Arrazonamendu klinikoa esku terapian (Jones et al, 2004)

Ref:

• JONES, Mark A. RIVETT, Darren A. (editoreak). 2004. Clinical Reasoning for Manual Therapists. Ed. Butterwoth-Heinemann (Elsevier Science Limited). https://www.elsevier.com/books/clinical-reasoning-for-manual-therapists/jones/978-0-7506-3906-4

Azkenean amaitu dut, joan den udaberrian eskuratutako “adreilua”. Duela 14 urtekoa izan arren, bertan azaltzen diren gauzak zeharo atenporalak dira, arrazonamendu klinikoak ez du-eta iraungitzen. Gustatu zait, orokorrean, editoreek ikuspegi pragmatiko xamarra mantentzen dutela; norabidea ebidentzia zientifikoan oinarritutako arrazoitzea bada ere, bizitza errealean askotan ez dira ematen hori horrela egiteko baldintzarik; horrelakoetan, pazienteei laguntzeko gakoak “dagoenarekin” aurkitu behar dira. Idazlanaren diseinua ere gustatu zait: editore omnipresenten hitzen artean (batzutan pixka bat astunak eta errepikakorrak!), fisioterapeuta desberdinek haien kasuak aurkezten dituzte, esplorazio eta tratamendu prozeduraren kanpo-azterketa kritiko batekin. Honek balio handia du niretzat, eta liburuaren ekarpenik onena delakoan nago. Jarraian doaz, nik hartu bezala, irakurketan zehar idatzi ditudan zenbait ohar:

• Prefazioan (p.XI) “The original professional training of the manual therapist. whether it be in physiotherapy, chiropractic, osteopathy, medicine or another profession. is not important because the clinical reasoning process is universal”. Bistan da Espainan dugun egoera legala ez dela beste herrialdeetakoa; hemen dena sinpleagoa da, terapia fisikoak fisioterapeuten esparru legalean daudenez.
• Arrazonamendu Klinikoaren oinarriak esku terapian (p.10): “Reflection can occur in what Schon (1983. 1987) has called reflection-in-action, where you literally pause during a patient encounter and consider any of these issues, or in hindsight as a reflection-about action. Too often a patient’s status changes, for the better or the worse, without the therapist having or taking the time to reflect on the change. In a busy practice, improvement is a godsend as it means the treatment can be repeated with little deliberation. A lack of improvement typically leads to a change in treatment with some consideration of the options available, but often without any serious reflection on prior judgments made and the underlying reasoning that led to the current lack of improvement”.
• Ebidentziarantz, baina dogmatiko izan barik. Hauxe izan behar da jarrera (p.10-11, Principles of Clinical Reasoning in Manual Therapy izeneko atalean): “A healthy reflective scepticism, where a particular philosophy, position or justification is not taken for granted simply because it has been presented by a source or authority or been unchanged for a long time, is important for skilled clinical reasoning and continued professional growth. This is not to suggest that the only legitimate decisions and actions are those that can be conclusively substantiated by current research, as we hold the view that experience based non-propositional and personal knowledge. As discussed below, are equally important (Higgs et al.. 200la: Jones and Higgs. 2000). However, it is important to recognize the basis and biases of one’s own views and that alternatives exist. This requires looking beyond your own perspectives and contemplating other possibilities, some or which may even be beyond what is empirically known at the present time. Such open reflection about oneself (by therapists and patients) is no easy task. as Brookfield ( 2000. p. 63) points out: “No matter how much we may think we have an accurate sense of our practice. we are stymied by the fact that we are using our own interpretive filters to become aware of our own interpretive filters!… To some extent we are all prisoners trapped within the perceptual frameworks that determine how we view our experiences. A self confirming cycle often develops whereby our uncritically accepted assumptions shape clinical actions which then serve only to confirm the truth of those assumptions”. Because of this, it is usually difficult to explore your own assumptions effectively. Clinical reasoning in general, and self-reflection in particular, is enhanced when we enlist the help of others. On this basis, Brookfield (2000) describes clinical reasoning as an inherently social process. Peers, teachers and also our patients can be erfective critical mirrors, as we can be to our patients, to foster the critical self-reflection necessary to promote change. Brookfield labels the reluctance most of us have for this (i.e. to exposing our reasoning to the critique of others) as ‘impostorship’: the deep feeling many clinicians have that they do not really understand a problem or how best to manage it and their fear of being ‘found out’ by the patient and their colleagues. Acknowledging this reality is critical ir therapists are seriously trying to improve their own clinical reasoning. Section 3 discusses ways in which this barrier can be broken down and in which critical reflection, and hence transformalive learning, can be facilitated”.

• Mekanismo patobiologikoetan, zuntzaren eta minaren arloaz gain, estresatutako organismoak ondorio neuroendokrinoak eta neuroimmunologikoak ere baditu, osatze prozesua baldintza dezaketenak. (p.16)
• Esplorazio fisikoa egiterakoan, minaren mekanismoa kontuan hartu behar da: nozizeptiboa edo neurogeniko periferikoa denean, esplorazioa fidagarriagoa izango da; sentsibilizazio zentral egoera batek, ostera, positibo faltsuak eman ditzake (p.17).
• Yellow flagen barruan, lanari dagokien blue eta black flagak bereizten dira (p.19):
  • Blue flags, perceived features of work:
    • high demand and low control
    • unhelpful management style
    • poor social support from colleagues
    • perceived time pressure
    • lack of job satisfaction.
  • Black flags, policy concerning conditions
    • National
      • rates of pay
      • negotiated entitlements (benefit system, wage reimbursement)
    • employer
      • sickness policy
      • restricted duties policy
      • management style
      • organization size and structure
      • trade union support
    • content-specific aspects of work
      • ergonomic (e.g. job heaviness, lifting frequency, postures)
      • temporal characteristics (e.g. number of working hours, shift pattern).
• Gero terapeuten kasu klinikoen atala dator: ez da ahuntzaren gauerdiko eztula norbere lan egiteko prozedura horrela erakustea, besteen kritiken jopuntuan ipiniz! Eskertzekoa, horretxegaitik hain zuzen ere. Nire zalantza: ongi ateratzen diren kasuak bakarrik ekarri dira, ala lagin aleatorioa da? Izan ere, nire eguneroko lanaren lagin bat hartuko banu, badakit emaitza ez litzatekeela hain perfektua izango: koadratzen ez duten esplorazio datuak, hobetzen ez diren pazienteak… (PD oharra: bai, kasuen artean badaude “txarto” eboluzionatu duten pazienteenak; eta argigarrienetakoak dira gainera).
• Lunboziatalgiadun emakumearen kasua (Mark Bookhout): ikuspegi osteopatiko ortodoxo(egi) xamarretik.
• Arazo global xamarra sentsibilizazio zentralarekin duen emakumearena (David Butler): hemen ikusi ditut tipo honek nire lankideen artean duen arrakastaren gakoak (enpatia, eta intuizioari zabalik utzitako bideak). Lehenengo kontsultan anamnesi eta esplorazio hutsa egitera ausartu da!