The Three Question Test for Exercise Implementation

3 question test

One of the first tasks given to students on clinical rotation is to come up with an exercise flowsheet, or plan, for a patient they have just evaluated. This seems pretty standard in the outpatient orthopedic setting for students.

This task is often hard enough for many students. They work through it and I question their decisions and ask why they picked a certain movement. It’s harder than it sounds to predict how things will go and what they should work on. I always let them work on this independently at first, then we discuss their thought processes.

I’ve started using a Three Question Test for each item on the flowsheet. I’m not sure this originated with me, as I have been mentored by many and have picked up ideas from lots of smart folks. But here is the current question sequence:

N=1

N=1 has turned into a symbol,  a representation meaning to treat a person as an individual, as a unique complex being that has personal factors and history that make them who they are. (see the mountain stream analogy via Aaron Swanson.) When we speak about treating the person in front of us we can say “N=1.”

This is being championed by many groups. The “Pain Science crowd” certainly incorporates individualism and biopsychosocial constructs.  Cause Health is bringing awareness, and I’ll also recommend Neil Maltby’s blog: Becoming More Human.

Split brains and causation

There’s gotta be a reason. You can’t have an event pass by you without knowing why, right? Right.

“Well, you know, the weather made it hurt. It’s all that rain…”

“My back is hurting today, I was at a family BBQ and I stood for an hour yesterday, so…”

“The knee feels much better, I think it was the tape you put on there.”

Post Hoc Ergo Proctor Hoc. After that, therefor because of that.

Making a reason for things is not conscious, often. We always see cause and effect as a truth. If we’re wrong, it’s confabulation, not a lie. It’s “only human.” See a quote below from some of the Split Brain research:

The Person Sitting in Front of You

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I saw my patient walking up to the door as I pulled up to the clinic. A tall and very thin woman. She was heavily dependent on her rolling walker, I saw that immediately. It struck me. Saturday hours at the clinic were supposed to be simple post-op patients. Quick in and out’s. I think I was even slightly pessimistic at this first glance…because I could tell she was struggling. I estimated this was more work than I bargained for at 8:30 am eval on a Saturday. Four weeks status post a

The advice we give

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Do this drill: Ask yourself “Do you think that everything you believe or think about the world is the truth?”  (Most thinking people will say ‘no.’) Follow-up with this question: “What are you wrong about?” … hmm…

We often think our way of thinking and understanding the world is correct. Well, we always think we are correct and act on it, but we know deep down that, since we are human, we cannot always be right. This is besides the point a bit, but this post deals with our advice, our own beliefs in what we and others should do. Sometimes there is a disconnect.

I just want you to KNOW…

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I was getting sick. Ugh. I was able to hold off long enough to finish my caseload, but once I was home, I let my resistance to the bug go. My clinical crew knew I wasn’t feeling well, but I thought I’d be back by the next day.

Next morning: nope. I needed to stay home. I tell my wife I’ll be staying home as she leaves for work, “s’all good, honey.”

So I call in to the clinic to let them know.  When they answer the phone my voice changes a bit ( I notice retrospectively). I explain I’m worse *cough*, and thank them for arranging the schedule to cover me *cough*. Then hang up.

What was that about? I ask myself. I was not sure that I sounded sick, or did I?  Did I just throw in an extra throat-clear for emphasis? I realized that I felt a strong urge to sound sick, to “sell” that I wasn’t feeling well. My sickness was the truth. Yet, I was pulled very strongly to embellish it in my short 30 second interaction… hmmm.

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The purpose of communication is often to get a point across to some audience outside of yourself. You express yourself so others will know what you mean, how you feel, why you think, etc.

Experience and the Experiment

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“Dad, let’s do an experience” my 6.5 year old said to me this morning. “Let’s see how far away these walkie-talkies can go and we can still hear each other.”

“Do you mean experiment?” I ask. “Yes, ex-per-i-ment” she says. We go over its pronunciation a few times. It’s a mix between my daughter having no front teeth and that she just gets her word choices mixed up now and then. Experience. Experiment. It’s an easy one to slip up on, plus they could be viewed in the same category in her head. “I will have an experience and learn something.” “I will do an experiment and learn something.” Same thing, basically, to a 1st grader.

So, you can see this question coming: Do you get Experience and Experiment mixed up?

Cervical Artery Dissection: Implications for the Physical Therapist A Case Report from a Direct Access Environment

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Intro:

You receive a call from your friend and fellow DPT classmate to evaluate her neck… the patient herself is a physical therapist by occupation. A healthy and fit 29 year old female, 5’0″, 115lbs. She reports she is having some cervical musculoskeletal issues going on. She has an achy pain in the bilateral upper traps., levator scapula, and peri-cervical muscles. She is limited by pain with the following cervical motions: right side-bend, right rotation and extension. No signs of central or peripheral neurological issues.

You are an experienced PT and have completed many cervical manipulations on a patient like this and it’s the end of your day. So you are going to do a quick favor for a friend and manipulate her neck, complete some STM, and maybe some PROM/SNAGs/isometrics/METs or whatever your favorite manual therapy technique is. What could go wrong? She’s a therapist herself so she wouldn’t miss anything serious. Being that you are friends you want to do some “magic” giving her some relief of symptoms. So… snap, crackle, manip. You move into some PROM and she reports severe vertigo, nausea, double vision, and you notice hemi-facial asymmetries as she talks about her onset of symptoms. Now what?  Your table, your hands, your patient.

Five Days of Fallacies: Day 5, Fallacist’s Fallacy

Five Days of Fallacies: Day 1 here, Day 2 here, Day 3 here, Day 4 here. I have discussed  some common mistakes we humans make in reasoning, in the hope that you can 1) Understand what they are 2) Recognize them when others speak 3) Recognize them when you think this way 4) Attempt to correct your thinking on old, current and future ideas.

The Fallacist’s Fallacy (I like saying that) refers to an argument being refuted, simply because it uses a fallicious approach, not because the content is false. For example: “These old-school classic basketball shoes always hold up better.” (an appeal to antiquity). The argument commits a fallacy (they are old = they are better), but perhaps they are constructed with more craftsmanship or durable supplies, so the content may still be true. (*are we to assume more craftsmanship and better supplies make a better B-Ball shoe?!  Oh my, don’t let me make assumptions here!)

The Gambler’s Fallacy is also a nice one to be aware of….

Five Days of Fallacies: Day 4, Circular Argument

Five Days of Fallacies: Day 1 here, Day 2 here, Day 3 here, Day 5 here. I am discussing some common mistakes we humans make in reasoning, in the hope that you can 1) Understand what they are 2) Recognize them when others speak 3) Recognize them when you think this way 4) Attempt to correct your thinking on old, current and future ideas.

The Circular Argument, or Begging the Question. “Fascia is a tissue in the body that holds one’s emotions. I know this because the research I did indicates that releasing fascia results in released emotions. Therefore, fascia holds our emotions.”  In my opinion, these fallacies are very hard to understand and uncover in conversation. In circular arguments the conclusion of the statement is stated up front, and any statement after that simply restates the presumed conclusion.

Let me give a simple example: “Everyone is using METs at the hip because they are so popular right now!” Did you catch it?