Friday’s AAOMPT conference started off very strong with a keynote lecture by Ali Rushton. Ali discussed the topic of the subjective examination.
She began her talk by discussing clinical reasoning frameworks and stating that clinical reasoning is supported by “cognitive processes or thinking used in the eval and management of a patient”. She further stated it employs “metacognition”, which is the “thinking about thinking”.
Moving forward, she transitioned into discussing “expertise”. She reported the ability to determine who is an “expert” is quite difficult but used this quote by Mark Twain: “Good decisions come from experience. Experience comes from making bad decisions”. She suspects the characteristics of expertise in OMPT are:
- Justification of decisions
- Criticality of practice
- Criticality of evidence
- Self analysis
- Supports of in-action activities
She stated, “Expertise is not just based upon a duration of time, but the quality of work performed during that time”. This quote is quite important for us who practice Physical Therapy. Many argue the time of practice defines expertise but it is actually the quality of work, and reflection during that time, is what truly defines an “expert”. It is suspected that 10 years of quality and reflective work defines this.
Moving on, she stated, “The subjective exam data is essential to clinical reasoning and processes and its theoretic support is strong. Understand why you ask every question. Every question should serve a purpose in your clinical practice.”
She went on to state evidence supporting the CPRs is lacking and discussed a potential better approach to care, stratification. She cited evidence on the STaRT back tool.
She wrapped everything up by discussing the importance of distinguishing the biological, psychological and social factors which impact practice and the importance of gathering hypotheses throughout the subjective examination.
One really interesting stat she offered: “Experts” spend more time and develop more hypotheses (12) during the subjective exam as compared to novices (9).
The next keynote, Duncan Reid, discussed the process of the Physical Examination. He discussed the importance of the physical exam and the importance of justifying why we do certain tests. “Is there evidence to support the test I use, and if the statistics are lacking, is the test still beneficial?” Does being a novice or expert matter? He then discussed how good are our tests?
In doing this, he looked at Laslett’s work on LBP (without nerve root compression). If during the examination, there was centralization or peripheralization, it’s likely a disc lesion. If there isn’t, perform the SIJ provocation tests and if 3 or more are positive, you are likely looking at a SIJ problem. If not, likely low back pain. He then stated, but in understanding Laslett’s research, have you ever thought about: “How hard did he push”? “What was the direction of force”? “How much pain was produced”? “Was the familiar pain produced”? “What do I do if the patient is bigger than me”? “Improving standardization of a special test will improve the ability to obtain a more accurate clinical diagnosis”.
Excellent quote: “We are victims of our own training unless we self reflect and critique our own practice”.
His views on CPRs were similar to Rushton’s by stating that most of the rules are still in the derivation phase, lacking validation.
He discussed the “Patient Response Method”, which is supported by the Maitland model and quotes work done by Cook and Hegdus . This type of approach to care is driven by a “patient’s response” and that most clinicians are moving towards this model, as our/their experience grows.
Best quote, “Do not follow gurus or be a product of your training”.
The third keynote address was given by Jim Meadow’s and it definitely got a response. He discussed the use of science in manual therapy. He believes we should be doing as much as possible to incorporate this into practice and the clinic. His first slide got a gasp when he stated, “Special Tests do not exist”. He said, “When do special tests become unspecial”?
To Meadow’s, there are two ways of coming to a diagnosis:
- Maximum information theory—very deductive method in which novices do every test possible, and then stand around like a deer in headlights, and then use the first piece of evidence that makes sense to them, and have difficulty letting it go. “Experts don’t do this”. He stated we need to stop teaching students this method.
- Minimum information theory—only taking in the information necessary.
Script focused deduction
- Minimum information theory
- Pattern recognition
- The illness script: the picture the patient has in their head about their condition. The clinician does this about every condition in which they have had “reflective experience”
- Hypothetic Deductive Reasoning: Generating and testing that hypothesis
He stated the first question always evokes a 100% sensitive response, “Where are you experiencing your pain”? “Being wrong is one of the only ways we learn—its ok to be wrong”—If the hypothesis isn’t correct, change it.
The keys to Script Focused Deduction:
- Generate an immediate hypothesis on the earliest symptoms report and test only that one
- Stick to the essential illness script
- Change hypothesis when the preceding once is invalidated or another is a better fit
To reduce bias, one needs to limit these four concepts:
- Anchoring: grabbing first piece of info and not letting go of it
- Framing: info prior to the exam that biases your thinking (ie. imaging reports)
- Premature Closure: finishing the exam premature
- Regression to the familiar
Provisional Diagnosis –> Bias Error Secession –> Treatment Planning (gut feeling, psychoscial functions. Etiological variables) –> If treatment works, you have your diagnosis.
Pathoanatomic Diagnosis vs. The Tick Box Method.
Great quote, “Classification schemes are only good if you are treating average patients. We don’t treat average patients. We treat individuals”. We should be thinking about what we are doing; not just checking off boxes or following a matrix.
More Great Points from Meadows:
- The place of the expert opinion is lower than any study we have (including case studies). We are at the mercy of “unreliable studies” and “confounding systematic reviews”.
- EBP in North America: Research Evidence, Patients Input and Clinical Expertise. Should be patient and clinician centric”. “Not everything that can be counted counts and not everything that counts can be counted!”
- The meat of our practice is about “people”. RCTs don’t give us insights about “individuals”.
- Not everything we do is quantifiable. EBPT is a paradigm; not a method, nor a tool. Is EBPT viable; is it scientific, does it work; is it being used? We have very little proof to know if EBPT works? Is the model liked? We need “theorists” more than we need “researchers”.
- The evidence needs to be extraordinary if the research claim is extraordinary. We should be evidence-influenced practice. It is patient-centric.