Transcript Clinical Reasoning and Evidence Based Practice

Clinical Reasoning and
Evidence Based Practice
The Cervical Spine
Clinical Problem Solving
Clinical Reasoning
Evidence Based Practice
Clinical reasoning can be
defined as the
thinking and decision making
processes used in the
evaluation and management
of patients.
“The conscientious and
judicious
use of current best evidence
in making decisions
about the care of individual
patients.”
Both Constructs focus on a Patient
Centric Approach to Care
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Values and beliefs
Goals
Physical attributes
Illness and wellness
experiences
• Psychological
presentation
• Social and cultural
factors
Hierarchy of Evidence
Bridging the Gap
5 Elements of Patient Management
APTA Clinical Practice Guideline
Examination
Intervention
Patient
Outcome
Prognosis
Evaluation
Diagnosis
Clinical Reasoning Model: Barrows & Tamblyn
Information Perception &
Interpretation
Initial Concept & Multiple
Hypothesis Generation
Data Collection
 Subjective
 Objective
 Cognition
Evolving Concept of the
Problem
 Knowledge
 Metacognition
Decisions: Diagnosis &
Management
Intervention
Reassessment
Examination
Throughout data
collection, hypotheses
are refined, ranked, reranked, rejected or
verified until a
diagnosis can be
reached. In evidence
based practice this is
called a treatment
threshold.
Data Collection
Diagnosis
Diagnosis
• Pathoanatomical
– Structures involved
– Pathology affecting those structures
– Co-morbidities
• Identification of clinical syndromes
• Classification of the problem
• Regional Interdependence
Presentation: SINSS
• Severity of the symptoms
– Numeric pain scales (NPRS)
– Impact on function
• Neck Disability Index
• Patient Specific Functional Scale
– Fear Avoidance Beliefs Questionnaire
– Screening for Depression
• Irritability:
– Amount of activity to exacerbate the symptoms
– The degree of the exacerbation
– The time to subside
• Nature: Pathological considerations
• Stage: Acute, subacute, chronic, recurrent , episodic
• Stability: Rate or progression of change in the condition over time.
Hypothesis Generation and Testing
• Inductive reasoning =
Pattern recognition =
Clinical Syndrome =
Classification
• Deductive reasoning =
Hypothesis testing
similar to Clinical
Prediction Rule (CPR),
Test Item Cluster (TIC)
Inductive Reasoning
• Proceeds from a set of
observations to a
generalization.
• Hypothesis generation
via pattern recognition
• Characteristic of
experienced clinicians
Deductive Reasoning
• Proceeds from a
generalization to a
conclusion in relation to a
specific hypothesis.
• Hypothesis testing provides
the means by which patterns
are refined and proved
reliable
• Hypothesis testing: “If this
…then this ....”
• Slower, characteristic of
novice
Hypothesis Testing
• The hypothesis developed during the
subjective examination is specifically tested in
the physical examination.
• A hypothesis is verified when a comparable
sign is found in structures at the site of the
symptoms or in remote structures capable of
referring symptoms.
The Role of Treatment in Hypothesis
Testing
• Assessment of patient response to treatment
provides additional evidence to confirm or modify
the working hypothesis.
• The hypothesis is accepted when treatment alters
the structures in question and results in an
improvement in the symptoms and signs.
Clinical Reasoning in Experts
Experts confronted
with an unfamiliar
pattern rely on the
hypotheticaldeductive
reasoning model.
- Jones, Jensen and Rothstein
Experts engage in reflective practice
• Reflection in action: thinking about what they are doing
while they are doing it, allowing for corrective action or
adaptation of practice.
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What is the key problem here?
What are the salient features?
What are the most likely explanations?
How can I test these explanations further?
• Reflection about action and outcomes
• Immediately following treatment: short term cause and
effect.
• Retrospective analysis: outcome at the end of treatment.
What is the
Evidence?
Risk Factors Neck
Pain: Incidence
and Determinants
in the General
Population
(Hogg-Johnson, et al., 2008)
Incidence
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ranged from .055 per 1000 person years
(disk herniation with radiculopathy) to 213
per 1000 persons (self reported neck pain)
Incidence of neck with sports ranged from
.02 to 21 per 1000 exposures
12 month prevalence 30-50%
12 month prevalence of activity limiting pain
was 1.7- 11.5%
More prevalent among women and peaked
with middle age
Risk factors included genetics, poor
psychological health, and exposure to
tobacco. Disc degeneration was not
identified as a risk factor
The uses of sporting gear such as helmets was
not associated with increased neck injury in
bicycling, hockey or skiing.
What is the
Evidence?
Diagnosis
• Classification system for neck pain
which was developed by examining data
for 274 consecutive patients receiving
physical therapy over a period of one
year. They patterned their system after
the one proposed by Childs, Fritz, Piva
and Whitman (2004).
TBC Classification
for the Cervical
Spine
• Patients receiving matched
interventions demonstrated greater
improvements in NDI scores and pain
rating scales than those receiving nonmatched treatments.
(Fritz & Brennan, 2007)
• Both studies used the subgroups:
mobility, centralization, headache, pain
control, exercise and conditioning.
What is the
Evidence?
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Course and
Prognostic Factors
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(Carroll, Haldeman, Carragee, Nordin,
& Guzman, 2008)
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50-85% with current neck pain will report neck
pain again 1-5 years later.
Younger age predicted better outcomes
General exercise was unassociated with
outcome, but regular bicycling predicted a poor
outcome in 1 study
Psychosocial factors including psychologic health,
coping patterns, and need to socialize were the
strongest predictive factors, modest effect, with
LR's between 2 and 6
– Poor psychologic health, worrying, becoming
angry or frustrated in response to neck pain
were associated with poorer prognosis
– Greater optimism, coping that involves self
assurance and having less need to socialize
were all associated with better prognosis.
Gender was a weak predictor for recovery with
men more likely than women to recover.
Poor health and prior pain episodes are
associated with poorer prognosis (modest effect)
What is the
Evidence?
Treatment
Clinical Practice
Guideline
(Childs, et al., 2008)
Recommendations for intervention:
• Cervical mobilization and manipulation,
thrust and non-thrust , should be used to
reduce neck pain and headache. Combining
cervical mobilization and manipulation with
exercise is more effective for reducing neck
pain, headache and disability than
manipulation and mobilization alone.
(Recommendation based on strong
evidence)
• Thoracic spine thrust manipulation can be
used for patients with primary complaints
of neck pain, as well as reducing pain and
disability in patients with neck and neck
related arm pain (Recommendation based
on weak evidence)
What is the
Evidence?
Treatment
Clinical Practice
Guideline
• Flexibility exercises can be used for patients
with neck symptoms . Examination and
targeted flexibility exercises for the
following muscles are suggested: anterior,
middle and posterior scalenes, upper
trapezius, levator, scapulae, pectoralis
major, and pectoralis minor
(recommendation based on weak evidence)
• Coordination, strengthening and endurance
exercises should be used to reduce neck
pain and headache (Recommendation
based on strong evidence)
(Childs, et al., 2008)
• Clinicians should consider use of upper
quarter and nerve mobilization procedures
to reduce pain and disability in patients with
neck and arm pain (recommendation based
on moderate evidence.)
What is the
evidence?
Treatment
Clinical Practice
Guideline
(Childs, et al., 2008)
• Clinicians should consider the use of
mechanical intermittent traction,
combined with other interventions such
as manual therapy and strengthening
exercises for reducing pain and disability
in patients with neck and neck related
arm pain. (Recommendation based on
moderate evidence)
• To improve recovery in patients with
whiplash associated disorder, clinicians
should
– Educate patient that early return to
normal, non-provocative is important
– Provide reassurance to the patient that
good prognosis and full recovery
commonly occurs (Recommendation
based on strong evidence)
What is the
Evidence?
Thoracic Spine Thrust
Manipulation Improves
Pain , Range of Motion and
Self-Reported Function in
Patients with Mechanical
Neck Pain : A Systematic
Review
Cross, Kuenze, Grindstaff
and Heriel , (2011)
• Systematic review of 6 randomized
controlled clinical trials examined the effect
on thrust manipulation to the thoracic spine
on pain , range of motion and self reported
pain.
• Effect sizes were significant for all studies
but not conclusively significant at the end
range of active range of motion.
• The effect size point estimate of changes in
scores of functional questionnaires also
showed a significant treatment effect.
• Conclusions: Thoracic thrust manipulation
may provide short term improvement
patients with acute or subacute mechanical
neck pain. Given the small body of literature
the evidence is weak and not generalizable.
Level 1B evidence.
Level of Evidence
Strength of Evidence
The Australian Approach
Primacy of the Clinical Evidence
=
Symptoms & Signs
Two compartment thinking
Anatomy
Pathophysiology
Biomechanics
Neurophysiology
Symptoms
History
Signs
Clinical
Syndromes
The Process
Subjective
Examination
Intervention
Reassess
Plan of the
Objective
Objective
Examination
Clinical Decision Making
• Intervention
• Subjective
Asterisks
Manual
Therapy
Patient
Symptoms
&
Functional
Restrictions
Exercise
Hypothesis
Testing
Value of Each
Technique
• Assessment
Impairments
• Objective
Asterisks
Relative Importance
Treatment
Subjective
Examination
Objective
Examination
Assessment
Outcomes: Measure It
Pain
• Numeric Pain Rating Scale
• Visual Analog Scale
• Neck Disability Index
Function • Patient Specific Functional Scale
• Percentage of Improvement
Change • Global Rating of Change (GROC)
Hierarchy of Evidence