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Clinical Reasoning Rises

By David Bolton Patient examples 23 Nov 2016

 Nocebo Land

On a weekly basis, I have to listen to the opening statements of a disheartened new patient recounting the ‘doom & gloom’ that has been portrayed to them following the sage interpretation of their MRIs. This patient usually arrives after a long journey through varied failed treatments that has ended with a surgical opinion. A common opening sentence is

“I’ve come to see you because a close friend/relative thinks you’re marvellous – (serotonin booster) but you’ll see I’m a hopeless case when you read my MRI report (serotonin killer). I’ve tried everything so I don’t know what you have to offer. My surgeon’s had a look at my scans and says if I don’t go ahead with surgery now I’ll be desperate for it in two years’ time.”

Too often, based on those MRI findings alone, clinical decisions have been made, treatment protocols formulated and even operative procedures carried out to eliminate the ‘source of the pain’.

Live, first hand, subjective and objective information

When I started training in 1967 we didn’t have MRIs and x-rays were used sparingly, apart from anything else, because of the radiation. We had to rely on actual, live, first hand subjective and objective information to build our treatment strategies. I don’t believe that we worked as technicians back then, but instead tried to formulate a diagnosis and create solutions for the findings that we had discovered. We weren’t allowed to have a favourite go-to treatments – we had to be constructive and choose the best approach to resolve the issues, based on our clinical reasoning.

Technique drive applications

Getting back to the present, my experience is that practitioners work less from a place of clinical reasoning and more from a camp of commercial, technique driven applications of one-tool-fits-all approach. It’s the core, no no, it’s the muscle imbalance, no no, it’s the tight fascia – not a process in sight!

A Case History

Tim (case used with permission) presented with bilateral painful knees which had reached, after three years, a time and place where his quality of life was being severally affected and he was increasingly becoming more limited in his daily pursuit of an active, busy and very successful career and personal life. Tim had tried, unsuccessfully, numerous other approaches – the “favourite technique” type with little to no reference to the three basic clinical reasoning questions. Questions which, in my opinion, remain the basis of all clinical reasoning, but are sadly often vacant today. Those three questions are:

Based on a careful examination, what likely processes are suggested?

What changes need to occur to those processes to safely bring about positive change?

How do the patient and I bring about those changes?

In today’s world, a fourth question relating to resources is equally relevant.

Stabs in the dark

Tim had been exposed to hypotheses for his experience relating to core stability, inappropriate foot wear, tight hamstrings and muscular imbalances. When I questioned Tim as to the reasoning behind those hypotheses Tim could not recollect any explanation at all. His last attempts at change had been strengthening of the thigh muscles. I must admit that I’ve never understood that thinking – it would be a little like my dentist suggesting that I strengthen my jaw muscles to alleviate my toothache! The last port of call, the surgeon, concluded that he could see on the MRI where Tim’s pain was coming from – two replacement knees was offered as the solution.

The elephant in the room

Anyway, back to Tim and, as usual cutting a long story short, when walking into the room it was obvious from a distance that, right more than left, Tim’s knees were always in a few degrees of flexion. Passive extension towards what I believed to be his ‘normal’ range was painfully restricted. Joint palpation demonstrated that ‘boggy, leathery’ feel, no heat, but a mild increase in joint fluid (whether the presenting condition is deemed acute or historical, my patients get the Full Monty when it comes clinical examination), DIMs were present in his private life, in addition to the processes in his knees (and the rest) spoiling his quality of life. In my clinical reasoning process, before going anywhere those knees needed to get healthier!

Tim had had little to no ‘hands on’ examination from his therapists and was not examined physically by his doctor or surgeon who made their diagnoses solely from the MRIs.

If you look at this case from a point of view of functionality and rehabilitation it would seem obvious that the loss of active and passive extension of the knees was maybe an adaptive protection initially, but had now become one of the maladaptive drivers.

Treatment & Outcome

Weighing up the facts and, based on clinical reasoning, a mixture of mobilisation of the joints, graded functional increases in activity and pain education was my planned course of action.

Tim has regained full active and passive painless extension of both knees. Palpation findings have considerably improved. He is again leading a full pain free life, both professionally and privately. No Protectometer book needed – just an awareness of some of the ideas it contains. No left/right discrimination either – but visualisation and virtual movement training have been helpful. The DIMs are ongoing and the MRIs unchanged – but what the patient does have now is knowledge of pain, and an understanding that he – not I – has control over his destiny.

The dangers of dualism

That which I have endeavoured to express in recent posts is that no one process is the only driver of any one condition. All processes, major or minor, whether peripheral or central will be involved. Unless we address them all, we risk missing the minor players that may have a major impact on the bigger picture.

While I feel clinical reasoning was lost somewhere along the way in recent decades, there are signs that it is now enjoying a revival through new knowledge, a biopsychosocial approach, and a (re)focus on the patient in front of us.

-David Bolton, London


(Editorial note – the three recent posts from David Bolton brought to mind other great trilogies – other post names considered included The Battle of Clinical Reasoning, Clinical Reasoning Revolutions, The Lord of the Clinic: The Return of Clinical Reasoning, The Clinical Reasoning Ultimatum, Clinical Reasoning and the Last Crusade, Clinical Reasoning with a Vengeance (a close second), and The Clinical Reasoner who Kicked the Hornets Nest, but the caped crusader seemed a good fit with David, who had no choice in the matter) 



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    1. davidbutler0noi

      Hi Zach,
      DIMs are “danger in me” neurotags. SIMs are “safety in me” neurotags. They can be classified in groups such as: things I say; things I think and believe; places I go; people I meet; things I hear, see, smell, taste and touch, things I do and things going on in my body. They hide in hard to find places sometimes but a practical formula based is that we will have pain when our brains weigh the world and ‘judge’ that there is more danger to our bodies (DIMs) than safety (SIMS).


    1. Hey Max
      Unfortunately, Reloaded was the second instalment in the Matrix Trilogy, and the editorial team are, if nothing else, sticklers for accuracy when it comes to punnery for post titles!

      1. Hey Tim,

        Thanks for clarifying, can seem like a cruel world at times!


  1. I may have interpreted this wrongly but I find there is some inconsistency in this argument…and perhaps I am being quite picky.

    David suggests that other therapists haven’t explained the reasoning why their theories for the patient’s pain exists. The patient could not explain why tight muscles, imbalances, foot problems or core stability relate to the patients complaint.

    David then goes onto to do a clinical examination that finds restrictions in knee flexion and extension. It is just assumed that somehow these proposed impairments are contributing to his pain. It is never explained how and the reasoning is not laid out. Lack of range of motion is not well related to pain. These types of impairments can just as easily be viewed as any findings seen on imaging.

    Pointing out these normal changes in range of motion and then suggesting to the patient that they need to be changed with some “skillful” hands-on, self-efficacy stealing mobilizations can be just as nocebo creating as any of the previous explanations.

    You’ve told the patient that they have pain because they lack some range of motion. How can a lack of range of motion possible cause pain? The idea that ROM is related to pain is pretty antiquated. I fail to see how this process has been explained to the patient.

    In fact, I can see a similar patient showing up to my office in a year and explaining to me that they have pain because they are missing a few degrees of knee extension and some knee flexion. They have been working incredible hard to change that ROM and until they do they believe they will have pain. I will have to shake my head and slowly explain how poorly range of motion is related to pain and wonder what the clinical reasoning was that suggested ROM changes causing the pain.

    1. One last note, when I reread my comment it seems unnecessarily harsh. My apologies. I would note that your treatment sound similar to my own (although I may not mobilize) and your article just spurred me to debate with myself.

      Regardless, I am still interested in why you think tiny changes in ROM or lack of some ROM can contribute to pain. Do you think they need to be changed?

      1. Dear Gregory, I am so delighted that my humble article has stimulated a thought process within yourself. When I attempt to express my experiences and views, I only wish is that they stimulate thought and debate to stir the stagnation of thinking that has occurred.
        As to whether a limit of joint range can create a pain process, I have no idea. I only believe that we need to identify as many peripheral and central processes as we can and attempt to bring about change within them all. If I want to be a better tennis player, focusing only on my forehand is not going to do the job is it ?

  2. davidbutler0noi

    Interesting discussion. Process wise, I think that any physical finding reasoned to be clinically relevant as the loss of range in David’s patients clearly is, can’t be interpreted via a pain/movement relationship. The clinical finding is an expression of the person’s best intentions to cope and heal. All homeostatic mechanisms will be involved – endocrine, immune, sympathetic/parasympathetic, cognitive, emotional, respiratory, motor, pain, inflammation, creativity and many others. The massive redundancy of the nervous system means that the formula of mechanisms involved at any one time will continually change depending on time and place. This is why biopsychosocial approaches are absolutely vital.


    1. Yes David, exactly. The obvious clinical finding is simply a window into one of many variable processes going on and working on that particular finding one of many ways to encourage change. My point is simply don’t forget the “issues in the tissues” by being brain centric….maybe, once upon a time those knees were painlessly lacking full extension…..the riddle continues…..

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