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Integration and Application of the

Scientic Method, Evidence-Based

Practice, and Clinical Reasoning

Independent Study

Course 31.2.1

Sean P. Riley, PT, DPT, ScD

Sacred Heart University

Faireld, CT

Integration and Application of the

Scientic Method, Evidence-Based

Practice, and Clinical Reasoning

Guy G. Simoneau, PT, PhD, FAPTA—Editor

Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor

Cover Illustration by Joseph Kinstler

Dear Colleagues,

I am pleased to welcome you to Integration and Application of the Scientic Method, Evidence-Based Practice, and Clinical Reasoning by Sean P. Riley, PT, DPT, ScD. is is the ﬁrst monograph in the Academy of Orthopaedic Physical erapy Independent Study Course series 31.2, Current Concepts of Orthopaedic Physical erapy, 5th Edition. In this edition, the material is presented both as a narrated PowerPoint, consisting of 7 sections, and a matching written outline.

Sean P. Riley is an Assistant Professor in the Physical erapy program at Sacred Heart University in Fairﬁeld, CT, USA. He graduated from the University of Connecticut Physical erapy Program in 2004 and completed his Doctorate in Physical erapy at Simmons College in 2006. He obtained his Doctor of Science from Texas Tech University Health Science Center in 2013. Sean became board certiﬁed in Orthopaedics through the American Board of Physical erapy Specialties in 2007. He completed his certiﬁcation in Orthopaedic and Manual erapy (COMT) in the Extremities in 2012 through the International Academy of Orthopaedic Medicine-US. He completed his Fellowship in Manual erapy from Regis University in 2018. Sean has 16 published manuscripts in peer-reviewed journals since 2014 and has presented his research at the national level each of the last 7 years. He has reviewed articles for e Journal of Manual and Manipulative erapy, Musculoskeletal Science and Practice, and Physiotherapy eory and Practices within the previous year. Sean is also an Associate Editor for e Journal of Manual and Manipulative erapy. He is part of the team revising the Clinical Practice Guideline for Adhesive Capsulitis. Sean serves as a research committee member for the American Academy of Orthopedic Manual Physical erapists. He has served as a grant reviewer, poster presentation judge, and abstract mentor for research submissions.

In the monograph, Dr. Riley integrates concepts related to the scientiﬁc method, evidence-based-practice, and clinical reasoning to guide the reader on how to apply this knowledge in clinical practice. e author ﬁrst discusses the process of clinical reasoning along with common errors in reasoning – a section every clinician will be able to relate to. is section is followed by a discussion of what evidence-based practice is and what it is not, along with the process to formulate a meaningful question relevant to patient care. is section ends by providing the reader a list of on-line resources for evidence-based practice, several with “pre-processed” information. Finally, the author provides a theoretical model of clinical reasoning based on the type of pain perceived by the patient (pain mechanism), a systematic process of symptom modiﬁcation (the origin of the pain), and an understanding of the mechanical input associated with pain generation. Considerations for interpretation of the quality of diagnostic, prognostic, and intervention type research is also presented.

Clinical reasoning based on current evidence is key to optimal clinical decision-making and outcomes in clinical practice. e author has provided an excellent background for readers to gain an increased appreciation for clinical reasoning. I would like to extend my sincere gratitude to Dr. Riley for sharing his expertise on a topic so challenging to master.

Sincerely,

Guy Simoneau, PT, PhD, FAPTA

Editor

2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Oﬃce 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965

TABLE OF CONTENTS

ACRONYM LIST ................................................................................................................................................................................................................4

SECTION 1

SECTION 2

SECTION 3

SECTION 4

SECTION 5

SECTION 6

SECTION 7

..........................................................................................................................................................................................................................5

ACRONYM LIST

ADTO: assessment-diagnosis-treatment-outcome APTA: American Physical erapy Association CEBM: Centre for Evidence-Based Medicine CINAHL: Cumulative Index of Nursing and Allied Health Literature CPG: clinical practice guideline EBP: evidence-based practice FABER: ﬂexion, abduction, external rotation LBP: low back pain LR: likelihood ratio MCID: minimal clinically important diﬀerence MDC: minimal detectable change MRI: magnetic resonance imaging NLM: National Library of Medicine PICO: patient, intervention, comparison, outcome PMC: PubMed Central RRC: rehabilitation reference center SI: sacroiliac SIJ: sacroiliac joint SLR: straight leg raise

Opinions expressed by the authors are their own and do not necessarily reﬂect the view of the

Academy of Orthopaedic Physical erapy. e authors declare no conﬂict of interest.

e publishers have made every eﬀort to trace the copyright holders for borrowed material.

If we have inadvertently overlooked any, we would be willing to correct the situation at the ﬁrst opportunity.

Course content is not intended for use by participants outside the scope of their license or regulations.

Integration and Application of the Scientic Method,

https://t.me/med1917

Evidence-Based Practice, and Clinical Reasoning

Sean P. Riley, PT, DPT, ScD Sacred Heart University Fairﬁeld, CT

e outline contained in this written format is from Dr. Riley’s PowerPoint presentation titled, “Integration and Application of Clinical Reasoning, Evidence-based Practice, and the Scientic Method”.

1.1 Title: Integration and Application of the Scientiﬁc Method, Evidence-Based

Practice, and Clinical Reasoning-Sean P. Riley, PT, DPT, ScD

e purpose of this monograph is to discuss evidence-based practice (EBP), clinical

reasoning, the relationship between these concepts, and how to apply these concepts in a clinical context. Having a better understanding of these concepts individually and how they are related may help to improve the integration of evidence and reasoning into practice and help to facilitate better communication with colleagues and patients.

Disclaimer

1.2

• e purpose of this monograph is to help clinicians clinically integrate and ap-

ply the concepts of clinical reasoning, evidence-based practice, and the scientiﬁc method

• It is expected that the reader of this monograph has a foundational understand-

ing of the concepts that are discussed

• If the reader is not familiar with or does not have a comprehensive understanding

of any of the information that this monograph seeks to integrate, the reader is encouraged to explore that topic further

• is monograph is not meant to be a comprehensive resource for all the princi-

ples discussed

—NOTES —

1.3 Conﬂict of Interest and Acknowledgement

• Conﬂict of Interest-e author of this monograph certiﬁes that he has NO aﬃliations with or involvement in any organization or entity with any ﬁnancial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-ﬁnancial interest (such as personal or professional relationships, aﬃliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

• Acknowledgement-I would like to thank Brian Swanson and Josh Cleland for their assistance with writing “e why, where, and how clinical reasoning model for the evaluation and treatment of patients with low back pain.” is clinical reasoning model served as the foundation for the integration and application for the concepts discussed in this monograph.

—NOTES—

https://t.me/med1917

1.4 Table of Contents

Section Content

Section 1 Truth, Reasoning, and the Scientiﬁc Method Section 2 Evidence-based Practice, Statistical Tools, and Methodological

Rules Section 3 Clinical Reasoning and Diagnosis Section 4 Integration of Clinical Reasoning Concepts and Suggestions for

Improvement Section 5 Using the Literature in a Reasoned Approach to Evidence-based

Practice Section 6 Review Questions & Case Scenarios Section 7 References

• e table of contents for the entire presentation is included here

• Additionally, at the end of this presentation, you will ﬁnd a list of references

• e references are cited using the preferences of the AMA Manual of Style, 11th

edition and are located either in the PowerPoint slides, the slide notes, or both

Learning Objectives

1.5

• Upon completion of this monograph, the course participant will be able to:

° Identify and describe the diﬀerent types of clinical reasoning strategies used

during patient management.

° Discuss the process of clinical reasoning. ° Identify common errors in reasoning. ° Identify, compare, and contrast commonly accepted deﬁnitions of evi-

dence-based practice (EBP).

° Create a speciﬁc, answerable clinically meaningful question. ° Identify the best available evidence. ° Analyze examples of clinical reasoning strategies and apply research evidence to

clinical decision-making.

° Discuss the challenges with the clinical application of EBP and the need for a

reasoned approach.

° Discuss the intent and purpose of the scientiﬁc method.

1.6 Truth, Reasoning, and the Scientiﬁc Method

• Section 1

1.7 Do you promise to tell the truth, the whole truth, and nothing but the truth?

• is is an oath taken by individuals prior to giving sworn testimony

• e oath attempts to capture all aspect of the truth and prevent individuals from

leaving out important contextual elements of the truth as well as preventing the sworn testimony from being tainted by mixing the truth with things that are not true or that are partially true

1.8 What is truth?

1.9 “It depends on what the meaning of the word ‘is’ is.”-Bill Clinton

1.10 Getting to the Truth

• A common meaning of truth is information related to facts, reality, or informa-

tion that is consistent with a gold standard

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• e problem is that there are several theories and views regarding what the truth

https://t.me/med1917

‘is’ that scholars, philosophers, and theologians have debated

• Without getting into an in-depth discussion regarding truth from these various

perspectives, I am going to discuss truth from the perspective of Neil deGrasse Tyson

° Objective truths are established by evidence ° Personal truths by faith ° Partisan truths by incessant repetition

• e purpose of science is to identify an objective and measurable truth that may

be independent of personal and partisan truths (aka biases)

• Science also looks to control for the biases that may occur as our brains interpret

incomplete information gathered through our senses

Why is the interpretation of the truth important?

1.11

• Does an empirical truth exist beyond the biases related to personal truth and

partisan truth?

• Do you believe that the scientiﬁc method is a valid means of answering clinical

questions?

• If you don’t believe that the scientiﬁc method is valid, can the process of EBP be

valid?

• Can EBP be valid without accurate critical appraisal of the literature?

• If a clinician does not understand what reasoning is and what it is not, they can-

not apply a clinically reasoned approach in the clinic

• If a clinician does not believe that an empirical truth exists beyond the biases

related to their personal truth and political truth, they do not believe that the scientiﬁc method is a valid means of answering clinical questions

• If a clinician does not believe that the scientiﬁc method is valid, they do not

believe that the process of EBP that is based on the scientiﬁc method is valid

• If a clinician does not believe in the validity of EBP or the importance of accu-

rate, critical appraisal in the process of EBP they cannot use clinical reasoning to apply the best available evidence in a clinical context

• If a clinician does not understand what reasoning is and what it isn’t, they cannot

accurately apply a clinically reasoned approach in the clinic

• is is a linear (deductive) reasoning framework that connects a to b, b to c, and

c to d. If the premises are correct, then a deductive connection has been created that directly links a to d in a linear framework through deductive reasoning

• More to come moving forward on the details of what reasoning is and is not and

why these concepts are essential in a reasoned approach to clinical practice

—NOTES—

1.12 What does it mean to be rational, and why is it important?

• In order to understand what clinical reasoning is, we must understand what it is

to be rational.

• Rational clinicians formulate opinions and make decisions based on facts and/or

a reasoned approach by eliminating or minimizing logically fallacious thinking and cognitive biases

• Professional opinions that are not supported by the best available evidence using

an overt reasoned approach are irrational

• It, therefore, becomes vital to recognize what reasoning is and isn’t

1.13 Are you rational, or are you rationalizing?

• Rational thinking involves generating a hypothesis (abductive reasoning), col-

lecting data (deductively, inductively, or probabilistically) and then linking the data together (deductively, inductively, or probabilistically) to make a conclusion in the context of the best available evidence

—NOTES—

https://t.me/med1917

• Rationalization starts with the answer and then uses hypotheses and data that

supports the answer with disregard for the data that do not

° Rationalizing is a logical fallacy that is recognized in the Diagnostic and Statis-

tical Manual of Mental Disorders (DSM) IV

° If you are starting with the answer during your clinical reasoning process, you

are rationalizing

What is reasoning?

1.14

• Reasoning is the process of thinking about something in a logical manner

• Formally, logic is deductive reasoning

• Deductive reasoning attempts to use a reasoned approach to link all the com-

ponents of evidence together in a linear fashion to prove that something is true beyond a reasonable doubt

° An example of a deductive framework is the ADTO clinical research model.

is model uses a linear deductive process to create a direct link between the assessment and patient’s outcome by linking the Assessment-Diagnosis, Diag-

nosis-Treatment, and Treatment-Outcome

Other Primary Forms of Reasoning

1.15

• Inductive reasoning - reasoning that collects disconnected pieces of evidence that

increases the probability of something being true. It can never create absolute proof that something is true

• Abductive reasoning - reasoning is used to generate and modify hypotheses

Common Reasoning Errors

1.16

• Logical Fallacies and Cognitive Biases

Common Logical Fallacies

1.17

• Two of the most common logical fallacies are post hoc ergo propter hoc and

cum hoc ergo propter hoc. e Latin translations for these two logical fallacies

are “after this therefore because of this” and “with this therefore because of this,” respectively. An example of this would be that you treat your patients, and they get better. You then connect the reason they improved to the treatment that you provided. ere are many diﬀerent reasons why patients get better. e most common reason is the natural passage of time. If most of your patients are getting better in 4 to 6 weeks, it is likely that their improvement is not related to the interventions that are being provided to them

• An ad hominem occurs when an individual attacks somebody personally instead

of discussing the problems with the evidence that they are using or their reasoning process. An example of this may be when somebody suggests that a clinician’s point of view is invalid because they are a novice or because they haven't done any research on a topic of interest. Just because an individual is a novice and/ or doesn’t do any research does not mean that their point of view is invalid. A proper discussion would discuss why their speciﬁc point of view isn’t valid related to the best available evidence and by discussing errors in their reasoning process

• An appeal to authority is when an individual will state that something is true

because an authoritative source has said that it is true. Just because somebody is an authority does not mean that their point of view is accurate, followed the EBP process, or used a reasoned approach

• A straw man argument occurs when somebody counter argues a point that a per-

son has made by creating an argument to refute a point that the individual never made. For example, if during a professional conversation, a clinician says that

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

there is no high-level evidence to support the use of ultrasound for the treatment

https://t.me/med1917

of patients with musculoskeletal disorders, and the responding clinician says that this clinician is denying treatment to the patient. e clinician is not denying treatment to the patient. ey are just suggesting that this may not be the best treatment for the patient

• An appeal to ignorance is a logical fallacy based on the assumption that a state-

ment must be true if it cannot be proved false. is logical fallacy involves shifting the burden of proof from somebody that is making a claim that holds the burden of truth to somebody that is saying that there is no high-level evidence that something is true that does not hold the burden of truth. In a clinical context, the burden of proof is always on the clinician that is purporting the eﬃcacy of an intervention to provide moderate to high-quality evidence that has a moderate to low risk of bias that it is eﬀective. e burden is never on the individual that suggests that it is ineﬀective

• e bandwagon logical fallacy simply suggests that because everybody else is

doing it that it is the best way to do it or the way that it should be done

• A red herring is information that misleads the clinician or distracts the clinician

from what is important. For example, meniscal tears are a common ﬁnding in the older asymptomatic healthy population. e assumption that a meniscal tear in an older population is the cause of an individual’s symptoms may therefore not be accurate, and, thus, may create a red herring argument as to the cause of a patient’s symptoms

—NOTES—

1.18

Common Cognitive Biases

• Some common cognitive biases include conﬁrmation bias, hindsight bias, an-

choring bias, false consensus bias, and recall bias.

• Conﬁrmation bias occurs when a clinician only uses evidence that supports

their point of view and disregards the higher quality of evidence with a low risk of bias that does not support their point of view. is can also occur clinically if a clinician prefers using a speciﬁc system to evaluate and treat patients. Does the patient ﬁt the system, or is the clinician just recognizing the parts of the system that ﬁt and ignoring the parts of the system that don’t ﬁt the patient’s presentation?”

• Hindsight bias occurs when, after events unfold, the clinician treats the outcome

as being predictable or foreseeable. is may occur when a clinician applies their favorite intervention, the patient responds positively, and the clinician expresses the outcome as if they knew it was going to happen or predicted that it was going to happen. It is always easier to predict an outcome after it has already happened.

• Anchoring bias may occur when a clinician is overly inﬂuenced by the ﬁrst evi-

dence they collect and the hypothesis it generates. It happens when clinicians fail to modify or change their hypothesis when additional evidence does not support this hypothesis.

• False consensus bias occurs when a clinician overestimates how much his/her

peers agree with their clinical approach.

• Recall bias is the tendency of a clinician to remember their favorable results and

not remember the less than spectacular outcomes.

1.19 What the Scientiﬁc Method Is

• Traditionally, the scientiﬁc method is a reasoning process that uses observational

inductive reasoning to formulate questions

• For example, a clinician may observe a response to a speciﬁc intervention in a

speciﬁc patient population repeatedly. e more times that they make this ob-

—NOTES—

https://t.me/med1917

servation the more reﬁned their question may become and the more likely they are to believe that what they are seeing is true

• is question however must be reﬁned into a hypothesis through abductive rea-

and tested to make sure that these observations are not being driven by

soning conﬁrmation and hindsight biases

• A key component to consider when generating a hypothesis is that it must be

falsiﬁable

• e hypotheses are then tested through a deductive reasoning process5

• It has been argued that a scientiﬁc hypothesis can never be proven to be true

4,6

through one experiment but that it can be proven false by one experiment

• e objective, measurable truth is therefore attained by repeatedly testing hy-

potheses that survive falsiﬁcation

1.20 What the Scientiﬁc Method Isn’t

• Generate a question

• Formulate a hypothesis

• Test the hypothesis

• If the hypothesis is found to be false, retest the hypothesis

• e emphasis here is that once a hypothesis is tested and not veriﬁed, it is clearly

not universal or generalizable to the population of interest

2.1 Evidence-based Practice, Statistical Tools, and Methodological Rules

• Section 2

Myth of EBP

2.2

• “I think that we need to abandon the quest for absolute truth and look, in-

stead, at clinical research as way to develop a reasoned philosophy about patient

-Richard Di Fabio

care.”

• If a hypothesis is rejected, it strongly suggests that the approach should not be

used

• If the hypothesis is not rejected, it may be a poor assumption that one study or

a small group of studies, that may have low methodological quality with a high risk of bias represent the only, right, or best answer to a clinical question for an individual

• Keep in mind that hypotheses need to be consistently veriﬁed to be considered

accurate

• A major reasoning challenge for clinical research is that it seeks to collect data on

a sample of individuals that represent a population of interest. From that sample, conclusions are drawn from statistical analyses that use measures of central tendency (such as the mean for parametric statistics and median for non-parametric statistics)

• If your patients are not accurately represented by these measures of central ten-

dency, the research ﬁndings may not be applicable to them

• Clinicians, therefore, need disciplined reasoning strategies to answer clinically

meaningful questions when using research evidence in the context of the individual patient

2.3 “ere are three kinds of lies: lies, damned lies, and statistics.” -Mark Twain

• “is is a logically fallacious ad hominem attack on math and those that use math

to make decisions. Does math have the ability to lie? Of course not?

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