Clinical Reasoning in the Management of LBP – A Personal Exploration
I have an interest in clinical reasoning and attended a workshop run by Peter O’Sullivan; it sparked ideas on how multiple classification systems could be used simultaneously to, perhaps, gain further insight into a patient’s complaint. I must declare that Peter and his team have had a huge influence on how I practice and I would like to acknowledge and thank them in this blog. In fact, the clinical reasoning tool I use is based on the cognitive functional therapy approach following the workshop that I attended in 2012. We recognise that lifestyle, physical, psychosocial factors, pain mechanisms and their manifestations as well as beliefs, thoughts and feelings affect the therapeutic encounter. However, how can we bring this together?
I constructed, alongside help by Peter O’Sullivan in 2012, a clinical reasoning tool that combines broad continuums of clinical reasoning processes that may inform clinical decision-making as well as prognostic profiling. Profiling–the key word here– is information taken from the patient, clinical research and one’s clinical expertise used to formulate a profile that informs our clinical decision-making. Therefore, one must be mindful of our own cognitive and personal bias when interpreting this data.
Here is the clinical reasoning tool:
There are four broad domains each coloured differently that represent characteristics that impact clinical decision-making. It is not exhaustive but facilitates the clinical reasoning process. Each of the continuums can be marked to guide a therapeutic intervention and perhaps guide priorities as well as goal setting.
The literature recognises that patients do not fall into sub-classification systems particularly well. However, understanding the multiple dimensions and how they interact may be more helpful.
The blue domain represents the physical or movement characteristics that the patient displays during the assessment. At each polar end they represent either loading impairment, control impairment or movement impairment.
Loading impairment represents the subjective and physical evaluation of a patient displaying intolerances to load. There could be a multitude of reasons for that, the patient may be guarding their movements through co-contraction of their trunk muscles, or their fear may drive anticipatory behaviour that makes them hold themselves in an upright posture for prolonged periods of time. Loading impairment may also be associated with a patient’s tolerance of repeated axial loading, either sustained (such as standing for periods of time) or impact (such as running). Three characteristics of loading impairment may need to be taken into consideration such as the movement or direction of force, the orientation of that force to external forces (e.g. gravity) and time. Changing the loading characteristics of a patient’s provocative task may reduce their symptoms, such as changing the force, altering direction or changing the temporal characteristics of the task. Each of these factors is taken into consideration in turn and used to tailor treatment to the individual patient.
Next is movement impairment. This represents the patient’s ability to produce appropriate range of motion. In clinical practice this can be evaluated through both active and passive movement assessments. Care may be needed to ensure that other factors are taken into consideration when evaluating this. Examples include fear, anxiety and apprehension that can produce false results. The question that one asks in this area is, can this patient’s trunk physically able to move through a range of movement that I would expect them to? If not, is this due to physical restriction factors such as loss of hip or lumbar spine range of movement?
The final component of the blue domain is control impairment. My interpretation of control impairment refers to the difficulty patients have with thoughtless, fearless and efficient goal directed movement. Control impairment is challenging movement behaviour to describe (I hope to do this in a later blog). The research literature does not describe motor control, core stability or other similar concepts with any clarity. However, in the clinical environment, I believe that a collaborative approach can be useful. The patient can give fantastic feedback when viewing themselves (using a mirror, it may also reduce pain. Have a look at this great blog post by Steve Nawoor) and relating it to how they interpret what ‘feels’ right. The therapist can construct their own opinion of optimal movement and provide the patients with feedback. Agreement between patient and therapist may be useful on this concept of control as a therapist centred evaluation of controlled movement may not be comfortable or appropriate for the patient.
The red line represents psychosocial and emotional factors with the positive prognostic factors (Now for Pink Flags! by Louis Gifford) on the front-left and the negative prognostic factors on the rear-right. Again, the continuum is broad and takes into consideration factors such as depression, loneliness, anxiety, guilt and outlook on life. I also use it in the context of what I determine as traits or states of the patient. How much are these factors contextual and changeable and how much are these factors are likely to be simply characteristics of the patient? Both require acknowledgement and management. States are modifiable; traits need to be managed. For example, an engineer who is a perfectionist and is frustrated and anxious is likely to be managed in a different way to an musician who has a different world view and a laid back attitude but has low mood. The engineer may want more information and therefore reconceptualization of the problem through pain education and relationships to movement as opposed to the insurance broker who responds to a careful assessment and permission to exercise through graded exposure. The context, as well as the degree of psychosocial factors, appears to be important. Completing a psychosocial prognostic measurement may inform the clinician as to the current status of the patient in this regard, but does little in respect in how to rehabilitate the patient.
The yellow continuum represents lifestyle factors. Examples of this include diet, social interaction, work status, stress management, levels of physical activity, smoking and sleep hygiene. Again, these factors may be modifiable, perhaps through a motivational interviewing approach, but some may not be and therefore accepted. The restoration of hope through recognising that most lifestyle factors are modifiable can be hugely influential in the therapeutic encounter. Guidance in this regard, from the therapist can also facilitate goal-setting and focussing the patient’s attention.
The neurophysiological factors are represented in green. This is a continuum of the type of pain mechanism that is predominant in the patient’s presentation. On the near-left hand side is primarily a nociceptively-driven pain response where symptoms respond in a way that is predictable and in keeping with a peripherally generated source. The symptoms in this case usually have a linear relationship to the aggravating and easing factors that are found on the subjective interview. On the other end of the spectrum is primarily a centrally driven pain mechanism where there is a poor relationship between symptoms and response to movement. Often there is a wider area of pain distribution and the accompaniment of hyperalgesia and allodynia.
The interaction of all of these elements could produce a meaningful prognostic indicator for the patient and guide further management options. Each of the continuums can be marked and viewed. If there is a tendency for the patients factors lie within the top left aspect of the rectangular face of the prism, the better the prognosis. The further the patients factors corresponds to the bottom right of the rectangular face of the prism the poorer the prognosis. The hope is that the therapeutic encounter facilitates the elements of the reasoning tool to the top left of the rectangular face.
For example: The area represented with the blue circle represents a better prognosis with the red circle representing a poorer prognosis.
Each of the movement related behaviors on the diagram show ‘optimum’ characteristics. Shifting towards the polar ends of movement, load or control impairment may direct the movement treatment strategy.
Using a multi-dimensional method may derive a closer patient-centred approach to the individual. The same clinical reasoning tool could be modified for other areas for example for shoulder instability. The clinical reasoning tool uses the Stanmore triangle for this patient group.
As you can see, all of the continuums can be marked and be used to describe the patients presentation across multiple dimensions. All of the continuums inter-relate with each other, and in turn, effect each other. What manifests as a result provides an insight to the individual patient in front of the clinician. I hope that this tool is helpful in tackling clinical variation and uncertainty.
These are just a few thoughts and over the years I have put this into practice and found it helpful as a personal guide but also in teaching others.
Feel free to comment below and let me know your thoughts.
As always, thanks for reading!