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90 m a s s a g e & b o d y wo r k s e p te m b e r/o c to b e r 2 0 2 1 Putting the Pieces Together Clinical Reasoning for an Evidence-Informed Practice By Erik Dalton, PhD Each of us has a toolbox packed with assessments and techniques for treating clients with various pain complaints. Using clinical reasoning, we can evaluate these practices and apply them effectively. Put simply, clinical reasoning is the process by which a therapist interacts with a client, collects information, and tests a hypothesis to determine an optimal treatment plan. It is a reflective process of inquiry between therapist and client with the aim of understanding more about the context and clinical presentation of the pain. Such understanding, in turn, allows us to build an evidence-informed practice. Novice clinicians often think all they need are better hands-on skills and more techniques. I agree techniques are the foundation from which to build a strong skill set. However, in a clinical reasoning practice, the goal is to constantly reflect on what we're doing so we better understand what has or hasn't worked for our clients in the past. If we don't reflect on what we're doing, it will be more difficult to improve future treatment outcomes. Observation, communication, assessment, pattern recognition, inference, and problem solving are important clinical reasoning skills you'll need to hone as you work toward an evidence-based approach. CONFRONTING CONFIRMATION BIAS The first step toward improved clinical reasoning is to realize we all have blind spots and biases. Most of us do not like to challenge our firmly held beliefs. Not only does it make us uncomfortable, which no one likes, but it also forces us to reconsider what we think we know. The tendency to interpret evidence based on one's existing beliefs is termed confirmation bias. The way a therapist clinically reasons their findings through assessment and history-taking can strongly influence how a client's case is interpreted. As we evaluate movement restrictions, gait abnormalities, biomechanical faults, and mental states, it's important to observe for red flags that may give weight to how the pain or injury complaint could have developed. Skilled manual therapists can then apply more accurate anatomical, pathological, and biomechanical assessments to the client's particular technique | MYOSKELETAL ALIGNMENT TECHNIQUES presentation and construct a therapeutically effective treatment plan. INDUCTIVE AND DEDUCTIVE REASONING To develop a successful pain-management treatment plan, we begin by using inductive and deductive reasoning. Inductive reasoning is a bottom-up approach that looks at the client's situation from their point of view through communication. It begins with an observation, supports it with pattern recognition, then arrives at a theory about the client's problem. For example, "My client Mary has pain down her leg during prolonged sitting. The last two clients who presented with pain down their leg during prolonged sitting were medically diagnosed with piriformis syndrome. Therefore, Mary must have