REVIEW

Cynefin Framework for Evidence-Informed Clinical

Reasoning and Decision-Making
Christian Lunghi, DO (Italy); Francesca Baroni, DO (Italy)

From the Clinical-Based Osteopathy (manipulative care provided by foreign-trained osteopaths)

Human Research Department
in the Research Division of
COME Collaboration in
Pescara, Italy.
Financial Disclosures:
None reported.
Support: None reported.
Address correspondence to
Christian Lunghi, DO, COME,
Collaboration Foundation,
Via Vespucci, 188 Pescara
Italia, Rome, Italy 65126.
Email:
christianlunghi@gmail.com
Submitted
March 15, 2018;
final revision received
May 18, 2018;
emphasizes manual techniques as the cornerstone of patient care. Although
osteopathic medicine has been well integrated into traditional health care
systems in the United States, little is known about the role of osteopathy in
traditional health care systems outside the United States. Therefore, it is
incumbent on the osteopathy community to gather evidence in order to prac-
tice scientifically informed effective methods. This narrative review outlines
the Cynefin framework for clinical reasoning and decision-making and
encourages a broadening of the evidence base among osteopaths to
promote health in an interdisciplinary care setting. This review also presents
the concept of an osteopath’s mindline, in which the osteopath combines
information from a range of sources into internalized and collectively
reinforced tacit guidelines.
J Am Osteopath Assoc. 2019;119(5):312-321
doi:10.7556/jaoa.2019.053
Keywords: Cynefin framework, integrative medicine, osteopathic manipulative therapy, osteopathic models

accepted
June 15, 2018.

P
ublic health is achievable through the science and art of preventing disease,
prolonging life, and promoting health.1 The major causes of chronic illness and
death can be directly related to excessive behavioral, environmental, and social
stress.2,3 To promote more holistic person-centered health care,4,5 the theory of
Adaptive Health Practice6 was designed to incorporate a personalized approach to
health care and to motivate behaviors needed to confront challenges to reducing those
stresses.7 To resolve complex illness, the World Health Organization suggests that
health care systems should focus on improving different components of an individual’s
health over the disease that affects him or her8 and integrating adjunctive approaches to
traditional medicine.9
Osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-
trained osteopaths) is considered useful for conditions such as acute and chronic non-
specific low back pain, dysfunctional disorders in pregnancy, headaches, irritable bowel
syndrome, and chronic respiratory disorders.10 Osteopathic manipulative therapy has
also been shown to reduce the length of hospital stay and costs in a large population of
preterm infants11 and to promote relevant neurophysiologic effects in terms of cortical
plasticity.12 Although positive effects were found in psychological, neurologic, and
chronic inflammatory disease management,13-15 as well as in the fields of gynecology
and obstetrics,16 further investigations with more pragmatic methods are recommended
to obtain solid and generalizable results.17,18 Moreover, the differences in osteopathic

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practice between the United States and the rest of
19,20
the world need to be considered. Osteopaths may
need to implement new standards for osteopathic
21
education and practice, integrating evidence-informed
and anecdotal perspectives20 and paying attention to the
distinct components and roles of the non-US
osteopathic profession in modern integrative health
17,22
care.
The Italian Register of Osteopaths produced the
Italian Core Competencies Framework in Osteopathy,
which is based on the Italian health care system and
focuses osteopathic competencies on the important
health needs of the population: promotion of health
and prevention, management, and support of complex
illnesses.23 To achieve holistic and person-centered
osteopathic care, it is crucial to contextualize evidence
and use critical thinking to review traditional osteo-
pathic principles and their application.24 The frame-
work of the 5 structure and function models25,26 could
be valuable to osteopaths for implementing scientific
findings in practice and promoting an integrative
27
approach that could help patients become more resili-
ent and autonomous promoters of their own health.23
Although osteopathy has recently been recognized as a
health profession in Italy, combining OMTh with
traditional medicine has not yet occurred.
Implementation science is “the study of methods to
promote the systematic uptake of research findings and
other evidence-based practices into routine practice . . .
to improve the quality and effectiveness of health
services.”28 Complexity science, meanwhile, is “con-
cerned with complex systems and problems that are
dynamic, unpredictable and multi-dimensional.”29
Both implementation and complexity science involve
some properties of health care systems that favor
30
more effective, evidence-informed integrated care.
Therefore, creating proposals and discussions about
clinical reasoning and the distinctive role of osteopaths
in health care processes is paramount to adapting an
implementation science intervention to osteopathy.
Working with the osteopathic community could facili-
tate ways to get osteopaths on board with an
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evidence-informed intervention by leading it, reflecting
on progress among stakeholders, and providing feed-
back to participants to help embrace implementation
over time. Osteopaths do not typically work with expli-
cit codified knowledge or guidelines, but instead use
knowledge in practice, combining information from a
wide range of sources into internalized and collectively
reinforced tacit guidelines, or mindlines, to inform their
practice.31
In the present review, we sought to introduce a
complex medical framework32 in osteopathic models
of care that provides a common language of reference
and a multidimensional-complexity-informed model to
draw appropriate conclusions for insight, decisions,
and actions. Through this framework, we encourage
deep reflection in the osteopathy community to estab-
lish a common clinical reasoning and decision-making
process that aligns with risk-based thinking and
promotes health in an interdisciplinary care setting.
We also describe our mindlines31 (Figure 1) as an
example of osteopathic practice that needs to be
negotiated through a range of informal interactions in
free-flowing communities of practice, experience with
patients, and consensus workshops. The resulting con-
struct will be a day-to-day evidence-informed practice
based on socially constituted knowledge.
Cynefin Framework: Clinical
Reasoning and Decision-Making
Process
Beyond contextualizing the results of scientific evi-
dence for the management of a particular disease,
health approaches to a complex adaptive system
should adapt procedures to the values and preferences
of each person. Complexity and uncertainty are funda-
mental features in health care processes.33 Complexity
science has more recently been used in health care to
realize the implementation of interventions and to trans-
late evidence into practice.30 Systems analysis tools
need to be applied to understand complex problems
and develop solutions.34 The Cynefin framework (CF)
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Adaptive approach Symptom-based

approach
ie, Structure/function
model individualized ie, Evidence-based
approaches practice guidelines
Complex domain Complicated domains
C
E C E

Hypothesize - perceive - Perceive - analyze - respond

respond

Emergent practice Good practice

Intuitive system Disorder Analytical system
Pattern recognition Space Hypotheticodeductive reasoning
Chaotic domain Simple domain

Act - perceive - respond Perceive - categorize -

Operator-patient respond Objective
proximity examination
Nonverbal behaviors
Novel practice Best practice
ie, Interoceptive Single test
approach
C
E C=E

Figure 1.
The Cynefin framework in the field of osteopathy (manipulative care provided by foreign-trained osteopaths). The application of the Cynefin
framework domains is useful to better understand clinical reasoning and the decision-making process. Modified from: Lunghi C, Baroni F, Alò M.
Ragionamento clinico osteopatico: trattamento salutogenico ed approcci progressivi individuali. EDRA, Milano 2017: 25. Abbreviations: C, cause;
E, effect.

has emerged from research conducted in the theory of
complex adaptive systems, cognitive sciences, anthro-
pology, and narrative models, as well as in evolutionary
psychology.35 Figure 1 shows the relationship between
the individual, experience, and context, which all
enable new approaches to decision-making processes
in complex environments,32 such as the relationship
between patient and osteopath. In the field of osteop-
athy, especially in countries where osteopathy is pro-
23
posed as an analytic hierarchy process, the CF could
be useful to better understand the decision-making
process (Table 1 and Figure 2).
The CF has 4 domains and a disorder space, as
35
follows :
▪ Simple domain. Cause and effect are in linear rela-
tion; therefore, the operator can identify 1 or 2 good
responses. This approach involves 3 actions required
to apply best practice: perceive, categorize, and
respond.
▪ Complicated domain. Cause-effect relationship is
not fully known to the experts and requires analysis
or some other form of investigation or application of
specialist knowledge; reference is made to systematic
reviews and guidelines to find real-world hypotheses
and discover a range of possible reactions. This
approach involves 3 actions required to apply “good
practice”: perceive, analyze, and respond.
▪ Complex domain. The relationship between cause
and effect can be perceived only retrospectively. It is
therefore defined as an emerging relationship because
events can be understood on the basis of stories,
narration, relationships, and patterns of dysfunctional
behavior. This approach involves 3 actions required
to elicit “emergent practice”: hypothesize, perceive,
and respond.

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Table 1.
Application of Cynefin Framework’s Domains in the Practice of Osteopathya

Domain or Space Description

Simple domain During the objective examination, the DM follows anatomic-physiological rules and standard operating
procedures and finds scientific evidence; an appropriate clinical test is selected to confirm or refute a
diagnosis.

Complicated Using a symptom-based approach, the osteopath relies on expert opinion and diverse stakeholder
domain perspectives to identify a cause-effect relationship and select an appropriate treatment plan for a patient.
This method is used when a patient has poor motivation and therefore complex adaptive care cannot be
implemented.36 The patient’s capacity for adaptive health work can be assessed with appropriate tools (eg,
the Patient Activation Measure).37

Complex domain In this domain, psychosocial factors that influence adaptive capacity (learning mindset, autonomy
orientation, self-regulatory strength, social networks) are particularly important in treatment planning.36 The
osteopath should assess the patient’s willingness to comply or accept adaptive care.37 The adaptive
approach is based on the 5 structure/function models26: biomechanical, neurologic, circulatory/respiratory,
metabolic, and biopsychosocial; osteopathic philosophy and practice are centered on the unit of body,
mind, and spirit, which is consistent with a person-centered approach and the biopsychosocial model.36
Anamnestic and observational decoding of disorders, self-regulation systems overload related to the
patients’ complaints and associated with the allostatic overload index, and palpatory findings lead an
osteopath to evaluate a local or general overload of self-regulatory systems. This process leads the
osteopath to select the models that evoke the same activation forces of the detected overload, focusing on
dysfunctional structures or overload functions, as well as offering lifestyle recommendations, including
nutritional and exercise advice and referrals to other professionals. Within the complex domain of health
care, great improvements could be achieved not only by measuring the impact of osteopathy on patients’
experience of disease-related symptoms, but also from assessing improvements in the empowerment
process.38,39 Furthermore, measuring the strength of SOC39 could help identify important factors involved
in developing and maintaining health, even under difficult external circumstances.39 While pathogenesis is
important to understand disease and disease development, salutogenesis contributes to the
comprehension of the development and maintenance of health. A strong SOC can be progressively
developed by individuals capable of drawing on general, sufficient, and adequate resilience resources.39

Chaotic domain In this domain, stabilization is needed for patterns to emerge. Osteopaths should use multimodal program
aims (eg, cognitive behavioral approaches and exercise) to increase psychological flexibility and improve
function,40 as well as osteopathic approaches based on operator-patient proximity and nonverbal
behaviors, such as interoceptive touch.41 During these procedures, the osteopath maintains contact with
the patient and is contextually engaged in a focused tactile attention task (eg, perceiving myofascial
movements to balance the activity of the autonomic nervous system, the interoceptive threshold, and the
cortical integration centers41 to elicit a response). Decoding health improvement findings within a
multimodal program integrated with osteopathic interoceptive treatment could encourage the patient to
engage in a process approach40 and allow an integration between the symptom-based and the adaptive
approaches with the support of other health care professionals.

Disorder space If it is impossible to recognize a domain, the osteopath should search for any confounding DM factors. To
identify an action domain, the assessment procedure must be repeated. Of note, if the osteopath bases
DM on predefined, linear knowledge rather than on single case assessment, he or she risks choosing a
procedure just because it succeeded in the past, and previous positive outcomes will not necessarily recur.
Thus, some patients require referral to specialists.

a
Manipulative care provided by foreign-trained osteopaths.

Abbreviations: DM, decision-making; SOC, sense of coherence.

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Case • Objective Examination: Constitutional and postural observation; physical

History examination tests
• Differential Diagnosis: Indication-contraindications
• Multidimensional Aspects of Condition: Familiar symptoms and
comparative signs
• Individual Adaptive Ability: Salutogenesis indicators; allostatic index;
self-regulation functionalities tests (B-N-EM-CR-BPS)

Assessment • Tissue alterations related to general adaptation syndrome and self-regulatory

capacity (ie, fascial pattern)
OR
• Tissue alterations related to local adaptation syndrome (ie, somatic dysfunction)

Diagnosis • Integration of biomedical and osteopathic findings for the selection of structure-
function models and osteopathic techniques
• Evaluation of the clinical relevance hypothesis: Structure-Function Provocation
Test

Treatment • Current session: Integration of the maximalist or minimalist approach with the
Plan symptomatic approach
• Entire treatment: Frequency between sessions, ongoing management, etc
• Share the plan with the patient

Treatment • Minimalist: Specific techniques (direct, indirect, combined)

Approach • Symptom-Based: Techniques selected by research studies conducted on
similar clinical context and/or related to regional interdependence
• Progressive Individualized: Lifestyle, exercise, nutritional advice
• Maximalist: Systemic, homeostatic-adaptogenic techniques

Follow-up • Evaluate treatment and patient outcomes

Figure 2.
Decision-making process in osteopathy (manipulative care provided by foreign-trained osteopaths). Osteopathic
decision-making is based on the integration of clinical history, objective examination of patient presentation, allostatic load
index, and osteopathic palpatory findings (somatic dysfunction and/or fascial pattern). The decision-making process leads to
an adaptive treatment with different manipulative approaches: one focused on SD related to local adaptation syndrome
(minimalist approach), one focused on fascial pattern related to general adaptation syndrome and functional overload
(maximalist approach), and one based on the outcomes of research studies on similar complaints (symptom-based
approach). During the integration of the structure/function models, attention should be paid to the different types of touch
and their different effects on patient’s perception, tissue alterations, and self-regulation systems. Abbreviations: B, biomechanical;
BPS, biopsychosocial; CR, circulatory respiratory; EM, energetic metabolic; N, neurological.

▪ Chaotic domain. When the evaluation process
does not show clinically relevant cause-effect
relationships, the approach is to act, perceive, and
respond to discover new practice (or “novel
practice”).
▪ Disorder space. At the center of the framework,
the disorder space applies to situations in which
selecting from any of the 4 previously named
domains is impossible.
Knowledge in health care is a multidimensional
dynamic construct that is personal, is discovered, has
explicit and tacit dimensions, and can be concerned
with content or context. Complex adaptive systems

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science views knowledge as both constructed and in
constant flux. The CF model helps osteopaths in under-
standing knowledge as a personal construct achieved
52
through sense making. Specific knowledge aspects
temporarily reside in either 1 of 4 domains—simple,
complicated, complex, or chaotic—but new knowledge
can only be created by challenging the known and
moving it through the other domains. Thus, health care
is inherently uncertain, and osteopaths require a
context-driven flexible approach to knowledge discov-
ery and application in clinical practice, as well as in
52
health service training and planning.
Cognitive Processes in the CF
Pattern recognition and hypotheticodeductive reasoning
are the foundations of the intuitive and the analytical
53
systems, respectively. Osteopaths, like other health
care professionals, mainly adopt both pattern recogni-
tion and hypotheticodeductive approaches as part of
their diagnostic reasoning, which depends on the per-
ceived level of complexity of the patient presenta-
54,55
tion. The recommendations on perceptual training
53,55,56
described in several articles can be gradually
applied by osteopaths who adopt domains of complex-
ity to aid with decision-making. When the patient-
osteopath relationship is located in the simple domain,
an osteopath is anchored with routine and previously
used patterns. Osteopaths seek confirmation with tried
53
and tested ways of diagnosis and management. Liem
reported that there is little room for experimentation
and originality within the simple domain.
Osteopaths operating in the complicated domain
must be open and inquisitive. In the complex domain,
osteopaths move out of their limited frame of reference
and attempt to see the world through the patient’s
eyes because being empathetic with patients may
53
bring radical new insights. In the chaotic domain,
osteopaths begin to perceive the fullness of information
that emerges at each moment of perception and can
draw from their reliable and trustworthy intuition to
evolve and foster innovation at all levels.53
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Improving the awareness and development of intuitive
processes in practical decision-making of both osteo-
paths and osteopathic students should be introduced in
teaching and learning processes. The introduction to
these concepts will improve “reliance on intuition” or
“problem-oriented” strategies and launch CF to develop
clinical reasoning in osteopathic education.53,56
The CF is a useful tool for classifying a system’s
complexities and its environment. The framework does
not tell us how to solve problems or give a solution.
Instead, the CF points out in which domain the patient-
osteopath relationship is located, and it gives no sug-
gestions for shifting domains. The most interesting
element in the CF is the differentiation between the
complicated and the complex domains. The analytical
approach adopted in the complicated domain does not
work in all cases because the osteopath is required to
stick to the analytical model. This is the typical
guideline-focused approach aimed to manage an
aspect of a disease on the basis of protocols derived
from research studies and established treatment
recommendations.54
On the contrary, the osteopath applying clinical rea-
soning in the complex domain has no model available
to predetermine all aspects of the process. Treatment is
directed to all components related to the patient’s adap-
tive capacity (eg, fascial system alterations, somatic
dysfunctions, behavioral habits) that emerge as clinic-
ally relevant for the patient’s presentation and state of
health. In the complex domain, both patient and osteo-
path can share a high-value experience, which can be
investigated through the patient’s narrative and under-
stood by decoding a metaphorical language: not just
what the patient says but what the patient does not say
and what the patient’s body language communicates.
The complex domain calls for the recognition of
system behavior patterns that may evoke adequate
models of salutogenic interaction with the whole
person. Consequently, it is up to the osteopath to under-
stand the complexity of the person–environment–health
system and use their skills to contextualize the available
scientific literature in their clinical practice. In
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particular, osteopaths should refer to research studies
that address the effects of OMTh and related manipula-
tion sources on physical parameters and physiological
functions involved in causes, maintenance, or aggrava-
tion of different disorders.
Clinical and diagnostic reasoning must be better
understood and incorporated into osteopathic practice
and education to ensure patient safety and optimal
care.56 Osteopathic educational institutions should
actively promote the basic understanding of the dual-
process theory and facilitate this process. The institu-
tions should also include case-based learning
approaches during training and postgraduate mentor-
ship programs to reinforce the acquisition of clinically
relevant patterns (Table 2).56 Because decision-making
habits of osteopaths remain relatively unexplored, it is
necessary to design experimental and qualitative
research to obtain a common framework and develop
teaching programs and clinical practice.55 Therefore,
as proven by other health-related practice research such
as ergonomics,57 the CF could also be a powerful tool
for advancing decision-making processes and establish-
ing practiced based in complexity science in the field of
osteopathy.32
New Complex Perspective in
Osteopathic Research for Best
Practices
The CF was originally developed as a tool for decision-
making processes in management. Although occasion-
ally applied to health care,34,52,57,58 the CF has not
been implemented in medical research and practice, to
our knowledge. The CF is no substitute for solid scien-
tific solutions to the consequences of complexity, but it
provides a common reference language and conceptual
framework to discuss complexity and draw conclusions
regarding insights, decisions, and actions.32
In a 2017 article, Kerry18 noted that “clinical practice
should be based on best evidence, and an era of clinical
freedom should not be returned to.” Kerry also claimed
that “limitations of existing approaches to clinical
research can be re-examined and reconceptualized.”
Complexity principles can be endorsed to propose a

Table 2.
Allostatic Overload Index Involved in the Decision-Making Process in the Practice of Osteopathya

Identifiers Examples

Markers

Biomarkers Neuroendocrine, metabolic, immunologic markers42,43

Psychomarkers Body perception questionnaire-short form44; depression, anxiety and stress scales45;
salutogenesis index (sense of coherence questionnaires)39

Life markers Social Readjustment Rating Scale46

Self-Regulation Systems
Functional Tests

Biomechanical Postural control test47

Neurologic Manual assessments of central sensitization48 and autonomic nervous system tone49

Respiratory-circulatory Manual assessment of respiratory motion50 and examination of the amplitude of the
peripheral pulses, considering its relationship with arterial stiffness49

Metabolic Gastrointestinal distress signs49

Psychosocial Waddell signs51

a
Manipulative care provided by foreign-trained osteopaths.

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new research vision in osteopathic and other pro-
fessional practices. The core elements include a
reexamination of what constitutes best evidence in the
osteopathic clinical decision-making processes and
health policy. Clinical reasoning and decision-making
processes associated with clinical practice build on the
foundation of evidence-based best practice to achieve
59
evidence-informed competence. Using research to
inform practice can increase accountability and trans-
parency in decision-making processes, which will be
helpful to better determine which interventions are
likely to produce the desired outcomes and ensure
that osteopaths’ decisions are informed by the best
59
knowledge available.
In line with a humanistic framework, patients should
be at the core of future studies. Forthcoming research
agendas should be focused on transdisciplinary studies
that consider the humanities and involve stakeholders
to expand research context and theories. The complex-
ity of clinical practice exposes the empirical and philo-
sophical limitations of current methods. Clinical
practice provides a context in which additional sources
of evidence can and should be scientifically examined.
For instance, in 2018, the Italian Register of
Osteopaths proposed a list of core competencies for
osteopaths, focusing on specific activities, such as the
promotion of health through OMTh based on adapta-
23
tion. To provide a longitudinal index of the impact
of osteopathic interventions on health promotion and
maintenance, future research through prospective longi-
tudinal studies must include measurement of the self-
39
regulation systems activities, a sense of coherence,
and examination of the allostatic load battery.42,43,60
It is time to create an ambitious research program to
effectively establish a person-centered and evidence-
informed framework for the practice of osteopathy.
Conclusion
Today, health care systems are promoting a more holis-
tic approach to person-centered care by considering and
empowering the whole patient.3,8 Like the foundational
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role of primary health care, osteopaths should support
patients who are not motivated to care for themselves
and teach them to recover trust by providing an
appropriate process of care.61 Complexity thinking
adds a real world, multidimensional appreciation of
the system’s density and dynamics, but it does not
make it easier to effect change. Through interdisci-
plinary work, it should be possible to identify ways
to create richer and more valid forms of evidence-
informed knowledge.
Osteopaths should follow the osteopathic medicine
model in the United States and closely monitor the
practice of OMTh. However, if appropriately imple-
mented, the mindlines model should enable osteopaths
to provide expert guidance and to empower patients.
The time has come to create a health system that con-
siders the expectations and needs of the community
through the social context of a personalized and
evidence-informed practical approach.
Acknowledgments
The CF is a useful tool to renew the principles of osteopathy and
contextualize it in contemporary health systems; thus, we are
grateful to Stephen Tyreman, PhD, for introducing the concept
of complexity science and CF in the field of osteopathy.
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