The clinical reasoning of musculoskeletal physiotherapists in relation to the assessment of vertebrobasilar insufficiency: a qualitative study.

The aim of this study was to investigate the clinical reasoning processes of physiotherapists in relation to the assessment of vertebrobasilar insufficiency (VBI). Using a qualitative multiple case studies design 12 physiotherapists (mean=12.89 years clinical experience, SD=3.44) with an MSc in Manipulative Physiotherapy were shown 2 patient vignettes of a cervical spine disorder and associated symptoms of VBI sequentially in 4 sections and questioned as to their clinical reasoning processes via audio taped semi-structured interviews. Transcripts of the interviews were analysed for common themes. The therapists' hypothesis generation in relation to VBI was mainly based on the subjective examination (SE) with no new patho-anatomic hypotheses being generated in the physical examination. The major indicators of VBI involvement were dizziness particularly if associated with other symptoms (visual disturbances, history of trauma and headache) and if exacerbated by cervical spine movements. Therapists demonstrated a lack of confidence in functional positional testing (FPT) and based decisions on the use of high velocity thrust techniques on subjective findings. The results of this study emphasise the importance of physiotherapists' clinical reasoning process during the SE particularly in view of the questionable diagnostic utility of FPT.