clinical reasoning for spinal patient Flashcards
define clinical reasoning
thought processes used in patient diagnosis and management
model of chronic pain
psychological factors in response to acute pain are predictive of chronic incapacity
MSK clinical translation framework
individuals perspective individual problems functional capacity goals/ expectations Diagnosis: specific diagnosis non specific red flags
stage of disorder acute sub chronic recurrent
pain features
types - nociceptive neuropathic nociplastic missed
characteristics - mechanical /non
sensitisation - low to high
psychological characteristics cog affective social low to high
work considerations
workplace factors
low to high
blue flags
lifestyle considerations
lifestyle factors
low to high
whole person consideration
general health and co-morbidities
functional behaviours helpful - protective unhelpful - provocative impairment of movement impairment of control pain behaviours reconditioning
clinical decision making
diagnosis
stages
important contributing factors
MSK clinical translation framework
individuals perspective
individual
key questions
main problems?
pain function QOL?
functionals capacity
how do problems affects ADLs / QOL
what can you do?
goals/ expectations
addressed goals is important to align with PCC
early clinical reasoning categories
- diagnosis
- pain mechanisms
- red flags vs specific diagnosis vs non-specific disorder
consider source of symptoms - pain mechanisms - mixed mechanisms can co-exist concurrently
nociceptive - pain from acute or threatened damage to non-neural tissue and is due to activation of nociceptors
Neuropathic:
Pain caused by a lesion or disease of the somatosensory nervous system
Superficial, burning, shooting, within all or part of nerve innervation field.
+/- Paraesthesia or corresponding muscle weakness.
Nociplastic:
Pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors, or evidence for disease or lesion of the somatosensory system causing the pain.
subjective Ax
body chart behaviour of symptoms special questions HPC PMHx Social Hx - physical activity profile family Hx patients goals and expectations sleep patterns
body chart
Type & Area of current symptoms Pain, stiffness, instability etc Knowledge of pain patterns NB Quality of pain Severity & Frequency Irritability Abnormal sensation P&Ns Numbness Relationship of symptoms Hierarchy (usually label worst as P1) Temporal Continuity re. aggr. factors
somatic referral pain patterns
bone - deep nagging dull muscle dull ache nerve root sharp shooting nerve sharp lightning like sympathetic nerve burning pressure like stinging aching vascular throbbing diffuse
Pain - aggravating factors
mechanical
What activities / positions e.g. LBP - sitting, standing, walking, bending
How do individual structures handle ‘load’
severe enough to stop activity?
24 hour pattern
am
night - sleep position
EOD weekday vs weekend
easing factors
mechanical - activities / positions
drugs heat cold
mechanical vs inflammatory pain
SCREEN EM skin - psoriasis rash C- colitis, Crohn's R - relative - any family hx E - eyes uveitis, dry eyes., photosensitivity E - early morning stiffness N - nocturnal pattern, nails and no. of joints E - exercise response/ effect M- medication effect
behaviour of symptoms - OTHER
stiffness giving way / instability of spine locking clicks - painful / painfree weakness paraesthesia - sensory gain numbness - sensory loss deadness / heaviness
special questions
general health unexplained weight loss severe unremitting pain night pain cancer pain
spine - cord compression symptoms
cervical spondylitis myelopathy
LxSp: Cauda equina syndrome -gait saddle anaesthesia B+B symptoms
patient goals / expectations
symptoms tpainfree or less pain function = return to all activities or delay return until all symptoms are gone social - return to work/ sport / take time off
subjective Ax
Attune your language & approach to pt
Make sure pt understands the question
Listen & look – give pt your full attention
Make them feel you are not in a hurry, even when you are
Explore their fear; anxiety = pain magnifier
NB: Watch for signs of incongruity between what
they say & what you see – body posture, non-
verbal communicationExamine methodically – go back over doubtful points i.e. question again
Explain things clearly
Check patient’s understanding
Handle the pt considerately and with confidence
The 1st thing you say is what they will probably remember
Always be aware that the pt may hang on every word, facial expression & change of manner
Be careful of attempting to gain sensitive info in an unsuitable environment
reflection after subjective examination
Diagnostic Triage:
1% pts with spinal pain will have serious pathology e.g. tumour or infection
Identify other conditions requiring urgent specialist investigation & treatment (e.g. fracture, cardiac pathology)
Generate hypothesis for musculoskeletal diagnosis
Structures involved – articular / muscle / neural systems
If 2 pains – are they related or separate sources?
Pain mechanisms
Contextual factors – pain behaviour DRIVERS
Plan Physical examination –
Tests to be included
Priority areas for day 1
Precautions? e.g. SIN
Clues for Rx
