Peeling the onion…

By Brett Windsor, PT, PhDc, MPA, OCS, FAAOMPT

Defense: The standard reaction to anything new. We act to protect that which exists. “We’ve always done it this way.” Well, as W.L. Bateman said, “If you keep on doing what you’ve always done, you’ll keep on getting what you’ve always got”. And so it is with clinical reasoning…largely, the inductive approach rules. No matter the time, no matter the patient, the full and complete examination must be done…right? Perhaps there should be nuance, perhaps we should give students the ability to inject context and circumstance into each patient encounter. This would provide a continuum of options available to the learner when presented with a case scenario.


Such a continuum would expose the student to the deductive and inductive approach, encouraging them to choose which approach best fits a particular patient. As we discussed yesterday, when a patient presents with more acute symptoms that are localized, the deductive approach often works well. There are generally a few diagnoses that are statistically likely in these situations. Choose one that you believe is most likely…and assess for it, using tests and measures that are most likely to give us good information about the diagnosis. If we’re truly serious about evidence-based practice, then this really is the way it should be done.

With any patient, we ultimately need to develop an effective management plan. To get there, we need to make a series of decisions, each backed by some kind of evidence. First, is the patient within our scope of practice? Generally, the physical therapist is looking for mechanical signs – intermittent, with moderate intensity, moderate referral; ones that can be aggravated and relieved by movements, positions, activities and postures. If this is not the case, then we consider referral for consultation. If mechanical signs do predominate, then we tend to move forward with evaluation and treatment, assessing for any yellow or red flags along the way.

Now, it’s about evaluating. We need to reach the ‘treatment threshold’. The treatment threshold is the point where we have good information about the problem at hand; any further information is not likely to change management. My hypothesis is that we often reach this threshold fairly early and then continue evaluating. Why? It’s adding nothing. Manage…Treat. Don’t keep evaluating just because we have a list of things we were taught to do by someone, somewhere. This is the essence of EBP and the deductive approach. Make decisions, do what needs to be done and then move on. So why don’t we do this? Why do we almost always favor inductive approaches?

Largely, the primary reason is fear. Fear of missing something important. Fear of being wrong. Fear of making mistakes. To this end we can ask the question: When is something more likely to be missed? Is it more likely to be missed when a therapist is critically evaluating a patient with a mind to what is wrong, thinking about each test and measure that will be used? Or is it more likely when a therapist follows a series of preset tests and measures that may or may not be directly related to the hypothesis at hand? I’d suggest the latter. As to mistakes and being wrong…that will never stop. But both help drive good patterns…so as to recognize it for next time.

It’s important to note that the deductive approach doesn’t ‘cut-off’ evaluation. It requires s diagnostic decision and an early move to management. But just as we would in a patient after a heart attack, once we know the what, we continue to ask the why. Because only in answering the why can we truly manage the patient appropriately. Often in manual therapy, we focus on the ‘why?’ to the exclusion of the ‘what?’. It’s ok to look at the encounter as an onion and to slowly peel back the layers as we go. When a patient comes into therapy the first time, let’s get the diagnosis right efficiently with the best use of the evidence. Then peel back the onion…

What say you?

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