Clinical Kit - 7 Mistakes to Avoid Part 1

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A difficulty expressed by newly qualified clinicians when conducting their examination, is knowing what to do next. What do I mean? Well, we are told that we live in the "Information Age", but I think that we have well and truly roared through it. Basically every test, procedure or disease - our body of knowledge, can be found on the internet. All the information is out there in a variety of forms. In the same way a client is the internet - they have all the information. We are now in the "Synthesis Age." As clinicians, we need to type in the correct search parameters (know the correct questions) and be doing this in a logical sequence, thereby adding or subtracting to our clinical hypothesis. We need to be "physiosleuths" or "chirosleuths" before we can be "physiotherapists" and "chiropractors".

While titled "7 Common Mistakes to Avoid", this newsletter really is an overview of areas that newly qualified clinician's can reflect on and benchmark themselves personally.
Thoughts like; Could I have said that better? Been more alert to the person's anxiety? Detected the cancer sooner? or Provided more detailed information.... so here are some suggestions to consider with your next client

Confirm Expectations

Not the title of a Charles Dickens novel, but never the less, a critical rapport building block. In simple terms, if you don't know what the client is expecting from you, you are unlikely to deliver. They may not be primarily concerned about getting rid of their pain; perhaps they just want to know if it serious, dangerous. Or the limited ankle movement is inconvenient but they want to know if they can wear high heels for a wedding. Often there is an emotional aspect behind seeking treatment. Determining this will assist in meeting your clients expectations (emotional) and their needs (physical). Also, by knowing their expectation you will understand their point of view. This means if it is inappropriate "I want to play this weekend," you have a starting point from which to educate them about reality, "tendon tissue has the poorest blood supply, so it is slower to heal & respond. We need to allow ..."
I often think of clients as blank TV screens that I need to clearly paint their clinical picture. I try not to take any knowledge for granted and start off on basic principals of tissue healing and known time frames. This means explaining the different aspects to their problem and this naturally leads to the solutions that will need to be addressed for a successful outcome. This provides me with a structure that usually works.

Functional Outcomes

I will talk later about physical examination and tests, but a youthful pitfall can be to zoom into a tissue, stage of pathology or negative bunch of biomechanical factors. They are necessary, but not usually to your client. They want to know big picture stuff - when can I start back on the motorbike, wake boarding, 18 holes of golf, picking up my child, wear high heels (not so big picture stuff...).
Informally this can be gained from a question like "if it wasn't for this injury, what would you be doing?"More formally it can be ascertained using a Patient Specific Functional Goal. This goal and a range of other outcome scales can be found HERE.

Consider Red Flags

The presence of serious pathology is suggested by;

pain that is worse during rest vs. activity
pain that is worsened at night
a poor response to conservative care including a lack of pain relief with prescribed bed rest

Serious etiologies related to spinal pain that include fractures, tumors, and infections are relatively rare; accounting for less than 1% of all medical cases seen during spinal assessment. In our case it is probably less, but they still present to us being primary contact practitioners. I am on the lookout for 3-5 tumors per year and consciously screening out the other pathologies during my subjective examination.
I use the F. I. I. T acronym to help me remember red flags for my specialisation examination. The "F" relates to fractures; overuse, traumatic or metabolic. The "I" relates to inflammatory conditions such as RA and the spondyloarthopathy group of ankylosing spondylitis, reactive arthritis, psoriatic arthritis and enteropathic arthritis. The next "I" is for infections and the "T" for tumors.

When conducting the history, isolated findings of;

failure of conservative management
unexplained weight loss
cancer history
age greater than 50

represent only minor concerns during the subjective examination. Conversely, occurrence of all four findings demonstrates a sensitivity of nearly 100% for identifying a malignancy. Similarly, an age greater than 50 and long-term corticosteroid use do not warrant immediate attention, however, when both factors are present, the likelihood of a spinal compression fracture is dramatically increased.

In the next eZine/newsletter, I will be discussing clinical followup, yellow flags, client's memory retention and over testing. In the meantime, check out our Clinical Skills Scorecard to see how you rate across a range of clinical indicators.

All the best,

Doug Cary FACP

Specialist Musculoskeletal Physiotherapist

email doug@aapeducation.com.au

ph/fx 08 90715055

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