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:

Patient Education Binder

Visual aid with pt Ed. My imaging and pain concept binder v1.0 HT @AdamMeakins @paincloud1 … pic.twitter.com/RKippepias

— Matt Dancigers, DPT (@MattDancigers) April 29, 2016

Seeing is believing. It can be also expressed as “only physical or concrete evidence is convincing” which you surely have heard as a popular argument on many fronts.

Well, your patients are human, and thus, adding physical evidence to your statements or positions can aid in understanding and spur conversation.

Dr. Spencer Muro ( @SpencerMuro ) suggested that, when educating pt’s on pain science or imaging results, we use the above concept to corroborate our “claims.” Use visible evidence, not just repeat it verbally. Enter: The Patient Education Binder.

We used to show patient’s pictures of these images on our phones, but a print-our hard copy in large font is more useful and meaningful (personal anecdote). So we did not make these images, and I will give credit to the maker’s / authors of them. I asked The Sports Physio ( @AdamMeakins ) to tweet some of them, PainCloud.com ( @PainCloud1 ) produces great stuff, the rest are found on Twitter or a search engine. Disclaimer disclaimer etc.  (Most credit is available on the image itself). They are great representations of current understanding.

If they help us understand, why not share with your patient?

Pain is like the Wind

Pain is like the wind.

It can only be viewed by its interface with the environment. 

We see the trees move, the leaves rustle, the flower petals quiver. We see the thick dust in the air, the yard furniture toppling in a pile by the fence, the branches dropping to the street.

Our skin turns alive with an unseen pressure. We are urged to move to the left by an unseen force from the right. It blew my hat off.

“I cannot take a picture of the wind. I can show you a picture of a windy day… but not the wind.”

A Year In Review: II

We have seen large changes over the past year from personal perspectives here at the PTBT. The posts have continued… a host of topics following our varied and changing interests.

The transition from student-blogger to practicing-clinician-blogger is an interesting one. You must walk the walk. Cerebral idealism, philosophical concepts and metacognition are affronted by the real world N=1 scenarios, workplace pressures, time constraints, technique and exercise challenges and more comorbidities than you can shake a stick at.

“You wrote about how you should interact with this type of person/case, now they are in front of you.” Writing and reflecting on how to treat has kept the ship pointed in the right direction. Through the process of trying to form a thought, and even a thought that another person might understand (we hope!) you develop a skill for reduction. Reduction to the fine points.

The Person Sitting in Front of You

Image Credit: https://muhc.ca/glen/feature/glen/gallery

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

image credit

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.

Who is Satisfied?

Image Credit

How are we going to do this?

In other industries customer satisfaction is part of the delivery, but not directly tied to product price. Companies are “paid” by happy customers with more business (referral, word of mouth, etc), or market leverage to increase the cost of service (increased value of product) with customers happy to pay that increase due to increased value, to them.

This works in a market system, where individuals are in charge of their monetary decisions. But that isn’t health care.

In a move towards payment for outcomes, where will customer satisfaction have a role? (we don’t know whether we will be paid better for better outcomes, or paid a set fee for an average expected outcome and it’s up to us to beat that average… who knows)

Is there any talk of adding customer satisfaction directly to payment? Sometimes that’s all we have. No significant change in patient status, but a very satisfied customer with the care, service, advise and input given. Perhaps they leave with an understanding of their condition, ways to manage it and strategies to avoid deleterious effects of their disease/dysfunctional process… but no change in ROM, strength or patient reported outcome measures.

Experience and the Experiment

Image Credit

“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….