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Systematic Clinical Reasoning in Physical

Therapy (SCRIPT): A Tool for the Purposeful
Practice of Clinical Reasoning in...

Article in Physical Therapy · July 2016

DOI: 10.2522/ptj.20150482

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 Case Report

Systematic Clinical Reasoning in

Physical Therapy (SCRIPT): Tool for
the Purposeful Practice of Clinical
Reasoning in Orthopedic Manual
Physical Therapy
Sarah E. Baker, Elizabeth E. Painter, Brandon C. Morgan, Anna L. Kaus,
Evan J. Petersen, Christopher S. Allen, Gail D. Deyle, Gail M. Jensen S.E. Baker, PT, DPT, DSc, Army-
Baylor University Doctoral Fellow-
ship in Orthopaedic Manual Phys-
Background and Purpose. Clinical reasoning is essential to physical therapist prac- ical Therapy, Brooke Army
tice. Solid clinical reasoning processes may lead to greater understanding of the patient Medical Center, Fort Sam Hous-
condition, early diagnostic hypothesis development, and well-tolerated examination and inter- ton, TX 78234 (USA). Address all
vention strategies, as well as mitigate the risk of diagnostic error. However, the complex and correspondence to Dr Baker at:
often subconscious nature of clinical reasoning can impede the development of this skill. [email protected].
Protracted tools have been published to help guide self-reflection on clinical reasoning but E.E. Painter, PT, DPT, DSc, Army-
might not be feasible in typical clinical settings. Baylor University Doctoral Fellow-
ship in Orthopaedic Manual
Case Description. This case illustrates how the Systematic Clinical Reasoning in Physical Physical Therapy, Brooke Army
Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a Medical Center.
physical therapist to search the literature to answer a clinical question and facilitate formal B.C. Morgan, PT, DPT, DSc, Army-
mentorship sessions in postprofessional physical therapist training programs. Baylor University Doctoral Fellow-
ship in Orthopaedic Manual
Outcomes. The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan Physical Therapy, Brooke Army
Medical Center.
the examination, query the literature to answer a clinical question, establish a physical
therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the A.L. Kaus, PT, DPT, Department of
mentee’s clinical reasoning and provided the mentor insight into the mentee’s clinical reason- Rehabilitation Medicine, Brooke
ing. The reliability and validity of the SCRIPT tool have not been formally studied. Army Medical Center.

E.J. Petersen, PT, DPT, DSc, Army-

Discussion. Clinical mentorship is a cornerstone of postprofessional training programs and Baylor University Doctoral Fellow-
intended to develop advanced clinical reasoning skills. However, clinical reasoning is often ship in Orthopaedic Manual
subconscious and, therefore, a challenging skill to develop. The use of a tool such as the Physical Therapy, Brooke Army
SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach Medical Center.
to data gathering and making clinical judgments to bring clinical reasoning to the conscious C.S. Allen, PT, DSc, Army-Baylor
level, facilitate self-reflection, and make a mentored physical therapist’s thought processes University Doctoral Fellowship in
explicit to his or her clinical mentor. Orthopaedic Manual Physical
Therapy, Brooke Army Medical
Center.

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January 2017 Volume 97 Number 1 Physical Therapy f 1

SCRIPT in Orthopedic Manual Physical Therapy

G.D. Deyle, PT, DPT, DSc, Army-Baylor Uni-

versity Doctoral Fellowship in Orthopaedic
Manual Physical Therapy, Brooke Army Med-
ical Center.
T he mentoring process is critical to
the physical therapist profession
and a requirement of residency
and fellowship education. Mentoring in
advanced clinical training extends
Although substantial literature attests to
the diagnostic accuracy of physical ther-
apists,16 –19 the inherent complexity of
differential diagnosis requires careful,
consistent clinical processes. Break-
G.M. Jensen, PT, PhD, FAPTA, Department of
Physical Therapy, School of Pharmacy and beyond entry-level clinical supervision downs in clinical processes, such as fail-
Health Professions, and Center for Health by guiding and facilitating the mentored ure to document differential diagnoses,
Policy and Ethics, Creighton University, physical therapist’s continual learning in leads to increased incidence of diagnos-
Omaha, Nebraska. the development of advanced practice. tic error.9 Clinical reasoning strategies to
[Baker SE, Painter EE, Morgan BC, et al. Sys- Clinical mentoring centers on patient prevent diagnostic error should focus on
tematic Clinical Reasoning in Physical Ther- management, with an emphasis on devel- systematic data gathering, synthesis, and
apy (SCRIPT): tool for the purposeful prac- oping advanced clinical reasoning and documentation.14 Formal training in clin-
tice of clinical reasoning in orthopedic reflective practice skills.1 ical reasoning facilitates the mental agil-
manual physical therapy. Phys Ther. ity to appropriately consider and docu-
2017;97:xxx–xxx.] Clinical reasoning is an ongoing decision- ment alternative diagnostic hypotheses
© 2016 American Physical Therapy Association making process used throughout the epi- in physical therapist practice.15 Purpose-
sode of care.2– 6 Sound clinical reasoning, ful practice in reasoning strategies in
Published Ahead of Print: to include using a systematic patient- both didactic and clinical environments
July 28, 2016 is key to developing expertise.15,20 These
tailored approach to data gathering and
Accepted: July 7, 2016
forming early prioritized diagnostic advanced clinical skills, combined with a
Submitted: August 27, 2015
hypotheses,7 followed by a carefully willingness to search the literature for
selected interactive patient history tak- answers to diagnostic questions, may
ing and examination to test hypotheses, assist appropriate screening and accurate
may reduce cognitive bias and lead to a differential diagnosis.11
greater understanding of the patient pre-
sentation.7,8 This greater understanding Clinical reasoning is a challenging skill to
reduces the risk of diagnostic error and develop because it is a high-level and
overly aggressive, poorly tolerated phys- typically subconscious cognitive pro-
ical therapy sessions.9,10 When clinical cess.14 Reasoning must be exercised con-
reasoning generates diagnostic hypothe- sciously to facilitate self-reflection,
ses requiring medical management, change professional behaviors and
incorporating best-evidence screening thought processes, and improve diagnos-
strategies may facilitate timely and tic accuracy.3,14,21 Mentors must be pres-
appropriate medical care.11 ent and fully engaged to understand their
mentees’ thinking as mentees gather and
Clinical reasoning is more complex than interpret evidence to manage the
applying an analytical, deductive pro- patient. In other words, mentors need a
cess.2– 6 Practitioners must engage in ana- way for their mentees to “show their
lytical and inductive (narrative) thinking math” to make the mentees’ thinking
that helps uncover important contextual explicit. An important learning strategy
elements that contribute to uncertainty.3 for making the mentee’s thinking more
Practitioners must systematically con- explicit is facilitating reflection.22,23
sider and prioritize variable and uncer- Reflection is part of a process of self-
tain factors, such as understanding the monitoring, called meta-cognition or
patient’s environment, beliefs, and val- thinking about your thinking.22,23 A tool
ues, as part of the clinical reasoning pro- that provides a framework for the learner
cess, ultimately leading to the ability to to critically examine his or her thought
make appropriate clinical judgments. processes may be an important teaching
The ability to probe deeper with appro- and learning instrument for facilitating
priate follow-up questions often stems reflection.
from a more complete understanding of
the patient’s story.12,13 As such, clinical The purpose of this case report is to
reasoning is best developed within describe the application of a teaching
the context of a patient encounter tool developed by an orthopaedic man-
and includes reflecting on previous ual physical therapy fellowship program
encounters.14,15 titled the Systematic Clinical Reasoning
in Physical Therapy (SCRIPT). In this
case, the SCRIPT served as a teaching

2 f Physical Therapy Volume 97 Number 1 January 2017

 SCRIPT in Orthopedic Manual Physical Therapy

and learning tool for facilitating clinical likely and alternate hypotheses for all (labeled as P2), such as lateral thigh pain,
reasoning within the patient encounter areas of symptoms. The tool helps prior- also might increase, thereby suggesting
and clinical case analysis in one physical itize and focus intervention strategies at a the 2 areas of symptoms are related.25
therapy education program. This case dose that is likely to be effective and
report describes: (1) the mentee’s man- well-tolerated by the patient, minimizing A novice physical therapist might mistak-
agement and use of evidence in a patient the potential to irritate painful structures enly assume that patients will indicate all
case and (2) the teaching and learning or exacerbate the condition while maxi- areas of symptoms on a body chart and
occurring in the clinical reasoning mizing the opportunity to understand that any other body region is symptom-
process. the patient’s problem and achieve the free.2 Additionally, a novice physical
patient’s goals.27 The SCRIPT also may therapist might limit gathering the his-
Case Description help identify potential pathologies out- tory and body chart information to only
To our knowledge, the only clinical rea- side the scope of physical therapist prac- one area of symptoms.2 Reasons for this
soning tool published in the peer- tice that need to be screened for and decision could include time limitations,
reviewed literature is used in a pediatric ruled out. When the standard of screen- an attempt to focus on the areas of symp-
residency.24 Other clinical reasoning ing for a diagnostic hypothesis is toms for which the patient was referred
forms published in textbooks are unknown, a physical therapist should for physical therapy, or to mitigate a
detailed, yet lengthy,21,25 potentially pos- generate appropriate diagnostic ques- sense of being overwhelmed in complex
ing challenges to utilizing the form dur- tions and search the professional litera- cases or cases with multiple areas of
ing a typical patient encounter, and may ture for best-evidence screening symptoms. This rather limited approach
be more useful retrospectively. strategies.11 could hinder the physical therapist’s abil-
ity to recognize relationships between
In 1994, the Army-Baylor University Doc- Section I: Guiding Hypothesis areas of symptoms2 or patterns indicative
toral Fellowship Program in Orthopaedic Generation and Differential of nonmusculoskeletal conditions, such
Manual Physical Therapy faculty began Diagnosis as systemic illness. Pattern recognition
developing an expedient tool using a Section I guides the mentee’s hypothesis may assist experienced physical thera-
combination of sources, including work- development and consideration of differ- pists with early hypothesis formation.28
sheets from other programs, clinical ential diagnoses early in the patient- However, a physical therapist working
experience, and examples from a variety physical therapist interaction. After solely from pattern recognition of com-
of unpublished sources, with feedback establishing the patient’s profile, includ- mon causes in cases such as this might
from fellows-in-training and other fac- ing age, sex, work, and recreational hab- assume21 that all cases of back and con-
ulty. This tool, titled the SCRIPT, was its, the mentee gathers information on all current leg pain are of the same origin
designed primarily to develop clinical areas of symptoms by completing a body and overlook other potential sources of
reasoning skills during a patient encoun- chart or symptom map. Accuracy and unrelated leg pain, such as tumor, deep
ter, appropriately tailor examination and detail of the body chart, including the venous pathology, peripheral neuritis, or
intervention strategies, promote diagnos- location, behavior, character or quality, a distinct local musculoskeletal problem.
tic accuracy, and assist with planning and intensity of all symptoms, are crucial Expert clinicians may use pattern recog-
subsequent patient encounters (eAppen- to understanding the patient’s baseline nition in the differential diagnosis pro-
dix, available at ptjournal.apta.org). The presentation and are the foundation for cess but also must maintain an open
form is completed for initial patient early comprehensive diagnostic hypoth- mind and a willingness to generate, doc-
encounters during formal one-on-one esis generation. ument, and systematically test multiple
mentorship sessions between the fellow- alternative hypotheses.7,18,21,29,30
in-training (mentee) and the fellowship-
The mentee places a check mark over
trained faculty (mentor) and during sub- The flow of the typical formal mentor-
potentially relevant areas on the body
sequent encounters to reflect on initial ship session is illustrated in Figure 1.
chart that are screened and determined
hypothesis formation and decision mak- After completing the body chart, the first
to be asymptomatic. To help prevent
ing.26 The SCRIPT is a tool that provides of two 5- to 10-minute pauses occurs
misunderstanding, the mentee touches
structure for the mentee and insight into away from the patient to allow the men-
the patient or points to the body region
the mentee’s clinical reasoning process. tee to complete section I of the SCRIPT.
and asks the patient appropriate screen-
The SCRIPT also facilitates individual These pauses are critical to clinical men-
ing questions such as, “Do you have any-
self-reflective practice and guides patient torship, enabling the mentee to reflect
thing that is not normal or recently
case discussions between physical ther- on action,6 plan the remaining examina-
changed here?”25 Determining and doc-
apists in clinical and educational settings. tion, ask the mentor questions, and gain
umenting relationships between areas of
symptoms on the body chart is helpful to guidance. This approach also provides
The Process hypothesis formation and the differential an opportunity for the mentor to gain
The SCRIPT facilitates planning and exe- insight into the mentee’s clinical reason-
diagnosis process. For example, when a
cuting a comprehensive, yet well- ing, reinforce their positive decisions,
“primary concern” area of symptoms
tolerated, history taking and examination and make suggestions and pose ques-
(labeled as P1), such as mid-lumbar pain,
by delineating current symptom inten-
increases, a secondary area of symptoms
sity and behavior, as well as the most

January 2017 Volume 97 Number 1 Physical Therapy f 3

SCRIPT in Orthopedic Manual Physical Therapy

likely, less likely, and remote hypotheses nature of the disorder is a multifactorial
in section II of the SCRIPT. The mentor judgment based on the mentee’s percep-
reviews the form with the mentee, pro- tion of unique factors associated with the
viding immediate feedback and helping probable condition, such as typical mus-
to refine or provide additional hypothe- culoskeletal origin, nontypical presenta-
ses.31 The mentor ensures that the men- tion requiring screening, complex disor-
tee has a plan to effectively utilize the ders (eg, whiplash, acute radiculitis), and
remaining patient history to refine and personal factors (eg, being a single
prioritize competing hypotheses with working parent, exhibiting high fear-
carefully selected and formulated ques- avoidance behavior).25,32,37 Stage refers
tions and to determine likely symptom to the duration of symptoms, classified as
behavior during the physical examina- acute, subacute, or chronic or a combi-
tion and intervention. Hypotheses nation of stages (eg, acute and
derived and prioritized during the his- chronic).25,32 Stage can be an important
tory taking are subsequently examined factor directly related to the nature of the
with appropriate tests and measures, and problem, particularly in disorders with
later by the patient’s response to inter- healing tissues or inflammatory pro-
vention, thereby requiring both deduc- cesses. Stability may be characterized as
tive (analytical) and inductive thinking. a sign or symptom improving, worsen-
ing, or not changing over the course
During a mentorship session, the second of the present episode or previous
planned pause occurs at the conclusion episodes.25,32
of the history taking for the mentee to
complete sections II, III, and IV of the Section III: Considering
SCRIPT. Additional Contributing Factors
Completing section III prompts the men-
Section II: Making Clinical tee to consider additional factors contrib-
Judgments uting to the patient’s condition, such as
Section II requires judgments on the con- poor conditioning or psychosocial fac-
structs of severity and irritability of symp- tors, that may change the prognosis or
toms and nature, stage, and stability of require therapeutic attention. These fac-
the disorder, collectively referred to as tors are considerations but should not be
Figure 1.
Flow diagram of how to use the Systematic SINSS.25 The SINSS, initially described by overly weighted in the differential diag-
Clinical Reasoning in Physical Therapy Maitland and elaborated on by various nosis process. A patient with decondi-
(SCRIPT) tool during a mentorship session. other authors,25,32,33 are evaluated for tioning or psychosocial issues would
each symptomatic area, as different areas have as many possible sources of symp-
of symptoms may have different symp- toms as a patient who is more physically
tom behavior and possibly different ori- fit or emotionally stable, and those pos-
tions to highlight alternatives in
gins (Fig. 2). The SINSS are determined sible sources should be systematically
reasoning.
by analyzing information gathered dur- considered and ruled out.38 This patient,
ing the history taking.25,32,33 This con- however, did not display contributing
The mentee lists all structures that must
cept helps determine the extent and factors that required additional
be considered as possible sources of the
vigor of the examination and treatment consideration.
patient’s symptoms, to include joints and
that are likely to be well-tolerated.27,33
bony structures; muscles, tendons, and
soft tissue structures; structures that may
For example, if a mentee judges a Sections IV and V: Planning the
patient’s symptoms to be severe (high Examination
refer symptoms into the area of concern;
intensity) and irritable (easily provoked Section IV provides a flexible framework
and other structures or conditions that
and persisting), the examination should for planning the examination. The men-
must be considered or ruled out, such as
be limited to the first onset or increase of tee refers to the hypotheses in section I
visceral pathology, infections, space-
symptoms, and the overall number of and reprioritizes the most likely hypoth-
occupying lesions, and systemic non-
examination procedures should be eses based on information obtained dur-
musculoskeletal pathology. This proac-
reduced accordingly.25 Conversely, a ing the remainder of the history taking.
tive planning makes explicit the
patient whose symptoms display mild Tests and measures typically prioritized
connections between thinking and
severity and irritability might tolerate and selected for the initial examination
future actions.
examination including provocative diag- provide essential evaluation of the most
nostic special tests, manual examination likely hypotheses and rule out potentially
After completing section I, the mentee
to end of range of motion (ROM), and serious conditions (Fig. 3). The vigor of
formalizes their differential thought by
combined or repeated motions.34 –36 The the examination is strongly influenced by
generating and prioritizing the most

4 f Physical Therapy Volume 97 Number 1 January 2017

 SCRIPT in Orthopedic Manual Physical Therapy

II. INFLUENCE OF THE SYMPTOMS ON THE EXAM. Detailed by Area of Symptoms rately determine the patient’s response
as Mapped on Body Chart . to intervention. In section VIII, the men-
Px Severity Irritability Nature Stage Stability Limit tee records prognostic information. If a
Exam patient is not responding according to
P1 Moderate Mild MS K, postsurgical, Chronic Not changing N
degenerative
the prognosis evidence and the mentee’s
P2 Mild– Mild MSK, nerve, possible Chronic Worsening N clinical experience, further consider-
moderate systemic disease ation of alternate hypotheses, additional
contribution examination, or more formal screening
P3 Mild– Mild MSK, nerve, possible Chronic Worsening N may be warranted. The mentee’s ability
moderate systemic disease
to assess a patient’s response to interven-
contribution
Mild Mild (Healing, fragile Acute, Improving Yes= Y
tion in order to test diagnostic hypothe-
Moderate Moderate tissues, inflammatory, subacute, Worsening No=N ses, combined with the ability to exam-
Severe Severe psychosocial) chronic Not changing ine and treat patients over multiple
Non-MSK/MSK/both Acute on clinical sessions, should improve diag-
chronic nostic accuracy, particularly when clini-
Subacute on
chronic
cal reasoning is utilized throughout the
What will be the vigor of your exam? P1 P2 P3 Do the nature, diagnosis, or
episode of care.10,11
comorbidities warrant special
Examine to first onset or change in pain caution for exam or treatment? Application of the Process
Examine to end of active range of What? Y/N
We present a patient case where the
motion/ACTIVE limit (eg, trauma/red
X SCRIPT guided the clinical reasoning
flags/instability/pathological process)
No process during a patient encounter with
Examine to end of passive range of Which symptoms will be desirable to a 64-year-old retired man who was
motion/PASSIVE limit reproduce? referred by a physician for physical ther-
Back pain (P1) and peripheral
apy with a diagnosis of axial back pain.
symptoms (P2 and P3)
Examine with OVERPRESSURE Do you expect a comparable sign to
The patient reported a primary com-
sufficient to determine end feel be EASY or HARD to reproduce? plaint of chronic lower back pain (LBP)
Easy in lumbar spine, hard in periphery and a secondary complaint of bilateral
Use sustained, repeated, or combined What do you expect to be treating? plantar foot tingling. The care of this
movements (Circle one) patient met Health Insurance Portability
PAIN and Accountability Act (HIPAA) require-
X X
RESISTANCE
R ESISTANCE RESPECTING PAIN ments of the institution for disclosure of
RESISTANCE protected health information.

Figure 2. In the case example below, the patient

Section II of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT). identified his primary complaint as a con-
MSK⫽musculoskeletal, Px⫽area of symptoms, P1⫽primary area of symptoms, stant, but variable in intensity, deep ache
P2⫽secondary area of symptoms, P3⫽tertiary area of symptoms. or stiffness in his central lower lumbar
spine (P1) (Fig. 4). He also described
deep, constant tingling of variable inten-
the judged SINSS of the patient’s symp- guidance and may assist in treatment as sity on the plantar surfaces of both feet,
toms. The examination also is used to needed. Sections VI through VIII are more pronounced in the right foot (P2)
identify impairments amenable to physi- completed at the conclusion of the initial than the left foot (P3). The patient
cal therapy interventions. Relevant patient encounter. Section VI is used reported that there was no relationship
examination procedures deferred during to record the intervention, patient among the areas of symptoms.
the initial examination should be docu- response, and prescribed reinforcing
mented and prioritized for completion in exercises. In section VII, the mentee Using the information from section I, the
subsequent sessions. applies deductive and inductive thinking mentee considered degenerative disk dis-
to reprioritize the hypotheses based on ease with central or bilateral foraminal
Sections VI–VIII: Recording, the supporting evidence accumulated stenosis as the most likely hypotheses.
during the examination and treatment. The mentee judged chronic lower lum-
Reprioritizing, and Making the
The mentee then quickly reassesses bar dysfunction with a separate periph-
Prognosis
whether there has been any change in eral neuropathic disease (PND) to be a
Prior to implementing treatment, the
SINSS or additional screening is needed. less likely hypothesis. The mentee tai-
mentee communicates to the mentor the
Finally, the mentee records important lored the history to further test the most
mentee’s differential diagnosis, key
baseline findings from the patient’s his- likely and alternative hypotheses (Fig. 4).
examination findings, and plan of care
while in front of the patient. The mentor tory and examination that should be
provides any immediate feedback or rechecked at subsequent visits to accu-

January 2017 Volume 97 Number 1 Physical Therapy f 5

SCRIPT in Orthopedic Manual Physical Therapy

IV. PLANNED EXAM PROCEDURES: Prioritize based on most likely hypotheses and response to lumbar intervention to help
SINSS. determine the relationship between the
Day/Visit 1 Day/Visit 2 Day/Visit 3 LBP and foot tingling.
Lumbar AROM, LE MNSI: inspection of feet, Repeated motions to assess
neurological exam, SLR, vibration for centralization/
Interview and physical examination find-
palpation exam of lumbar Slump test for neural tension peripheralization
spine, segmental mobility of symptoms Clear hip/SIJ ings are documented in the patient
lumbar spine Prone knee bend to assess record, and key findings are marked with
anterior hip structure asterisk signs to denote them as impor-
flexibility tant parts of the baseline presentation.
Figure 3. These key findings are frequently reex-
Section IV of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT). SINSS⫽severity, amined to determine patient response to
irritability, nature, stage, stability; AROM⫽active range of motion; LE⫽lower extremity; examination and treatment. These key
SLR⫽straight leg raise; MNSI⫽Michigan Neuropathy Screening Instrument, SIJ⫽sacroiliac baseline findings are recorded in section
joint. V of the SCRIPT (Fig. 5).

In this case, manual treatment with rein-

forcing exercise was initiated to address
The patient’s history revealed previous tingling seemed to change more than the impaired lumbar spine extension.
bilateral L3–L5 hemilaminectomy proce- back symptoms, suggesting that it was Because the key finding of lumbar symp-
dures and lateral recess decompression less stable and potentially of a different toms during passive mobility assessment
for spinal stenosis 1 year prior, with no origin than the LBP. Due to the overall of the L3 vertebral segment was most
effect on the feet tingling. Therefore, ste- mild severity and irritability, the mentee comparable with the patient’s primary
nosis did not seem likely to be the pri- decided to examine the patient to the complaint, treatment at the initial visit
mary cause of his tingling. Additionally, extent necessary to elicit all areas of consisted of six 30-second bouts of grade
the patient had medically managed type symptoms. A neurological screening also IV central posterior-to-anterior mobiliza-
2 diabetes mellitus. As PND is prevalent was deemed necessary due to the pres- tions directed to the L3 vertebral seg-
in the diabetic population and neurolog- ence of peripheral tingling. ment, followed by supine pelvic rocking
ical symptoms associated with this con- motions in a painless ROM. After treat-
dition may be similar to those seen with The examination planned for this case ment, the patient’s lumbar extension and
a variety of lumbar conditions, the alter- included neurological screening, lumbar pain were moderately improved, but the
native hypothesis of PND could not be ROM testing, soft tissue and lumbar tingling remained unchanged (Fig. 6).
ruled out and was documented on the mobility assessment, and neural tension The prognosis of long-standing sensory
SCRIPT.39 Other potential sources of tests. Standing lumbar extension active changes suggested it may be difficult to
LBP, such as neoplasm, infection, or aor- ROM was limited, with increased LBP at influence these symptoms in one treat-
tic abdominal aneurysm, were judged to end range that quickly returned to base- ment session, further contributing to
be remote hypotheses for this 64-year- line upon return to neutral. The neuro- diagnostic uncertainty.
old immunocompetent patient who had logical screening demonstrated reduced
never smoked and was without general right ankle reflex, reduced sensation on The diagnostic uncertainty at the end of
health changes and, therefore, did not the right plantar foot and heel to light the initial examination and the docu-
require additional screening at this point. touch, and absent Babinski and clonus mented alternative hypotheses noted in
tests. Bilateral lower extremities demon- section VII of the SCRIPT warranted
During the history taking, the patient strated 5/5 strength in L2–S1 myotomes. additional screening for the cause of the
reported unchanging LBP for 2 years and Passive mobility assessment of the lum- foot tingling before completing sections
bilateral foot tingling for 4 to 5 years, but bar spine demonstrated hypomobility VII and VIII of the SCRIPT. Peripheral
that these symptoms had worsened in and localized pain, with central and right neuropathy in patients with diabetes
intensity and frequency over the past unilateral posterior-to-anterior mid-range increases the risk of foot ulceration and
year. His LBP and tingling both increased mobilization at L3–L5, but did not affect infection by up to 7-fold,34 highlighting
after standing for 30 minutes and eased the patient’s foot tingling, nor did active the importance of early identification.
with walking for 10 minutes. He used ROM testing of the lumbar spine. Bilat- Therefore, the mentee performed a liter-
Celebrex (Pfizer Inc, New York, New eral straight-leg-raising tests with sensitiz- ature search11 to find the best screening
York) daily for his LBP and Percocet ing maneuvers did not reproduce or strategies to answer the following clini-
(Endo Pharmaceuticals Inc, Malvern, change lower extremity symptoms. cal question: “In a 64-year-old man with
Pennsylvania) occasionally for break- Although it seemed likely based on these type 2 diabetes and chronic LBP, what is
through pain. His sleep and activities of findings that the LBP and the neurologi- the best way to screen for a diabetic PND
daily living were not limited. Therefore, cal symptoms were of distinct origins, as the source of plantar foot tingling?”
the mentee judged the severity of his LBP the examination did not adequately dis-
as mild to moderate and the severity of tinguish between the 2 hypotheses.
Clinical practice guidelines recommend
his irritability as mild. The LBP seemed Given the diagnostic uncertainty, the
using a cluster of tests to screen for dia-
mechanical in nature, whereas the foot mentee chose to use the patient’s

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 SCRIPT in Orthopedic Manual Physical Therapy

I. WHAT AREAS/STRUCTURES MUST BE CONSIDERED AS POSSIBLE for diabetic PND.36 A score of ⱖ2 has a
SOURCE(S) OF SYMPTOMS? specificity of 83% (95% confidence inter-
Joints Muscles, Pain- OTHER P1: central val⫽75%, 89%) and a positive likelihood
low back
and bony tendons, producing structures pain; achy, ratio of 3.9 (95% confidence inter-
structures and other structures or stiff, deep val⫽2.5, 6.1), suggesting that further
UNDER soft tissue that may conditions 2–10/10
Resting quantitative neurological testing was
the area UNDER REFER that must pain 2/10
of and IN the into the be appropriate.36
symptoms area of area of considered
symptoms symptoms or ruled Based on the literature, the mentee
out planned to administer the MNSI at the
-Bilateral -Lower -Lower - Lower following visit to further differentiate the
lower lumbar thoracic extremity P2 (left genesis of the peripheral symptoms
lumbar paravertebral spine vascular foot) and
facet muscles -Upper - GI system P3 (right (Fig. 7). Subsequent examination demon-
foot): strated a reduced ankle reflex on the
joints -Bilateral lumbar - GU system bilateral,
-Bilateral quadratus spine - Space- foot right and absent vibratory sense at both
lower lumborum Mid occupying tingling, ankles, resulting in an MNSI score of 2.5
deep,
lumbar muscles lumbar lesion constant, and the need for further screening. The
vertebral -Bilateral spine (tumor) 2–5/10 diagnostic gold standard for diabetic
joints proximal -Upper, - Spinal Resting
-Bilateral gluteal pain 2/10 PND is electromyography and nerve con-
mid, and infection
ilium muscles lower
duction study (EMG/NCS) testing.34 Due
-Sacrum -Bilateral foot lumbar to the patient’s complaints of worsening
-Bilateral intrinsic disks lower extremity neurological symptoms,
sacroiliac muscles -Bilateral the physical therapist communicated
joints -Bilateral sacroiliac with the patient’s primary care provider,
-Bilateral plantar joints
fascia
who ordered EMG/NCS testing.
hindfoot -Bilateral
joints -Bilateral hip joints
-Bilateral lower -Bilateral The EMG/NCS testing demonstrated mild
tarsal extremity talocrural demyelinating PND affecting the sensory
joints peripheral joints and motor fibers in the lower extremi-
-Bilateral nerves ties, as well as evidence of chronic bilat-
tarsometatarsal (tibial,
joints deep/
eral L5 and S1 radiculopathies that did
-Bilateral superficial not warrant surgical intervention. This
metatarsal fibular, knowledge helped the mentee deter-
phalangeal medial/ mine the likely clinical diagnoses and
joints lateral overall prognosis (Fig. 7). Physical ther-
plantar) apy treatment would likely influence the
Most Likely Hypotheses: Less Likely Hypotheses: Remote Hypotheses: patient’s chronic LBP more than the
 Chronic central lower  Spinal stenosis with  Space-occupying chronic neurological symptoms. How-
lumbar dysfunction neurogenic claudication lesion in the lumbar ever, understanding the contributions of
with bilateral  Myofascial pain status post spine
the diabetic PND to the patient’s symp-
radiculopathy/radiculitis, lumbar surgery with bilateral  Lower extremity or
most likely of S1 chronic neural tension abdominal vascular toms enabled the mentee to provide
nerve root symptoms pathology appropriate patient education, devise a
 Chronic central lower  Referred pain from treatment plan respective of the patient’s
lumbar dysfunction viscerogenic pathology comorbidity and reconnect the patient
with peripheral  Spinal infection with his primary care provider for con-
neuropathic disease tinued medical management.
(polyneuropathy or
mononeuropathy)
In accordance with the Guide to Physi-
Figure 4. cal Therapist Practice,37 the appropriate
Section I of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT). clinical care for this patient included
GI⫽gastrointestinal, GU⫽genitourinary, P1⫽primary area of symptoms, P2⫽secondary area treating the LBP consistent with best-
of symptoms, P3⫽tertiary area of symptoms. evidence strategies and referring the
patient for further evaluation of his PND.
The data from the SCRIPT helped guide
clinical reasoning and plan management
betic neuropathy, including foot and ment (MNSI), consisting of a foot inspec- throughout the episode of care.
lower limb inspection and sensory test- tion, ankle reflexes, and vibration per-
ing.35 The literature indicated that the ception, has been validated in the type 2
Michigan Neuropathy Screening Instru- diabetic population as a screening tool

January 2017 Volume 97 Number 1 Physical Therapy f 7

SCRIPT in Orthopedic Manual Physical Therapy

V. EXAM FINDINGS apists in all settings should be able to

Important baseline findings from patient Important baseline exam findings: search, find, and apply or recommend
history: screening strategies when clinical rea-
soning suggests they are appropriate.
Stand >30 min produces back and peripheral Reduced reflex right ankle, reduced sensation The SCRIPT provides a systematic means
symptoms to light touch in right plantar foot
of considering examination-derived data
Walk >15–30 min produces peripheral Standing lumbar extension 10%, 5/10 pain for the purpose of formulating diagnostic
symptoms hypotheses and determining the appro-
priate scope and vigor of the examina-
Figure 5.
tion and intervention. In this case, the
Section V of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT).
SCRIPT guided the mentee to conduct an
initial intervention that allowed the
patient to leave the clinic with less LBP
Outcome research is needed to examine the use-
while providing the mentee with
Utilizing the SCRIPT tool enabled the fulness of the SCRIPT in the postprofes-
diagnostically helpful information of
mentee to generate appropriate hypoth- sional academic setting.
unchanged symptoms in the patient’s
eses and create an examination plan to feet, facilitating the appropriate addi-
systematically test the hypotheses, ulti- Discussion tional screening.
mately leading the mentee to query the This case illustrates how the SCRIPT
literature to answer a clinical question, guided the clinical reasoning process for
Published clinical reasoning tools are
establish a physical therapy diagnosis, a patient with symptoms commonly seen
available for pediatric physical therapist
and design a treatment plan that entailed in an outpatient physical therapy prac-
practice.24,41 To our knowledge, the
continued physical therapy to address tice. Using the SCRIPT to identify a spec-
peer-reviewed literature does not have a
the patient’s LBP and a referral to the trum of potentially involved structures
tool to guide clinical reasoning in other
patient’s primary care provider for con- enabled the mentee to consider alterna-
areas of practice. The SCRIPT could be
tinued management of the PND. The tive diagnostic hypotheses. The SCRIPT
used to teach and structure clinical rea-
patient elected to continue physical ther- provided the mentee with a systematic
soning for a number of educational and
apy at another clinic closer to his home, way to gather information to guide clin-
professional development activities,
so no additional information is known ical reasoning and reflection while also
such as clinical mentorship, case-based
about subsequent physical therapy inter- providing the mentor with valuable
tutorial sessions, new-employee orienta-
vention or changes in his symptoms asso- insight to help usher the mentee’s clini-
tion and mentorship,42 assessing a phys-
ciated with the treatment that he cal reasoning to the level of an expert
ical therapist’s clinical reasoning skills,42
received. In addition to facilitating the clinician.40 Additionally, the tool spurred
and self-reflective practice.
mentee’s clinical reasoning processes to the mentee to search the literature when
establish a diagnosis and plan of care, the the origin of the foot tingling was
SCRIPT tool provided the mentor with unclear and more information was The SCRIPT provides a framework for
insight into the mentee’s clinical reason- needed to evaluate potential alternative developing clinical reasoning for use
ing. Although the SCRIPT was beneficial hypotheses. Although not rapidly pro- throughout the patient encounter. Struc-
in the clinical reasoning and mentoring gressing or life threatening, this systemic tured processes to develop clinical rea-
processes for this patient case, the reli- nerve condition will likely require medi- soning skills improve the differential
ability and validity of the SCRIPT tool cal management and influences the diagnosis process,2 reduce the risk of
have not been formally studied. Future patient’s overall prognosis. Physical ther- diagnostic error,9 and facilitate well-
tolerated examination and intervention
strategies.9,25 Similar to Atkinson and
Nixon-Caves’24 pediatric clinical reason-
VI. TREATMENT PROVIDED ing tool, additional research is needed to
Manual Direction Grade Amount Duration Reinforcing Exercises:
Therapy
demonstrate the SCRIPT’s influence on
Treatment clinical reasoning thought processes,
1st Central Pelvic anterior and posterior rocks utility in developing a novice to an
L3 posterior- IV 3 reps 30 s in hook-lying position expert clinician, and effectiveness as an
anterior aid to reflective practice. It ultimately
2nd Response to Treatment: may be useful in a variety of academic
L3 Lumbar extension movement was and clinical settings.
Central symmetrical to 25% of the range
posterior- IV 3 reps 30 s before limited by 2–3/10 low back
anterior pain. No effect on peripheral As with any tool, however, the SCRIPT
symptoms. has its limitations and challenges. Born
out of a manual physical therapy fellow-
Figure 6. ship program, the verbiage in the SCRIPT
Section VI of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT). Grade IV⫽50% is biased toward the typical practice pat-
of normal movement within resistance, reps⫽repetitions.

8 f Physical Therapy Volume 97 Number 1 January 2017

 SCRIPT in Orthopedic Manual Physical Therapy

V I I. ASSESSMENT END OF DAY 1 SCRIPT is not an exhaustive tool. A more

Most Likely Hypothesis: Alternate Hypotheses: meticulous tool may be necessary for a
Chronic central lower lumbar dysfunction with Chronic central lower lumbar dysfunction more novice physical therapist. For
peripheral neuropathic disease (polyneuropathy with bilateral radiculopathy/radiculitis, most example, the SCRIPT attempts to help
or mononeuropathy) likely of S1 nerve root. identify relevant psychosocial factors but
Supporting Evidence:
does not inherently prompt an in-depth
Lumbar exam and treatment did not change Supporting Evidence:
peripheral symptoms, potentially pointing to 2 Central technique applied to lumbar spine examination of such factors.
separate origins of symptoms. Central improved lumbar symptoms. Long-standing
technique applied to lumbar spine improved sensory changes associated with The development of clinical reasoning
lumbar symptoms. radiculopathy may be difficult to influence skills is a defining feature of residency
Reduced reflex in right ankle, reduced in one visit , limiting ability to exclude a root- and fellowship education1 and central to
sensation to light touch in right plantar foot. level lesion.
developing expertise. Expertise is not a
Absence of motor weakness in S1 myotome. Peripheral symptoms in S1 dermatomal
pattern. status solely acquired through residency
Reduced reflex in right ankle, reduced or fellowship education but is a process
sensation to light touch in right plantar foot. of continued development. An expert’s
Has there been a change in your assessment of SINSS? What? No career advances through continuous
Is there a need for additional screening? What? Why? Yes, diagnostic uncertainty at end of learning and progressive problem solv-
initial evaluation; risk of ulceration and infection in patients with diabetic neuropathy. MNSI ing, a process called “adaptive exper-
is warranted.
tise.”43 Meta-cognition is a critical
element of progressive problem solv-
VIII . PROGNOSIS ing44,45; some authors22,46 argue that this
What is the natural history of the disorder? is the most important component of pro-
Chronic, progressive lumbar pain with uncertainty surrounding peripheral symptoms fessional competence.
Expected level and rate of recovery based on evidence for prognosis:
Short Term: Stand 45 min without worsening back pain. Expert clinicians differ from novices
Long Term: Walk 45 min without worsening back or foot symptoms. with respect to their use of clinical rea-
How many visits over what period of time do you expect to see this patient?
soning strategies and their ability and
6–8 visits over 4 wk
Factors that may limit rate or extent of recovery:
willingness to consider, document, and
History of diabetes mellitus and associated limited ability to heal. Two back surgeries with test alternate hypotheses and to control
minimal change in lumbar pain. the environment of the patient encoun-
Likelihood of recurrence: MILD/MODERATE/HIGH ter.3,5,21,28,40 Mentorship in residency
and fellowship programs is paramount to
How will you attempt to prevent a recurrence of symptoms?
Patient education, maintenance HEP of lumbar mobility and strengthening exercises, regular the development of advanced clinical
low-impact aerobic exercise reasoning skills and developing exper-
tise,1 yet we have much to understand
At the next visit, what treatment will you choose if the patient is: and discover in the teaching and learning
Better: Same: Worse: process for developing clinical reasoning
Progress depth of CPA Continue and progress central Layer in CPA at adjacent skills. Clinical reasoning tools, such as
mobilization at L3, increase PA mobilization at L3. Layer levels (L2, L4). Defer CPA
the SCRIPT, may help clinicians develop
number of bouts of treatment. in CPA at additional levels at L3.
(L4, L 5). consistent clinical processes that aid in
the differential diagnosis process. Resi-
Figure 7. dency and fellowship education with
Sections VII and VIII of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT).
this central focus on clinical reasoning is
SINSS⫽severity, irritability, nature, stage, stability; MNSI⫽Michigan Neuropathy Screening
a rich environment for continued
Instrument; HEP⫽home exercise program; CPA⫽central posterior to anterior.
research.47,48

terns of a manual physical therapist and may be of benefit to have a third planned All authors provided concept/idea/project
utilizes verbiage best known from Mait- pause after the examination to discuss design and writing. Dr Deyle and Dr Baker
land’s work.25 Additionally, utilizing a key findings, reprioritize diagnostic provided project management. Dr Jensen
tool such as the SCRIPT requires dedi- hypotheses, and plan treatment. This provided consultation (including review of
manuscript before submission).
cated time and effort, which may prove third planned pause may be well worth
to be obstacles to its utilization in typical the additional cost of time for novices or DOI: 10.2522/ptj.20150482
clinical practice. Our program allots 90 mentees who the mentor identifies as
minutes to an initial evaluation in order struggling with a particular patient
to allow for the 2 planned pauses away encounter. Lastly, although the SCRIPT
from the patient and the ongoing discus- attempts to concisely marry the
sion between the mentee and mentor hypothetico-deductive reasoning strate-
during the examination and treatment. It gies with narrative reasoning, the

January 2017 Volume 97 Number 1 Physical Therapy f 9

SCRIPT in Orthopedic Manual Physical Therapy

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10 f Physical Therapy Volume 97 Number 1 January 2017

 SCRIPT in Orthopedic Manual Physical Therapy

eAppendix.
Systematic Clinical Reasoning in Physical Therapy (SCRIPT) Blank Forma

I. WHAT AREAS/STRUCTURES MUST BE CONSIDERED AS A POSSIBLE SOURCE(S) OF SYMPTOMS?

Joints and bony Muscles, Pain- OTHER

structures tendons, and producing structures or
UNDER the area other soft tissue structures conditions that
of symptoms UNDER and IN that may must be
the area of REFER into considered or
symptoms the area of ruled out
symptoms

Most Likely Hypotheses: Less Likely Hypotheses: Remote Hypotheses:

II. INFLUENCE OF THE SYMPTOMS ON THE EXAM. Detailed by Area of Symptoms as Mapped on Body Chart.

Px Severity Irritability Nature Stage Stability Limit Exam

Mild Mild (Healing, fragile tissues, Acute, subacute, chronic Improving 1 YesⴝY
Moderate Moderate inflammatory, Acute on chronic Worsening 2 NoⴝN
Severe Severe psychosocial) Subacute on chronic Not changing
Non-MSK/MSK/both

What will be the vigor of your P1 P2 P3 P4 Do the nature, diagnosis, or comorbidities

exam? warrant special caution for exam or
treatment? Y/N What? (eg, trauma/red flags/
Examine to first onset or
instability/pathological process)
change in pain (P1)

Examine to end of active range

of motion/ACTIVE limit

Examine to end of passive Which symptoms will be desirable to

range of motion/PASSIVE limit reproduce?

Examine with OVERPRESSURE Do you expect a comparable sign to be

sufficient to determine end EASY or HARD to reproduce?
feel

Use sustained, repeated, or What do you expect to be treating? (Circle

combined movements one)
PAIN
RESISTANCE RESPECTING PAIN
RESISTANCE

(Continued)

January 2017 (eAppendix, Baker et al) Volume 97 Number 1 Physical Therapy f 1

SCRIPT in Orthopedic Manual Physical Therapy

eAppendix
Continued
III. INFLUENCING FACTORS: Are there contributing factors that need to be addressed with this patient? (check all that apply)

Posture Ergonomics Conditioning Psychosocial Factors Other

IV. PLANNED EXAM PROCEDURES: Prioritize based on most likely hypotheses and SINSS.

Day/Visit 1 Day/Visit 2 Day/Visit3

V. EXAM FINDINGS

Important baseline findings from patient history Important baseline exam findings:

VI. TREATMENT PROVIDED

Manual Therapy Direction Grade Amount Duration Reinforcing Exercises:

Treatment

1st

2nd Response to Treatment:

VII. ASSESSMENT END OF DAY 1

Most Likely Hypothesis: Alternate Hypotheses:

Supporting Evidence: Supporting Evidence:

Has there been a change in your assessment of SINSS? What?

Is there a need for additional screening? What? Why?

VIII. PROGNOSIS
What is the natural history of the disorder?

Expected level and rate of recovery based on evidence for prognosis:

Short Term:
Long Term:
How many visits over what period of time do you expect to see this patient?

Factors that may limit rate or extent of recovery:

Likelihood of recurrence: MILD/MODERATE/HIGH

How will you attempt to prevent a recurrence of symptoms?

At the next visit, what treatment will you choose if the patient is:

Better: Same: Worse:

a
Developed for Army-Baylor University Doctoral Fellowship in Orthopaedic Manual Physical Therapy. Px⫽area of symptoms, P1⫽primary area of symptoms,
P2⫽secondary area of symptoms, P3⫽tertiary area of symptoms, P4⫽quaternary area of symptoms, MSK⫽musculoskeletal; SINSS⫽severity, irritability,
nature, state, stability. The Systematic Clinical Reasoning in Physical Therapy (SCRIPT) may not be used or reproduced without written permission from the
authors.

2 f Physical Therapy Volume 97 Number 1 January 2017 (eAppendix, Baker et al)

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