It"s easy to treat pain when "x " marks the spot!
How often do we ask a patient to explain their pain? Possibly using a pain chart that is filled out and a pain score .Then questions related to the history and onset of the pain.
Is this a good basis of understanding the history, context and injury? Indeed what else could be contributing to the reason that person has walked , hobbled or limped through your door?
As podiatrists the foot is often our focus of attention and predominantly we are managing foot pain. There is a little problem here . The foot is attached to the rest of the body .So when we ask about a history are we being inclusive ?
Sometimes our tunnel vision can be limiting, and information that is provided by the patient is not complete because they "didn't think it was important for us to know ". Perhaps our information collection form creates confusion or medical language and definitions are used inappropriately. Using a systematic approach can minimise misunderstandings and miscommunication
1. Use full body illustrations as well to assist in collecting information
The suggestion when a full body chart is placed in your patient questionnaire is that the foot is attached to the rest of the body ! It also gives an opportunity for more details and other injuries whether related or not to be included.
- Look for mirrored pain patterns
- Note how the pain pattern is marked - using a dot, a cross, heavy marking or general large scale marking
- Beware of full body pain patterns - suggestive of CRPS
2. Visual Analogue Scale
The VAS can be a difficult concept for individuals to use . People have an opinion of pain, pain perception and their individual pain threshold. It is important for the VAS to represent a reference point of a moment in time.
- Use both words and symbols to assist in gathering information.
- Use the words "At The Moment", pain can vary according to the day, activity and time.
- Refer back to VAS to monition progress during the consultation if treatment is initiatied or in the review consultations
3. Words & Metaphors used in description of pain/injury
Listen to the words used . People can inappropriately use a term which get really confusing. Treating Achilles insertional tendinopathy when described as a "Bunion " is very different to a 1st MPJ pain.!
Metaphors and words can be an indicator of how entrenched the pain is and catastrophising of events, feelings, associations and pain.
"My feet are Killing me", "I hate my feet" ,"They are so ugly", "They feel like bricks" "They are as cold as ice" "It feels like ants are crawling all over them " "They are as itchy as hell". These words and metaphors can be indicative of the sensitisation of the tissues in addition to the injury and the possibility of CNS sensitisation . Start to think "Am I dealing with nerve, joint, soft tissue or a combination pain"
- Make sure if anatomical terms are used they are correct and relevant .
- Quote the words used as an indication you have been paying attention and use those words when reassessing the pain and progress
- Check and recheck the area /foot involved
4. Show me where it hurts.
Having gathered information ask the question :-
"Using your finger show me where it hurts "
Look for awareness , confusion or consideration
Is the movement specific/nonspecific? Is the finger used pointing at a structure , an area, the whole foot or leg or describing the pain as a line ? This will assist in the diagnosis. TIP - when the finger used draws the pain along a line think nerve involvement
5. What about the medical history ?
- The medical history if a good insite into the overall health and wellness of the patient -if the full medical history is revealed.
- Be investigative , ask the hard questions .
- Chronic disease history, autoimmune disease, previous illness, injuries and medications can have a significant impact on your treatment , treatment outcomes and management
HOW, WHAT & WHY Approach
The words HOW, WHAT & WHY are helpful when pulling information together and communicating back to the patient.It will show your understanding on "what " the pain is ,"Why" it has occurred and "How " it can be managed.
Minimising miscommunication can save you time , embarrassment and frustration. People in pain may have had varied experiences in treatment and results. Their history -medical,family, social - can all influence the treatment outcomes and should be taken into account when making treatment choices
Be careful with your choice of words. Words can be helpful , threatening or harmful.
Optimising your treatment starts with your first contact, words and ability to gather information.
In up coming posts I will be discussing more patient management concepts with particular emphasis on pain and treatment options and interventions.
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Be Optimised . Be the best your can be.