The case studies

Many students find the HOAC II algorithm a little (or a lot) intimidating when they (us included) first see it. At first sight the algorithm may seem a little too massive and many find it hard to grasp how to apply the algorithm in practice. Our idea here on is to chop the HOAC II algorithm into logical and easily-digestible steps. This way students and clinicians alike can engage in practicing a structured way of clinical reasoning following the principles laid out in the HOAC II algorithm. The step-by-step structure also allows users to focus on selected clinical reasoning steps instead of the complete process.

The three trial cases

We created three cases (Anna, Paul and Maya) to feed the case study database of All three cases are based on patients we worked with in our internships. The content of ‘Anna’ works with common problems met in neurological rehabilitation providing case content that most users are familiar with. ‘Paul’ offers more challenging case content that encourages users to work with varied aspects of the HOAC II clinical reasoning process. ‘Maya’ is a case with more complicated problems that work with the more complex aspects of the HOAC II and stimulate the users think about the possibilities and responsibilities of working in a multidisciplinary team.

Different levels of difficulty

We do our very best to accommodate users with different levels of knowledge, experience and clinical reasoning skills. Therefore, we have worked out case studies at three levels of difficulty. The level is of course a little bit arbitrary, but the levels go along these lines:

  • Easy: content is very much simplified; case includes 1-2 problems.
  • Medium: content is simplified, yet more complex than an easy case; 3+ problems; anticipated problems.
  • Hard: all the more complex (multipathology) cases with a variety of different problems.

Neurological PT

All case studies at this stage are about neurological physical therapy. We have two reasons for this. First, the complexity of neurological cases allows us to demonstrate different dimensions of the HOAC II. Second, we like neurological PT and wanted to have a chance to develop our own knowledge during this project. Plus, importantly, we had case studies from our internships and could therefore work with a sample set of real-life cases.


Each case study is built up with an introduction, seven clinical reasoning steps and conclusion. All clinical reasoning steps proceed in the same step-by-step manner: actions to take, case details, solution, rationale & evidence. We have extensively discussed the structure with clinical reasoning and HOAC II experts at the Hogeschool van Amsterdam (Engelbert 2011, de Bakker 2011, Voigt 2011, van Egmond 2011, van Hartingvelt 2012, Simons 2012).

The ‘actions to take’ follow the original HOAC II algorithm by Rothstein et al. (2003) and constitute the centrepiece for learning the HOAC II way of clinical reasoning. The final format has been reviewed and approved by the HOAC II specialists at the Hogeschool van Amsterdam.

The ‘case details’ are given in flow text and at the beginning of each section, we have included a Canvas filled with case details up to that section. This way the user can go through the entire case in a step-by-step manner or choose to focus on a specific part of the clinical reasoning process and still be able to easily catch up with the case content.

In the ‘solution’ we offer one expert-validated solution. The idea is that the user compares his solution to the provided solution. This way the user gets immediate feedback on his work and automatically reflects on his clinical reasoning process. When we give the solution in the Canvas, all case details related to that section are highlighted for easy overview. At the end of each section give the ‘rationale’ for the provided solution and list the ‘evidence’ we have used. The rationale is kept short, yet precise to avoid overload of information.

Integration of different elements of clinical reasoning skills

Our aim is that the case studies help users develop their knowledge but also cognitive and metacognitive skills. Cognitive skills are developed with constant analysis of data and synthesis of the collected information. Metacognitive skills are improved with reflection of own progress. All three factors are key elements in the development of clinical reasoning strategies and professional growth (Atkinson et al. 2011). The little yellow sticky notes are meant to motivate the users. They are also a means for us to give case specific tips when necessary.

We hope the case studies are clear and easy to follow and help you develop your clinical reasoning skills. We would love to hear your comments and ideas about them so please feel free to leave us your feedback through the ‘feedback’ button on the left side of each page!


  • Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model. Phys Ther. 2011;91:416-30.
  • de Bakker P. Professor in Physiotherapy (Hogeschool van Amsterdam, the Netherlands). Personal communication. 18 October 2011, 13 December 2011.
  • Engelbert R, Wittink H. Klinisch redeneren volgens de HOAC II (eng. Clinical reasoning with the HOAC II). Houten: Bohn Stafleu van Loghum; 2010.
  • Engelbert R. Director of education in Physiotherapy (Hogeschool van Amsterdam, the Netherlands). Personal communication. 6 December 2011, 15 December 2011.
  • Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83(5):455-70.
  • Simons J. Professor in Physiotherapy (Hogeschool van Amsterdam, the Netherlands). Personal communication. 9 January 2012.
  • van Egmond M. Professor in Physiotherapy (Hogeschool van Amsterdam, the Netherlands). Personal communication. 26 October 2011.
  • van Hartingsvelt F. Professor in Physiotherapy (Hogeschool van Amsterdam, the Netherlands). Personal communication. 9 January 2012.
  • Voigt J-J. Professor in Physiotherapy (Hogeschool van Amsterdam, the Netherlands). Personal communication. 29 November 2011.
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