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:
- What does this exercise do?
- How does that help the problem?
- Is it medically necessary?
What does this exercise do? (AKA: Base Level Understanding) What soft tissue structures does it tension? What muscles are used and what muscles are challenged? What angle and force is the external load coming from?What glide is occurring on the joint? What body areas are protected? The point is to know all of this prior to moving on to the next question.
Ok, now that you’ve stated what the exercise does- How does that help the problem? (AKA: The Clinical Reasoning Process) Here is the real test for everyone. Now this is where I’ll allow a lot of variation. I don’t think like you, you don’t think like me. If you can justify it, let’s give it a try. I’m a big supporter of testing your thought processes, especially in the student affiliation realm.
You may justify a calf raise in the plan of a patient with chronic low back pain just to get them moving, reduce fear of what they think PT will be, or to use a plan of “work your way from distal towards the affected area.” Does fear-reduction help the problem? Yeah, I’d be good with all that. You may also give calf raises without hand support to challenge a patient with balance, adding movement and reducing their contact area to the ground with this motion. You may also give calf raises to a musculotendinous junction strain in a soccer player, challenging tissue tolerance to load and progressing strength. All good, but you had better know how that calf raise helps the problem.
Ok, now a sticky one. Is it medically necessary? (AKA: The ethics of the intervention) Something might be helpful, or fun, or part of making someone more powerful, but does that need to be completed in the medical setting? At some point, those calf raises need to be completed at home, not in the medical setting (except maybe that gastroc strain which may need extra tissue monitoring) It may be medically necessary to progress a load under our supervision, or to increase the balance challenge in this patient by adding head turns that require more guarding for your balance patient. We are not personal trainers, we are medical rehab providers and thus this question should be considered in your program. This may even be a good razor to trim your interventions to address the most impactful items.
The concept of Medical Necessity is one of perception with a lot of grey. Now there are certainly black and white examples, but a lot of what you think is important to work on, is, well, your professional opinion. See the link here for a short commentary:
Medically necessary: Who should decide? by R Collier, 2012.
This weeks challenge? Ask these questions of your students. Ask them of yourself and your own programming. Really know what you are doing. If you find that you’re not quite sure why you added something to the plan, it just seemed right or you did it because of habit, then review some anatomy, converse with a colleague or take a CEU course to re-ignite your thought processes.
Your world can change based off the questions you ask of it.
“Judge a man by his questions rather than his answers.” – Voltaire
“We make our world significant by the courage of our questions and by the depth of our answers.” – Carl Sagan