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.

Keywords:

• Direct access
• physiotherapy
• clinical reasoning
• decision-making
• low back pain
• examination

Acknowledgements

The authors sincerely thank all the physiotherapists who participated in this study and their managers for the preselection of the participants and for making it possible for the physiotherapists to attend the interviews. The physiotherapists descriptions and reflections on their work were invaluable. The authors also sincerely thank the funding sources for enabling this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Minna Roine has received a grant of 1200 euros from the Finnish Physiotherapy Association as an individual and her employee HUS Helsinki University Hospital granted her four weeks of paid leave of absence in 2022 to conduct her research. No funding sources were involved in the research project itself (no involvement in study design, data collection, analysis, or interpretation of data), in the writing of the report nor in the decision to submit the article for publication.