Manual Therapy 12 (2007) 40–49 Original article The clinical reasoning of pain by experienced musculoskeletal physiotherapists Keith Smart a,Ã , Catherine Doody b a Physiotherapy Department, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland b School of Physiotherapy, University College Dublin, Ireland Received 25 February 2005; received in revised form 26 January 2006; accepted 15 February 2006 Abstract 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. r 2006 Elsevier Ltd. All rights reserved. Keywords: Clinical reasoning; Pain; Physiotherapists 1. Introduction It has been suggested that pain is the main symptom with which patients present to musculoskeletal phy- siotherapists (Watson, 1996; Cheing and Cheung, 2002). It has also been suggested that within physiotherapy considerable importance is placed upon the patient’s report of pain, as elicited through the patient-therapist clinical interview, by physiotherapists when reasoning and decision-making with regard to its nature and treatment (Main and Watson, 1999). Epidemiological studies and reviews suggest that between 10% and 20% of the populations of industrialized western societies have a persistent pain problem (Magni et al., 1993; Verhaak et al., 1998; Pain in Europe, 2003). The personal cost to sufferers of ‘chronic pain’ can be devastating. One in five chronic pain sufferers have lost a job as a result of their pain, and one in five sufferers have been diagnosed with depression as a result of their pain (Pain in Europe, 2003). Financially, the costs to societies both directly (through expenditure on healthcare) and indir- ectly (through lost productivity and tax revenue and disability compensation) run into the billions (US dollars) (Turk, 2002). ARTICLE IN PRESS www.elsevier.com/locate/math 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.02.006 Ã Corresponding author. Tel.: +353 1 2094354; fax: +353 1 2696018. E-mail address: k.smart@st-vincents.ie (K. Smart).