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The magic of assessment

 

“We haven’t done much on treatment”. This is common feedback that we receive every year from Physiotherapy students about to go on placement for the first time. Often followed by we don’t know how to treat “a shoulder” or “ a knee”. Apart from the obvious annoyance on our behalf that 1. The person seems to have been forgotten in this- that they are not a condition, but a person who happens to have a knee or shoulder problem and 2. That there is much more complexity about the condition itself- not all painful knees are the same, there is also a heart sink moment when you realise that the students have missed all the good stuff about a decent assessment which then lends itself to an individualised, personal and unique management strategy.

Actually, this is not unique to pre-registration students. Often social media discussions start with questions such as “does anyone know the best way to treat lateral hip pain or cervical radiculopathy? With responses such as “oh try cardiovascular exercises”, or “I never find manual therapy any good for treating these”. Difficult, I get it, to have a deep and meaningful discussion about how best to manage patients in 140 characters, but are we still trying to find the panacea on treatment of conditions?

There seems to be some sort of paradox of practice where on the one hand we have embraced the use of psychological strategies to best engage with our patients, to enhance practice and ensure a stronger patient: therapist relationship and yet at the same time many still believe that there is a specific way to treat a condition. This is quite a medicalised view of the world- if there is a lump, work out if it harmful, if it is cut it out. This is quite a simple solution to a “not too difficult to define problem”, and as for the patient who wouldn’t want a lump cutting out? The point is this, that most of our patients don’t come with a condition which is instantly recognisable, and which requires a simple and effective way to treat them because most of our patients are living with a condition which requires careful, considered and skilled assessment and individualised management (yes the person with the lump still needs this care too, but you get my drift).

You may at this point be wondering what on earth this blog is about, so I will simply cut to the chase if you aren’t with me and say this: this blog is about the magic of the assessment of the patient. The detailed, empathetic, discourse that you have on your first (and subsequent) encounter/s with the patient. It is about how you use the subjective examination to build your relationship, guide and plan a specific, targeted physical examination, building up your hypotheses and proving/disproving as you go, and from these planning a unique, individualised management strategy.

This is not a new concept, it is part and parcel of our undergraduate education – look, listen, question, use clinical tests and formulate your hypotheses. We have for some time in our pre and post-registration courses at the University of Brighton advocated the use of Mark Jones’s clinical reasoning hypotheses (Jones, 1992). Before some of you roll your eyes and go “oh not that old chestnut again”, it is really worth re-looking at this system of gathering evidence to prove and disprove your hypotheses. It enforces you to capture not only the findings which signal pathological processes, or pain mechanisms, but to consider, with equal weighting, the words that the patient uses to better understand their lifeworld. The version I have referenced is the older version, so see here for a more updated version (Jones, 2006). I think it is worth looking at the first model though as it gives a lovely overview of clinical reasoning and puts the categories into perspective.

The essential first step to gathering the information so necessary to work out these hypotheses in the first place is of course to talk to the patient in front of you. The subjective examination is, in my opinion, the most important aspect of the whole examination, and essentially predicts the patient’s outcome (powerful words, and no I don’t have specific evidence, but I have seen enough terrible (and wonderful) first encounters to know how it ends!) I am not going to discuss in detail the way in which you ask your questions, or the approach you use, far more eloquent and clever people have wonderful ideas on how to best communicate with your patients (see Chester et al., 2014  King and Hoppe, 2013 and a great YouTube series on motivational interviewing (motivational interviewing). My focus is not on the skill required to access the information, but on what to do once you have it.

Ok, how about a clinical example of this. A patient (let’s call her Brenda) comes into see you with right sided cervical spine pain with some pain into the lateral aspect of her arm to her mid-forearm. “A cervical radiculopathy” I hear you all shout. But of course, you would be wrong because she is a person NOT a cervical radiculopathy, OK so putting that aside I hear you all shout, “a person with a cervical radiculopathy”. So, better, but still you have jumped far too quickly into making this assumption (you know what I am going to say)- a prime example of “faulty” pattern recognition. Many of us are guilty of too early a judgement on what the primary source of symptoms or pathobiological mechanisms are, and this is probably alright as long as you are open to being wrong (Kempainen et al (2003) see table 1) . However, combine a too early diagnosis with a focus on treatment (“how do I treat a cervical radiculopathy”), then we are likely to have an unsuccessful outcome. Worse still (although not for this person) we then spiral into delving into different tool bags to treat “the cervical radiculopathy” in all future cases of people with seemingly referred arm pain which inevitably all fail, so we give up. And that is the end of that, but not for long (Horrible Histories fans, I hope you spotted that!), as of course we then feed this lack of success to managers, more junior members of staff, students and the masses on social media waiting for an answer to an impossible question. The grand conclusion of all of this being “Physiotherapy does not work”. This conclusion may then be supported by the lack of any decent “evidence” as no RCTs have found statistically significant improvements of x over y with a large enough effect size with a clinically meaningful effect.

So let us go back to Brenda. Brenda finds that the arm pain is indeed linked to the neck pain (it hurts at the same time, the same aggravating factors make both areas hurt, both started at around the same time- after painting her newly extended kitchen ceiling). She finds looking up and turning to the right brings on both her pains and that the pain then hangs around for a few seconds before relinquishing back to a low, rumbling 2/10 on the NPRS. She has had a history of a sore neck over the past 20 years (when she was around 40) which was really helped by seeing the chiropractor but then someone told her that she shouldn’t go anymore because it would make her worse as she probably had weak bones now. Anyway this feels differently to that old pain, and she knows it is because of her worn out bones in her neck, so what is the point of getting someone to click it for her? She is pretty sure it won’t get any better because she is “over the hill” and although she would really like an operation on it, she doubts anyone would bother because you have to be young and fit to get an operation like that on the NHS.

Meanwhile Jonathan (30 years), the new registrar on cardiac surgery has been complaining of right sided neck and lateral arm pain after performing cardiac surgery on a patient which lasted around 10 hours. Or come to think of it might have been after his last intensive British Military fitness training session (both happened on the same day). He woke up with this terrible pain down his neck and his lateral arm. Both come on together most of the time (esp if he turns or tilts his head to the left), but his arm pain is made much worse when he reaches his arm out quickly. He has had physiotherapy in the past for various sporting injuries (ACL tear in his knee, ankle sprain, shoulder dislocation), but all resolved well, and he is happy that this will quickly resolve too.

For good measure let’s have Tracy, the 45 year old shelf stacker from a supermarket near you. She has had a long standing history of neck and R sided arm pain after a RTA 10 years ago. More recently the pain has got worse and might now be spreading to her left arm too. It might have been made worse because of having to lift her grandchild who has cerebral palsy, but is getting a bit big now (he is 5) and wheelchair bound. Her daughter isn’t able to look after him anymore because of having the new twins, so when she isn’t working he stays with her most of the time. She notices she is tired a lot of the time (isn’t everyone?) and has general aches and pains (“her age”).

Ok ok I know what you are going to say – “you have picked three very different people, of course we would manage them differently”. The point is this, at first glance they may have a cervical radiculopathy, and yet all 3 have very different narratives, and are likely to respond to very different management strategies. This is before we have even got on to the physical examination. Brenda is likely to need a lot of reassurance, but also she has little hope for her future, and her beliefs about surgery (possibly being the only thing that would help, but she will be denied it) are likely to hold her back (see Linton ,2000; Nicholas et al., 2011). Jonathan has so many positive prognostic factors he is practically running out of the exit saying “Hurrah for Physiotherapy- cured again!” (see Bialosky et al., 2016 re expectations of Physiotherapy). As for Tracy, she has so many social factors (see Shaw et al. 2013) as well as something like chronic fatigue syndrome, what on earth can we offer to her?

So before we get to the Physical examination, our own beliefs about the outcome are already influencing us, and possibly starting to lead us down a path of management which may or may not be adaptable to change based on our findings. Now, I am not saying hold back on those thoughts and dispel any hypotheses until all the information has been gathered. Indeed, the knowledge you have gained from the patient during the subjective enables the bright eyed, smart Physiotherapist to adapt their questioning, their language used during the physical examination, and of course the choice of tests which are carried out in the Physical examination. This is important stuff, but I am saying don’t let it bias you to jump the evidence gathering in the Physical examination and make a decision solely on the subjective (I have actually almost gone full circle as I did say at the beginning, the subjective was the most important aspect of the whole interaction with the patient- I still believe it is, if used with appropriate care and attention).

Let’s imagine now that Brenda when asked to do AROM has (expected) pain in her Cx spine and arm during extension (1/2 ROM) and right rotation (~15 degrees), her neuro reveals a slight loss of pin prick in the C6 dermatomal area, her upper limb neurodynamic test (ULNT) 1 is negative (i.e. whilst some pain is reproduced during the test, it is not altered with structural differentiation), and she has both her pains in the neck and arm on right unilateral PA accessories to C6 esp with a ceph inclination. On reassessment (this is essential to see the impact of the examination procedures on the patient’s pain) her ROM of extension is now ¾ ROM, right rotation ISQ but only pain in the neck, neuro ISQ. The PAIVM is repeated for 4 x 30 secs (based on aiming to reduce pain via descending inhibitory pain pathways see Pentelka et al., 2012) in neutral. On reassessment Cx extension is now ¾ ROM and RR has increased to ~ 20 degrees with no arm pain, but neck pain.  Brenda is delighted that just wriggling her bones about a bit has made such a difference, and wants to know if she can do something similar for herself at home. I think I need say no more about the shift in prognosis that such a result would induce. That isn’t to say that Brenda now is predicted to be 100% better in 3 treatments, and that she won’t require a lot of time dedicated to her perception of her age, recovery, treatment options etc, but perhaps her hope and expectations of treatment may be enhanced. I am also not suggesting that PAIVMS alone (either given by the therapist, or done by herself at home) are going to cure her, and may indeed only be used in the first couple of sessions alongside a multimodal package of care. The point is that Brenda is unique and deserves a detailed, thorough examination and individualized management strategy.

What about Jonathan? Let’s imagine he has slight restriction in his left lateral flexion leading to some right sided arm pain, normal neuro, positive ULNT 1 (Cx lat flexion (arm pain 3/10), sh dep, WE, SUP, ABD, EXT ROT, EE -45 degrees increased pain in arm, relived by lat flexion to neutral). PAIVMS reveal slight tenderness over C5 and C6 in Cx lateral flexion. On reassessment all markers ISQ. So he is asked to perform a tensioner ULNT to onset of arm pain 15 reps x 3 (there is no clear accepted treatment doses for neurodynamic treatment, this dose comes from (Nee et al., 2012 ). On reassessment his Cervical ROM was the same, but his elbow extension in the ULNT was -30 degrees with arm pain. Again, this does not indicate that he will only require neurodynamic tensioners for his treatment, but it indicates that the first line treatment will be very different to that of Brenda

Tracy has pain on all movements of her cervical spine, all resulting in uni or bilateral arm pain. Neurological integrity is not significant for loss of function, but she has widespread bilateral hyperalgesia to pin prick and allodynia on light touch. PAIVM assessment reproduces pain locally on all segments early in range. Elevation through abduction of both shoulders results in restriction to around 100 degrees resulting in pain of the cervical spine and respective arms, altering Cx spine lateral flexion makes the pain worse regardless of which side, wrist ext/flex was not remarkable, indicating tests for nerve mechanosensitivity would not be useful. All of this indicates a more central mechanism as a driver for her pain (see Nijs et al. 2014). Tracy reports that whilst everything hurt, she feels a bit better because she was taken seriously and was offered a proper assessment and for once someone explained “stuff” to her. Tracy will require a radically different approach to management than Brenda or Jonathan, where more focus will be needed on helping her manage the social aspects of her lifeworld as well as pain management strategies, but fundamentally she would just like to be heard.

So, what does this all mean? How do I now go back to my students and reassure them that it is ok not to have been taught every possible treatment technique for every possible condition? I simply say to them, talk to your patient and listen, really listen to them. Allow them to speak, and try to figure out what their man problem is, and what they really want from Physiotherapy. Find out their preferences, expectations and hopes. Work out the hypotheses from a physical, psychological and social perspective. Plan a management strategy based on all of these factors, make it up, be creative, but always have a reason for doing it.  Let’s never lose sight of the person in all of this. Let’s never give up on a thorough and detailed assessment and examination of the person. Let’s never follow some recipe based on your weekend course, the last systematic review or because “that clever bloke on twitter said so” because the recipe was never devised for Brenda, Jonathan or Tracy. Only you and the patient can devise that unique recipe.

Colette Ridehalgh