The beauty of the art of the clinician, and of the observant therapist, is her ability to “go off label”. To know when to adhere to printed guidelines or directions when administering a standardized test to derive standardized scores, as opposed to letting a child do what they habitually do in order to make observations about performance that helps explain behaviors.
As you can see from the discussion above, such is the case when looking at tests or probes of fine eye-hand coordination. But I am frequently reminded of the same question even when the test being administered is non-standardized and involves head and/or body position. How does one handle the patient’s head position when conducting clinical tests?
Let’s take a specific example of measuring free space phoria or fusion, as referenced in this article on prescribing prism. Is it “the right way” to measure phoria to allow the patient to adopt their habitual or natural head position? Or, should the examiner be positioning the patient’s head so that it is “straight” without any tilt or turn? From the standpoint of measurement you may wish to know what the absolute numbers look like as referenced to deviating from the straight position. However when it comes to performance and prescribing, you should want to know the impact of the patient’s measurements and ranges in the habitual state.
So if I had to summarize this clinical pearl it would be that adhering to a standard set may be suitable or even required for measuring, but it is inadequate for probing.
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This is an important post. At SUNY I was taught the value and beauty of the “empty instructional set.” I think that this is a great corollary for better understanding a patient’s response.
Great question. I believe we all go off-label much more than we realize. Although it is important to have a consistent starting point, all too often patients do not fit in that box. Marie Bodack and I did a course at SECO this year where she took the PEDIG studies and I took a position of the patient sitting in your chair who did not meet the criteria. The intent of the course was not to sway anyone to either side (only RCT or only off-label) but to show that there are patients sitting in your chair where there is no specific well documented clinical trial to follow. The clinical trial certainly gives a place to start but in the care of our patients, the majority do not meet the criteria. The discussion will be interesting.
I agree with you, Dr. Steele. Frequently I am called upon to work with a patient who is developmentally young. In many cases, following the “protocols” tell me a whole bunch of stuff the patient cannot do. I am fortunate that I am given a “blessing” to go off script to do what I need to do to probe what the patient can do – that is so important in helping me get “a foot in the door” when VT starts.