Pragmatic Application of Logic and the Scientific Method to Clinical Reasoning Exposes Some Avoidable Traps for Young and Old Players
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PURPOSE: To explore the rationale and underlying reasoning associated with some clinical decision making. RELEVANCE: Common clinical reasoning practices can lead to unsubstantiated conclusions through flaws in logic or the application of evidence. Clinical examples will be presented and methods discussed that can be incorporated in everyday practice to improve the integrity of the reasoning process. DESCRIPTION: Examples of reasoning processes used in clinical decision making will be used as illustrations of the underlying processes. (1) A patient with neck pain has improvement in the most limited range of motion following mobilization to C6; therefore, mobilization to C6 should be continued. (2) Patients with chronic back pain have altered patterns of muscular activity; therefore, treatment should target improving patterns of muscular activity. (3) Patients with neck pain improve with thoracic spine manipulation and there are minimal risks associated with thoracic manipulation; therefore, patients with neck pain should receive thoracic manipulation. (4) Patients with back pain get greater improvement with exercise and manual therapy combined than when receiving either individually; therefore, patients with back pain should receive both treatments. EVALUATION: The above propositions will be evaluated by the application of logic, the scientific method, statistical inference, and principles of evidence- informed practice. Methods of overcoming questionable reasoning processes will be presented, including (1) rigorous interpretation of evidence from the literature; (2) application of all 3 pillars of evidenceinformed practice, including clinical expertise and patient values/preferences; and (3) structuring assessment and reassessment to reduce the risk of bias. CONCLUSIONS: Many common clinical reasoning practices are potentially unreliable. Flawed or incomplete reasoning does not necessarily mean that interpretations are wrong, rather that the interpretations are not necessarily right. IMPLICATIONS: Robust clinical reasoning processes combined with small changes in clinical practice could improve our ability to be confident in the accuracy of clinical judgments.
IFOMPT 2012 Rendez-vous of hands and Minds
Copyright 2012 Journal of Orthopaedic and Sports Physical Therapy. Reproduced with permission of the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA). Please refer to the journal's website for access to the definitive, published version.