Rotation 1 Fourth Year - Communication STARES

Situation
A 47 year old man was referred to outpatient physiotherapy at Armadale Hospital two months post a MVA where he sustained a neck injury. The car in front of him suddenly braked and he went into the back of it. He did not present to his GP for treatment until one month after the accident, he reported this was due to running out of the strong pain medication he had at home after previous surgeries. He didn’t have any insurance claims pending and there appeared to be no red or yellow flags.

Task
I was asked in the referral letter to assess and treat him accordingly.

Action
From the subjective assessment I found that the patient had a very long history of lumbar, thoracic and cervical pain and had cervical surgery two years previously. Whilst the cervical surgery minimally resolved all of the pains (thoracic and lumbar included), it was the MVA that brought all of the pains back again to intense levels. He did not know what would help to relieve his pain or what goals he had for physiotherapy as he believed this was the duty of the doctor and the physiotherapists to decide for him. He also had a very passive attitude to treatment. On objective examination he had widespread pain all over the back and he was unable to distinguish which pain was worse than the other. All movements of each part of the spine caused equal amounts of pain.

I therefore diagnosed the man with centrally dominant chronic back and neck pain and set out to educate him accordingly. I explained central mediation and its relationship to chronic back pain. I explained the impact the brain has on the pain experience. I explained that if it was just the injuries that were causing his pain, the surgery would have completely resolved his pain, however, it didn’t. I also explained that he may never be pain free and that working towards functioning with the pain may be a more realistic goal than being pain free. He said that he understood what I was saying and was happy to start an exercise program working towards functioning with the pain. I gave him some simple exercises staying early in range as he said that these were pain free and asked him to think about what his goals were to tell me when he returned the next week.

When the patient returned I asked him how he was feeling and how his week had been. He spoke about how bad the pain was and how nothing he did seemed to ease the pain. He expressed his frustration at not being pain free and that the exercises were doing nothing to ease the pain. I again reiterated everything from the week before, making sure that at the end of each point he understood what I was saying. I asked him to explain what I had said in his own words to ensure that he understood. He repeated what I had said and that he understood it all. I progressed the exercises and we went to make an appointment for the next week.

After ten minutes in the waiting room whilst waiting for his wife to pick him up he came to find me in the office. He explained that he did not want to return for the same thing the next week. I asked him if he meant that he would like to be discharged, he said no, that he would like ‘proper physiotherapy’. I asked him what he meant by this and he stated that he was in pain and that I should be able to fix the pain. I told him that I had already explained his pain to him and that he had told me he understood. I again asked him if he understood and he said he understood but that the pain was not in his head and he would like to speak to my supervisor. I said that I would be happy to get my supervisor for him and went to find him. My supervisor and I had a discussion away from the patient and he said that he agreed with me 100% and came with me to discuss this with the patient. I had to leave as I had another patient booked in, but my supervisor discussed the issues with the patient and reported back to me afterwards.

Result
My supervisor told me later that the patient would agree with what he said and then come back with the same issue that he had pain and we weren’t helping him get rid of it. My supervisor decided that the conversation was going around in circles and made an appointment with the patient for a week later. A week later it was revealed that the patients GP and surgeon felt the same way as I did and had already referred the patient to pain management, however, they had not explained to the patient why. My supervisor continued the education and eventually the patient understood. It was therefore decided by both the patient and my supervisor that pain management was the best route for him and he would be discharged from physiotherapy.

Evaluation
This situation really taught me about the polite patient effect and the importance of reading body language as well as verbal language. The patient was just agreeing with me to be polite although he really had very little understanding of the situation or what I was trying to tell him. I was also working against the doctors telling him that surgery would help him and then when it didn’t help not explaining why to him. Whilst the patient was saying that he understood something about his eye contact told me that he didn’t understand which is why I kept asking him if he did and to explain it back to me.

In the end there were also cultural issues affecting the situation and I should have had that in mind when I first met the patient. He was Middle Eastern, and culturally they have high respect for doctors, hierarchy and men. I fit none of these categories and so I was in a bad position to begin with. At least my supervisor was male and the head of physiotherapy outpatients so he had something to back him up in the eyes of the patient.

While I feel that I did my best in this situation and there were a lot of factors that I could not change I would definitely read his body language over his verbal language and try to explain the issues in a different way over and over until the patient understands. Chronic pain is a very hard concept to explain to patients - especially centrally mediated chronic pain – but I feel that as I went through the five weeks of rotation my explanation became simpler, clearer and more confident.

Strategies
I feel that if I am faced by this situation again I would book another appointment with the patient, but have my supervisor (or someone else) present to back me up. I think it showed a lack of conviction on my part to pass the patient on to my supervisor. However, cultural issues must be treated with sensitivity, so it was possibly the best solution that the patient ended up with the male head of department. Getting in touch with someone who understands the culture well and could point you in the right direction for successful treatment would definitely be something to consider in the future. Finally, a strategy that was put in by the end of my rotation was a series of information sheets that explain chronic pain and central mediation were put together to aid in the explanation and also for the patient to take home with them.