A pencil and a piece of paper cost an euro and ten cents. The pencil costs one euro more than the paper.How much does the pencil cost?

Sure?I´m so sorry buddies:

Pencil= 1,05 Paper= 0,05

Total= 1,10 euros

introCLINICAL

REASONINGin PHYSICAL

THERAPYPablo C. García Sánchez

OMT1

clinical reasoning

The thinking underpinning the

clinical practice

Cognitive, intuitive and mental

operations, which lead to decision

making processes at clinical health

field

What is for you?

Everybody confront clinical

problems in a similar way, but

with different approach and

usually different results

INTUITION

(fordward)

REFLEXION (backward)

INDUCTIONPROSPECTIVE

Experts in front of well-known problems

FORWARD

DEDUCTIVEBAYESIANANALITIC

Novels & Experts in front of new

problems

BACKWARD

intuitive reflective

2 systems

Do they interact?

continuumPureintuitive

Purereflective

How reliable is it?

How many animals traveled with Moises in the arch?

How many animals traveled with Moises in the arch?

A. Less than 1000B. Between 1000-5000C. Between 5000-

10000 0!

Noah did…

How reliable is it?

intuitive reflective

attention decision

mixdetection &

memory

Who is the boss?

problem solution

It is LESS important how

much knowledge do U have inside…

...is MORE important how it is

built and connected

Knowledge

Propositional knowledge “knowing

that”

ResearchEvidence

Non-propositional knowledge

Craft knowledge

Personal knowledge

Three Forms of Knowledge Essential, Higgs and Titchen, 1995

Knowledge

Theory

MemorizedReasoned

Practice

Learned RepeatedReasoned

Craft

Knowledge is stored in the brain in chunks or data-boxes

This store way facilitate thinking and improve communication

Signs Symptoms

Personal rememberi

ngImages

This is what are we going to call “categories”

Pathobiological

mechanisms

Physical impairments

and associated

structure/tissue sources

TISSUESTRUCTURE

HEALING phase

Contributing factors

YELLOW flags

Precautions & contraindication P/E & Rx

Activity and Participation capability/res

triction

Management, treatment &

prognosis

Patient’s perspectives

on their experience

Jones, M. and D. A. Rivett (2004). "Introduction to clinical reasoning." Clinical reasoning for manual therapists: 3-24.

CATEGORIES

Pathobiological

mechanisms

Physical impairments and

associated structure/t

issue sources

TISSUESTRUCTU

REHEALING

phase

Contributing factors YELLOW

flags

Precautions &

contraindication

P/E & Rx

Activity and

Participation

capability/restrictio

n

Management,

treatment &

prognosis

Patient’s perspecti

ves on their

experience

Data acquisition

Association of RELATED data of DIFFERENT categories build CLINICAL PATTERNS

white

• Parallel nerve trunks• Weakness• Pins & Needles• “Ants running”• Worst at night

Association of RELATED data of DIFFERENT categories build CLINICAL PATTERNS

• Pain• Heat• Redness• Tumor• Functional deficit• Improve with cold

and NSAID• Worst with

movement

inflammationneurogenic

pain

What are we going to do with this knowledge?

intuition

cognition

We´ll do it nonconciously…

Which ones?Discuss it 3´with your partner

What are we going to do with this knowledge?

cognition

Mental processes list: 1 2 3 4 5 6 7 8

Anything else?

metacognition

“Awareness and ability to think about your thinking”

Wanna share any examples with the class?

Inductive reasoningReflective BEFORE action

Reflective IN action

Reflective AFTER actionDeductive reasoning

Schon, D. A. (1983). La formación de profesionales reflexivos.

Ryan, S. and Higgs J (2008). ”Teaching and learning clinical reasoning." Clinical reasoning in the health professions: 379-387.

CR & DM Errors

Source of knowledge

Low evidence Poor research

Physiotherapist

Intuition

Cognitive

Cognition

Metacognition

Assessment

ExaminationTools

Interpretation

Treatment Techniques

Health system

decision making

The best-judged action

 

Treatment / management

Researcher

Patients

Resource$

Teacher

Policy maker

Patient

Desease Disfunction Disability

BioPsychoSocial

DiagnosticNon

diagnostic

DiscreteWell

definedAmenable

to technical solutions

Complex

Multifactorial

Changing

Poor

defined

EBP

Intuition

Expertise & CR

Pat opinions

0 10 20 30 40 50 60 70 80

Which are the basis of PT decisions?

5%only take in account patient beliefs in

their decisions

EBP

Intuition

Expertise & CR

Pat opinions

0 10 20 30 40 50 60 70 80

Which are the basis of PT decisions?

15%only take in account EBP in their

decisions

intuitive

reflective

experience

intuition

cognitionreflective

Educating intuition, Hogarth, 2001 (adapted)

Mechanic Ischemic

Improve with heat

Improve with movement

Worst at night

During sustained activities

On an spot, well localized

area

ON-OFF

Pablo César García Sánchezhttp://pcgarciasanchez.wordpress.com/