Combined Effects of Glenohumeral Mobilization, Stretching, and Thoracic Manipulation on Shoulder Internal Rotation Range of Motion.

Background/purpose: Interventions including posterior glenohumeral mobilizations (PGM), sleeper stretches, and thoracic manipulation are commonly used to address posterior shoulder tightness. The purpose of this study was to assess the effects of adding thoracic manipulation to PGM and sleeper stretches on passive range of motion (PROM), joint mobility, and infraspinatus electromyographic (EMG) activity in shoulders with decreased internal rotation (IR) PROM. Design: Randomized Sequential Intervention Laboratory Study. Methods: Forty individuals with clinically significant IR loss attended two study sessions. Participants were randomized to receive five 30 seconds bouts of either grade III PGM or sleeper stretching. Following a seven-day washout period, all participants attended a second session and received a prescriptive supine HVLA manipulation targeting the T3-4 segment, followed by the previously randomized intervention. Outcome measures included internal rotation PROM, horizontal adduction PROM, posterior glenohumeral joint translation assessed via ultrasound imaging, and EMG activity of the infraspinatus during a PGM. All outcome measures were assessed pre- and immediately post-intervention and compared statistically. Results: There were significant within-group, but not between-group, differences for IR and horizontal adduction PROM following a single session of PGM or sleeper stretch. When combined with thoracic manipulation, significantly smaller within session changes of IR PROM were observed for both PGM (mean difference 4.4, p=0.017) and sleeper stretches (mean difference 6.4, p=0.0005). There were no significant between group differences for horizontal adduction PROM, humeral head translation, or EMG activity across all time points. Discussion: Both GH posterior mobilizations and sleeper stretches improved IR and horizontal adduction PROM in a single session. The addition of thoracic manipulation prior to local shoulder interventions resulted in smaller gains of both IR and horizontal adduction ROM. Level of evidence: Level 2.

Is there 'trustworthy' evidence for using manual therapy to treat patients with shoulder dysfunction?: A systematic review.

The primary objective of this review was to create a 'trustworthy,' living systematic review and meta-analysis for the application of manual therapy interventions in treating patients with shoulder dysfunction. Included studies were English-language randomized controlled trials published between 1/1/2010 and 8/3/2023, with searches performed in: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINHAL, ProQuest Nursing & Allied Health, EBSCO Medline, and PEDro. The population of focus included adults 18 years and older with musculoskeletal impairments related to shoulder dysfunction. Our primary outcomes included pain and region-specific outcome measures. We excluded trials, including participants having shoulder dysfunction resulting from surgery, radicular pain, instability/dislocation, fracture, lymphedema, and radiation. Our screening methodology was based upon a previously published 'trustworthy' systematic review protocol. This included the application of our PICOTS criteria in addition to screening for prospective clinical trial registration and following of prospective intent, as well as assessment of PEDro scores, risk-of-bias ratings, GRADE scoring, and examination of confidence in estimated effects. Twenty-six randomized controlled trials met our PICOTS criteria; however, only 15 of these were registered. Only three were registered prospectively. Two of these did not have discussions and conclusions that aligned with their primary outcome. The remaining single study was found to have a high risk-of-bias, meaning the remainder of the protocol could not be employed and that no randomized controlled trials could undergo further assessment or meta-analysis. The results of this systematic review indicate there are no 'trustworthy' randomized controlled trials examining the effectiveness of manual therapy interventions for the treatment of patients with shoulder dysfunction, as defined by the prospectively established methodology. Therefore, these findings signal that creating a 'trustworthy,' living systematic review on this clinically relevant topic is not yet possible due to a lack of 'trustworthy' randomized controlled trials.

Does manual therapy meaningfully change quantitative sensory testing and patient reported outcome measures in patients with musculoskeletal impairments related to the spine?: A 'trustworthy' systematic review and meta-analysis.

OBJECTIVES: To perform a 'trustworthy' systematic review (SR) with meta-analysis on the potential mechanisms of manual therapy used to treat spinal impairments. DESIGN: SR with meta-analysis. LITERATURE SEARCH: Articles published between January 2010 and October 2022 from CENTRAL, CINAHL, MEDLINE, PubMed, ProQuest, and PEDro. METHODS: This SR included English-language randomized clinical trials (RCTs) involving manual therapy to treat spinal impairments in adults. The primary outcome was pressure pain thresholds (PPTs). To synthesize RCTs with high confidence in estimated effects using the GRADE, RCTs with questionable prospective, external, and internal validity, and high risk of bias (RoB) were excluded. RESULTS: Following title and abstract screening, 89 full-text RCTs were reviewed. Twenty-two studies included the criteria of interest. Sixteen were not prospectively registered, two contained discussion/conclusions judged to be inconsistent with the registry, and one was rated as having a high RoB. Three studies met the inclusion criteria; heterogeneous interventions and locations for PPT testing prevented synthesis into practice recommendations. The two studies with high confidence in estimated effects had small effect sizes, and one study had confidence intervals that crossed zero for the outcome measures of interest. DISCUSSION: Standardized PPT testing, as a potential measure of centrally mediated pain, could provide clues regarding the mechanisms of manual therapy or help identify/refine research questions. CONCLUSION: High-quality RCTs could not be synthesized into strong conclusions secondary to the dissimilarity in research designs. Future research regarding quantitative sensory testing should develop RCTs with high confidence in estimated effects that can be translated into strong recommendations.

Myofascial and discogenic origins of lumbar pain: A critical review.

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

Effect of Dupilumab on Type 2 Biomarkers in Chronic Rhinosinusitis With Nasal Polyps: SINUS-52 Study Results.

OBJECTIVES: Chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and non-steroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD) are frequent coexisting conditions and share type 2 inflammatory pathophysiology, with interleukin (IL)-4 and IL-13 as key cytokines. Dupilumab is a monoclonal antibody that blocks the shared receptor for IL-4 and IL-13. The objective of this analysis was to evaluate dupilumab's effect on type 2 inflammation biomarkers in patients with CRSwNP with/without coexisting asthma or NSAID-ERD from the SINUS-52 (NCT02898454) study. METHODS: Patients received treatment with dupilumab or placebo for 52 weeks. Blood and urinary biomarkers were evaluated through 52 weeks, and nasal secretions and mucosa brushings through 24 weeks. RESULTS: Of 447 patients, 60% had coexisting asthma and 27% had coexisting NSAID-ERD. At baseline, blood eotaxin-3, eosinophils, and periostin, nasal secretion eotaxin-3, and urinary leukotriene E4 were significantly higher in patients with coexisting NSAID-ERD than without. Dupilumab reduced eotaxin-3, thymus and activation-regulated chemokine, periostin, and total immunoglobulin E in blood, eotaxin-3, periostin, IL-5, and eosinophil cationic protein in nasal secretions, and leukotriene E4 in urine. Reductions were generally similar or greater in the subgroups with asthma and NSAID-ERD than without. Dupilumab also reduced MUC5AC and mast cell counts in nasal mucosa brushings. CONCLUSION: Dupilumab reduced local and systemic type 2 inflammatory biomarkers in patients with CRSwNP, including mast cells in nasal mucosa and cysteinyl leukotrienes in urine. These findings provide insight into the processes driving CRSwNP and the mechanisms of dupilumab's therapeutic effects. CLINICAL TRIAL REGISTRY NAME: SINUS-52 https://www.clinicaltrials.gov/ct2/show/NCT02898454. CLINICALTRIALS.GOV IDENTIFIER: NCT02898454.

Manual therapy for non-radicular cervical spine related impairments: establishing a 'Trustworthy' living systematic review and meta-analysis.

OBJECTIVES: To establish a 'trustworthy' living systematic review (SR) with a meta-analysis of manual therapy for treating non-radicular cervical impairments. DESIGN: SR with meta-analysis. LITERATURE SEARCH: Articles published between January 2010 and September 2022 were included from: Cochrane Central Register of Controlled Trials (CENTRAL); CINAHL; MEDLINE; PubMed; PEDro, and ProQuest Nursing and Allied Health. METHODS: This SR included English-language randomized clinical trials (RCTs) of manual therapy involving adults used to treat non-radicular cervical impairments. The primary outcomes were pain and region-specific outcome measures. Cervicogenic headaches and whiplash were excluded to improve homogeneity. Two reviewers independently assessed RCTs. The prospective plan was to synthesize results with high confidence in estimated effects using GRADE. RESULTS: Thirty-five RCTs were screened for registration status. Twenty-eight were not registered or registered prospectively. In 5 studies, the discussion and conclusion did not match the registry, or this could not be determined. One study did not meet the external validity criterion, and another was rated as having a high risk of bias. One study met the inclusion and exclusion criteria, so practice recommendations could not be made. The remaining study did not identify any clinically meaningful group differences. DISCUSSION: Only one prospectively registered RCT met this SR's strict, high-quality standards. The single identified paper provides initial high-quality evidence on this topic. CONCLUSION: This SR establishes a foundation of trustworthiness and can be used to generate research agendas to determine the potential clinical utility of manual therapy directed at the cervical spine for non-radicular cervical complaints.

"Trustworthiness," confidence in estimated effects, and confidently translating research into clinical practice.

Trustworthy, preprocessed sources of evidence, such as systematic reviews and clinical practice guidelines, are crucial for practicing clinicians. Confidence in estimated effects is related to how different the outcome data were between the two groups. Factors including the effect size, variability of the effect, research integrity, research methods, and selected outcome measures impact confidence in the estimated effect. The current evidence suggests that post-randomization biases cannot be ruled out with a high degree of certainty in published research, limiting the utility of preprocessed sources for clinicians. Research should be prospectively registered to improve this situation, and fidelity with prospective intent should be verified to minimize biases and strengthen confidence in estimated effects. Otherwise, discussions related to preprocessed literature, including P-values, point estimates of effect, confidence intervals, post-randomization biases, external and internal validity measures, and the confidence in estimated effects required to translate research into practice confidently, are all moot points.

Protocol for the development of a 'trustworthy' living systematic review and meta analyses of manual therapy interventions to treat neuromusculoskeletal impairments.

BACKGROUND: Preprocessed research resources are believed to be highly 'trustworthy' when translating research to clinical practice. However, the overall 'trustworthiness' is unknown if this evidence contains randomized clinical trials (RCTs) where prospective has not been/cannot be verified, has low confidence in estimated effects, and if they are not up to date. OBJECTIVES: This protocol will be used to create a baseline benchmark for a series of trustworthy living systematic reviews (SRs) regarding manual therapy interventions. METHODS: Data will originate from RCTs related to manual therapy neuromusculoskeletal interventions, indexed in 6 search engines in English from 1 January 2010, to the present. Two blinded reviewers will identify the RCTs and extract data using Covidence. The data will be synthesized based on consensus and analyzed using the Cochrane collaboration's Review Manager. EXPECTED OUTCOMES: It is expected that there will be a shortage of RCTs with at least a moderate confidence in estimated effects that will allow for strong practice recommendations. DISCUSSION: Identifying evidence that can be translated into strong practice recommendations is essential to identify beneficial and harmful interventions, decrease practice variability, and identify neuromusculoskeletal manual therapy interventions that require further disciplined methodological focus.

Is the quality of systematic reviews influenced by prospective registration: a methods review of systematic musculoskeletal physical therapy reviews.

INTRODUCTION: It is unknown if verified prospective registration of systematic reviews (SRs) and the randomized clinical trials (RCTs) that they use affect an SR's methodological quality on A MeaSurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). METHODS: Data originated from interventional SRs published in International Society of Physiotherapy Journals Editors (ISPJE) member journals, indexed in MEDLINE, between 1 January 2018 and 18 August 2021. Blinded reviewers identified the SRs and extracted the data for the variables of interest for the SRs and the RCTs. RESULTS: Two of 14 ISPJE member journals required prospective SR registration. Twenty SRs were identified, and 169 unique, retrievable RCTs were included within those SRs. One (5.0%) of the 20 SRs and 15 of the 169 (8.9%) RCTs were prospectively registered and published consistent with this intent. Nineteen (95.0%) of the 20 identified SRs was categorized as 'critically low' on the AMSTAR 2. DISCUSSION: SRs and the RCTs identified within them were infrequently prospectively registered, prospectively verifiable, or prospectively verified based on the established research record. CONCLUSIONS: Ensuring that SRs and RCTs have fidelity with the research record from conception to publication may help rule out low-value interventions, decrease variability in physical therapy practice, and solidify evidence-based physical therapy practice.

Acceptance of online education in China: A reassessment in light of changed circumstances due to the COVID-19 pandemic.

Online education in China, previously considered ineffective, has undergone significant infrastructural improvements as a result of the COVID-19 pandemic requiring students to attend classes at home. This paper explores the experiences of Chinese students who have studied online during the COVID-19 pandemic to investigate whether the use of online education for degree-seekers has become a more acceptable way to expand access to higher education in China. Specifically, this study utilizes a phenomenological approach which focuses on the perspectives of the Chinese students' impressions from their recent experience with taking online courses. Findings indicate that while there is a growing acceptance of online education, there remain key challenges online educators must overcome to gain true legitimacy in China's higher education sector.

Effect of Load on Muscle Activity, Kinematics, and Force Production During the Reverse Hyperextension Exercise.

The reverse hyperextension exercise is used to strengthen posterior chain musculature without axially loading the spine; however, there are no suggestions for loading. Twenty recreationally active individuals (13 males and 7 females; aged 25.4 [2.5] y; height 1.76 [0.09] m; mass 79.3 [15.8] kg) performed 2 sets of 10 repetitions with 50%, 100%, and 150% of bodyweight. Surface electromyography measured erector spinae, gluteus maximus, and biceps femoris activity. Motions of the trunk, lower extremities, and reverse hyperextension exercise pendulum were tracked. A 1-way repeated-measures analysis of variance was used to analyze differences. Few differences were found between 100% and 150% loads; however, heavier loads resulted in increased hip (5.0°) and trunk (4.0°) flexion compared with the 50% load. Similar patterns emerged for peak and integrated muscle activity, with erector spinae and gluteus maximus activity greater in the 100% and 150% loads than in the 50% load, and biceps femoris activation increasing as load increased. Peak force significantly (P < .001) increased with 100% (28% [31%]) and 150% (34% [40%]) loads compared with the 50% load. Findings suggest the reverse hyperextension exercise targets posterior chain musculature, but increasing loads does not linearly increase force and muscle activation.

Do Prospective Intent and Established Metrics Correlate with Journal Impact Factor in Musculoskeletal Physical Therapy Trials?: A Secondary Analysis of A Methodological Review.

OBJECTIVES: To determine if there are any statistically significant associations between: 1) randomized clinical trials (RCTs) investigating physical therapy musculoskeletal interventions, 2) journal impact factor (JIF), 3) frequency of RCT citation, 4) whether prospective intent was identifiable, and 5) the Physiotherapy Evidence Database (PEDro) scores. METHODS: MEDLINE indexed RCTs addressing musculoskeletal interventions published between January 2016 and July 2020 in physical therapy journals were included. Two blinded reviewers identified the RCTs and extracted the variables of interest. RESULTS: With a familywise alpha adjustment, there was no statistically significant correlation between JIF and number of citations (rho = 0.187; p = 0.0280). Statistically significant weak positive correlations were identified between the JIF and prospectively registered RCTs (rho = 0.240; p = 0.0046), JIF and PEDro scores (rho = 0.250; p = 0.0031), and PEDro scores and prospectively registered RCTs (rho = 0.335; p < 0.0001). CONCLUSION: The findings of this study suggest that JIF and PEDro scores may not be accurate measures of RCT quality. Failing to ensure that published RCTs followed their prospective intent and using bibliometrics that fail to accurately measure what they propose appears to create untrustworthy preprocessed resources for practicing physical therapists during the evidence-based practice process. LEVEL OF EVIDENCE: 1a.

Cervical disc degeneration: important considerations for the manual therapist.

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

The Unknown Prevalence of Postrandomization Bias in 15 Physical Therapy Journals: A Methods Review.

OBJECTIVES: To determine the prevalence of prospective clinical trial registration and postrandomization bias in published musculoskeletal physical therapy randomized clinical trials (RCTs). DESIGN: A methods review. LITERATURE SEARCH: Articles indexed in MEDLINE and published between January 2016 and July 2020 were included. STUDY SELECTION CRITERIA: Two independent blinded reviewers identified the RCTs using Covidence. We included RCTs related to musculoskeletal interventions that were published in International Society of Physiotherapy Journal Editors member journals. DATA SYNTHESIS: Data were extracted independently for the variables of interest from the identified RCTs by 2 blinded reviewers. The data were presented descriptively or in frequency tables. RESULTS: One hundred thirty-eight RCTs were identified. One third of RCTs were consistent with their prospectively registered intent (49/138); consistency with prospectively registered intent could not be determined for two thirds (89/138) of the RCTs. Four RCTs (8%)reported inconsistent results with the primary aims and 7 (14%) with the outcomes from the prospective clinical trial registry, despite high methodological quality (Physiotherapy Evidence Database [PEDro] scale score). Differences between prospectively registered and non-prospectively registered RCTs for PEDro scale scores had a medium effect size (r = 0.30). Two of 15 journals followed their clinical trial registration policy 100% of the time; in 1 journal, the published RCTs were consistent with the clinical trial registration. CONCLUSION: Postrandomization bias in musculoskeletal physical therapy RCTs could not be ruled out, due to the lack of prospective clinical trial registration and detailed data analysis plans. J Orthop Sports Phys Ther 2021;51(11):542-550. Epub 21 Sep 2021. doi:10.2519/jospt.2021.10491.

Dupilumab suppresses type 2 inflammatory biomarkers across multiple atopic, allergic diseases.

BACKGROUND: Type 2 inflammation is common in numerous atopic/allergic diseases and can be identified by elevated biomarker levels. Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4 and interleukin-13, key and central drivers of type 2 inflammation. OBJECTIVE: Assessment of dupilumab effect on type 2 inflammatory biomarkers in atopic dermatitis (AD), asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) and eosinophilic esophagitis (EoE). METHODS: Data were extracted from three randomized placebo-controlled trials of dupilumab in AD (NCT02277743, N = 671; NCT02277769, N = 708; NCT02260986, N = 740); and one each in asthma (NCT02414854, N = 1902); CRSwNP (NCT02898454, N = 448); and EoE (NCT02379052, N = 47). Biomarkers assessed were serum thymus and activation-regulated chemokine (TARC), plasma eotaxin-3, serum total immunoglobulin E (IgE), serum periostin and blood eosinophil count. RESULTS: Dupilumab versus placebo significantly suppressed most type 2 inflammatory biomarker levels across all studies/indications where data were assessed. Reductions in serum TARC, plasma eotaxin-3 and serum periostin occurred rapidly, whereas reductions in serum total IgE were more gradual. Across diseases, at the end of treatment, median percentage change from baseline in TARC levels ranged from -24.8% to -88.6% (placebo +2.6% to -53.6%); -38.2% to -51.5% (placebo +8.3% to -0.16%) in eotaxin-3; -24.8% to -76.7% (placebo +8.3% to -4.4%) in total IgE; and -13.6% to -41.1% (placebo +10.1% to -6.94%) in periostin levels. Blood eosinophil responses to dupilumab varied by disease, with minimal changes in AD in the SOLO studies (median percentage change from baseline to end of treatment: 0% [95% CI: -15.8, 0]); transient increases followed by decreases to below-baseline levels in asthma (-14.6% [-20.0, -7.7]) and CRSwNP (-29.4% [-40.0, -16.3]); and significant decreases in EoE (-50.0% [-50.0, -33.3]). CONCLUSION AND CLINICAL RELEVANCE: Dupilumab reduced levels of type 2 biomarkers across clinical studies in patients with AD, asthma, CRSwNP and EoE.

Should low-quality evidence dominate high-level evidence? A systematic review and meta-analysis of systematic reviews of musculoskeletal physical therapy interventions.

OBJECTIVES: To determine the: 1) quality of articles cited in systematic reviews (SRs); 2) methodological quality of the SRs; and 3) impact of quality on level 1A evidence. METHODS: SRs related to musculoskeletal physical therapy interventions were identified. The methodological quality of the SRs and articles cited by the SRs were assessed by two blinded reviewers. Data analysis was performed by a third blinded researcher. Additional comparisons were made based on the Journal Impact Factor, spin, financial bias, and conflict of interest. RESULTS: Twenty-four SRs were identified; 21/24 SRs had 'critically low' quality on the AMSTAR 2. Thirty-four percent of included studies were 'low quality,' and 58% of SRs included studies that had unreported external validity. One-half of the SRs represented 'spin,' and one-third of the SRs generated conclusions based on low-quality clinical trials. DISCUSSION: The 'critically low' SRs methodological quality was exacerbated by low-quality research inclusion. Most SRs failed to follow best practices, including prospective registration and integration of professional librarians in the search process. Based on the high proportion of SRs that include low-quality trials and overall low methodological quality, further discussion regarding practice recommendations on level vs. quality of evidence is warranted. LEVEL OF EVIDENCE: 1a.

The why, where, and how clinical reasoning model for the evaluation and treatment of patients with low back pain.

BACKGROUND: There is considerable overlap between pain referral patterns from the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip. Additionally, sciatic like symptoms may originate from the lumbar spine or secondary to extra-spinal sources such as deep gluteal syndrome (GPS). Given that there are several overlapping potential anatomic sources of symptoms that may be synchronous in patients who have low back pain (LBP), it may not be realistic that a linear deductive approach can be used to establish a diagnosis and direct treatment in this group of patients. OBJECTIVE: The objective of this theoretical clinical reasoning model is to provide a framework to help clinicians integrate linear and non-linear clinical reasoning approaches to minimize clinical reasoning errors related to logically fallacious thinking and cognitive biases. METHODS: This masterclass proposes a hypothesis-driven and probabilistic approach that uses clinical reasoning for managing LBP that seeks to eliminate the challenges related to using any single diagnostic paradigm. CONCLUSIONS: This model integrates the why (mechanism of primary symptoms), where (location of the primary driver of symptoms), and how (impact of mechanical input and how it may or may not modulate the patient's primary complaint). The integration of these components individually, in serial, or simultaneously may help to develop clinical reasoning through reflection on and in action. A better understanding of what these concepts are and how they are related through the proposed model may help to improve the clinical conversation, academic application of clinical reasoning, and clinical outcomes.