6 Assessment and treatment planning
Clinical reasoning
Clinical reasoning is the process by which clinical decisions are made. This clinical decision-making, a continuous event that begins before treatment, is applied and maintained through the treatment programme in an ongoing evaluation of its effects, leading to any necessary adaptation. It culminates in discharge or re-referral of the patient. A wider reflection is also appropriate, whereby the therapist evaluates a series of patient interventions and the service she provides as a whole, on both a personal and a wider professional level. A useful approach to treatment is a problem-based approach which ensures that the essential cognitive steps are followed. With this approach, the thinking begins with the recognition and identification of the problem; essential information is acquired to help with analysis of the problem; and then decisions can be made to meet all the stages of problem-solving. For clinical reasoning to occur at its highest level, the therapist must develop the related intellectual skills; this is just as important as the acquisition of the psychomotor skills which enable the therapist to act on any clinical decisions made. Intellectual skills are divided into cognitive and metacognitive (Henley 1994). Cognitive skills are knowledge, understanding, synthesis, analysis and evaluation, which is known as Bloom’s taxonomy (Bloom 1956). This is an acknowledgement of the hierarchical nature of intellectual functioning. The first step is to gain knowledge as this provides the foundation that underpins useful clinical thought. This knowledge can be applied to different situations only if it is understood. It must then be placed in a wider context so that aspects of previously acquired knowledge are selected if judged to be relevant, or temporarily disregarded if considered irrelevant. The new knowledge is then made to fit comfortably with previously gained knowledge in a synthesis which enhances the understanding of any individual component. At a higher level, this synthesis can be analysed, when a deeper interpretation, deconstruction and judgement takes place. Finally, the material can be evaluated when it is further examined critically in the light of other knowledge bases, experience, personal judgement, acknowledged opinion and so on. The total process occurs throughout undergraduate study and should continue when an individual acquires new knowledge, either experiential or theoretical. However, of interest here is the fact that, experientially, the same process occurs throughout the assessment and treatment of patients. The metacognitive skills involved in clinical reasoning include reflection, in which an awareness and monitoring of our thinking processes (asking how and why) takes place (Henley 1994).
Payton (1985) applies this to the clinical situation and identifies the stages of clinical reasoning as follows:
• Cue acquisition—information is gathered from a variety of sources to provide ‘clues’ to the problem;
Hypothesis generation—an experienced clinician will often formulate a hypothesis very early on in an assessment as to what the problems are;
• Cue interpretation—an essential step in which the ‘clues’ are interpreted in detail; and
The order in which the therapist travels through these stages may vary as ideas and thoughts are mentally checked and revisited. This occurs to satisfy the need to ensure that the decisions made are valid. Mattingley and Fleming (1994) term this hypothetical reasoning procedural reasoning. This is an additional category of reasoning which is interactive. The exact style varies, depending on the individual patient the therapist is working with, but it reflects the relationship between therapist and client and the impact this interaction has on the reasoning process. The same authors suggest that a holistic approach requires a further stage in reasoning, conditional reasoning, in which the problem is seen in its widest context.
Narrative reasoning is the term used for understanding the context in which the meaning and richness of the patient’s story is understood, extending the specific facts and linear history (Fleming & Mattingley 2000, Jones & Rivett 2004). The therapist is required to respect and understand the individual’s perception and unique experience of their problems and symptoms (Mezirow’s meaning perspective). The individual’s reality of the meaning of their condition and its impact on their emotions, physical and psychological well being and the significance of this to their life is a central factor in how they respond to both the condition and the treatment. Understanding the patient at this level will enable the therapist as an individual and the therapeutic relationship they build with the patient to become part of the treatment. The intervention will be directed at the person, not the problem (Jones & Rivett 2004). There is growing evidence that certain types of responses to injury (such as fear avoidance behaviour) is likely to lead to a chronic pain syndrome with its disabling behaviours. Patients exhibiting these traits should not be treated passively with massage. However, some patients in emotional distress may respond well to painless touch therapies as enabling techniques to build the confidence to actively participate in a functional, goal-driven rehabilitation process. The quality of the therapist’s narrative reasoning will enable an appropriate, effective treatment prescription.
The theory of ‘fuzzy traces’ assumes that experiences are organised in the memory and retrieved in both verbatim and gist representations. These two types are encoded and stored independently. It is thought that gist representations support pattern recognition and verbatim memories assist in explaining things to others (Lloyd & Reyna 2001).
So, how do we go about this? Clearly, the central activity is assessment of the patient.
Patient assessment
• What the patient’s problems are;
• Whether massage can help these problems;
• What the limitations of massage will be in this particular set of circumstances;
• The presence of any dangers or contraindications;
• Any factors that will necessitate modifications to the preferred method of application;
• Which massage techniques will be most effective;
• Which media should be used; and
Subjective assessment
It is also important to employ the use of closed questions to ensure that specific and necessary information is obtained (‘Do you ever experience pins and needles?’ ‘How exactly do you sit when typing?’). These can be ‘search’ questions which are very specific, or ‘scan’ questions which are somewhat wider and attempt to pick up further cues (Henley 1994). It is sometimes necessary to control a verbose patient tactfully, especially if time is re-strained (‘Could we leave that for the moment—I need to ask you some specific questions about your thumb stiffness’; ‘I understand, but where exactly is the sharp pain? Could you point to it with one finger?’).
The following is a checklist of information required from the patient:
