Week 3: Communication

Situation:
Patient A immigrated from Egypt four months ago. She lives alone with her husband in a single storey house. Patient A was referred to the outpatient clinic for reveiw and management of her left shoulder pain after two recent falls. One fall involved a bus door closing on her and the other "tripping over the kurb on the road." Patient A had recent x rays indicating no fractures and an ultrasound in which bursal inflamation, a supraspinatus tear and biceps tendon thickening were detected. Patient A was accompanied by her husband.

Task
To complete a thorough subjective assessement in which i would need a detailed pain chart, the history of the incident, any relevent previous injuries, a social history and a thorough medical screening. Before commencing my objective assessement my supervisor requested that i come and discuss my findings with him and inform him of my intended approach for my objective assessement.

Actions
I chose to start with the history of the incident. this required me to ask detailed questions about both falls. I not only required the details of the mechanism of the fall, but also the management of the injuries immediately after the incident. After i was satisfied with this history i progressed on to the body chart. I started with the left shoulder and then allowed my patient to inform me of the other aches and pains she was experiencing associated with the falls. From the pain chart i went into a social history. I asked about my patients current living situation, employement, hobbies and daily activities. After i had attempted to get a medical history, i informed my patient that i was going to speak with my supervisor and that i would return to continue the assessement very shortly.

Results:
From the start of my subjective assessement i knew that the language barrier was going to interfere with me retrieving the information i required to make an accurate diagnosis. With the assistance of body language and a lot of questioning i was able to obtain a clear history of both falls. The first real problem i encountered was on the body chart. My patient seemed extremely eager to inform me of all her aches and pains. It was however very difficult to distinguish which pain came from which fall. My patient had difficulty describing the nature of the pain. She did not understnad words such as ache, pulling, dull or sharp. With the assistance of her hands and facial expressions i was able to assume the difference between the three main pains that she was experiencing. Patient A also had difficulty describing the aggravating factors. She appeared to have difficulty conveying which activity brought each different pain on. All of the pains seemed to blur into one. Patient A gave me a very brief social history, in which she revealled she did not work but had been studying english at tafe untill recently. She did not reveal any hobbies and her daily activities consisted only of housework and an occasional visit to the shops. I had a lot of difficulty getting a medical history of my patient as she did not understand any medical terminology. My discussion with my supervisor took longer than expected. When i returned to the room to continue my assessement 15 minutes later, my patient had left and was sitting back in the waiting room with an angry husband. I apologised for the wait and after gaining consent again, directed my patient and her husband back into the treatment room.

Evaluation:
This patient was particularly challenging as i not only had a cultural barrier but also a communication barrier. When i was asking questions for my body chart i needed to make it clear that we would discuss one pain at a time. I feel this directed approach would give me more accuracy in my assessement and more detail of each different pain. As my patient was new in the country and was unfamiliar with australian culture and lifestyle i feel i should have probed into my patient's social, cultural and religious background a bit more. I feel this would enable me to engage with my patient and give me a better understanding of their 'pain' experience.The next thing i need to monitor is the explanations and instructions i give to my patients. My patient's husband decided that she should leave the treatment room as the session was completed. As i later discovered, in muslim culture the husband is the authoritive figure. Therefore i needed to explain to the husband who was waiting outside, that i was going to speak with my supervisor and that i would return to continue.

Strategies:
1: I need to identify that there is a language barrier early in the assessement and organise for an interpreter to sit in on the session and assist with the communication
2: I need to do do a more thorough social history to engage with my patient. In this case i had no understanding of their culture, religion or way of life. This information is crucial for me to gain trust from my patient and design an appropriate home exercise program for their lifestyle.
3: I need to be more specific with my body chart and work chronologically through each pain, rather than discussing them all at once.

Week 1

Situation
Patient A was referred to the Bentley outpatient hospital by the pain clinic with request for a graduated exercise program for ongoing and progressive lower back and right hip pain secondary to osteoarthritis and fibromyalgia. Patient A is on the disability pension and had an extensive medical history of depression, sleeping difficulties, vertigo, tinnitus, left upper limb lymphodema post left mastectomy in 2002, chronic ongoing pain over the left scapular region and narrowing of the c5/c6 resulting in a progressive right radiculopathy for the past fifteen years. Patient A underwent facet joint injections for her chronic lower back pain one year ago with no success. She is on numerous medications and regularly takes antinflammatories for her back and hip pain however has never previously recieved physiotherapy services. During the subjective assessement patient A described herself as an obssessive personality. She lives independently in a one storey house and recieves help for domestic activities from her daughter. She explained recent difficulties with her daily cleaning and vacuming regime as her daughter has returned to full time work, and her pain levels do not enable her to do the daily cleaning. Patient A has relatively low activity levels outside of her cleaning regime, she stopped gardening one year ago and only takes occasional 20 minute walks outside. Patient A explained the only two things that helped ease her pain was a forward supported sitting position with her arms fixed and heat. Objectively, i could not find a preferential movement direction during the active range of motion assessement. All movement was painful. Patient A had a slow waddling gait and a slight right trendelenburg. Sit to stand and stand to sit was slow and difficult with alot of assistance from her upper limbs and very poor quadricept control. Patient A also had difficulty moving in and out of supine as she could not move through sidelying due to her hip pain. I did not perform an accessory or passive physiological intervertebral assessement.
Task
To educate my patient on pain management techniques and discuss the goals and intentions of a graded exercise program. I then needed to choose an appropriate starting point for the mobility program in which the patient would be challenged but would not cause her pain levels to sky rocket.
Actions
I started off by educating my patient on different methods of handling her pain. I explained that it is better to take lots of breaks throughout the day rather than taking a bust boom approach and doing too much and then needing to rest for two days, i wanted her to take regular breaks before her pain peaked. I advised use of a heat pack throughout the day and as her pain levels would usually increase mid day and throughout the afternoon, i suggested she break the day up with a hot shower. Patient A was concerned that "her leg joints were stiffening up and she was not getting enough exercise" as she could not walk on days when the pain was bad. I suggested an unloaded mobility routine she could do when the pain was restricting. I adviced foot pumps, active knee extension and hip flexion in sitting. I then needed to device a mobility program for her lower back pain. This was particularly difficult as all movement caused her pain to jump straight to a 7-8/10. I finally decided to put my patient in crook lying where she could do gentle lumbar rotation, flexion and pelvic tilts.
Results
Patient A agreed that she needed to break up her daily activities with more regular breaks howver she was concerned that it would be difficult not to let her pain peak as some days the pain would go straight to a 9/10 as soon as she commenced activity or before she had even started. Patient A was very happy with the seated lower limb exercises and responded well to the light lumbar mobility exercises in crook lying. She then informed me that it would be impossible to perform the lumbar exercises on her bed as it is a water bed and her couch is too small to lie on so she did not have anywhere in the house to perform the exercises.
Evaluation
I decided that i would somehow need to give my patient a means of objectively monitoring her pain scores and her breaks so that she could ensure her pain did not reach a peak throughout her daily activity. Patient A and myself her both happy with the alternative to walking when the pain was bad, as seated lower limb range of motion exercises would enable her to sustain lower limb flexibility without further increasing her pain. I did however have a conflict with the lumbar exercises. I knew the floor was not an option as patient A was currently unable to get down and back up from the floor. The only option i had was to change the position she performed the exercises in. I decided to adapt the lumbar flexion, rotation and pelvic tilts to a seated position. This required further feedback and correction of body position, however it was relatively pain free for my patient and she was still getting the same benefits from the exercise.
Strategies
1: I used a two point pain discrimination rule where by Patient A was only allowed to carry out activity or exercise if her pain was below or equal to 5/10. Once the pain got to 7/10 she needed to sit down, have a rest and apply heat if necessary untill the pain dropped back to a 5/10. This strategy will enable my patient to monitor her pain scores and stop her from letting the pain peak during activity.
2: Have the flexibility to adapt my exercises as necessary. This may mean a change of body position or a change of equipment. It is important that i make the exercises easy and accessible to the patient, otherwise they will not be performed.

Initial Entry

One week prior to the commencement of my Bently Outpatient placement i have attended an orientation and made contact with my supervisor. As this is my second musculo skeletal placement, my own expectations have changed. I have increased expectations of my level of clinical reasoning, my time efficiency in managing my caseload and the accuracy and effectiveness of my techniques. During the orientation day my supervisor discussed our caseload and the plan of attack for the first week. I will be seeing on average two to three patients per day for the first week and consulting my supervisor inbetween my subjective, objective and treatment sessions. This is a lot more supervision than i have previously recieved on placement, it is also a much smaller caseload than i would normally manage in a day. I expect that my caseload will gradually increase over the five weeks and that i will become more independent with my assessement and treatment sessions.

As it is an outpatient hospital ward i am expecting to be seeing a mixed presentation of musculoskeletal patients, orthopaedic patients, maybe some cardiorespiratory and even postnatal patients. As in previous placements i expect to be constantly referring to text books and journal articles to reveiw the relevent material for the different presentations.

During my orientation day my supervisor went through our initial patient assessement form in thorough detail, explaining the detail he will be expecting. My supervisor explained that he is looking for a very thorough and accurate subjective and objective assessement rather than speed and efficiency. Throughout my previous placements my feedback has been consistent with excellent time management and clinical reasoning however i need to ensure that my assessements are more thorough and that i don't jump to a diagnosis too early. I am concerned that i am going to find this very challenging during my Bently placement as i will have more supervision and input from my supervisor than previously and i will be constantly challenged to dig deeper into the patient presentation and do a thorough assessment before i diagnose.

The Bentley hospital seems like a very friendly and welcoming environment, i have no concerns that i will enjoy my placement there. I hope that throughout this five weeks i can take my musculoskeletal knowledge, my clinical reasoning and my practical skills to a more advanced level. I am hoping to get a few complex patients to challenge my clinical reasoning, i intend to hone my soft tissue and mobilisation techniques and work on the depth and accuracy of my assessments.