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A few things I learned from today's clinical reasoning class

06 Aug 2016 11:57 PM | Anonymous

1)  Patient’s pain mechanisms are composed of 3 things:  a) centralized pain (from brain) b) nociceptive tissue (from tissue sources such as a bursa) and c) peripheral neurogenic (from nerves like sciatic).  So the sum of these 3 mechanisms will be 100%.


Examples: Patients with fibromyalgia may weigh heavily on the centralized mechanism.  An athlete may have mostly nociceptive pain. 

I need to work on drawing a pie chart in my head during subjective, which will guide a more tailored objective exam.  For example, if the patient’s subjective is nociceptive heavy, I will design my objective exam to find the tissue source.   However, if the patient shows more centralized mechanisms, I will focus more on learning about their lifestyle, personal and environmental factors, and to determine appropriate dosage for graded activity.  

2)  I can use narrative reasoning to understand the patient’s story.  Learning about the patient becomes especially important with chronic pain population.  This will help me understand about patient’s lived pain experience, perceptions, personal and environmental factors.  

As a result, I will 1) build a better rapport, 2) deliver tailored patient education 3) get a better idea about the underlying pain mechanism/pie chart, 4) design possible interventions, amongst many others.

If good narrative is achieved, the clinician should be able to answer the following questions. (Jones and Edwards 2006).  

  • What are the patient’s perceptions about their pain/illness?
  • How informed is the patient about their pain/ condition and the appropriate strategies for managing it?
  • What is/has been the effect of the pain/disability on the patient?
  • How is the patient perceived by others and how has this affected how feels about self?
  • How does the patient compare self to others?
  • Explore what can/cannot do, self-worth, perception of contributions/lack of contributions.
  • Does the patient think others believe them, and how do they say or imply this makes them feel?
  • Does the patient ever avoid activities or withdraw from others because of pain/disability

3) I used to deliver my patient education at the end of the evaluation, but I have learned that I can start “sprinkling" patient education as I perform the subjective and objective exams.  Doing so will improve time efficiency.   The patient will also be less likely to be overwhelmed with information overload.  Also, if I deliver patient education all at once, it is hard for me to recall everything, so some information might be left out unintentionally.  

Until next time!

Jones M, Edwards I. Learning to facilitate change in cognition and behavior.  Gifford L, ed. Topical Issues in Pain 5. Falmouth: CNS Press; 2006:273-310.

Kay Lin, DPT, CSCS

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