Reference: School of Physiotherapy, University of South Australia Page 1 of 15

CLINICAL REASONING REFLECTION FORM

NAME..........................DATE..............PATIENT'S NAME....................................

PERCEPTIONS / INTERPRETATIONS ON COMPLETION OF THE SUBJECTIVE EXAMINATION

It is important to recognise that the patient’s presentation and factors affecting it (eg physical, environmental, psychosocial and health management via physiotherapy or other means) can be characterised in pain language/mechanisms by the dominant Input, Processing or Output pain mechanisms that appear to be affected. This should be considered when forming judgements regarding the other hypothesis categories as interpretations of the patient’s symptoms, psychosocial status and signs will vary with the dominance of pain mechanisms present. BODY CHART:

1. ACTIVITY CAPABILITY/RESTRICTION Identify key abilities and difficulties the patient has in executing activities: Abilities ………………………………………………………………… Restrictions……………………………………………………………….

2. PARTICIPATION CAPABILITY/RESTRICTION Identify abilities and restrictions the patient has with involvement in life situations (work, family, sport, leisure): Abilities............................................................................…......................Restrictions..................................................................................................

3. PATIENT’S PERSPECTIVES ON THEIR EXPERIENCE

Identify the patient’s perspectives (positive and negative) on their experience (e.g. Cognitive – patient understanding, beliefs, attributions and Affective – patient feelings/emotions regarding the problem and its management): ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Reference: School of Physiotherapy, University of South Australia Page 2 of 15

4. PATHOBIOLOGICAL MECHANISMS 4.1 Tissue Mechanisms At what stage of the inflammatory/healing process would you judge the principal disorder

to be? (e.g. acute inflammatory phase 0-72 hrs, proliferation phase 72hrs-6weeks, remodelling & maturation phase 6weeks-several months).

................................................................................................................................…………………………………………………………………

………………………………………………………………………….. If the disorder is past the remodelling & maturation phase, what do you think may be

maintaining the symptoms/activity-participation restrictions? (e.g unhelpful perspectives/psychosocial factors, physical/biomechanical impairment, systemic disease, environmental/ergonomic factors, behavioural factors, central processing factors, etc.)?…………………………………………………………………………..

………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… 4.2 Pain Mechanisms

List the subjective evidence which supports each specific mechanism of symptoms. Remember that all mechanisms are operating in every presentation but in different ways. The key is to identify the dominant mechanism and potential risk factors for normal mechanism involvement to become pathological (ie counterproductive to recovery):

Input Mechanisms Processing Mechanisms Output Mechanisms

Nociceptive Symptoms

Peripheral Evoked

Neurogenic Symptoms

Centrally Evoked

Neurogenic Symptoms

Cognitive and

Affective Influences

Motor & Autonomic Mechanisms

Reference: School of Physiotherapy, University of South Australia Page 3 of 15

4.3 Draw a “pie chart” on the diagram below that reflects the proportional involvement of the pain mechanisms apparent after completing the subjective examination.

4.4 Identify any potential risk factors (e.g. yellow, blue & black flags) for normal mechanism

involvement to become maladaptive (i.e. counterproductive to recovery). …………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4.5 From your subjective examination, identify any features in the patient’s presentation that may

reflect dysfunction in the neuroendocrine and neuroimmune systems. Neuroendocrine:………………………………………………………… …………………………………………………………………………… Neuroimmune:…………………………………………………………… ……………………………………………………………………………

Reference: School of Physiotherapy, University of South Australia Page 4 of 15

5. THE SOURCE(S) OF THE SYMPTOMS 5.1 List in order of likelihood all possible structures at fault for each area/component of

symptoms. Source Area 1: Area 2: Area 3: Area 4: Somatic Local Somatic referred Neurogenic (peripheral and/or central) Vascular Visceral

5.2 Highlight with * those structures which must be examined DAY 1 5.3 Do the symptoms appear to fit those commonly associated with a particular physical syndrome/disorder/pathology?...................................………….. ........................................................................................................................ If not, does this suggest the need to examine other factors (eg yellow flags, sinister

pathology)?..................………………………………………………………. ……………………………………………………………………………...

Reference: School of Physiotherapy, University of South Australia Page 5 of 15

6. CONTRIBUTING FACTORS 6.1 Are there any contributing factors associated with the patient's symptoms? Specify

Physical (eg biomechanical, muscle length/strength/control, joint mobility, neural mobility,

posture, etc.). ............................................................................................……… Environmental/Ergonomic……….......................................................................... Psychosocial (e.g. patient’s perspectives/understanding of problem and requirements for

recovery/management, feelings regarding problem and its management, attributions, health beliefs,

etc…………….………………………………………………………… ………………………………………………………………………………… 6. THE BEHAVIOUR OF THE SYMPTOMS 6.1 Give your interpretation for each of the following.

Severity |————————|————————| low high Irritability symptom 1 |————————|————————| non-irritable very irritable Irritability symptom 2 |————————|————————| non-irritable very irritable Give example:

.........................................................................................................………… .........................................................................................................................

What are the implications of this answer to your physical examination? (see 8.3, 8.4)

……………………………………………………………………………………………………………………………………………………………… Relationship of patient’s activity/participation restrictions and/or symptoms to each other

Behavioural (eg can symptoms occur alone or are they linked via aggravating and easing

factors)......................................................................................................…… ......................................................................................................................... Historical (eg what is the relationship of the symptoms over time – biomechanically, motor

control, pathophysiological processes?)…................…….………………….. ………………………………………………………………………………………………. Precautionary questions (eg general health, [red flags: e.g. spinal cord, vertebrobasilar

insufficiency, cauda equina, weight loss], medications, investigations, yellow flags and

psychosocial factors, etc.)...............................................………………………… .......................................................................................................................................……………………………………………………………………...

Reference: School of Physiotherapy, University of South Australia Page 6 of 15

6.2 Is the nociceptive component predominantly inflammatory or mechanical? Inflammatory |————————|————————| Mechanical List those factors that support your decision. Supporting Evidence

Inflammatory

Mechanical

What are the implications of this answer to your physical examination? (see 8.3,

8.4)…………………………………………………………………………………………………………………………………………………

7. HISTORY OF THE SYMPTOMS 7.1 Give your interpretation of the history (present and past) for each of the following:

Nature of the onset (eg is it consistent with a particular syndrome or suggest a dominant

pain mechanism?)………………………………………………………..

……………………………………………………………………………………… Extent of impairment and associated tissue damage/change (eg mild versus severe and

supporting evidence). Also does this fit with a predominantly peripherally evoked or

centrally mediated process?)...........................…………………………….

.................................................................................................................. What are the implications for the physical examination (specifically, how do your

priorities change for day 1 physical examination?....................................…………….

…………………………………………………………………………. Progression since onset (including stage & rate of impairment & stability of the

disorder)..................................................................................................................……

.................................................................................................................. Are the patient’s symptoms consistent with the history?....................................…

Explain if not, why not: ..…………………………………………………... ………………………………………………………………………….

Reference: School of Physiotherapy, University of South Australia Page 7 of 15

8. PRECAUTIONS AND CONTRAINDICATIONS TO PHYSICAL

EXAMINATION AND MANAGEMENT 8.1 Does the subjective examination indicate caution? (e.g. highly irritable condition, rapidly

worsening, progressive neurologically, general health, potential vertebrobasilar or spinal cord

dysfunction, weight loss, medications, investigations, etc).

Explain.........................................................................................................................……………………………………………………………………….

........................................................................................................................ 8.2 Do the symptoms indicate the need for specific testing as a day 1 priority (e.g. instability tests,

peripheral or central nervous system neurological, vertebral artery tests, further medical

investigations, etc.)?

Explain........................................................................................................................………………………………………………………………………..

8.3 At which points under the following headings will you limit your physical examination? Circle the

relevant description. Local symptoms (consider each component)

Referred symptoms (consider each component)

Dysthesias Symptoms of Vertebrobasilar Insufficiency Other VBI Symptoms

Visceral symptoms

Short of P1 Short of Production Point of onset/ increase in resting symptoms

Point of onset/ increase in resting symptoms

Point of onset/ increase in resting symptoms

Point of onset/ increase in resting symptoms

Point of onset/ increase in resting symptoms

Partial reproduction Partial reproduction Partial reproduction Partial reproduction Partial reproduction Total reproduction Total reproduction Total reproduction Total reproduction 8.4 Considering your answers to Question 8.1, and in addition to your answer to Qquestion 8.3, at which

point will you limit the extent of your physical examination? (ie, if there are no red flag issues to take into account, is there any reason why you should not examine a particular movement fully if it does not provoke the symptoms outlined above?) Tick the relevant description.

Active examination Passive examination •Active movement short of limit •Passive movement short of R1 •Active limit •Passive movement into •Active limit plus overpressure moderate resistance •Additional tests •Passive movement to full over- pressure

Reference: School of Physiotherapy, University of South Australia Page 8 of 15

If the dominance of the presentation is central as opposed to peripherally evoked, how will that influence your approach to the physical examination for this particular patient?…………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………….

What would your priorities for this patient be for day 1?…………………………….. ………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………

8.5 Is a peripheral or central nervous system neurological examination necessary?

Why?..................................................…………………………………………………………………………………………………………………………………………..

Is it a day one priority?………………………………………………………………..

…………………………………………………………………………………………

8.6 If relevant, do you expect a comparable sign(s) to be easy/hard to find?...................

Explain....................................................................................................................…… ...........................................................................................................................

.....…………………………………………………………………

8.7 What are the clues (if any) in the subjective examination to management and specific treatment

techniques that may be used?...........................……………………………… .................................................................................................................. ..............…………………………………………………………………

Reference: School of Physiotherapy, University of South Australia Page 9 of 15

PERCEPTIONS, INTERPRETATIONS, IMPLICATIONS FOLLOWING THE PHYSICAL EXAMINATION AND FIRST TREATMENT

9. CONCEPT OF THE PATIENT’S ILLNESS/PAIN EXPERIENCE 9.1 What is your assessment of the patient’s understanding of his/her problem (Have you asked the

patient – see question 3)?……………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

9.2 What is your assessment of the patient’s feelings about his/her problem, its affect on his/her life

and how it has been managed to date?....................................…………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9.3 What does the patient expect/want from you/your management (i.e. patient’s

goals)?………………………………………………………………………………………

……………………………………………………………………………… Are the patient’s goals appropriate?…….Explain…………………………………………..

………………………………………………………………………………Have

you and the patient been able to agree on modified goals?….Explain……………. ……………………………………………………………………………… ………………………………………………………………………………

9.4 What effect do you anticipate the patient’s understanding and feelings regarding his/her problem

to have on your management or the prognosis?.....................……………… ……………………………………………………………………………………

………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………

Reference: School of Physiotherapy, University of South Australia Page 10 of 15

10. Identify the key PHYSICAL IMPAIRMENTS from the physical examination that may require management/re-assessment (e.g. posture, movement patterns/motor control, soft tissue/muscle/joint/neural mobility/sensitivity, etc.).

1.……………………………………………………………………… 2.……………………………………………………………………… 3.……………………………………………………………………… 4.……………………………………………………………………… 5.……………………………………………………………………… 6……………………………………………………………………… 7.……………………………………………………………………… 8.……………………………………………………………………… 9.……………………………………………………………………… 10.…………………………………………………………………….. 11………………………………………………………………………

Reference: School of Physiotherapy, University of South Australia Page 11 of 15

11.0 THE SOURCES AND PATHOBIOLOGICAL MECHANISMS OF THE PATIENT’S SYMPTOMS

11.1 List the components of symptoms and pathobiological mechanisms identified in Sections 5.

& 4. and number in order of likelihood the possible structure(s) at fault for each apparent component. Then identify supporting and negating evidence from the PHYSICAL EXAMINATION for each structure and pathobiological mechanism

Component

Possible structure(s) at fault

Physical Examination Supporting Evidence

Physical Examination Negating Evidence

Pain Mechanisms Supporting Evidence Negating Evidence Input Mechanisms: Nociceptive Peripherally evoked neurogenic

Processing Mechanisms: Centrally evoked neurogenic Cognitive & affective

Output Mechanisms: Motor Autonomic

Tissue Mechanisms Supporting Evidence Negating Evidence

Acute inflammatory phase

Proliferation phase

Remodelling and maturation phase

Reference: School of Physiotherapy, University of South Australia Page 12 of 15

11.2 Indicate your principal hypothesis regarding the primary syndrome/disorder and the dominant pathobiological mechanism(s)..............................................................…………

....................................................................................................................... ...........……………………………………………………………………… 11.3 Tissue Mechanisms - Healing Mechanisms Do your findings on Physical Examination change your interpretation related to Question 4.1

regarding the stage of the inflammatory/healing process? Explain………………………

………………………………………………………………………………………………..

.......................................................................................................................... .......................................................................................................................... 11.4 Based on your understanding of the nature of the disorder (eg inflammatory, degree of

irritability, worsening, rate of impairment, and other indicators of the need for caution), the pathobiological mechanisms operating, the patient’s perceptions of their experience and possible contributing factors, list the favourable and unfavourable prognostic indicators:

Favourable Unfavourable

IMPLICATIONS OF PERCEPTIONS AND INTERPRETATIONS ON ONGOING MANAGEMENT

12. MANAGEMENT 12.1 Do the physical signs fit with the symptoms? If not, how might this influence your management

and treatment prognosis….................................................................. ……………………………………………………………………………………

………………………………………………………………………… 12.2 Is there anything about your physical examination findings which would indicate the need for

caution in your management?...............................................................…………………

Explain..........................................................................................................................……. ................................................................................................................................

......…………………………………………………………………………………………………………………………………………………..

Reference: School of Physiotherapy, University of South Australia Page 13 of 15

12.3 Does your interpretation of the physical examination change the emphasis of treatment as

outlined?…………………………………………………………………………………… ........................................................................................................................................……………………………………………………………………

........................................................................................................................ 12.4 What was your management on day one (eg explanation/advice, exercise, passive mobilisation,

referral for further investigations, etc.)?…………………………………………………… ………………………………………………………………………………………………

Why was this chosen over the other options? …………………………………….. ……………………………………………………………………………… If passive treatment was used, what was your principal treatment technique(s)? ...........................................................………………………………………………………………………………………………………………………

What physical examination findings support your choice? (Include in your answer a movement

diagram of the most comparable passive sign). .....................................................…………………………………………...

......................................................................................................................................…………………………………………………………………….

MOVEMENT DIAGRAM

12.5 If you used an active or passive treatment or advice on day one, what was its effect?

............................……………………………………………………………………………………………………………………………………………

What was the patient’s perception of the effect of the first treatment and his/her expectation

over the next 24 hours?………………………………………………………..

......................................................................................................................................…… What is your expectation of the patient's response over the next 24 hours?

......................................................................................................................................…………………………………………………………………….

If your expectation is different from the patient’s, explain why this is so.........…………...

………………………………………………………………………………………………………………………………………………………………

Reference: School of Physiotherapy, University of South Australia Page 14 of 15

12.6 What is your plan and justification of management for this patient?

(rate of progression; addressing other problems/components; sources/contributing factors;

appreciation of pathobiology, etc:)……………………………………………….. ……. ......................................................................................................................................……………………………………………………………………

12.7 Do you envisage a need to refer the patient to another health provider (eg physician,

orthopaedic surgeon, neurologist/neurosurgeon, vascular surgeon, endocrinologist,

psychologist/psychiatrist, anaesthetist, dietician, feldenkrais practitioner,

etc.)………………………………………………………………………………………. 13. REFLECTION ON SOURCE(S), CONTRIBUTING FACTOR(S) AND

PROGNOSIS AFTER THIRD VISIT 13.1 How has your understanding of the patient's problem changed from your interpretations made

following the first session? ............................................…………………………..

How have the patient’s perceptions of his/her problem and management changed since the first

session?........................................................................................................………….

Are the patient’s needs being met?……………………………………………………….

……………………………………………………………………………………………

13.2 On reflection, what clues (if any) can you now recognise that you initially missed,

misinterpreted, under- or over-weighted?..............................................................………

……………………………………………………………………………………………

What would you do differently next time?........................................................................

…………………………………………………………………………………………… AFTER SIXTH VISIT 13.3 How has your understanding of the patient's problem changed from your interpretations made

following the third session? ………………………………………………………….

......................................................................................................................................…….

How have the patient’s perceptions of his/her problem and management changed since the third

session? .......................................................................................................................

…………………………………………………………………………………………….. 13.4 On reflection, what clues (if any) can you now recognise that you initially missed,

misinterpreted, under- or over-weighted?…………………………………………………... ................................................................……………………………………

What would you do differently next time?....................................................………………

Reference: School of Physiotherapy, University of South Australia Page 15 of 15

13.5 If the outcome is to be short of 100% (i.e. “cured”), at what point will you cease management and why?………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

AFTER DISCHARGE 13.6 How has your understanding of the patient’s problem changed from your

interpretations made following the sixth session? ……………………………………….

.......................................................................................................................................….

How has the patient’s perceptions of his/her problem and management changed since the third

session?………………………………………………………………………………

................................................................................................................…. 13.7 In hindsight, what were the principal source(s) and pathobiological mechanisms of the patient's

symptoms? ………......................................................................................……

……………………………………………………………………………………………… Identify the key subjective and physical features (i.e. clinical pattern) that would help you

recognise this presentation in the future.

Subjective Physical

University of South Australia, School of Physiotherapy, Clinical Reasoning Form