Section 2: Clinical reasoning as a framework

International Framework for Examination of the Cervical Region


Clinical reasoning is employed to underpin the framework detailed in this document. The cognitive and metacognitive processes of reasoning, using evidence-informed knowledge within OMT are the central components to expertise of practice in OMT[1].

IFOMPT Standards

The IFOMPT Standards Document[2] states that:

“Advanced clinical reasoning skills are central to the practice of OMT Physical Therapists, ultimately leading to decisions formulated to provide the best patient care. Clinical decisions are established following consideration of the patient’s clinical and physical circumstances to establish a clinical physical diagnosis and treatment options. The decisions are informed by research evidence concerning the efficacy, risks, effectiveness, and efficiency of the options[3]. Given the likely consequences associated with each option, decisions are made using a model that views the patient’s role within decision making as central to practice[4], thus describing a patient centred model of practice”.
“The application of OMT is based on a comprehensive assessment of the patient’s neuromusculoskeletal system and of the patient’s functional abilities. This examination serves to define the presenting dysfunction(s) in the articular, muscular, nervous and other relevant systems; and how these relate to any disability or functional limitation as described by the World Health Organisation’s International Classification of Functioning, Disability and Health[5]. Equally, the examination aims to distinguish those conditions that are indications or contraindications to OMT Physical Therapy and / or demand special precautions, as well as those where anatomical anomalies or pathological processes limit or direct the use of OMT procedures”.

IFOMPT competencies relating to clinical reasoning

Dimension 6 of the detailed competencies relates to clinical reasoning in postgraduate physical therapy practice in OMT, as follows:

Dimension 6: Demonstration of critical and an advanced level of clinical reasoning skills enabling effective assessment and management of patients with neuromusculoskeletal dysfunctions

Competencies Relating to Knowledge

Competency D6.K1 Demonstrate critical understanding of the process of hypothetico-deductive clinical reasoning, including hypothesis generation and testing
Competency D6.K2 Demonstrate effective use of the process of pattern recognition, including the importance of organising clinical knowledge in patterns
Competency D6.K3 Demonstrate critical application of the various categories of hypotheses used in OMT, including those related to diagnosis, treatment and prognosis
Competency D6.K4 Demonstrate effective recognition of dysfunction requiring further investigation and / or referral to another healthcare professional
Competency D6.K5 Demonstrate critical evaluation of common clinical reasoning errors

Competencies Relating to Skills

Competency D6.S1 Demonstrate accurate and efficient selection of inquiry strategies based on early recognition and correct interpretation of relevant clinical cues
Competency D6.S2 Demonstrate critical and evaluative collection of clinical data to ensure reliability and validity of data
Competency D6.S3 Demonstrate advanced use of clinical reasoning to integrate scientific evidence, clinical data, the patient’s perceptions and goals, and factors related to the clinical context and the patient’s individual circumstances
Competency D6.S4 Demonstrate integration of evidence based practice and experiential reflective practice in clinical decision making
Competency D6.S5 Demonstrate application of collaborative clinical reasoning with the patient, carers / care-givers and other health professionals in determining management goals, interventions and measurable outcomes
Competency D6.S6 Demonstrate effective prioritisation in the examination and management of patients with neuromusculoskeletal dysfunction
Competency D6.S7 Demonstrate effective use of metacognition in the monitoring and development of clinical reasoning skills

Competencies Relating to Attributes

Competency D6.A1 Demonstrate patient-centred clinical reasoning in all aspects of clinical practice
Competency D6.A2 Demonstrate critical understanding of the key role of clinical reasoning skills in the development of clinical expertise
Competency D6.A3 Demonstrate effective collaborative and communication skills in requesting further investigation or referral to another healthcare professional
Competency D6.A4 Demonstrate learning through critical reflection during and after the clinical encounter
Competency D6.A5 Demonstrate learning through precise and timely reassessment


2.3 Implications for practice

The framework requires effectiveness in the above clinical reasoning competencies to enable effective assessment and management of a patient, and thus effective, efficient and safe assessment and management of the cervical region. It is clear that many documented adverse events following the application of cervical manipulation could have been avoided if more thorough clinical reasoning had been exercised by the clinician[6]. The framework is therefore designed to be an aid to patient-centred clinical reasoning.

References

  1. Rushton A, Lindsay G (2010). Defining the construct of masters level clinical practice in manipulative physiotherapy. Manual Therapy, 15: 93-99.
  2. IFOMPT (2008). IFOMT Educational Standards Document. http://www.ifompt.com/Standards/Standards+Document.html
  3. Haynes RB, Devereaux PJ, Guyatt GH (2002). Physicians’ and patients’ choices in evidence based practice. British Medical Journal 324:1350-1351.
  4. Higgs J, Jones M (2000). Clinical Reasoning in the Health Professions, 2nd edn, Oxford, Butterworth Heinemann.
  5. World Health Organisation (2001). International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organisation.
  6. Rivett DA (2004). Adverse effects of cervical manipulative therapy. In J.D. Boyling and G.A. Jull (eds.), Grieve’s Modern Manual Therapy of the Vertebral Column (3rd ed). Churchill Livingstone: Edinburgh 533-549.