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.

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

On the subjective nature of pain

Image Credit: “Inverted qualia of colour strawberry” by made by Was a bee. – Original strawberry’s image is from Image:Fragaria_Fruit_Close-up.jpg uploaded by User:FoeNyx,and original man’s image is from Image:Munemitsu Mutsu 2.jpg uploaded by User:Ueda.H,and I User:Was a bee combined it in one image.. Licensed under CC BY-SA 2.5 via Commons – https://commons.wikimedia.org/wiki/File:Inverted_qualia_of_colour_strawberry.jpg#/media/File:Inverted_qualia_of_colour_strawberry.jpg

Some things in life are definite. Some are definitely not. And some are somewhere in between.

Same goes in healthcare and medicine. When you see a hyperactive deep tendon reflex or produce an upper motor neuron sign via Babinski or Hoffmann’s, its pretty obvious. Usually, there isn’t much debate about its existence. There may be some back and forth about the degree to which it exists or to its implications; but, again, most parties will agree “that just happened.”

Same goes for an infected wound. One look, maybe one smell, most people can agree about the degree of bacterial colonization (i.e. infection or no). We can take this further with abnormal heart sounds, clubbing of the digits (indicative of lung/heart disease), or yellowing of the sclera indicating jaundice. The list can go on, but it doesn’t need to. There are a host of objective signs that indicate the presence of disease or pathology. We can even go further with laboratory diagnostics and imaging studies to attempt to confirm or rule out suspicions about the presence of a disease processes.

We have quite a body of information and resources at our disposal when trying to figure out what is wrong with the patient sitting before us. Even more than that, we have gained enough knowledge to decipher and utilize people’s reported symptoms, their subjective report, to aid in this process. As fraught with bias and inaccuracy as an individual’s own perception of their situation could be, we still have found ways to weed through the minutiae and find bits of key detail that aid in the diagnostic process. It could be how long their symptoms have been present, or what activities exacerbate their symptoms. You might ask, “Do you have any popping or clicking? Or feelings of instability?” Or if the patient reports numbness or tingling in a certain area. All of these details paint a little more of the broad picture of the patient’s condition. And one of the most helpful details when painting that picture

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

http://2.bp.blogspot.com/-mayPxpjVzes/U-y_PpjFEzI/AAAAAAAABA0/9NntkiP_fsk/s1600/A9RBABA.jpg

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?

Five Days of Fallacies: Day 3, Irrelevant Appeals

Five Days of Fallacies: Day 1 here, Day 2 here, Day 4 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.

Irrelevant Appeals are seen often when someone is trying to persuade you. This can be during an argument, debate, casual discussion, sales pitch, etc. The irrelevance is to the point at hand, it may seem like an important retort, however, it has no bearing on the facts. Some examples:

Appeal to Antiquity: The idea is valid, because it has been around for a long time. “This is traditional natural medicine, it was done this way for 2,000 years,of course it’s valid.” Well, many old ideas and practices are bad. The antiquity of an idea has no bearing on it’s usefulness. Bloodletting, lobotomies, acupuncture, essential oils, they are all old, right?

Appeal to Novelty: The opposite of above. “The newest thoughts on how to treat X are ABC.” The newness is irrelevant, but it seems better, right?

Five Days of Fallacies: Day 2, Complex Question

Five Days of Fallacies: Day 1 here, Day 3 here, Day 4 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 Complex Question Fallacy is in the family of Fallacies of Presumption. It makes assumptions, thereby defining the conversation and the result of the outcome, when asking a question.

An easy example of this is seen here: “When are you going to admit that you lied?” You cannot say “Right now” because that is an admittance of lying. If you say “Never!” you uphold the assumption that you lied, and that you are just not admitting it. Lose lose.

How does this show up in the clinic?