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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.