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• If the patient does not have any red ﬂag ﬁndings or the cluster of ﬁndings con-

https://t.me/med1917

sistent with nociplastic symptoms, this mechanism can be ruled out

• If the patient responds to interventions with an increase in symptoms related to

mechanical input, nociplastic symptoms may be a secondary contributing factor and nociceptive and peripheral neuropathic contributions to the patient’s primary complaints should be ruled out

4.7 e First Decision, the Clinician, Must Make

• During the history and evaluation process, clinicians must use clinical reasoning

to decide if they are going to evaluate and treat, evaluate and refer, or refer the patient

• Patients with nociplastic ﬁndings have symptomatic complaints that do not sig-

niﬁcantly change with mechanical input

• As a result, patients that present with nociplastic ﬁndings also have ﬁndings that

are consistent with red ﬂags that may include visceral referred symptoms

• Ruling out red ﬂags in the presence of primary nociplastic ﬁndings should, there-

fore, be paramount before treatment

—NOTES—

Peripheral Neuropathic (Radicular or Referred)

4.8

• Patients with primary peripheral neuropathic pain have symptoms that are re-

ferred in a dermatomal (radicular) or cutaneous (referred) distribution, have a history of nerve injury, pathology, or mechanical compromise of the nerve with symptom provocation with mechanical testing

• is is the classiﬁcation that most patients with spinal conditions will ﬁt into

• is cluster of ﬁndings was found to have a sensitivity of 86.3% and a speciﬁcity

of 96.0%

• An important consideration is that a patient may have radicular symptoms,

radiculopathy, and referred symptoms at the same time. It is important that the clinician identify which mechanism is driving the patient’s primary symptomatic complaint at any given time

Nociceptive

4.9

• Patients with nociceptive pain have symptoms that are localized to an area of

injury or dysfunction, provocation and/or alleviation are clearly identiﬁable and proportionate, match known mechanical and anatomical distributions, symptoms are usually intermittent and start with the onset movement or mechanical provocation, and the quality of symptoms may be a constant dull ache or a throb

at rest

• is group of patients should not have pain in association with other dysesthe-

sias, night pain or disturbed sleep, antalgic postures or movement patterns and pain that is described as burning, shooting, sharp, or electric-shock-like

• is cluster of ﬁndings was found to have a sensitivity of 90.9% and a speciﬁcity

of 91.0% and most closely matches the pathoanatomic model

• A more speciﬁc response to posture, position, motion, repetitive motion, load,

or tension through the structure should be expected with individuals with nociceptive dominant symptoms

4.10 How do these mechanisms interact?

• Diagnostically we are likely looking for the DOMINANT mechanism probabi-

listically at any given time. is is not pathoanatomic

• It is based on hypothesis generation, hypothesis testing, and patient response

• is process is more accurately probabilistic Bayesian reasoning through symp-

tom modiﬁcation

—NOTES—

https://t.me/med1917

4.11 Pain Diagram and Hypothesis Generation

• e patient’s pain diagram may be useful in hypothesis generation by allowing

the patient to provide a visual representation of:

° Local symptoms = Likely nociceptive ° Proximal to distal symptoms = Likely peripheral neuropathic (radicular or

referred)

° Global symptoms = May represent red ﬂags that need to be ruled out or a

nociplastic source of symptoms

° It is also essential to consider that red ﬂag ﬁndings may not be global and may

be speciﬁc as is the case with McBurney’s point with appendicitis and fever that may be consistent with infection

Pain Diagram and Nociplastic Symptoms

4.12

• Chronic widespread pain deﬁned as ≥20% of coverage of the surface area of a

pain diagram has been shown to be correlated to “severe” or “extremely severe” anxiety scores, 5 or more psychosocial stressors, 5 or more signiﬁcant life events, and the use of 7 or more pain management strategies

• Very early in the exam process, this tool may be valuable in helping the clinician

make the evaluative decision to evaluate and treat, evaluate and refer, or refer the patient to rule out red ﬂag ﬁndings. Patients that have symptoms in the absence of red ﬂags that are not modiﬁable through mechanical input require an approach to address central sensitization

4.13

Application of the Mechanism-Based Classiﬁcation

Reprinted with permission from Hensley CP, Courtney CA. Management of a patient with chronic low back pain and multiple health conditions using a pain mechanisms-based classiﬁcation approach. J Orthop Sports Phys Ther. 2014;44(6):403-414. © 2014, The Journal of Orthopaedic & Sports Physical Therapy

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• A detailed description of the application of the mechanism-based classiﬁcation

https://t.me/med1917

approach is beyond the scope of this monograph

• A detailed application of this approach can be found in a case study written by

Hensley and Courtney

in the context of a complex presentation of a patient

with low back pain (LBP)

• If the clinician can understand the application of this model in a complex patient

with LBP, they should also be able to apply this approach to other complicated musculoskeletal conditions and less complicated musculoskeletal conditions that are primarily nociceptive

• On the right side of the slide is the pain diagram for the patient in the case study

written by Hensley and Courtney

• Based on the pain diagram that the patient ﬁlled out, you should be formulating

hypotheses regarding which primary mechanism is driving the patient’s primary symptomatic complaint

• Can you rule out red ﬂag ﬁndings?

• What questions do you need to ask this patient?

• Can you rule out a primary nociplastic mechanism?

• Can you rule out a primary peripheral neuropathic mechanism?

• Can you rule out a primary nociceptive mechanism?

• What are your primary, secondary, and tertiary hypotheses based on the mecha-

nism at this time?

• What would the physical exam look like for this patient if they had red ﬂag ﬁnd-

ings and if each one of these hypotheses were true?

• Answering these questions before collecting the data may help the clinician ob-

tain data with a low risk of conﬁrmation bias and provide a vehicle for funneling the primary mechanism through the process of elimination

• By the time the clinician has completed the history, they should have decided to

refer or evaluate the patient

—NOTES—

Step 2 of 4-What is the primary location that is driving the patient’s symp-

4.14

4.15 In the Context of Low Back Pain (LBP)

toms?

• For example, in the context of LBP, the lumbar spine, sacroiliac joint (SIJ), and

hip are 3 potential dominant sources that have convergent, overlapping referral patterns

65-70

• Independent of the location of the patient’s primary symptoms, it may be prudent to identify how these primary symptoms change with mechanical strategies at one of the 3 regions based on hypothesis generation and modiﬁcation from

the patients physical exam

—NOTES—

https://t.me/med1917

4.16 Symptom Modiﬁcation rough Symptom Alleviation

Illustrations by Kinstler Design

• If you were performing a lumbar physical exam and reproduced that patient’s pri-

mary symptoms in any of the areas depicted in the pictures, what would be your primary hypotheses as to the source and/or contributing factor to the patient’s primary symptomatic complaint?

• From left to right, these images represent zygoapophyseal,

hip,67 and SIJ,66

referral patterns that were conﬁrmed with an anesthetic block

• Given the considerable overlap of referred symptoms from the lumbar spine,

SIJ, and hip in patients that suﬀer from low back pain, symptom provocation, or alleviation in this region may not be able to answer any speciﬁc, meaningful clinical question

• In the context of low back pain, symptom modiﬁcation through symptom alle-

viation may be a powerful tool that may be used to identify the potential source and/or contributing factor(s) to a patient’s primary symptomatic complaint through a process of elimination

Can we rule out the hip?

4.17

• Hip hypomobility is a commonly identiﬁed potential source or contributing

factor in patients with LBP

85-88

• If the patient has hip hypomobility and low back or SIJ symptoms, the hip can-

not be immediately ruled out as a potential primary driver of symptoms

• Testing the hypothesis by providing an intervention that should improve hip

hypomobility and then reassessing the impact of the improved mobility on the patient’s primary symptomatic complaint may provide an easy access point to rule out the hip as the source or contributing factor to the patient’s primary symptomatic complaint

• If the patient’s primary symptomatic complaint does not change in response to

improved hip mobility, the hip is likely not the source or a contributing factor

• If the patient’s symptoms do change with an intervention directed at the hip, the

clinician should treat the hip until these symptoms no longer change in response to treatment

4.18

Is the SIJ the primary source?

• If the answer is yes, exam procedures and interventions directed to this anatomic

region should have the most signiﬁcant impact on the patient’s primary symptomatic complaint

• e cluster as described by Laslett et al has been shown to have utility in both

ruling out and ruling in SIJ pathology

• Modiﬁable SIJ symptoms may be determined through:

° A positive active SLR test

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

° A positive FABER test91

https://t.me/med1917

° Resisted hip abduction

° Special tests and function can be signiﬁcantly modiﬁed by generating internal

force closure or external force closure with an SI belt

—NOTES—

Ruling Out

4.19

• If the hip can be ruled out, and the SIJ can be ruled out, it leaves the lumbar

spine as the primary source or contributing factor to the patient’s dominant symptoms

• is hypothesis should, however, be tested in the context of the determination of

the change of symptoms in response to testing and/or interventions directed to this region

4.20 Determining the Location

• e above example is meant to illustrate one possibility of how the patient’s story

may unfold

• In general, it is easier to get something moving than it is to make something

stable

• In the context of identifying the where, ﬁrst ruling out hypomobility in the hip,

SIJ, or lumbar spine, may provide the most pragmatic way to funnel the primary location that needs the most attention at any given time through the process of elimination

• Ensuring that a hypomobility is not contributing to hypermobility or the pa-

tient’s primary symptoms before initiating interventions to improve stability may be the most pragmatic approach

4.21 Step 3 of 4-What is the mechanical input that signiﬁcantly changes the pa-

tient’s primary complaint?

4.22 Mechanical Input

• e patient’s response to mechanical input may help the clinician identify the

primary mechanism and primary location of the patient’s primary symptomatic complaint

4.23

Relationships Between Mechanical Inputs

• We are attempting to answer the question of which mechanical input has the

most signiﬁcant impact on the patient’s primary symptomatic complaint at any given time

• at said, mechanical inputs do not occur in isolation

• For example,

° e seated position is a ﬂexed loaded position ° Standing is a relatively extended loaded position

—NOTES—

https://t.me/med1917

° Laying supine is a relatively extended, unloaded position ° Walking is a loaded mid-range motion

• If we consider the essential elements of load, position, and motion, we can

further discuss how these elements modify mechanical input through posture, repetitive movement, and tension through anatomic structures

• e patient’s preference with these variables and their symptomatic response to

these variables may provide valuable insight into symptom irritability and the impact of mechanical input on provocation and alleviation

4.24

Step 4 of 4-Generating and Modifying Hypotheses

• e generation of hypotheses is an iterative process that begins when you ﬁrst

meet the patient and evolves during the examination process

• e evolution occurs as data are progressively gathered, organized, and priori-

tized using Bayesian reasoning

4.25

Observation

• We can attain important information from the patients as we greet them in the

waiting room

° Do patients prefer to stand, sit, or move? ° If they are seated, what type of chair do they choose to sit in? ° Is it a high chair, a low chair, does the chair have arms? ° How do they transition from the chair? ° Do they have to repeatedly rock their body before getting up? ° Do they have any aberrant motion with the transition? ° Do they have to use their arms? ° Do they require assistance? ° If they are not sitting, it may be a good follow-up question to ask them, why?

4.26

Controversy Regarding the Cause

• Controversy exists regarding the “cause” of a patient’s symptoms

• e cause of the output that the patient experiences may not be attributable to

94-96

kinesiopathological or pathoanatomic variables,

yet clinicians that practice

musculoskeletal medicine are interested in seeing if the patient’s primary com-

plaint at any given time is modiﬁable through mechanical input

e Patient’s Response

4.27

• e patient’s symptomatic response to mechanical input may help the clinician

identify the primary pain mechanism, primary location, and primary mechanical input that is probabilistically going to modify the patient’s primary symptomatic

complaint at any given time

• When a patient’s primary symptomatic complaint does not signiﬁcantly respond

to mechanical input, a nociplastic mechanism must be considered if red ﬂag

ﬁndings can be ruled out

4.28 Symptom Irritability

• e reasoning process includes the reasoning related to musculoskeletal pain

irritability

• Musculoskeletal pain irritability is related to the amount and nature of the activ-

ities that produce pain or aggravate a patient’s symptoms and the extent of the

persistence of pain

• is concept may be an essential consideration as the clinician plans on how the

data should be collected following the medical history before performing the physical examination

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• Given that most testing is provocative, it is vital that the clinician does the least

https://t.me/med1917

amount of testing to attain the most amount of information

• If the patient has high symptom irritability, symptom alleviation may be the

most powerful tool to use at that time and defer a more comprehensive physical exam to a later date, while still oﬀering meaningful information regarding symp-

tom behavior

• is hypothesis testing strategy may include using a comparable sign related to

the patient’s primary symptoms as a benchmark for the hypothesis testing strategy to determine if the hypothesis is probabilistically accurate

4.29 Symptom Modiﬁcation

• is is a process that tests a hypothesis by determining if an examination proce-

dure or intervention changes (increases, decreases, or stays the same) the patient’s primary symptoms

• Rationally, the thought that any procedure or intervention “caused” the modi-

ﬁcation in symptoms can never be assumed to be completely accurate without creating the risk of the conﬁrmation, hindsight, anchoring, and recall biases

• is type of thinking also creates an environment rich for the development of

cum hoc ergo propter hoc and post hoc ergo propter hoc logical fallacies

• e premises of any treatment system may be used to generate and modify hy-

potheses at any given time during the examination process

• e hypotheses, however, must be tested and veriﬁed probabilistically through

symptom modiﬁcation within the context of an n=1 in a patient-centered approach

—NOTES—

4.30 Clinical Reasoning Process

• Classiﬁcation is not a start or end-point in the clinical reasoning process. It is also

not a static phenomenon

• Clinical reasoning is a probabilistic determination of the most likely drivers

(mechanism, location, and mechanical input) of the patient’s primary symptomatic complaint at any given time

° Have hypotheses been generated? ° Has serious pathology been ruled out? ° Can the primary mechanism, location, and mechanical input that signiﬁcantly

changes the patient’s primary complaint at any given time be identiﬁed?

° Have the hypotheses been tested and veriﬁed, refuted, or modiﬁed? ° Has this process continued within and between treatment sessions?

• If the patient’s primary symptomatic complaint does not change or improve

with mechanical input, serious pathology should always be considered ﬁrst. If serious pathology can be ruled out, the patient’s primary symptoms are most likely attributable to nociplastic changes and interventions directed at central and peripheral mechanisms must be considered and implemented

4.31 Intervention Procedures Reasoning

• Intervention procedures reasoning is about testing the hypothesis that is proba-

bilistically most likely to be true at any given time

• If the clinician understands the dominant mechanism, dominant location, and

the probabilistic primary mechanical input that should modify the patient’s primary symptomatic complaint, they should be able to select an intervention that will allow them to test their hypothesis

• If the clinician has decided to test a hypothesis through symptom modiﬁcation,

they are probabilistically conﬁdent that there are no red ﬂag ﬁndings and that the patient’s primary symptomatic complaints are not driven by nociplastic dominant mechanisms

—NOTES—

https://t.me/med1917

• For patients that have nociplastic dominant symptoms, symptoms should not be

discussed

• e primary consideration should be on cortical and peripheral desensitization

without worsening the patient’s primary symptomatic complaint

4.32 Measure and Evaluate the Patient’s Response

• If the patient’s primary symptomatic complaint signiﬁcantly changes, the hy-

pothesis is probabilistically correct at that time

• If the patient’s primary symptomatic complaint does not signiﬁcantly change,

the clinician must test an alternate hypothesis or formulate a new hypothesis

• It is essential to consider that the primary hypothesis regarding the dominant

mechanism, dominant location, and dominant mechanical input should evolve and change as the patient improves within and between treatment sessions

• If the patient’s symptoms do not change in the absence of red ﬂag ﬁndings, the

context of interventions should focus on progressively improving function without signiﬁcantly increasing the patient’s primary symptomatic complaint within and between treatment sessions

e Why (Mechanism), Where (Location), How (Mechanical Input) Clinical

4.33

Reasoning Model

• It is important to understand that clinical reasoning is a dynamic, reﬂective,

iterative process that evolves within and between treatment sessions by using the method of hypothesis generation, hypothesis testing, and hypothesis modiﬁcation

• e practicing clinician must recognize that there are several potential mech-

anisms, locations, and mechanical inputs that may contribute to the patient’s primary symptomatic complaint that overlap

• At any given time, the clinician is interested in the primary mechanism, primary

location, and primary mechanical input that has the most signiﬁcant inﬂuence on the patient’s primary symptomatic complaint at that moment

• is should evolve and change within and between treatment sessions as the

clinician establishes hypotheses, tests hypotheses, and modiﬁes hypotheses based on the patient’s symptom response

In the context of Low Back Pain…

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

4.34 “If it does not ﬁt, it is the theoretical statement that must be wrong because the

https://t.me/med1917

clinical presentation cannot be wrong.” -Geoﬀ Maitland

4.35

How is clinical reasoning diﬀerent between novice and expert clinicians?

• It is how they process information

—NOTES—

4.36

Novices

97-103

• Use Type 2 Processing ° Is the process of analysis ° It is the process that should be used more often ° e reason we don’t use it is humans, by nature, are mentally lazy ° We will very often take the easy way out

• Mostly use a hypothetico-deductive (maybe more accurately hypothetico-induc-

tive) approach

• ey have very few patterns to recognize

• Standardized and data-driven

• Do not recognize that clinical reasoning is a collaborative process between the

clinician and the patient

97-104

4.37

Experts

• Use Type 1 Processing

° Involves intuitive snap judgments ° Amongst experts this process is most often well-informed and correct ° It is an evolutionary tool that allows us to recognize and instantly react ° It can’t be switched oﬀ ° e problem is that it is easily fooled

• Rely on pattern recognition

• Use hypothetico-deductive (and/or hypothetico-inductive) approach with com-

plex patients

• Reasoning is individualized to the patient and includes the contextual element

related to the patient-clinician interaction

4.38 e Metacognitive Process

• inking about thinking through reﬂection

Reﬂection on Action

4.39

• Is most often used by novice clinicians

• Clinical reasoning “on action” is the reﬂective metacognitive process on:

° What went well ° What did not go well ° What should be done diﬀerently in the future

4.40 Reﬂection in Action

• Is most often used by expert clinicians

• Clinical reasoning “in action” can recognize what is going well, what isn’t going

well, and involves the ability to make on the spot corrections in real-time

Questions at May be Used to Improve the Metacognitive Process

4.41

(Appendix 1)

4.42 Questions to Improve Clarity, Accuracy, Precision, Relevance, and Depth of

Knowledge

105

—NOTES—

https://t.me/med1917

• Considerations of whether the reasoning adequately addresses the underlying

complexity of the issue

• For example:

° Could you put that another way? ° How could we verify that? ° Could you be more speciﬁc? ° How does that relate to the main issue?

4.43 Questions to Improve Breadth of Knowledge

105

• Considerations of whether there is a need for another point of view

• For example: Have you thought about any other ways to interpret the situation?

4.44 Questions to Determine the Most Pragmatic Approach for the Patient

105

• Are used to determine the most important things to focus on

• For example: If you could only address one item, which one would have the most

impact? Why? How?

4.45

Questions to Determine if Conclusions are Fair

105

• Self-reﬂection on the potential bias, assumptions, or vested interests that may be

unconsciously inﬂuencing reasoning

• For example: Are there any conclusions you may have jumped to that you have

not yet validated?

4.46 How can you improve your clinical reasoning?

47,48

• By recognizing common causes of clinical reasoning errors

° Inadequate knowledge ° Faulty data gathering ° Faulty data processing ° Faulty metacognition

• By recognizing logically fallacious thinking and cognitive biases

• By recognizing when you are starting with the answer (rationalizing) instead of

starting with a question or a hypothesis (rational thinking)

4.47 How is clinical reasoning developed?

102,106-109

• Students need a “diagnostic reasoning strategy”

• By slowing down and verbalizing their thinking, experts can make their reason-

ing explicit for learners

• When learners do the same, their reasoning processes can be assessed and im-

proved with feedback

• It is a “hands-on process”

• It is “reﬂective”

4.48

Five Micro Skills Model for Mentorship to Improve Clinical Reasoning

(Appendix 2)

110

1. Obtain a commitment from the learner about what they think is happening

with the patient’s problem ﬁrst (instead of a summary of the case so that the mentor can solve the problem)

2. Probe for underlying reasoning (eg, consider all relevant reasoning strategies)

3. Teach/review general concepts, principles, and speciﬁc knowledge relevant to

understanding the case (if needed or if gaps in knowledge have been revealed that are critical to caring for the patient at that juncture)

4. Provide positive feedback about what the learner has done well

5. Correct errors (as needed in the moment, for the beneﬁt of the patient)

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