Learning objectives: Risk management is an inherent component of rehabilitating patients with neck disorders. Varying degrees of adverse events resulting from inadequate assessment and from inappropriate use of rehabilitation interventions have been documented. Practitioners in Rehabilitation Medicine must employ careful and judicious clinical reasoning when determining the diagnosis and subsequent treatment interventions to minimize risks of adverse events. The purpose of this case presentation is to demonstrate the importance of expert clinical reasoning in the prevention of diagnostic error among rehabilitation practitioners in the ambulatory setting.
Case information: A 50 year-old man presented with a 2-week history of progressive weakness and dysfunction in the left upper extremity. Subjective history suggested shoulder impingement syndrome. However, a more detailed examination revealed compression of cervical nerve roots that required a referral to a specialist and subsequent surgical intervention to address the underlying problem. Post-operatively, the patient’s arm function improved dramatically. A retrospective interview was conducted with the rehabilitation practitioner to discuss aspects of the clinical reasoning process used in this case.
Discussion: While clinical guidelines have been established for optimal management of neck disorders, the application of sound clinical reasoning remains critical to risk management. This case highlights the importance of a thorough and systematic patient examination in the management of a patient with deteriorating signs and symptoms that would otherwise have resulted in permanent disability. The clinical reasoning process demonstrated in this case is strongly founded on the principles of reflective practice and expert clinical reasoning. As these skills cannot be assumed of all practitioners, explicit attention must be paid to the development of these skills in the context of Rehabilitation Medicine. Strategies to develop the requisite skills for appropriately managing the risks associated with neck disorders are proposed and applied to the ambulatory setting.
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