Intro CR & DM Dual system

2. A pencil and a piece of paper cost an
euro and ten cents. The pencil costs
one euro more than the paper.
How much does the pencil cost?

3. Sure?
I´m so sorry buddies:
 Pencil= 1,05
 Paper= 0,05
 Total= 1,10 euros

4. intro
CLINICAL
REASONING
in PHYSICAL
THERAPY
Pablo C. García Sánchez
OMT1

5. clinical
reasoning
The thinking
underpinning the clinical
practice
Cognitive, intuitive and
mental operations,
which lead to decision
making processes at
clinical health field
What is for you?

6. Everybody confront
clinical problems in a
similar way, but with
different approach
and usually different
results

7. INTUITION
(fordward)
REFLEXION
(backward)
INDUCTION
PROSPECTIVE
Experts in front of
well-known problems
FORWARD
DEDUCTIVE
BAYESIAN
ANALITIC
Novels & Experts in
front of new
problems
BACKWARD

8. intuitive reflective

9. 2 systems
Do they interact?

14. continuumPure
intuitive
Pure
reflective

15. How reliable is it?

16. How many animals traveled with Moises in the arch?

17. How many animals traveled with Moises in the arch?
A. Less than 1000
B. Between 1000-5000
C. Between 5000-10000
Noah did…

18. How reliable is it?

19. intuitive reflective

20. attention
decision
mixdetection
& memory
Who is the
boss?
problem solution

21. It is LESS important
how much knowledge
do U have inside…
...is MORE important
how it is built and
connected

22. Knowledge
Propositional
knowledge
“knowing that”
Research
Evidence
Non-
propositional
knowledge
Craft
knowledge
Personal
knowledge
Three Forms of Knowledge Essential, Higgs and Titchen, 1995

26. Knowledge
Theory
Memorized
Reasoned
Practice
Learned Repeated
Reasoned
Craft

27. Knowledge is stored in the brain in chunks or data-boxes
This store way facilitate thinking and improve communication
Signs Symptoms
Personal
remembering
Images
This is what are we going to call “categories”

28. Pathobiological
mechanisms
Physical
impairments
and associated
structure/tissue
sources
TISSUE
STRUCTURE
HEALING
phase
Contributing
factors
YELLOW flags
Precautions &
contraindication
P/E & Rx
Activity and
Participation
capability/restri
ction
Management,
treatment &
prognosis
Patient’s
perspectives on
their experience
Jones, M. and D. A. Rivett (2004). "Introduction to clinical reasoning." Clinical
reasoning for manual therapists: 3-24.
CATEGORIES

29. Pathobiolog
ical
mechanism
s
Physical
impairment
s and
associated
structure/tis
sue
sources
TISSUE
STRUCTU
RE
HEALING
phase
Contributin
g factors
YELLOW
flags
Precaution
s &
contraindic
ation P/E
& Rx
Activity
and
Participati
on
capability/r
estriction
Managem
ent,
treatment
&
prognosis
Patient’s
perspectiv
es on their
experience
Data acquisition

30. Association of RELATED data of DIFFERENT categories
build CLINICAL PATTERNS
white

31. • Parallel nerve trunks
• Weakness
• Pins & Needles
• “Ants running”
• Worst at night
Association of RELATED data of DIFFERENT categories
build CLINICAL PATTERNS
• Pain
• Heat
• Redness
• Tumor
• Functional deficit
• Improve with cold and
NSAID
• Worst with movement
inflammation
neurogenic
pain

32. What are we going to do with this knowledge?
intuition
cognition
We´ll do it
nonconciously…
Which ones?
Discuss it 3´with your
partner

33. What are we going to do with this knowledge?
cognition
Mental processes list:
 1
 2
 3
 4
 5
 6
 7
 8

34. Anything else?
metacognition
“Awareness and ability to think about your thinking”
Wanna share any examples with the class?

35. Inductive reasoning
Reflective BEFORE action
Reflective IN action
Reflective AFTER action
Deductive reasoning
Schon, D. A. (1983). La formación de profesionales reflexivos.
Ryan, S. and Higgs J (2008). ”Teaching and learning clinical reasoning." Clinical
reasoning in the health professions: 379-387.

36. CR & DM
Errors
Source of
knowledge
Low evidence
Poor research
Physiotherapist
Intuition
Cognitive
Cognition
Metacognition
Assessment
Examination
Tools
Interpretation
Treatment Techniques
Health system

37. decision
making
The best-judged
action

38. Treatment / management
Researcher
Patients
Resource$
Teacher
Policy maker

39. Discrete
Well defined
Amenable to technical
solutions
Complex
Multifactorial
Changing
Poor defined

40. Patient
Desease
Disfunction
Disability
Bio
Psycho
Social
Diagnostic
Non diagnostic

42. 0 10 20 30 40 50 60 70 80
EBP
Intuition
Expertise & CR
Pat opinions
Which are the basis of PT decisions?

43. 5%
only take in account patient beliefs in their
decisions

44. 0 10 20 30 40 50 60 70 80
EBP
Intuition
Expertise & CR
Pat opinions
Which are the basis of PT decisions?

45. 15%
only take in account EBP in their decisions

46. INTUITI
ON
(fordwar
d)
REFLEXION
(backward)
HYPOTHETIC
DEDUCTIVE
Novels & Experts in
front of new
problems
BACKWARD

47. intuition
reflexion

48. INTUITION
(fordward)
INDUCTION
PROSPECTIVE
Experts in front of
well-known problems
FORWARD

49. experience
intuition
cognition
reflective
Educating intuition, Hogarth, 2001 (adapted)

50. Role Playing activities

51. Drills in practice

52. Case studies

53. Clinical Pattern Booklet

54. “Overflow/Sublimation of evidence”
How to start to make decisions in
each area/cathegory?

55. Mechanic Ischemic
On an spot, well
localized area
Improve with
heat

56. “Overflow/Sublimation of evidence”

57. Mechanic Ischemic

58. Mechanic Ischemic

59. Mechanic Ischemic

60. Pablo César García Sánchez
https://slowpt.com/
@pcgarcias
pcgarciasanchez@Gmail.com