The clinical reasoning of pain by experienced musculoskeletal physiotherapists.

There is currently no research within Physiotherapy to explain the extent to which current theories and models of pain influence clinicians' reasoning related to clinical presentations of pain. The purpose of this qualitative study was to investigate the clinical reasoning of experienced musculoskeletal physiotherapists in relation to three different presentations of pain. A qualitative multiple-case studies method was used in this study. A purposive sample of seven experienced musculoskeletal physiotherapists viewed three videotaped patient-therapist clinical interviews describing three different pain presentations. An audio taped, semi-structured interview was carried out with each participant during which the participants were encouraged to verbalize their thoughts regarding aspects of each patient's pain presentation. All interviews were subsequently transcribed, coded and analysed. Results showed a dynamic, multidimensional nature to the therapists' clinical reasoning, which was found to be grounded in a number of established models of pain. Five main categories of pain-based clinical reasoning were identified. These were (i) biomedical, (ii) psychosocial, (iii) pain mechanisms, (iv) chronicity and (v) irritability/severity. Reasoning within these categories influenced therapists' prognostic decision-making as well as the planning of physical assessments and treatment. The clinical reasoning of pain by the participants in this study appeared to reflect the integration of diverse models and theories of pain into current clinical practice. Mechanisms-based clinical reasoning has not been previously observed amongst physiotherapists.