Good clinical decision making is key to effective patient management. Physical therapists play a critical role in assessing neuromusculoskeletal problems. As more patients enter the medical system through the general practitioner, the patient is often referred to physical therapy without a clear diagnosis, especially those patients with musculoskeletal complaints. Physical therapists are educated in both the technical skills to carry out the examination and intervention procedures and the analytical skills to make the appropriate diagnosis and prognosis.

The physical therapy profession continues to move toward more autonomous practice. The majority of “practice acts” in the United States allow for practice without referral by the physical therapist. And the educational level of the physical therapist at the professional level is quickly changing to the Doctorate in Physical Therapy (DPT) degree. The greater the practitioner autonomy, the more critical effective and efficient clinical decision making becomes. The following case is an example of this need.

Your patient is a 35-year-old female runner who comes to you complaining of midback pain for 6 months. The pain disrupts her running in the early morning but not when she runs in the early evening. She tells you she bought a new mattress a month ago, convinced that her old one was “too soft and worn out.” No change in symptoms occurred. Ice and heat have not worked either. She called her family physician and asked for a referral to physical therapy. She has not had a physical examination for almost a year and is scheduled for one next month.

Several key issues pertain to this case. The first is that she has had no physician-based medical screening. Second, the symptoms are not consistent with her running, despite the fact that she relates them to this activity. Third, she has tried to manage the pain with simple modalities as well as a change in mattress and nothing has worked. Given these three issues, it is critical that the examination lead to a valid diagnosis.

While asking the patient some historical questions concerning the current condition, she stated that she had not tried anti-inflammatory drugs because they upset her stomach. With further questioning a past medical history revealed stomach ulcers and acid reflux. The patient stated that she had been off her gastric medication for almost a year. Given this information, the questioning then focused on the differential diagnosis of a systemic problem (gastric in nature that will refer pain to the midback) versus a musculoskeletal issue in the thoracic spine and ribcage.

The patient indicated that she ran in the early morning before ingesting any food. In the evening, she would often run a couple hours after a light supper. She also stated that her stress level at work was considerable over the last 6 months and she used running as a way to cope with that. Upon physical examination, the spine range of motion was normal, the ribcage movement was equal and smooth bilaterally, and the muscle strength of the trunk was normal. I was unable to replicate her symptoms, even with having her run for 15 minutes on the treadmill. I sent her back to the physician with my examination findings and my diagnosis, which stated a question of visceral problems (and lack of musculoskeletal ones) that required physician workup. The physician called me after examining the patient and stated that an endoscopy revealed a return of her stomach ulcer. Medication was used to manage the condition, and her symptoms promptly disappeared.

Effective and efficient decision making requires approaching a patient problem in a systematic and orderly fashion. Using the same process over all types of patients facilitates valuable learning so that each case decision allows the clinician to add to the experiential knowledge base. It also helps make the results of the examination reliable (you or someone else can reproduce what you do) and valid (what you do is generalizable and is what you say it is).

Good clinical decision making requires foundation knowledge applied to each patient. The use of anatomic and kinesiologic information is critical to assessing normal and abnormal movement. Understanding both the pathologic and healing processes helps determine the diagnosis, prognosis, and plan of care.

Theory must be combined with evidence from the research literature for effective and efficient use of resources and achieving optimal outcomes. Sacket et al, in Evidence Based Medicine, suggest that evidence-based medicine is a combination of the best research evidence available from basic, applied, and clinical research; the clinical expertise of the practitioner, including skills, knowledge, and experience; and the patient’s values, including concerns and expectations.3 It is each and every clinician’s responsibility to stay current with the literature, especially as it relates to their patient populations.

Buy the Book that holds this excerpt: Techniques in Musculoskeletal Rehabilitation

Related Articles