Clinical reasoning provides physiotherapists and other clinicians with a basis for assessing, diagnosing and managing a patient’s condition. 

However, pain physiotherapists find that the standard clinical reasoning framework doesn’t always match the complexity of a patient with chronic pain. 

A group of pain physiotherapists, including APA Pain national group chair Zoë Harper MACP; Dr Anne Daly FACP, a Specialist Pain Physiotherapist (as awarded by the Australian College of Physiotherapists in 2021); Dr Dianne Wilson MACP; Dr Tim Austin FACP, a Specialist Pain Physiotherapist (as awarded by the Australian College of Physiotherapists in 2021); and Dr Tania Gardner MACP, have designed a clinical reasoning framework for chronic pain, which they presented during the APA-sponsored pre-conference workshop at the Australian Pain Society Annual Scientific Meeting. 

The idea grew out of conversations at the 2025 Australian Pain Society conference, Zoë said. 

‘We wanted to embrace all of the broader impacts of pain, recognising that this is a complex cohort of patients and there is a huge impact, not just on their physical health, but on their mental health, their ability to engage in valued activities, and their ability to do all the things in life that bring them joy and meaning. 

‘The challenge was to bring that biopsychosocial framework into clinical reasoning rather than just the bio side of it.’ 

The workshop started with a brief introduction to clinical reasoning processes by Dianne. 

‘Clinical reasoning is a reflective process of inquiry and analysis that we carry out in collaboration with a patient. 

‘Those of us in the pain world know just how important that is. 

‘The aim is to understand the patient, their context and their clinical problem in order to guide evidence-based practice,’ she said. 

Dianne noted that the process was hypothesis-driven and collaborative between the clinician and the patient and involved shared decision-making. 

She stressed that clinical reasoning frameworks help to guide the ‘thinking processes’ rather than telling physiotherapists how to do an examination. 

‘We’re exploring the thinking behind the interpretation of the examination.’ 

Following Dianne’s presentation, Anne walked the workshop participants through the clinical reasoning form, explaining how to use it. 

She described the aim of the form as being to help clinicians identify the most relevant contributors to a person’s experience of pain, gain an understanding of how those contributors interrelate to each other and then create a pain formulation that would underpin the treatment strategy. 

‘The first area of the form, the subjective examination, is trying to work out the pain contributors that are most relevant at this point. 

‘This isn’t an assessment form – this is a reflective form – so you’ll also have your assessment form sitting alongside this,’ Anne said, noting that clinicians would find it most useful as a reflective tool, after completing the patient session. 

The subjective form asks the clinician to reflect on various pain contributors such as pain descriptors used by the patient, medical history including comorbidities and previous treatments, biological or psychological risk factors, current life and impacts of pain, and the social context. 

The patient’s understanding of their pain and expectations in relation to treatment are also included, as are patient values and goals. 

The second part of the form involves making a pain formulation, which is a visual flow chart that not only identifies the pain contributors, but suggests their interrelationship. 

The formulation can also indicate the pain types (nociceptive, neuropathic or nociplastic) that are suggested by the patient’s symptoms. 

From there, said Anne, the form moves to planning the physical assessment, taking into account the information gathered, the pain formulation and any red flags or areas of caution raised in the subjective assessment. 

Findings from the physical assessment can be added to the pain formulation and then a treatment and management plan can be developed. 

‘As you’re putting together all the bits and pieces you found in the whole assessment, you should be thinking not only about what direction to take your treatment, but also how that might sit with the patient’s expectations of you. 

‘Have you and the patient been able to agree on some goals? 

‘At this point, it might be too early to have firm goals, but as these clinical reasoning processes occur, maybe over a few sessions, down the track you might have a really nice set of goals that you’ve agreed on,’ Anne said. 

The final part of the form allows clinicians to add to their findings in subsequent sessions with the patients – for example, by adding in barriers and facilitators to patient progress, or discerning the goals, as noted previously. 

Anne’s presentation was followed by two case studies, first by Zoë, who showed how she might use the clinical reasoning form with a complex patient, and then by Tim, who led a robust interactive session with workshop participants who had attempted to complete the form first. 

Since the workshop, a mixed-methods research study led by Tania from the University of Sydney has been set up to evaluate the clinical reasoning form and incorporate user feedback into the final version of the form and framework. 

Over the next few months, the researchers plan to send the form out to workshop participants for a couple of rounds of feedback and updates, using a Delphi format to refine it. 

Ultimately, they hope to land on a form that can be used by any physiotherapist who works with clients living with pain. 

‘It’s a form that we think is going to really fit with the complex client group we see as pain physiotherapists but will be easily adaptable to other areas of physio practice as well. 

‘I think it’s a very contemporary version of clinical reasoning that will resonate with most physios,’ Zoë said. 

She and Anne have both had specific interest from physiotherapists in other areas of practice, including pelvic health and aquatic physiotherapy, but also believe it will have wide application across all clinical groups of the profession. 

Anne said having a strong clinical reasoning framework would help to uplift the profession. 

‘Clinical reasoning has long been one of the key attributes that distinguishes physiotherapists from many other health professions. 

‘It underpins our ability to assess complex presentations, make nuanced decisions and deliver high-quality, individualised care across diverse practice settings,’ she said. 

‘Across many areas of physiotherapy practice, there is a perception that proficiency in clinical reasoning is declining, particularly with complex presentations. 

‘Protecting and strengthening this capability is essential, not only for maintaining professional standards, but also for preserving one of the profession’s greatest strengths and points of differentiation. 

‘We need to actively reclaim, support and advance high-level clinical reasoning to ensure it remains central to physiotherapy practice into the future.’ 

Zoë said that the key feature of the framework is considering the psychosocial factors as much as the biological factors in assessing and managing a patient in pain. 

‘A big part of it is trying to gauge what the patient understands about their situation and what their expectations are. 

‘The other part of the framework, which I think is quite unique and personally find the most helpful part, is the pain formulation (or map), where we identify all the different contributors to someone’s pain experience and look at the interactions between the contributors and the pain,’ Zoë said. 

‘I find that very useful because it gives you a treatment plan. 

‘You’ve got all the contributors there and it’s really workable with the patient so it can be a lovely visual part of your education and your treatment to draw the pain map or formulation with them. 

‘Then, ask the patient to reflect on the interactions and identify the key priorities that they want to work on. 

‘I think that’s a truly person-centred approach that can beautifully lead into treatment planning and goals.’ 

Anne says the framework leads clinicians into a deeper understanding of both pain and ways to manage it. 

‘It helps physiotherapists to recognise why a particular type of treatment may or may not work well with a particular person. 

‘It not only keeps building up the physio’s knowledge on pain and its complexity, but it also simplifies that complexity,’ she said. 

‘This approach can make it easier to talk to a patient about why they should consider a specific treatment option or explain to a GP or other health professional the rationale behind a treatment plan. 

‘It can help explain why we are going to start off in a particular way and why we might be doing something differently from what has been done before. 

‘It also helps decision-making for which conditions hands-on treatment or manual therapy might be useful, and why some other medical interventions or pharmacological interventions might be helpful or not helpful.’ 

Ultimately, Anne and Zoë would like to see the framework incorporated into career pathways, mentoring processes and other points where the reflection built into the clinical reasoning process can lead to ongoing learning.