Should evidence or sound clinical reasoning dictate patient care?

Enhancing Healthcare Decision-Making Process: Findings from Orthopaedic Field

In the healthcare field, the decision-making process is part of the broad spectrum of “clinical reasoning”, which is recognised as the whole process by which a physician decides about patients’ treatments and cares. Several clinicians’ intrinsic variables lead to this decisional path. Little is known about the inference of these variables in triggering biases in decisions about the post-discharge period in the surgical field. Accordingly, this research aims to understand if and how cognitive biases can affect orthopaedists in decision-making regarding the follow-up after knee and hip arthroplasty. To achieve this goal, an interview-based explorative case study was run. Three key-decisional orthopaedic surgeons were interviewed through a quality control tool aimed at monitoring the causes and effects of cognitive distortions. Coherently with the literature, eight biases come to light. All the interviewees agree on the presence of four common biases in orthopaedic surgery (Affect heuristic, Anchoring, Halo effect, Saliency). The other biases (Groupthink, Availability, Overconfidence, Confirmation), instead, depending on specific physicians’ intrinsic variables; namely: (i) working experience; (ii) working context. This finding contributes to the debate about the application of cognitive tools as leverage for improving the quality of clinical decision-making process and, indirectly, enhancing better healthcare outcomes.

Clinical Reasoning for Speech Sound Disorders: Diagnosis and Intervention in Speech-Language Pathologists' Daily Practice

Purpose This study aims to give an insight in clinical reasoning (diagnosis and intervention) of speech-language pathologists (SLPs) in the Netherlands for children with speech sound disorder (SSD). Method The study featured a mixed-method (qualitative and quantitative) design. Semistructured interviews containing nondirective, open-ended questions were conducted with 33 SLPs, which were analyzed using a constant comparative analysis. Other SLPs (137) filled out a questionnaire on the same topics. Multiple-choice questions were analyzed by descriptive frequencies, while open-ended questions were analyzed thematically. Results The results indicate that SLPs use a variety of assessments to diagnose SSD, complemented by observation and, often, case history. In total, 85 different diagnostic labels were reported. The choice of intervention is based on what is appealing to the child and what matches his or her age as well as on the specific diagnosis and severity. Interventions are used for multiple speech disorders, and according to SLPs, parents play a large role in diagnostics and intervention. Conclusion These results reveal the need for (a) a clear and consistent terminology of diagnoses in the field of pediatric SSD, (b) a fast and easy-to-administer comprehensive differential diagnostic instrument in combination with an instrument to assess participation in everyday life, and (c) a tool to conduct a case history online.

THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT

BACKGROUND/AND PURPOSE

Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in physical therapy, which allows for dynamic visualization of tissues in real time. Plantar fasciitis is a common condition causing heel and arch pain and has been related with degenerative changes in the plantar fascia resulting in tissue thickening. Instrument Assisted Soft Tissue Mobilization (IASTM) is an intervention that allows clinicians deep penetration to treat tissues. The mechanical forces caused by IASTM might cause localized tissue trauma leading to stimulation of the body's natural inflammation and healing processes. The purpose of this case report is to demonstrate the use of ultrasound imaging to guide the decision-making process and to discern the optimal location for the application of IASTM.

CASE DESCRIPTION

The subject was a 46-year-old female yoga practitioner and runner, who presented with right foot pain. The clinical impression was formulated based on the combination of traditional physical therapy examination procedures and MSK US imaging findings of the plantar fascia demonstrating thickness and tendinosis like changes within the plantar fascia 3 cm distally from the calcaneus.

OUTCOMES

The subject was seen for eight treatment sessions over four weeks, at which time the goals of normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and no reported pain during gait were achieved.

DISCUSSION

This case report illustrates the use of MSK US imaging as a method to objectively assess tissue quality and guide decision-making when managing patients with plantar fascia related pain. MSK US was used to determine the optimal location for the application of IASTM during the conservative management of a runner with plantar fasciitis.

LEVEL OF EVIDENCE

Therapy, Level 5.

Musculoskeletal ultrasound imaging and clinical reasoning in the management of a patient with cervicogenic headache: a case report

Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause-effect relationship between the treatment and positive outcomes in this case report has to be further validated.

An empirical, pragmatic approach applying reflection in interaction approach to manual therapy treatments

Background: Most literature on decision processes within physiotherapy relates to "reasoning that results in action" - decisions based on information including assessments that are gathered prior to treatment decisions. A process of "reasoning in interaction" that is often used, particularly by expert clinicians, has received less attention. Objective:  To provide a theoretical and practical approach to applying reasoning in interaction in a musculoskeletal setting. Methods: The theory is: If an impairment that can be directly targeted by treatment (i.e. pain or limitation of passive movement) is related to patient's active impairments and functional limitations, then moment-to-moment changes in the targeted impairment can be used as feedback to guide real-time treatment modification before formal reassessment of functional limitations and other impairments. Results: Applying the theory to manual therapy results in parameters of techniques such as force, speed, direction and duration no longer being pre-determined, but rather being continually adjusted in real-time according to feedback from the patient through both therapist perception (changes in movement quantity or quality) and patient verbal responses. Conclusion: A process of continuous decision-making is described that the authors believe is used by many experienced clinicians but has not previously been adequately described in the literature. .

Preliminary reliability and validity of the shoulder functional reach score

OBJECTIVE

The purpose of this study was to determine (a) if the newly developed shoulder functional reach score (SFRS) is reliable; (b) if the SFRS demonstrates construct validity by being able to differentiate between patients' symptomatic and asymptomatic shoulders; (c) if the SFRS is able to detect changes over time; and (d) if the potential changes in the SFRS demonstrated criterion validity at three different time intervals by being associated the Numeric Pain Rating Scale (NPRS) and Shoulder Pain and Disability Index (SPADI).

METHODS

Patients were consecutively screened for consultation related to complaints of shoulder pain. Thirty-eight subjects agreed to participate and signed informed consent. Twenty-nine subjects fulfilled the study after the 4 weeks of follow-up. Outcome measures were collected at the initial evaluation and at the first follow-up visit prior to the initiation of treatment. Data were then collected after 2 and 4 weeks of treatment.

RESULTS

There were statistically significant differences between symptomatic and asymptomatic shoulders on the SFRS. Intratester reliability of the SFRS was intraclass correlation coefficient (ICC_2,1 ) = 0.94. Intertester reliability of the SFRS was ICC_2,1  = 0.92. Statistically significant differences were observed between the initial evaluation, 2 and 4 weeks for the SFRS, SPADI, and NPRS. Moderate (r_s  = 0.62) to strong (r_s  = 0.87) positive correlations were observed between the NPRS and SPADI. Moderate negative (r_s  = -0.50-0.51) correlations were found between the SFRS and the SPADI. Moderate negative (r_s  = -0.36-0.54) statistically significant (p < 0.05) correlations were found between the SFRS and the NPRS.

CONCLUSION

In this small sample, the SFRS was an objective, reliable, and valid tool for assessing shoulder active range of motion in a clinical setting.

Applying a systems approach to thyroid physiology: Looking at the whole with a mitochondrial perspective instead of judging single TSH values or why we should know more about mitochondria to understand metabolism

Classical thinking in endocrine physiology squeezes our diagnostic handling into a simple negative feedback mechanism with a controller and a controlled variable. In the case of the thyroid this is reduced to TSH and fT3 and fT4, respectively. The setting of this tight notion has no free space for any additions. In this paper we want to challenge this model of limited application by proposing a construct based on a systems approach departing from two basic considerations. In first place since the majority of cases of thyroid disease develop and appear during life it has to be considered as an acquired condition. In the second place, our experience with the reversibility of morphological changes makes the autoimmune theory inconsistent.

While medical complexity can expand into the era of OMICS as well as into one where manipulations with the use of knock-outs and -ins are common in science, we have preferred to maintain a simple and practical approach. We will describe the interactions of iron, magnesium, zinc, selenium and coenzyme Q10 with the thyroid axis. The discourse will be then brought into the context of ovarian function, i.e. steroid hormone production. Finally the same elemental players will be presented in relation to the basic mitochondrial machinery that supports the endocrine.

We propose that an intact mitochondrial function can guard the normal endocrine function of both the thyroid as well as of the ovarian axis. The basic elements required for this function appear to be magnesium and iron. In the case of the thyroid, magnesium-ATP acts in iodine uptake and the heme protein peroxidase in thyroid hormone synthesis. A similar biochemical process is found in steroid synthesis with cholesterol uptake being the initial energy-dependent step and later the heme protein ferredoxin 1 which is required for steroid synthesis. Magnesium plays a central role in determining the clinical picture associated with thyroid disease and is also involved in maintaining fertility. With the aid of 3D sonography patients needing selenium and/or coenzyme Q10 can be easily identified. By this we firmly believe that physicians should know more about basic biochemistry and the way it fits into mitochondrial function in order to understand metabolism. Contemplating only TSH is highly reductionistic.

Outline

•

Author's profiles and motivation for this analysis

•

The philosophical alternatives in science and medicine

•

Reductionism vs. systems approach in clinical thyroid disease guidelines

•

The entry into complexity: the involvement of the musculoskeletal system

•

Integrating East and West: teachings from Chinese Medicine and from evidence based medicine (EBM)

•

Can a mathematical model represent complexity in the daily thyroid practice?

•

How effective is thyroxine treatment?

•

Resolving the situation of residual symptoms in treated patients with thyroid disease

•

Importance of iron, zinc and magnesium in relation to thyroid function

•

Putting together new concepts related to thyroid function for a systems approach

•

Expanding our model into general aspects of medicine