In this pilot study, qualitative methodology was used to examine the c
linical reasoning of four experienced occupational therapists as they
presented and modified therapeutic activities to treat patients with s
pinal cord injuries. The therapists demonstrated the multilayered thin
king discovered in previous research, but hierarchical structuring of
knowledge emerged as an unexpectedly dominant theme in their reasoning
. Examples of hierarchical thinking about therapeutic activity include
d creating mental files of therapy tasks and materials sequenced from
elementary to advanced and determining the level of difficulty at whic
h to present an activity in order to build the patient's skills in a s
tepwise manner. The therapists reported that they learned to make deci
sions about the use of activities in treatment by observing skilled cl
inicians and by treating patients.