With the expanding roles of physiotherapists and greater autonomy in decision making, clinical reasoning has emerged as an important subject for education in physiotherapy. Clinical reasoning has been described as “a process in which the therapist, interacting with the patient, structures meaning, goals & health management strategies based on clinical data, client choices, professional judgment & knowledge ” (Higgs and Jones 2000, Edwards et al 2004).
This article explains the steps in the hypothetico deductive reasoning strategy (HDRS). According to HDRS, scientific inquiry proceeds by formulating a hypothesis in a form that could conceivably be falsified by a test on observable data. A test that could and does run contrary to predictions of the hypothesis is taken as a falsification of the hypothesis. A test that could but does not run contrary to the hypothesis corroborates the theory. It is then proposed to compare the explanatory value of competing hypotheses by testing how stringently they are corroborated by their predictions.
1. Observational Cues – As the patient walks into the treatment room and during the subjective interview, patient’s body language, attitude and demeanour may provide useful cues as to the underlying pathology for the physiotherapist.
2. Subjective history – In order to be able to formulate a hypothesis, a physiotherapist must undertake a detailed subjective interview, looking into the pattern of symptoms, the present episode and any previous episodes of the same condition. In addition medical, social and occupational history of the patient can also provide valuable information as to the cause of the presenting complaint.
3. Hypotheses Generation – A number of hypotheses need to be generated from the first two steps. These are then categorised on the basis of their likelihood of occurrence. A diagnostic sieve is a useful tool to aid hypotheses generation. From all the possible hypotheses, the three most likely diagnoses are selected.
4. Examination Planning - It is important that a plan is made for the physical examination, the purpose of which is to either confirm or refute our hypotheses. The examination should move sequentially from standing to sitting and further on to lying or vice versa. This helps to avoid repositioning the patient.
5. Reviewing the hypothesis – based on the physical examination findings, the hypothesis is either confirmed or refuted and a specific cause or causes can be related to the presentation.
6. Treatment Planning – The management approach chosen should be based on recent evidence and should be specific and targeted to the alleviation of the condition. A combination of approaches can be used to affect the differing causes of a patient presentation.
7. Reflection – After treatment, it is important that a therapist analyses the effect of session on patient, and whether anything could have been differently. If a management strategy is not working, then again therapist needs to rationally think about the approach chosen and its justification. If needed, the hypothesis needs to be revisited and revised and a reassessment carried out.
Usually, clinical therapists become adept in the first 6 steps and with experience are able to develop the pattern recognition capabilities, which is another clinical reasoning methodology. But it is usually the last step which is missed, where therapists do not focus on reflection to learn from their omissions and build up on their knowledge base. Use of a reflective cycle and a reflective diary are useful tools and will be explained in a separate article.