Constructivism and cognitive reasoning
Understanding constructivism (clinical reasoning) through the deconstruction of competencies required for map reading in Orienteering
by Martin Krause (2007 and 2013)
Orienteering involves complex decision making using multiple variables of information to ascertain the optimal path. Clinical reasoning is a similar balance of gleaning the right amount of information to build a clinical picture. Too much information and we have information overload and with too little information we again arrive at an impass with the likelihood of making mistakes such as 'confirmation biases'. Information optimisation in the form of clinical reasoning, and deductive reasoning in particular, is a process of confirming expectations through the process of questioning and examination. When expectations aren't realised, then the therapist must revert to inductive reasoning, which requires deconstruction back to first principles, to rebuild a clinical picture, which makes sense, both to the client and anyone else who askes for face and constuct validity for the evidence of efficacy of treatment. When reading a map in a sport like orienteering, it is important to read the map ahead of where you are going, so that when the runner comes to the terraine they are confirming or negating their expectations. There is a positive correlation between motor performance and map reading skills. That is, the feedforward mechanisms of motor control are more finely tuned, when the runners map reading skills are more finely tuned. Importantly, in order to optimse cognitive performance, the information on the map needs to be simplified into meaningful small chunks of information. The following are map reading exercises for the development of competency in orienteering. By de-constructing various elements of map reading, greater competency can be obtained. Additionally, physiological variables can also be manipulated to enhance cognitive skill. Ultimately, feed-forward predictive reasoning skills should be accomplished. It is very rare for an injury to occur when the cognitive processing is optimal. Similarly, in the clinical situation, the more finely tuned the predictive reasoning skills are, the less likelihood of getting lost during the examination resulting in a mis-diagnosis. Additionally, by making predictions throughout the clinical reasoning process, scientific credence is given to the process of examination and re-examination, whereby variables are defined, included and eliminated. The predictive validity of testing becomes the clinicians 'null hypothesis'. In orienteering competitions, economy of movement and information processing capacity, are reflected by the fastest time as the metric of choice; whereas in the clinic, it is the minimal intervention which derives the maximal and most optimal outcome which should define the economic value of the health intervention.
When reading a map, a rock is a rock, however the identification of features on how to find the location of the rock will be different if it is in a Siberian birch forest on the side of a Japanese mountain, a baltic pine forest in Europe, beech forest in New Zealand or Eucolypt forest in Australia. What is the significance of a rock in a boulder field and how does the topography of the landscape contribute to finding the correct rock? Similarly, the features associated with a supraspinatus shoulder problem will be different in an elderly person, an office worker and a freestyle bouldering rock climber. What are the salient clinical features which make the supraspinatus significant in the presence of multiple pathology from shoulder, neck and rib cage trauma? In all cases, it is the context which drives the analytical process of reducing the problem to the most significant variables in order to construct a picture which achieves the desired outcome.
Looking for controls in a given area based on all aspects (variables) of map reading and the control descriptions
Click on each map if you would like larger detail.
Track orienteering - relatively simple correlation of a track network with 'sense of distance' and control description.
Blind Compass orienteering - as hard as it gets. Only 1 variable and hence no correlations with other information is possible
Pure contour map used during winter training. My first mistake was to write the control numbers upside down. The terraine was covered by at least 1 - 1.5m of snow. Due to the inherent dangers of such training, we used 'shadow orienteering' whereby pairs of orienteerers shadowed each other over alternating controls.
Pure contour work. This map is riddled with tracks. Hence the exercise becomes very demanding when all other features normally associated with the forest are obliterated and yet they still exist. The brain is forced to focus on one variable - the contours. The previous exercises demonstrate how weaknesses and biases in cognitive strategy can come to the fore, thereby allowing the possibility of self analysis of their thinking through meta-cognitive strategies.
An interesting loop relay event, where several different courses were run in parallel, with some common controls, in highly tricky, negative terraine. (Kaajani, Finnland 1989). Many controls were close to one another and hence it was important that the correct controls were being checked off. The physiological variable of increasing speed was correlated with the need for increased cognitive processing efficiency. That is, reducing each attack point to a clearly defined feature in the terraine, which would in turn immediately indicate the direction of the control flag, during which time it is important to commence reading the map for the following control. For example, start -> 1 : saddle, 1->2 small gully leading into depression - need to maintain height as control sits high between 2 depressions (note map had extensive 'negative terraine'), 2->3 small spur with small gully on right - exagerated due to negative and positive terraine, 3->4 large clearing, 4->5 long gully with major depression on left parallel to line of run for control feature, 5->6 clearing and then large negative depressions, 6->7 off edge of semi cleared area and get direction correct - the control feature of a gully beyond high points should be obvious, 7->8 track, 8->9 contour around the very large depression, 9->10 semi cleared then track end then depression on left, 10->finish need to get direction correct before arriving at 10. Moreover, the runner has a mental image of the terrraine before they arrive in the attack point area, where they should compare their conscious and subconscious expectations to what they see. Hereby, the imagery creates a path to the subconscious.
In this last scenario, there were several parallel courses and/or 'dummy controls. The objective was to run from the bottom of the hill up to the loop and repeat the exercise at least 4 times in a given period of time (e.g. 40 minutes). Ideally, the athlete preforms better on each loop, even though they should in theory be fatiguing. If the loop is the same then the cognitive demands should reduce on each loop, whilst the physiological demands are increasing. The concept involved the use of anaerobic threshold cognitive capacity. At an elite level we demonstrated that at least half of the Swiss elite orienteers could concentrate better at supra-anaerobic threshold. Unfortunately, Dr Toni Held's thesis, on this phenomenon, was never published as it went against the consensus of the time. Since, early this century, researchers have come to recognise lactic acid is an important fuel for aerobic-anaerobic exercise through the production or conservation of the energy substrate, pyruvate, via the Ciori cycle in the liver. The pathways of lactic acid metabolism probably depend upon the internal metabolic conditions when exercise stops. High levels of lactate and slightly reduced levels of other substrates such as liver glycogen and blood glucose appear to favor lactate oxidation to pyruvate, thus saving some glycogen; whereas, the effects of prolonged exhaustive exercise may favor lesser oxidation and greater conversion to glucose. Thus lactate is an important reservoir of carbon energy during recovery (Brooks et al 1999, Exercise Physiology : Human Bioenergetics and Its Applications; Mayfield Publishing). In this case, the downhill running was the recovery phase, even though it was at maximum speed, but the soft ground also allowed for maximum efficiency of elastic recoil in the bounding muscles.
The previous discussion revolves around map reading, the reduction of variables and the use of this reductionist approach to become self-aware of strengths and weaknesses in different information biasing scenarios in the same terraine. Similar exercises should be done in various terraines, to help the orienteer determine which strategy is best for which terraine or more importantly, which combinations of variables optimises the decision making cognitive processing to determine the best strategy. Also, which predictive reasoning variables from the map can be used as 'checks and balances' in determining that the runner is still going in the correct direction. By using these meta-cognitive strategies the runner can reflect on the reasonableness of their biases which weigh more heavily in their reasoning. It is important to remember that 99% of our cognitve processing occurs at the subconscious level. Through verbalisation and visualisation and using strategies such as predictive reasoning we can gain access to our subconscious. Ultimately, the runner wants to run efficiently and cleanly to the control without cognitive overload. Flowing through each and every control in an effortless manner until the finishing line is the ultimate 'da sein'.
Using the analogy of the orienteer running throught the terraine, we can examine clinical reasoning or 'the unbearable lightness of being' in a similar way. In the forest the runner wants to come across features in the terraine which ultimately leads them to their destination. Clinically, the practitioner wishes to do the same thing. During the 'subjective' examination, questions are asked to confirm or negate the 'working hypothesis'. Whilst during the 'physical' examination, tests are carried out and treatments undertaken and signs and symptoms are assessed and reassessed to confirm the diagnosis as well as create a prognosis. During this entire process 'feed forward' predictive reasoning mechanisms are being put in place which act as 'checks and balances' that attain the desired outcome, which is the amelioration of suffering and the improvement of impairments.
The map for clinical reasoning may look like the following (taken from the Maitland concept), whereby a structured process of deductive reasoning allows the organisation of knowledge retrieval, to take place, whilst creating a mechanism for the correlation of information. Clinical pattern recognition reflects the storage of the correlated information into meaningful chunks. Clarification and refining of information is what is referred to as inductive reasoning. When pattern recognition doesn't take place, then the clinician needs to revert back to 'first principles' reconstructing information into a new clinical picture. Incorrect confirmation biases, and hence getting lost in the examination and treatment process, should be reduced by reflecting on the 'checks and balances' in questioning, so as to correlate these with differential diagnostic manouvres, so that all aspects of the subjective and physical examination are covered in a precise and effective manner.
Just as the orienteer uses a map to develop a picture of the terraine ahead, the clinician also forms needs to form a picture of the expected clinical presentation from the narrative of questions and answers with the client. Hence, the features of the signs and symptoms create the picture. The narrative between the clinician and client, with the appropriate questions and reasoned explanations allow the conscious to access the subconscious where 99% of our cognitive processing occurs. The working hypothesis creates the scientific rationale by making a prediction. Further construct validity is attained by testing the prediction, through the reduction of the clinical variables. The correlation of the confirming and negating information also reduces the likelihood of making a mistake through confirmation biasing when using too few clinical features. Ultimately the power of the prediction is verified through successful clinical outcomes. Constructing a clinical picture through the correlation of all the significant variables is the ultimate objective of a successful outcome. Successful outcomes can then be laid down in the brain as a template, for quick recognition, in future use for a now familiar clinical problem. Similarly, in new terraine, the orienteer needs to consider the familiar and unfamiliar features and decide whether they need to revert to first principles of reasoning. By considering all the unfamiliar features, the cognitively more demanding short term memory and conscious processing comes into play, which deconstructs the problem, before constructing a map reading strategy using familiar features (eg compass bearing, contours), in order to arrive at the destination of unfamiliar new terraine. Hereby, the orienteer lays down new long term memories of successful navigational strategies (cognitive templates), to use at a later date, for a new but familiar terraine. In chess the laying down of sufficient 'cognitive templates' to attaine expertise takes around 10 years of consistent congnitive effort.
During the second week of July 2013, the world orienteering championships took place in the middle of Finland. This is a particularly important place for me, as it is where I started my professional orienteering physiotherapist - trainer career back in 1989. The following are a snap shot of maps with route choices and errors which occured amongst the worlds best.
The longer the leg, the greater the number of choices correlates with the greater the variability of success. Clinically, the longer the story, the greater or more complex the clinical picture, the greater the possibilities of intervention. However, similar to orienteering, the speedier the intervention, the more structured the cognitive processing, the sooner the improvements in signs and symptoms, the better the rate of success.
Uploaded 31 December 2006
Updated 18 July 2013
based on Orienteering exercises with OLG Chur and the Swiss National Team 1988 - 1993
WOC Vuokatti, Finland 2013