Figure 1 - uploaded by Christopher R. Showalter
Content may be subject to copyright.
Evidence-supported practice wheel: Pt = patient needs, concerns; PT = clinician's observations, judgment, and decisions; BIOPSYCH = biopsychosocial constructs; RCT's = randomized control trials; SCD = single case design.
Similar publications
Objective
A vital part of the initial examination performed by a physical therapist is to establish whether the patient would benefit from physical therapist intervention. This process includes knowledge about contraindications for treatment and screening for serious pathologies. However, little is known about the physical therapists’ views and tho...
Cognitive load is a key mediator of cognitive processing that may impact clinical reasoning performance. The purpose of this study was to gather biologic validity evidence for correlates of different types of self-reported cognitive load, and to explore the association of self-reported cognitive load and physiologic measures with clinical reasoning...
Background
To facilitate the development of clinical reasoning skills in nursing students, educators must possess the ability to teach and evaluate them. This study aimed to describe the development and validation process of an analytic rubric of clinical reasoning skills based on the nursing process in undergraduate nursing students.
Methods
A se...
Background: The teaching and assessment of clinical-practical skills in medical education face challenges in adequately preparing students for professional practice, especially in handling emergency situations. This study aimed to evaluate the emergency medical competencies of junior doctors using Virtual Reality (VR)-based scenarios to determine t...
Introduction
The adoption of advanced reasoning models, such as ChatGPT O1 and DeepSeek-R1, represents a pivotal step forward in clinical decision support, particularly in pediatrics. ChatGPT O1 employs “chain-of-thought reasoning” (CoT) to enhance structured problem-solving, while DeepSeek-R1 introduces self-reflection capabilities through reinfor...
Citations
... Foundational basic sciences, including anatomy, physiology, and biochemistry, form the cornerstone for comprehending disease mechanisms and pathophysiology [32]. Without this foundational knowledge, clinical reasoning can drift into empiricism, potentially compromising the quality of patient care [33]. However, when firmly rooted in basic sciences, clinical decisions become evidence-based, resulting in improved diagnostic accuracy and therapeutic outcomes [34]. ...
... On the premise that the symptoms experienced by these patients could be reproduced with palpation of the nodules, as well as improved treatment effectiveness when targeting the specific lipomas, this case series suggests that more research on this condition is warranted. Due to the improvement with deep tissue palpation techniques exhibited, dry needling may be a possible treatment intervention to manage these lipomas, as the use of them in treating myofascial trigger points has been well documented at this time [14]. ...
... Foundational basic sciences, including anatomy, physiology, and biochemistry, form the cornerstone for comprehending disease mechanisms and pathophysiology [32]. Without this foundational knowledge, clinical reasoning can drift into empiricism, potentially compromising the quality of patient care [33]. However, when firmly rooted in basic sciences, clinical decisions become evidence-based, resulting in improved diagnostic accuracy and therapeutic outcomes [34]. ...
Introduction. Since the early 20th century, medical education has evolved, notably with the Flexner report emphasizing the fusion of foundational sciences and clinical reasoning. As the field grew, educators adeptly incorporated new sciences and technologies, ensuring curriculum balance and depth. Aim. This research aimed to explore the role of basic sciences in contemporary medical education, focusing on their integration with clinical practice. Methods. An institutional-based cross-sectional study design was implemented at Umm Al Qura University, College of Medicine, Makkah, Saudi Arabia, from March to June 2023. This study involved surveying 470 medical students, from a total campus population of 1,360 students (excluding preparatory year), using a pre-tested and structured self-administered questionnaire. All questions in the survey were formatted to elicit dichotomous responses, namely “yes” or “no”, and the collected data were analyzed using SPSS version 20. Results. The study discovered that while a high percentage of medical students (96.6% in earlier years to 94% in senior years) recognized the importance of basic sciences in the MBBS curriculum, there was a noticeable decline in this belief as students advanced through their clinical years. Similarly, the perception of the utility of foundational knowledge of basic sciences for understanding clinical subjects decreased slightly from 93% in earlier years to 85% in senior years. About 92.7% of students across all years believed a strong understanding of basic sciences was crucial for clinical proficiency. However, the perceived benefit of suggested readings/textbooks declined from 82% in earlier years to 77% in senior years. Feedback on curriculum enhancements showed robust support for more engaging teaching methods, with over 90% favoring the incorporation of multimedia tools and group-based sessions. Conclusions. Our findings underscore the foundational role of basic sciences in medical education for clinical competency, highlighting a gradual shift in student perceptions as they progress through their training. This shift signals the necessity for adaptive teaching strategies that effectively integrate basic sciences with clinical practice to maintain relevance and efficacy in medical curricula.
... There is a sort of interdependence between the two actors that can lead the entire process and its results (Lippa et al. 2017). In particular, more is the clinician's self-efficacy in her/his patient management abilities more is the patient reliance on that clinician's approach (Sizer et al. 2016). ...
... Concerning the field of this study, orthopaedic surgery, it is important to underline that it focuses on both the emergency and clinical/therapy medicine fields; therefore, the orthopaedic surgery field can be led both by "emergency bias" (mostly heuristics) and by the "clinical biases", depending on which kind of healthcare services we focus on. Particularly, Sizer et al. (2016) proposed a model to drive the clinical decision process in the orthopaedic field: the "evidence-supported practice wheel" that poses the clinician's expertise and the patient at the centre of the problem, it makes the physician more flexible to adapt to the patient's needs and context, still relying on scientific literature. According to the author, some technical factors influence decision-making in orthopaedic surgery; Sizer defines the biomedical information on the patient that has to be taken by the physician in order to provide an aware decision-making process. ...
In the healthcare field, the decision-making process is part of the broad spectrum of “clinical reasoning”, which is recognised as the whole process by which a physician decides about patients’ treatments and cares. Several clinicians’ intrinsic variables lead to this decisional path. Little is known about the inference of these variables in triggering biases in decisions about the post-discharge period in the surgical field. Accordingly, this research aims to understand if and how cognitive biases can affect orthopaedists in decision-making regarding the follow-up after knee and hip arthroplasty. To achieve this goal, an interview-based explorative case study was run. Three key-decisional orthopaedic surgeons were interviewed through a quality control tool aimed at monitoring the causes and effects of cognitive distortions. Coherently with the literature, eight biases come to light. All the interviewees agree on the presence of four common biases in orthopaedic surgery (Affect heuristic, Anchoring, Halo effect, Saliency). The other biases (Groupthink, Availability, Overconfidence, Confirmation), instead, depending on specific physicians’ intrinsic variables; namely: (i) working experience; (ii) working context. This finding contributes to the debate about the application of cognitive tools as leverage for improving the quality of clinical decision-making process and, indirectly, enhancing better healthcare outcomes.
... Many SLPs were found to combine interventions or methods, without any scientific evidence such as a randomized controlled trial (Baker & McLeod, 2011b;Joffe & Pring, 2008). However, SLPs should be able to apply these combinations of interventions based on their clinical experience (Sizer et al., 2016). Although expert opinions are not the strongest evidence, this should play a bigger role in evidencebased practice (e.g., Hofmeijer, 2014). ...
Purpose
This study aims to give an insight in clinical reasoning (diagnosis and intervention) of speech-language pathologists (SLPs) in the Netherlands for children with speech sound disorder (SSD).
Method
The study featured a mixed-method (qualitative and quantitative) design. Semistructured interviews containing nondirective, open-ended questions were conducted with 33 SLPs, which were analyzed using a constant comparative analysis. Other SLPs (137) filled out a questionnaire on the same topics. Multiple-choice questions were analyzed by descriptive frequencies, while open-ended questions were analyzed thematically.
Results
The results indicate that SLPs use a variety of assessments to diagnose SSD, complemented by observation and, often, case history. In total, 85 different diagnostic labels were reported. The choice of intervention is based on what is appealing to the child and what matches his or her age as well as on the specific diagnosis and severity. Interventions are used for multiple speech disorders, and according to SLPs, parents play a large role in diagnostics and intervention.
Conclusion
These results reveal the need for (a) a clear and consistent terminology of diagnoses in the field of pediatric SSD, (b) a fast and easy-to-administer comprehensive differential diagnostic instrument in combination with an instrument to assess participation in everyday life, and (c) a tool to conduct a case history online.
... 2 Clinical decision-making is dependent on the accuracy and reliability of clinical tests and should not be based on imaging alone. 3,4 However, when correlated with patient history and physical findings the likelihood of proper imaging related decisions and interventions increases. 2 Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in medicine and physical therapy, which allows for dynamic visualization of tissues in real time with devices that are often portable. ...
Background/and purpose:
Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in physical therapy, which allows for dynamic visualization of tissues in real time. Plantar fasciitis is a common condition causing heel and arch pain and has been related with degenerative changes in the plantar fascia resulting in tissue thickening. Instrument Assisted Soft Tissue Mobilization (IASTM) is an intervention that allows clinicians deep penetration to treat tissues. The mechanical forces caused by IASTM might cause localized tissue trauma leading to stimulation of the body's natural inflammation and healing processes. The purpose of this case report is to demonstrate the use of ultrasound imaging to guide the decision-making process and to discern the optimal location for the application of IASTM.
Case description:
The subject was a 46-year-old female yoga practitioner and runner, who presented with right foot pain. The clinical impression was formulated based on the combination of traditional physical therapy examination procedures and MSK US imaging findings of the plantar fascia demonstrating thickness and tendinosis like changes within the plantar fascia 3 cm distally from the calcaneus.
Outcomes:
The subject was seen for eight treatment sessions over four weeks, at which time the goals of normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and no reported pain during gait were achieved.
Discussion:
This case report illustrates the use of MSK US imaging as a method to objectively assess tissue quality and guide decision-making when managing patients with plantar fascia related pain. MSK US was used to determine the optimal location for the application of IASTM during the conservative management of a runner with plantar fasciitis.
Level of evidence:
Therapy, Level 5.
... The accuracy and reliability of clinical tests affect this reasoning process. Therefore, it has been proposed that only the best available evidence should be used to support this reasoning process (Sizer et al., 2016). ...
Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.
Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.
Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.
Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause–effect relationship between the treatment and positive outcomes in this case report has to be further validated.
... Both of these systems use inter- ventions to determine their immediate impact on the patients symp- toms and range of motion within a treatment session to identify what treatments should be considered in managing the patient (McKenzie & May, 2003;Wayne et al., 2015). Contemporary clinical reasoning models and procedures continue to suggest that patients should be assessed within and between treatment sessions ( Levett-Jones et al., 2010;Lewis, McCreesh, Barratt, Hegedus, & Sim, 2016;Sizer Jr. et al., 2016) and that an immediate response to an intervention within a treat- ment session may be able to predict changes between treatment ses- sions ( Cook et al., 2014;Hahne, Keating, & Wilson, 2004;Tuttle, 2005). ...
Objective
The purpose of this study was to determine (a) if the newly developed shoulder functional reach score (SFRS) is reliable; (b) if the SFRS demonstrates construct validity by being able to differentiate between patients' symptomatic and asymptomatic shoulders; (c) if the SFRS is able to detect changes over time; and (d) if the potential changes in the SFRS demonstrated criterion validity at three different time intervals by being associated the Numeric Pain Rating Scale (NPRS) and Shoulder Pain and Disability Index (SPADI).
Methods
Patients were consecutively screened for consultation related to complaints of shoulder pain. Thirty‐eight subjects agreed to participate and signed informed consent. Twenty‐nine subjects fulfilled the study after the 4 weeks of follow‐up. Outcome measures were collected at the initial evaluation and at the first follow‐up visit prior to the initiation of treatment. Data were then collected after 2 and 4 weeks of treatment.
Results
There were statistically significant differences between symptomatic and asymptomatic shoulders on the SFRS. Intratester reliability of the SFRS was intraclass correlation coefficient (ICC2,1) = 0.94. Intertester reliability of the SFRS was ICC2,1 = 0.92. Statistically significant differences were observed between the initial evaluation, 2 and 4 weeks for the SFRS, SPADI, and NPRS. Moderate (rs = 0.62) to strong (rs = 0.87) positive correlations were observed between the NPRS and SPADI. Moderate negative (rs = −0.50–0.51) correlations were found between the SFRS and the SPADI. Moderate negative (rs = −0.36–0.54) statistically significant (p < 0.05) correlations were found between the SFRS and the NPRS.
Conclusion
In this small sample, the SFRS was an objective, reliable, and valid tool for assessing shoulder active range of motion in a clinical setting.
... However, when treating the individual patient the clinical manual examination allows us to choose an adequate approach with manual therapy and acupuncture. Sizer et al. [43], when talking about orthopedic manual physical therapy point out the following: "… the clinician-patient team can make appropriate care decisions that may or may not match what the 'best evidence' may recommend" (page 117 in [43]). The authors concluded their article with the following statement: "Moreover, while a chosen alternative may not be fully supported by presently available evidence and could be considered an outlier, that outlier of today may be the basis for developing future evidence. ...
... However, when treating the individual patient the clinical manual examination allows us to choose an adequate approach with manual therapy and acupuncture. Sizer et al. [43], when talking about orthopedic manual physical therapy point out the following: "… the clinician-patient team can make appropriate care decisions that may or may not match what the 'best evidence' may recommend" (page 117 in [43]). The authors concluded their article with the following statement: "Moreover, while a chosen alternative may not be fully supported by presently available evidence and could be considered an outlier, that outlier of today may be the basis for developing future evidence. ...
... The authors concluded their article with the following statement: "Moreover, while a chosen alternative may not be fully supported by presently available evidence and could be considered an outlier, that outlier of today may be the basis for developing future evidence. Thus, choosing that alternative based on sound clinical reasoning places the clinicians in a position to navigate future clinical science discoveries" (page 118 in [43]). Mazzocchi has discussed the topic on how to be holistic, i.e. how to reach a concept of systems biology [44]. ...
Outline:
•Author's profiles and motivation for this analysis•The philosophical alternatives in science and medicine•Reductionism vs. systems approach in clinical thyroid disease guidelines•The entry into complexity: the involvement of the musculoskeletal system•Integrating East and West: teachings from Chinese Medicine and from evidence based medicine (EBM)•Can a mathematical model represent complexity in the daily thyroid practice?•How effective is thyroxine treatment?•Resolving the situation of residual symptoms in treated patients with thyroid disease•Importance of iron, zinc and magnesium in relation to thyroid function•Putting together new concepts related to thyroid function for a systems approach•Expanding our model into general aspects of medicine.
... Reviews by Bialosky et al. [3] and others provide a model of how OMPT influences pain, outlining the most common mechanisms associated with the procedures. Sizer et al. [4] developed a sequence for assessment and management linked to clinical reasoning and appropriate patient's fear of their symptoms and redirect their cognitive processes towards recovery, while using OMPT to restore their movement capacity and exercise to increase their movement confidence. Let us keep developing new learning and research venues to teach and assess the timing, dosage, benefits and cost-effectiveness of treatment strategies that merge education, OMPT and movement science. ...
