Model of Clinical Reasoning in Physiotherapy
2014
Model of Clinical Reasoning in Physiotherapy
This Model of Clinical Reasoning in Physiotherapy is the result of a joint developmental project
involving physiotherapy lecturers and clinical teachers and is used in the theoretical and clinical
courses at the Faculty of Physiotherapy, University College Metropolitan, Copenhagen, Denmark.
The concept of the Model of Clinical Reasoning in Physiotherapy
The Model of Clinical Reasoning in Physiotherapy is a pedagogical tool for promoting awareness
of one’s own reflections. The model expresses the circular process of reasoning which is
constantly under the influence of many factors in any physiotherapy context. The following process
recording form has a linear construction due to the technical difficulties of constructing and
capturing in wiriting a complicated circular process.
Any encounter between physiotherapist and patient takes place in a cultural context which
contributes to defining the meaning of and laying out the framework for the process of reasoning.
The cultural context also has influence on the environment, which in turn establishes possiblities
and limitations for the encounter and thus for the clinical reasoning. Finally, each encounter takes
place within a historical societal context which likewise will influence the process of reasoning.
The process of reasoning is made up of the physiotherapist’s reasoning and the patient’s
reasoning as well as their joint verbal and nonverbal reasoning.
Objective
The objective is for the physiotherapy students to develop and deepen their actual clinical
reasoning, with the use of The Model of Clinical Reasoning in Physiotherapy, throughout the
course of their education so that they will have a solid and conscious foundation for their
professional physiotherapy career.
Across the course of education
The model expresses a common frame of reference for the clinical process of examination,
reasoning and diagnosis as well as the process of intervention and evaluation in physiotherapy.
The students acquire knowledge of the comprehensive framework from the beginning of their
course of education, after which known basic methods of examination (such as measurement of
joint movement and muscle testing) are continuously elaborated and related to the theoretical
curriculum. After this the students apply elements of The Model of Clinical Reasoning in
Physiotherapy in their short periods of clinical training. Knowledge of the model is continuously
developed further throughout the theoretical courses and is applied in practice in the clinical
training. Finally the students are able to use the model for the analysis, evaluation, diagnosis and
treatment/intervention of actual clinical problems. In the last phase of the education theoretical,
clinical and pedagogical elements of clinical reasoning are elaborated.
Written by:
© Gerd Buch Andersen, Nanna Linde, Jeanette Præstegaard, Merete Quvang
Marts 2009, 3rd edition.
Reviewed sept. 2014 by Gerd Buch Andersen, Nanna Linde, Susse Broberg
Reading guide:
Heavy and normal lettering is used for the procedure of the process
*/Lavender lettering is used for reflective questions for the physiotherapist
**/Red lettering is used for reflective questions on first-time mobilisations
***/Blue lettering is for the catalogue of examination suggestions
1
Model of Clinical Reasoning in Physiotherapy
2014
i
Model of Clinical Reasoning in Physiotherapy
Context
Physiotherapist
Pre-comprehension
First
impressions and
hypotheses
Data collection
Background
information
Anamnesis
Activity assessment
Impairment assessment
Patient
Perception of
own situation
and capability
Goals
Hypotheses
Knowledge
Cognition
Metacognition
Comprehension
of the diagnosis
Goals for treatment/
intervention
Comprehension and
acceptance of goals for
treatment/
intervention
Plan/intervention
Pedagogical
considerations
Comprehension
and acceptance of
plan/intervention
Ethics
Ethics
Overall evaluation
and diagnosis
Ability to
comprehend,
manage, experience
meaning.
Motivation
Collaborators
Documentation of
treatment results
Re-evaluate/manage own
situation/
Increase experienced
capacity for action
Final evaluation
Context
The Model of Clinical Reasoning in Physiotherapy was inspired by and adapted on the basis of
the following references: 1,2,3,4,5,6,7.
The process of evaluation is not included in the written form recording the clinical reasoning process which the student
fills out in connection with the clinical courses. Therefore the boxes in the model with the physiotherapist’s and the
patient’s process of evaluation are framed by dotted lines. In the same manner the patient’s knowledge, cognition and
metacognition are boxed in with dotted lines, since these are implicitly active factors in the patient’s motivation, ability
to manage, comprehend and experience meaning in his/her situation.
2
Model of Clinical Reasoning in Physiotherapy
2014
Manual of Reflection for
Clinical Reasoning in Physiotherapy
Date/s of examination:
Patient’s initials:
Completed by:
Gender:
Age:
Referral diagnosis:
Pre-comprehension of the Physiotherapist
Describe your expectations before the first encounter: Previous experience with other patients, hypotheses, theoretical
understandings, professional perspective, biases, etc.:
*/Which information do you need to collect previous to the first meeting with the patient and why?
Background Data
Collect and describe relevant information about the current problem/illness/course of events and previous illness with
relation to the current situation from journals, relatives, care givers, etc. (for example admission dates, operation dates,
medicine, plans for mobilisation or weight-bearing, previous activity level) (4):
*/Is the information consistent with your pre-comprehension- which hypotheses do you have now
and why?
*/Which further information do you need from the patient and why?
*/What are your ethical considerations on the basis of the given information?(5)
First Impressions and Hypotheses
Describe your immediate impression of the patient; including physical appearance:
*/Which (if any) new hypotheses are you able to form?
Patient`s History (anamnesis)
Investigate and describe the patient’s history, resources and main problem and the patient’s hypothesis about the
reasons for the problem in relation to Activity and Participation, Body Functions and Body Structures as well as
Contextual Factors (4). Remember the goals and expectations of the patient in regard to the treatment (10):
*/Do you need to supply or change your hypotheses – why?
*/Your initial evaluation of the patient:
• Can you continue the examination: Describe and explain factors to be aware of, eg. regimen,
+/- SIN (annex 1a), ROK (11) or other factors?
• Is it necessary to examine the patient´s Body Function and - Structure before examination of
3
Model of Clinical Reasoning in Physiotherapy
2014
Activities? – Explain:
*/Which activities do you need to see the patient perform, and what do you need to be aware of and
why?
Examination of Activities
Describe your general observations of relevant activities (4, 143ff.):
For example The patient’s ability to
- change and maintain body posture, including postural control (postural stability and postural orientation)
(15,16)
- carry, move and handle objects
- be in lying position, sit, stand, walk and move around
- use means of transportation
- perform ADL
*/On the basis of the above your hypotheses are now:
Analysis from Activities to Body Function and – structure.
Select relevant functions for detailed description and analysis on the basis of the above general
observations. These functions include eg. posture, gait, respiration etc. (Body Function and –
Structure).
Describe and analyze your inspection of the above:
*/On the basis of the above you now have the following hypotheses:
Examination of Body Function and- Structure
Choose relevant examinations/tests based on your hypotheses:
(You may select from the following):
***/Function of specific tissues (8)
Active range of motion (AROM) (9) (11)
Passive range of motion (PROM) (9) (11), incl. joint play (14) and the patient´s reaction to being
moved passively (11)
Isometric resistance test in order to evaluate damage of contractile tissue (14)
Muscle strength in order to evaluate weakness, (0-10/0-5 (12) or other standards)
Muscle endurance/aerobic capacity or other factors
***/Neurological screening (annex 2a, 2b)
Muscle strength/isometric endurance for evaluation of paralysis (central/peripheral), tonus, surface
sensibility proprioception, reflexes, coordination
***/Provocation tests
Various specific tests, including overpressure, repeated movements, impingement, compression etc.
(10)
***/Special tests/examinations
For example measurement of leg length, respiratory function, balance
***/Local inspection of colour, contour, malalignment etc.
***/Palpatory examination of changes in quality of any relevant tissue structure (9) (11)
In case of suspected need for specific examinations, for example in connection with damage to the central nervous
system, psychiatric issues or other, the student must refer to specific literature and practice.
4
Model of Clinical Reasoning in Physiotherapy
2014
Describe the relevant Body Function and Body Structure assessment findings:
*/Reflect critically on your examination findings. Are any other complementary examinations or
standardised tests needed?
Overall assessment and diagnosis
Give a brief presentation of the patient and describe his/her most serious problem:
Describe your overall findings and knowledge of the patient:
Discuss possible causal relations between Body Function and Body Structure, Activity and Participation.
Consider the patients resources:
Discuss short-term prognosis of the patient (relating to the current problem) as well as long-term (any problems the
patient might be in risk of developing) based on your knowledge of the patient and pathology:
Discuss any ethical considerations you may have in connection with setting goals with the patient:
(Eg ensuring the consent of the patient, avoiding unrealistic goals from the patient, etc.)
Goals for treatment/intervention
Main goal (10):
Set a realistic and measurable main goal together with the patient within Activity and Participation components based
on the overall assessment:
Intermediate goal:
In order to achieve the main goal, set time-limited, prioritized, measurable and assessable goals within Activity and
Participation components and Body Function and Body Structure component
Intermediate goals Activity :
Intermediate goals Body Function and Body Structure:
Plan/Intervention, pedagogical considerations
Together with the patient plan and prioritize the intervention according to previous goals:
Discuss appropriate pedagogical approach:
Collaborators
Consider relevant collaborators and mention how you think they may be able to contribute in relation to the patient’s
problems:
Discuss any ethical considerations in connection with the collaborators:
(eg informed consent, confidentiality, etc.)
5
Model of Clinical Reasoning in Physiotherapy
2014
Documentation of treatment results
Describe and argue which outcome measures may document the physiotherapy intervention. Include more ICF
components (annex 3):
6
Model of Clinical Reasoning in Physiotherapy
2014
References
The model was inspired by and adapted on the basis of the following references:
1. Den fysioterapeutiske kliniske undersøgelses- og beslutningsprocess. (2002) (2003)
Udarbejdet af kliniske undervisere ved Fysioterapeutskolen i København
2. Blom, L., Linde, N., Østergaard AB. (2001) Den fysioterapeutiske undersøgelses- og
diagnosticeringssystematik. Fysioterapeutskolen i København
3. Jones, M., Jensen, G., Edwards, I. Clinical reasoning in physiotherapy. I: Higgs, J., Jones,
M., ed. 2000. Clinical reasoning in the Health Professions. Oxford: ButterworthHeinemann. Pg. 117–137
4. Sundhedsstyrelsen. (2003) ICF – International Klassifikation af Funktionsevne,
Funktionsevnenedsættelse og Helbredstilstand. København: Munksgaard, side 11-105
5. Birkler, J(2006)Etik i sundhedsvæsenet. København: Munksgaard
6. Danneskiold-Samsøe et al. (2003). Klinisk reumatologi for ergoterapeuter og
fysioterapeuter. København: Munksgaard, side 279–282 oversat fra Jones, M., Jensen, G.,
Edwards, I. Clinical reasoning in physiotherapy. I: Higgs, J., Jones. M, ed. 2000. Clinical
reasoning in the Health Professions. Oxford; Butterworth-Heinemann. Pg. 117–137
7. Albert et al. (2005). Case rapport. København: Munksgaard. Side 29-40
8. Antonovsky,A. (2002). Helbredets mysterium. København: Hans Reitzels forlag
9. Linde, N., Borg, J. (2. udgave 2010). Lærebog i massage. Manuel vævsbehandling for
fysioterapeuter. København: Munksgaard.
10. Hertling D, Kessler RM. (1996). Management of Common Musculoskeletal Disorders.
Physical Therapy, Principles and Methods. Philadelphia, Lippincott Williams & Wilkins,
3rd edition. Side 69–74, 74–112
11. Bunkan BH. (2001). Kropp, respirasjon og kroppsbilde. Ressourceorienteret
kroppsundersøkelse og behandling. Oslo: Gyldendal Norsk Forlag
12. Kendall et al. (2005). Muscles Testing And Function - with Posture and Pain. Lippincott
Williams & Wilkins, 5th ed., Kap. 1
13. Greene, WB & Heckmann, JD. (1994). American Academy of Orthopaedic Surgeons. The
Clinical Measurement of Joint Motion. Rosemont: AAOS
14. Kaltenborn, FM. (2002). Manual Mobilization of the Joints. The Kaltenborn Method of
Joint Examination and Treatment. Oslo; Olaf Norlis Bokhandel, 6th edition.
15. Ringvold,M.L.T., Svensen, A.R. (2. udgave 2014) Første skritt - Undersøkelsesmetoder for
fysioterapeuter. Bergen: Fagbokforlaget.
16. Shumway-Cook AM, Woollacott, MH (2001) Motor Control. Theory and Practical
Applications. Lippincott, Williams & Wilkins, 2nd Ed. Kap. 7
17. Lund, H. et al (2010) Basisbog I Fysioterapi. København: Munksgaard
Annex:
1.a
1.b
2.a
2.b
3.
Patient kategori. +/- SIN. MT-gruppens arbejdskompendium
Hansen, AH., Brix, M. (2006). Beskrivelse af SIN-begrebet
Linde N. Neuromuskulære screeningstests med henblik på udredning af neurologiske
symptomer.
Bickerstaff, E.R.(1974). Neurology for Nurses. London: Unibooks, pp. 30-34,
"Oversigt over væsentlige kliniske tegn på læsioner af nervesystemet"
Herbert et al. (2005) Outcome measures measure outcomes, not effects of intervention.
Australian Journal of Physiotherapy, vol 51, 3-4
7