STARES WEEK THREE: Communication

Situation: I received a referral for a patient with chronic low back pain. The patient is in his 50's. On presentation he complained of pain in his lumbar spine and a broad pain in the lateral aspect of the thigh. The onset was insidious dating back 2 years ago. He has been working as a gardener three times a week for 5 hours a day in that time and was frustrated that he has been unable work more due to his back pain. Aggravating factors at work include lifting loads and bending. Pain is eased my sitting. After half an hour of work he needs to sit down as the pain is too severe and it takes 5-10 minutes for the pain to ease. The difficulty in communication was due to the fact that his primary language is Cantonese and although he does speak some English he tended to repeat himself and focus on how work has been so frustrating.

Task: To perform a subjective and objective assessment that was not only effective but safe.

Action: I had to make sure that I spoke clearly and precisely. I established early that it was going to be difficulty getting as much information as possible from the subjective so I decided to focus getting the basics first. Finding out where his pain was, what aggravated it, what eased it, how long its been going on for and making sure that an objective assessment was going to be safe to perform. Where I could I tried to use gestures to help. I overall had to spend more time on the assessment part of the session to get an understanding of the problem that I would normally.

Result: It was difficult to even get a basic understanding of the problem from the subjective. The body chart and aggravating factors were the two areas of the subjective that were most difficult. Even though I knew the general area of pain in both his leg and back he had difficulty understanding the concept of specifically mapping out the area of pain and couldn't really describe his pain. Nor did he have an understanding of what I meant by how bad the pain was. I was able to determine the aggravating factors to the pain but trying to get more information about them was hard. I didn't really know what part of lifting was hurting him and what the duties at work were the worst for his back. When performing an objective in the musculoskeletal setting it is important when finding the source of symptoms that we ask the patient "is that the pain you've come to see me about". Many people have pains that are not those they are complaining of but could be a contributing factor or a different problem completely. The barrier in communication meant that although I was finding structures that were painful but I didn't know if this was his main pain. Nor was I able to find a true asterisk motion segment in the lumbar spine because multiple levels were sore and he was unable to tell me which one was truly worst. Generally getting him to perform different movements was also difficult.

Evaluation: Overall I don't think I did all that well in this situation. As much as he was repeating himself I was probably repeating myself. I found it really difficult to get my messages across which meant I didn't have all the information I wanted from the subjective. I was able to get a basic understanding of the problem from the objective and eventually was able to determine which direction of movement caused his pain and what level seemed to be the worst from the way he reacted to my palpation. In saying that it meant that I had to spent a lot of time with this particular patient.

Strategies: I think next time rather then asking opened ended questions I should delve more into the aggravating factors about questioning him about certain things. Whats it like walking uphill? Downhill? Gardening above your head? and other questions of the like. Using visual cues and the reactions of the patient is also beneficial. Bentley Health Service also have the option of the interpreter so I think that if it is still too difficult next session I may have to go down that path. My hesitation to do so is that I think it makes it difficult to build rapport with the patient but I guess at the end of the day getting a true understanding of the problem is in the best interest of the patient and if communication is a barrier then it should be addressed. Hopefully my second session with the patient will be more successful.

STARES WEEK ONE: Assessment

SITUATION: Working in a musculoskeletal outpatient setting I received a referral from a local GP for a patient that suffered from neck pain and migraines. The lady was middle aged and had suffered from this neck pain and "migraines" for 25 years. The pain that she described was an ache that starts in the neck, usually on the right, and expands into the head unilaterally to behind the eye. She highlighted that the headaches were mainly on the right but occasionally shifted to the left in a separate episode. She had only described an aura on one occasion but most headaches were not associated with such a symptom. Occasionally she experienced nausea but had never vomited as a result of the headaches. Aggravating factors for the headaches included lack of sleep and stress. The only easing factor identified was the use of Imigran, a prescribed pain medication. By the end of the subjective there was significant evidence to support that this patient suffered from cervicogenic headache, so an appropriate and thorough objective examination would be able to confirm or deny the diagnosis.

TASK: Perform an objective examination for this patient to rule in or rule out cervicogenic headache.

ACTION: The objective examination included observation, palpation, active movements of the upper cervical spine, overpressures and combined movements in an attempt to reproduce these ladies symptoms. It was also important to highlight to the patient the reason for wanting to reproduce her pain and that as soon as she felt her pain to let me know as to not create fear and unnecessary discomfort.

RESULT: The patient had a classic "chin poked" posture. The asterisk sign from her active movement examination was right rotation which was limited to half range. There was no pain reproduced with active movements or overpressures. I decided to perform a combined movement exam but unfortunately the symptoms could not be reproduced. It was at this stage that I was starting question the suspected diagnosis aswell quality of my objective examination. Having still not found where the patient's pain was stemming from I performed sustained movements of the upper cervical spine. Again this offered no answers. I moved on to the muscles around the neck. The patient had a decreased ability to recruit her deep neck flexors so I thought that this could be a contributing factor to the problem but without the ability to reproduce her symptoms I didn't have a distinct answer. I decided that I would go to my supervisor and explain the situation. He suggested that I try a more aggressive palpation of the musculature around the cervical spine. Palpation of sternocleidomastoid turned out to be the asterisk sign with pain reproduced with palpation of the muscle's origin.

EVALUATION: Even though it took me a while to find the patients symptoms, I felt like my examination wasn't too bad. Each test that I performed stemmed from the result of the previous test and I progressed examination with each test. One aspect that was done poorly was that I tended to focus on the joints of the cervical spine, disregarding the musculature. When the patient performed deep neck flexor recruitment it was evident that sternocleidomastoid was working overtime. I thought that this could be a contributing factor but never really considered that it could be a direct source of symptoms. Reflecting back on the situation the fact that right rotation was limited further supports tightness in the right sternocleidomastoid so one group of tests that could have been beneficial in this case and which were not performed were muscle length tests. I learned from the situation to consider more that just joints as a source of symptoms but consider muscle and all other relevant anatomical structures that could produce pain when performing an objective.

STRATEGIES: Consider all anatomical structures when performing an objective examination and make sure that palpation is specific and directed towards those structures that are likely to be the source of symptoms.

Initial Entry Ist Placement 2010

I'm thoroughly looking forward to my placement at Bentley hospital. Although I had a musculoskeletal based placement in my second year of studies, this rotation allows me to integrate all that I have learnt about the periphery and in particular the spine, and apply the principles to real patients. I feel that by the end of this placement I should be ready to step out into the workforce and work in a musculoskeletal setting. I think this would be the expectation that my supervisors will have and what we will be working towards.

As I am working in a public hospital I think the patients presenting to the clinic will be quite complex. I'm expecting many will have comorbidities such as diabetes and obesity as the demographic will generally be from a lower socioeconomic profile. This will challenge my clinical reasoning skills but I am excited at the prospect of developing this aspect of my profession.

The structure of the placement will probably change as the weeks progress. I think that as I get more practice and improve with my assessment, treatment and clinical skills the amount of supervision that I have will reduce. Initially I may have to consult my supervisor after each the subjective and objective so that they can make sure that I am covering all that I need to to make an educated diagnosis. I suspect that if they feel I can conduct a safe and appropriate assessment and produce an effective treatment plan they will wean their supervision and allow me to work more independently.

The thing that I am a little concerned with is time management. If conducted properly there is a lot of information to gain from a subjective and objective assessment and the more complex a patient the more information there is to get. The ability to get the right information, clinically reason through it and treat the patient in a limited period of time is definitely a skill in itself and one that I think comes with experience. Therefore I am hoping that by the end of this placement I have improved on this skill and am able to conduct an assessment and treatment in a similar timeframe to a more experienced physiotherapist.

Overall I'm looking forward to being able to manage my own caseload and improve on my clinical skills so that I am best equipped to step out into the workforce at the end of 2010 if i were to choose to go down a musculoskeletal path.