipuiatl've[)hysiotherapy}

Ke}, -,ords: C]inieal reasoning, Physical thErapy, Clhiical

praeL.icc

yeur existing beliefsand

to

embrace alternative

ideas. Improving clinical reasoning skills

is

about.

thinking,niore eritically, more creatively and more

deeply

about. what. yoti do.

Mark emphasised ishisopening address _thatour

biomeclical and clinical knowledge

base

and the

organisation of this knowLedge are two

important

factors

inrluencing

our levclof clinical reaso-ing

expertise.

Our

knowledge base can be developed

Lhrough reading Lhe biomedical literature,wriLing

iiteraturerevie-rs on topicsoC interest

(especiaHy

if

thcreview relates to an aspect relevant toa current.

patient)and

by

attending short courses, Personally

the most significant learning experience in my

career was t'ormal post-graduate educaLioll which

invotved much supervised clinical "Jork.

I

have

found thatsince thisintense eclucational experience

T1]ave

been

ab]e to

better

inLegrate

knowledge and skills

from

short courses.

Longer

terin,residency style 1)ostgraduate progra:ns are obviously the best

means tomaxiTnally improve _your biornedica]and

clinical knowledge and reasoning skiLls but Irealise

this

is

noL _practical

for

everyone. Shorter term

continuing education courses art tha next option such as Lhoseorganised through the

_Japanese

Phys-icalThcrapy Association. While two and

three

day

eourses are usefut to introduce therapists to new

eoncepts and techniques, theirgreatest

limitation

is their

inabi]it'y

to

incorporate

supervised work with

patientsinsuch a short time.

Before

I

discuss

specific

learning

strategies

designed to

improve

your clinieal reasoning that.

l80

'ee\as?dk\

to reinforce

rvaark's

discussion

of

hypothesis

categories. The hypothesis categories outlined by

Mark

Jones

at thisconfercnce and elscwhereE)2)are

an cffective toolinorganising biornedica}and clini-cal knowledge into clinical thoughts relevant to

each patient problem.

Personally

I

flnd

the

hypoth-esis categories outlined by Mark a very useful t.ool

in organising my clixLical thoughts. Improved

organisation of

knowledge

or reasoning techniques

are equaily valuable to all manua] therapy approaches.

Dysfunction

The

dysfunction

category was

defined

by

Mark

in

his

address as 'tthe

patient'sfunctionalproblems

for

which

hefshe

is

seeki'ng treatment".

Thjs

appears a very simple hypothesis category for the

Lherapist Lo thiRk about. The "dysfunction" _is

likely

to

be

one of the first.

things

pat.ientstell_you

in

the

interview.

Itw{11

be

elbow _pain with a _golf

s"ring, back _pain after minding grandchildren, or

an

inabMty

to continute

to

cOpe with

the

intensit.y or constancy of the pnin that coriceriis them. This "dysfunction"

will

be

a rel'lection of

the

patho-biologicalmechanisms operating sueh as altered

raltge and _pattern$ of rnovement,

inf]ammation

or a "sensitised"

central nervous system

(CrNJS).

As

therapistswc can focus on aspects ef a _patieni

pro-blem

that

interest

us,

for

exampJe, iniproving

muscle control or strategies for eoping with a

sensitized

CNS.

It

is

irnportant

for

patient/

therapistrapport and a successful outcorne not

to

Loscsight of patients'perspectives of their

function-al

limitations.

Source

of

the

Symptorns/Dysfumctiem

and

CoRtributing

Factors

ln the clinic:itisuseful to think about these

hy-pothesis categories together and to differentiate which specific

joint$,

muscles, nerves and/or other soft ti'ssuesare thc source of the symptorr]s and which tissuesor other environmental or

psycholog-icalfactorshave contributed tothe developrnent or

ag

25

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4

E'

ma]ntenance of the symptoms.

Organisation

of

therapists' thoughts into these hypothesis categories helps them te interpret test findings.

Consider the common _patientscenario of unilateral

cervical, upper thoraclc, and uppcr latera]arm

?iching aggravated

by

working at a computer.

TheTe are likelyto be_positivetestsof Iow cervicaL

joints

and a$sociated soft tissues,upper thoracic

joints

and soft

t{ssues,

neural

tissues,

shoulder

joint

and associated seft tissues,issuesof muscle control

and posture, poor ergonomics at work, sleeping

posture, reduced exercise

tolerttnce

and affective

issues such as overwork or unsatisfactory work

conditions.

The

complexity of

individual

patient

presentations can

be

overwhelming and weighing

up and making sense of all the positive clinical

findLngs requires skM. Therapists with _good

cal skills will bc able t.o liypothesise regarding

source and contributing factors

by

weighing up all

the _presenting signs and symptoins. For example

in

one patient a therapist may

hypothesise

the

upper theracic

joints

are

the

most Iikelysource of

the syinptoins because these

_joints

had the most

Hmited movEment and

the

most significant muscle

spasm inthe associated soft tissues.

Intervertebral

movement testsmay

have

reproduced _pain intothe

arm and cervical spine. The _past history of a

shoulder injury and the finding of a stiff, _painfree

shoulder and a recent change inofficc ergonomics

were identifiedas two likelycontributing factorsto

the onset. ot'symptoms.

Identificationof the like]vsource amd relevant

'

contributing factorsleadsto speedy resoLution of a

patient'sproblem,

For

example,

in

the acute

tion,quick pain retiei isimportant and accurate

and specific at.tention to the

injured

structures

is

essentiaL Ifsymptoms are lessacute ancl intense

and a specific contributing factor predominates in

the clinical _picture,thisfactor may be beLter

drcssed as the initialform of management. While

attention to the source of the symptoms will often

provide immediate relieL aUention to the

NII-Electronic Library Service

c

deyeloping

in

tE']e

first

place

is

essential touiinii'nise

futurerecurrenee.

Pathobielogieal

Mecharmismas

It

is

[rnportant

for

physiotherapists to

hy-r)othesise re/t.varding the pathobiology

behind

indi-vidual _{pat'ientpresentations.} Gifford and Butler

have _proposed useful categoTies inwhich to

organ-isc,'

i.houghtGregarclirig pathobiology2i. 'I'hey

sug-gcst considering pathobiology eitthe local

pcriphcr-eiltissues,

input

inechanisi'ns to the

CNS,

the

pro-cessing of sensory inpul that occurs irtthe CNS, and the resultant out/put niec;hanisms of the CNS.

Thinking

about the

input,

processing, and output of the CNS w"/h each individual

'problem

ensures a

co]npreheiisive collsideratioll oi' thepathobiological

mechtmisms operatirig,

One pattentcase may, beas simp]e as

hypothesis-ing

that

i-flsrniuatiou

is

the

local

tissue patho-biological inechanism, resulting in nociceptive

neural input tothe CNS. This sensory input may

be

processecl

by

a

CNS

opcrat.ing in its"normal" inodc ancl _positively iufluenced by the _patie"Vs

thoitghts an,'1

fcelings

about l.heprob}ei".1.hnt

is,

the _patiGnt is coping well with the dyst'unction.

The mot/or system may be influenced by output

t'rom

the

CNS

resulting

in

inuscle spasm and altered move[nent. However in most of eur pa-tlents more complex pathobiological mechanlGms are operatirig. The loca]tissuesmay be at various

stagcs of in[lammation and repair, including fidly

healed,

and sensory

input

rnay

be

coming frernany of the sense/ry $ystems thatinforinthe body ttbout

Lhe environment,

lnternaEly

and externally.

I]ro-eessing may be occurring by an abnormal or

seiLsiti.sed CNS ancl affective influericcssuch as

anxiety and anger may

be

furthcr inf]uencing t.he

processing cf sensory input. Cther systems along with 1-/hemotor systern will then

be

influenced

by

output from the CNS inclilding the autonomic,

neurocndocrine and

immune

svsten'is.

This year Ihad a very interesting_pal/ientwho suffered t.horacicpain aiter a liftinginjuryat ",ork.

linical

Reasoning

in

1]hysical Therapy PracLice

181

The

presentation was characterised by cxtreme

pain and

'`spasms"

and an extreme reaetion to

touch that vi'as out ot'_{propurtion to}

1iis

abiLity to

rnove and

functien.

T-Ie

was

helped

by

a

psycholo-gist

who specialised jn_pain rnanagement. He had

been

suffering _genuine mal-t.reat/ment, at work

for

sometime

by

hi$ supervisor who was a verbal "bully". _The

pat.ientfelt

Uie

supervisor was in_part

to

b]ame

for

theaccident as he

had

him working on

a roof in very windy conditions and he was very

emgry. The _psychologist used hypnosis _to

help

him

to

ctealwith his

feelings

and reaction tot/hisman as we" as the _pain ilselL

")ithin

a

few

weelcs the patienVs toleranceand response tomanual therapy

was far more normal. I interpretcd the

patho-biologicalmechanisms worki'ng initia!lyint/hiscase

as iRflEirnmatorylocaltlssue changes resutting

in

nociceptive input to the

CNS.

1'roccssing of this

sensory

input

was

being

influenccd

negatively by

emotions such as fearand anger resuLt.ing in exces-sive act.ix,ity inthe niotor system that was

mcchan-icEillv

scnsitised

to

touch.

Preeautions

altd

Comtraimdications

to

Physical

Examnimation

and rTreeatment

This hypothesis category isextremely iTnportant

to

those of us inelirticul _practice,

No

mntter which

school of manual therapy in which you trainitis

important.

to stop yourself

be[oi'e

you perform

phys{cal treatment and think whether there are any factors that mfake _you eaut{ous about treat-menL There needs

to

be

an eleinent of routine

in

your subjcctive and _phy$ical exarnination so that

indications

of sinistcr pathology, systemic

diseases

etc. are screened aRd recognised, ""{any_patientsdo not readUy give inforrnation aboui rnore serious

health _problcms forthciroMJn _privacy and

because

they _perceive itas irrelevantto their _present

symp-torns.

Asking

about medication

is

often yevealing.

People will tellyou theirgeneral heaLthisgood and

yet

have

a

leng

list

uf rnedications they need to

takc. Total contra-indications to physical

182 ttM[-:-b.th?attl,E

to _physical examination and treatmenL This can

be

Eur

a variety of rea6ons

including

general

irrita-bility

or sensitivity tornechanical input,a

sponta-neous worsening of a condition, age or

known

pa-thology such as rheurnatoid arthritis or osteoporo-sis.

Management

and

Treatmemt

Management

wlll

be

the

hypothesis

category that will be most influenced by the rnanual therapy

ap-proach in which an individual therapist istrained.

A

particular inanagement approach or specific

treatment technique should

be

a re6ult of reasoning

Lhrough a particglar patient problern.

It

should

be

a logic?ilextension of a thorough exainination and Tiot recipe based.

ProgRosis

Prognosis

regarding an

individualsi

prospects

for

recovery andi return to function is the most

chaLlenging of the hypothesis caLegories.

In[orma-tion

from

allaspects of your subjective and

physi-cal examination contribute to _your collective

deci-sion regarding prognosis.

There

will

be

conflicting

evidence, for example a _person may have _youth,

miniinal _past history of musculoskeletal _problerns

and

l'itness

as _positiveelements

but

the

trauma

in-volved at the onset of injuryand a lessthan

ideal

work situation as more negative e]ements.

Patients

expect to know how much and how _{quickly you}

believe

you can help them and togive them _this

jn-formation

it

gs

important

toweigh up the positive

and negative

indicators

to prognosis and teEIthem

your opinion and some

information

regarding

how

you came to thisdecision.Even with a lotof expe-rience _your hypothesis regarding _prognosis will not

always

be

accuTate. Itisa useful }earning

experi-ence toreflect at the end of treatment as to why a

particular patient's rate of

improvement

wa$ rnuch

fasteror slower than you firstanticipated. Which

elements did you give too much or not enough

weight to,when initial]yhypothesising about

prog-nosis?

eg

25

tseg

4

Following-up patients'progress after they stop

treatment

is

important

to

Eearn

about the longer

term elfects of treatment ancl improve _your skilg$

at _predicting

how

_quickly and hQw completely

treatment a$$ists the various _{patient presentations.}

My personal policy is to ring _patients several

weeks after cornpleting trcatment and enquire

about symptoms or

functional

_problems. Some of

these patient cases

I

then

follow-up

over longer

periods of time. Over the _yearsIhave found the

formation gained

by

long term

follow-up

very

useful

in

advising patients of a

Iikeiy

ou ±come to

theirpresent

disorder.

In

summary,

hypothesis

categories are very

useful fororganising clinical thoughts. They assist

in broadening your thinking about _patient

lems

from

the perspective of a partjcular manual

therapy approach, It enab]es con$icleration of the patient

information

in

categories suitable for any

patient with a musculoskeletal disorder, Clinical

reasoning in hypothesis categories

helps

_the

therapist

to

determine

what clinica] characteristics

of a pat.ientproblem are part of recognisable

cal patterns and what coinpenents are

individual

to

a _{presentation.} Physiotherapy school teaches the

basic clinical _patterns of _presentation and itis

by

using a

hypothesis

test,ing

approach that we

learn

more variety and _greater eomplexity of cLinical terns.

Learning

Strategies

for

the

Clinician

Learning

strategies successful

in

promoting

tinued

development

of

knowledge

organisation and

reasoning skills

jnclude

self reflection strategies,

peer teaching strategies, and discussion _groups.

Selfreflection isan advanced thinking skill that

expert therapists use alrriost unconsciously. The

more _you engage in reflection, the more automatic

it

becomes.

InitiaLLy,

as a rneans of _prompting

yourselftoreflect on _your observations,

tiensand analysis of patient

information,

I

mend using something likethe

LLCIinical

Reasoning

NII-Electronic Library Service

Clinical

and _postgraduate courses in Adelaide, Sout,h

Aus-tralia. 'rZhe

C;linicaL

Reasoning

_{Forni is}

cssentially a seif reflectioi}

Corm

consisting of _questions de$igncc]

to elicit. therapists' int.eTpretations,

hypothescs

and

plans.

The

questions 3re _gearecl Loward tlie

hy-pothosis

categor'ies and rev'eal therapists' depth of

unders'tanding e'ftheir patients'prob]ems. This

specif]c form was construcLed foruse with _patients

having neuroinusculoskeletal problems and would

need somc revision tobc more appropriate for use

wi'th _patients having ncurological or respiratory

problems,

IE'hiie

in

most

busy

clinius itisnot

prac-t/icalto complete a forrn for each _patic]ntbeing

treaLed it,may be pessible to choose one _paLient eaeh week

t'o

reflect upon.

In addition to aslcing Lhe therapistspecific ques-tions regardl/ng

inforn'llition

obtaincd inthe

subjec-'tive

_and

physicaE examinarion. the end of the form

also requests theraplststo refiect on their

rcason-ing

1/hrough

the

ongoing managenient.

In

a

busy

practice.when a _patient has not responc]cd as you

wou]d tike,

it

is

casy to chans,e _srourdirectionof

'L'rea'trnent

_{w'it.hout taking the}

'l/li"e

_{to re[Lect. You}

rnay. end u,p treating some component of the patieAt's problein quite dift'erenUy

lrom

how you

sLarted t.reating

(e,g,

change t.oa {lifferenL passive tecl]nlque, or change to an active!'rehab oriented

al)proach). The patient inny improve but ifyou

haven/'t taken the tirneto refLect on why your

i-i-tialapproach was inefl'ectiveyou rnay

be

missing a

valuabLe learning opportunity. Ofl/e"a lack of

iin-provement can be tracecl

back

in_p?ir{.totherapists' reasoning L'hrough thcir

initial

exauiinati,on.

Rea-soning e'rr'ors such as only consiclering the rriost ob-yious

h),,pothescs

ancl not atternpting tu test all

possibilitiesi']'equent.lyIeadtherapist.s toineffective init.ialtreat]'ncnts.

XUhen.

throiigh Lhe course of

your ongoing management. you have chang'ed _your

impression

of Lhe patienL's probEem

(e.g.

structures a'L

t'ault,

contribuLing [actors,F)aiiimechanisms, etc.)

you should Lry torcflect on why you

didn't

consid-er this_perspectivo from the starL. Did vou over-weigh or underweigh inforrna'Lioncollected inyour

Reasoning

in

Physical

Therapy

Practice

183

initial

examination or perhaps you missed

somc-thing altogether?

While

aLl therapists will rnake rnistakes, it

'is

t.hethlnking,reflective therapistwho

learnsfren'Lthem.

Another useful self reflection tooL is to keep a

diary of clinical _patterns.

An

inexpertenced

thcrapistniay onl>,

have

patLerns "rhich

havc

been

learned through texts. I- contrast, experts

have

a

broader st/ore of clinical paLterns acquired

from

their individual experiences that rnay not rnatch

the pat.ternsof other therapi$tsor the textbook.

The

key toacquiring more patt.erns

including

vari-ations or subpatterns from the classic textbook paV

terp jsagain reflecl.ive thiiiking.

Good

reasoning

means _{paying particular}attention towhen some of

the features ol a _{patlenVs presenttition}don't fit

with the rest. For exaniple, one therapistmay

hear

the _patienthas central back pain and difficulty

siL-ting, _particularlywith flexing

his

neck to get

into

the car and

jurnp

to thc conclusion thaL itisa

lumbar

disc

problern,

disrcg;irding

t/he information

about the neck

fiexion

which [ioesn:t qiiite ]Tiake sense, Incontrast thereflective therapistattempts

tounderstand thi$

feature

and through

further

test-ing discovers the _problem to be discogenic with all.ered neurod> namics. By keeping a

diary

of clini-cal patterns you cornmonly encounter

in

your

prac-tice _you wM becomc more familiar with the

paL-terns and begin to

identify

Lypicalvariations. ,'1. diary of clinical _patterns i$a toolto assist _you in

organising your

knowiedge.

You can

desig'n

your

own ternplatetorecord your pat±erns ",･hich should

at Leastinclude a body chart to

illustrate

typical

areas of symptoms, and sections to record typical

behavioiir,

hisLory,_pt)ysicalfindings and manage-rnent as well as ariy _precautions which must be considerect.

Te

make the clinical _patterns relevant

to_{your practice}itisgood tostart

by

outlining the pat.ternof a

few

patients you are preseritly treating.

Then as _you read litcratureor att'end courses with

inrormation specific to a clinical pattern you

have

outlincd, t.hiscari be compared to the dinicaE

184

mp#diza\

added.

In

thisway you arc always revtewing and revising your cliTiical patterns. This iscritical

re-flection.

'I"he

next learning strategy you can use to im-prove your reasoning skills

is

referrecl to

in

the

ed-ucational

literature

as peer/ceoperative learning. While itmay be idealto have an expert therapist

observe _you with _{your patients} and a$sist you

in

your reasoning, _you can also Learnmuch from

pro-fe$siona]

colleagues with similar levelsof

experi-ence as _your own. Itisthe _process of reflection

that emerges from discussing _patients with _your

peers that results in

Iearning.

Peerfcooperative

learntng can

be

structured

in

a variety of formats

including

having

a colleague observe you, or _you

observe

him/her,

examining or treating a _patient;

presenting case studies te _{your peers} or role play-rng a _{patient you} are having

difticulty

with to a colleague. Inallof these

formats,

the key isforthe

individuals

involved

Loshared theirthoughts.

In

the case study format,

therapists

often only

present thekey findings from thepatient

examina-tion

and

then

what

treatment

was

delivered.

This

provides

iittle

insight

to the therapist'sevolving

thoughts as the

information

was collected. A more

valuable approach isto _present chunks of _patient

information and then discuss amongst the _group

theirinterpretations of that

information.

Thera-pistswill inevitablyhave differentopinions and the

discussion

surrounding such differencesis

invalua-ble to broadening _{your perspective} and

depth

of

understanding. Similarly when observing each

other examine and treat patients, the two therapists shottld

hold

an ongoing discussion of

theirobservations and interpretations.Itismy

ex-perience thatmost _patientsappreciate

the

added

at-tentionof two therapists discussingtheirproblem.

Another

variation of the peer

teaching!coopera-tive

learning

strategy outside your immediate work

environment

is

to participate in a _{physiotherapy}

discussion

group on the Internet.There are

numer-ous _general physical therapy and specific _physical

therapy related

cliscussion

_groups covering a wide

ag

25

igeg

4

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range of special

interest

topics such as

back

_pain,

pain,biomechanics, etc. Individuals can also set up

their own discussion _greup,

for

example, a case

study, clinical reasoning

discussion

_group. This

would enable therapi$tswith a common interestin

clinical _problem solving toshare their

ing

and management strategies fordifferent

Lems. Once organised _patient cases could be

sequentially _presented with the therapisVsevolving

thoughts while inviting other _group members to

similarly share theirthoughts. The aim of such a

discussion

isnot to necessarily reach a consensus,

but

to consider _perspectives differentthan _your

own.

In

summary Iwant to emphasis that improving

your ciinical reasoning does not have _to

be

served

for

those attending formal _postgraduate

$tudy. Practicing clinicians can also improve their

reasoning. To improve _your reasoning _you first

have

to

be

open tothe concept that thinking skills,

like

manual skills and knowledge can

be

improved.

Even experienced therapists will

fal!

into

habits

and routines and are vulnerable tomaking errors

of reasoning.

Being

aware of the reasoning _process

as will have occurred throughout thisconference

is

essentiaL

Occupied

by the commitments of a

busy

department or clinic many therapistsmiss _the

full

opportunity to learn from _their own patients.

Simply treatingpatients, even successfully, wiil not

necessarily

lead

to improved reasening.

Clinical

th¢rapists must make special efforts

to

set time

aside to work with others or utilise self refiection

forms such as the

Clinical

Reasoning

Form

Enorder

to broaden their knowledge of clinical _patterns and

improve

theirreasoning abi]ities. References

1)

Jones

M,

Jensen

G,Rothstein J:Clinicalreasoning in

physiotherapy.In/Higgs

_J,

_Jones

M

(eds)

Clinica]

soning in the Health Professions. New York,

worth-Heinemann, 1995.

2)GiffordL,ButlcrD]The integrationol'pain sciences