Kowalski Katie L, Gillis Heather, Henning Katherine, Parikh Paul, Sadi Jackie, Rushton Alison
School of Physical Therapy, Western University, London, Ontario, Canada.
BMC Med Educ. 2024 May 2;24(1):486. doi: 10.1186/s12909-024-05399-x.
Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.
To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.
Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein's diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).
For all participants (n = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant's clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).
Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.
头颈部血管病变较为罕见，但可能表现为肌肉骨骼问题。国际矫形手法物理治疗师联合会（IFOMPT）颈椎框架旨在辅助基于证据的临床推理，以便在考虑血管病变可能性的情况下对颈椎进行安全评估和管理。临床推理对物理治疗至关重要，培养高水平的临床推理能力是研究生（获得执照后）教育项目的首要任务。
探讨该框架对研究生物理治疗专业学生临床推理过程的影响。
采用出声思考法和解释性描述的定性案例研究设计，以定性研究报告的统一标准为指导。参与者是通过标准化授课学习该框架的研究生肌肉骨骼物理治疗专业学生。通过两个颈椎病例探讨临床推理过程。转录本的编码和分析以埃尔斯坦的诊断推理成分和研究生肌肉骨骼物理治疗实践模型为指导。使用主题分析（归纳和演绎）对个体数据进行分析，然后对所有参与者的数据进行分析，从而能够分析临床推理过程中的关键步骤以及该框架的使用情况。通过多种策略（如第二位研究人员对编码提出质疑）提高可信度。
对于所有参与者（n = 8），该框架主要通过假设演绎过程支持临床推理。它在病史中为血管假设的产生提供依据，并通过病史问题和体格检查测试的选择来检验血管假设，从而为诊断和管理的明确性及支持提供依据。大多数参与者的临床推理过程具有高水平特征（如优先级排序），但存在熟练度的连续体。临床推理过程以对该框架的深入了解为基础，并与广泛的知识相结合，并得到一系列个人特征（如反思）的支持。
研究结果支持在研究生物理治疗项目中使用该框架作为教育资源，以便在考虑血管病变可能性的情况下，为颈椎疾病的安全有效评估和管理提供临床推理过程的信息。由于临床推理熟练度存在连续体，可能需要采用个性化方法来支持学生。未来需要进行研究，以探索该框架在不同水平学习者临床推理过程中的应用。
