Physiotherapists’ clinical reasoning in examination of clients with low back pain in direct access practice: a theory-driven qualitative content analysis

Abstract

Aim The aim of this study was to gain deeper understanding of physiotherapists’ clinical reasoning in examination of clients with low back pain (LBP) in direct access (DA) practice. Method Data were collected through individual semi-structured thematic interviews of ten physiotherapists who described their clinical reasoning in one of their LBP clients in direct access practice. The interviews were recorded and transcribed verbatim and then examined using a theory-driven qualitative content analysis. Four clinical reasoning models, hypothetico-deductive, pattern recognition, narrative and systematic, were used as theoretical frameworks to analyse the descriptions of physiotherapists’ clinical reasoning in examination. Results In this study clinical reasoning in examination manifested as a process where physiotherapist proceeds from interview to clinical assessment and decision-making, simultaneously taking into consideration the DA setting and the specific role of the physiotherapist. As described by the physiotherapists working in DA practice clinical reasoning in examination presented by extracting facts from the interview in relation to symptoms or certain diagnosis, identifying and excluding red flags and identifying the factors that were important to consider in acute musculoskeletal pain in relation to individual client’s problem. Physiotherapists described having improved differential diagnostic skills, wider range of physical assessment techniques and more precise assessment. Based on the data, the physiotherapists presented to use either the hypothetico–deductive or the systematic clinical reasoning model when examining an LBP client in DA practice. Conclusions Clinical reasoning in examination with LBP clients in direct access practice started with anamnesis and proceeded by using either the hypothetico–deductive or the systematic clinical reasoning model.