Mark A. Jones In this chapter clinical reasoning in musculoskeletal practice is presented as being multidimensional and involving fast, intuitive first impressions and slow, more analytical deliberations. It is hypothesis oriented, dialectic, collaborative and reflective. Skilled clinical reasoning contributes to clinicians’ learning and to the transformation of existing perspectives. The scope of clinical reasoning is presented through discussion of three key frameworks: (1) biopsychosocial philosophy of practice, (2) clinical reasoning strategies and (3) hypothesis categories. Cognitive processes involved in clinical reasoning (e.g. deduction, induction, abduction) are explained, and key factors influencing skilled clinical reasoning and expertise are discussed, including critical thinking, metacognition, knowledge organization, data collection and procedural skills, and patient–therapist therapeutic alliance. Lateral thinking is proposed as important to the generation of new ideas. Why do we need to study and practice clinical reasoning? Nobel Laureate Daniel Kahneman highlights the numerous biases of human judgment that occur due to quick judgments and a lack of analytical thinking. He describes two broad forms of thinking: fast (System 1) thinking characterized by automatic and effortless first impressions and intuition (as with tacit pattern recognition) and slow (System 2) thinking characterized by analytical deliberations requiring more attention, time and effort (Kahneman, 2011). Both of these fictitious1 systems operate together, with System 1 running automatically and System 2 normally in a low-effort mode. Our System 1 quick impressions receive minimal scrutiny from our slower System 2 analysis, and if endorsed, those initial impressions and intuitions turn into beliefs that lead to actions. More simply, you accept your fast impressions as representing a prior belief without further scrutiny (note that this is true for patients as well as clinicians). However, when System 1 runs into difficulty, as when the representativeness of a finding (e.g. within a patient’s story, physical assessment or outcome re-assessment) is unclear, contradictory or not what you expected, System 2 is called upon for more attentive processing. A wide range of errors (e.g. poor, inaccurate judgments) can be attributed to quick first impressions and decisions based on insufficient information and lack of further deliberation. For example, consider the following puzzle (Kahneman, 2011, p. 44) and your first impression/intuition (without formally trying to solve it): A bat and ball cost $1.10. The bat costs one dollar more than the ball. How much does the ball cost? The quick, intuitive and wrong answer is 10 cents2 (50% of Harvard, MIT and Princeton students studied got this wrong; 80% of students from less prestigious universities) (Kahneman, 2011). Although heuristics, or shortcuts in thinking, work well in many circumstances, if they go unchecked by more deliberative thinking, as with this example, errors will occur. When you consider that every patient cue perceived (verbal, visual, kinaesthetic) undergoes some level of System 1 and/or System 2 processing, it is easy to appreciate the potential for analogous errors in musculoskeletal clinical reasoning. For example: Acromioclavicular joint (ACJ) pain is provoked with shoulder movement into horizontal flexion. Horizontal flexion provokes ACJ-area pain on active-movement testing. The patient’s pain is due to nociception in the ACJ. The patient reports mid-thoracic pain consistently provoked after sitting to eat lunch. The patient reports sitting in fully slouched position when eating lunch. Mid-thoracic pain is due to nociception associated with slouched sitting at lunch. Inappropriate pain beliefs and cognitions contribute to nociplastic pain sensitization. A patient has inappropriate pain beliefs and cognitions. The patient has nociplastic pain sensitization. These examples illustrate errors of deduction. Nociception from other structures can be responsible for ACJ-area pain (e.g. subacromial tissues); other predisposing factors than slouched sitting can precipitate mid-thoracic pain (e.g. gallbladder nociception secondary to eating fatty foods); and inappropriate pain beliefs and cognitions can also exist with nociceptive dominant pain. Although you may believe your System 2 would not uncritically endorse these System 1 conclusions without obtaining further supporting information, it is a bit disheartening to contemplate the large number of biases evidenced in health-related and non-health-related human judgment that Kahneman and others (e.g. Croskerry, 2003; Hogarth, 2005; Kahneman et al., 1982; Lehrer, 2009; Schwartz and Elstein, 2008) report. Some examples easily recognizable in clinical practice include the following: The greater the coherence of our fast-thinking impressions, the more likely we are to jump to conclusions without further System 2 analysis. Unfortunately, humans are prone to find and accept coherence on the basis of limited information, so much so that Kahneman (2011, p. 86) has characterized this trait associated with many of our biases as ‘What You See Is All There Is’, that is, the assumption or acceptance that the information at hand is all that is available. You build a story (explanation) from the information you have, and if it is a good, coherent story, you believe it. Paradoxically, coherent stories are easier to construct when there is less information to make sense of. Although fast thinking is the source of many of our errors, ironically, it is also the source of most of what we do right. When you break down the overall synthesis and analysis of a patient’s presentation and consider the vast number of first-impression, fast-thinking judgments that lead up to and inform our understanding of patients and their problems (e.g. quick recognition of when a patient’s telling of his or her story requires clarification; patient discomfort and emotions; observed postural, movement and control impairments; when additional physical testing is required for physical differentiation, etc.), the ubiquity of our fast thinking is obvious. With appropriate training and experience, we learn to effectively use our fast thinking to recognize potentially significant cues, interpret contextualized meanings, recognize when clarification and further testing are required to refine interpretations, and identify appropriate actions and solutions. The key is not to deny the use of initial impressions and fast thinking but to build our skill with this through quality practice and to be aware of the pitfalls and common errors of bias. One of the foremost researchers in problem solving, Herbert Simon (also a Nobel Laureate), perhaps best known for his seminal problem-solving research with chess masters, explains intuition as ‘nothing more and nothing less than recognition’ (Simon, 1992, p. 155). That is, accurate intuitions of experts are best explained by the effects of prolonged practice. Although we articulate our judgments and make decisions through our analytical thinking, that is not to say this system is without error. Our slow analytical thinking will often simply endorse or rationalize ideas generated through our fast thinking (Kahneman, 2011). Research has demonstrated that experts function largely on pattern recognition (e.g. Boshuizen and Schmidt, 2008; Jensen et al., 2007; Kaufman et al. 2008; Schwartz and Elstein, 2008) and that overanalyzing also leads to errors in judgment (Lehrer, 2009; Schwartz and Elstein, 2008). However, although not flawless, our slow analytical thinking provides a backup, a check for our fast first impressions and pattern recognition that reduces error and as such needs to be understood and developed, especially in areas of uncertainty and complexity. Kahneman concludes that humans need help to make more accurate judgments and better decisions. We need to study and practice clinical reasoning, alongside our other professional competencies, to improve the accuracy of both our fast and slow thinking. Clinical reasoning can be defined as a reflective process of inquiry and analysis carried out by a health professional in collaboration with the patient with the aim of understanding the patient, the patient’s context and the patient’s clinical problem(s) in order to guide evidence-based practice (Brooker, 2013, supplied by Mark Jones). Although more extensive definitions are available (see Christensen and Nordstrom, 2013; Higgs and Jones, 2008), this captures the broad essence of what we hope to promote in this book. Musculoskeletal clinicians work with a multitude of problem presentations in a variety of clinical practice environments (e.g. outpatient clinics, private practices, hospital- or outpatient-based rehabilitation and pain unit teams, sports settings, home care and industrial work sites). The clinical presentations they encounter are, therefore, varied, ranging from discrete, well-defined problems amenable to technical solutions to complex, multifactorial problems with uniqueness to the individual that defy the technical rationality of simply applying a ‘proven’ protocol of management. Schön (1987, p. 3) characterizes this continuum of professional practice as existing between the ‘high, hard ground of technical rationality’ and ‘the swampy lowland’ where ‘messy, confusing problems defy technical solution’. To practise at both ends of the continuum clinicians must have good propositional (scholarly, research based) and non-propositional (professional craft) knowledge as well as advanced technical skills to solve problems of a discrete, well-defined nature. However, to understand and manage successfully the ‘swampy lowland’ of complex patient problems requires a rich blend of biopsychosocial knowledge and professional know-how, combined with personal awareness of your own philosophy of practice, potential biases and diagnostic, procedural and teaching skills. Contemporary musculoskeletal clinicians must have a high level of knowledge and skills across a comprehensive range of competencies, including assessment, management, communication (including teaching, negotiating, counselling), documentation and professional, legal and ethical comportment. Effective performance within and across these competencies requires a broad perspective of what constitutes health and disability and equally broad skills in both diagnostic and non-diagnostic clinical reasoning. The biopsychosocial framework was originally put forward by Engel (1977). As depicted in the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) model (WHO, 2001) (Fig. 1.1) the biopsychosocial perspective recognizes that disability is the result of the cumulative effects of the biological health condition (disease, illness, pathology, disorder), external environmental influences (e.g. physical, social, economic, political, etc.) and internal personal influences (e.g. age, gender, education, beliefs, culture, coping style, self-efficacy, etc.). This is in contrast to the reductionist biomedical model that previously dominated medicine and musculoskeletal practice where disease and illness were primarily attributed to pathogens, genetic or developmental abnormalities or injury. By understanding disability as also being socially constructed, the health professions, including musculoskeletal practice, expanded or made more explicit the need for clinicians to understand all potential biopsychosocial influences and integrate that understanding into their existing assessments, reasoning and management (e.g. Borrell-Carrió et al., 2004; Edwards and Jones, 2007a, 2007b; Epstein and Borrell-Carrió, 2005; Imrie, 2004; Jones et al., 2002; Jones and Edwards, 2008). The contribution of psychosocial factors to the development, and particularly the maintenance, of patients’ pain and disability and clinicians’ assessments of their patients’ psychosocial status is the focus of Chapters 3 and 4. For the purpose of this chapter, the biopsychosocial framework illustrated in Fig. 1.1 is used to highlight the scope of knowledge, skills and clinical reasoning required to fully understand our patients’ problems and our patients themselves (i.e. the person behind the problem). The boxes across the middle of the diagram depict the patient’s clinical presentation, incorporating physical impairments of body functions and structures, restrictions and capabilities in functional activities and restrictions and capabilities in the patient’s ability to participate in life situations (e.g. work, family, sport, leisure) that collectively make up the patient’s disability. Bidirectional arrows between the clinical presentation and the biomedical, environmental and personal influences reflect the reciprocal relationship whereby each has the potential to influence the other (Borrell-Carrió et al., 2004; Duncan, 2000; Pincus, 2004). For example, where traditionally functional restrictions, physical impairments and pain would have been conceptualized as the end result of a specific injury/pathology or syndrome, the reciprocal arrows highlight that these also can be associated with and even maintained by environmental and personal influences. A holistic understanding of a patient’s clinical presentation therefore necessitates attention and analysis of the patient’s physical health, environmental and personal factors. Although musculoskeletal clinicians are generally well educated to assess and manage the physical and many environmental dimensions of the patient’s health condition, formal education and experience assessing, analysing and managing psychological and social factors contributing to both acute and chronic pain is often less developed and less structured (e.g. Barlow, 2012; Bishop and Foster, 2005; Foster and Delitto, 2011; Main and George, 2011; Overmeer et al., 2005; Sanders et al., 2013; Singla et al., 2014). The sociological dimension of psychosocial in particular is generally given less attention as a factor contributing to the pain experience (Blyth et al., 2007). A growing body of literature is now available informing musculoskeletal clinicians’ psychosocial assessment and management (e.g. French and Sim, 2004; Hasenbring et al., 2012; Johnson and Moores, 2006; Jones and Edwards, 2008; Keefe et al., 2006; Main et al., 2008; Muncey, 2002; Schultz et al., 2002; also see Chapters 3 and 4) with literature also explicitly relating the WHO ICF to categorization of clinical problems, clinical reasoning and management (e.g. Allet et al., 2008; Childs et al., 2008; Cibulka et al., 2009; Edwards and Jones, 2007a; Escorpizo et al., 2010; Jette, 2006; McPoil et al., 2008; Steiner et al., 2002). Being able to practice within a biopsychosocial framework requires different sets of knowledge and clinical skills to be able to understand both the biological problems and the environmental and personal factors that may predispose to the development or contribute to the maintenance of the patient’s pain and disability experiences. As such, a distinction can be made between understanding and managing the biological problem to effect change versus understanding and interacting with the person to effect change. To assist clinicians’ application of biopsychosocial practice, we have promoted our evolving use of two frameworks for guiding the focus of clinical reasoning required (clinical reasoning strategies) and the categories of decisions required (hypothesis categories) (Edwards et al., 2004a; Jones, 1987, 2014; Jones et al., 2008). When students first consider clinical reasoning in musculoskeletal practice, they typically only focus on diagnosis, with diagnosis itself often limited to categorizing the type of problem, injury or pathology. When all potential influences present in the biopsychosocial perspective (Fig. 1.1) are considered, as well as the reasoning required in the corresponding management of identified influences, then clearly reasoning about diagnosis represents only a portion of the reasoning that actually occurs in clinical practice. Research and theoretical propositions across a range of health professions (e.g. physiotherapy, medicine, nursing, occupational therapy) have identified explicit foci of clinical reasoning, including diagnostic reasoning, narrative reasoning, procedural reasoning, interactive reasoning, collaborative reasoning, predictive reasoning, ethical reasoning and teaching as reasoning (Higgs and Jones, 2008). Edwards and colleagues (Edwards, 2000; Edwards et al., 2004a) investigated the clinical reasoning of expert physiotherapists in three different fields of physiotherapy (musculoskeletal, neurological and domiciliary/home health care) and found that these physiotherapists employed a range of ‘clinical reasoning strategies’ despite the differing emphases of their examinations and management. The following clinical reasoning strategies were each associated with a range of diverse clinical actions: Consideration of these diagnostic and non-diagnostic foci of reasoning assist by highlighting the broad scope of clinical reasoning we should be aware of, critique and strive to improve. The complexity of our reasoning is further evident in the finding that expert physiotherapists have been shown to dialectically move in their reasoning between contrasting biological and psychosocial poles in a fluid and seemingly effortless manner (Edwards, 2000; Edwards et al., 2004a). For example, a diagnostic test may elicit a patient response reflecting fear of movement underpinned by inappropriate beliefs and cognitions regarding their diagnosis, pathology and/or pain. Sensitivity, specificity and likelihood ratios of the diagnostic test inform the likelihood of having that condition. At the same time, the expert clinician perceives the more qualitative patient expressions of fear, tempering their diagnostic analysis and dialectically shifting their reasoning from biological to psychosocial. Attending to patients’ psychosocial status alongside physical/diagnostic findings is essential. It is not possible to fully understand a patient’s pain and disability experience without a comprehensive physical examination that reveals the extent of physical impairment and disability they have to cope with. Similarly, psychosocial assessment will not only inform diagnostic reasoning, but it also enables identification of unhelpful perspectives that need to be addressed in management for both acute and chronic presentations. Although the clinical reasoning strategies provide a framework to assist students and practicing clinicians recognize the different foci of reasoning required, it is also helpful to recognize the different categories of clinical decisions required within these different reasoning strategies. It seems obvious that clinicians should know the purpose of every question they ask their patients and every physical assessment they conduct. That is, what do you want to find out, and what decision will that information inform? It is not necessary or even appropriate to stipulate a definitive list of decisions all clinicians must consider, as this would only stifle the independent and creative thinking important to the evolution of our professions. However, a minimum list of categories of decisions that can/should be considered is helpful to those learning and reflecting on their clinical reasoning because it provides them with initial guidance to understand the purpose of their questions and physical assessments, encourages breadth of reasoning beyond diagnosis and creates a framework in which clinical knowledge can be organized as it relates to decisions that must be made (i.e. diagnosing, understanding psychosocial influences, determining therapeutic interventions, establishing rapport/therapeutic alliance, collaborating, teaching, prognosis and managing ethical dilemmas). What follows is a list of ‘hypothesis categories’ initially proposed by Jones (1987) that has continued to evolve through professional discussion to this current format (Table 1.1). Research evidence regarding musculoskeletal clinicians’ focus of clinical reasoning, including reasoning across and within these different categories, is available (e.g. Barlow, 2012; Doody and McAteer, 2002; Edwards et al., 2004a; Jensen, 2007; Rivett and Higgs, 1997; Smart and Doody, 2006). This, combined with reflective discourse from experienced clinicians and clinical educators, broadly supports the relevance and use of these particular hypothesis categories. Nevertheless, these specific hypothesis categories are not being recommended for uncritical use by all clinicians, and whatever categories of decisions are adopted should continually be reviewed to ensure they reflect contemporary health care and musculoskeletal practice. TABLE 1.1 Patients’ activity capabilities and restrictions directly relate to the ICF framework of health and disability presented in Fig. 1.1 and refer to the patient’s functional abilities and restrictions (e.g. walking, lifting, sitting, etc.) that are volunteered and further screened for. To gain a complete picture, it is important the clinician identifies those activities the patient is capable of alongside those that are restricted. Patients’ participation capabilities and restrictions refer to the patient’s abilities and restrictions to participate in life situations (e.g. work, recreation/sport, family, etc.). Again, determining participation capabilities, including modified participation (e.g. modified work duties), is important because this will contribute to other decisions such as prognosis and management. Note that identifying patients’ activity and participation restrictions and capabilities, either through interview or through questionnaire, does not really qualify as formulating ‘hypotheses’ in the sense that these are not clinicians’ judgments or deductions; rather, they are simply essential information to obtain in order to understand the extent of the patient’s disability and quality of life. They are included in the hypothesis categories framework simply to facilitate attention to these critical aspects of the patient’s pain/disability experience. Later, when making judgments about pain type, the proportionality of activity and participation restrictions and the physical impairments/pathology identified through examination will need to be considered. When activity and participation restrictions are out of proportion to identified physical impairments and pathology, then it may reflect a nociplastic pain type (IASP Taxonomy 2017; Nijs et al., 2015; Smart et al., 2012c; Woolf, 2011), and it is likely the patient’s psychosocial status will be negatively contributing to the patient’s disability. Patients’ perspectives on their experiences and social influences relate to the patient’s psychosocial status, which the clinician needs to assess and understand. Musculoskeletal clinicians’ psychosocial assessment is discussed in more detail in Chapters 3 and 4. But briefly, psychosocial assessment incorporates such things as: In the clinical reasoning strategies framework presented earlier, hypotheses regarding psychosocial status fit within narrative reasoning focused on understanding patients’ pain, illness and/or disability experiences. When assessing understanding of their problem (e.g. diagnosis, pain), this is not simply their superficial understanding (e.g. what the doctor told them or what they have read); rather, it refers to what meaning they attach to that understanding (e.g. likely recovery, fear of further damage, etc.). Understanding pain, including types of pain, differences between acute and chronic pain, referred pain and the associated neurophysiology, is essential knowledge to musculoskeletal clinicians. For this knowledge to be useful in clinical practice, it then must be linked to clinical reasoning, for example, clinical patterns of different pain types and the implications to precautions in assessment and management, management strategies and prognosis. Chapter 2 provides an overview of contemporary pain science understanding linked to clinical reasoning. For the purposes of this chapter, pain type is discussed as a hypothesis category because of its overarching importance to these other reasoning decisions, especially management. The three main types of pain musculoskeletal clinicians need to be able to assess for and recognize include nociceptive pain (with and without inflammation), neuropathic pain and nociplastic pain3 (e.g. Gifford et al., 2006; IASP Taxonomy 2017; Nijs et al., 2014b; Woolf, 2011, 2014). Nociceptive pain is protective and refers to pain that is associated with actual or threatened damage to non-neural tissue and involves activation of peripheral nociceptors (IASP Taxonomy 2017). Nociceptive inflammatory pain occurs with tissue damage, and/or immune cell activation in the case of systemic inflammation, facilitating repair by causing pain hypersensitivity until healing occurs (Woolf, 2010). Neuropathic pain refers to pain arising as a direct consequence of a lesion or disease affecting the somatosensory system and can be further differentiated into peripheral or central neuropathic pain depending on the anatomic location of the lesion (IASP Taxonomy 2017; Jensen et al., 2011; Treede et al., 2008). Nociplastic pain is dysfunctional pain associated with altered nociceptive processing in the central nervous system in the absence of overt peripheral drivers such as tissue injury or neuropathy. Nociplastic pain has been demonstrated in a wide range of conditions commonly treated by musculoskeletal clinicians, including non-specific chronic back pain, complex regional pain syndrome, chronic fatigue syndrome, fibromyalgia, post-surgical pain, and visceral pain hypersensitivity syndromes (Ashina et al., 2005; Clauw 2015; Coombes et al., 2012; Fernandez-Carnero et al., 2009; Lluch Girbés et al., 2013; Meeus et al., 2012; Nijs et al., 2012a; Perrotta et al., 2010; Price et al., 2002; Roussel et al., 2013; Woolf, 2011). The hypersensitivity manifests as increased responsiveness to a variety of stimuli, including mechanical pressure, chemical substances, light, sound, cold, heat, stress and electrical, with links to a range of CNS dysfunctions, as discussed in Chapter 2. Although both subjective and physical clinical features of pain types have been reported (Bielefeldt and Gebhart, 2006; Mayer et al., 2012; Nijs et al., 2010; Nijs et al. 2015; Schaible, 2006; Smart et al., 2012a, 2012b, 2012c; Treede et al., 2008; Woolf, 2011), diagnostic criteria and biomarkers of nociplastic pain are still not definitive (Kosek et al., 2016; Vardeh, Mannion & Woolf, 2016; Woolf, 2011, 2014). As such, when clinical features of different pain types co-exist, differentiation is challenging. This is particularly true for initial appointments where the full picture of the patient’s presentation (subjective, imaging, physical findings) is still emerging. For example, the full pain experience, including initial screening for adverse psychosocial factors by interview and/or questionnaire, often is not fully revealed at the first appointment. As clinician–patient rapport develops and time allows for questionnaire responses to be explored and clarified, a fuller picture will usually become available. Both physical and psychosocial stress can contribute to neuroimmune system dysregulation and thus contribute to pain hypersensitization. Clarification of apparent overlap in pain mechanisms (e.g. nociception with and without sensitization) may be assisted through outcome re-assessments of targeted treatment interventions over a defined period of time. That is, nociplastic pain occurs in response to both internal and external inputs, including cognitive and emotional modulation (e.g. thoughts, beliefs, fears, anxiety) and can be triggered, but not maintained, by nociception from pathological, inflamed or overloaded tissues if present, enabling increased sensitivity (or decreased load tolerance) to co-exist with somatic and visceral nociception. While pain type informs management, the mechanisms and contributors that underpin pain type can differ and change over time. As such, hypotheses about the dominant pain type may change as further information comes to light. Short-term treatments and re-assessments to potentially relevant physical impairments may assist in establishing how much an apparent sensitization is being driven by the symptomatic physical impairments or other co-existing cognitions, emotions and life stressors. Although interventions directed at musculoskeletal tissues have central modulatory influences (e.g. Cagnie et al., 2013; Nijs et al., 2011a, 2012a; Schmid et al., 2008; Smith et al., 2013, 2014; Vincenzino et al., 2007b; Zusman, 2008), they are unlikely to be sufficient on their own to resolve persistent nociplastic pain. However, when physical impairments and associated disability underpin psychological stress and negative cognitions, skilled physical and environmental management would be expected to improve if not resolve negative psyche and disability. When both physical and cognitive/affective factors appear to contribute to maintained pain and disability, management would logically address both. In contrast, successful management for dominant nociplastic pain and persistent pain memories maintained by psychosocial factors will likely require combinations of pharmacotherapy and cognitive-behavioural strategies through pain neuroscience education, facilitation of active coping strategies, graded activity and exercise (Louw et al., 2011; Moseley, 2004; Moseley & Butler, 2017; Nijs et al., 2011a, 2011b, 2012b, 2014a; Turk and Flor, 2006; Zusman, 2008) and is unlikely to be helped by traditional tissue-based approaches. The importance of recognizing clinical features of nociplastic pain is also evident when hypothesizing about potential nociceptive tissue pathology or sources based on joint, muscle and soft tissue assessments. Nociplastic pain can create local false-positive provocation of symptoms suggestive of tissue pathology (Gifford, 1998; Nijs et al., 2010) illustrating the influence of one hypothesis category (e.g. pain type) on another (e.g. source of symptoms) and the complexity of clinical reasoning required. Although the majority of patients with musculoskeletal problems present with pain as a symptom, they also present with other symptoms such as hyper-/hypoesthesias, paraesthesias, dysesthesias, vascular associated symptoms, stiffness, weakness, joint sensations (e.g. instability, clicking, locking) and urinary urgency and incontinence, among others. Patients in other areas of clinical practice (e.g. neurological, cardiorespiratory) present with additional symptoms characteristic of disorders of those systems. Consequently, as discussed under General Health Screening, it is important thorough screening occurs for other symptoms beyond the patient’s main complaint to ensure that relevant symptoms not spontaneously volunteered and that relevant health comorbidities are not missed. When patients do present with pain, and when a nociceptive ‘pain type’ is hypothesized, then it is appropriate to reason further regarding potential sources of nociception. Although validation of the source of nociception on the basis of a clinical examination alone is often limited, biological and clinical knowledge of pain distribution, patterns of provocation and relief and common mechanisms of onset enables clinicians to hypothesize about the likely sources of nociception. The accuracy of this aspect of diagnosis is significantly better with some types of problems (e.g. muscle and ligament injuries) than others (e.g. low back pain). However, even when a specific tissue cannot be confirmed, broader hypotheses about body regions (e.g. spine versus shoulder or hip) are still helpful in differential questioning and testing through the subjective and physical examination. As an example of generating hypotheses regarding possible sources of nociception for a patient’s symptoms based on the area of symptoms, consider the body chart in Table 1.2 depicting a common area of shoulder pain and the potential nociceptive, neuropathic and visceral sources of nociception that should be considered. TABLE 1.2 Considering potential structures involved within the suggested columns assists a thorough generation of hypotheses that can then be ‘tested’ with further questioning through the behaviour of symptoms (aggravating and easing factors), history, general health screening and physical examination–treatment–re-assessment. As alluded to earlier, hypotheses about specific tissue sources of nociception for the patient’s symptoms must be made with consideration of the dominant pain type hypothesized. Although clinical examination cannot always confirm the actual nociceptive source of a patient’s nociceptive-dominant symptoms, clues from the area and behaviour of symptoms, history, physical examination and treatments/re-assessments, combined with knowledge of common clinical patterns, will enable the clinician to hypothesize the likely structures at fault and possibly their pathology.
Clinical Reasoning
Fast and Slow Thinking in Musculoskeletal Practice
Introduction
The Scope of Clinical Reasoning
Clinical Reasoning in a Biopsychosocial Framework
Focus of Our Clinical Reasoning: Clinical Reasoning Strategies
Categories of Clinical Decisions Required: Hypothesis Categories
Activity and Participation Capability and Restriction
Patient Perspectives on Their Experiences and Social Influences (Psychosocial Status)
Pain Type
Source of Symptoms
Potential Local Nociceptive Sources
Potential Neuropathic Sources
Potential Nociceptive Sources of Somatic Referral
Potential Nociceptive Sources of Visceral Referral
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Fig. 1.1 Adaptation of World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) framework. (Reproduced with permission [WHO, 2001, p. 18].)
