理学療法におけるクリニカル・リーズニング

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Ifidillutilltlt7i･

tt

25

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4-"]･ 147

--

164IY{

(1998

iii)

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I

CXnical

Reasoning

inPhysicag

Therapy*

IwaarkA.

Jones*'

Are you an expert inyour owri area of _physical

therapy _practice? Simon45) has suggested that

it

takes at

least

ten

_years'experience toobtain

profi-ciency

in

any _profession. While experieFcc is obvi-ously necessary toobtain expert status, itis

cqual-ly

recognised

that

therapists with comparable _years

ot'experience can has,cmarkedly differen'L]evelsof cxpertise.

I

have

compiled a

little

self evaluation

test of clinical expertise

based

on expert-novice

re-search across the healthprofessions.

How

many of the

items

listed

in

Tab]e

1 ca- _you tickfor

your-seEf?

Expcrt.ise is obviously rnultidimensional

in-e()rporating Et combinari/ion ol innate and

learned

characteristics

including

intellectua]apt.itude; per-sonality

(eg.

curiosity, ernpathy,

humility);

knowl-edge orgE-mi:sation; communication, rnanual and thinking skMs.

Experts

arc often considered tobe "good _thinkers"

but

_{traclitona!lyour}

physical

thera-py schools and continuing ec]ucation _pregrams

have

gi'ven

little

formai attention to specifically

assessing amd. 1.eachingthinking skills. Rather itis

assurned Lhat the thinking progess will irnprove as stuclents acquire the necessary

knowlcdge

base and

practice

applying this knowledge inclinical situa-tions. "rhiLethiscan

be

true

and our _physical

ther-apy

.sc;hools

havc obviously _procluced rriany _good

thinkers,many _poor thinkers have also conie out of

'this

_{traditionaleducat{onaL systern,}

U,'eakerstu-' _{]1li1･/;i:stE2ki[SiJao ]) ;" !v}

-

_i)

--

.7t=:

_{y p'}

" _Vniversity

of SouthAustralia

J{ey wo#dE: Cliniutilreasoning, Physicaltherapy,

Cdge Ol-Elal'IL5atlOll

dents often lack key aspects of skilled elinical

reasoning which limit thcir abi]ity to acquire

knowledge

through theireducation or they acquiTe

the k"owledge but have great difficultyin

Eipply-ing thisknowledge

in

a clinical context.

Stronger

students already seem to _{possess good} thinking skills so whell equipped with

increasiiig

amounts of

knowledge they tend toexcel.

0r

do

Lhey?

Do

we

take our streng students as faras they are

capa-ble?

They

may have very _good logicalthinking

skills while

lacking

the creative and }ateral

thlnk-ing abilities required to advance our profession.

Thcrc isan emerging consensus across the health

professions that the thinking _process, or clinical

reasoning, can

be

learned

and iniproved when

spe-ci[ic attentlon is

paid

tofacilitatingclinical

reason-ing and theke},factersthat influenceit24).Greater

attention to clinical rcasoning shoulcl also lead to

improved

paticntoutcornesi6).

1]oor clinicat reasoning

is

not always obvious

unless specific measures are taken to revcal _thc

thjnking underlying the therapist's actions.

Con-sider the

following

example:

Cgimicag

Reasoning

of

Two

Physiotherapists

an

an

Orthopeeedic

Settimg

A

physical theTapist examined and treated a 45

year old p]umber who presented with a "hip

achc".

The fjrsttreatment consisted ot'

stretchinglmobilis-ing

the

hip

into

flexion and fiexionladduction

which

improv'ed

the patient'ship mobility and the

patienL came back at the second appointment

treat-148

ve\tstk\eg

25

igag

4

g

Table 1

l.Experts achieve superior clinical outcemes in rnanaging _patientswithin theirspecialised area of

tice

2.Experts can recognjse clinical _patterns and have a iarger range of clinical _patterns stored in their

memory than novices. That is,experts have a superior organisation of knowledge

3,Experts' organisation of knowledge include _{propositional} knowledge

(eg.

research based biomedical

knowlcdgeL

professional craft

knowledge

(

¢g. experience

based

clinical

knowledge>

and personal

edge

(eg.

knowledge

of one's self).

Experts

seek

to

understand patients'problems with respect towhat

the

profession

has empirically learned and what science can contribute regarding the underlying

pathoblology.

4.Experts are fast,they solve problems quickly

5.Experts make fewer errers

in

theirinterpretations,

judgements

and conclusions reached

6.Experts concept"alise problems at a

deeper

level

than novices

7.

Experts

spend a great

deal

of time analysing a problem qualitatively

8.Experts have strong self monitoring skills, they can reflect on the significance of _patient

data

as

it

foldsand recognise limitationsof the _qualityof data obtained as well as lirnitationsin theirown skills

and

knowledge

9.

Experts

have

a

depth

of understanding of the clinical _problem which

includes

the patienVs perspective

10.

Experts

take

a more holisticapproach to

their

patients

11.Experts have _great¢r confidence

in

predicting _patientoutcomes

]2.Experts have _greater ability incontrolling their work enviromiient

13.Experts _possess superior verbal and nonverbal communlcation with their_patients

14.Experts make greater and more effective use of teaching intheirpatient rnanagement

l

5.

Experts

engage

iri

collaborative

decision

making with the _patient

16.

Experts

atteltd toproblem prevention not

just

problem resolution

17.Experts are more

through

intheir_patientexamiriation

18,Experts do not simply follew routines or recipes, they engage incritical, reflective, hypothesis driven

thinking

19.Experts are critical and open minded

20.Expcrts don't$top at

being

effective, Lhey are always tryingto

be

more effective

2I.Experts possess superior creative,

lateral

thinking abiHties

ment was rcpeated much the same

two

more

times

with furtherincrease in

hip

range of motion

but

no

change inhisache and at

his

East

appointment the hip was mobilised more firmly with no

fllrther

im-provement.

A physical therapy colleague was asked

to

exam-Lneand treat the patient. His treatment consisted

of postero-anterior accessary movement over the

L5/Sl

posterior

Lntervertebral

joint

from a

com-bined _positionof right rotatien, extension and right

lateralflexion,

into

stiffness and provoking the

patlentJs

"hip

ache". This treatrnent produced

sustained improvement and progression of

the

same technique rendered the patientsymptom free

aiter

four

treatments.

Assuming

Therapist

One'$

decision

to treat the

hip

was incerrect why did these two therapists

arrive at

different

treatment

decisions?

Was

Therapist One's examination incomplete or

did

he

mi$interpret information obtained?

A

review of

each therapist'sexamination summary will reveal

significant

differences.

Orily

structural

considera-tionsregarding the source of the patientsache are

considered here to highlight the clinical reasoning

process. Equally

important,

non-structural

factors

as

discussed

Iaterin this_paper should also

be

con-sidered.

Therapist

One's

summary of his examination

findingsare as foLlows:

(ET=examiner's

thoughts)

The

_patient

is

a 45 year o!d _plumber whose main complajnt was a "hip" ache which

developed

threeweeks earlier. He was

kneeling,

attempting

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Cljnical

Reasoning

in

Physical

Therapy

sllpped resulting

in

an

iinmediate

jab

of _pain in

the buttock

(ET/twi'stjng

injury

to

hip).

It

was

very sore

for

a

few

day$,

then improvecl although

itstill achecl after being on

his

feet

t'ormoTe than

20

minutes. Sleeping had not

been

a probtem

and he would typicaLly feelhis

"hip"

first

thing in

the morning when _getting out of bed,

There

was

no past hisLory of any

hip

or

back

_problems

though the _patienthas had more

dlfficulty

over

the past fjveycars assuming

low

squat positions

{ETi

patiEnt must have injured hisotctstif'l'hip).

The

physical examination revcaled good post.ure

and

fuL[

_painLess luinbar _{physiotogical}

move-ments inalL clirections. He was a

bit

sore to pest-eroaRterior g]ides t.othe right of the 1.5$pinous

process, lml.the most significant findings were

his

restricted

hip

inovement.s "ihich were worse

on the right

(ET:

thi$ stiff hip will have to

be

nnobilised}.

Therapist

Two'6 summary of

his

examination

findingsare as

follo"rs:

A 45 yeai'olct plumber presented with complednts

oi'an ac;he irihis "hip" _localisedto

just

below Lhe

right

iliac'.

crest with no syinptems inany other

areas.

(ETi

atypicat

for

hip,

must consicler

lumbar

spine, sacro-iLiac

joint,

]ocal

soft tissues,neural

strucLures and the hip itselfas potentialsources

of the s.vmptoins). His main _problem was a

eral aclie with walking more than 20 iuinutes. It

was not related to any specific _pha$c of

his

_gait,

iiever

increased

and settled completely wil/hin

t'ivemintites oE sltting down {IEI[':mechanical,

non-irritable, non-inflarnmatory disordcr).Sitt{ng

would ease the ache and getting up

from

sitting

was riot a _problein,

I.ying

in

any position

but

prone wouLd settle theachE and he feLtbest ifhis

knees were bent up.

(ET:

spiual and/'or lower

limb

exi.cnsion are more implicated). When

questioned about specific activities afid _postures

w･

hieh

might. irn_plicate othcr sources, he

149

remembered

feeling

a slight ache a few times

with

twisting

right toreverse the car.

All

other act[vities and _pesture$ sttggested t.oimplicaLe

lumbar, neural, sacro-iliac or hip sources

(eg.

bencSing,

liiting,

sustained t'lexion, crossing legs,

using stairs, stcpping off curb,

dressing,

squat-ting)were negative

(ETi

source of symptoms

is

lcss

likely

muscle, sacro-iliac

joinL,

hip or lumbar

disc).Squatting isanother action that gives him

difticulty.He has

found

gettjnginto a ftillsquat

position ])rogressively more

difficutt

over the

pa3t fivc years. He

doesn't

get any

djscomfort

with squatting, but Lhe hips feel''stiff"

and he felt.

certain this hadnl been any differentsince he

has been having his

hip

ache'CET: not likeEythe

clirectsource of hissyrnptems but may well be a contributi'ng

factor).

Sleeping was not a problern

(ET:

supports

disorder

being non-inf]ammatory).

This all started three weeks ago when he was

trying

to

loosen a tight

fitting

aRd the wrench

slipped. He was kneeling and leaning

forward

under a

kitchen

sink at the time and as the

wrench letgo

his

body

twisted quickly to the

right wlth a suclden

jab

of pain.

From

his

dem-onstration most rnovement occurred at the Lrunk

(ET:

this cou}d

'fit

with lumbar

joint,

neural

tissue,sacro-iLiac or musclelfascia

in

Lhe

lumbar-pelvicarea however the

hip

joint

continues to be

lessLikely).He worked on "rith only slight ache

and

had

no

dlfficulLy

standing up after about ten

minutes

_(ET:

_posterior intervertebral

joint

not

]ocked).

It

has

stayecl the same since and

he

hasn't

had anv other treatment or tried any

tablets. There was no signif'icant _past history

except the fiveyears of _progressive

hip

stiffness.

On physical examination sitting and twisting

right tosimulate hisreversing the'car was not a

problem but when yarious combined movements

were assessed inthisposition, the combination of right rotation, extension then right lateralflexion

reproduced hisache.

There

was no change -rhen

neck flexion,knee extension or hip movements

150

ew\wtza\

were altered from this combined _position

(ETi

this

supported

lumbar

spine

but

not the

hip

joint

or adverse neurodynamics).

He

had

_{good posture}

with no pelvic asynimetry's and conventional

spinal movements were all fuILand _painLess

though the ache was again reproduced with the

same movement combination

in

standing.

All

sacro-iliac, neurodynamic and resisted static

traction

tests

were negative

(ET:

lumbar

ioints

were st.illhighest on the listof sources). Hip

arnination revealed _painlessstiffness jn aLl

tionsespecially

flexion,

flexion/adduction

and

ternal rotation, right

being

more

limited

than

left

{ET:this

supports the

hip

is

not thesource of the

symptoms but fitswith the _patienVs difficulty

squatting and may be a contributing factor

requiring treaLrrient).There was marked

ing over the right L5fSl _posteriorintervertebral

.ioint

which was

hypomobile

to posterier-anterior

accessory movement testing but only produced

minimal local soreness. When this was

assessed in a cornbined _posture to simulEite

the

combined movement findings,the localsoreness

was accentuated and the right "hip"

ache was

reproduced

(ET:

these are the

local

signs

pected for _posteriorintervertebral

joint

ment}.

So

what

is

the

difference

between

the reasoning

of these two therapists? Therapist One did appear

to be reasoning logically.He was not blindly

fol-Iowing a referral nor was he $o

biased

as

to

exam-ineonly the _{patient'sperceptien} of the_problem, the

hip.

Was

Therapist

Two's

different

conclusion simply thea-esultef a more thorough routine

exam-ination

or was

Therapist

Two

acLually reasoning

differently than Therapist One? That js,what

facters guicled the respective therapists'specific

questions ancl _physical

tests

and what ifany were

Therapist

One's

deficiencies

in

reasoning?

Hopeful-ly

it

wiLl

become

evident throughout this paper that

it

was

Therapist

Two

who applied the more skilled cHnical reasoning by using an hypothesis

ij

25

tsee

4

{}

directed

inquiry.

Clinical

reasoning refer6

te

the

thought

_processes

and decision making associated with a therapisVs

examination and management of a patient or client.

Itisthe foundation of clinicai _practice. In

the

ab-sence of sound clinical reasoning, clinical _practice

beeomes

a technical operation requiring

direction

frorn

a decision maker. A _question asked

through-out the literatureand one which academics have

yet to reach a consensus,

is

whether a universal

process of clinical reasoning exists. When the

liter-ature across the

health

professions isreviewed

nu-merous forms of reasoning are described including

hypothetico-deductive

reasoning, narrative

reason-ing, "diagnostic"

or _procedural reasoning,

interac-tive/coltaborativereasoning, conditional reasoning,

pragmatic reasoning and ethical reasoning. To

gain a trulybroad _perspective of what clinical

rea-soning entails and how itis_practiced,

I

highly

rec-ommend key _perspectives from the medical,

physi-cal therapy, nursing and occupational therapy

pro-fessions

be

reviewed.

WhatI

present

here

is

my

own perspective of clinical reasoning based on

ex-tensive review of the

Iiterature

and my own

re-search at the University of South AustralLa.

Isupport the _{predomjnantly} medical perspective

that

clinical reasoning can

be

portrayed as a

hypothetico-deductive

processi5). This _process

in-volves a

hypothesis

oriented approach where

pa-tientdata _generates hypotheses which are

in

turn

tested _through

_further

_data

collection. This simple

diagram

(Fig.

1)

is

used toportray a process of

clin-icalrea$oning used

in

physical therapy. Inall

clini-cal settings, the therapist'sreasoning begins with

the

initial

data!cues obtained, For example, in a

rehabilitation setting this may be a referral, case

notes, observation of

the

_patient

in

the waiting

room as well as opening introductionsand

inquiries

with the patient and or

family.

This

preliminary

information

will elicit a range of impressions or

working

interpretations.

While typicaUy not

thought of as such, Lhese can be considered

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Clinical

Reasoning inPhysical Therapy

_t51

n

/

/

.tmk

/

-INFOewmaATSON

PERCEPTION

eemct leeTHRPRETATEOee }ptgTiALCONCEge1' areel swULTfiPLE

MYPOTNE$E$

'"--r

mereI"eorma neede T

tgvoLviNa

.-ii'ewNCEPT

'

oftitepmoBxerma

(g?ypantkeses

-mcrctatleci} #rE"

opFP

rk

ecsuawggajase e Cog pmESijasmn

o

_{iveetteasgegpmitS#m} tngarmatlon needeel '

R

x1

'moW

z'k

x

eq

tsbeg>

'xtu

Fgg. 1[. The

Clinical

Reasoning

generation [nc]udes a combination of specific data

interpretations or induct.ionsand thc synthesis of

]iiultipie clues or decluctions, In most settings the

jnitial

hypot/heses

wiil

be

quite

broad,

such as

"ap.

pears to be a back or hip problem".

Initial

hypothescs may bc physical, psycholegical or

so-ciaiLy re]ated with or witinout a "diagnostic"

impLi-catlon.

All

therapists

have

an etement of routine to their

examination. Individua] therapist/s will have

identi[ied,through experience, the categories of

in-form?itionwhich

thcy

havc found tobe _particularly

useful ior _probleiTiidentificationand inanagement

decisions

<eg.

site,

behaviour

and

history

of

symp-t.oms;fami]y and social information; psychological

cogriitive,/affective profile; functionaland sLructure specific testsof the carcHovascular, respirattory and

neuromuscutoskeietal systems; ergonornic and

/

Process

_(Adapted

from Barrows & Tamblyn I9so3))

vironmental analysis, etc.). While a degree or

rou-tine commonly exists, the specific inquiries and

testsshould be tailored to eaeh _patient'sunique

presentation.

Initial

hypotheses

will

lead

tocert.ain

inquiries

and testsspecific t/othat patient. This

cognit,ive activit}' of hypothesis testing would ide-ally

include

the search

for

both supporting and

negating evidence. The resulting data are then

in-terprete(i

forthierfitwith _previously obtained

data

and

hypotheses

considered.

Even

routine inquirics,

testsand spontaneous information offered by the

patient wM be interpreted inthe context of initial

hypotheses. This hypothesis _generation and

test-ing

process continues until suffcient

infonnation

is

obtained to understand the _{patient'sproblem(s)} and

reach a managcment

decision.

Thc understanding

requjred of _physical therapi$tsismultlfaceted and

pro-152

lgd}gtaIk#eg

25

igem

4

･{i

blems;

the sources of the _patient'spain,

dysfunc-tion und

{mpairment;

the

_pathobiology underlying

any dysfunction;

factors

contributing to the

devel-opment and or maintenance of each _{problem ;}

factors

signatling

the

need forcautien

in

_physical

te$tingand management, and how the patient

feels

about

his

or

her

problems and

the

effect those

pro-bleins

are having en

his

or

her

tife.

The clinica] reasoning process continues

through-out the ongoing management. In particular,

clinl-cal intervention serves as another stage where

hypotheses

are

tested.

Re-assessment may provide

support

for

existing hypoLheses and chesen course

of management, or itmay elicitthe formation of

"ew hypotheses or _perhaps signal the need for

fur-ther data colLection and _problem clarMcation

(eg.

additional exarnination or referral

for

other

special-ist

consultatien}. At the micro leveltherapistsare constantly reading pEitients' responses and making

in-treatment

clinical decisionstomodify and

impro-vise theiractions, At a macro Levelwhote

treat-ment sessions or even multiple treatments will

be

used totestvarious hypotheses.

The clinical reasoning _{process portrayed} here

shouLd

be

seen as a combination of pattern

recogni-tionand hypothesis testing. Pattern recognition is

based

on

the

notion that the storage of

knowledge

in

memory occurs inthe form of

"schemata".

They are prototypes in memory of

frequently

experi-enced situations that

individuals

use to recogmse

and interpretother situations40).

A

clinical pattern

or schema stored in memory would

lnclude

not only the syunptoms, context of those symptoms

(ie.

history,current behaviour of syrnptoms over 24

hours, _{patient'sperception,} thoughts and feeling

about the problem),and _physical signs,

but

also the

associated "if...then.,." production rules which

guide

our action. Production rules state that

if

cer-tainfeaturesor conditions are present,then certain

clinical patterns and management strategies are

recalled, For exarnple, inthe example _given at the

start oi this paper

Therapist

Two obviously

pos-sessed a thorough organisation of knowtedge

(ie.

schemata or clinical patterns)regarding _{the typical} clinical

features

of spinal, sacroiliac, neurodynamic,

muscular and hip dysfunction. }Ie not only

thought in terms of structures that may

be

the

source of the symptorns but simultaneously he was

also considering factorsthat may have contributed

tothe onset and maintenance of

the

_patient's

symp-toms. Associated with the _principalsource of the

symptoms hisorganisation of knowledge included not only the "diagnostic"

recognition of the clinicai

pattern

but

also a management strategy of how the

restricted spinal movement could

be

improved

and

maintained.

Experts can often recognise a

familiar

clinical

pattern ancl appropriate management

considera-tions very _quickly through a process of forward

reasoning22}36)38}. Tlie wheeze of an asthrnatic, the

posture

and

_galt

following

a cerebrovascular

acci-dent, the appearance of a

lateral

ankle sprain all

eHcit _quick recognition by experienced therapists

working in the respec ±ive areas of _practice. For-ward reasoning

is

efficient, fastand

dcpendent

on a

geod

knowledge

base

jn

the particular area of

practicei).

On

the other

hand,

when confronted

with unfamiliar _problems, experts, likenovices, are

forced to test theirhypotheses in what

is

called

backward

reasoning, in backward reasoning,

hypotheses

elicita return to the data foreither

re-interpretation

or the collection of

further

con-firming or negating evidence34).

While

broad

prob-lernsmay be easily recognised, the extent of each

preblem,

the

relationship between problems,

patients'perception of their impairments and the

influence

of external variables such as

family,

home and work which

impact

on their problems

will vary considerably across patients

despite

their

having similar diagnoses.

Ciearly

a

degree

of

back-ward reasoning isneedcd with all patients. In fact

in

those $ituations where _pure forward reasoning

or simp!e _pattern recognition has dominated, the result

i$

often a naive cLassification of a _patient's

problems into a $ingle "diagnostic" _label

and an

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CEinica

the paticnt'sproblems.

Curren'L

rerorrns inhealth care are changing the relat.ionship

between

the consumer and. the

provici-er or'

health

care services36]. Increasing

health

care cost.s

have

led

patientsand the niedical community

in gcnera} to expect greater accountability,

e'ffec-tiveness and efficiency from physical t.herapists.

Physiuat therapists inust have a broad

understand-ing

of not only

disease,

but

also

the

deter]Tiiiiants

of

hea]lh

inotuding environrriental, psychosocial and cu]tura] influences. There isan lncreasing

em-phasis on _prex,entior]an[1 _promotion ef healthy

lifestylesa,s well as involvcment of patients and

f'amiliesEnthe

decision

making _process. Physicai

therapistswork with a multitude of _probletn

situa-tj.ons,rnany of which can becharacterised by

com-plexit'y.unaqueness and ambiguit}r. Technical

knowledge alone

is

insui'iicientto solve the

prob-lem,

C}inical

judgement

inust

inciude

"wise

act{on"

in

what are oft,en unclear

_{presentations.}

SkilLed

clinical reasoning is essential for physical

therapists ±o meet these changing health care

demands

and manage the

diversity

of _patient

prob-lems.

The

cver

increasing

knowledge

base

regard-iRg

human

mov･ernent, function ancl

dysfunction

hELs!ed to :specialisation wit.hin heaLth care where

physical t.hurapists

in

theirrespective areas of

prac-'i'ice _are becoming the _{recognised experts} inthe

as-sessinent and management/ of patients wit.h

cardjorespirator), and neuromusculoskeletal

dys-function. Respanding to this rcsponsibility

neccssi-tatesthe same expleratory, criticaL,creatjve and

re-flective

sk{11s frorn our therapisLs as wc expect

from our rescachers. Itshouid no iongerbe

accept-able for therapiststo

blii]dly

fo]low protocols or

recipe Lreatments.

T.

his

'Ls _the

role of a technician

not a thinking therapist.

To

optimise our clinical

effeL'tiveness and contribute t.othe advancemen'L' of our l)rofess'/on,we need to proiriote skilleclclinical reasonmg.

gractors

kn.x"Emuemeing

()1･imieal

Reasoning

CIInicalrcasening isinfluenced

by

a :･nixture of

1Reasoning inPhysjcaE Therapy 153

internal

and external

factors

which relate tothe de-cision maker, the patient.the setLing and the

specif-ictask. Internal

factors

include

personal values and

bellefs;

general arid domain specific knowtedge

antl

indivi[kial

cegnitive or reasoning strategies.

External

factors

include

the pat,ients--their

under-stading, expectations and

feelings

about their

prob-Lems;

professionaland

institutional

canon;

commu-nity needs and expectations; resource availability

and funding,

Critical

factors_pertaining tothe

deci-sion maker,

including

the therapist's knowledge

base ttnd hl,sor her cognitive and metacognitive

$kil}s, and the

importance

of the _patienVs

perspec-tivesare

discussed

lurther.For a more

detailcd

dis-cussion of other

facLors

inf]uencing clinical

reason-ing the reader

is

referred to

)L,lay

and Dennis9i].

Cegnition

Cognition

refers Lo thjnk{ng _processes such as

data analysis and synthesis and ioquiry sLrategies

such as hypothesis testingii) and shared

decision

making. "･'hileclinical expertise 1iasbeen linked

more to the Lherapist.!sorganisation of knowledge

than the process of clinical reasoning used,

cog-nitive skilis and knowledge are interdependent,

For exainple, the

inquiry

sLrategy of hypothesis

testing, incLuding searching

for

supporting and

negating cvi'dence, _plays a significant role

in

the ac-quisition of

knowledge29L

Experts may have a

greater store o[ cjlnical _patterns they recognise but

this levei of knowledge can onty

be

acquired

through skitled clinical reasoning using a

combina-tionof thorough hypothesis testingt,oidentify.

clin-ical

pattcrns and reflection to continually re[ine

those _patterns and acquire new ones.

ErrorsincEnical reasoning are

frequentLy

relatcd

to errors [ncognition. Examples of these include

overemphasis on finciingtiwhich support an

ex-isting

hypothesis,

misinterpreting non contributory

information as confirming an existing hypothesis,

ignoring

findings

whjch didnot support a favoured

hypothesis, and ineorrectinterpretat.ionsrelated

in-appropriately applied iriducLive and

deductive

154

ve\ktz{:k

Iogici3}27)37).

Many therapists

however

will

be

un-aware of the thinking processes they use when

ex-amining and treating a patient and hence errors

may well _go un-noticed.

The most common error isan over focus on ene's

favourite

hypothesis.

This

of course

is

an

inherent

limitation

of pattern recognition--that

is

wheri you

try to put things into discrete boxes, the boxes

themselves become the

focus

of _your attention and

it is difficultto see any _patterns outside those

boxes.

Care

is needed _to avoid a preoccupation

with one "diagnosis", one structure or ene system at the expense of the others as thiswill be reilected

in the management. That

is,

ifall _you have isa

hammer, everything lookslikea naiL

1}fetacognition

Metacognition refers to therapists'awareness of

theirown thinking,that istheirabillty to;nonitor

or think about theirthinking. Most spontaneous

actions thatprofessionalstake are not elicLted

by

a

ruie or plan that was eonscious]y

En

the mind

before actingiOj.

Experienced

therapistsare able to

recognise and respond appropriately to relevant cues, even without explicit awareness of theirown

reasoning, This may

be

characterised as

"Knowing-in-action",

a phrase coined

by

Donald

shon42)4n).

Therapists however do not emerge from their

formal education with thislevelof knowing.

Ex-pertisecan only be reached through ctinical

experi-ence where reasoning i'nvolves "reflection-in-action" and "reflection-about-action". "Reflectjon-in-action"

refers to thinking about what you are doing whi]e

you do it.As the t.herapistencounters a _problem,

he or she should engage in a _process or critical

analysis that allows for self-correction or

adapta-tion of _practice. This is _particularly

important

when working

in

situations of uncertainty or when

unexpected results arG obtained. For example, in

the midst of working through a difficult

_problem

therapisitsmay ask themselves "What

is

the key

problem here? What are the salient features?

What are the rnost like]yexplanations? How could

eg

2i)

ts

fi

4

e

I

testthesefurther? etc." This "reflective

conversa-tion"with the situation involves on

the

spot

experi-ments or what could also

be

called

hypotheseis

generation and

testing.

FlavelliB)

has

proposed a

model which includes three categories of

metacognitive knowledge : Person knowledge

(awareness

of your own

knowledge

base

and

its

llmitations);Task knowLedge

_(awareness

of the

quality and relevance of the

data

obtained); ancl

Strategy

knowledge

_{awareness

of specific strategies required toobtain the necessary data and achieve the desired _goals>. Reflection-about-action

isa similar _process that occurs retrospectively as

the therapistthinks

back

about what

happened

in

practice. By promoting awareness, reflection and

critical appraisaL, the recognition of cljnical

pat-terns hjdden in the ambiguity of

the

presentation

or the acquisition of new _patterns not _previously

appreciated can

be

realised and clinical outcomes

can bebetterunderstood and improved upon,

Knewledge

The thirdfactor cited which significantly

influ-ences clinical reasoning isknowledge.

A

consistent

finding in the clinical reasoning literature

is

that

expertise and "diagnostic"

accuracy are dependent

on therapists' knowledge in a particular

areai)2)7]8)i4}20)2i)32)33)4i}.

Of

importance

is

not simply the amount of

knowledge,

in

the

form

of

how many facts_they might

know,

but

more the

organisation of theirknowledge. With the

recogni-tion that

knowLedge

is_probably the most

impor-tant variable influencing elinieal reasoning, and

realising thebody of knowledge _pertaining to

phys-ical therapy and the associated sciences is more

than any single therapistcould

hope

toacquire, yet

alone manage, physicaL therapists must be critical

of knowledge sought and keep in _perspective what

they need toknow vevsus what isnice, marginal or

irrelevanttoknowZ6).

Biomedical knowteope vensus clinicat knowledge

knowl-Japanese Physical Therapy Association

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Cliniua

edge

have

been classified,

but

forthe _purposes of

"[hiG

paper the

distinction

between

biom

¢

dical

and

cLinical knowledge isu$ed2a). For a more t.horough

discussion of knowledge the reader

is

referred to

Higgs

and

Titchen25).

In

the context of _physical therap>,, biomedical

knowledge

is

used to refer to

what is known or believed

in

the

basic

sciences

particular]y as it relates to anatomy,

patho-mechanics, pathobiology, ps.ychology, pain meeha-nisms and

healing.

C}inical

knowledge

on

the

other

hand refers to knowEedge such as clinieal patterns

snd if/then _guides toactiori which therapisLsuse

on a

day

today basiswith or without a sound

bio-rrledlcal basis.

Optirnal

patient care should emerge

from

the

in-"Legration

o'1/'both clinical and biomedical

knowl-edge.

However,

consideration shou]d be _given to

how

biomedical

knowledge is taught and what

levelof biemedicaE

knowledge

is

LLsefulto the

prac-ticirigtherapistg)3n).

_For

_knowledge

_to

_be

accessible

itrr]ust beacquired Lnthe context

for

which

it

",il1

be usediO}40}4'U. Thercfore,inorder tomake the

bio-medical sciences Linclerpinning physical therapy ac-cessible tot.he_practicing therap[st,care isneeded

to continuall>,

]ink

the relevant

biomedical

princi-plesand concepLs with theirclinical significance.

How

to

Prownote

Skglaed

ClinicaG

Reas(ming

Ifitisaccepted that physical therapistsshould

be

thillking therapistswho question, expjore, and

re-flect,

then consideratlon must be _given tis towhat can be done to

improve

therapists'and stuclents' clinical res.sonlng.

Reasoning

that iscritical _yet

creative and reasoning which makes use of

both

clinical and biomedical

information,

There

are a

riumber of n']casures which could

promote

thisstyle

of reasoning

including

increasing awareness of rea-soning _processes;a'itending to Lhe patienifs

disabili-tylpain experience and

involving

the patient in

shared deci$ionmaking; crcakng greater awareness

of reasonins, errors; encouraging grcateruse oi

hy-pothesis testing to prove or

disprove

hypotheses;

irnproving knowledge and organisation of

knowl-1Reasoning inPhysical Therap>

edge

'

;encouraging regular use of reflection.

155

1.

inereasing

agvareness or reasoning

_process

Physical

{/herapistsare regularly attempting to

improve theiTclinical skills. This ismost

success-fully achieved, for example with manual skills,

through supcrviscd l)ractice.

An

experiencGd

in-structor observes or feelsthe manual technique and

provides fee[lbackon good and poor aspects of the

performance. That is,thernost efficient way

to

im-prove a skill istofirstbe made aware or how you

are currently performing

it.

The

same can

be

said

for tmproving _your reasoning. Firstitisnecessary

to be aware of how you reaso" tc)then rriake

at-tempts

at improving it, This is best achieved

through a combination of literaturereview to

un-derstand thetheory of clinical reasoning and

super-vised reasoning where a more skilled reasoner

assist _you to _{probe your} Lhoughts Lhrough a

pa-tient

encounter

(using

simuLated or real _patients)

while providing thenecessary feedback.

2 Attendtng tothepatients disabigityipain

experience and shesred decision nvaking

Shared

decision

making between _patient and

therapist iscruciai to optirnise clinical outcomes

and ensure success

is

realised

from

both

the

patient'sand the therapisVs _{perspectives.} Rather

than solely focussing assessment on "diagnosis",

or

identifying

the source of rhe synzptoms and

focuss-ing treatment on the

injured

tissues,a

broader

per-spective of clinical reasoning

is

needed.

Cheryll Mattingly, an anthropologist who has

contributed signiEicantly to clinical rcasoning

rc-search in

Occupational

Therapy. has criticised the "diagnostic" _focus

of clinical reasoning in

medicine30).

Matting}y

suggests that "diagnostic"

reasoning isinsuifjcienttoaccount for the clinical

reasoning of therapistswhose roie

it

is

to

personal-ly interact in the rehabilitation _process. Direct

physi¢al involveineiitin the patient's treatment

re-quircssensitivity to theindividual context of each

patienVs presentation.

156

l-tr'{:,as211\

Mattingly

has

used the concept of a _patienVs

"ill-ness experience" 1.o encourage this broader

perspective3e), She deflnes illnessexperience as

"the

meaning that a disabilitytakeson fora

partic-ular patient,

that

is,

how disease and disability

enter the phenomenological world of each person,"

Th¢ individual meaning patientsgive to their

disa-bility

or their "painXdisability

experience" will

significantly influencetheiremotions, expectations,

goals,motivation and involvement inthe treatment

process.

It

is

inadequate

to view _patient

assess-ment as merely being an exercise in

problem-solving where theaim istoidentifyand

label

or

di-agnose thecausative factor.A nonpatient directed

style of patient assessment, where the examiner

follows

a

_{pre-determined,}

structured course of

in-quiry and is insensitiveto the patient'spersonal

frame of reference or context, also tends toexclude

the _patient frern the decision making.

But

if

the

patient

is

not an active _participant

in

the _process

and

if

the context of the patient'sdysfunction and

pain are not truly cons

idered,

the _problem will

never

be

fully understood and the outcome will

always be

jeopardised.

To

guide the continual

improvisation

which

occurs

in

treatmenC therapists must be able to

simultzneously perceiye and

interpret

rnultiple

physicaL psychological and socia[ aspects to a

patient'sproblem and adjust theirexamination and

management to the evolving patient

interaction.

This

form

of

dynamic

interaction requires more than strong bioTnedical

knowledge.

Itrequires

un-derstanding

how todisabilityhas impacted on the

patienVs lifeand skilled communication strategies.

The

significance of the _{physicaL psychological}

(cognitive

and affective) and social aspects of an

individual'sproblem tosuccessful management wM

vary.

On

the one hand, clinical reasoning through

some _problems will appear to

be

pure :`diagnostic"

reasoning. For example, a patient with an acute

antalgic _posture of the neck can often be

success-fully

treatedinolte or two appointrnents.

Here

"di-agnostic" reasoning isessentia] tocorreetly

recog-zz

2s

_gza

･i

g

nise the clinical syndrome and subsequently choose

an effective treatment.

The

patient'spersonal

life

will often not

be

significantly affected and thus

this

is

not a major

issue

in

the therapisVs

reason-ing.

In

contrast,

in

most neurological,

cardio-respiratory and many orthopaedic _{patientproblems}

it

is

essential to understand the patient'sunique

disability!pain

experience and treat the whole

person rather than

just

thephysical problems.

Per-haps

the

best

example

in

the orthopaedic area

is

the "chronic

pain patienVl The complexity of

many chronic _{pain presentations} Iiesnot only in

the multistructural involvement and extent of

pa-thology which commonly exists, but also the

signif-icant

disturbance

toall aspects of these

individuals'

liveswhich in turn has directand indirect

conse-quences on their_pain and disability.CHnical

rea-soning with these _patients must include attention

totheirpain experience.

Figure

2i2)

refrects the

importance

of

the

patient's

role in the clinical reasoning

_process.

Patients'

have their own

hypotheses

regarding what their

problem might be and what information they

con-sider relevant and worth yolunteering. Through a process of explanation, reassurance and shared

de-cision making, the "enlightenment" of the therapist

regarding "diagnosis"

and management of a

prob-lem is_paraileledby the "enlightenment"

of the

pa-tientregarding hisor her own _problem or situation

and ability

to

do

something about

it.

This

increase

in

patient,and on occasion

family,

understanding

and self efficacy, enhances the

likelihood

for

addi-tional information tocome forward. Responsibility

isshared between _patient and therapist,wjth the

patient being encouraged totake an active role in

the management, increasing the likelihoodof

con-tinued self managernent.

This

inclusion

of the

pa-tientin the

_prob]em

solving and decision making

process enhances the therapist'sability to

under-stand the _problem inciuding the affect ithas on the

Japanese Physical Therapy Association

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JapanesePhysicalTherapyAssociation /s

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Reasoning

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2･

a

lbecreasin.a.awrareness or reasongreg erro]s

It

js

'lntcresting

to reflect on rnisdirctions that

have occurred throughout the

history

ol science,

largelts･'due to a

lack

of ci'jtica] and open

inquiry,

two essential e]ememts of clinical reasonir)g. A

somewhaL dramatic example

is

evident,

in

the

mis-conceptions which surrollncled the role o'fthe heart and avteries iu the

days

o'fAristotle4).Influenced

b},tbe teaching of l'ythagorasand

Plato

and

by

his

own anirna] disseetions,Aristotlebelieved that the

substancc of life,Lv'hich he Labelled"quintessence",

was carried from the heavens int.ohunian body

throvig,h the trachea [othe

]ungs

e,nd thc,inon tothe

heart, The hollow arteries oj' the

body

were

believed to carry th[squintessence or lifeforcete

al] othcr organs of 'Lhe

body.

These _conclusions led

Aristotle to assign th(,'function of inte]ligent

Cooperative

Decision Making between Patier]tand

Therapisti2)

i

thought tothe

heart,

not the

brnin.

This

belief

that

thc hcart was the honie of the highest soul and the

organ of rational thought was to _persist for

centuries.

It

was nearly

2000

years

befove

Ari$totle's

bclief

inthe importance of quintes$ence

was challenged

by

Williarn

Harvey

through the

publicat/jonof this

book

on the circu]ation of blood.

How can rrtisbeliefs seemingly as ]argeas this be

perpctiiated for so long? Could science and its

associated disciplines,such as medicine or _physicai

therapy.

be

mi'sdirected to thisextent

in

modern

times? Richard Bergland, in

his

book

The Fabric

of Mind, suggest they can and are, and Bergland

provides the example of the commonly accepted

notion that electricity isthe stuff of thought, a mis-conception t.hat

has

existed for200 years4}.

158

-e}gtaza\

discipline

is

enormous.

Research

and treatment

practlceswill

be

directed

by the

_prevailing

phiioso-phy and

if

it

is

in

error, the advancernellt of science

and in turn

_.heaith

care can

be

misdirected.

Bergland4)demonstrates convincingly

how

thishas

occurred

in

modern neurology and goes on to

plainhow thecurrent understanding thatthe brain

is

a _gland, a view which

is

stilL relatively new, is

changing the understanding of

brain

i]lness

and

its

associated treatment.

As

a profession,with

its

clinical theories

being

based

on a combination of scientific rationale and

empirically acquired

beliefs,

physical therapy

is

'

also vuEnerable to misdirection. A _principal

fault

behind many of the colossal misdirections through

the

history

of science

has

been

the

blind

acceptance

of what iswritten or _professed as truthat the time.

Open

niinciedness, the questioning of existing

beliefs,

and reflective thinking are essential

to

avoid mi$direetion. Clinicalreasoning _provides a

safeguard against

the

risk of

having

the popular

theory and clinical techniques of the day adopted

without question and

hence

thwarting alternative

theoriesand clinical _practice.While clinical

reason-ing iscenceptually very simple, effective clinical

reasoning

in

_practicecan

be

extrernely

difficult

and

isfraught with errors.

The

summary of

Therapist

One

in

the opening

example

does

not reflect the fullextent ot

reason-ing errers rnade, Surprisingly even direct

observa-tion.ofTherapist

One

examining and treating the

patienL weuld not reveal many of the reasoning

errors which

become

evident when one attempts to

access the therapist'songoing thoughts.

When

this

was done retrospectively, Therapist One was

clear-lynot reasoning

through

the

_patient examination.

Instead he was foLlowing a routine series of

ques-tions

and tests,merely colrecting

information

and making the simpLest

level

of

interpretations,

with

no attempt to collate information or test

hypotheses.

The

only real extension of the

subjec-tive examination to the physical examination was

the therapist's

biased

attention tothepatient's

con-ag

25

igeg

4

tinualreference to his"hip".

Other

potentiaL

tures at faultwere iriadequatelyexamined allowing

Therapi$t

One

to

be

misled by the hip stiffness

without trulytestingitsrelevance

to

the

_patient's

present

problem. Therapist

One's

physical

nation was a combination of routine tests not

tailoredtothe specMc _patient.

He

overattended

to

those findings

(eg.

stlff

hip}

thatsupported the one

hypothesis

he

had

maintained

from

the opening

moments of the _patientencounter.

The

continued

hypothesis

testing which must occur through the

ongoing reassessment of treatrnent was aiso

ing as only the

hip

mobiEty and subjective report

were reassessed,

further

supporting

the

therapist's

misinterpretation that the hlp was the source of

symptoms.

In contrast Therapist Two was active}y

ing from the start.

The

patienVs opening

tion

of siteof symptoms elicited a working

esis regarding source(s) of the symptoms which

cluded several _potential structures, Further

questioning can be $een to scan the same _general

categories of information as did Therapist One's

questions.

however

the search for

details

were

taiLoredto this specific _patient and _the evolving

hypotheses being considered.

When

_information

was not spontaneously forthcorning as with

vating factors,Therapist

Two

xvould specifically

question other possibEe aggravating

factors.

This

served as a testof the different_potentialsources

and can

be

seen as attending to the negating as

well as the supporting features of a problem.

Therapist Two's physical examination was clearly

an extension of

the

subjective where structures

were examined to testthe hypothe$es of sources

and contributing

factors

and not simply a routine

followed with all _patients. This was most apparent

with

his

use of a functinalaggravating pesition to

differentiate

the

most

likely

source and

identify

a

cornbined movement _position which later_proved

useful as a clue to

how

the minimal

lumbar

passive

accessory intervertebralmovement sign could be

delib-Japanese Physical Therapy Association

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Clinical

Reasoning

_inPhysical

_Therapy

₁₅₉

cral/ely considered to oniy highlighl.the _thcra]]ists'

reasoning rcgarcling the sources and contributing

fact/orsassociated with the patiellVscorriplaint,

in

real lifeifattention was not also _given to the

patienVs understandirig and feelingsregarding his

l)roblem, including the effect it,

has

had

on all

aspcets of

his

lifc,

thistoo would

bc

a serious error of 1'easoning.

ErrorG of reasoning can obvious]y occur _through

any stage o'f the clinical reasoning _proccss

in-cluding errors of perception,

interpretation,

inquiry,

s}'nthesis and planning. "Experts"

also make errors

as demc)nstrat.edby thc t/endency,ciien for those

therapists who arrive at the correct conclusion, to

overernl)hasisc _positivefindings,ignoreor

misinter-pret.negative findings,deny findings that conflict

with a

favouri'e

hypothesis

and obtain redundant

iniurinationiiDi7).

LVha'Lisitthat causes a therapist

to misfnl.erpret. informaLicm or I'ail_to L'onsidcr a

highly'

pi'obable hypothosis? Errors of

interpreta-tion and syiithesis inay be related less to the

therapisVs liTnitedaTnount of n)edical or cliriica]

know]cdge than one might think,and more so to

the t/herapis/t'sinadequate organisation ot' that

knov,,Icdge Liillitimgthe abiliLy to retrieve reLevant

knowledge aLready stored

in

memory''

'J,

Reason-irigerrors are often unrccognised as even sk[[led

therap)'stsrare]y consider theirown cliniea]

rcason-ing'as suggested here.

Physica] thcrapy school provides the foundation

of our clinical practice.

Curricula

should

'thercfore

[llc]udethe thinkirigor clinical reasoning skills

nec-essary to testconLinually our knowLeclge base ancl

acquire new knowleclge and new clinical _patterns.

4.Great･erisse ufhmpoehesis eesting

Hypothesis testing

is

at the core of good clinical

reasonirig. Ii)}pressionsrnust atway･s be testedwith

particularat(.ention paid not onlF,' to those f'eatures

that support a hypothcsis but also to thoso which

do

not. While hypoLheses are _general]y associa ±ed

wiLh

identification

of clinical problerrisor

syn-droincs

t.hey also exist for inquiry/communication

stratcgies and for specific

interventioris

inthe

()ver-all managemenL

There

are many ways torelate t.o

patients inorder toobtain the rnost useful

infurma-tion and fullyundcr their_problems and

it

is

inipor-tant that therapists acquiro skMed communication

strategies to enhance thcir reasoning and patient

management,

While

we all

have

our own approach

to _patients we musL be wilting to monitor ifits

",orkiiig, that isto testthe success of our

commu-ni¢ation and inturn tomodify our style as necded

to findan effectivc approach foreach paLient.

Sini-ilar]y,

there are nuinerous ways totreatany given

probleni.

The treatinent,intervention shouLd bc] evaluatecl througri speeific; re-assessrr]ents and

if

in-effective other appruaches trialed.

5.Improving knowgedge and orgareisation or

knowtedge

Iniproving

organisation of

knowLedge

requires a

closer look at

how

knowledge

is

acquired,

Glaseri9]

(I)

99) stated that.

"Effective

thinking isthe rcsult ef

conditionatised knowledge-the knowledge that

beeonies associated with the conditions and

con-straints ol'itsusc". Thus thcfacts,_procedures,

coii-cepts, _principles and _patterns unique to physical

therapy need Lo

be

Linked with the conclitions and

constraints of theiruse, or

integrated

irito

}ear-ing cxpcricnces "rith _{patient problerns.} And for new

lnforniation to be succes$i'uLLy integrated

into

ex-isting knowledge, eclucational actlvities musL

pro-vide opportunity for st.udent.s toactivate their

ex-isLing

knowlec]ge, ret'lect on the new information and use their nexvl), integraLed kno"iledge in a

clinically relevant viay. Adult learning _provides

the ideateducational philo$ophy and

framework

to

facil{tate the attributes and skill$ inherent in

skilled clinical reasoning39} 46).

Key

eLements to

con-sider to facilitateclinical reasoning through the

adult learningmodeHnclude:

e Students _{must make} thc transitienfrem

depend-ent toself directed learnersincluding taking

160

IMI}ges?!;･dY:

self monitoring of

learning

.

_Students

_must

_be

_encouraged

_to

_{relate new}

_ideas

toprevious

knowledg'e

,

Students

_{must relate evidence} to _conclusions

b Students _must be _critica} in _examining 1/helogic

of the argurnent

e

_Students

must Iearn

beyond

the

superficiat

tures,

facts

and strategies and

devetop

an

standing of the pr'incipies and concepts

ing physical therapy assessment and

menteEdueator$lsupervisors

must _provide opporV

unities

for

students toaccess relevant resources

.Educators/supervisors must

develop

_open munication with students and be tolerantof takesoEducators/supervisors

must utiHse Iearning

tivit.ieswhich are crinically

based

(eg.

real and

simulated patient problems),

involve

active

ticipation and include

provision

for access to

students' thoughts

e

_{Educators/supervisors} must encourage reflection

e Educators/supervisors rriust provide constructive

feedback

and modeling

b Educators/supervisers _mu6t foster _students'

skills inexpressing theirreasoning and

justifying

their

intervention

.

Educators/supervisors

must help students

op skills

in

lifelong

Eearning

In addition to constructing educational activiLies

designed

to

facilitate

reasoning skills and the

ac-quisition and organi$ation ot' clinically useful

knowiedge,

l

suggest thc use of

hypothesis

categories te assist studerits and practicing

therapists organise their

knowledge.

Ilypothesis

categories are key areas of clinicaL _J'udgement

(ie.

hypotheses) which need to be made through thc

clinical reasoning _{process27)2S).} Instead of over

focussing on the rnost obvious _problerr}such as a

painfuL

back,

a stiff movement, increased tone,

decreased

balance

or a _poor

breathing

_pattern as

sometin')es occurs, a broader model of _pain and

dys-eg

25

_tseg

4

-ff･)-funct.jon

hjgh]ighted through hypothesis categorics

wil] encourage greater considerat.ion of the who]e

person as

is

taught

in

our schools but not always

practiced

in

the clinic. This has _proved very su¢

-cessful at my school in as$isting $tudents'

under-standing of the value of differentexamination

jn-quiriesand _physical

tests

while _providing a

frame-work

for

students to organise and

integrate

their

clinical and

biomedical

knowledge.

The following hypothesis categories are

sug-gested as a means of organising therapists'

knowl-edge and clinical

decision

rnaking:

1.

Dysfunetion

2.Source of thesymptoms/dysfunction

3.Pat.hobiologicalmechanisms

4.

Contributing

factors

5.Preeautions and contraindications to

_physicai

examination and treatment

6.Management and treatment

7.Prognosis

Itisessential that therapists are ablc torecognise

the

different

problems each patient

has.

A

_patient's

dy$function

may be _physical,

psychologicai

or a cornbination ef both. The dysfunction represents

the _patienVs functional _problems forwhich

he!she

isseeking treatment stieh as

difficulty

inwalking,

breathing,

or performing some activity of

daiiy

Living. While the basis to these _problems may, be

found

in

the _patienVs abnormal or maladaptive

af-fectivelcognitivestatus, sensory function,

respira-tory function,

_joint

Jnobil[ty, muscle control,

litness,

posture, ergonomics, etc., therapistsmust

be

cau-tious not to ioose sight of the broader functional

problems

in

theireffort toanalyse and treatthe

re-spective causes. Mobility and strength may

im-prove but itisnot until thismanifests a$ a change

infunction such as walking or ability toearry out

eyeryday activities of

daily

Hving that ittake$ on

real meaning to

the

_patient.

The source of the symptoms refers to theactual structure or targettissuefrom which the symptoms