Thursday Thoughts: Toolbox Vs Clinical Reasoning

I hope when a patient asks this you have a good answer

One of the recent Therapy Insider Podcasts was about Exercise Prescription.

A common idea that we all shared was that while there are an unlimited variations of exercise for different applications, the clinical reason behind why you are giving them and the mode at which you do should be scientifically sound.

The same goes for any of the tools in your toolbox. As a novice clinician, I gravitated toward standard OMPT courses that taught 300 different ways to passive assess a joint and tissue and 500 more ways to manipulate them. While I was fascinated by them and loved practicing the psychomotor skill, they were not exactly the type of courses you could go back on Monday and immediately apply. Come Monday morning, it was more like, "Ok.... here is a cervical patient.... so which of those bajillion assessments and/or treatments should I try?"

A former fellow mentee recently asked, "Hey Erson, I work with someone who routinely does Dry Needling, IASTM, and cupping all in the same treatment. What are your thoughts on this?"

My thoughts were that it was overkill, and to ask him why he was using all of them routinely. The answer was not "not a good one" according to the mentee. With that in mind, do you have an answer to why....

• you chose a pain science explanation for patient A, versus a bit more mechanistic explanation for patient B?
• you chose to do IASTM on one shoulder patient, and dry needling on another?
• why you should consider using cervical manipulation, especially if the patient has a positive expectation of a benefit after that type of technique?
• one patient needs strength training versus the other needing motor control despite them both being runners with knee pain?

Having a varied tool box is great, but all the tools in the world will not help unless you can selectively use the most effective ones for that patient at the right time. You also need to be able to explain to the patient why you chose those particular set of treatments/exercises, to educate on how to maintain the improvements with self assessment as well.

The framework behind your clinical decision making is more important than having a varied toolbox ;both combined, along with experience that comes from making mistakes and pattern recognition is something you cannot rush, but will come in time to those who strive for excellence.

Keeping it Eclectic...