September 2021: Physiotherapy is a scientific profession where physiotherapists utilise evidence-based thinking, relying on our knowledge of disease and chronic illness, of anatomy & physiology, and of biomechanics. However, there is not just one logical sequence of steps or rigid structure to assess the people who seek help from a physiotherapist. After an assessment, there isn’t one path to follow in choosing and delivering treatments; there isn’t a magic formula for choosing the parameters of techniques, and/or treatments.  I believe that in addition to science there is a form of art to physiotherapy, to tailor assessment and treatment, to customise a plan to suit a particular individual, to guide individuals on choosing the best option, to communicate with empathy and compassion while above all, to make actions objective, righteous and ethical.

I am not the first person to believe that physiotherapy or medicine can be a form of art. The Hippocratic Oath, reads “In purity and according to divine law will I carry out my life and my art,” and, “So long as I maintain this oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art”.  The Hippocratic oath, has been a feature of medical study and practice for hundreds of years, and refers to the practice of physicians as a form of art.

Since then we have established that assessment and treatment is not a straightforward process; this got me thinking about the processes that we make decisions through a process of clinical reasoning. Clinical reasoning is taught in the undergraduate curriculum from day 1, and every physiotherapist in clinical practice uses this process, but what exactly is it? and how do physiotherapists use it to make their decisions? So, first what is clinical reasoning? Well, there isn’t just one definition…here are a few…

‘Clinical reasoning is the process by which the clinician interprets subjective information along with physical examination findings, in order to identify the most appropriate management decisions for individual patients’ (Petty & Ryder 2017)

‘Clinical reasoning is the thinking and decision-making processes used in clinical practice that enable therapists to take the best-judged action for individual patients e.g. making a diagnosis, determining management plans and selecting strategies to establish collaborative interactions with patients’ (Edwards et al, 2004)

‘Clinical reasoning is the means to wise action’ (Cervero, 1988 cited in Hengeveld & Banks 2014)

The one thing that these three definitions have in common is that by using clinical reasoning a physiotherapist must make ‘good decisions’ (wise action 1^st quote, most appropriate management 2^nd quote, and best judged action 3^rd quote). What are our clinical reasoning and decision making processes to take logical steps to make the ‘wise decision’ of assessment and treatment? One model which has been suggested to aid the clinical reasoning process is a biopsychosocial model presented by Edward & Jones in 1995 (see figure below), they suggest clinical reasoning as a collaborative process between the physiotherapist and patient. The physiotherapists reasoning begins with initial concept, possibly from referral or cues from initial informal discussion and observation, where the physiotherapist starts with multiple hypothesis. The physiotherapist then refines these initial hypotheses collaboratively with the patient through the subject and objective examination, with their own knowledge, cognition and metacognition and the patients understanding of their problem that they are presenting with. This aids decision making in diagnosis and management.

Ref: Edwards and Jones (1996) in Jones and Rivett (2004) 

This hypothetico-deductive reasoning model is common in physiotherapy practice, but is not the only model, and often physiotherapists won’t stick to one model. As an experienced rheumatology physiotherapist I often reflected that if you really listened to the person (patient), (top right within this model) they always told you what was wrong with them, or the thing that they really wanted help with. Often the initial cues that I received, possibly an altered gait, or change in movement pattern, was long-standing and not what the person in front of me was seeking help for, so my first reflection is that an initial hypothesis frequently could be wrong and taking time to listen to the person in front of you was the most valuable part of the assessment. My second reflection, is within my knowledge base. Physiotherapy is a very rich profession with very knowledgeable and compassionate people. As my knowledge base widened I did not just have hypothesis A, B & C, I had also experience of A-Z, and while I could deduce that hypothesis B, M & X were the most likely ones I often could not discount the unusual presentation of a previous patient. Effectively, the more I knew, the less certain I became. Discussions with colleagues (mostly with a cup of tea) were always helpful to me.  As an anxious practitioner, I never wanted to miss anything or get something wrong, but as time went on I realised I often didn’t have definite answers, but once I had considered and discounted red flags I could continue to define then refine my hypotheses.

When working in rheumatology with people with long term chronic conditions, we really got to know our patients and their journey. From a humanistic point of view, health emphasises the whole individual rather than the focus of certain parts such as a shoulder problem, or a flare of the arthritis. From my point of view, although the clinical reasoning model is useful and part of my practice, I needed to consider the value of the interactions between physiotherapist and person, to consider the compassion and empathy that we show individuals that seek help and share their story with us (which might not be easy for them).

I have been very privileged to work and learn from compassionate members of the MDT. I have been told that often patients valued the interactions and the therapeutic ability to share their story, to be listened to and understood, more than a treatment or strategy that was offered. Therefore, to conclude, as physiotherapists our knowledge of science is our base, with clinical reasoning and clinical reasoning models integral within our practice. The variation that clinical reasoning allows in our thought processes and decision making forms part of the ‘art’ of physiotherapy. In addition, listening allows us to focus on the whole person in front of us – what is important to them, and place value on the quality of our interaction, so we can deliver care with empathy and compassion. There really are many skills to being a physiotherapist, and I’m sure many more which I haven’t touched on.

Marie Therese

References

Clinical Reasoning for Manual Therapists (2004). Publisher: Edinburgh, United Kingdom: Elsevier, Butterworth-Heinemann. Editors: Jones M.A., Rivett D.A

Ian Edwards, Mark Jones, Judi Carr, Annette Braunack-Mayer, Gail M Jensen, Clinical Reasoning Strategies in Physical Therapy, Physical Therapy, Volume 84, Issue 4, 1 April 2004, Pages 312–330, https://doi.org/10.1093/ptj/84.4.312

Management of musculoskeletal disorders (2014). Publisher: Edinburgh : Churchill Livingstone / Elsevier. Authors: Kevin Banks, Elly Hengeveld, Matthew Newton, G.D. Maitland.

Musculoskeletal Examination and Assessment – 5th Edition, A Handbook for Therapists (2017). Publisher: Elsevier. Editors: Nicola Petty, Dionne Ryder