Module 2 Script Focused Deduction.
What is the working hypothesis for each case? What two questions and two tests would you use to rule in your hypothesis?
1. Pt is a 40 year old male with left sided upper cervical pain, pain with rotation to the left and extension.
2. Patient is 34 year old female with restricted range of motion, moderate to severe pain. Pins and needles into the left middle finger.
3. 52 year old male with moderate pain in the right cervical spine, dull pain radiating into the left upper arm, occasional on and off tingling into the right thumb.
4. 60 year old male, report funny feeling of disequilibrium, neck pain, notes decrease cervical motion with end range pain.
5. 58 year old female post MVA 2 weeks with moderate pain irritation note with daily activity, ROM is painful at 75% range all planes. with pain no radicular sx.
6. 58 year old male with pain in the arm down to the medial right elbow after paining ceilings. Had this pain 3 years prior.
7. 45 yo female presenting with complaints of left cervical pain and tightness with complaints of numbness and tinging present in the thumb hand (thumb and thenar) began with insidious onset.
Great discussion on differentiation in disc pathologies and presentations. Please view this week along with the condition script for acute disc herniation.
By Jim Meadows
The condition scripts highlight the key subjective and objective information used to create your initial hypothesis. These are the typical presentations for each condition and work well with non complex cases.
2-3 focused questions and the 2 tests are used to rule in the diagnosis. Ideally one test that is sensitive and one test that is specific would be the best option but the validity of many special tests are questionable. In this part of the process general questions may confound the reasoning process so keep the questions focused on the condition scripts. Followup questions and examination will be focused and serve as bias correction to further rule out competing differentials and to identify contributing etiologies.
Segmental Dysfunction
Subjective Questions
- Pain quality. Moderate pain in most common with segmental dysfunction compared to disc herniation which is severe. Pain is also likely to be unilateral and not banding pain across the back.
- Have you has these episodes in the past? Commonly these episodes occur couple times a year and may last a few days to a week.
- Have you been able to do your regular daily activity? We are looking for non obligate loss of function. They can go to work and do regular daily activity. They may cancel golfing or stop running as these are optional and not obligate activities but in may cases they may still exercising.
Assessment
- ROM: likely mild restriction or pain in one direction. Unlike an acute disc herniation where there is typically severe loss of range of motion. All planes are likely to be limited with acute disc herniation.
- PA’s: screening for pain reproduction, limited motion ect. The biomechanical exam will later be used to identify if we have a subluxed joint, pericapsular restriction, hypermobility, capsular pattern or muscular guarding.
Biomechanical Exam
When performing the biomechanical assessment with a subluxed joint or precapsular restriction we will have a restricted passive physiological intervertebral motion(PPIVM). We will then proceed to check the end feel with the passive arthrokinematic intervertebral motion(PPAVIM) to determine if the end feel is pericapsular restriction(hard capsular) or a subluxed pathomechanical end feel.
In the presence of a normal, muscle hypertonicity or hypermobile end feel the PAIVM is not required since we already know there is not a restricted end feel. The links below are to the biomechanical assessment and manipulation for the jammed(subluxed end feel).
- PPIVM and PAIVM for flexion restriction
- PPIVM and PAIVM for extension restriction
- Manipulation direct technique for extension
Script focused deduction uses minimal information to develop and test a hypothesis. A few key pieces of information are gathered to develop your first hypothesis or the ” H1″. From the H1, 2-3 questions and 2 tests are then used to support or reject the hypothesis. This is very useful for the developing therapist to establish a provisional hypothesis.
Experts use pattern recognition where 4-5 common differential presentations are compared to the patient presentation. These are the common conditions seen in clinic and they focus the subjective and objective examination on ruling in or out this condition. Script focused deduction allows the therapist to start developing pattern recognition. Over the next 8 modules we will be working on developing clinical reasoning skills starting with script focused deduction.
The next section is adapted from Jim Meadows work on script focused deduction. He uses elbow pain as an example case. In the next post we will look at the lumbar essential illness scripts.
Thin Slicing
- Using the evidence coming in about thin slicing it should be possible, especially in the less complex cases to generate H1 with the bare bones of the patient presentation.
- Using the principle of minimizing information in complex decision making
- To keep the work area clear and decrease the noise and so improve the signal
Hypothetic-deduction
- If H1 is supported from the subjective exam then only the tests making up the illness script are initially carried out.
- If H1 is refuted then the most likely hypothesis generated from this information becomes H2 and its illness script is used.
- This process is repeated until the final hypothesis is successfully tested and becomes the diagnosis.
- If no diagnosis can be made a full examination is carried out
- Typically hypothetic-deductive reasoning is done as part of the general subjective examination,
- This method minimizes incoming information by asking only questions and doing only tests on the essential illness script
- So typically only three or four questions are asked and two or three tests done
- To avoid search satisfaction bias other questions are asked and the usual differential examination is carried out but after the diagnosis has been made
- If the extension of the examination refutes the diagnosis then it should also prove the replacement diagnosis but care must be taken to avoid anchoring bias so some deliberately non-supporting questions and tests are needed
Eg. Lateral Elbow Pain
- The patient reports isolated pain on the lateral side of the elbow
- The therapist considers the tissues underlying the pain and the likelihood of each condition that can give such pain.
- Statistically the most likely condition is common extensor tendonosis and this becomes H1.
- The essential illness script for tennis elbow is accessed and the questions drawn from this; for example does using the hand or elbow cause the greatest pain.
- If the answer is gripping activities then H1 is strengthened and the next question from the ECS is asked the answer to which will either strengthen or weaken H1.
- If H1 is weakned by say pain on elbow movement rather than hand function then H2 may be articular dysfunction.
- The essential illness script for articular dysfunction is accessed and questions from it asked.
- If H2 is supported objective tests are carried out, these may be quadrant tests of the full biomechanical exam of the elbow.
- Assuming the diagnosis is upheld then questions can be asked about etiology for example, have you done anything usual recently, changed work positions or tools, do you have neck pain, are there any neurological symptoms, and null questions can be asked for example do you have pain with neck movements or positions, or shoulder movements.
- The neck and the rest of the upper limb can now be examined to see if there are any predisposing factors, you can repeat the isometric tests in various neck position etc…
In short more time can be spent on the more complex aspects of the problem (level of inflammation, etiology and contributing remote pathologies etc.) when less time has to be spent on the differential diagnosis
Strengths and Weakness
- It is simple and easy to understand
- It reduces the noise and improves the signal coming from the patient and so minimizes the potential for the clinician to become confused
- It does not work well with atypical variants and where two different pathologies are generating symptoms
- It is not as efficient nor probably as accurate as pattern recognition in the hands of an expert
Bias Correction
- Diagnostic anchoring and regression to the familiar can be reduced or eliminated by making the diagnosis a null hypothesis and try to disprove it
- A complete examination carried out once the diagnosis is made will be the final arbiter until the clinician is confident enough in their ability to diagnose.
Essential Illness Script
- This is the unique cluster of signs and symptoms that identifies the average presentation of the condition
- Usually it consists of 3-5 questions and 2 or 3 tests
- Usually if two of the subjective responses or one or two objective tests do not support the H then it needs to be replaced
Summary
The uncomplicated diagnosis should be easily available to non- experts and not a struggle
It mimics what experts do with pattern recognition, that is ask a few supporting questions and do a few tests, without the experience of expertise being required
But by completing all aspects of the examination after the diagnosis has been made it reduces bias and error
For more information here is a link to moodle for Jim Meadows manual on Script focused deduction. If not in a current course email me and I can forward you the text.
TBWF Episode 4 – Listen to Fred Stoot and his colleagues discuss PT related topics.
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TBWF Episode 2 – Listen to Fred Stoot and his colleagues discuss PT related topics.
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TBWF Episode 1 – Listen to Fred Stoot and his colleagues discuss PT related topics.
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Coming soon…podcasts from IMPACT featuring discussions about manual therapy with emphasis on critical thinking.
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Fit Demonstrations of techniques used in the the article: Use of Thoracic Spine Thrust Manipulation for Neck Pain and Headache in a Patient Following Multiple-Level Anterior Cervical Discectomy and Fusion: A Case Report
These techniques are part of the IMPACT curriculum. Additional more segmental specific techniques are taught in all IMPACT courses.
Posted by IMPACT Fellows in Training Shannon VanAntwerp PT and Matt Johnson PT.
The Use of Upper Thoracic Manipulation in a Patient With Headache. James A. Viti MSc, PT, OCS, Stanley V. Paris, PhD, PT. The Journal of Manual & Manipulative Therapy Vol. 8 No. 1 (2000), 25 – 28.
Assessment: PIVM and PAIVM in flexion and extension.
Treatment: Upper thoracic manipulation is effective in relieving cervicogenic headache symptoms. In addition to upper cervical mobilizations and soft tissue mobilization, upper thoracic helped to reduce headache symptoms. Decreasing upper thoracic hypomobility may improve forward head posture and CV extension. Thrust techniques to the segments where the semispinalis capitus attach may cause reflex inhibition to that muscle and decrease associated pain referral/ headache symptoms.