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Observations in Practice: Clinical Toolbox vs. Clinical Reasoning

This post is the second part on my series: Observations in Practice (part 1 here).

On his blog, NOIJam, Dr. David Butler introduces a great discussion on grade V manipulation and wants to know who is doing it, is anyone researching outcomes,  “And are there others like me who have moved to more educational/mobilising strategies – but in the  back of their minds they don’t want to give it up completely and so they keep “cracking” as an option?”  A great discussion has started in the comments section and I highly recommend you check it out.

While Dr. Butlers post leads to the debate of the use of manipulation, I would like to begin a discussion on a similar but broader topic…“The Clinical Toolbox” vs. “Clinical Reasoning“.

Over the past several years, I have interacted with, and observed, the practice of many Physical Therapists and students.  I have been fortunate to take some great CEU courses and interact with some very bright minds in the field.  Like many, I have enjoyed learning new “techniques”, but in the end, I have to wonder, is it about the “technique” or “the interaction?”  What drives my outcomes?

I have written in the past about uncertainty, placebo, and expectations, and as we learn more about the therapeutic alliance between clinician and patient, how important is the infamous toolbox, really?  In an age where literature has challenged the relationship between patho-anatomical abnormalities and patients symptoms, do we need to know 10 different ways to manipulate the spine?  Is my patient not getting better because I only learned 9 ways?   Is my practice not eclectic enough?  Maybe it’s because the state of PA has yet to embrace dry needling?

Through my own observations and reflection, I suspect that the toolbox is only as deep as one’s ability to clinically reason.   Great clinician’s are those who have an understanding of the human condition.   They are those who are able to achieve outcomes with minimal amount of force, tools and rules.   They are those who embrace the individual nature of a condition and can justify (cognitively and meta-cognitively) each of the interventions they employ.   They are lateral thinkers who do not blame the individual or the tissue; they instead learn how to interact with it.

So all of this said, what would you prefer:  To have an uncanny ability to clinically reason OR have every tool in the toolbox?

Let’s discuss…

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13 replies »

  1. I like to think of the clinical toolbox as being a necessary component within the overarching context of clinical reasoning. I think when it comes to the research on the importance of the therapeutic alliance and the interaction wih the patient, the results don’t completely negate the other aspects of the person, as a whole, such as changes in tissue. Think of the neuromatrix diagram… there still is a sensory signalling input in addition to the cognitive and the emotional related brain areas.

    Clinical reasoning is what lets us determine the best ‘tool’ for an individual patient.

  2. In post graduate training, the school of training was largely clinical reasoning-based. Techniques taught were the essential ones, not too many. As we know, there can be so many techniques to achieve the same outcome. Which technique we choose is always in the best interst of the client (comfort, signs and symptoms, irritability, etc). The outcome? I am a better clinician who can diagnose and plan a management plan with a small but sufficient tool-kit.

  3. Great thinking guys. Erik, you state “Clinical reasoning is what lets us determine the best ‘tool’ for an individual patient.” Now I suppose we have some similar tools as well as some different ones. But why do you choose, let’s say, a grade 5 vs. a grade 3? What led you to performing one technique vs another? And how sure are you that the other tool wouldn’t have produced the same results? How can we know that it’s even about the tool?

    I am curious why one chooses one technique over another, and if outcomes, are based upon us making the “right choice of tool” OR simply interacting w that patient???

    Thoughts?

  4. Why not have both? In our fellowship program we emphasize MDT as a system to start with, and less versus more techniques. What makes me choose a particular technique? At least a 50/50 split between patient preference/expectation and my my clinical expertise (or is that equipoise). In the end, any technique I choose is what I consider a cheat to get the patient to be more compliant with their home program, which is what keeps the transient neurophysiologic changes going.

  5. Joe, we can’t be sure it’s about the tool without using prospective randomized controlled trials. Even then, we are only looking at a comparison of the tools tht were chosen to be studied. I think that point is important when looking at, for example, the LBP treatment based classification – manipulation, motor control, directional preference, traction. DNM and simple contact techniques weren’t studied, nor was CBT, tape, or any other tool that therapists may think of using. That’s why I support the tools I use to my colleagues and patients with ‘the best current evidence,’ of course meaning the combination of peer reviewed evidence, clinician expertise (feels weird to use that word one year out), and patient beliefs and values. So, there is a ‘best tool’ for each combination of the therapist (with their experience, thoughts, beliefs, current knowledge) and the the patient (their diagnosis, current neuromatrix/neurotag, knowlege of options). That tool always comes with the interaction, and the interaction may be the tool sometimes. Maybe there can be a wrong tool, though, like DG’s example on LinkedIn of the bicep strengthening in a baseball pitcher or the grade V manip into extension for an old lady with osteoporosis or mets to the spine.

    Maybe this new evidence and thoughts on therapeutic alliance, non-specific effects, emergence, etc should make us step back a little and consider PT as both an art and a science. Sure, it would be nice to have a ‘pure’ science of therapy, but I think that is impossible, considering all of the variables involved and the fact that everything hasn’t been studied yet (and it never will).

  6. Again great discussion. Erik, what would you classify as “art” and what would you classify as “science”? I would argue we are learning that science is supporting the nature in which we interact w patients and the effects of this interaction. While I would have once categorized this as art, I would say the supporting science of this is strong.

  7. Can’t art be the way in which the science is applied, maybe? They kind of blend into each other, I think.

    But then again, isn’t science more a process than a body of information? I know plenty who try to justify their practice by searching for articles supporting something they do, instead of applying critical thinking and considering what the ‘evidence’ is really telling us… why a specific thing may work. Again, back to linkedin discussions, thinking of CST and MFR… they seem to ‘work,’ but it may just not be via the proposed mechanism.

  8. Just what is that human condition is the first question that comes to mind… Through what kind of lense do we view it. Do we include a certain level of understanding of ourselves and our personal experience of adaptation to our individual environments and their challenges in viewing, or attempting to view our patients’ individual human condition?

  9. Great post Joe. Thank you.
    To be very blunt, my toolbox has been emptied to just a few essentials: hands-on gently, and my education of the patient.
    That is all.
    It used to be filled with many more. And not cheap at that.
    Can’t say those tools are sorely missed, since my understanding is improving, and my education has improved a lot.
    Finding the right language to connect with the patient appears to be the single biggest therapeutic tool I have improved on.

  10. Great discussion and view points. More tools in the tool box does not make one a better carpenter (or therapist) is my personal view point. Understanding (based on the current best science evidence) how the tool might work is more important. Some woodworkmen can use very simple tools and create masterpieces, while a less skilled one can have the best and most tools and not create anything near as wonderful.

    The art of therapy is in the interaction, while there is science to guide how this interaction should occur, there is much that is unknown (and probably will always been unknown when dealing with a unique individual going through their unique human experience).

    Why would I select a grade 5 (HVLA thrust) over a grade 3 (large amplitude into resistance)? Based on patient preference through our interaction together, my clinical experience should make me more in-tune with what the patients system is looking for to improve their human experience. They don’t have to have a grade 5 or grade 3 to get better (unlike, they probably need an appendectomy for a ruptured appendix to get better). But if there system likes the movement produced through the selection of technique (tool) and it produces a favorable outcome (improvement in comparative sign) then for this specific point in time it was the right choice (it may very well change at some other point in time). Of course there may be many types of movement that can create a favorable outcome. Often this is probably due to the explanation that the technique is wrapped in along with fitting the patient’s current expectations and beliefs. Also the handling skill is important I believe, not from a moving this bone on that bone or releasing fascia standpoint, but from a communicative tool. If I use harsh language most people will probably be more defensive and not be as open to the communication that I am offering, whereas a softer more gentle language will open up communication channels to allow dialogue to occur. I believe our handling techniques can offer this same sort of communication process between a therapist and the patient. Again I don’t think the hands are doing much to operational change the tissue, but they are working to interact with a patient which can help that individual let their own self start changes for a more favorable outcome.

    It’s tempting to think that I, the therapist, am the change maker through the tools that I use such as the woodworker on a piece of wood. But ultimately it is the patient that is the change maker and we are just there to help catalyze something they already have within themselves – thus leaving the locus of control where it should always belong, with the patient.

  11. I think a few tools are needed. These tools are the ones the patient believes will help. These need to be a part of the encounter. This is why I ask what they believe is the problem and what intervention they believe will help. I supply they along with a liberal dose of pain education and most importantly – homework.

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