Case Report

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,

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Evan J. Petersen, Christopher S. Allen, Gail D. Deyle, Gail M. Jensen S.E. Baker, PT, DPT, DSc, Army-
BaylorBaker,
S.E. University
PT, DPT,Doctoral
DSc, Fellow-
Army-
­Bship
aylorinUniversity
Orthopaedic Manual
Doctoral Phys-
Fellowship in
Background and Purpose. Clinical reasoning is essential to physical therapist prac- ical
­O Therapy,
rthopaedic Manual Brooke Army
Physical Therapy,
tice. Solid clinical reasoning processes may lead to greater understanding of the patient Medical
Brooke Center,
Army Medical Fort SamFort
Center, Hous-
Sam
condition, early diagnostic hypothesis development, and well-tolerated examination and inter- ton, TX 78234
Houston, TX 78234 (USA).
(USA).Address
Address all
all
vention strategies, as well as mitigate the risk of diagnostic error. However, the complex and correspondence
correspondence to Baker
to Dr Dr Baker at:
at: sarah.
often subconscious nature of clinical reasoning can impede the development of this skill. sarah.elaine.baker@gmail.com.
elaine.baker@gmail.com.
Protracted tools have been published to help guide self-reflection on clinical reasoning but E.E.Painter,
Painter,
E.E. PT,PT,
DPT,DPT,
DSc, DSc,
Army-Army-
­Baylor
might not be feasible in typical clinical settings. Baylor University
University DoctoralDoctoral Fellow-
Fellowship in
ship
­O in Orthopaedic
rthopaedic Manual Physical Manual
Therapy,
Case Description. This case illustrates how the Systematic Clinical Reasoning in Physical Physical
Brooke ArmyTherapy, Brooke Army
Medical Center.
Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a Medical Center.
B.C. Morgan, PT, DPT, DSc, Army-
physical therapist to search the literature to answer a clinical question and facilitate formal B.C.
­BaylorMorgan,
UniversityPT, DPT, Fellowship
Doctoral DSc, Army-in
mentorship sessions in postprofessional physical therapist training programs. Baylor University
Orthopaedic ManualDoctoral Fellow-
Physical Therapy,
ship Army
Brooke in Orthopaedic
Medical Center. Manual
Outcomes. The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan Physical Therapy, Brooke Army
A.L. Kaus,Center.
Medical PT, DPT, Department of
the examination, query the literature to answer a clinical question, establish a physical Rehabilitation Medicine, Brooke Army
­
therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the A.L. Kaus,
Medical PT, DPT, Department of
Center.
mentee’s clinical reasoning and provided the mentor insight into the mentee’s clinical reason- Rehabilitation Medicine, Brooke
E.J.
Army Petersen,
MedicalPT, DPT, DSc, Army-
Center.
ing. The reliability and validity of the SCRIPT tool have not been formally studied.
­Baylor University Doctoral Fellowship in
E.J. Petersen,
Orthopaedic PT, DPT,
Manual DSc,Therapy,
Physical Army-
Discussion. Clinical mentorship is a cornerstone of postprofessional training programs and Baylor Army
Brooke University
MedicalDoctoral
Center. Fellow-
intended to develop advanced clinical reasoning skills. However, clinical reasoning is often ship in Orthopaedic Manual
C.S. Allen, PT,
Physical DSc, Army-Baylor
Therapy, Brooke Univer-
Army
subconscious and, therefore, a challenging skill to develop. The use of a tool such as the
sity Doctoral
Medical Fellowship in Orthopaedic
Center.
SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach Manual Physical Therapy, Brooke Army
to data gathering and making clinical judgments to bring clinical reasoning to the conscious C.S. Allen,
Medical Center.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. Author informationManual
Orthopaedic continues Physical
on next
page.
Therapy, Brooke Army Medical
Center.

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January 2017 Volume 97 Number 1 https://academic.oup.com/ptj
Physical Therapy f 1

January 2017 Volume 97  Number 1  Physical Therapy    61

SCRIPT in Orthopedic Manual Physical Therapy

G.D.

Manual
Deyle,PT,
G.D. Deyle,
versity
PT,DPT,
DoctoralDoctoral
Physical
cal Therapy,
ical Center.
DPT, DSc,
DSc,

BrookeTherapy,
Army-Baylor
Army-Baylor
FellowshipFellowship
Brooke
Army Medical
Uni-
University
in Orthopaedic
in Orthopaedic Manual Physi-
Army Med-
Center.

G.M. Jensen, PT, PhD, FAPTA, Department of Phys-

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
16–19

differential diagnosis requires careful,

consistent clinical processes. Break-
G.M. Jensen,School
ical Therapy, PT, PhD, FAPTA, Department
of Pharmacy of
and Health Pro-
Physical Therapy,
fessions, and Center School of ­PPharmacy
for Health and
olicy and Ethics, beyond entry-level clinical supervision downs in clinical processes, such as fail-
Health
Creighton Professions, and Center
University, ­Omaha, Nebraska. 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-
[Baker SE, Painter EE, Morgan BC, et al. S
­ ystematic
Omaha, Nebraska. the development of advanced practice. tic error.99 Clinical reasoning strategies to
Clinical Reasoning in Physical Therapy (SCRIPT):
[Baker SE, purposeful
tool for the Painter EE, Morgan
practice BC, etreasoning
of clinical al. Sys- Clinical mentoring centers on patient prevent diagnostic error should focus on
tematic Clinical
in orthopedic Reasoning
manual physical in Physical
therapy. PhysTher-
Ther. management, with an emphasis on devel- systematic data gathering, synthesis, and
apy (SCRIPT): tool for the purposeful prac-
2017;97:61–70.] oping advanced clinical reasoning and documentation.14 14 Formal training in clin-

tice of
2017clinical reasoning in orthopedic reflective practice skills.11 ical reasoning facilitates the mental agil-

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© American Physical Therapy
manual
Association physical therapy. Phys Ther. ity to appropriately consider and docu-
2017;97:xxx–xxx.] Clinical reasoning is an ongoing decision- ment alternative diagnostic hypotheses
Published Ahead of Print:
© making process used throughout the epi- in physical therapist practice.15 15 Purpose-
2017 American
July 28, 2016 Physical Therapy Association
Accepted: July 7, 2016 sode of care.2–2–66 Sound clinical reasoning, ful practice in reasoning strategies in
Published Ahead of Print: to include using a systematic patient- both didactic and clinical environments
Submitted: August 27, 2015
July 28, 2016 is key to developing expertise.15,20
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,77 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.1111

greater understanding of the patient pre-

sentation.7,8
7,8 This greater understanding
reduces the risk of diagnostic error and
overly aggressive, poorly tolerated phys-
ical therapy sessions.9,10
9,10 When clinical
Clinical reasoning is a challenging skill to
develop because it is a high-level and
typically subconscious cognitive pro-
cess.14
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
3,14,21 Mentors must be pres-

appropriate medical care.11 11 ent and fully engaged to understand their

Clinical reasoning is more complex than
applying an analytical, deductive pro-
cess.2–
2–66 Practitioners must engage in ana-
lytical and inductive (narrative) thinking
that helps uncover important contextual
elements that contribute to uncertainty.33
Practitioners must systematically con-
mentees’ thinking as mentees gather and
interpret evidence to manage the
patient. In other words, mentors need a
way for their mentees to “show their
math” to make the mentees’ thinking
explicit. An important learning strategy
for making the mentee’s thinking more
explicit is facilitating reflection.22,23
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
22,23 A tool

ues, as part of the clinical reasoning pro-
cess, ultimately leading to the ability to
make appropriate clinical judgments.
The ability to probe deeper with appro-
priate follow-up questions often stems
from a more complete understanding of
the patient’s story.12,13
12,13 As such, clinical
reasoning is best developed within
the context of a patient encounter
and includes reflecting on previous
encounters.14,15
14,15
that provides a framework for the learner
to critically examine his or her thought
processes may be an important teaching
and learning instrument for facilitating
reflection.
The purpose of this case report is to
describe the application of a teaching
tool developed by an orthopaedic man-
ual physical therapy fellowship program
titled the Systematic Clinical Reasoning
in Physical Therapy (SCRIPT). In this
case, the SCRIPT served as a teaching

2
62  f  Physical
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Volume97
97  Number
Number11 January 2017
 SCRIPT in Orthopedic Manual Physical Therapy

and learning tool for facilitating clinical
reasoning within the patient encounter
and clinical case analysis in one physical
therapy education program. This case
report describes: (1) the mentee’s man-
agement and use of evidence in a patient
case and (2) the teaching and learning
occurring in the clinical reasoning
process.
Case Description
To our knowledge, the only clinical rea-
soning tool published in the peer-
likely and alternate hypotheses for all
areas of symptoms. The tool helps prior-
itize and focus intervention strategies at a
dose that is likely to be effective and
well-tolerated by the patient, minimizing
the potential to irritate painful structures
or exacerbate the condition while maxi-
mizing the opportunity to understand
the patient’s problem and achieve the
patient’s goals.27 The SCRIPT also may
help identify potential pathologies out-
side the scope of physical therapist prac-
tice that need to be screened for and
(labeled as P2), such as lateral thigh pain,
also might increase, thereby suggesting
the 2 areas of symptoms are related.25
A novice physical therapist might mistak-
enly assume that patients will indicate all
areas of symptoms on a body chart and
that any other body region is symptom-
free.2 Additionally, a novice physical
therapist might limit gathering the his-
tory and body chart information to only
one area of symptoms.2 Reasons for this
decision could include time limitations,

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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
In 1994,
1994, thetheArmy-Baylor
Army-Baylor University Doc­ Doc- Section I: Guiding Hypothesis areas of symptoms2 or patterns indicative
toral
toral Fellowship
Fellowship Program
Program in Orthopaedic Generation and Differential of nonmusculoskeletal conditions, such
Manual
Manual Physical Therapy faculty began began Diagnosis as systemic illness. Pattern recognition
developing
developing an an expedient
expedient tool tool using
using a Section I guides the mentee’s hypothesis may assist experienced physical thera-
combination
combination of of sources,
sources, including
including work-
work- development and consideration of differ- pists with early hypothesis formation.28
sheets from other programs, clinical
sheets ential diagnoses early in the patient- However, a physical therapist working
experience,and
experience, and examples
examples from from aa variety physical therapist interaction. After solely from pattern recognition of com-
of unpublished sources, with feedback
of establishing the patient’s profile, includ- mon causes in cases such as this might
from fellows-in-training
from fellows-in-trainingand and other
other fac-
faculty. ing age, sex, work, and recreational hab- assume21 that all cases of back and con-
ulty. tool,
This Thistitled
tool,the titled
SCRIPT,the was
SCRIPT, was
designed its, the mentee gathers information on all current leg pain are of the same origin
designed to
primarily primarily
developtoclinical
develop clinical
reasoning areas of symptoms by completing a body and overlook other potential sources of
reasoning
skills during skills during encounter,
a patient a patient encoun-
appro- chart or symptom map. Accuracy and unrelated leg pain, such as tumor, deep
ter, appropriately
priately tailor examination
tailor examination and interven- and detail of the body chart, including the venous pathology, peripheral neuritis, or
intervention
tion strategies, strategies,
promotepromotediagnostic diagnos-
accu- location, behavior, character or quality, a distinct local musculoskeletal problem.
tic accuracy,
racy, and assist and with assist
planning with planning
subsequent and intensity of all symptoms, are crucial Expert clinicians may use pattern recog-
subsequent
patient patient(eAppendix,
encounters encounters (eAppen-
available to understanding the patient’s baseline nition in the differential diagnosis pro-
dix,academic.oup.com/ptj).
at available at ptjournal.apta.org). The formThe is presentation and are the foundation for cess but also must maintain an open
form is completed
completed for initial
for initial patient patient
encounters early comprehensive diagnostic hypoth- mind and a willingness to generate, doc-
encounters
during formal during formal mentorship
one-on-one one-on-one esis generation. ument, and systematically test multiple
mentorship
sessions sessions
between thebetween
fellowin- thetraining
fellow- alternative hypotheses.7,18,21,29,30
in-trainingand
(mentee) (mentee) and the fellowship-
the fellowshiptrained fac- The mentee places a check mark over
trained
ulty faculty (mentor)
(mentor) and during and subsequent
during sub- The flow of the typical formal mentor-
potentially relevant areas on the body
sequent encounters
encounters to reflecttoonreflect initialon initial
hypoth- ship session is illustrated in Figure 1.
chart that are screened and determined
hypothesis
esis formation formation and decision
and decision making.mak- 26
After completing the body chart, the first
to be asymptomatic. To help prevent
ing.26
The The SCRIPT
SCRIPT is a tool is athat
toolprovides
that provides
struc- of two 5- to 10-minute pauses occurs
misunderstanding, the mentee touches
structure
ture for the formentee
the mentee and insight
and insight into into
the away from the patient to allow the men-
the patient or points to the body region
the mentee’s
mentee’s clinical
clinical reasoning
reasoning process.
process. The tee to complete section I of the SCRIPT.
and asks the patient appropriate screen-
The SCRIPT
SCRIPT also facilitates
also facilitates individual
individual self- These pauses are critical to clinical men-
ing questions such as, “Do you have any-
self-reflective
reflective practice
practice and andguides
guides patient torship, enabling the mentee to reflect
thing that is not normal or recently
case discussions between
case between physical ther- on action,6 plan the remaining examina-
changed here?”25 Determining and doc-
apists in clinical and educational settings.
apists 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

January 2017 Volume 97  Number 1  Physical Therapy    63
SCRIPT in Orthopedic Manual Physical Therapy
Figure 1.
Flow diagram of how to use the Systematic
Clinical Reasoning in Physical Therapy
(SCRIPT) tool during a mentorship session.
tions to highlight alternatives in
reasoning.
The mentee lists all structures that must
be considered as possible sources of the
patient’s symptoms, to include joints and
bony structures; muscles, tendons, and
soft tissue structures; structures that may
refer symptoms into the area of concern;
and other structures or conditions that
must be considered or ruled out, such as
visceral pathology, infections, space-
occupying lesions, and systemic non-
musculoskeletal pathology. This pro-
active planning makes explicit the
connections between thinking and
future actions.
After completing section I, the mentee
formalizes his or her differential thought
by generating and prioritizing the most
4
64  f  Physical
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Number11
likely, less likely, and remote hypotheses
in section II of the SCRIPT. The mentor
reviews the form with the mentee, pro-
viding immediate feedback and helping
to refine or provide additional hypothe-
ses.31 The mentor ensures that the men-
tee has a plan to effectively utilize the
remaining patient history to refine and
prioritize competing hypotheses with
carefully selected and formulated ques-
tions and to determine likely symptom
behavior during the physical examina-
tion and intervention. Hypotheses
derived and prioritized during the his-
tory taking are subsequently examined
with appropriate tests and measures, and
later by the patient’s response to inter-
vention, thereby requiring both deduc-
tive (analytical) and inductive thinking.
During a mentorship session, the second
planned pause occurs at the conclusion
of the history taking for the mentee to
complete sections II, III, and IV of the
SCRIPT.
Section II: Making Clinical
Judgments
Section II requires judgments on the con-
structs of severity and irritability of symp-
toms and nature, stage, and stability of
the disorder, collectively referred to as
SINSS.25 The SINSS, initially described by
Maitland and elaborated on by various
other authors,25,32,33 are evaluated for
each symptomatic area, as different areas
of symptoms may have different symp-
tom behavior and possibly different ori-
gins (Fig. 2). The SINSS are determined
by analyzing information gathered dur-
ing the history taking.25,32,33 This con-
cept helps determine the extent and
vigor of the examination and treatment
that are likely to be well-tolerated.27,33
For example, if a mentee judges a
patient’s symptoms to be severe (high
intensity) and irritable (easily provoked
and persisting), the examination should
be limited to the first onset or increase of
symptoms, and the overall number of
examination procedures should be
reduced accordingly.25 Conversely, a
patient whose symptoms display mild
severity and irritability might tolerate
examination including provocative diag-
nostic special tests, manual examination
to end of range of motion (ROM), and
combined or repeated motions.34 –36 The
nature of the disorder is a multifactorial
judgment based on the mentee’s percep-
tion of unique factors associated with the
probable condition, such as typical mus-
culoskeletal origin, nontypical presenta-
tion requiring screening, complex disor-
ders (eg, whiplash, acute radiculitis), and
personal factors (eg, being a single
working parent, exhibiting high fear-
avoidance behavior).25,32,37 Stage refers
to the duration of symptoms, classified as
acute, subacute, or chronic or a combi-
nation of stages (eg, acute and
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chronic).25,32 Stage can be an important
factor directly related to the nature of the
problem, particularly in disorders with
healing tissues or inflammatory pro-
cesses. Stability may be characterized as
a sign or symptom improving, worsen-
ing, or not changing over the course
of the present episode or previous
episodes.25,32
Section III: Considering
Additional Contributing Factors
Completing section III prompts the men-
tee to consider additional factors contrib-
uting to the patient’s condition, such as
poor conditioning or psychosocial fac-
tors, that may change the prognosis or
require therapeutic attention. These fac-
tors are considerations but should not be
overly weighted in the differential diag-
nosis process. A patient with decondi-
tioning or psychosocial issues would
have as many possible sources of symp-
toms as a patient who is more physically
fit or emotionally stable, and those pos-
sible sources should be systematically
considered and ruled out.38 This patient,
however, did not display contributing
factors that required additional
consideration.
Sections IV and V: Planning the
Examination
Section IV provides a flexible framework
for planning the examination. The men-
tee refers to the hypotheses in section I
and reprioritizes the most likely hypoth-
eses based on information obtained dur-
ing the remainder of the history taking.
Tests and measures typically prioritized
and selected for the initial examination
provide essential evaluation of the most
likely hypotheses and rule out potentially
serious conditions (Fig. 3). The vigor of
the examination is strongly influenced by
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

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Non-MSK/MSK/both
What will be the vigor of your exam?
Examine to first onset or change in pain
Examine to end of active range of
motion/ACTIVE limit
Examine to end of passive range of
motion/PASSIVE limit
Examine with OVERPRESSURE
sufficient to determine end feel
Use sustained, repeated, or combined
movements
Acute on clinical sessions, should improve diag-
chronic nostic accuracy, particularly when clini-
Subacute on
chronic
cal reasoning is utilized throughout the
P1 P2 P3 Do the nature, diagnosis, or
episode of care.10,11
comorbidities warrant special
caution for exam or treatment? Application of the Process
What? Y/N
We present a patient case where the
(eg, trauma/red
X SCRIPT guided the clinical reasoning
flags/instability/pathological process)
No process during a patient encounter with
Which symptoms will be desirable to a 64-year-old retired man who was
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)
Do you expect a comparable sign to
The patient reported a primary com-
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
What do you expect to be treating? plantar foot tingling. The care of this
(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-
MSKmusculoskeletal, Pxarea of symptoms, P1primary area of symptoms, stant, but variable in intensity, deep ache
P2secondary area of symptoms, P3tertiary 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-

2017
January 2017 Volume97 
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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). SINSSseverity, amined to determine patient response to
irritability, nature, stage, stability; AROMactive range of motion; LElower extremity; examination and treatment. These key
SLRstraight leg raise; MNSIMichigan Neuropathy Screening Instrument, SIJsacroiliac baseline findings are recorded in section

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joint. V of the SCRIPT (Fig. 5).

In this case, manual treatment with rein-

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

6
66  f Physical
PhysicalTherapy
Therapy  Volume
Volume97
97  Number
Number11 January 2017
 SCRIPT in
SCRIPT in Orthopedic
Orthopedic Manual
Manual Physical
Physical Therapy
Therapy

I. WHAT
WHAT AREAS/STRUCTURES
AREAS/STRUCTURES MUST MUST BE BE CONSIDERED
CONSIDERED AS AS POSSIBLE
POSSIBLE SCRIPT in Orthopedic for diabetic
for diabetic PND.36 Physical
Manual
PND. AA score
36 score of ofTherapy
2 has
2 has aa
I.
SOURCE(S) OF
SOURCE(S) OF SYMPTOMS? SYMPTOMS? specificity of 83% (95% confidence
specificity of 83% (95% confidence inter- inter-
central SCRIPT in Orthopedic Manual 36 Physical
Joints Muscles, Pain-- OTHER score ofTherapy
P1: central val75%, 89%) and a positive
positive likelihood
Joints Muscles,
I. WHAT AREAS/STRUCTURES MUST BEOTHER
Pain CONSIDERED AS POSSIBLE
P1:
low back for diabetic
val75%, 89%)PND. and aA likelihood
2 has a
and bony
and bony tendons, producing structures low back
ratio of of 3.9 3.9 (95% confidence inter-
SOURCE(S) SYMPTOMS? producing structures
OF tendons, pain; achy,
pain; achy, ratio
specificity of 83% (95% (95%confidence
confidence inter-
structures
structures and other
and other structures or
structures or stiff, deep
I. WHAT AREAS/STRUCTURES
Joints
UNDER Muscles,
soft tissue
tissue
SCRIPT
MUSTin
that -may
Pain BEOrthopedic
CONSIDERED AS
OTHER
may conditions
conditions
Manual
POSSIBLEP1:Physical Therapy val2.5,
stiff, deep
central
2–10/10
val2.5,
for diabetic
val75%, 6.1), 6.1),
PND.
89%) and suggesting
36 A score that
suggesting
a positive of
that 2 further
furthera
has
likelihood
UNDER SYMPTOMS?that
OF soft
2–10/10
low back
specificity of 83% (95% confidence
SOURCE(S)
and bony
the area
area tendons,
UNDER producing
REFER structures
that must
must Resting
Resting
pain; achy,
quantitative
quantitative neurological
ratio of 3.9 neurological(95% confidence testing inter-
testing was
was
inter-
the
structures
Joints UNDER
and other
Muscles, REFER
Pain-the
structures that
or
OTHER pain
P1: 2/10
central
pain
stiff, 2/10
deep val75%,
appropriate. 89%)36 and a positive likelihood
of
MUST BE CONSIDERED
of and
AS POSSIBLE
and IN
IN the
the intointo the be
be for diabetic PND. 36 A score
low back of 2 has a appropriate.
val2.5, 6.1),
36 suggesting that further
UNDER
and bony soft tissue
tendons, that may
producing conditions
structures 2–10/10
symptoms
symptoms area
area of
of area
area of
of considered
specificity of 83% (95%
considered pain; confidence
Resting achy, inter- ratio of 3.9 neurological
quantitative (95% confidence testing inter-was
the area
structures UNDER
and other
symptoms REFER
structures
symptoms that
or
or must
ruled stiff, deep val2.5, 6.1), suggesting that further
ain- OTHER P1:
symptoms central symptoms or val75%,
ruled 89%) and pain
a 2/10
positive likelihood Based on
appropriate.
Based on the
36
the literature,
literature, the mentee
the mentee
of
UNDER and
soft INlowthe
tissue back into
that themay be conditions 2–10/10
oducing structures out
out quantitative
planned to neurological
to administer
administer the testing
MNSI at at was
the
symptoms
the area area
UNDER of achy, area
pain; REFER of that ratio
must of 3.9 (95%Resting
considered confidence inter- planned the MNSI the
-Bilateral
ructures or -Bilateral -Lower
-Lower -Lower
stiff, deep -Lower - Lower pain 2/10 appropriate.
into the -or Lower 36
of symptoms
and IN the symptoms be val2.5, 6.1), suggesting that further following
ruled following
Based onvisit visit to further
theto literature, differentiate
further differentiatethe mentee the
the
at may conditionslower
lower lumbar
lumbar 2–10/10 thoracic
thoracic extremity
extremity P2 (left
(left
symptoms area Resting
of area of out
considered
quantitative neurological
P2 testing was genesis of
genesis
planned of administer
to the peripheral
the peripheralthe MNSIsymptoms
symptoms
at the
EFER lumbar
that must
lumbar paravertebral spine
paravertebral spine vascular foot) and
and
symptoms -vascular foot)
symptoms
-or ruled
-Bilateral -Lower pain 2/10 -Lower Lowerappropriate.36 Based 7).on
(Fig. 7). thetoliterature,
Subsequent examination the mentee
demon-
to the facet
be facet muscles
muscles -Upper
-Upper - GI
GI system
system
P3 (right
P3 (right (Fig.
following Subsequent
visit examination
further differentiate demon- the
lower lumbar thoracic out
extremity foot): planned
strated a to administer
reduced ankle the MNSI
reflex onat the
ea of joints
considered
joints -Bilateral
-Bilateral lumbar
lumbar - - GU
GU system
system foot):
P2 (left
bilateral, strated
genesis a ofreduced ankle reflex
the peripheral on
symptoms the
-Bilateral
lumbar -Lower
paravertebral spine
-Lower -vascular
Lower bilateral,
foot) and following
right 7). visit
andSubsequent
absent to further
vibratory differentiate
sense demon-
at boththe
both
mptoms or ruled -Bilateral
-Bilateral
lower
facet
quadratus
quadratus
lumbar
muscles
spine
spine
thoracic
-Upper ---extremity
Space-
Based on the literature,
Space-
GI system
foot(right
foot
P3 the mentee right (Fig. and absent vibratory
examination sense at
lower
out lower lumborum
lumborum Mid
Mid occupying
occupying
planned to administer
P2 (left
tingling,
tingling,
foot): the MNSI at the genesis
ankles,
ankles,
strated ofreduced
resulting
resulting
a the in in peripheral
an
an
ankle MNSI
MNSI symptoms
score
score
reflex onof
of 2.5
2.5
the
lumbar
joints
lumbar
paravertebral lumbar
-Bilateral
muscles
spine
lumbar -lesion
GU system
vascular foot) and
deep,
deep,
bilateral,
ower - Lowerlumbar muscles lumbar lesion (Fig.
and the7).
the Subsequent
need examination
for vibratory
further screening. demon-The

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facet
-Bilateral muscles
quadratus -Upper
spine - following visit to further
GI system
Space- P3 (right
constant,
constant,
foot differentiate the and right and need
absent for further screening.
sense at The
both
oracic vertebral
extremity
vertebral -Bilateral
-Bilateral spine
spine (tumor)
(tumor) foot):
2–5/10 strated
diagnostic a reduced
gold instandardankle
standard reflex
for onof the
diabetic
joints
lower -Bilateral
lumborum lumbar
Mid --occupying
GU genesis
system of the peripheral
P2 (left 2–5/10
tingling, symptoms diagnostic
ankles, gold
resulting an MNSI for
score diabetic 2.5
ine joints
vascular
joints proximal
proximal -Upper,
foot) and -Upper, - Spinal
Spinal bilateral,
Resting
Resting
deep,
-Bilateral
lumbar quadratus
muscles spine
lumbar - Space-
lesion(Fig. 7). Subsequent examination
foot
pain 2/10 demon- right
PND
PND
and and
is
is
the absent
electromyography
electromyography
need for vibratory
further sense
and
and at
nerve
nerve
screening. both
con-
con-
The
pper -Bilateral
- GI system gluteal P3 (right mid, and infection pain 2/10
constant,
-Bilateral
lower
vertebral gluteal
lumborum
-Bilateral
foot): Mid and infection
mid,
spine occupying
(tumor)
strated a reduced 2–5/10
tingling,
ankle reflex on the duction ankles,
ductionresulting
study instandard
(EMG/NCS)an MNSI score
testing. ofDue
34 2.5
Due
mbar ilium
- GU system
ilium muscles
muscles lower
lower deep, diagnostic study gold(EMG/NCS) testing.
for diabetic
34
lumbar
joints
-Sacrum
muscles
proximalbilateral,
-Bilateral
lumbar
-Upper,
foot lumbar
- lesion
Spinal Resting
and
to thethe need
patient’s for further
complaints screening.
of worsening The
ine - Space-
-Sacrum
vertebral
-Bilateral -Bilateral
foot
-Bilateral
gluteal foot lumbar
spine
right
(tumor)
infection
and absent vibratory
constant,
pain 2/10 sense at both PND
to the is electromyography
patient’s complaints andof nerve
worsening con-
-Bilateral intrinsic mid,
disks and - Spinal
2–5/10 diagnostic
lower extremity
extremitygold standard testing.
neurological forsymptoms,
diabetic
symptoms,
id occupying
-Bilateral
joints
ilium
tingling,
intrinsic
proximal
muscles disks ankles, resulting in an RestingMNSI score of 2.5 lower duction study (EMG/NCS)
neurological 34 Due
sacroiliac muscles deep, -Upper,
lower PND is electromyography and nerve con-
mbar lesionsacroiliac
-Bilateral muscles -Bilateral
-Bilateral and the need for pain 2/10
further screening. The the
the physical
to thephysical therapist
patient’stherapist communicated
complaintscommunicated of worsening
-Sacrum
joints
gluteal
-Bilateral
-Bilateral mid, and infection
foot lumbar
constant,
ine (tumor)
joints
ilium -Bilateral
2–5/10
intrinsic
muscles sacroiliac
sacroiliac duction
with the study
patient’s(EMG/NCS)
primary testing.
care 34 Due
provider,
-Bilateral
-Bilateral plantar lower
disks diagnostic gold standard for diabetic with
lower the patient’s
extremity primary
neurological care provider,
symptoms,
pper, - Spinal
-Bilateral
-Sacrum
sacroiliac plantar
muscles
Resting
-Bilateral joints
foot joints to
whothephysical
patient’s
ordered complaints
EMG/NCS of worsening
testing.
hindfoot fascia pain 2/10 lumbar
-Bilateral PND is electromyography and nerve con- who the ordered EMG/NCS
therapist testing.
communicated
id, and infection hindfoot
-Bilateral fascia
intrinsic
-Bilateral -Bilateral
-Bilateral
joints
joints -Bilateral disks
sacroiliac lower
duction study (EMG/NCS) testing. Due with the patient’s primary care
34 extremity neurological symptoms,
provider,
wer joints
sacroiliac -Bilateral
muscles
plantar hip joints
hip joints
-Bilateral
-Bilateral lower -Bilateral
joints the
The physical
EMG/NCS therapist
testing communicated
demonstrated mild
mbar -Bilateral lower
-Bilateral -Bilateral
-Bilateral to the patient’s complaints of worsening who
The ordered
EMG/NCS EMG/NCS
testing testing.
demonstrated mild
joints
hindfoot fascia
extremity sacroiliac
-Bilateral with the patient’s primary care provider,
sks tarsal
tarsal extremity talocrural lower extremity neurological symptoms, demyelinating PND affecting
demyelinating PND affecting the sensory the sensory
-Bilateral
joints plantar
-Bilateral talocrural
joints
hip joints
ilateral joints
joints peripheral
peripheral joints the physical therapist communicated and who ordered
and EMG/NCS
motor EMG/NCS
fibers in the
the testing.
lower extremi-
extremi-
hindfoot
-Bilateral fascia
lower joints
-Bilateral The motor fibers
testingin lower
demonstrated mild
croiliac -Bilateral
-Bilateral nerves
nerves ties, as well as evidence of chronic
chronic bilat-
joints
tarsal -Bilateral
extremity hip joints
talocrural with the patient’s primary care provider, ties, as well
demyelinating as evidence
PND affectingof the bilat-
sensory
nts tarsometatarsal (tibial,
tarsometatarsal (tibial,
-Bilateral
joints lower
peripheral -Bilateral
joints who ordered EMG/NCS testing. The
eral EMG/NCS
eral
and L5 and
L5 andfibers
motor S1testing
S1 demonstrated
radiculopathies
radiculopathies
in the thatmild
that
lower extremi- did
did
ilateral joints
joints deep/
deep/
tarsal
-Bilateral extremity
nerves talocrural demyelinating
not warrant PND
surgical affecting
intervention.the sensory
This
p joints -Bilateral
-Bilateral superficial
superficial not
ties, warrant
as well assurgical
evidence intervention.
of chronic bilat- This
joints
tarsometatarsal peripheral
(tibial, joints and motor
ilateral metatarsal
metatarsal
-Bilateral
fibular,
fibular,
nerves
deep/
The EMG/NCS testing demonstrated mild knowledge eral L5 andfibers
knowledge helped
helped in the
the lower
S1 radiculopathies menteeextremi-
mentee that deter-
deter-
did
joints medial/ ties, asthe
welllikely
minewarrant
the assurgical
likely evidence
clinical ofdiagnoses
chronic bilat-
diagnoses and
locrural phalangeal
phalangeal medial/ demyelinating PND affecting the sensory mine
not clinical intervention. and
This
(tibial,
tarsometatarsal superficial
-Bilateral
nts joints
joints lateral
lateral eral
overallL5 prognosis
and helped
prognosis S1 radiculopathies
(Fig. 7).mentee
Physical that did
ther-
joints
metatarsal deep/
fibular, and motor fibers in the lower extremi- overall knowledge (Fig.the7). Physical ther-
deter-
plantar)
plantar) not
apy warrant
treatment surgical
would intervention.
likely influence This
the
-Bilateral
phalangeal superficial
medial/ ties, as well as evidence of chronic bilat- apy
minetreatment
the likely would likelydiagnoses
clinical influence and the
Most Likely
Most Likely Hypotheses: Less Likely Hypotheses:
Likely Hypotheses: Remote Hypotheses:
Hypotheses:
metatarsal Hypotheses:
joints fibular,
lateral Less eral L5 and S1Remote radiculopathies that did patient’s knowledge
patient’sprognosis
overall helped
chronic
chronic LBP
LBP
(Fig.the7). mentee
more
more thandeter-
than
Physical the
the
ther-
 Chronic central
phalangeal
Chronic central lower
medial/
plantar)
lower  Spinal stenosis
 Spinal stenosis with with  Space-occupying
 Space-occupying mine
chronic theneurological
likely
neurological clinical diagnoses
symptoms. and
How-
not warrant surgical intervention. This chronic apy treatment would symptoms.
likely influence How-
the
lumbar
joints
Most Likely
lumbar dysfunction
lateral
Hypotheses:
dysfunction Lessneurogenic
neurogenic claudication
Likely Hypotheses:
claudication lesionHypotheses:
Remote
lesion in the
in the lumbar
lumbar overall
ever, prognosis
understanding (Fig.
the 7). Physical
contributions ther-
of
with bilateral
bilateralplantar) Myofascial pain
 Myofascial
knowledge
pain status
status post
post
helped spinethe mentee deter- ever, understanding
patient’s chronic the
LBP contributions
more than of
the
 with
Chronic central lower
radiculopathy/radiculitis,

 Spinal stenosis with
mine the likely spine
Space-occupying
clinical diagnoses and apy
the
the treatment
diabetic
diabetic
chronic PNDwould
PND to the
neurological to likely
the influence
patient’s
patient’s symp-
symptoms. the
symp-
How-
Most Likely Hypotheses: Lesslumbar surgery
Hypotheses:
Likelysurgery with bilateral
bilateral   Lower extremity
Remote extremity or or
radiculopathy/radiculitis,
lumbar dysfunction lumbar
neurogenic with
claudication lesionHypotheses:
Lower in the lumbar patient’s chronic
toms understanding
enabled the LBP mentee moreto tothanprovidethe
most likely
most likely of S1
of S1 neuraloverall
chronic neural
chronic tensionprognosis (Fig.
tension abdominal
abdominal 7). Physical
vascularther- toms
vascular ever, enabled the mentee
the contributions provide of
Chronic
 with central lower
bilateral  Spinal stenosis
Myofascial pain with
status post  Space-occupying
spine chronic
appropriate neurological
patient symptoms.
education, How-
devise
nerve root
nerve root symptoms
symptoms apy treatment would pathology
likely influence the appropriate
the diabetic patient
PND to education,
the patient’s devise
symp- aa
ss Likely Hypotheses: lumbar dysfunction
radiculopathy/radiculitis,
Remote neurogenic
lumbar
Hypotheses: surgery with bilateral  pathology
claudication lesion in
Lower the lumbar
extremity or ever, understanding
treatment plan respectivethe contributions
of the patient’s of
 Chronic
 Chronic central
central lower patient’s chronic Referred
LBP more pain from
than the treatment
toms enabled plan respective
the mentee of the to patient’s
provide
with bilateral
most likely of S1lower Myofascial
 chronic neural pain status post
tension  Referred
spine
abdominal pain from
vascular
Spinal stenosis with lumbar dysfunction
dysfunction viscerogenic pathology the diabetic patient
comorbidity PND to education,
and reconnect the patient’s
reconnect thedevisesymp-a
patient
lumbar root  Space-occupying
radiculopathy/radiculitis,
nerve lumbar surgery
symptoms chronic neurological
with bilateral  viscerogenic
Lower
pathologysymptoms.
extremity orHow- comorbidity
pathology appropriate and the patient
with peripheral
neurogenic claudication
with peripheral lesion in the lumbar Spinal
 Spinal infection
infection toms
with enabled
his primary thecare
carementee
provider to patient’s
provide
for con-
most
 Chronic likely of
centralS1lower chronic neural ever, understanding
tension  the
abdominal contributions
 Referred pain from vascular of with his
treatment primary
plan respective provider
of the for con-
neuropathic
Myofascial pain status disease
spine
nervepost
neuropathic
lumbar root disease
dysfunction symptoms the diabetic PND pathology
to the
viscerogenic patient’s symp-
pathology appropriate
tinued medical
tinued medical
comorbidity patient
and education,
management.
management.
reconnect the devise
patient a
lumbar surgerywith (polyneuropathy
bilateral
(polyneuropathy or
Lower
 lower
or extremity or treatment plan respective of the patient’s
Chronic
with central
peripheral 
toms enabled theSpinal Referred
mentee pain
infection from
to provide with his primary care provider for con-
mononeuropathy)
chronic neural tension
mononeuropathy) abdominal vascular
lumbar dysfunction viscerogenic comorbidity and reconnect thetopatient
symptoms
neuropathic disease
pathology appropriate patient education,pathology devise a In In accordance
accordance
tinued medical with the Guide
management.
with the Guide Physi-
to Physi-
with peripheral or
(polyneuropathy  Spinal infection with his primary care 37 provider for con-
Figure
Figure 4.
4.
neuropathic  Referred pain from
disease treatment plan respective of the patient’s cal Therapist Practice,
cal Therapist Practice, the appropriate
37 the appropriate
mononeuropathy) tinued medical management.
Section
Section II ofof the
(polyneuropathy theviscerogenic
Systematicpathology
orSystematic Clinical Reasoning
Clinical Reasoning
comorbidity in Physical
in Physical
and reconnect Therapythe(SCRIPT).
Therapy (SCRIPT). clinical
patient clinical
In care for
accordance
care for
with this
this patient
thepatient
Guide to included
included
Physi-
GIgastrointestinal,
GIgastrointestinal,
mononeuropathy) GUgenitourinary,
 Spinal infection
GUgenitourinary, P1primary
P1primary area
with area of symptoms,
his primary P2secondary
care P2secondary
of symptoms, provider for con- area treating
area treating the LBP consistent with best-best-
Figure 4. cal Therapistthe LBP Practice,consistent with
37 the appropriate
of symptoms,
of symptoms, P3tertiary
P3tertiary area area ofof symptoms.
symptoms. tinued medical management. In accordance
evidence with
strategies the
and Guide to
referring Physi-
the
Section I of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT). evidence clinical care strategies
for thisand patientreferring
included the
Figure 4.
GIgastrointestinal, GUgenitourinary, P1primary area of symptoms, P2secondary area patient cal Therapist
patient for
treatingfor the Practice,
further
further
LBP evaluation
37 the appropriate
evaluation
consistent of of his PND.
his PND.
with best-
Section
of symptoms, I ofP3tertiary
the Systematic Clinical Reasoning
area of symptoms. In accordancein Physical
with the Therapy
Guide to (SCRIPT). clinical
Physi- The datacare
The data
evidence from
from for
thethis
the
strategies SCRIPT
SCRIPT
and patient helped
helped included
referring guide
guide
the
GIgastrointestinal, GUgenitourinary, P1primary area of symptoms, 37
cal Therapist Practice, P2secondary the appropriate area treating
clinical for
clinical
patient thefurther
reasoning
reasoning LBP and consistent
and with
plan management
plan
evaluation management
of his best-
PND.
betic
betic neuropathy,
of symptoms,
neuropathy, including
P3tertiary foot
area of foot
including and ment
symptoms.
and ment (MNSI),
(MNSI), consisting
consisting of of aa foot
foot inspec-
inspec- evidence
throughout strategies
thethe episode andof of referring
care. guide the
c Clinical Reasoning in Physical Therapy (SCRIPT). clinical care for this patient included throughout
The data from the episode
SCRIPT care.
helped
lower
lowerarea limb
limb inspection
inspection and sensory
and sensory test- test- tion,
tion, ankle
ankle reflexes,
reflexes, and
and vibration
vibration per- patient
per- for further evaluation of his PND.
urinary, P1primary of symptoms, P2secondary area treating the LBP consistent with best- clinical reasoning and plan management
f symptoms. ing.
ing.35
betic neuropathy,
The literatureincluding SCRIPT
35 The literature indicated that the
indicated thatinand
foot theOrthopedic
ception,
ception,
ment
evidence
Manual
has
has
(MNSI), been
been
strategies
Physical
validated
validated
consisting infoot
ain
andof referring
Therapy
the
the type 22 The data from the SCRIPT helped guide
type
inspec-
the throughout the episode of care.
Michigan
Michigan
lower Neuropathy
limbNeuropathy Screening
inspection Screening
and sensory Instru-
Instru-
test- diabetic
diabetic
tion, population
population
ankle reflexes, asand
as aa screening
screening
vibration tool
per- clinical reasoning and plan management
tool
betic neuropathy, including foot and patient
ment for
(MNSI),further evaluation
consisting of a of his
foot PND.
inspec-
ing. TheASliterature
MUST BE CONSIDERED
35
POSSIBLEindicated that the for
The diabetic
ception, has PND.
been A score
validated
36 of
in the
2 has
type 2a throughout the episode of care.
lower
Michigan limb inspection and sensory
Neuropathy Screening Instru- test- tion,data
ankle
specificity
diabetic
from the SCRIPT
ofreflexes,
83% (95%
population asand
helped guide
vibration
confidence
a screening per-
inter-
tool
January 2017literature
ing.35 (MNSI),
The indicated clinical reasoning and plan management Volume 97 Number
Number 11 Physical
Physical Therapy
Therapy f 7
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foot andOTHERJanuary
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consisting of a footthat the
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val75%,
throughout 89%)been validated
the and a positive
episode
in the typeVolume
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oducing
nsory test-structures
tion, ankle reflexes,pain; and vibration per-
achy, ratio of 3.9 (95% confidence inter-
ructures
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ception,2017 stiff, deep in the type 2
has been validated val2.5, 6.1), suggesting that further Volume 97 Number 1 Physical Therapy f 7
at may conditions 2–10/10
ing Instru- diabetic populationResting as a screening tool quantitative neurological testing was
EFER that January
must 2017
January 2017 pain 2/10
Volume97 
Volume 97 Number
Number1 1 Physical
PhysicalTherapy 
Therapy  f 67
7
to the be appropriate.36
ea of considered
mptoms or ruled Volume 97 Number
Based on the1 literature,
Physical Therapy f 7
the mentee
SCRIPT in Orthopedic Manual Physical Therapy
V. EXAM FINDINGS
Important baseline findings from patient
history:
Stand >30 min produces back and peripheral Reduced reflex right ankle, reduced sensation
symptoms
Walk >15–30 min produces peripheral
symptoms
Figure 5.
Section V of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT).
Outcome
Utilizing the SCRIPT tool enabled the
mentee to generate appropriate hypoth-
eses and create an examination plan to
systematically test the hypotheses, ulti-
mately leading the mentee to query the
literature to answer a clinical question,
establish a physical therapy diagnosis,
and design a treatment plan that entailed
continued physical therapy to address
the patient’s LBP and a referral to the
patient’s primary care provider for con-
tinued management of the PND. The
patient elected to continue physical ther-
apy at another clinic closer to his home,
so no additional information is known
about subsequent physical therapy inter-
vention or changes in his symptoms asso-
ciated with the treatment that he
received. In addition to facilitating the
mentee’s clinical reasoning processes to
establish a diagnosis and plan of care, the
SCRIPT tool provided the mentor with
insight into the mentee’s clinical reason-
ing. Although the SCRIPT was beneficial
in the clinical reasoning and mentoring
processes for this patient case, the reli-
ability and validity of the SCRIPT tool
have not been formally studied. Future
VI. TREATMENT PROVIDED
Manual Direction Grade Amount Duration Reinforcing Exercises:
Therapy
Treatment
1st Central
L3 posterior- IV 3 reps
anterior
2nd
L3
Central
posterior- IV 3 reps
anterior
Figure 6.
Section VI of the Systematic Clinical Reasoning in Physical Therapy (SCRIPT). Grade IV50%
of normal movement within resistance, repsrepetitions.
8 f  Physical
68  PhysicalTherapy
Therapy  Volume
Volume97
97  Number
Number11
Important baseline exam findings:
to light touch in right plantar foot
Standing lumbar extension 10%, 5/10 pain
research is needed to examine the use-
fulness of the SCRIPT in the postprofes-
sional academic setting.
Discussion
This case illustrates how the SCRIPT
guided the clinical reasoning process for
a patient with symptoms commonly seen
in an outpatient physical therapy prac-
tice. Using the SCRIPT to identify a spec-
trum of potentially involved structures
enabled the mentee to consider alterna-
tive diagnostic hypotheses. The SCRIPT
provided the mentee with a systematic
way to gather information to guide clin-
ical reasoning and reflection while also
providing the mentor with valuable
insight to help usher the mentee’s clini-
cal reasoning to the level of an expert
clinician.40 Additionally, the tool spurred
the mentee to search the literature when
the origin of the foot tingling was
unclear and more information was
needed to evaluate potential alternative
hypotheses. Although not rapidly pro-
gressing or life threatening, this systemic
nerve condition will likely require medi-
cal management and influences the
patient’s overall prognosis. Physical ther-
Pelvic anterior and posterior rocks
30 s in hook-lying position
Response to Treatment:
Lumbar extension movement was
symmetrical to 25% of the range
30 s before limited by 2–3/10 low back
pain. No effect on peripheral
symptoms.
apists in all settings should be able to
search, find, and apply or recommend
screening strategies when clinical rea-
soning suggests they are appropriate.
The SCRIPT provides a systematic means
of considering examination-derived data
for the purpose of formulating diagnostic
hypotheses and determining the appro-
priate scope and vigor of the examina-
tion and intervention. In this case, the
SCRIPT guided the mentee to conduct an
initial intervention that allowed the
patient to leave the clinic with less LBP
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while providing the mentee with
diagnostically helpful information of
unchanged symptoms in the patient’s
feet, facilitating the appropriate addi-
tional screening.
Published clinical reasoning tools are
available for pediatric physical therapist
practice.24,41 To our knowledge, the
peer-reviewed literature does not have a
tool to guide clinical reasoning in other
areas of practice. The SCRIPT could be
used to teach and structure clinical rea-
soning for a number of educational and
professional development activities,
such as clinical mentorship, case-based
tutorial sessions, new-employee orienta-
tion and mentorship,42 assessing a phys-
ical therapist’s clinical reasoning skills,42
and self-reflective practice.
The SCRIPT provides a framework for
developing clinical reasoning for use
throughout the patient encounter. Struc-
tured processes to develop clinical rea-
soning skills improve the differential
diagnosis process,2 reduce the risk of
diagnostic error,9 and facilitate well-
tolerated examination and intervention
strategies.9,25 Similar to Atkinson and
Nixon-Cave’s24 pediatric clinical reason-
ing tool, additional research is needed to
demonstrate the SCRIPT’s influence on
clinical reasoning thought processes,
utility in developing a novice to an
expert clinician, and effectiveness as an
aid to reflective practice. It ultimately
may be useful in a variety of academic
and clinical settings.
As with any tool, however, the SCRIPT
has its limitations and challenges. Born
out of a manual physical therapy fellow-
ship program, the verbiage in the SCRIPT
is biased toward the typical practice pat-
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:
Chronic central lower lumbar dysfunction with
peripheral neuropathic disease (polyneuropathy
or mononeuropathy)
Supporting Evidence:
Lumbar exam and treatment did not change
peripheral symptoms, potentially pointing to 2
separate origins of symptoms. Central
technique applied to lumbar spine improved
lumbar symptoms.
Reduced reflex in right ankle, reduced
sensation to light touch in right plantar foot.
Absence of motor weakness in S1 myotome.
Alternate Hypotheses:
Chronic central lower lumbar dysfunction
with bilateral radiculopathy/radiculitis, most
likely of S1 nerve root.
Supporting Evidence:
Central technique applied to lumbar spine
improved lumbar symptoms. Long-standing
sensory changes associated with
radiculopathy may be difficult to influence
in one visit , limiting ability to exclude a root-
level lesion.
Peripheral symptoms in S1 dermatomal
meticulous tool may be necessary for a
more novice physical therapist. For
example, the SCRIPT attempts to help
identify relevant psychosocial factors but
does not inherently prompt an in-depth
examination of such factors.
The development of clinical reasoning
skills is a defining feature of residency
and fellowship education1 and central to
developing expertise. Expertise is not a
status solely acquired through residency

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pattern.
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
SINSSseverity, irritability, nature, stage, stability; MNSIMichigan Neuropathy Screening
a rich environment for continued
Instrument; HEPhome exercise program; CPAcentral posterior to anterior.
research.47,48

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

2017
January 2017 Volume97 
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9
SCRIPT in Orthopedic Manual Physical Therapy
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