Tuesday, November 26, 2013

Clinical Pattern Recognition - Low Back Pain

Clinical reasoning has been described as “a process in which the therapist, interacting with the patient, structures meaning, goals & health management strategies based on clinical data, client choices, professional judgment & knowledge ” (Higgs and Jones 2000, Edwards et al 2004). While the most comprehensive means of developing and implementing clinical reasoning in practice is the use of hypothetic-deductive approach and diagnostic sieves, as physiotherapists gain experience and skills, they are able to use clinical pattern recognition to aid their clinical reasoning and decision making.

Clinical pattern recognition have developed a guideline based orthopedic rehabilitation app which aims to help students and clinicians hone their clinical reasoning skills regarding examination, differential diagnosis, movement faults, treatments and exercises for low back pain, as per the description on the developer’s page. The app is currently available for low back/ lumbar region only, but hip, knee, neck, shoulder are under development and are expected to be released in a phased manner over the next few months. In this article, I have reviewed the lumbar region clinical pattern recognition app for development of clinical reasoning skills related to low back pain. 


Description of App
The app is presented is a well organized interface with sections for clinical pattern recognition, clinical practice guidelines, physical examination, manual therapy and therapeutic exercises. Each of these sections then provides further comprehensive information about the pain patterns.
Clinical Pattern recognition section identifies 8 major hypotheses related to back pain presentation (centralised pain, lumbar disc pathology, lumbar facet syndrome, lumbar instability, lumbar muscle strain, SI joint sprain, sciatica and spinal stenosis. It also has a separate sub-section on red flags. For each of these hypotheses, prevalence, clinical findings (divided into acute, sub-acute and chronic), physical examination, interventions and use of outcome measures are presented.


This section is pretty comprehensive with clinical findings focusing on aspects of subjective presentation, reported findings and examination findings, physical examination including the key findings and assessment tests, movement faults, associated impairments and differential diagnosis related to the specific pain pattern. Clinical reasoning for each pattern is discussed through use of audio-visual aids. Each test/ movement is also defined in further detail through text and demonstrated through the use of videos.
The intervention section within each pain pattern provides interventions specific to that pain pattern for e.g. there is no manual therapy or modalities section for interventions related to centralised pain. But the therapeutic exercises are further divided into mobility, motor coordination and functional movement exercises. Again each of these exercises is described in detail through textual information and demonstrated through videos. Each of the technique for assessment and management interventions is also supplemented by provision of related references which can be used for further reading. The references are also liked to their relevant abstracts on Pubmed database.

While the first clinical pattern recognition provides details of assessment, differential diagnosis, examination and interventions related to a specific pain pattern, subsequent sections provide a comprehensive directory of evaluation and management approaches. For e.g. the general manual therapy section contains description and demonstration videos for over 40 manual therapy techniques which are useful in evaluation and management of patients presenting with low back pain.

The app has a pleasing, user friendly interface, professionally edited and pleasing videos with adequate description and demonstration of techniques, along with textual description. The interface of the app feels very intuitive. It is easy to navigate and make use of the various options available. The different sections can be navigated and results clearly displayed. The app can be useful for students as well as practising clinicians looking to refresh their clinical skills as well as to develop further skills and clinical reasoning.

However, there are certain other features which can be quite useful, but seem to be missing from the app. One most important example is the use of a search feature. As discussed above, the general sections related to examination, manual therapy and exercises are pretty comprehensive, so searching for a specific technique and its description can be a bit cumbersome by trying to scroll through several sections/ names to find what we are looking for. I have seen several apps which utilise the voice to search feature of iOS to allow clinicians to search for relevant information on the go. Another useful feature can be integration of bookmarking, which will allow the users to save specific information or their favourites in a separate folder and access it as needed.


Overall, this is a useful app for students and clinicians to develop their clinical reasoning and pain pattern recognition. It is professionally compiled with extensive information, clear and detailed demonstration videos and user friendly interface.

Price – $9.99
Availability – iOS (iPhone and iPad)
Pro’s –
•Wealth of information
•Easy to use interface
•Evidence based clinical practice guidelines
Con’s –
•No means of organizing information
 •Lack of an Android version

Written by Devdeep Ahuja

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