An empirical, pragmatic approach applying reflection in interaction approach to manual therapy treatments

ABSTRACT

Background: Most literature on decision processes within physiotherapy relates to “reasoning that results in action” – decisions based on information including assessments that are gathered prior to treatment decisions. A process of “reasoning in interaction” that is often used, particularly by expert clinicians, has received less attention. Objective:  To provide a theoretical and practical approach to applying reasoning in interaction in a musculoskeletal setting. Methods: The theory is: If an impairment that can be directly targeted by treatment (i.e. pain or limitation of passive movement) is related to patient’s active impairments and functional limitations, then moment-to-moment changes in the targeted impairment can be used as feedback to guide real-time treatment modification before formal reassessment of functional limitations and other impairments. Results: Applying the theory to manual therapy results in parameters of techniques such as force, speed, direction and duration no longer being pre-determined, but rather being continually adjusted in real-time according to feedback from the patient through both therapist perception (changes in movement quantity or quality) and patient verbal responses. Conclusion: A process of continuous decision-making is described that the authors believe is used by many experienced clinicians but has not previously been adequately described in the literature. .

KEYWORDS:

• Clinical reasoning
• spinal mobilization
• individualized patient care
• clinical prediction rules

Declaration of Interest

The authors report no conflicts of interest.

Notes

1. Impairments will be used in accordance with the International Classification Framework and will generally indicate pain or limitation of active movement or functional activity, but can refer to “any loss or abnormality of psychological, physiological, or anatomical structure or function. In principle, impairments represent disturbances at the organ level.” (http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf?ua=1).

2. Deficit here is will be considered to have a somewhat different meaning than that used in ICF. In this case, deficit will be used to indicate the specific limitations within a particular structure or motion segment that a person actually has. For example, a patient with symptoms on right rotation thought to be coming from C4/5 might be expected to have a limitation of passive right rotation and right lateral flexion at C4/5 (and/or of unilateral PA to C4 on the right). The deficit that is actually found, however, might be in entirely different directions.