Take a look through any of the popular trade publications in our field and you will find a wealth of advertising for courses that are teaching you new techniques. The extravagant claims for methods that provide "permanent pain relief" or "immediate results in one or two treatments" can certainly pique your interest and make you think this is something you must have. Clearly, learning new techniques is a great way to retain enhanced skills and abilities as well as provide more ways to address client problems. However, the emphasis on techniques can be misleading when you are working with rehabilitative massage approaches because technique is only a small piece of the puzzle. Clinical success in treating pain and injury conditions requires a much more comprehensive approach and that is what orthopedic massage is all about.

Orthopedic massage is not a technique, although you use a wide variety of techniques as you apply this approach. Instead, it is a comprehensive system for alleviating pain and injury conditions with massage. A brief story helps illustrate why a systematic approach like this is so important. In the first year of my professional practice, I rented a small space in a medical office building; to build my business, I began networking with some of the physicians in that building. One day a physician sent a patient to me who was having severe back pain. I realized as I began talking to her that I had no idea what was wrong with her and I was genuinely puzzled as to whether massage would help her or hurt her. I had been taking all kinds of new technique workshops, but they hadn't really helped me learn how to make important clinical decisions such as: Should I try to treat her or not? If so, what techniques or approaches would be the most helpful?

I wanted the physician who referred this patient to me to respect massage as a beneficial treatment approach, so I felt uncomfortable just sending her back to the doctor who had sent her, telling him I didn't know if I could help or not. It was at that point I realized I needed to learn more about clinical management. What I hadn't realized is that what I was really looking for was not just a particular technique. Instead, it was a comprehensive approach for applying clinical reasoning skills.

Clinical reasoning is at the core of all successful clinical practice in the health care professions. Yet, you don't hear much about it in massage education because it's much easier to sell a sexy new technique. Simply put, clinical reasoning is "...the sum of the thinking and decision-making processes associated with clinical practice."1 The more effective you are at using your clinical reasoning, the more effective and successful you will be as a clinician. Developing effective clinical reasoning is not as simple as just taking a course in it. It is a more complex process that calls upon your skills abilities in a variety of different areas. Let's take a look at some of the most important aspects of clinical reasoning and how to improve those skills.

Researchers have looked into what separates experts from novices when it comes to clinical management skills in the medical field. One of the main factors they have found is that experts develop certain shortcuts by recognizing patterns of information that novices might tend to miss.2 For example, suppose a client comes in complaining of foot pain and reports a recent increase in running on hard pavement and plantar foot pain that is most pronounced first thing in the morning. These are just two clinical factors that have been shared, but someone familiar with plantar fasciitis will immediately recognize them as fitting into the pattern of that pathological problem. It does not mean that we have determined the client's condition with just those two elements. Yet, the ability to see that symptom pattern gives us a significant advantage over someone else who may only hear the client rattle off an accumulation of symptoms and not be able to make any sense of them.

The practitioner using effective clinical reasoning will then take these recognized information patterns and apply deductive thinking to analyze the clinical problem further. Deductive logic is what occurs with an "if, then..." statement. For example, IF this client reports sharp shooting pain in the upper extremity along with paresthesia on the ulnar aspect of the hand, THEN there is a good chance the pain complaint is originating from some neural pathology, in either the neck or upper extremity. This deductive analysis helps us determine if massage is appropriate and if so, how we should apply it.

Clinical reasoning is crucial not only in clinical assessment, but in the treatment process as well. Often you will hear treatment recipes and routines given that describe how to address a particular pathology; they will say perform this treatment X number of times and your client will get better in two treatments, etc. However, this approach is highly problematic and doesn't reflect clinical reality. Each client is an individual and each individual has a unique presentation of his or her soft-tissue disorder. One person's carpal tunnel syndrome should be treated differently than the next person's, even though they may have been diagnosed with the same disorder. It is your use of clinical reasoning and decision-making skills that help you determine how to modify your treatment approach for each client's unique needs.

As with many aspects of health care delivery, clinical reasoning relies on both art and science. You need a comprehensive understanding of science (anatomy, physiology, kinesiology, etc.) to help in symptom pattern recognition, construction of treatment strategies, and proper application of rehabilitative concepts in massage. Use of effective clinical reasoning is an art and skill that is developed with constant practice and study.

Treatment techniques will help you fill your tool bag, but if all you do is amass a series of techniques you only have a bag of tools and no knowledge about how to effectively use them. A wrench is a great tool, but you don't want to try using a wrench when a screwdriver is the proper tool. Similarly, you will be far more successful and your massage technique skills will have much more effect when you expand your use of effective clinical reasoning.

References

1. Higgs J, Jones M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3rd ed. Amsterdam: Elsevier, 2008.
2. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA Jan. 9 2002;287(2):226-35.