Explicit Theory-Informed Clinical Reasoning Curriculum in a Hybrid Learning Physical Therapy Program.

Despite agreement among educators that clinical reasoning (CR) is an essential skill for health care professionals, use of explicit, theory-informed CR strategies and tools are lacking in Doctor of Physical Therapy (DPT) educational programs. The purpose of this commentary is to describe a four-step process whereby CR is implemented as an explicit curricular component in an accelerated, hybrid DPT program. Our process utilized four steps: 1) Identifying relevant literature and theories that informed our current understanding of CR, 2) Creating a programmatic definition of CR, 3) Delineating educational principles and curricular components that operationalize the teaching and assessment of CR, and 4) Developing the faculty to implement CR in the curriculum. A DPT program that explicitly implemented CR into its curriculum received state and regional approval, and Candidate for Accreditation status and admitted its first cohort in 2022. Programmatic outcomes will be reported in two years. The curriculum was purposefully constructed with the goal to make proficiency in CR a required outcome. Robust teaching, learning, and assessment strategies were developed to cultivate and make explicit the essential behaviors and skills of CR. Setting high expectations for adaptive learners will add to the culture that supports excellence in PT education.

Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective.

Clinical reasoning errors in health-care can be mitigated with the use of systematic strategies and tools. One of these strategies is the SINSS construct, an acronym for Severity, Irritability, Nature, Stage, and Stability. The construct of SINSS appears in several textbooks and peer-reviewed articles. However, it has been inconsistently defined and applied in clinical practice. In this clinical perspective, the terms of the SINSS construct are defined in detail and their application to clinical practice is discussed. Current research showing the application of SINSS as a whole in clinical practice and educational settings is also presented. Recommendations for future application of SINSS are provided to advance the study of clinical reasoning and help minimize diagnostic, prognostic, and interventional clinical errors. The systematic use of SINSS allows the clinician to gain a thorough understanding of the patient's condition and symptoms, which can lead to a well-tolerated and appropriately tailored physical examination and intervention. Additionally, the proper use of this construct can result in more optimal patient outcomes, as well as provide a structure for the mentor and learner in helping uncover errors in the learner's clinical reasoning process.

Reliability and accuracy of an expert physical therapist as a reference standard for a manual therapy joint mobilization trial.

Objective: Previous studies on learning joint mobilization techniques have used expert practitioners as the reference standard as there is no current evidence on what ideal forces would be for effective mobilizations. However, none of these trials have documented the reliability or accuracy of the reference standard. Therefore, the purpose of this study was to report both the reliability and accuracy of an expert physical therapist (PT) acting as a reference standard for a manual therapy joint mobilization trial.Methods: A secondary analysis was performed using data from a published randomized, controlled, crossover study. The mobilization technique studied was the central posterior to anterior (PA) joint mobilization of the L3 vertebra. Reliability and accuracy data for the reference standard were collected over four time periods spanning 16 weeks.Results: Intrarater reliability of the expert PT for R1 and R2 joint forces was excellent (R1 Force ICC3,3 0.95, 95%CI 0.76-0.99 and R2 Force ICC3,3 0.90, 95%CI 0.49-0.99). Additionally, the expert PT was 92.3% accurate (mean % error±SD, 7.7 ± 5.5) when finding Grade III mean peak mobilization force and 85.1% accurate (mean % error±SD, 14.9 ± 8.3) when finding Grade IV mean peak mobilization force. Finally, correlations between actual applied forces and computed ideal forces were excellent (Pearson r 0.79-0.92, n = 24, P < 0.01 for all correlations).Discussion: The expert PT in this manual therapy joint mobilization trial showed excellent reliability and accuracy as the reference standard. The study supports the use of implementing quantitative feedback devices into the teaching of joint mobilization when a reliable and accurate reference standard has been identified.Level of Evidence: 2b.

The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial.

OBJECTIVE: To examine the effects of real-time, objective feedback on learning lumbar spine joint mobilization techniques by entry-level Doctor of Physical Therapy (DPT) students. METHODS: A randomized, controlled, crossover design was used. Twenty-four 1st Year DPT students were randomized into two groups. Group 1 (n = 12) practiced with the real-time feedback device first and then without it, while Group 2 (n = 12) practiced without the device first and then with it. Both practice periods with and without the device were 4 weeks long. Data were collected at Baseline, 5 weeks, 11 weeks, and 16 weeks. The crossover period was 5 weeks long, during which neither group practiced with or without the device. Eight force parameters were measured: R1 force; R2 force; Grade III and Grade IV mean peak force, frequency, and amplitude. RESULTS: When students practiced with the real-time feedback device, they more closely matched the reference standard for two outcomes: 1) the mean difference in R2 force between student and reference standard was better with device (38.0 ± 26.7 N) than without it (51.0 ± 38.5 N); P = .013; and 2) the mean difference in Grade III peak to peak amplitude force was also better with device (8.9 ± 9.3 N) than without it (11.8 ± 11.0); P = .026. All other force parameters improved when students practiced with the real-time feedback device, however, the differences between when they practiced without the device were not statistically significant. DISCUSSION: Real-time, objective feedback using a direct force measurement device improved learning for some aspects of lumbar spine joint mobilization by entry-level physical therapy students. LEVEL OF EVIDENCE: 2b.

Differential Diagnosis in a Patient Presenting With Both Systemic and Neuromusculoskeletal Pathology: Resident's Case Problem.

Study Design Resident's case problem. Background Patients presenting with multiple symptomatic areas pose a diagnostic challenge for the physical therapist. Though musculoskeletal and nonmusculoskeletal symptoms typically present separately, they can occur simultaneously and mimic each other. Consequently, the ability to differentiate between musculoskeletal and nonmusculoskeletal symptoms is an important skill for physical therapists. The purpose of this resident's case problem was to describe the clinical-reasoning process leading to medical and physical therapy management of a patient presenting with upper and lower back pain, bilateral radiating arm and leg pain, and abdominal pain. Diagnosis The patient was a 30-year-old woman referred to physical therapy for upper and lower back pain. A detailed history and thorough examination revealed that the patient had signs and symptoms consistent with a possible abdominal aortic aneurysm. She was referred for medical management and was diagnosed with symptomatic cholelithiasis. She subsequently had a cholecystectomy, which ultimately resolved her abdominal pain and reduced her pain in other areas significantly. Although many of her symptoms resolved postoperatively, her pain in other areas remained and was potentially musculoskeletal in origin. Following re-evaluation and 3 physical therapy treatments over a 2-month period, she was relatively symptom free at discharge and had achieved all functional rehabilitation goals. Discussion This resident's case problem provides an opportunity to discuss the differential diagnosis, clinical reasoning, and outcome of a patient who presented with both systemic and neuromusculoskeletal pathology. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2018;48(6):496-503. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7652.