Mechanisms-based clinical reasoning of pain by experienced musculoskeletal physiotherapists

Abstract

Objective

In light of recent advances in understanding of the neurophysiological basis of pain, the use of mechanisms-based clinical reasoning strategies for pain has been advocated within physiotherapy. The purpose of this qualitative study was to investigate the nature and extent of mechanisms-based clinical reasoning of pain by experienced musculoskeletal physiotherapists, in relation to three different clinical pain presentations.

Design/participants

Guided by an interpretative approach, a qualitative multiple-case studies design was used. Three videotaped patient–therapist clinical interviews were produced, each describing a different pain presentation. During and after the viewing of each of the three pain presentations, an audiotaped semi-structured interview was carried out with a purposive sample of seven experienced physiotherapists. The therapists were encouraged to verbalise their thoughts on aspects of each patient's pain presentation. All interviews were subsequently transcribed, coded and analysed.

Results

Four main categories of mechanisms-based clinical reasoning were identified. These were: (1) nociceptive; (2) peripheral neurogenic; (3) central; and (4) autonomic/sympathetic. There was some evidence to suggest that reasoning within these categories variously influenced therapists’ prognostic decision making as well as the planning of physical assessments and treatment. There was minimal evidence of reasoning according to the cognitive–affective mechanisms of pain, and no evidence of reasoning associated with motor, neuroendocrine and immune mechanisms and influences on nociception.

Conclusion

The mechanisms-based clinical reasoning of pain by the participants in this study appeared to reflect the integration of a limited understanding of the neurophysiological basis of pain into clinical decision making associated with patients with musculoskeletal disorders. Physiotherapists may benefit from continuing education in order to broaden and update their knowledge of applied pain neurophysiology.

Citation

Mechanisms-based clinical reasoning of pain by experienced musculoskeletal physiotherapists
Keith Smart, Catherine Doody
Physiotherapy - September 2006 (Vol. 92, Issue 3, Pages 171-178, DOI: 10.1016/j.physio.2006.04.004)