Clinical reasoning and critical reflection in physiotherapists’ examinations of patients with low back pain in its early phase: a qualitative study from physiotherapists’ point of view

"How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?"

BACKGROUND

Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed.

OBJECTIVE

The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making.

DESIGN

This was an exploratory interview study using inductive content analysis.

METHOD

Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity).

CONCLUSION

This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.

An exploration of clinical reasoning and practices used by physiotherapists in the rehabilitation of horses following interspinous ligament desmotomy surgery

INTRODUCTION

Clinical reasoning has not been studied in veterinary physiotherapy and so the methods used and factors involved are unknown. Similarly, the practices of veterinary physiotherapists within a certain rehabilitation programme have not been documented. The aim of this study was to explore the clinical reasoning and practices of veterinary physiotherapists during rehabilitation of horses following interspinous ligament desmotomy surgery.

METHODOLOGY

A qualitative approach was taken and six members of the Association of Chartered Physiotherapists in Animal Therapy were interviewed using a semi-structured approach. The data were transcribed and analysed using Thematic Analysis.

RESULTS

Five themes were identified as relevant to the participants clinical reasoning. These related to structure of the assessment, modalities and reasoning of treatment, involvement of owner and veterinarian and the impact of comorbidities. The data highlight several different factors that influence clinical reasoning and decision making throughout the rehabilitation. An insight into practices involved is also documented.

CONCLUSION

The process of clinical reasoning and decision making described appears complex. The input of both owner and veterinarian are evidently important and require the physiotherapists consideration. Decisions regarding assessment and treatment are influenced by many factors. A mixture of clinical experience and research evidence were used as support.

The skills, knowledge and attributes needed as a first-contact physiotherapist in musculoskeletal healthcare

OBJECTIVES

The provision of musculoskeletal assessment and pathway management by physiotherapists in primary care is an expanding innovation within the UK National Health Service. This new model of care is challenging physiotherapists to work in new ways, and so an understanding of these roles is timely and wil contribute to the growing knowledge regarding these practitioners and their impact.

METHODS

This qualitative study aimed to improve the understanding of the clinical practice of first-contact clinicians in musculoskeletal healthcare. The study used a think-aloud method to explore eight clinicians' views via a stage 1 semi-structured interview process. This was followed by a stage 2 focus group involving physiotherapists and a general practitioner trainer. A thematic analysis then followed, which involved the researcher and a research colleague coding the data and subsequently developing themes.

RESULTS

The themes identified were: medical assessment and systems knowledge; speed of thought in an uncertain environment; breadth of knowledge; people and communication skills; common sense/simplify; and responsibility and experience.

CONCLUSIONS

The identified themes should help to underpin the competence, capability and training requirements for these new roles, and should be considered when developing new services utilizing first-contact primary care physiotherapy practice.