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• Do researchers have the ability to be biased either consciously by understanding

https://t.me/med1917

that they are biased or subconsciously by removing controls to eliminate their personal biases? Absolutely

• Although a detailed description of statistical methods is beyond the scope of this

monograph, it is important to have a basic understanding of the application of statistical tools

• Without this ability, we cannot detect errors in the application and interpretation

of statistics

• Clinicians must understand that the application of statistical methods is a process

• e process starts with a question, evolves into a hypothesis, and establishes the

rules to the game and statistical analyses that will be used to answer each hypothesis before playing the game

• e game is then played, and the data are analyzed based on the established rules

of the game

• Statistics are, therefore, an essential and powerful tool that uses math to mini-

mize the biases that come from our senses through direct observation

• Take home message. It is all about process and starting with a question. If we

start with the answer and seek evidence to support that answer, we have already lost the game”

2.4 Frequentist Statistical Methodology

• It is the traditional statistical methodology that the practicing Physical erapist

is most likely going to encounter

• is form of statistical methodology makes several assumptions

• It is, therefore, essential to understand these assumptions so that you can recog-

nize when a researcher is taking liberties with the application of this statistical methodology

—NOTES—

2.5 Frequentist Assumptions

• Assumption 1- e sample is a smaller representation of the population. Sam-

pling bias may occur if a researcher only includes patients that they feel will meet the inclusion and exclusion criteria for a study instead of screening the population of interest to see if the patient meets the study’s inclusion and ex-

clusion criteria. a non-random relationship with what is being studied.

If this occurs, the researcher may be creating a sample that has

is is a threat to the internal validity of the study and external validity of the study. is also hinders the repeatability of the research in future trials

• Assumption 2- e choices for the statistical tools that were used to answer each

research question were made before the data were collected. Running multiple analyses that were outside the original intent injects bias into the process

• Assumption 3- e statistical analysis used the p-value as a rigid decision point

used to accept or reject the null hypothesis. Null statistical hypothesis testing is a vital reasoning aspect in the use of frequentist statistical methods. We use inductive reasoning to formulate research questions. When designing a research study, we need to select which statistical tools will be used to answer each question before collecting the data. From the research questions, abductive reasoning is used to generate the research/alternative hypotheses (what you expect to ﬁnd). is type of hypothesis generation creates a risk for conﬁrmation bias. We must always make sure that we are not starting with the answer to a question and creating an environment that seeks to support that answer. e purpose of using the null hypothesis is to prevent this reasoning error from occurring. Null statistical hypothesis testing is used to make the decision to accept or reject the null

—NOTES—

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hypothesis. at is it! If you accept the null hypothesis, you are done. is means that the research hypothesis has been falsiﬁed

• Assumption 4- e researcher made the decision of what is “meaningful” if statis-

tical signiﬁcance is present (rejection of the null hypothesis) before collecting the data. For example, if there is a statistically signiﬁcant diﬀerence between the two groups, is it larger than the measurement error of the instruments used to take the measurements? Does the diﬀerence represent at least a moderate (0.50) eﬀect size? Is the diﬀerence larger than the minimal clinically important diﬀerence (MCID) of the tools used to take the measurements?

• Assumption 5-e researcher reports the truth, the whole truth, and nothing

but the truth. “Spin” is deﬁned as “speciﬁc reporting strategies used by authors to convince readers that the beneﬁcial eﬀect of the treatment of interest is greater than that shown by the results”

2.6 Bayesian Statistical Methodology

• e Bayesian approach is not a one and done approach like the frequentist ap-

proach

• It is an iterative process that uses prior knowledge and outcomes to construct the

probability of something being accurate or true (called a prior probability)

• It then collects data on that variable of interest. e data that are collected are

combined with the data from the prior probability to calculate the posterior probability

• e posterior probability then becomes the prior probability for the next itera-

tion of data collection

• e posterior probability may vary signiﬁcantly during the early iterations of the

process. e more iterations that are completed, the more stable the posterior probabilities should become

• is is not a rigid process and, ultimately, gets at what the truth is probabilisti-

cally. is process is most like the clinical reasoning process that clinicians use

Establish the Rules, Play the Game, and Get the Results

2.7

• e decision of which statistics are going to be used to answer the research ques-

tions needs to be made before data collection (a priori). To minimize the risk of a biased result, it is important to establish the rules for the game before you play the game

• Establish the rules

1. What are the research questions that need to be answered?

2. What are the statistical analyses that I am going to use to answer the research

questions?

3. How am I going to create an unbiased sample of the population of interest?

4. How can I minimize bias while collecting the data?

• Play the game according to the established rules

• Analyze the data based on the established rules

• Get the results

What if you don’t like the results?

2.8

• e results are the results

• Disciplined researchers accept the results and move on

• Unfortunately, some researchers do not like the results, so they try and change

the rules to the game retrospectively after they have played the game

2.9 How can I tell if the researcher changed the rules to the game after getting the

result?

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• ere are several conscious and unconscious sources of post-randomization bias-

https://t.me/med1917

es. Although a thorough discussion of these biases is outside the purview of this monograph, we will discuss a conscious form of post-randomization bias called

“cherry-picking”. literature as data dredging,

Cherry-picking has also been commonly referred to in the

13,14

but is most popularly identiﬁed as p-hacking.

15-17

A more detailed discussion of post-randomization biases can be found in an editorial that was written by Cook and Garcia

• “Cherry picking” may be assessed by checking to see if the study is registered

and comparing the registry to what was reported in the study to ensure that the

author was following their prospective intent

• Authors will often tout statistically signiﬁcant diﬀerences that are not meaningful

° What is the eﬀect size, and is it meaningful? ° Are the diﬀerences larger than the MDC and MCID for the outcome measures

used?

• Are the authors reporting a result that is inconsistent with the prospective study

design and intent?

° For example, the purpose of a randomized clinical trial is to determine if

there is a statistically signiﬁcant meaningful diﬀerence between the 2 treatment groups of patients on the prospectively registered primary outcome measure. If there are no statistically signiﬁcant diﬀerences between these groups for the primary outcome measure, do the authors focus on the secondary outcome measures? Do the authors focus on reporting on within groups changes or run a regression analysis to determine which variables were predictive of a result?

• Do the authors use “spin” by presenting the study’s ﬁndings in a positive light

that are inconsistent with the statistical ﬁndings?

—NOTES—

2.10 “It doesn’t matter how beautiful your theory is, it doesn’t matter how smart

you are. If it doesn’t agree with the experiment, it’s wrong.” -Richard P. Feynman

2.11 Current State of the Use of EBP in Physical erapy Practice

• As many as 25% of clinicians may not be able to identify the conventional deﬁ-

nition of EBP

• Ninety percent of respondents reported that their knowledge of research meth-

ods was “strong” or “good” yet were less conﬁdent (76%) in their understanding

of statistical methods.

ese concepts go hand in hand. Research methods require that the clinician can make prospective choices regarding the analysis that will be used to answer the research questions. ey also must be able to recognize when an analysis was consciously changed by researchers that are “cherry-picking” results

• ere exist unnecessary delays with the implementation of the best available

evidence in physical therapy practice

2.12 Current State of the Use of EBP in Physical erapy Practice (Cont.)

• It has been shown that most clinicians do not follow evidence-based guidelines

when treating musculoskeletal conditions

• Physical therapists report they favor the use of EBP in the clinic, yet recognize

that they need to improve their knowledge, skills, and clinical application of

22,23

EBP

• It has been suggested that most clinicians cannot generate a clinically meaningful

question to drive eﬀective searches for clinically relevant research, with reported

searches containing one or no elements of a PICO question

—NOTES—

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2.13 What EBP Is

• EBP has evolved into a cliché.

Many students, clinicians, and academics routinely parrot the phrase, “EBP is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.”

• In reality, EBP is a process that starts by asking a clinically meaningful question,

seeks to ﬁnd the best available evidence that can be used to answer the question, combines the best available evidence in the context of the clinician’s clinical experience, and the values of the patient, and evaluates the eﬃcacy of the process based on the patient’s response

• e commonly cited deﬁnition of EBP, therefore, is not a deﬁnition. It describes

the contextual elements for the application of the best available evidence after procedural aspects have been followed to determine what the best available evidence is

• To be clear, the best available evidence ﬁrst must be put in the context of a clin-

ically meaningful question, the highest level of evidence that can be found to answer the questions has to be identiﬁed. e literature then must be critically appraised to determine the external validity of the ﬁndings, and if the study has a rigorous enough degree of internal validity to help answer the clinical question

2.14 What EBP is Not

• EBP does not start by generating a clinically meaningful answer, look for ev-

idence that supports the answer, ignore the importance of critical appraisal of the literature if it does not support the answer, and then applies the evidence supporting an answer in the context of clinician’s experience and values of the patient

• If a clinician is incorporating this process in clinical practice, this is an example

of a cognitive bias known as conﬁrmation bias. is process is not rational; it is rationalizing

• EBP also does not involve removing the evidence from the EBP process and rely-

ing solely on clinical experience and patient values if the evidence is inconsistent with the preconceived answer. is is a logical fallacy known as the fallacy of incomplete evidence

2.15 “I would rather have questions that can’t be answered than answers that can’t

be questioned.” -Richard P. Feynman

What was the primary purpose of EBP?

2.16

• e whole purpose of EBP was to deemphasize dogma and “gurus” as a means of

informing clinical decisions

• One of the earliest manifestations of this was an editorial titled, “Science or

Cult?” that was published in PTJ in 1963. In this piece, Hislop stated, “Observations are the principal data of clinical science. Sometimes observations are inaccurate and faulty. Inferences and concepts can arise from such observations which also may be indeﬁnite and confused. For persons not well grounded in scientiﬁc thought and procedure, this kind of muddled thinking can result in the indefensible error of oﬀering explanation and rationalization of undocumented and unproved theory.”

2.17 How can clinical expertise help us make our clinical decisions?

• In 1996 Sackett et al sought to clarify what clinical expertise was in EBP.

Sackett et al wrote, “By individual clinical expertise, we mean the proﬁciency and judgment that individual clinicians acquire through clinical experience and

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

clinical practice.”

• e notion that expertise is attained through experience and practice is likely

https://t.me/med1917

not entirely accurate. e core dimensions of expert practice in physical therapy have been described as patient-centered care that involves knowledge, virtues/ values, clinical reasoning, and clinical practice style that emphasizes education

and individual care

• Experienced clinicians use information from the medical records, protocols,

observation of movement, problem-solving, consideration of the patients psy-

cho-emotional and cognitive-perceptual ability, and reﬂection in action

2.18

How can patient values help us make our decisions?

• e factors that patients appear to value most are their interactions with their

clinician, the organization of the clinic that treatment is being provided, and

32,33

their clinical outcomes

• Incorporating patient values in the process of applying EBP may be more accu-

rately considered patient-centered care. Patient-centered care in physical therapy involves individualized treatment options, continuous communication between the patient and clinician, educating the patient during all phases of rehabilitation, establishing goals in collaboration with the patient, sensitivity of the clinician to environmental factors that need to be addressed to empower the patient, and demonstrating clinical conﬁdence through the demonstration of knowledge

and skill while providing care to the patient

• Patient satisfaction may be inﬂuenced by:

° clinical outcomes; ° the personality and clinical skill of the physical therapist; ° personality and contextual factors related to the patient; ° the interactions that occur between the physical therapist and the patient; ° how the treatment is provided; and ° the features of the clinic where the treatment is provided.

—NOTES—

3.1

Clinical Reasoning and Diagnosis

• Section 3

3.2

What are the challenges in applying clinical reasoning?

• Academic programs within the United States do not have a shared view of what

clinical reasoning is, how it should be taught, and how it should be assessed

• is variability and lack of agreement of what clinical reasoning is maybe consid-

erably limiting the progress of our profession

• Recent eﬀorts have been made to clarify what clinical reasoning is based on the

literature

• is updated model discusses the collaborative interaction between the patient

and clinician, recognizes that clinical reasoning is an iterative, adaptive process, and integrates perspectives, cognitive, aﬀective, and psychomotor conceptional

elements

• What this model does not discuss or integrate are the diﬀerent types of reasoning

or how the process of clinical reasoning may be performed within and between

treatment sessions

3.3 Additional Clinical Reasoning Challenges

• One of the signiﬁcant challenges for any clinical reasoning approach in a clinical

or academic setting is how to account for the lack of certainty when combining linear (Deductive) and non-linear (Inductive) reasoning processes when going through the clinical reasoning process

—NOTES—

https://t.me/med1917

• Exam ﬁndings are not dichotomous. ey shift the probability of something

being true

3.4 Reasoning Strategies that are Used to Modify and Reﬁne Hypotheses

• Interactive reasoning (deductive and/or inductive) involves strategic communica-

tion to establish a therapeutic alliance with the patient

• Collaborative reasoning (deductive and/or inductive) is the communicative process

used to ensure that the clinician’s values and beliefs align with the patient’s values and beliefs

• Diagnostic reasoning (deductive) attempts to create a linear relationship between

the patient’s activity/participation restrictions, physical impairments, pathology of body structures, pain mechanisms, personal factors, and environmental fac-

tors.

It includes the reasoning related to musculoskeletal pain irritability40

° Musculoskeletal pain irritability is related to the persistence of pain and the

aggravating activities that produce a patient’s symptoms.

is concept may be an essential consideration as the clinician plans on how the data should be collected during the physical exam to do the least amount of testing to attain the most amount of information

• Narrative reasoning (inductive) is used to gather information related to personal

and environmental factors relevant to the patient

° is is established through open-ended questions and active listening strategies

that allow the patient to tell their story and experiences with their condition that provides the contextual elements of their beliefs and culture without hypothesis testing

• Intervention procedures reasoning (deductive and/or inductive) includes the choice

and execution of interventions that should help the patient if the hypothesis formulated is accurate

° is hypothesis testing strategy may include using a comparable sign related

to the patient’s primary symptoms as a test-retest strategy to determine if the hypothesis is probabilistically accurate

° is may be considered a symptom modiﬁcation process that tests an interven-

tion’s ability to change the patient’s symptoms

• Predictive reasoning (deductive and/or inductive) involves using musculoskeletal

pain irritability and the response of the hypothesis testing through intervention during the ﬁrst visit to establish a prognosis

° It also involves the process of assessing the patient’s 24- to 48-hour response to

the intervention provided and develops reasoning related to how the prognosis is modiﬁed if the patient is better, worse, or the same at the second visit

3.5 Additional Reasoning Considerations

• Additional reasoning considerations outside hypothesis generation, hypothesis

modiﬁcation, and hypothesis testing involve the reasoning used to educate the patient and ethical reasoning

• Patient education reasoning (deductive and/or inductive) involves formulating dif-

ferent ways to educate the patient and ensuring that the education was received by the patient

• Ethical reasoning (deductive and/or inductive) involves doing what is in the best

interest of the patient given the best available information

3.6 Bayesian Reasoning

• A possible solution to the integration of deductive and inductive clinical reason-

ing processes may be integrating the concepts of Bayesian reasoning into clinical training

• Bayesian reasoning involves the application of probability theory to deductive

and inductive reasoning

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• As data are progressively collected, it shifts the probability that something is true

https://t.me/med1917

• ere is a growing body of literature to support that theoretical instruction in

Bayesian concepts improves the estimation of post-test probabilities during the reasoning process

44-46

3.7 Additional Common Reasoning Errors

• To optimize clinical reasoning, the clinician must recognize common errors in

the clinical reasoning process

• e two major categories of errors in clinical reasoning are related to logical

fallacies and cognitive biases

—NOTES—

What Causes Errors in Clinical Reasoning?

3.8

47,48

• Inadequate knowledge

• Faulty data gathering

• Faulty data processing

• Faulty metacognition

• e inability to recognize logically fallacious thinking and cognitive biases

3.9 Common Errors in Narrative (Inductive) Reasoning

• Superﬁcial psychosocial assessment

• Attempting to use a deductive approach to narrative (inductive) process

• False dichotomy (this or that)

3.10 Where does the clinical reasoning process start?

• e clinical reasoning process starts with, evolves through, and ultimately ends

with the patient

• To attain accurate information from the patient, the patient must be central

during the clinical reasoning process

• How the clinician interacts with the patient, therefore, may be crucial to the de-

velopment, reﬁnement, and testing of hypotheses related to the patient’s primary symptomatic complaint

3.11

Creating a Patient-Centered Environment

• e signiﬁcant factors that inﬂuence the patient-clinician interaction are

° e physical therapists interpersonal and communication skills ° e physical therapist clinical skills ° Individualized patient-centered care that takes the thoughts and opinions of the

patient into account

° e time the clinician spends with the patient as well as ﬂexibility with sched-

uling clinical appointments

Patient Expectation and Outcome

3.12

• A patient’s expectation may have a considerable impact on clinical outcomes,

and how the examination, evaluation, and treatment is explained to the patient may have a meaningful eﬀect on the patient’s expectation and clinical outcomes

• An understanding of the contextual factors of the patient-clinical interaction

related to communication may be an essential aspect to consider that may not be currently present in clinical training

3.13 What is a therapeutic alliance?

• A therapeutic alliance is a relationship between the physical therapist and the

patient that involves mutual agreement on clinical goals and the interventions that will be used to attain those goals

53,54

51,52

55,56

—NOTES—

https://t.me/med1917

3.14 Establishing a erapeutic Alliance

58,59

• Although evidence is lacking in musculoskeletal rehabilitation,

establishing

a strong therapeutic alliance with the patient may have a signiﬁcant impact on

57,60-63

pain outcomes

and patient satisfaction64

• erapeutic alliance may be enhanced through active listening strategies, chang-

ing the tone and inﬂection of voice, using nonverbal behaviors, and demonstrat-

ing empathy

3.15

How to Establish a Diagnosis

• Classically diagnostic reasoning is a deductive process that is based on a medical

pathoanatomical model

• e purpose of a diagnosis is to create homogeneous subgroups of patients and

match that subgroup of patients with interventions that are most likely to improve the patient’s symptoms

3.16

Diagnostic Assumptions

• e primary assumption in the medical literature is that a diagnosis is a deductive

process

• is assumption requires a cause and eﬀect relationship between pathoanatomy

and the patient’s primary symptomatic complaint

• is may not always be accurate in physical therapy practice

• It is more likely to be true when dealing with conditions outside the axial skel-

eton and less likely to be true when treating spinal conditions secondary to the convergence of several nerves in this region

• For example, there is considerable overlap between pain referral patterns from

65-70

the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip

that make it diﬃcult to ascertain the potential cause of a patient’s symptoms based on symptom location

3.17 Deductive Errors Related to Diagnosis

• Given that over-focus on early/superﬁcial recognition is self-evident, and that

premature anchoring has already been discussed, premature closure is when the

clinician fails to consider other alternatives after the initial diagnosis is made

• e framing eﬀect occurs when the clinician may frame the question in the posi-

tive or in the negative related to the patient. When this happens, people typically are looking to avoid the negative by framing something in the positive or look for risk when framing something in the negative

• Commission bias occurs when somebody erroneously thinks that they need to

use a speciﬁc intervention to make the patient feel better when they may likely just get better as a result of natural recovery

• An extrapolation error occurs when you extend previous and occurring events

into those that may arise in the future

• Veriﬁcation bias occurs when the results of a single diagnostic test keep the

clinician from selecting a more accurate test

3.18 Diagnostic Reasoning and Physical erapy Practice

• Physical therapy clinical practice guidelines suggest diagnostic classiﬁcation

based on:

° Pathoanatomy and e International Classiﬁcation of Disease (ICD) ° e International Classiﬁcation of Functioning, Disability, and Health (ICF)

3.19 What are the requirements of a diagnostic system that is used to classify and

Academy of Orthopaedic Physical erapy, APTA.

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treat patients?

• It must be able to discriminate between groups of patients

https://t.me/med1917

• It needs to be comprehensive in its ability to classify all patients and create mu-

tually exclusive groups

• It should not have subgroups that patients never or rarely ﬁt into

• Any system that does not meet these criteria has signiﬁcantly limited clinical

utility

• To date, there are no known classiﬁcation systems that satisfy these criteria

73-76

3.20 Challenges With ese Classiﬁcation Systems

• Pathoanatomical ﬁndings are common in the asymptomatic healthy population

• Identifying impairments does not create a deductive link between the assessment

and the diagnosis, the diagnosis and the treatment, and the treatment and the outcome (ADTO)

• Given that there are several overlapping potential sources of symptoms that may

be synchronous in patients who have musculoskeletal symptoms, it may not be realistic that a linear deductive approach can be used to establish an anatomical diagnosis for patients that are under the care of a physical therapist

• I am therefore going to discuss a hypothesis-driven, probabilistic, mecha-

nism-based clinical reasoning approach to managing patients that eliminates the challenges related to using any single diagnostic paradigm

• Without the ability to ﬁrst determine if the patient’s primary symptoms are mod-

iﬁable through mechanical input, it becomes challenging to create a link between the diagnosis and the treatment

—NOTES—

3.21 A Symptom Modiﬁcation Approach

• e primary goal of a symptom modiﬁcation approach is to reduce symptoms

and to improve function using a variety of clinical approaches

• In cases where a patient’s symptoms are modiﬁable during the physical exam, a

symptom modiﬁcation approach

may help create a deductive link between the patient’s diagnosis and intervention most likely to improve their primary complaint at any given time

3.22

Value of a Symptom Modiﬁcation Approach

• Pain relief may be the desired outcome for many patients

• Reducing the experience of pain with simultaneous improvement in function

may contribute to reducing the impact of the negative inﬂuences of fear-avoidance beliefs, kinesiophobia, and catastrophizing while improving the positive aspects of self-eﬃcacy

• Educating the patient that their symptoms are modiﬁable, especially in the con-

text that they can modify them, may be a powerful tool for treatment compliance

• If symptoms are reduced, the patient may be able to introduce functional tasks

to help further modulate symptoms

3.23 Uncertainties With a Symptom Modiﬁcation Approach

• Having a patient focus on symptoms may not be prudent in the context of cen-

trally or peripherally mediated symptoms

• It is unknown how long symptom modiﬁcation must persist to be clinically

meaningful

• It is unknown if symptom modiﬁcation is even necessary

• ere are other considerations beyond symptom relief that may be important for

the patient, such as improvements in function

• Modiﬁcation of biomechanics may be beneﬁcial for other reasons beyond symp-

tom modiﬁcation

—NOTES—

https://t.me/med1917

4.1 Integration of Clinical Reasoning Concepts and Suggestions for Improvement

• Section 4

4.2 How do we work through the problem?

4.3 Step 1 of 4-What is the dominant mechanism that is driving the patient symp-

toms?

4.4 Potential Mechanisms-Based Sources of Symptoms

• Smart and colleagues identiﬁed 3 possible sources of a patient’s symptoms

through a mechanisms-based classiﬁcation for musculoskeletal pain that included

° Central sensitization ° Peripheral neuropathic (radicular or referred) ° Nociceptive

• ey have also established the discriminative validity of these 3 pain mecha-

nisms

4.5 Reﬁnement of the Mechanism-Based Model

• Chimenti et al82 modiﬁed the work of Smart and colleagues by:

° Changing the name of the central sensitization classiﬁcation to nociplastic ° Placing each mechanism in an overlapping Venn diagram to illustrate that all

3 sources of symptoms may occur at the same time

° Putting the interaction of these classiﬁcations in the context of the movement

system and psychosocial factors

° Linking these mechanisms to physical therapy interventions that may be most

appropriate to address the patients symptoms

• Generating a hypothesis related to the mechanism of the patient’s dominant

mechanism at any given time and then attempting to modify their symptoms by testing the hypothesis with an exam strategy or intervention that should improve their symptoms may provide a robust and reasoned approach when applied iteratively within and between treatment sessions

4.6 Nociplastic (Central Sensitization)

• In the absence of red ﬂag ﬁndings, nociplastic symptoms are characterized by

pain that is disproportionate, non-mechanical, unpredictable, and diﬀuse

• Patients that have nociplastic symptoms have a strong association with maladap-

tive behaviors related to the presence of negative beliefs (fear-avoidance), lack of positive beliefs related to self-eﬃcacy, and dyskinetic movement related to kinesiophobia

• is cluster of ﬁndings was found to have a sensitivity of 91.8% and a speciﬁcity

of 97.7%

• If a patient has nociplastic mediated pain, it is expected that the physical exam

may not signiﬁcantly change the patient’s primary symptomatic complaints

• ese ﬁndings strongly suggest that the patient should be educated that their

pain experience may not be driven through mechanical input, especially early during the rehabilitation process

• e focus should be on using techniques to increase the patient’s function with-

out increasing their symptoms

• Numerous techniques have been proposed to be useful in this context. e

method that matches the patient’s and clinician’s beliefs is likely the best choice of intervention at any given time

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