1. 1. What were your initial thoughts about Peter’s presentation? In particular, did you entertain any hypotheses at this time relating to ‘precautions and contraindications to physical examination and treatment’ and also ‘contributing factors’ to the insidious onset?

There appeared to be no initial precautions or contraindications to conducting a physical examination. From the history, it was apparent that the symptoms were responsive to different postures and positions, being worse with long periods of sitting and better when he was moving, which was considered to be a positive sign that Peter might respond well to mechanical therapy (McKenzie and May, 2006). Hypothetically, the source of the symptoms could be related to a nerve root, but identifying the source of the symptoms (or contributing factors) was less clinically relevant in this case than determining whether the symptoms were responsive to mechanical therapy.

1. 2. Pain is clearly Peter’s main complaint. What were your hypotheses at this stage regarding the dominant ‘pain type’ (nociceptive, peripheral neuropathic, nociplastic)? What evidence supported or negated your hypotheses?

The clinical reasoning process undertaken in this case was not greatly focussed on identifying either the source of pain or the hypothesized ‘pain type’, whether it be nociceptive, peripheral neuropathic or nociplastic. However, from the clear mechanical nature of the presenting pain (i.e. linked to activities) and the lack of apparent psychological factors, it did not appear to be the latter, which has been defined as pain associated with maladaptive processes in the CNS (Wright, 2002) in which there is ‘an amplification of neural signalling within the central nervous system that elicits pain hypersensitivity’ (Woolf, 2010). The location of the symptoms and their consistent response to mechanical forces suggested that his pain was a mixture of nociceptive neck pain and peripheral neuropathic pain, with the referred arm symptoms and tingling in the hand originating from compromise of the peripheral nerve(s) or nerve root(s) (Wright, 2002). However, the clinical distinction between nerve root pain and musculoskeletal nociceptive pain is not straightforward: somatic structures can refer distally (Bogduk, 2002), and dermatomal pain patterns have been found not to be useful in the diagnosis of radicular pain (Murphy et al., 2009). Further testing of a neuropathic component would require a neurological examination.

Although the ‘hypothesis categories’ framework presented in Chapter 1 is not integrated into all musculoskeletal approaches, these responses still reflect a clinical reasoning process guided by the McKenzie mechanical therapy approach. Patient cues (e.g. from the behaviour of symptoms) have elicited recognition of a mechanical pattern of aggravation and easing supportive of a nociceptive and/or peripheral neuropathic pain type and indicative of a favourable prognosis.

It is likely that the clinician did not undertake any procedures that peripheralized Peter’s symptoms, partly because it is associated with a less successful outcome but also because it may be associated with further ‘neural’ irritation/compromise. In other words, the clinician is attending to the ‘sources’ of the symptoms. Further, the fact that the clinician is associating the arm symptoms with the neck symptoms, based on the pattern of behaviour, means it is also likely the judgement is being reached that the arm symptoms are arising from neck structures. This too represents consideration of ‘sources’. This can be seen to reflect that while clinical reasoning language is not necessarily universal across musculoskeletal approaches, the actual processes of clinical reasoning and the actual hypothesis judgements made have a great deal of commonality.

This supports the supposition that hypotheses are generated as a normal or generic component of human thinking and problem solving, based on accessible knowledge derived from personal and direct clinical experiences, as well as empirical research and experiential professional craft knowledge. It is likely that whatever particular approach to musculoskeletal management that clinicians may typically prefer to adopt following their training, they will generally employ an underpinning clinical reasoning process similar to that of other clinicians providing they are not simply following pre-determined protocols on the basis of imaging rather that the patient’s specific clinical presentation..