Download Challenging Patients Curriculum Instructor Guide The Patient with

Challenging Patients Curriculum Instructor Guide
The Patient with Chronic Pain
Goals:
A PGY-1 resident will be able to evaluate and develop a treatment plan for a patient with no
major co-morbidities presenting with low back pain.
ACGME Core Competencies:
Patient Care/Interpersonal Communication Skills

Demonstrate a comprehensive history and physical examination on an uncomplicated
standardized patient with low back pain
Patient Care / Medical Knowledge

List red flag signs, symptoms, and findings following a standardized patient encounter

Write out a plan to work up back pain in a standardized patient

Engage in a group discussion about medications and therapies to be used and avoided in
patients with chronic back pain, as well as the principles of the WHO Analgesic Ladder
Medical Knowledge

Generate a differential diagnosis specific to a patient presenting with low back pain
Session Guide
Time Needed: 3-4 hours total. One to one-and-one-half hours for didactic lecture on low back
pain, one half-hour to review and practice the physical exam, and one hour for discussion.
Equipment Needed:



Computer with projector if PowerPoint is to be used in the didactic lecture
Room with several chairs and tables which can support residents as they practice the
physical exam
Examination rooms for the standardized patients during the separate standardized patient
interaction (generally scheduled the day after this session is taught).
Suggested online modules:
https://www.apps.som.vcu.edu/vculms/custom_PM/entry.aspx, modules “Overview and
Assessment,” “Treatment Goals,” “Legal and Regulatory Aspects,” and “Virginia.”
Instructor Script and Notes
Part 1 – 90 minutes
I. Introduction to Pain Management
A. Introduce Specialist co-teacher
B. Struggles with treating chronic pain
i.
Describe a personally difficult experience trying to treat a patient with
chronic pain.
ii. Ask residents about their struggles and successes managing chronic pain.
Elicit questions.
C. PowerPoint presentation and lecture, “Issues in Pain Management: The Patient
with Chronic Low Back Pain” by Robin Hamill-Ruth (LBPorthoGR.ppt)
BREAK
Part 2 – 30 minutes
II. Physical Exam
A. Demonstrate the LBP physical exam (Word document outline); and
B. Residents practice on one another.
Part 3 – 60 minutes
III. Group Discussion
A. What questions were left unanswered?
B. What other questions have come up? What resources are available if questions
arise in the future (specific faculty, online references such as the Johns Hopkins
Opioid Calculator, VCU Online Modules)?
C. Alternative Activity/Conversation Starter: Pain Management Jeopardy. This
activity can be used in several situations: either as a conversation starter if the
students are shy or for diagnostic purposes to gauge the knowledge base of the
students. The activity consists of one round of Jeopardy with one Final Jeopardy
question. It takes approximately 30 minutes to complete, longer if you use the
questions as jumping-off points for discussion.
LOW BACK PAIN PHYSICAL EXAM
STANDING:
Inspection
 Spine
 Leg length discrepancy/pelvic tilt
 Scoliosis
 Postural dysfunction
 Muscle asymmetry
 Skin lesions, incisions
Gait
 Velocity, symmetry
 Heel and toe walking
Balance
 Romberg
Range of Motion
 Flexion (cephalad to caudal progression reversed at the L spine? Disc pain?)
 Extension (facet pain?)
 Rotation
 Lateral flexion
 Facet loading maneuver
Palpation
 Spinous processes, interspinous ligaments
 Lumbar paraspinal
 Buttock
 Other areas
Waddell Signs – Pain caused by:
 Rotating hips WITH spine
 Light pressure on the head
 Gentle effleurage of superficial tissues
 Non-physiologic pain/sensory patterns (e.g. non-dermatomal leg pain, sensory deficits
from waist down)
SITTING:
Extremity Strength
 Flexion of thigh at the hip against resistance (iliopsoas – L1, 2, 3)
 Extension of leg at the knee against resistance (quadriceps – L2, 3, 4)
 Heel walking (tibialis anterior – L4)
 Dorsiflexion of great toes (extensor hallucis longus – L5)
 Plantar flexion
Reflexes
 Patellar
 Achilles
 Babinski
Sensory exam
 Light touch
 Sharp stimulus (toothpick)
 Consider temperature (ice) if exam is difficult to evaluate
 Straight Leg Raise (Waddell’s if different seated vs. supine)
SUPINE:
Straight Leg Raise (pain at 30-60 degrees is positive - L5, S1)
 Ipsilateral
 Contralateral
FABER Test (sacroiliac dysfunction)
Gaenslen’s (SI dysfunction)
Decubitus position
 Palpation of trochanteric bursa, gluteal muscles
 Passive external rotation of the hip
 External rotation of hip against resistance, repeat while palpating piriformis
PRONE:
Femoral Stretch (L2, 3, 4)
Watch for fluidity of exam, ease of changing position, which leg used to get up on table, etc.
Look for consistency (inconsistency) between complaints, studies and behaviors.