The clinical reasoning process – Part 1
Erik Meira recently wrote an excellent blog post on why people “just load it” when prescribing exercise for pathologies/injuries. It is a must read in my opinion, it really defines what we must consider when prescribing exercise and how it leads to good clinical outcomes. http://www.tendinopathyrehab.com/…/just-load-it-guest-blog-…
It really got me thinking about the clinical reasoning process we go through when making decisions for patients and treatment approaches. Firstly, what is clinical reasoning? It is kind of a scary thing as a student, it sounds fancy and very complex. It is usually something that is thrown around a lot without any major defined criteria and everyone has a different process or definition. In my eyes, it is making decisions based off information and rationale. It is tying together knowledge, logic and reason to make decisions. It is having a rationale and explanation for what you are doing.
To break it down simply in relation to this blog it is:
Hamstring tear = damage to muscle fibres caused by eccentric weakness.
Isometric strengthening, Concentric strengthening, eccentric strengthening – which do we choose and why?
Firstly Isometric – why? The patient is in pain concentric or eccentric might stress the muscle fibres too much in the very early phase. Isometrics are suitable because they help to maintain strength and aren’t too painful as well as maintaining muscle activation. It also helps to ensure the patient feels comfortable to contract the muscle and prevents them becoming afraid of moving their leg. This is important, not just managing the pain but managing the patient. Letting the patient know that some pain is acceptable but that throughout rehab it will be kept to a minimum and at tolerable levels helps with buy in from the patient and helps to reduce the patients fears. Giving the patient belief that it is okay to move and contract the muscle is important from an early stage because the human body is a mixture of complex systems that interact. Psychological factors are vitally important to consider because they can impact upon physiology by increasing or reducing stress, not fearing a movement means more movement and means mechanotransduction can occur. Thinking that movement = damage leads to “protection” mode setting in and priming of pain and inflammatory systems. Fear of movement and loading can delay return to play, can lead to poor compliance to rehab, can reduce performance on return to play. Considering all these factors and answering the why is what clinical reasoning is.
When to move to concentric or eccentric? Here we go with some more clinical reasoning. Is the patient pain free with isometrics? Is the patient limping? Can the patient jog? Why choose jogging as a measure of progression? Well jogging requires a small amount of eccentric hamstring work to slow down knee extension. It gives an indication of the damage, the pain levels, functionality and the patients tolerance to eccentric load. Once isometrics and jogging are pain free eccentrics can commence at a low level. This is clinical reasoning, it is this simple……don’t be afraid of it, don’t let tutors and lecturers scare you with it. It seems scary and tough but it isn’t.
This is simplified I won’t deny it, you do need to know outcome measures, you do need to know your anatomy and functional anatomy and the physiological – psychological – social effects of treatments. The above blog will help you with the rationale for strengthening. Embrace evidence it will really help to develop your clinical reasoning process. We will develop this case study throughout other posts but in the meanwhile why not checkout out The Physio Matters podcast with Simon Murphy Leicester City Physiotherapists on hamstrings.