clinical reasoning

Clinical reasoning is that elusive ability to make informed decisions about how to best manager your patients. But how can you learn it...? And how can you teach it...?!
In this episode Shaun offers three things to focus your time and energy on to hone your clinical reasoning.

Dr. Nick Helton (E-mail, LinkedIn, Instagram) is interviewed by Dr. Leanna Blanchard on his award winning poster from this year’s 2023 AAOMPT Conference titled, “Non-Thrust Joint Manipulation to the Upper Cervical Spine for the Management of Balance Impairments in a Patient with Cervicogenic Dizziness: A Case Report.” This episode would be interesting for clinicians who enjoy working through the clinical reasoning and successful implementation of manual therapy to a complex patient case. 

Here are the references mentioned in the interview:

-How to Diagnose Cervicogenic Dizziness: Reiley et al (2017)

-Manual Therapy for Cervicogenic Dizziness RCT: Reid et al (2014)

-JOSPT Cervicogenic Case Series

Find out more about the Foundation for Orthopaedic Manual Physical Therapy (FOMPT) and the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) at the following links:

Foundation website: www.aaompt.org/foundation

Academy website: www.aaompt.org

Twitter: @AAOMPT

Facebook: https://www.facebook.com/aaompt/

Instagram: https://www.instagram.com/officialaaompt/?hl=en

Podcast e-mail: aaomptpodcast@gmail.com

Podcast website: https://aaomptpodcast.simplecast.fm

Here is the clinical story of a client that is presenting with pain/sensitivity in the area of the (R) posterior pelvis. 

A common area of symptoms for many patients. But there are many potential drivers and the need to differentially diagnose is crucial.  

Why?

Because you won't want to miss the hidden connections that are so often present in patients, that when missed, can make the difference between a successful outcome and a patient who walks away unhappy. 

In this episode, we discuss what has been unhelpful for her with regard to past interventions and why the biopsychosocial approach and creating the therapeutic alliance are so important to give her the ability to improve her movement system.

Meaningful activities, violating expectations, and movement system changes were key to her healing journey.

A glance at this episode:

• [1:35] History of the patient

• [5:30] Digging deeper to find the driver

• [9:19] Lifestyle changes that work

• [15:00] Establishing an alliance to explore fears

• [25:30] Making the evaluation meaningful to the patient

• [33:23] The reset exercise

• [37:33] The problem with a sagittal plane squat

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

In this episode, Erica explores the intersection of functional movement and persistent pain, offering a comprehensive blueprint for understanding and addressing movement dysfunctions that may contribute to ongoing discomfort. 

Join her as she discusses her insights and tips with examples from her patient caseload. 

Erica also speaks to functional movements that will help you find "hidden" drivers in other regions of the body. 

Whether you're dealing with persistent pain or are a healthcare provider seeing those persistent cases, this episode equips you with advanced clinical reasoning knowledge and tools to create a solid assessment so you don't miss important connections.

A glance at this episode:

• [2:41] Assessing low back pain

• [4:45] How to assess the squat the right way

• [6:57] Looking at functional movement patterns

• [9:11] Non-optimal movement patterning, symptomatic or not

• [11:08] Sling squats and heel raises

• [13:12] Inversion patters

• [14:57] How to evaluate neck pain

• [16:53] The connections in the body and they relate to functional movement

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the primary complaint of the client. 

How does the stiffness of the 1st MTP joint affect gait and lower quarter movement of all kinds?

We spend some great time with discussions of differential diagnosis, and practical interventions and share some new discoveries. 

Hint: the exam and intervention do not always center around the stiff 1st MTP - there is likely a primary driver elsewhere.

A glance at this episode:

• [5:05] Compensate and adjust your feet

• [11:23] Maintaining the pyramid of the foot

• [13:54] How to assess the foot position

• [17:17] Assessing the big toe

• [20:17] How to treat plantar flexion inversion

• [24:37] How to get started with the squat

• [27:46] What shoes to wear for diabetic feet

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

Heart rate variability is getting a lot of press recently. 

Join Susan as she presents a webinar on HRV as a predictor and intervention in sleep and stress. 

It doesn't take complicated interventions to make real changes in our health!

A glance at this episode:

• [1:59] What is heart rate variability

• [4:07] Inhibition of the flight or fight system

• [6:26] How you measure heart rate variability

• [8:58] When to measure heart rate variability

• [13:38] The cycles of sleep

• [15:31] Memory and sleep 

• [18:07] Prolonged poor response to stress

• [20:07] Aerobic fitness and heart rate variability

• [22:05] Biofeedback and the readiness measure

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? 

Carefully and specifically! 

When someone who is hypermobile complains of continued and persistent back pain, your first thought is, " Is this an overactive system? An underactive system? Or both?". 

This re-release of an episode from 2018 highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement and her dominant impairment. 

Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't. 

Doing the right thing at the right time is clinical expertise.

A glance at this episode:

• [5:55] Hypermobility Syndrome and the pelvic floor

• [12:11] How and why her back extensors are overworking

• [19:44] Taping-does it help here?

• [24:42] Recruitment of the diaphragm in back pain

• [28:34] Taking out the overactivity-Posterior pelvic tilt on all fours

• [32:33] Spinning and mirroring that into exercise

• [36:35] Not a stretching issue but a coordination problem

• [39:55] Flexion based stabilization and progression

• [44:38] Resistance bands on the bike

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

In this episode, Erica throws out some clinical gems when it comes to clinical reasoning through these scenarios.  

What do you do when your patient says, "I am 85% better but I am still getting (insert symptom) when I do (insert activity)." or " I am so much better but my foot hurts on and off when I still sit at my desk".  

The key is "what does my patient need at this point in time?"

Using 2 examples from her patient caseload, Erica discusses how changing the activity and the environment may be the last piece of the clinical puzzle. 

Erica also discusses the concept of "centering". If someone lives on their left side, as was the case with these 2 patients, how can you use this concept to give them more options for loading to the right?  

We need choices for movement- loading one side of your body for long periods takes away those choices and limits our options. This MUST be trained for your patient to have success. 

A glance at this episode:

• [2:05] Introduction to patient’s history

• [5:06] Advanced clinical reasoning

• [7:24] Changing input into the nervous system

• [9:48] How can you change the environment to suit your patient

• [11:30] Example of a patient with lower back pain

• [13:43] Do you need to treat the right knee and foot

• [15:55] Centering exercises for strength training

• [18:10] Kneeling strength training and centering

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

Shoulder pain, stiffness, and lack of functional mobility are not uncommon in clients with post-breast cancer. 

Join us as we discuss the evaluation and treatment sequence that addresses the particular soft tissue involvement and drivers of this client's limitation—hint: several tissue issues are involved. 

The clinical reasoning around the client's story is key here!

A glance at this episode:

• [2:04] Susan introduces her patient's history
• [7:34] Shoulder girdles and head position
• [10:34] Flexion of the cervical spine
• [16:40] Looking at passive vs. active range of motion
• [19:19] How Susan started the abduction exercise 
• [24:21] Towel roll exercise for mobility
• [27:27] How to add movement into decompression
• [33:29] The thorax is 360 right and left

Related links:

• Tough To Treat Website
• Erica’s Course: Decoding the Complex Patient
• Susan’s Pelvic Health Education Subscription
• Access the Transcript

In this 2 part episode, Susan and Erica discuss what it takes to become a clinical expert, and how that translates into effectively assessing and treating the "tough to treat".

They highlight common errors in clinical reasoning and how to avoid them. They also discuss common red and yellow flags and when to trust your gut.

This is part of what makes an expert.

Remember, the organization and structure of a clinician's knowledge are more important than the content itself. Learning how to ask the right questions will lead you to the driver more quicker.

A glance at this episode:

• [5:48] The importance of critical thinking in clinical practice
• [10:44] Clinical red flags and clinical yellow flags
• [12:35] Red flags that go along with back pain
• [18:08] Central sensitization is a good outcome measure
• [20:51] What does a successful outcome look like
• [26:47] How to get someone from free contemplative to contemplative
• [29:41] A brief case study of two patients with low back pain
• [35:24] What’s optimal for these patients
• [41:19] Nerves are bloodsuckers and need to move
• [48:32] How to know when to change posture
• [55:23] Case study of a client with progressive pain in back of pelvis

Related links:

• Access the Slides for this Webinar
• Tough To Treat Website
• Erica’s Course: Decoding the Complex Patient
• Susan’s Pelvic Health Education Subscription
• Access the Transcript

In this short episode, Susan discusses the upper cervical region and its effects on the rest of the body: core, pelvic floor dysfunction, muscle recruitment, balance, dizziness, etc. Join Susan as she takes a journey into the remarkable system from one of her lectures. Erl Pettman's work has long influenced Susan on her clinical reasoning and the importance of convergence of symptoms throughout the body from the upper cervical spine and the cervical trigeminal nucleus. Retraining this region is one of the reasons we "recommend" the Clock Yourself App - for the cervico-occular-vestibular reflex training.

A glance at this episode:

• [1:36] Trigeminal system
• [3:02] What is C5 C6 nerve root irritation
• [4:28] The three different nuclei for the trigeminal system
• [7:15] The biggest threat to mankind
• [8:21] The trigeminal system is a sensory experience

Related Links:

• Tough To Treat Website
• Erica’s Course: Decoding the Complex Patient 
• Susan’s Pelvic Health Education Subscription
• Access the Transcript

This episode highlights exercise progression for a patient with neck pain and concurrent headaches. This elusive driver can often be lost when it comes to exercise progression. Hint: the neck is one of the foundations for the movement system. And just because the neck is the driver, this doesn't mean that you exclude all other regions of the body. Why? Because EVERYTHING IS CONNECTED. We discuss how to design a movement program for both the upper and lower quarter while highlighting the neck. This region of the body does not move in isolation. Involving the eyes is KEY with these types of patients, especially in someone who has headaches. We have talked about this before on other episodes. Vision is often an overlooked part of the head/neck complex when it comes to exercise. Don't miss this.

Erica and Susan discuss in this podcast how treating the left hip as well as the left side of the low back, got rid of this young golfer’s knee pain. A functional and interactive evaluation really hones in on where the true source of his knee pain lies.

Assessing center of mass (COM) here is crucial. Think about golf, you don’t need a wide stance. Most of your patients will look different depending on how wide or narrow their stance is. Don’t miss it.

We also discuss the concept of picking a “meaningful” movement to assess with your patient. This alone will help you hone in on the driver quicker.

Did you know that right knee pain can be caused by an imbalance in your center of mass?

This is a rebroadcast of a popular earlier episode.

A glance at this episode:

• [1:24] Introduction to the driver and knee pain
• [7:54] The story of a golfer with knee pain
• [15:25] The expectation
• [20:09] Why you go right into the sport-specific problem
• [26:56] The power of videotaping people in motion
• [34:39] Recognizing left and right sides of the body
• [37:16] Mirror box
• [46:41] Why the need to reinforce
• [50:30] Trying something new

Related Links:

• Tough To Treat Website
• Erica’s Course: Decoding the Complex Patient
• Susan’s Pelvic Health Education Subscription
• Access the Transcript

What constitutes an effective and efficient exercise progression? How do you smartly move someone through a movement program targetting their driver? Do not get hung up on someone's symptomatic region if that's not what is driving their symptoms. In this episode 2 cases are presented where their drivers were distal to their symptomatic areas. Categories of movement, neutral to non neutral, as well as unloaded to loaded are discussed with specific exercise progression. Remember: you are building new brain maps here. Variance and clinically reasoning through a smart movement progression will get your patient far.

Berglind Bergmann sérnámslæknir í lyflækningum og Hildur Jónsdóttir sérfræðingur í almennum lyflækningum leiða okkur í gegnum tilfelli með klínískri rökleiðslu (e. clinical reasoning).

Þetta er annar þátturinn í undirsyrpu Dagáls læknanemans um klíníska rökleiðslu. Hildur kynnir í nokkrum bútum tilfelli sem hún kynntist í sínu sérnámi í Bandaríkjunum og eftir hvern bút eru umræður. Sólveig, Teitur og Berglind eru blinduð á tilfellið og hjálpast að við að leysa það í rauntíma. Hlustandi getur þannig tekið þátt og spreytt sig á tilfellinu með okkur. Áherslan er að hugsa vítt, koma með mismunagreiningar og læra af ferlinu. Hvað leiðir okkur í rétta átt og hvað villir sýn? Rétt greining er afhjúpuð í lok þáttarins.

Þátturinn byggir á raunverulegu tilfelli. Upplýsingum hefur verið breytt til að gera þær ópersónugreinanlegar og gæta trúnaðar. 

"Dagáll læknanemans" er hlaðvarp fyrir læknanema og annað áhugasamt fólk um hvaðeina sem viðkemur klínik og læknisfræði. Stjórnendur eru Sólveig Bjarnadóttir og Teitur Ari Theodórsson. Í þessum þætti leiða þær Berglind Bergmann sérnámslæknir í lyflækningum og Hildur Jónsdóttir sérfræðingur í almennum lyflækningum hlustendur gegnum tilfelli með klínískri rökleiðslu (e. clinical reasoning). 

Berglind kynnir tilfelli í nokkrum bútum og eftir hvern bút eru umræður. Sólveig, Teitur og Hildur eru blinduð á tilfellið og hjálpast að við að leysa það í rauntíma. Hlustandi getur þannig tekið þátt og spreytt sig á tilfellinu. Áhersla er lögð á að hugsa vítt, koma með mismunagreiningar og læra af ferlinu. Hvað leiðir okkur í rétta átt og hvað villir sýn? Rétt greining er afhjúpuð í lok þáttarins. 

Þátturinn er sá fyrsti í syrpu af klínískri rökleiðslu og byggir á raunverulegu tilfelli. Upplýsingum hefur verið breytt til að gera þær ópersónugreinanlegar og gæta trúnaðar. Fengið var leyfi sjúklings fyrir því að nota tilfellið við gerð þáttarins.

Dagáll læknanemans er sjálfstæð þáttasyrpa innan Hlaðvarps Landspítala. Þættirnir eru aðgengilegir á helstu samfélagsmiðlum Landspítala og einnig í streymisveitunum Spotify og Apple iTunes, ásamt hlaðvarpsveitum á borð við Simplecast, Pocket Casts og Podcast Addict.

(Tónlist: "Garden Party" með Mezzoforte. Notað með leyfi frá hljómsveitinni.)

SIMPLECAST:
https://landspitalihladvarp.simplecast.com/episodes/dagall-24

Dr. Evan Petersen (e-mail, ResearchGate) and Dr. Stephanie Thurmond (e-mail, ResearchGate) of the University of the Incarnate Word (Dr. Petersen) and Bowling Green State University (Dr. Thurmond) (Twitter, #BGSU_SOPT) are interviewed by Stephen M. Shaffer about a presentation they gave at the 2020 AAOMPT Conference. The title of the presentation was, “Systematic Clinical Reasoning: From Novice to Expert in No Time.” This episode contains information that should be interesting for musculoskeletal students, providers, and educators interested in learning more about how to use a structured approach to improve their clinical reasoning skills within physical therapy. Additionally, to find the articles mentioned by Drs. Petersen and Thurmond during the episode please use the following links: Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective, Huhn et al 2019, and Oostendorp et al 2020. 

Find out more about the American Academy of Orthopaedic Manual Physical Therapists at the following links:

Academy website: http://www.aaompt.org

Twitter: @AAOMPT

Facebook: https://www.facebook.com/aaompt/

Instagram: https://www.instagram.com/officialaaompt/?hl=en

Podcast e-mail: aaomptpodcast@gmail.com

Podcast website: https://aaomptpodcast.simplecast.fm

In the age of evidence-based medicine, we may be tempted to dismiss intuition – the quick and automatic thought process we call “sixth sense” or “gut feeling” – as unscientific guesswork. But in clinical decision-making, intuitive reasoning is just as important as the slower and more analytical causal reasoning that healthcare professionals are trained in. In fact, without it we would hardly be able to formulate new hypotheses.

Together with Eugene van Puijenbroek from the Netherlands pharmacovigilance centre Lareb, we explore the role of intuitive reasoning in the science of drug safety.

Tune in to find out:

• How clinical and intuitive reasoning complement each other for optimal decision-making
• How adverse drug reaction reporting forms could be improved to detect intuitive reasoning
• How pharmacovigilance professionals can train their intuition

Want to know more?

Here are a few reading resources to get you started:

• A study on real cases of intuition in family medicine concluded that automatic, non-analytical processes in clinical judgment extend beyond first impressions.
• The dual-process theory highlights the importance of physicians’ intuition and the high level of interaction between analytical and non-analytical processes in clinical reasoning.
• Gut feelings may help general practitioners efficiently navigate the often complex and uncertain diagnostic situations of general practice.
• In a discussion paper on intuition and evidence, professor Trisha Greenhalgh suggests that the experienced practitioner should follow clinical hunches as well as applying the deductive principles of evidence-based medicine.

If you’d like to hear more from the Netherlands pharmacovigilance centre Lareb, check out this interview with Linda Härmark on patient reporting.

Join the conversation on social media
Follow us on X, LinkedIn, or Facebook and share your thoughts about the show with the hashtag #DrugSafetyMatters.

Got a story to share?
We’re always looking for new content and interesting people to interview. If you have a great idea for a show, get in touch!

About UMC
Read more about Uppsala Monitoring Centre and how we work to advance medicines safety.

Dr. Saravana Kumar (e-mail, ResearchGate, Twitter) and Mark Jones (e-mail) of the University of South Australia are interviewed by Kevin L. MacPherson regarding a publication from Musculoskeletal Science and Practice titled, “An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey.” This episode contains information that should be interesting for musculoskeletal providers interested in the Biopsychosocial model as it relates to contemporary physical therapy practice.

Find out more about the American Academy of Orthopaedic Manual Physical Therapists at the following links:

Academy website: www.aaompt.org

Twitter: @AAOMPT

Facebook: https://www.facebook.com/aaompt/

Instagram: https://www.instagram.com/officialaaompt/?hl=en

Podcast e-mail: aaomptpodcast@gmail.com

Podcast website: https://aaomptpodcast.simplecast.fm

Drs. Brian Swanson (bswanson@hartford.edu, ResearchGate) of the University of Hartford and Sean Riley of Sacred Heart University (rileys4@sacredheart.edu, ResearchGate) are interviewed by Stephen M. Shaffer regarding a presentation that they gave at the 2019 AAOMPT Conference titled, “Precision Physical Therapy: Application of patient specific treatment via provocation and alleviation testing and purposeful communication.” This episode contains information that will be interesting for practitioners interested in an approach to specific and meaningful examination applied within a clinical reasoning framework. 

Find out more about the American Academy of Orthopaedic Manual Physical Therapists at the following links:

Academy website: www.aaompt.org

Twitter: @AAOMPT

Facebook: https://www.facebook.com/aaompt/

Instagram: https://www.instagram.com/officialaaompt/?hl=en

Podcast e-mail: aaomptpodcast@gmail.com

Podcast website: https://aaomptpodcast.simplecast.fm