CRstrategiesin Phys Ther

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Clinical Reasoning Strategies in Physical Therapy
Article in Physical Therapy · May 2004

DOI: 10.1093/ptj/84.4.312 · Source: PubMed
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䢇
Research Report
Clinical Reasoning Strategies in

Physical Therapy
Background and Purpose. Clinical reasoning remains a relatively under-
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў
researched subject in physical therapy. The purpose of this qualitative

study was to examine the clinical reasoning of expert physical thera-
pists in 3 different fields of physical therapy: orthopedic (manual)
physical therapy, neurological physical therapy, and domiciliary care
(home health) physical therapy. Subjects. The subjects were 6 peer-
designated expert physical therapists (2 from each field) nominated by
leaders within the Australian Physiotherapy Association and 6 other
interviewed experts representing each of the same 3 fields. Methods.
Guided by a grounded theory method, a multiple case study approach
was used to study the clinical practice of the 6 physical therapists in the
3 fields. Results. A model of clinical reasoning in physical therapy
characterized by the notion of “clinical reasoning strategies” is pro-
posed by the authors. Within these clinical reasoning strategies, the
application of different paradigms of knowledge and their interplay
within reasoning is termed “dialectical reasoning.” Discussion and
Conclusion. The findings of this study provide a potential clinical
reasoning framework for the adoption of emerging models of impair-
ment and disability in physical therapy. [Edwards I, Jones M, Carr J,
et al. Clinical reasoning strategies in physical therapy. Phys Ther.
2004;84:312–335.]
Key Words: Clinical practice, Clinical reasoning strategies, Decision making, Dialectical reasoning,
Knowledge.
Ian Edwards, Mark Jones, Judi Carr, Annette Braunack-Mayer, Gail M Jensen
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў
312 Physical Therapy . Volume 84 . Number 4 . April 2004

ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў
C
linical reasoning refers to the thinking and these reasons to justify the importance of clinical reason-
decision-making processes that are used in clin- ing, clinical reasoning is relevant because every physical
ical practice. Higgs and Jones1 have defined therapist has to make a wide variety of decisions in his or
clinical reasoning as a process in which the her daily clinical practice. All clinicians, therefore, have
therapist, interacting with the patient and others (such an interest in improving their decision making. Reflect-
as family members or others providing care), helps ing on decision making is part of a sound clinical
patients structure meaning, goals, and health manage- reasoning process and is an important source of learning
ment strategies based on clinical data, patient choices, in practice.1
and professional judgment and knowledge. Over the last
decade, clinical reasoning has come to prominence as a The Development of Clinical Reasoning in
subject for study. This has occurred, in part, because of Physical Therapy
the skills expected of physical therapists and develop- Early studies and models of clinical reasoning in physical
ment of the profession in a changing health care climate therapy provided explanations of clinical reasoning that
that requires increasing accountability in decision mak- were similar to those of physicians and were mainly
ing as part of the process of providing desirable out- concerned with “diagnosis.”4 –9 The common factor was
comes.1 Another reason for the rising importance of support of the hypothetico-deductive model of reason-
clinical reasoning is that independent and responsible ing. The hypothetico-deductive model remains the most
decision making is now regarded as one of the charac- enduring clinical reasoning model in medicine and was
teristics of an autonomous profession.2,3 In addition to derived from a cognitive science perspective.10 In the
I Edwards, PhD, Grad Dip Physio (Ortho), MAPA, is Physiotherapist, The Brian Burdekin Clinic, Adelaide, South Australia, Australia, and Lecturer,
School of Health Sciences, University of South Australia. Address all correspondence to Dr Edwards at School of Health Sciences, University of
South Australia, North Terrace, Adelaide, South Australia, Australia 5000 ([email protected]).
M Jones, MAppSc (Manip Ther), Cert Phys Ther, Grad Dip Advan Manip Ther, MMPA, MAPA, is Senior Lecturer and Director, Graduate Programs
in Musculoskeletal and Sports Physiotherapy, School of Health Sciences, University of South Australia.
J Carr, Dip Physio, Grad Dip F Ed, is Physiotherapist, Murray Mallee Community Health Service, Murray Bridge, South Australia, Australia.
A Braunack-Mayer, PhD, is Lecturer in Ethics, Department of Public Health, University of Adelaide.
GM Jensen, PT, PhD, FAPTA, is Professor of Physical Therapy, Associate Dean for Faculty Development and Assessment, and Faculty Associate,
Center for Health Policy and Ethics, School of Pharmacy and Allied Health, Creighton University, Omaha, Neb.
All authors provided concept/idea/research design. Dr Edwards, Mr Jones, and Dr Braunack-Mayer provided writing and project management.
Dr Edwards provided data collection, and Dr Edwards, Mr Jones, and Ms Carr provided data analysis. Dr Edwards provided fund procurement. The
authors thank Dr Marie Williams, Associate Professor, School of Health Sciences, University of South Australia, for her helpful comments in
reviewing the manuscript.
This study was approved by the Human Research Ethics Committee of the University of South Australia and supported by a grant from the South
Australian branch of the Australian Physiotherapy Association.
This article was received September 20, 2002, and was accepted October 17, 2003.
Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 313

hypothetico-deductive method, the clinicians attend to Clinical Reasoning Research Using Alternative
initial cues (information) from or about the patient. Methods to Cognitive Science
From these cues, tentative hypotheses are generated. Until the mid-1990s, the forms of clinical reasoning
This generation of hypotheses is followed by ongoing discussed were the main forms of reasoning described in
analysis of patient information in which further data are the physical therapy literature. Researchers of expertise
collected and interpreted. Continued hypothesis cre- and clinical reasoning in physical therapy,18 –20 nurs-
ation and evaluation take place as examination and ing,21–26 and occupational therapy27–31 then began to
management are continued and the various hypotheses consider alternative methods for studying the develop-
are confirmed or negated. ment of expertise and the nature of clinical reasoning.
In each field, engagement with the patient and family, as
The hypothetico-deductive reasoning model, although compared with the emphasis on the initial diagnosis, in
derived from cognitive science, has its roots in the our opinion, led clinicians to ask different kinds of
empirico-analytical research paradigm.11 The empirico- questions regarding the nature of patients’ experiences
analytical research paradigm, which is also known as the of pain, illness, and disability. That is, many of the
scientific or positivist paradigm, holds that truth or clinical tasks in these health care professions required an
reality (ie, knowledge) is objective and measurable, understanding of the person as well as the disease.25,27
thereby utilizing observation and experiment to produce This understanding raises a “world” for the patient that
a result that, in turn, can be generalized and also leads to has both biomedical and lived experience. This polarity
prediction. For example, randomized controlled trials has been described in the medical, adult learning, and
are carried out within this paradigm of research. In sociological literature.32–36
clinical practice in physical therapy (as in medicine),
hypothetico-deductive reasoning aims, within the limita- Most of the clinical reasoning research carried out up to
tions of available standards, to validate information or this point had been in the laboratory rather than at the
data acquired from the patient through measurement in actual site of practice.37 Researching clinical practice
a reliable fashion. from the site of clinical practice, by including the
perspectives of clinicians and patients, would require a
Other models of clinical reasoning from this same paradigm of research that could include many variables
cognitive science (empirico-analytical) perspective have over most of which the researcher would have little
focused less on the processes and more on the organi- control.38,39 In contrast to the empirico-analytical
zation and accessibility of knowledge stored in the research paradigm, an interpretive research approach
clinician’s memory. Examples of knowledge organiza- recognizes that truth or knowledge is related to meaning
tion used in clinical reasoning include “illness scripts”11 and the context in which it is produced and, therefore,
and “pattern recognition.”12,13 In making use of illness concedes that in any given situation there may be
scripts or pattern recognition, the clinician recognizes multiple realities, truths, or perspectives.11
certain features of a case almost instantly, and this
recognition leads to the use of other relevant informa- The explanations of clinical reasoning emanating from
tion, including “if-then” rules of production, in the this collective research in the interpretive paradigm in
clinician’s stored knowledge network.14 This form of the health care professions are said, by their various
reasoning moves from a set of specific observations proponents, to stand in contrast to hypothetico-
toward a generalization and is known as “forward rea- deductive or diagnostic reasoning. One such example is
soning.”12 Forward reasoning contrasts with hypothetico- narrative reasoning.27 Narrative reasoning seeks to
deductive reasoning where a person moves from a understand the unique lived experience of patients—a
generalization (multiple hypotheses) toward a specific reasoning activity that could be termed “the construc-
conclusion.14 Experts generally agree that both forms of tion of meaning.” In patients’ (or therapists’ for that
this cognitively oriented reasoning are used at different matter) telling of stories or narratives, there is a choice
times.10,15 Pattern recognition is faster and more effi- in which some elements are expressed, some elements
cient and is used by expert and experienced practitio- are emphasized over others, and still other elements may
ners in their domain.14 Hypothetico-deductive reasoning not find expression.40 For example, the particular “tell-
is used by more inexperienced practitioners and by ing” of a story or history by patients represents their
experts when faced with an unfamiliar problem or a interpretation of events over time. Such interpretations
more complex presentation.10,15 These 2 cognitively (albeit not necessarily consciously constructed) may not
oriented methods taken together are often referred to as be neutral in their effects on the teller.40,41 In the
“diagnostic reasoning.”4,5,16,17 context of clinical practice in physical therapy, narrative
reasoning concerns the understanding of patients’ sto-
ries in order to gain insight into their experiences of
disability or pain and their subsequent beliefs, feelings,
314 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

ўўўўўўўўўўўўўўўўўўўўўўўўўўў
and health behaviors.27,40 This includes the patients’ Besides technical skills, cultural, social, and personal
ability to make choices and learn new perspectives.35 knowledge and understanding together with diagnostic,
Patients’ narratives, therefore, may provide insights for teaching, negotiating, listening, and counseling skills
intervention and its outcomes.41 Narrative reasoning is might all play a greater or lesser role in the clinical
distinguished from hypothetico-deductive reasoning in reasoning process. A different mix of clinical reasoning
that “hypotheses” concerning patients’ interpretations skills may be needed for therapists working in the same
of their experiences are not validated by testing but by settings according to their own particular interests,
consensus between therapists and patients.27 beliefs, or clinical and life experiences. Perhaps the
same therapists use different combinations of clinical
Influenced by the critical social theory of the German reasoning skills at different times and occasions accord-
philosopher Habermas,33 Mezirow35 distinguished ing to the particular patient or client and the context of
between different forms of learning: instrumental learn- care.
ing and action, and communicative learning and action.
Instrumental learning and action (like hypothetico- We believe there is a need, therefore, for identification
deductive reasoning) has as its purpose the determina- of the range of clinical reasoning skills or strategies
tion of cause-effect relationships, which lead to predic- being utilized by experts in different aspects of physical
tions about observable events that are either correct or therapy care. This process of identification, we contend,
incorrect. The aim of communicative learning and action, is important as the profession considers the variety and
however, is not to establish cause-effect relationships but scope of its activities and seeks to answer questions such
to increase insight and a common understanding of a as, “How will physical therapy define itself and its role(s)
situation through a mutual learning process between the in the community in an increasingly competitive health
therapist and the patient. care market?” and “How can future practitioners be best
educated and prepared to function in the various fields
In communicative learning and action, the learner of health care in which physical therapists practice?”
(either therapist or patient) when confronted by an
unfamiliar experience or dilemma (eg, in a patient’s The aim of our study was to examine the nature and
case, ongoing pain, disability) becomes aware through scope of clinical reasoning and knowledge used by
critical reflection of the underlying assumptions or per- expert clinicians in 3 different fields of physical therapy:
spectives that he or she holds about particular situations orthopedic (manual) physical therapy, neurological
(eg, past experience and beliefs concerning injury or physical therapy, and domiciliary care (or home health)
physical therapy intervention).35 The capacity to first physical therapy. Our objective was to generate further
understand the perspectives a person currently holds, theory concerning clinical reasoning in physical therapy.
then reflect on the adequacy of these perspectives, and We also sought to develop a new model to explain the
finally adopt newer, more constructive or reliable per- clinical reasoning already in use among physical thera-
spectives is called “transformatory learning.”35 pist clinicians. Due to the large body of data generated
by our study, we will concentrate on reporting the
The Scope of Early Studies in Clinical findings in terms of the nature, scope, and manifestation
Reasoning in Physical Therapy of the clinical reasoning skills of the therapists. We will
Not only were the early studies of clinical reasoning in refer only briefly as to how the knowledge for these skills
physical therapy more concerned with the diagnostic is acquired.
process, the majority of these studies were carried out in
orthopedic settings.4,5,18,41– 45 Physical therapist practice, Method
however, occurs across a wide spectrum of health care
and, as a profession, requires solving complex and Design
poorly defined practice problems.36 In an Australian The research approach we used follows that of Jensen
setting alone, a person could consider the range of skills et al.18 Using a grounded theory, case study approach
needed, to do rehabilitation among aboriginal people in within an interpretive research paradigm (explained in
remote areas, cardiothoracic physical therapy in an the “Method” section), Jensen and colleagues were the
acute hospital, orthopedic (manual) physical therapy in first researchers to systematically study the clinical work
a private practice, physical therapy for children with of physical therapists in order to differentiate novice
orthopedic problems, or physical therapy aimed at help- practitioners from their expert counterparts. One of
ing retrain motor skills in adults following a stroke. The their early explanations (or conceptual frameworks) of
breadth and variation in the skills required, as the the differences among orthopedic physical therapists in
demands of each area are considered, is vast. outpatient settings was that expert clinicians exhibited
clinical qualities that differed from those of their novice
counterparts. Jensen et al identified the following as

Grounded theory is a field-based
research technique that seeks to gener-
ate theory.46 Although there is a debate
among proponents of grounded theory
concerning the level of preconceived
theory with which a researcher enters
the field, there is general support for
the idea that theory that is generated
from the data should be compared with
or contrasted to existing theories (if
they exist).46 – 48 An important feature
of grounded theory, therefore, is the
iterative relationship among data col-
lection, data analysis, and review of the
literature. This iterative process means
that the findings of the study are pro-
gressive and represent the develop-
ment of a series of conceptual frame-
works (or interim explanations of the
data). Each conceptual framework is
the result of a continued refinement of
data collection, data analysis, and refer-
Figure 1. Criteria of expertise. ence to existing theories in various
fields of relevant literature.
The 3 fields of orthopedic (manual)

physical therapy, neurological physical
therapy, and domiciliary care (home
health) physical therapy were chosen
for our study because they represent
quite diverse areas of physical therapist
practice from which we could investi-
gate the formation of potentially differ-
ent domains of knowledge and reason-
ing skills. The determination of the
sample size of 6 primary informants
(2 clinicians from each field) rested on
Figure 2. Interview guide questions. Kluzel’s argument that, “[t]he validity,
meaningfulness and insights generated
from qualitative inquiry have more to
attribute dimensions that distinguish between master do with the information richness of the cases selected
and novice clinicians: (1) ability to control the treatment and the observations/analytical capabilities of the
environment, (2) wide use of patient illness and disease research than the sample size.”49
data in a context-rich evaluation, (3) focused verbal and
nonverbal connection with the patient, (4) equal impor- The research panel (consisting of an orthopedic physical
tance of teaching to hands-on care, and (5) confidence therapist who was the primary researcher; 3 other phys-
in predicting patient outcomes. ical therapists with various expertise in qualitative
research, adult learning, and teaching; and one other
The grounded theory approach and case study work are member, a lecturer in ethics) agreed that 6 cases would
both methods that seek to understand human behavior yield a large and sufficient amount of data. The 6
within a natural context and from the participants’ point physical therapists were selected by a purposive50 or
of view.38,39,46 The phenomenon studied is clinical deci- critical case sampling method.47
sion making, and the context is the clinical practice in
which this decision making takes place. Each of the 6 Australian Physiotherapy Association (APA) consultants
physical therapists in the primary sample, together with are prominent physical therapists appointed to act as
their clinical practices, constitutes a “case” for study. public spokespeople for the profession on account of

Table 1.
Abridged Résumés of Participating Physical Therapistsa
Years Since
Graduation Work Setting Teaching Experience Qualifications
Denise* 14 Domiciliary care/senior PT Supervision of final-year students BAppSc, MAppSc candidate

Danielle* 13 Domiciliary care/senior PT Supervision of final-year students BAppSc Grad Dip
Health Counseling
Dianne 31 Community health center Supervision of final-year students Dip PT
Dorothy 30 Community health center Supervision of final-year students Dip PT
Neve* 33 Neurophysiotherapy/private practice Clinical tutor–undergraduate Dip PT, Dip Psychosynthesis
principal course
Narelle* 12 Neurophysiotherapy/private practice Clinical tutor–undergraduate BAppSc, MAppSc
principal course
Nancy 28 Associate professor Lecturing, research Dip PT, BA, PhD
Nicole 14 Senior lecturer Lecturing, research BAppSc, PhD
Michael* 22 Manipulative PT/principal private Lecturer–postgraduate courses Dip PT, Grad Dip Manip Ther,
practice MAppSc (physio)
Monica* 15 Manipulative PT/principal private Tutor postgraduate course in BAppSc, Grad Dip Manip Ther
practice manipulative therapy
Meredith 16 Manipulative PT/principal private Tutor postgraduate course in BAppSc, Grad Dip Manip Ther
practice manipulative therapy
Marion 14 Manipulative PT/principal private Tutor postgraduate course in BAppSc, MAppSc, PhD
practice manipulative therapy candidate
a
Asterisk denotes participant in primary sample. PT⫽physical therapist.
Table 2. dom, and all therapists agreed to participate in the study.

Observed Number of Treatments and Hours Spent With Each Physical
Therapist An information sheet was sent to each therapist before
confirming his or her participation and signing consent
No. of Hours
forms. These 6 primary informants had clinical practice
Treatments Observed experience ranging from 13 to 33 years (Tab. 1). All
therapists had current or past teaching experience and
Orthopedic (manual) therapist 22 12 either held postgraduate qualifications or were engaged
Michael
Orthopedic (manual) therapist 19 15
in formal postgraduate study.
Monica
Domiciliary care therapist 6 14.5
In this article, the physical therapists are identified by
Denise pseudonyms, with the first letter of these pseudonyms
Domiciliary care therapist 7 12 also being the first letter of the field in which they work
Danielle (eg, Neve is a neurological therapist). None of the
Neurological therapist Neve 12 13 therapists in this primary sample had formal training in
Neurological therapist Narelle 13 13 clinical reasoning theory. Data collection commenced
Total 79 79.5 following approval of the study by the Human Research
Ethics Committee of the University of South Australia.
Data Collection
their current standing and expertise in their respective Data collection took place, in the manner of grounded
fields. The APA consultants for each field were con- theory, in 3 “waves” over the course of approximately 1
tacted and asked to nominate, based on criteria of year. The first data collection consisted of observation of
expertise (Fig. 1), a short list of physical therapists treatment sessions and semistructured and unstructured
regarded by their peers as experts in their particular interviews (see Fig. 2 for sample questions). Each phys-
fields. Not all of the characteristics described in Figure 1, ical therapist was “shadowed”51 over the course of 2 or 3
however, are operationally defined. The consultants days of their usual work. The orthopedic and neurolog-
were asked to nominate only physical therapists whom ical physical therapists were all observed in the rooms of
they felt possessed at least 5 of the 7 criteria. Two their private practices. The domiciliary care (home
physical therapists from each list were selected at ran-

health) physical therapists were observed during visits to the 6 individual case studies had been written and sent to
the homes of their patients. the relevant therapist in the primary sample for corrob-
oration. The aim of this third wave of data collection
The treatment sessions and interviews were audiotaped were to see whether data in the form of responses and
to enable the researcher to focus on the more subtle themes began to recur.52 The data from the second
exchanges (such as nonverbal interaction) between sample were incorporated in the composite case studies
physical therapist and patient, while still permitting representing each field to provide further commentary
detailed analysis of the overall dialogue on later occa- or corroboration of the data from the primary sample.
sions. A microcassette recorder with a very small omni- These data were clearly distinguished in the composite
directional microphone was used. The cassette recorder case studies from the data of the primary sample and
was attached by Velcro* to the inside of a folder. Also also kept appropriately proportionate to the data from
within the folder was a notepad to write down field notes the primary sample. That is, data from this secondary
about nonverbal interactions, techniques, positions, or sample were used to support data from the primary
actions that the therapist (and the patient or caregiver) sample and not to provide the main evidence for theme
were engaged in and that would not have been obvious identification or development within the case studies.
from listening to the audiotape itself. Such observations
were recorded against the reading of the audiotape Data Analysis
counter. This meant that when listening to the audio- Data analysis for a study such as ours can be considered
tapes later, there was a written commentary supplying having 4 stages: coding, individual case studies, compos-
both contextual information and a workable “index” to ite case studies (cross-case analysis within settings), and
material on the audiotapes—an important factor for comparative analysis (cross-case analysis across settings).
coding and the later construction of case studies. The data reduction and analysis for the study was
Seventy-nine treatment sessions were observed across the organized around a set of cognitive processes identified
3 fields (Tab. 2). by Morse53(p27): (1) comprehending, (2) synthesizing,
(3) theorizing, and (4) recontextualizing. Comprehending
The second wave of data collection consisted of written is the cognitive process in which the researcher in the
material from each of the 6 physical therapists. The field gains both insight and sensitivity concerning both
purpose of this data collection was to identify potential the setting and the data. This process includes not only
sources of knowledge (eg, mentors, clinical and life data collection but also the initial processes of coding.
experiences) that may have influenced the therapists’ Synthesizing refers to the process of data reduction—a
professional development in a manner expressed in merging of stories, experiences, or cases to describe a
their clinical practices. The need for these data had been typical pattern of behavior or response. Theorizing is a
identified by the research panel in the process of the process whereby alternative explanations or models are
initial coding and data analysis about 4 months after the considered. Recontextualizing refers to the process in
first data collection period and was based on a prelimi- which the emerging theory is considered in relation to
nary identification of diverse sources of knowledge being other settings or groups. This process involves compar-
used in practice. At that time, the therapists were asked ing findings with existing or established theory. In a
to write down on a “timeline” those factors and people grounded theory approach, these steps are repeated
whom they considered important influences on their several times with each subsequent analysis of data.39,46
professional lives. The therapists were told that this was
not meant to be a curriculum vitae but rather a personal A panel of 3 coders examined transcripts reflecting what
reflection on those influences, which could include occurred during treatments and interviews and coded
people and events outside the profession. them for clinical reasoning strategies, knowledge frame-
works, and sources of knowledge. Ascertaining inter-
The third wave of data collection took the form of coder agreement was based on the method of Miles and
semistructured interviews with 6 other physical thera- Huberman,54 and, as a result, we produced intercoder
pists (2 therapists from each of the same 3 fields) 12 agreement among the 3 coders at over 90% for each of
months after the initial fieldwork. These therapists were the 3 coding definitions.
a convenience sample50 of expert therapists who were
involved in teaching in one of the relevant 3 practice The clinical reasoning strategy codes were developed by
areas through the University of South Australia. The the panel based on Jensen and colleagues’ attribute
therapists were asked the same sample questions regard- dimensions18 and other described clinical reasoning
ing issues of practice as those that the therapists in the methods used in health care such as narrative reason-
primary sample were asked. Before this process started, ing.27 That is, alongside the existing descriptions of
clinical reasoning used in fields such as nursing and
occupational therapy, the attribute dimensions provided
* Velcro USA Inc, 406 Brown Ave, Manchester, NH 03103.

Figure 3. Overview of case study formation.

areas of clinical practice (eg, teaching, psychosocial The process of case study analysis was done in the
focus, prognostic ability) among expert practitioners in following sequence. Individual case studies for each area
which to examine foci of clinical reasoning. were combined with the coded material from the inter-
views of the secondary sample of physical therapist
The knowledge frameworks and sources of knowledge experts to form 3 composite case studies. From these
coding definitions were adapted from Jensen et al.19(p71) composite case studies, cross-case analysis, first within
The knowledge framework codes included physical ther- settings and then across settings, was performed. Table 3
apists’ content knowledge of their field or speciality, illustrates how conceptual frameworks (explanations
their knowledge of patients (including of human behav- building on previous understandings) were developed
ior), a knowledge of teaching, a knowledge of self iteratively with this data collection and analysis process.
(including evidence of reflective ability, confidence, and
growth as a person and as a professional), and a knowl- Ensuring Rigor
edge of context (relating more to understanding the There is much debate concerning rigor in qualitative
larger picture and the role of their work, the work research.47 In our study, a range of strategies were used
environment, and the workings of the health care sys- to strengthen the integrity of the study’s findings. One of
tem). The sources of knowledge codes included per- these strategies, member checks,54 has already been men-
ceived influences from mentors, patients, colleagues, tioned in relation to the primary sample. Other strategies
friends and others, professional education (outside of used in the study include negative case analysis,39,54 an
that received during formal training), self-education, audit trail,55 thick description,56 and triangulation.50
reading, life events (happenings in life outside practice
that cause reflection on a clinician’s own clinical work), Negative case analysis occurs where incidences of data that
and research in which the therapist had personally been deviate from the overall patterns of data are pursued as
engaged. an opportunity to refine and review a conceptual frame-
work under development. One example in our study was
A typology of knowledge proposed by Higgs and where the physical therapists expressed regret or failure.
Titchen,11 which represents 3 types of knowledge used in These feelings were pursued and explicated in the case
clinical practice (propositional, professional, and per- studies. An audit trail is a record of decision making
sonal), was later adopted as a conceptual framework to (either of the primary investigator or of the coding
characterize the dimensions of knowledge described. panel), of turning points in the research, of correspon-
Propositional knowledge refers to public or declarative dence with various stakeholders, and of cognitive “road
knowledge in a particular field or part of the external maps” summarizing researcher understanding of the
world. Professional knowledge refers to forms of practice project at different points. Thick description is an anthro-
knowledge, often tacit or intuitive, that also reflect a pological term56 referring to an in-depth description of
practitioner’s practical and technical expertise. Personal particular and multiple characteristics of a case (ie, a
knowledge is experiential knowledge that comes about particular therapist’s clinical practice) in order to induct
through the practitioner’s reflection on experience the reader into an experience of the situation. This
(both work and non–work related) and helps form a in-depth description reduces the chance that identified
practitioner’s frame of reference or worldview with its elements of observed treatment sessions or interview
particular values. comments from informants are “taken out of context” to
suit the purposes of the researcher. Examples of thick
In our study, individual case studies describing the description are provided in the “Findings” section. Tri-
clinical practice of each therapist from the primary angulation is an important tool used in an effort to
sample, particularly in terms of the scope of clinical ensure rigor and involves the use of several data sources,
reasoning, were constructed drawing on the data methodological approaches, multiple analysts, and the
obtained through the observations, interviews, and time- consideration of diverse theories to explain findings in
lines (Fig. 3). Impressions from the field notes were order to reduce systematic bias in the data.50,54 In our
added to these data sources. Each case study was sent, on study, the different data sources were observation, inter-
completion, to the respective therapist from the primary view, and written reflection. There were positivistic
sample for his or her comments, a process known as methods (eg, coding reliability) juxtaposed with natural-
“member checks.”52 On follow-up, which was done via a istic methods (eg, thick description). Multiple analysts
telephone conversation, each therapist responded very considered coding definitions and identified the result-
positively to the question, “Was the case study a fair and ing constructs from the data. Finally, multiple perspec-
accurate interpretation of their clinical work with its tives were considered: the constructed case studies,
particular characteristics, emphases, and values?” which were the interpretations of each therapist’s clini-
cal practice by the researchers, the corroboration of
those case studies by each therapist in the primary

Table 3.
The Iterative Nature of Grounded Theory and Case Study Work
Time Literature Data Collection Data Analysis Conceptual Frameworks
April 1996 Ethics proposal

Attribute dimensions (Jensen et al,18
Literature review 1 1992), existing literature—forms of
November 1996 Shadowing therapists Reflection on daily reasoning
(observation, interview) experiences
Literature review continuing 2
Clinical reasoning strategies 1.
Physical Therapy . Volume 84 . Number 4 . April 2004

2
February 1997 ● qualitative methodology Transcript preparation, ● foci of thinking and action
● clinical reasoning coding meetings Knowledge: Jensen et al’s (1996)
● clinical practice issues framework (cited in Jensen et al,19 1999)
● models of practice 2
May 1997 ● professional socialization
2
Timeline reflections Individual case studies
● philosophies of knowledge/research
2
December 1997 Interviews with other
physical therapists
Therapist corroboration
2
Clinical reasoning strategies 2.
● combinations of cue-based reasoning
2 Knowledge: Higgs and Titchen,11
December 1998 Composite case studies 2000—personal, professional, and
Research folder: propositional
memos,
¡ communications, ¢ 2
Literature review 2 reflections, Cross case analysis and
2
June 1999 ● adult learning panel decisions thematic write-up Clinical reasoning strategies 3
● ethics ● dialectical relationship between different
● social theories of learning paradigms of reasoning
Knowledge: individual and social
learning in communities of practice
¡ Review of literature reviews 1 and 2

2
Final write-up
January-August 2000
Edwards et al . 321
sample, together with the views of the second sample of • Ethical reasoning includes the apprehension of ethi-
therapists (incorporated in the composite case studies) cal and practical dilemmas that impinge on both
were all compared with existing models of reasoning the conduct of intervention and its desired goals,
from the relevant literature. and the resultant action toward their resolution.
Findings Second Conceptual Framework—Cue-Based Combining

We used 3 stages in the conceptualization of the clinical of Reasoning Strategies
reasoning: (1) identification of different clinical reason- In the second conceptual framework, we acknowledged
ing strategies, (2) cue-based combining of reasoning strat- the fluidity of clinical practice. Clinical practice was
egies, and (3) interplay of reasoning strategies in different observed to consist of several dynamics or actions that
paradigms of knowledge leading to the final proposed either were happening at once or were closely juxta-
model of clinical reasoning— dialectic reasoning. posed to one another. In this conceptual framework, the
clinical reasoning strategies were combinations of cue-
First Conceptual Framework— based reasoning where there was interdependence
Clinical Reasoning Strategies among various strategies at any given time. That is, in
Clinical reasoning strategies can be thought of as a way agreement with Jensen et al,18 although these therapists
of thinking and taking action within clinical practice. A had frameworks for information gathering and carrying
number of different reasoning strategies were evident out procedures, they did not follow a strict order of
within the expert case studies and identified as being protocols in clinical practice. Instead, they attended to
common to the practice of all of the physical therapists the cues provided by patients:
across the 3 fields. We considered these strategies under
the broad headings of “diagnosis” and “management”: And I don’t always know when I start with them how I’m
going to . . . you know . . . what path I’m going to take, if
Diagnosis you see what I mean. I don’t have a recipe, but I tend to be
triggered by what they say and then move them from there.
(Neve, neurological therapist)
• Diagnostic reasoning is the formation of a diagnosis
related to physical disability and impairment with
I tend to let the person guide the interview. And then, at the
consideration of associated pain mechanisms, tissue
end, I think we haven’t covered shopping or we haven’t
pathology, and the broad scope of potential con- covered toileting or pressure care or whatever the gaps are. So
tributing factors. I guess I have got that sort of internal list, and I work out what
• Narrative reasoning involves the apprehension and hasn’t been covered at the end. But I let the person take it for
understanding of patients’ “stories,” illness experi- the first while. I’m not very good at sitting with someone with
ences, meaning perspectives, contexts, beliefs, and a form and saying “tick,” “tick,” “tick” down the form. It
cultures. doesn’t work for me. (Denise, domiciliary care therapist)
Management I actually think their information is more important than

your own sometimes because that’s the most powerful part
• Reasoning about procedure is the decision making of the relationship with them . . . and with subjectives [sub-
jective examinations], I’ll never write them up afterwards
behind the determination and carrying out of treat-
because it’s just . . . it’s so much information you’re getting,
ment procedures.
and it’s such valuable stuff. (Michael, orthopedic [manual]
• Interactive reasoning is the purposeful establishment therapist)
and ongoing management of therapist-patient
rapport. The following vignette illustrates how clinical reasoning
• Collaborative reasoning is the nurturing of a consen- strategies may be used in combination and is drawn from
sual approach toward the interpretation of exami- the field notes (and later discussion) of an observed
nation findings, the setting of goals and priorities, treatment between manual therapist Michael and his
and the implementation and progression of patient T:
intervention.
• Reasoning about teaching is thinking directed to the T has continued pain following diskectomy 5 weeks previ-
content, method, and amount of teaching in clini- ously. He reports that his leg symptoms have reduced by
cal practice, which is then assessed as to whether it 50%. However, he is distressed by continued backache.
has been effectively understood.
• Predictive reasoning is the active envisioning of future T’s distress, the way he walks in, the expression on his face,
scenarios with patients, including the exploration and his subdued manner provide initial cues that are
of their choices and the implications of those recognizable features or patterns lodged in Michael’s clin-
choices. ical knowledge. Michael realizes that there are likely to be
other contributing factors in T’s present pain experience

Third Conceptual Framework—Interplay
of Reasoning Strategies in Different
Paradigms of Knowledge Generation
The third and final conceptual frame-
work involves the dialectical nature of
reasoning within the clinical reasoning
strategies. A dialectic is a debate
intended to reconcile a contradiction
(in this case between fundamentally
different processes of reasoning) with-
out attempting to establish either view
as intrinsically truer than the other.57
The term “dialectical reasoning” was
Figure 4. used in our study to describe an inter-
Summary of the relationship between knowledge and reasoning paradigms with clinical
reasoning strategies. play between the different paradigms
of knowledge and reasoning processes
that are expressed in each of the vari-
apart from that emanating from the operated disk. What ous clinical reasoning strategies (as exemplified in the
those factors are will need to be explored. Outside of data). This interplay is summarized in Figure 4.
diagnosis, hypothesis formulation and testing will be
required in a number of areas. In the area of interaction The 2 research paradigms (as discussed in the introduc-
alone, what will be the best way to gain T’s confidence?
tion) generate knowledge from different assumptions
about the nature of reality. Therefore, the clinical rea-
Following assessment of symptom behavior, T undresses,
soning processes “diagnostic reasoning” and “narrative
and “ropes” of paraspinal muscle spasm are noted by
Michael. A few minutes into the physical examination, T, reasoning,” as described in clinical reasoning litera-
himself, provides a cue that Michael immediately follows ture,10,16,26,29 are representative of these different para-
up: “When I take a deep breath, my pain is eased for a digms of knowledge and reasoning. The clinical reason-
minute.” Michael asks T to demonstrate this, observes the ing strategies of interaction, procedure, teaching,
action, and, in response, teaches him how to enhance the collaboration, prediction, and ethics represent foci of
effect by contracting the transversus abdominis muscle. clinical decision making or action in areas of patient
management that may be oriented in either paradigm at
What occurs now is the combined use of teaching and particular times within a clinical encounter.
diagnostic reasoning; one informing the other. Having
enhanced T’s own method of pain relief by transversus The terms “narrative” and “communicative” and the
abdominis muscle contraction, Michael decides to teach
terms “hypothetico-deductive” and “instrumental,” as
him further about the relationship of the muscle behavior
applied to the reasoning strategies, may be considered
to his pain. He proceeds to carefully re-educate T’s lumbar
spine movement in various positions by controlling and synonymous. However, the terms “hypothetico-
releasing the lumbar extensor muscles. deductive” and “narrative,” in emanating from the clin-
ical reasoning literature, have traditionally been applied
On reassessment of lumbar flexion movement, both patient to the process of “inquiry” or diagnosis in clinical
and therapist agree that it is substantially better, although T practice.10,29 The terms “instrumental” and “communi-
is still tense and in pain. Thus, reasoning simultaneously in cative,” in emanating from the literature of adult learn-
these 2 areas of diagnosis and teaching has strengthened ing, are here applied to a range of learning and action
the hypothesis that at least one contributing factor to T’s tasks and are therefore, we believe, more appropriately
pain is an adverse and sustained tension in the lumbar applied to the diversity of clinical management strate-
extensor muscles. gies. For example, assessment leading to identification of
specific exercise needs would fall into the hypothetico-
Although 2 or more clinical reasoning strategies may be deductive inquiry framework whereby the specific
in operation concurrently and there may be overlap instruction, correct execution, feedback, and ultimate
between the reasoning strategies (eg, interaction and learning of the exercise would be described as a form of
collaboration), each clinical reasoning strategy requires instrumental management. Similarly, exploration of a
an orientation of thinking and action, which is not patient’s perspectives regarding his or her problem,
wholly subsumed by the others. including the patient’s understanding (or beliefs and
attributions), expectations, and coping, are examples of
narrative inquiry where management directed toward
facilitating reflection and consideration of alternative

perspectives (by patient and therapist) would constitute case, it was to put a nervous patient at ease and expedite
communicative management. rapport. At other times, the instrumental nature of
interaction was even more pronounced, with the inter-
The data in our study took the form of dialogues action obviously controlled by the physical therapist and
regarding treatments and interviews, and the length of characterized by closed questions. For example, during
these dialogues (thick description) created constraints some manual therapy techniques, patients were asked to
on presenting examples of instrumental and communi- respond only by stating numbers between 0 and 10. This
cative approaches to each reasoning strategy by each quantitative expression of symptoms, which might last
therapist or even within each field. Due to the con- several minutes over the duration of the technique, was
straints of space, the reasoning strategies are not pre- far removed from any narrative component. Here pain
sented in equal detail. However, all of the reasoning was metaphorically manipulated as a variable in the
strategies illustrate the dialectical nature of the physical intervention that was carried out. In these cases, inter-
therapists’ reasoning and can be found in more detail action was simply a measure gauging the success of
online in the non–peer-reviewed doctoral dissertation techniques that were being carried out.
on the research project.58 Diagnostic and narrative rea-
soning, being well documented in the clinical reasoning Interaction, however, could be quite communicatively (or
literature and having been explained in the background narratively) focused. At such times, interaction was char-
section, will not be further dealt with here, although acterized by open-ended questions with the purpose of
patient stories (or fragments of them) are included as simply understanding or finding out more about a
examples in the reasoning strategies of interaction, person’s values, beliefs, or assumptions regarding his or
teaching, and ethics. her (or his or her partner’s) illness or treatment. An
example of this is found in domiciliary care therapist
The Clinical Reasoning Strategy—Interaction Danielle’s visit to an elderly couple of Croatian origin.
There is no question that the physical therapists in our Mr G had terminal cancer. The visit had been very
study often appeared to socialize or interact with their problem oriented, without any particular expression of
patients out of pure enjoyment. On the many occasions how Mr G or his wife was feeling about the situation. Mr
in which the therapists were observed to divulge about G’s daughter had been present and acting as interpreter.
themselves, for example, sharing stories concerning Danielle, aware of the time and the day’s other commit-
their families, this was almost always a purposeful activity. ments, nevertheless, precipitated what was to follow with
Sometimes this was done to gain the confidence of the a simple question:
patient or facilitate the engagement of the patient in the
treatment session. The use of humor for this purpose Danielle: Is there anything we haven’t covered that you
also was observed. Consider these first exchanges in an think we really need to?
initial treatment session with Neve (neurological thera-
pist) and her patient, who had entered the room ner- Daughter: He [indicating her father] reckons the one thing
vously: he wants to know nobody wants to tell him: how long he’s
got to live!
Neve: Are you working, M . . . ?
Wife: I wouldn’t want to know [pointing to her husband].
Never sick [in the past] . . . just cold . . . cough.
M: I work 2 days a week as an occasional registered nurse at
St A . . .’s.
Daughter: She’s actually terrified. She panics.
Neve: I’ve got a daughter who’s just finishing nursing, and
she’s at Repat—the last day of her course. She told me they Danielle said nothing. It was not, however, a silence
were going to give her a Betadine† bath to mark the borne of awkwardness. There was a receptiveness in
occasion [joint laughter]. Danielle’s attention that was not only comfortable with
the momentary pause in conversation but then created
M: As long as she doesn’t come home with a cast on her the space and opportunity for the husband and wife to
arm. reflect with poignancy on their lives since coming to
Australia. They spoke of the richness of their married
Neve: Now you saw Dr B. . . . Did he give you a letter at all? life, describing their early years after immigration to
South Australia, working long hours on their fruit block
This kind of interaction was instrumental insomuch as it in the Riverland. This was the wonderful setting in which
was carried out to produce a particular effect. In this their children grew up. Husband and wife related what
each was doing now. By the end (perhaps 10 minutes),
Mrs G was able to give gentle expression to the tears that
†
The Purdue Frederick Company, One Stamford Forum, Stamford, CT 06901- had been rising but held so far during the visit.
3431.

The Clinical Reasoning Strategy—Procedure a standing position—required consideration of the pos-
By far the most commonly observed procedure across sible contribution of several factors affecting its success-
the 3 fields was the therapeutic use of movement. ful completion: Mr H’s position on the chair (buttocks
Movement, as a procedure, includes several subcatego- forward), the position of his feet, the flexibility of his
ries: touch, handling, palpation, massage, mobilization, knees, the height of the chair, and the use of arms to
manipulation, stretching, and guided exercise. Various push off. Denise addressed each factor, hypothetico-
scenarios focusing on movement as a procedure were deductively confirming or negating the influence of
described in the case studies. Almost always the use of each factor in Mr H’s inability to rise from the chair. The
movement in intervention was a highly instrumental outcome of her intervention was measurable—what Mr
procedure (ie, techniques were selected and applied and H could not do initially, he could do now. Many other
their effects were measured and predicted through examples of exercise instruction were similar to this.
reassessment of range of motion and so forth). However,
movement could also, at times, be a highly communica- A very different form of teaching— communicative
tive action where handling, touch, and massage were teaching—was observed when Neve (a neurological ther-
used to convey therapist attitude or empathy (ie, mean- apist) sought to provide a means by which M, a young
ing and intent) and were not assessed in any measurable mother with tension headaches, could become aware
way. Interviewed domiciliary care therapist Dianne how teeth clenching could result from a number of
expresses this idea: different behaviors.
My hands can actually do more than just about anything, Neve: I had a guy who was a plasterer, and he had terrible
and sometimes . . . most times they’re more powerful than headaches, and I said to him, “What do you notice happen-
what you can say anyway . . . putting hands on someone can ing?” . . . and he really didn’t notice very much. But he
speak enormous amounts. asked the people whom he worked with, and he said, “Well,
how do I look when I’ve got a headache?” and they said,
The following example was taken from field notes writ- “You smile all the time,” and he realized he was clenching
ten while observing neurological therapist Narelle at his teeth, trying to look like he wasn’t in pain . . . but teeth
work. Her patient, N, had a particularly aggressive form clenching was really perpetuating the headaches. So it’s not
the whole story of headaches, but sometimes the teeth
of multiple sclerosis. She was attending the treatment
clenching can be a problem, especially if there is a lot to do
session with her caregiver and friend H. It was not long
and not a lot of time to do it in. Sometimes we get into the
since N ceased being able to look after herself and was habit of just gritting our teeth and . . . keeping going when
forced to go into a nursing home. She was not an old we’re in pain. It’s sort of a chicken and egg thing. I don’t
woman, yet she gave an impression of feeling it to be so. know what comes first, whether the teeth clenching comes
N was depressed and, understandably, experienced first or the headache.
mood swings. Narelle, in the session, had been working
on tightness in N’s foot. The treatment atmosphere had A strong theme in the earlier part of this initial session
been loud (particularly on Narelle’s part) and also had been M’s poor coping mechanisms and unresolved
action filled. At one point, Narelle was called to the conflict with other family members. Some of this conflict
telephone. While she was away (no more than 2 min- had derived from M’s inability to keep her house main-
utes), N began to cry. When Narelle returned, she got in tained to the standards that she would like. Having a
very close, softened her voice, and cradled N’s left arm 2-year-old son was not helping her in this endeavor and
without speaking further for a short time. This was neither were the high expectations of her mother-in-law.
despite the fact that prior to the telephone call, she had The story that Neve told M regarding the plasterer with
been working on N’s foot. After a silent moment, N headaches appeared to have the aim of providing her
uttered, in response to Narelle’s proximity rather than to with the insight that people sometimes may be unaware
any question: “God, it’s heavy!” The session then slowly that their own responses, or coping behaviors can con-
resumed its course. tribute to the production or perpetuation of symptoms.
Thus, the plasterer, who in response to Neve’s question,
The Clinical Reasoning Strategy—Teaching “What do you notice happening?” (when he had these
Teaching was a ubiquitous activity in the practice of all of headaches), asked his workmates what he looked like
the physical therapists in our study. The scope of teach- and was told that he “smiled all the time.” The plasterer
ing included information provision, instruction, advice then realized that he was clenching his teeth, trying to
(including informal counseling), and explanation. look like he was not in pain, but in doing so was
contributing to further headache symptoms.
Examples of instrumental teaching were numerous.
Domiciliary care therapist Denise taught Mr H, who had Neve’s purpose in telling this story had been to encour-
a stroke, how to get up and down off a chair indepen- age M to reflect less on the “outcome” of her stressors
dently. The maneuver—rising from a sitting position to and more toward her own responses to these stressors as

possible factors contributing to her headaches. This is a even in your rooms or as an outpatient in the hospital;
communicative form of teaching: What perspectives definitely as an inpatient in the hospital. So it’s good
does M hold concerning her situation that are either because there’s no point in them saying, “Yes,” they’ll do
unreliable or unhelpful? something if they’re not going to.
The kind of communicative teaching used was accompa- A communicative approach to collaboration emphasizes
nied in the same session by Neve’s teaching M, in a more the plurality of choices and the necessity of “means to
instrumental way, how to recognize increased tension in ends” approaches to problem solving that relate to a
her temporalis and masseter muscles and to then be able person’s values and beliefs. It is not only this transfer of
to use relaxation techniques to decrease these factors. meaning (ie, where the intentions of the therapist and
Thus, we considered both forms of teaching, the instru- the perspectives of the patient are communicated and
mental and the communicative, essential components of mutually understood) but also the transfer of power
sound management of M’s headaches. We believe there (ie, the therapist’s letting go of a professional “right” to
is an intrinsic relationship between the instrumental and be right in favor of the patient’s assumption of a greater
communicative forms of management for each of the voice) that constitutes the move to a communicative
reasoning strategies. approach to collaboration. The instrumental and com-
municative forms of collaboration are not being set
The Clinical Reasoning Strategy—Collaboration against one another, and both could occur within a
Collaboration was observed to be about the meeting of single treatment session.
perspectives: the therapist’s with the patient’s (or care-
giver’s). The nature of certain procedures precluded— The Clinical Reasoning Strategy—Prediction
apart from a more generalized consent or imprimatur— Prediction as a task in clinical practice was found to vary
the therapist consulting the patient or asking his or her among settings. Prediction included such decisions as
permission at every decision point. Collaboration at such when athletes could return to their sport or when
times was necessarily instrumental. In instrumental injured workers could return to their jobs. Predictive
forms of collaboration, the patient, through either an reasoning also could be used to assess the potential
implicit or explicit negotiation with the therapist, was benefit a person who had a stroke was likely to obtain
observed to place himself or herself (even if only for from physical rehabilitation. However, predictive reason-
specific durations within a treatment session) in the ing was at times required in quite a different way to
hands of the expert practitioner. For example, the answer more existential questions pondered by those
therapist would say, “Lift your arm” or “Push harder” with terminal disease, or recalcitrant neurological con-
and the patient either did or did not do it. Its effect was ditions, or chronic pain states who asked either implicitly
observable and, to this extent, empirical. Consider or explicitly: “What does the future hold for me?” Such
Narelle’s (neurological therapist) work with her patient variations required quite different paradigms of reason-
J, who had hemiplegia as a result of surgery to remove an ing. Again, both forms would frequently be identified
aneurism: within the one treatment scenario.
Just try and drop that wrist down . . . slowly! Don’t push The Clinical Reasoning Strategy—Ethics
down at your shoulder! Don’t push down at your shoulder! Ethical problems were seen to take various forms within
Just relax it. Just think about rotating at the elbow. the 3 fields. A major source of ethical dilemmas in
clinical practice revolved around problems associated
and, with resource allocation. These problems took different
expressions according to setting. For example, in domi-
Lift those toes right up for me and let them down . . . and ciliary care, these problems often involved access issues
lift them up, right up . . . c’mon, c’mon . . . c’mon toes get such as waiting lists and availability of equipment,
moving . . . and drop down. And lift them up and drop. And whereas, in manual therapy, these problems took the
lift them up. Alright? form of determining adequate and fair treatment times
and billing issues. Ethical dilemmas arose from complex
Communicative approaches to collaboration were situations within therapy encounters as the following
observed in all settings, but were particularly found in example illustrates.
the domiciliary care (home health) setting. Danielle
spoke positively of a power shift from therapist to Neurological therapist Narelle works with J, who had
patient: hemiplegia and was introduced in the collaborative
reasoning section. J’s husband, Bob, is in attendance. As
The power difference is not the same as in the hospital. Narelle works with J to alleviate stiffness and abnormal
There’s none of this, “Do this because I say so.” People say
reflex activity in the lower limb, the conversation takes a
“no” to you more often in this setting than they ever would,
turn, one that reaches a point of unexpected intensity. It

concerns a 17-year-old boy, known to both J and Narelle, Narelle: I don’t know. I don’t know about the history. I
and his experience after a subarachnoid hemorrhage 3 couldn’t really comment.
years previously. He now has severe cerebellar ataxia.
The story provokes reflection by J on her own situation. J: Mmmm. Well, my aneurism was leaking, so I mean it
It also leads to Narelle being confronted with an ethical needed to be done straightaway.
dilemma. All this occurs as intervention continues (still
monitored) on the foot. Narelle: It probably had to be done.
Bob: Because when I asked, what’s his name, Dr Squirrel [a

J: Got a long way to go, and it’s been 3 years . . . and him
sarcastic nickname given by Bob], “What’s the percentage
and his brother had tests to see if it’s hereditary, and they
that [in] these operations there’s nothing goes wrong?” he
said, “You’ve got no worries.”
said, “Zero, there’s always something goes wrong.”
Narelle: Well, you can’t tell.
J: We’ll get there.
J: No, you can’t tell. It’s an awful thing to happen.
Narelle: Well, that’s actually not completely true. My sister
had an operation, and she’s fine. Sometimes probably it’s a
Narelle: Well, my mum’s father died of one, and my sister’s
bit more difficult to control, I don’t know.
had one, so . . . [with an ironic laugh] they do run in
families unfortunately. [Narelle is currently doing intertar-
[addressing J] I’m really going to cut this toe off!
sal glides.]
J: Yeah, you can if you like.

Wheee! [as she provokes some increased tone from J’s big
toe muscles]
Narelle: Would you mind?
J: Well, I’ve suffered from headaches since I was 16, well
over 30 years, and I’m sure it must have been my aneurism. J: Nah!
Narelle: But the statistics, J, are that 1 in 4 of us have some Narelle has just had to pilot her way through a situation
kind of malformation to our brains because it’s such an where, she needed to acknowledge J’s disappointment
incredibly intricate structure. and Bob’s burning anger toward the surgeon and surgi-
cal management of J’s aneurism. She also needed to
J: But when it happens to you . . . express another perspective about outcomes in such
cases. Working with neurologists and neurosurgeons on
Narelle: But a lot of people never have problems, but just a regular basis, Narelle is aware of some of their realities.
occasionally people will. There’s not a lot you can do. In J’s situation, Narelle decides not to make any defini-
tive comments about whether or not she would have
J: I never heard of it until it happened to me, and then been better not to have had the surgery. She mildly
everyone you speak to. . . . I spoke to someone yesterday. corroborates J’s own statement that “it needed to be
done straightaway.” Interestingly, she does not “toe” any
Bob: What gets me is that they know what the side effects professional line as such, feeling content to contradict
are, but they still go ahead and do the operation.
“Dr Squirrel’s” alleged remark that “there’s always some-
thing goes wrong” with the contrasting example of her
Narelle: The side effects of the operation?
own sister. Narelle apparently decides that there is
Bob: h-uh. . . . They still go ahead and do the operation,
nothing further she can add to the present conversation
they just chalk up: “Huh, there’s another life I’ve saved.” and returns the focus, through her “cutting off the big
toe” remark, to the foot that is being mobilized.
J: Bob’s a bit bitter about it.
The ethical reasoning that has taken place exhibits
Bob: Oh bitter? I’d cut the bastard’s hands off if I could. recognition of the particular faces (patterns) of patient
or caregiver anger. Although not necessarily evoking
J: That’s because I was told that I would have—might ready-made or protocol-based solutions to such dilem-
have—a minor stroke, and I don’t think this is . . . mas, nevertheless some elements of Narelle’s learned
experience are brought into action at these times: the
Bob: Might have a slight little bit of paralysis that’ll only last imperative to listen carefully to and take seriously the
a few weeks. patient’s or caregiver’s feelings or complaints; the
importance of determining perspective and the “com-
J: But I mean if I had the ultimatum, what do I do? Do I have pleteness” of the story; and the knowledge that her
the operation to cut the aneurism off? response is not only sought by the patient or caregiver

but will generally be considered to carry weight, and so The dialectical model of clinical reasoning arising from
it must be a wise and responsible response that does our study is depicted as reasoning that moves between
justice to all parties. Narelle appears to act from these those cognitive and decision-making processes required
principles, and yet there is that self-revelation both at the to optimally diagnose and manage patient presentations
beginning and near the end of the interaction that of physical disability and pain (hypothetico-deductive or
personalizes her perspective. Her response to Bob and J instrumental reasoning and action) and those required
is not wholly based on a detached set of principles. to understand and engage with patients’ (or caregivers’)
Narelle is able to introduce an experiential component experience of that disability and pain (narrative or
to her response with the introduction of her own sister’s communicative reasoning and action). Hypothetico-
experience. She chooses to contradict the medical deductive or instrumental reasoning and action involves
“defense.” Narelle has been a witness in this situation to physical therapists engaging in critical reflection of the
a narrative protesting the havoc of iatrogenesis (or underlying assumptions (ie, hypothesis testing) behind
medically induced harm to the patient). Such narratives, the content and process of their own decision-making
with their experiential truth and passion, compel and knowledge structures. Critical reflection in narrative
re-examination of medical (and other health care prac- or communicative reasoning and action, however,
titioners’) practices and precepts.59 involves physical therapists endeavoring to understand
the assumptions underlying patients’ beliefs and deci-
The dialectic nature of clinical reasoning continues, sion making and to communicate their own assumptions
therefore, in ethical decision making. On the one hand, to the patient. Following consensual validation of these
there is ethical decision making as the application of assumptions with their patients, we propose that com-
normative or professional rules and principles to partic- municative management then also involves physical ther-
ular situations in a deductive or instrumental manner. apists fostering a process of critical reflection on the part
Patient autonomy, justice, and not doing harm to of patients regarding the reliability and adequacy of
patients are examples of such principles.60 On the other those assumptions as exemplified by neurological phys-
hand, there is a narrative (or communicative) approach ical therapist Neve’s work with her patient M in facilitat-
to ethical decision making where the experiential and ing an understanding of her tension headaches.
contextual elements of a given situation (or narrative)
guide decisions and actions, in turn, providing perspec- Dialectical reasoning, with its notions of instrumental
tives on these broader rules or principles of right and and communicative management, fits well with recent
wrong.61 models of health and disability such as the biopsycho-
social model62 and the World Health Organization’s
Discussion (WHO) International Classification of Functioning, Disability
Previous clinical reasoning literature has proposed dif- and Health.63 For example, in the WHO classification the
ferent reasoning processes for particular tasks in clinical functioning of an individual in a given setting is “an
practice (eg, procedural [ie, doing something to the interaction or complex relationship between the health
patient] reasoning versus interactive [ie, knowing the condition and contextual factors.”62(p19) There is, there-
patient] reasoning).26,28 We found that there was an fore, an interaction between activity limitations (difficul-
interplay of different reasoning processes in every task of ties an individual may have in executing activities) and
clinical practice, suggesting both a complexity and scope participation restrictions (problems an individual may
of clinical reasoning activity not previously understood. experience as a consequence of his or her involvement
in life situations). It is recommended that health care
Our findings support existing research19,20,26,28 concern- practitioners “collect data on these constructs indepen-
ing the attention given, and importance attributed, to dently and thereafter explore associations and causal
the interaction between practitioners and their patients links between them.”63(p19) The clinical reasoning model
in a range of areas such as therapist-patient interaction, proposed here offers physical therapist clinicians a
collaboration, teaching, and ethical practice. Unlike the framework to be able to explore (and act in) the
seminal works in clinical reasoning in the allied health dynamic interaction of activity limitations and participa-
fields,19,26,29 however, our study leads to conclusions that tion restrictions.
do not seek so much to draw the contrast (and distance)
between cognitively based, rational models of reasoning Summary
(eg, hypothetico-deduction) and interactive or meaning- We found that all of the observed physical therapists in
based forms of reasoning (eg, the use of narrative). each of the 3 settings used a range of clinical reasoning
Rather, we contend that our conclusions concentrate skills or strategies representing a diversity of thinking
on illustrating their intrinsic relationship in clinical and actions in a variety of tasks and relating to many
practice. issues that exist in clinical practice. These skills or
strategies range from the act of making a diagnosis

through management issues through ethical decision 12 Schmidt HG, Boshuizen HPA, Norman GR. Reflections on the
making. These therapists used these reasoning strategies nature of expertise in medicine. In: Keravnou E, ed. Deep Models for
Medical Knowledge Engineering. Amsterdam, the Netherlands: Elsevier;
in an interplay that was governed by particular patients’
1992:231–248.
needs and their contexts.
13 Patel VL, Groen GJ. Knowledge-based solution strategies in medical
reasoning. Cognitive Science. 1986;10:91–116.
The grounded theory underpinning this dialectical
model represents the development of a series of concep- 14 Feltovich PJ, Barrows HS. Issues of generality in medical problem
solving. In: Schmidt HG, Devolder ML, eds. Tutorials in Problem-Based
tual frameworks describing clinical reasoning. In arriv-
Learning. Assen/Maastricht, the Netherlands: Van Gorcum; 1984:
ing at this model, the data concerning clinical reasoning 128 –141.
strategies and therapists’ use of knowledge has, in the
15 Arocha JF, Patel VL, Patel YC. Hypothesis generation and the
manner of grounded theory, been repeatedly compared coordination of theory and evidence in novice diagnostic reasoning.
and reapplied to existing theories or literature in rele- Med Decis Making. 1993;13:198 –211.
vant areas such as clinical reasoning, paradigms and
16 Rogers JC, Masagatani G. Clinical reasoning of occupational thera-
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such as Habermas’ “Critical Social Theory”33 and Mezi- Occupational Therapy Journal of Research. 1982;2:195–219.
row’s “Transformatory Learning Theory.”35 Our model 17 Jones JA. Clinical reasoning in nursing. J Adv Nurs. 1988;13:
draws on these theories but in a manner that recontex- 185–192.
tualizes them in relation to the data of this study in 18 Jensen GM, Shepard KF, Gwyer J, Hack LM. Attribute dimensions
particular and the scope of clinical reasoning in physical that distinguish master and novice physical therapy clinicians in
therapy in general. orthopedic settings. Phys Ther. 1992;72:711–722.
19 Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in Physical
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Invited Commentaries
Edwards et al have offered us a valuable extension of the ical therapists move between the 2 worlds of logical and
previous work on clinical reasoning in physical therapy. intuitive reasoning as they work with patients. Edwards
One of their most valuable contributions is to help et al have also made a very important observation in
differentiate the clinical reasoning of physical therapists their discussion of these dual modes of thinking related
from that of other health care professionals. to the concept of a disablement model of understanding
health and illness. The premise of defining health and
The most frequent mode of thinking described in the disability through application of a biopsychosocial
clinical reasoning literature is the hypothetico-deductive model has given physical therapists a means to articulate
reasoning model, as is described by Edwards et al in their and explicate what I believe we have done with our
review of the literature. While the work that explicated patients since the outset of our profession. Models of
this model most commonly explored physician decision health and disability that show a continuum from pathol-
making, this is a mode of thinking that feels familiar to ogy through impairments to functional limitations and
any practitioner trained in diagnostic reasoning and can possible disability have given us the language to describe
readily be used in teaching decision making to students our care more precisely.2
and in improving decision making among clinicians in
many different health care professions. The work by Edwards et al has given us the basis to fully
explore clinical reasoning in the context of this lan-
Understanding the hypothetico-deductive process, how- guage. There are many different paths this future work
ever, I believe does not necessarily help distinguish can take. For example: When a physical therapist
decision-making processes among various professions. progresses from novice to experienced to expert, does
Do physical therapists, occupational therapists, and phy- this ability to move between both modes of thinking
sicians all approach decision making in the same way? develop? Can physical therapists describe the purposes
Our clinical experience tells us that they do not. of their interventions, distinguishing between reducing
activity limitations and improving the ability of the
In earlier work in physical therapy, Jensen et al1 identi- patient to participate fully in life, or are these purposes
fied 4 themes that they contend contribute to a unified so entwined as to be indistinguishable? What are the best
philosophy of practice in expert practitioners: knowl- ways to help students and clinicians gain necessary skills
edge, clinical reasoning, virtue, and movement. I believe in the use and application of these 2 modes of thinking?
that the descriptions of knowledge and virtue based on What other differences distinguish physical therapists
this work could be applied to practitioners in many from other practitioners, especially as compared with
health care occupations. For example, experts stressed other practitioners who move comfortably in the realm
the need to see the patient as the most important source of health and disability, such as occupational therapists
of knowledge, and they emphasized the need to serve as and speech pathologists? Are there ways to structure
advocates for patients, sometimes placing their own practice, for example, through recommended patterns
livelihoods at risk. In the other 2 areas, however, it is of practice or documentation templates, to help phys-
possible to see some issues that distinguish physical ical therapists develop both modes of thinking of their
therapy practitioners from other types of practitioners. clinical decision-making skills? I look forward to
Physical therapist experts showed a preference for a future research, both phenomological and positivistic,
collaborative mode of clinical reasoning that involved that further explores this type of role between health
patients and families and that relied less on a diagnosis and disability in the context of physical therapists’
of pathology and more on identifying patient goals. The reasoning.
physical therapists whom Jensen et al studied also
showed an exquisite sense of movement, both their own Laurita M Hack, PT, PhD, MBA, FAPTA
movement as an instrument of patient care and the Professor and Chair
patient’s movement as a source of information and com- Department of Physical Therapy
munication. Temple University
Philadelphia, PA 19140
These attributes resonate with physical therapists, who I [email protected]
believe often speak of the differences in their view of
References
patients and patient care as compared with members of
1 Jensen G, Gwyer J, Hack L, Shepard K. Expertise in Physical Therapy
other health care occupations. This new work by Practice. Boston, Mass: Butterworth and Heinemann; 1999.
Edwards et al appears to validate the perception that
2 Guide to Physical Therapist Practice. Revised 2nd ed. Alexandria, Va:
there is a difference by demonstrating that expert phys- American Physical Therapy Association; 2003.
Physical Therapy . Volume 84 . Number 4 . April 2004 Hack . 331

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The practice of health care professionals such as physical of EBM is too frequently simplified down to reading the
therapists is frequently described as consisting of both results of a systematic review or practice guideline,
“art” and “science.” Optimally, these concepts are viewed without concern for the applicability of the results to the
as consonant and complementary in clinical practice. Yet unique situation presented by an individual patient.
among researchers, art and science often become
dichotomized to the point of becoming adversarial. The ultimate goal of EBM is to assist clinicians in making
There can be little doubt of the preeminence afforded more effective decisions about individual patients.8
to the “science” of practice in 20th-century Western Edwards et al utilized qualitative research methods to
medicine. Research standards have been grounded in a examine clinical reasoning and knowledge used by cli-
positivist epistemology, seeking to discover the truth of nicians identified as experts in 3 different fields of
the “best” intervention for patients with a particular physical therapy. The authors found that these clinicians
disorder.1 The emphasis within this paradigm has been made decisions based on an interaction between ratio-
on quantitative methods and deductive reasoning, with nal, cognitively based reasoning and interactive, narra-
the researcher testing prespecified hypotheses under tive reasoning. They labeled this clinical reasoning strat-
highly controlled conditions. egy as a dialectical model, indicating that the task of
clinical decision making is to reconcile information
Qualitative research, such as the study by Edwards et al obtained from both rational and interactive reasoning
reported in this issue of the Journal, operates within a paradigms. This finding cautions against any attempt to
different paradigm. The principal aim of qualitative reduce clinical decision making to a strictly cognitive
research shifts from attempting to uncover a single truth process of applying statistics to patients without regard
about the best management to acknowledging and to the patients’ situation and concerns.
understanding the influence of multiple perspectives on
clinical care.2 Qualitative research does not propose Although the overall findings generated by Edwards and
discrete hypotheses for testing, but instead utilizes colleagues are certainly consistent with the underlying
inductive reasoning to generate theories about observed principles of EBM, if the specific findings of this and
phenomena.3 Given the challenges presented by quali- other qualitative studies are to have an impact on the
tative methods to the sacrosanct principles of the dom- evidence base of the profession, then qualitative studies
inant quantitative research paradigm, it is not surprising cannot become an end unto themselves.9 The distinctive
that qualitative research has generally met with tepid characteristics that permit qualitative research to
acceptance by the broader scientific community.4 develop unique perspectives on clinical phenomena also
make it unable to test the hypothesis that the theories it
Recent emphasis on evidence-based medicine (EBM) generates are “true” or “better” than competing theo-
would appear to afford an opportunity for greater inte- ries. This is the domain of quantitative designs and
gration of qualitative research findings into the profes- deductive research methods. The “problem of induc-
sional knowledge base of health care professions such as tion,” a concern for the interpretation of all observa-
physical therapy. The initial model of EBM proposed 3 tional research, must be borne in mind when examining
overlapping and interconnected concerns that should qualitative research. That is, without a control group of
inform clinical decision making; research evidence, some kind, it is not possible to determine that what is
patient preferences and values, and the expertise of the observed is actually superior to some alternative. For
clinician.5 This model recognizes that clinical decisions example, bed rest for individuals with acute back pain
are not made strictly on basis of data gleaned from appeared to be effective based on observations that most
quantitative research. Evidence-based medicine supports people who received this intervention recovered within a
the necessity of understanding the interplay among matter of weeks. It was not until controlled studies
patients, clinicians, and the evidence. Qualitative showed that even more individuals would recover when
research methods certainly offer a means for such inves- alternative interventions were used that bed rest was no
tigations. As EBM has evolved, however, the balance longer recommended.10 Edwards et al, by selecting cli-
among patients, clinicians, and the evidence often seems nicians identified as “experts,” seem to presume that the
lost. Critics of EBM regularly cite an excessive allegiance dialectical model they have identified is a superior
to the authority of evidence for the efficacy of various clinical reasoning model. Recent research11 has ques-
interventions, with little concern for the unique needs of tioned the traditional ways used by Edwards and col-
individual patients or the complex interaction between leagues to identify “expert” therapists. Perhaps another
individual patients and clinicians delivering care.6,7 group of therapists would use alternative reasoning
Although not consistent with its philosophical underpin- strategies that would result in better clinical outcomes.
nings, there can be little doubt that the practical reality
332 . Fritz Physical Therapy . Volume 84 . Number 4 . April 2004

Only a comparative study using quantitative methods 2 Barbour RS. The role of qualitative research in broadening the
could ultimately address this hypothesis. “evidence-base” for clinical practice. J Eval Clin Pract. 2000;6:155–163.
3 Giacomini MK, Cook DJ. Users’ guide to the medical literature,
The Guide to Physical Therapist Practice12 makes it clear XXIII: qualitative research in health care. JAMA. 2000;284:357–362.
that end result of the entire clinical reasoning process is 4 Poses RM, Isen AM. Qualitative research in medicine and health
the patient/client outcome. Ultimately, this end must be care. J Gen Intern Med. 1998;13:32–38.
borne in mind. The present study generates some inter- 5 Evidence-Based Medicine Working Group. Evidence-based medi-
esting theories regarding the nature of the clinical cine: a new approach to teaching the practice of medicine. JAMA.
reasoning process used by therapists presumed to be 1992;268:2420 –2425.
experts. It is unlikely that traditional quantitative 6 Feinstein AR, Horwitz RI. Problems in the “evidence” of “evidence-
research methods could have identified these theories. based medicine.” Am J Med. 1997;103:529 –535.
Further qualitative work on the topic of clinical reason- 7 Hampton JR. Evidence-based medicine, practice variations and clin-
ing, without doubt, will raise new or modified theories. ical freedom. J Eval Clin Pract. 1997;3:123–131.
Quantitative studies are needed along with this process 8 Sackett DL, Rosenberg WMC. The need for evidence-based medi-
of theory generation if the results of qualitative research cine. J R Soc Med. 1995;88:620 – 624.
are to begin to have an impact on the evidence base of 9 Miles A, Bentley P, Polychronis A, et al. Recent progress in health
the physical therapy profession. services research: on the need for evidence-based debate. J Eval Clin
Pract. 1998;4:257–265.
Julie M Fritz, PT, PhD, ATC 10 Waddell G. A new clinical model for the treatment of low-back pain.
Assistant Professor Spine. 1987;12:632– 644.
Department of Physical Therapy 11 Resnik L, Jensen GM. Using clinical outcomes to explore the theory
University of Pittsburgh of expert practice in physical therapy. Phys Ther. 2003;83:1090 –1106.
6035 Forbes Tower 12 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:43.
Pittsburgh, PA 15260
[email protected]
References
1 Wilson HJ. The myth of objectivity: is medicine moving towards a
social constructivist medical paradigm? Fam Pract. 2000;17:203–209.
Physical Therapy . Volume 84 . Number 4 . April 2004 Fritz . 333

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Author Response
We are grateful to Fritz and Hack for providing these factors. We therefore argue that in evidence-based prac-
commentaries and for the opportunity to discuss the tice we do not move from one set of patient “directives”
issues that arise from them. to another set of “directives” as one proven theory
displaces another. Rather, we argue our mandate is to
We would like to address the question of what impact present the levels of evidence for particular courses of
qualitative studies can have on the evidence base of the management in therapy and assist our patients to make
profession when used as “stand-alone” methods. In par- decisions based on the choices available.
ticular, we consider the “problem of induction,” as Fritz
describes it, where without a control group it is not The further skill in collaborative decision making is to
possible to determine whether what is observed (and its facilitate our patients’ ability to work through the impli-
subsequent explanation) is actually superior to some cations of the various management options. There may
alternative. We do not see inductive learning or problem be a strong preferred direction or even a particular
solving as a “problem” even within a climate that treatment imperative based on evidence, but the overall
demands that knowledge derived from research should sets of management strategies, in our view, will necessar-
provide better evidence for practice. ily vary (perhaps considerably) according to the needs
and context of the patient. Research on expertise1–3
We believe it is worth reiterating, albeit briefly, that reminds us that experts do not have recipes, and they
qualitative research does not pretend to determine also tend to acknowledge that, in broad terms, there is
absolute truths such as which hypothesis, explanation, or often no one “right” path for a course of therapy to
theory is right and which is wrong or which is more true proceed. Theory generated from qualitative research, we
or superior than another, at least not in an absolute believe, does not have to be right or best in an absolute
sense. Does this mean that qualitative studies remain at manner in order for it to have an impact on clinical
the purely descriptive level, with little or no potential to practice. Instead, its role is to bring to light the multiple
actually have an impact on clinical practice? We do not realities of a particular experience, situation, or
think so. Were controlled studies really the only way or phenomenon.
possible catalyst by which the regimen of bed rest for
patients with acute pain could be replaced with a better Fritz, however, raises an important question regarding
alternative? We think not. Interestingly, the prescription qualitative research. Stated another way, it is whether
of bed rest for acute back pain harks back, in our theories generated by qualitative research have necessar-
opinion, to an era where the importance of understand- ily to remain as localized sets of observations and con-
ing and valuing the patient’s experience was perhaps less clusions. Do such theories remain tied to a specific
understood. Adherence to medical or therapist direc- situation or context without any kind of broader impli-
tives rather than collaborative decision making was the cation or applicability than the specific or unique situa-
order of the day. It is quite possible that these patients tion from which they were derived? After all, there can
could have informed us themselves, either through be no doubt that such research is not either statistically
formal qualitative studies or through the processes of generalizable or predictive.
decision making in clinical practice (if we had at that
time a framework for understanding and integrating The recent research, cited by Fritz, on identifying
these experiences as a source of clinical knowledge) of experts1 provides an opportunity to further discuss the
the anxieties, sense of helplessness, and deconditioning nature of theory in qualitative research. Both our study
that they may have experienced lying in bed for weeks and that of Resnik and Jensen1 are grounded theory
on end. studies, which build on previous grounded theory (that
is, particular theory generated inductively from the
The most basic premise underlying qualitative research data). Resnik and Jensen used retrospective analysis of
is that reality or truth is not singular or unchanging for outcome measures for the management of low back pain
all people at all times. Consider for example, a bright as a basis for identifying experts. This allowed for the
sunny day. This same reality is experienced differently by possibility of “ordinary” therapists to be involved in the
the person who is intending to spend the day at the study and not just those of long experience and senior-
beach and by the farmer perhaps 50 miles inland who is ity. Apart from mentioning that our study, based on the
experiencing a drought. So too, our patients may expe- research experience of others,2,3 did not use the tradi-
rience aspects of a condition (eg, a fractured neck of tional method (ie, choosing therapists based on years of
femur) that are generalizable and experienced by oth- experience) as our method for identifying experts, we
ers, but much else of what they experience will be believe it is worth noting that Resnik and Jensen1 found
unique and will be shaped by many personal and social that the experts they identified exhibited the same

multidimensional knowledge base and patient-centered generalizable, can be theoretically generalizable8 (or
values as those Jensen et al2 found in their grounded transferable9) where their “groundedness” in the partic-
theory work on the nature of expertise in physical ular does not necessarily limit their potential application
therapy. to broader situations and contexts.
Our study, as Hack suggests, also supports many of In summary, we concluded that experts move easily
Jensen and colleagues’2 findings such as the multidimen- between deductive and inductive forms of reasoning in
sionality of the therapists’ knowledge base, the pre- clinical practice. We believe that the several interesting
eminence of collaborative decision making in their research possibilities suggested by Hack offer a chal-
clinical reasoning, and the centrality of movement not lenge to the further building of theory regarding both
only “as an instrument of patient care” but “as a source the nature of expertise and clinical reasoning in physical
of information and communication.” The findings of therapy. In pursuing these research ideas, or any others
our study and those of Resnik and Jensen1 and Jensen et for that matter, the challenge, we argue, remains for
al2 represent a form of triangulation.4 That is, although researchers in physical therapy to move as easily between
each study sampled their “expert therapists” differently, deductive and inductive paradigms of research.
the methodological tools of observation and interview
were rigorous enough to point to similar findings with Ian Edwards, PhD, Grad Dip Physio (Ortho), MAPA
respect to the behaviors, values, and qualities of expert Mark Jones, MAppSc (Manip Ther), Cert Phys Ther, Grad
therapists that distinguish them from average practitio- Dip Advan Manip Ther, MMPA, MAPA
ners. Each of the 2 subsequent studies extended the Judi Carr, Dip Physio, Grad Dip F Ed
previous work, ours by proposing a model of clinical Annette Braunack-Mayer, PhD
reasoning somewhat different from but not inconsistent Gail M Jensen, PT, PhD, FAPTA
with Resnik and Jensen1 and Jensen et al2 by carrying out
a new and more inclusive sampling approach to the References
grounded theory work on expertise. 1 Resnik L, Jensen GM. Using clinical outcomes to explore the theory
of expert practice in physical therapy. Phys Ther. 2003;83:1090 –1106.
Based on the discussion of the relationship of theory 2 Jensen GM, Gwyer J, Hack LM, Shepard KF. Expert practice in
among our study and the studies by Resnik and Jensen1 physical therapy. Phys Ther. 2000;80:28 –52.
and Jensen et al2 and on our examination of the 3 Embrey DG, Guthrie MR, White OR, Dietz J. Clinical decision
literature, we conclude that there can be theory reso- making by experienced and inexperienced pediatric physical thera-
pists for children with diplegic cerebral palsy. Phys Ther. 1996;76:20 –33.
nance or dissonance between qualitative studies, each
either lending support to previous findings or raising 4 Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed.
new explanations or theory. Substantive theory, which is Newbury Park, Calif: Sage Publications; 1990.
grounded theory derived from particular instances or 5 Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory
contexts, not only can be compared with and contrasted Procedures and Techniques. Newbury Park, Calif: Sage Publications;
1990:281ff.
to other grounded theories regarding similar phenom-
ena for its fit and completeness as an explanation or 6 Shulman LS. Making differences: a table of learning. The Carnegie
theory, it also can be related to other “middle” or Foundation for the Advancement of Teaching. Available at: http://
www.carnegiefoundation.org/elibrary/docs/making_differences.htm.
“formal” theory for its applicability to other situations Accessed January 27, 2004.
and phenomena.5,6 Mezirow’s theory of transformative
7 Mezirow J. Transformative Dimensions of Adult Learning. San Francisco,
learning7 in the field of adult education is an example of
Calif: Jossey-Bass Inc Publishers; 1991.
this in our study. This theory both helped us interpret
what we were finding, and, in a modest way, our findings 8 Barbour RS. The role of qualitative research in broadening the
“evidence-base” for clinical practice. J Eval Clin Pract. 2000;6:155–163.
add some credence to what Mezirow proposes concern-
ing adult learning. We argue, therefore, that the findings 9 Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, Calif: Sage
Publications; 1990.
(eg, theories) generated by qualitative studies, especially
when they build upon each other, while not statistically
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Clinical Reasoning Strategies in Physical Therapy

Article in Physical Therapy · May 2004

Mark Jones Annette J Braunack-Mayer

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Clinical Reasoning Strategies in

researched subject in physical therapy. The purpose of this qualitative

312 Physical Therapy . Volume 84 . Number 4 . April 2004

A Braunack-Mayer, PhD, is Lecturer in Ethics, Department of Public Health, University of Adelaide.

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 313

314 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 315

The 3 fields of orthopedic (manual)

316 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Denise* 14 Domiciliary care/senior PT Supervision of final-year students BAppSc, MAppSc candidate

Table 2. dom, and all therapists agreed to participate in the study.

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 317

318 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Figure 3. Overview of case study formation.

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 319

320 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Time Literature Data Collection Data Analysis Conceptual Frameworks

April 1996 Ethics proposal

Physical Therapy . Volume 84 . Number 4 . April 2004

¡ Review of literature reviews 1 and 2

Findings Second Conceptual Framework—Cue-Based Combining

Management I actually think their information is more important than

322 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 323

324 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 325

326 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Bob: Because when I asked, what’s his name, Dr Squirrel [a

J: Yeah, you can if you like.

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 327

328 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 329

330 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Hack . 331

332 . Fritz Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Fritz . 333

334 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 335

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