Scientific Reasoning in the Clinical Examination – An Intro

Are you tired of seeing “stuff” like this? (I mean who’s he even talking to??)

Or maybe this? (Uhh…what just happened?)

Seriously…I don’t understand any of the rationale behind what just happened. And that’s just the problem. This kind of irrational, illogical, and (more to the point) unscientific reasoning creeps it’s way into treatments from practitioners of all kinds, all too often.

Why? Why do people, educated people fall into these lines of thinking? They start creating treatments or practice philosophies that have no scientific merit. I think the answer is multifaceted, but one big reason is a lack of scientific reasoning in the examination process.

Clearly I don’t have evidence for this theory of mine, but lets consider the possibility. If I understand disease/pathology, pain, and my own limitations as a diagnostician, then I can come to a reasonable conclusion about the source of a person’s ailment most of the time (or at least know who I should refer that individual to).

However, If I begin to forget one of these areas — I am lost. Neglecting my understanding and continued study of pathology and disease course will ensure that I miss making connections between signs and symptoms down the road. Not having a good understanding of pain and its origin (singular) will lead me to jump to conclusions and grasp at straws when I am at a loss for connecting signs and symptoms to a disease state. Thirdly, if I fail to understand that I cannot by myself make the correct diagnosis every time I encounter a patient (not only because of my scope of practice, but also my humanity), I will fail to provide accurate and appropriate treatment or referral.

Unfortunately, this is not an isolated incident. A visceral manipulation continuing education course was provided by the APTA this past fall, and there is another one being held this June. If you are unfamiliar with visceral manipulation click here for a Science Based Medicine article discussing the topic (and how the APTA supports it). (Disclaimer: I support the APTA and the advancement of the physical therapy profession, just not visceral manipulation.)

What happens when we treat these pain conditions and illnesses with theoretical treatments, of which perhaps few studies have been conducted? We delay constructive, beneficial, and necessary treatments for the healing process –and this starts with a lack of scientific reasoning in the examination process, followed by misdiagnosis.

Lets not underestimate the importance of correctly identifying the “cause of the cause,” the reason behind the symptoms that led the patient into your clinic. This is a changing era for physical therapy. We are pushing for unfettered direct access, and if we want it — we need to continue to make sure we deserve it.

Just this past summer I examined a young girl with a 7 month history of LBP. She had been treated almost 2 years prior for the same pain and was told that her core was weak which lead to her condition. If it had not been for my clinical instructor’s extensive training in the areas of differential diagnosis and musculoskeletal pathology, we would not have concluded that her pain and described signs/symptoms were too aberrant to be caused by such a claim. Turns out we were right. After a conservative course of physical therapy, she was diagnosed with PCOS and her pain resolved. (Trust me, we tried to refer out. Excellent example for why we need referral rights as well as direct access privileges).

 

The cost of diagnostic error can be great, seen here and here. To combat this we need to be more sound in our cognition when evaluating patients, more well informed, and more scientific. I am going to detail three areas of scientific methodology to incorporate into the clinical exam over a three part series. They might be common place in your exam rooms, and I hope they are. If they aren’t, you’re in the right place. In either case, we all need a refresher in the basics every once and a while. Check back next week for Part 1.

-Spencer

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3 thoughts on “Scientific Reasoning in the Clinical Examination – An Intro

  1. Pingback: Are you biased, bro? – Scientific Reasoning in the Clinical Exam (Part I) | PTbraintrust

  2. Pingback: The Best Special Test – Scientific Reasoning in the Clinical Exam (Part 3) | PTbraintrust

  3. Pingback: A Year in Review | PTbraintrust

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