Demonstration

Your role as a Patient Partner

As you have been learning, your role as a Patient Partner is to show doctors the system you have been taught for assessing musculoskeletal problems effectively and efficiently by using the three consultation principles of the history taking, the screening assessment and the principles of joint examination.

Before your presentation, you will introduce yourself and give an explanation of the session.  Develop  your own  script with your trainer. This will include  your  personal  introduction and a description of your problem  and  history  so that  you  can  respond  to questions  the  doctor should  ask you during the demonstration.

Throughout your demonstration, you need to include information at appropriate and relevant points about your own personal and individual disease experiences and findings. Having first-hand experience of the condition being  discussed gives you insight  that you can use to help doctors learn about musculoskeletal conditions;  this is what makes Patient Partners so unique.

If questioned about  the technique you use, mention  that this is the way you have been taught to perform an examination of the musculoskeletal system, but accept there may be variations in technique between different hospitals, clinics or surgeries.

The following  pages should  enable  you to see how the information  you have  read/studied so far in the Patient  Partner manual  is to be used and translated into the training sessions. A Patient Partner demonstration follows the order:

• Introduction to self and Patient Partner programme.
• An introduction and explanation  of the session  including  its aims

(this is now called  in educational terms the “learning  objectives”).

• The principles of history taking (Introduction script).
• Principles of examination (Introduction  script).
• The screening  assessment  (Introduction   script  and  then  practical demonstration).
• Demonstration of the assessment of a specific joint.

NB. Patient Partners will be guided on which joints they will study/demonstrate.

Introduction to self and the Patient Partners programme

“Good   morning/afternoon.  My  name  is  …  [insert  your  name]  and I would like to welcome you to the Patient Partner programme and thank you for attending  this session today.”

“First,  I’d  like  to  tell  you   a  little  bit  about   Patient  Partners. The programme is run in 22 countries  around  the world with over 600 Patient Partners  who,  like  me,  are  all  people   with  arthritis.  We’ve  all  been specially  trained  to work  with  *doctors  / *medical  students  / *nurses  /

*physiotherapists / *occupational therapists [*only mention those represented  in  your   audience]   to  provide   you   with   practical   and hands-on training in conducting a musculoskeletal examination.”

Some  of what  we cover  today  you may already  know,  but what we as Patient Partners uniquely offer you with this programme is the benefit of our experience  of living with our condition  – and  this is something you won’t find in your textbooks! This is an interactive  session, so please do   join   in  and   ask  me   questions   as  we   go  along   –  that’s   what I’m here for.”

*I’d also like to mention  here  that this programme is accredited by / is recognised  by   XXX [*mention   here   any   national   accreditation   / international recognition] so by attending you will receive XXX accreditation.

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The point of this section  is to introduce yourself to participants and to give a brief background. Do not give your complete history at this point. Remember you are teaching  the doctors  by role playing with them as if you were a new patient and helping them to arrive at an accurate diagnosis and understanding of how this affects you. This will not be so valuable  to the doctor (nor as much  fun for you!) if you start by telling them up-front what your condition is.

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Introduction and explanation of the session

“You  may  be  wondering why  you  might  need  additional training  in arthritic conditions. Around one in five people in the world has arthritis, which  affects people  of all ages and  is the most common form of long- term  physical  disability,  which  means  you’re very likely to see  a large number  people  with arthritic conditions in your medical  practice.”

“There  are  over  200  different types of arthritis,  the  two  most  common being  rheumatoid arthritis and  osteoarthritis. There  are  now  effective ways of treating many arthritic conditions, but for some, like rheumatoid arthritis, early diagnosis  is particularly  vital for successful management.”

“Today we  are going to work through a typical consultation  together using me as your patient, looking at history taking, and a physical  joint examination and also a screening  assessment. You will be provided  with Fact Sheets with  details  of all the  information  you  need  to conduct a comprehensive consultation in practice  at the end of this session.”

“Although  my condition has been  diagnosed, I’m not going to tell you about it at the moment. I want you to treat me as a new patient who has just walked into your consulting room and as we work through the examination together,  I want  you to find out as much  as you can about my condition.”

“As a new patient  I am going to present to you with a problem, which I  hope  you are going to be able  to help. You, as a doctor  / *nurse etc. [as appropriate  to  your  audience]  want  to  identify  the  cause  of  my problem, assess the impact it is having on my life and consider various treatment options, which  you will then discuss with me, the patient.”

“As  you  will  probably   have  limited  time  for  the  consultation, good communication is going to be very important.  I, as a patient, will have concerns about my problem, which I would like to have answered in the consultation. The sort of things I will want to find out are:

• ‘What is wrong?’
• ‘What will happen to me?’
• ‘What can you (the doctor) do about it?’
• ‘What can I do about it?’
• ‘Will I get better?’
• ‘Will I get worse?’”

“You, as the health professional, will need to gain a clinical understanding of the problem. You might want to know:

• ‘What is the cause of the problem?’
• ‘Is there an abnormality? If there is,

–   What is it’s character?

–   What is it’s effect?

–   What is the cause?’

• ‘Are there any predisposing risk factors to having the problem, such as obesity, lack of exercise, smoking, family history of the condition, or other illnesses such as psoriasis?’
• ‘Are there any complications?’
• ‘What are the physical and  psychological impacts of this condition on my patient?’

• ‘What is the response to treatment?’

“The ‘mock consultation’ process we will go through  today is designed to help  you obtain  the information  you need,  as well as answering  my questions  as a patient.”

“So,   let’s  first  consider   the   information   you  need   to  get   from   a consultation to meet both our needs.”

The principles of history taking

This script is designed  to be interactive, so you can ask the doctors/medical students  etc. what sort of questions  they  might ask a patient. They do not need  to mention every single question,  but if they do not respond, or leave out any important questions, you can prompt them  by saying, “You could have asked me about…”

As this script is about  the principles  of history taking, so you do not need  to go into detail  about  your history  here.  This will come later when  you go through your mock  consultation  in your demonstration.

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“Taking a good history will form an important  part of your consultation. To be  able  to understand the  problem, you  need  to ask a number  of questions.”

“First of all, what  sort of questions  might you ask at the beginning  of a consultation?”

“It is important to get a clear description of my problem.” “The normal questions are:”

• What’s the problem?  (Not,  ‘How are you?’)
• What are the characteristics of the symptoms?  (For example,  pain, loss of function,  stiffness weakness/giving way  of a joint, swelling or joint deformity)
• Where are the symptoms (the  site/s)  and do the symptoms have a pattern?
• Over what  time  scale  have  the  symptoms developed and  in what order did they appear?
• Are there any associated  symptoms?  (Such  as fever, loss of energy, depression, sleep disturbance,  weight  loss, rashes etc.)
• Have there  been  any  interventions, including  medications, which alleviate  these symptoms?
• Are  there  any  factors  that  have  preceded, or  precipitated  these symptoms?  (Such  as any illness or injury)

“To get further information to help make a diagnosis you should also know about:”

• My general health – am I in good health and/or  are there any other medical  conditions  I might have?
• My lifestyle  – exercise, diet, smoking  etc.
• My past history
• My family history

“Musculoskeletal conditions can be very debilitating,  so you might want to  ask  further  questions   about   how  my  symptoms   are  affecting  my everyday  activities. This will give you a more comprehensive insight into my condition and the impact  this has on my quality of life.”

“What  sort  of questions  might  you  ask  me  about  how  my  symptoms affect my lifestyle?”

Usual questions and possible prompts:

• My situation at home and work – tasks I need to do at home  and at work, my role in the family, carers etc.
• My self-care – washing, dressing, feeding myself  and going to the toilet?
• My ability to carry out domestic tasks – cooking, cleaning, doing the laundry and shopping?
• My work  – standing,  sitting, specific  difficulties,  time  lost  from work
• My leisure  interests  – walking,  going  out  for meals  or playing sports?
• My expectations

“So, it’s important  not to just think about  my condition in terms of pain or loss of movement, but to understand how  my condition can  restrict my activities and how I participate in normal  life.”

“Once you  have  a clear  understanding of my problem, you  will then need  to examine  me to establish  the nature  and  cause  of the problem. We will now move on to the principles  of examination before starting the practical  demonstration.”

Principles of examination

This script covers the principles  of examination. The doctors/medical students  will be able to fully put these into practice when  you conduct your demonstration in the mock  consultation.

“First, before  you start a joint examination, ask if there  are any painful areas,  including  pain from daily activities, and watch  your patient’s face for signs of discomfort  during the test. Tell the patient  to let you know if you are, or are likely to, hurt him or her.

“A joint examination should  be performed  systematically. Always assess and  compare both  sides of the patient’s body. There are five steps to a joint examination and these are:

• Look
• Feel
• Move
• Stress
• Listen

In  addition   to  these  there  may  be  other  tests  to  help  with  specific diagnosis.”

“First, what would you look for?

[You can demonstrate the next section  on yourself]

• Demeanour/walk/sitting/standing
• Inspect  joints at rest and in movement
• Swelling or redness
• Soft tissue changes
• Loss of symmetry and changes  in alignment
• Rheumatoid nodules  and bony  changes.

Always look before you touch.”

“Secondly, Feel or palpate the joint. Feel for warmth first by running the back  of your hand  lightly over a normal  area  towards  the affected  joint or area  in question.  Then  feel for tenderness by pressing  with  gradual increasing  pressure  until the person  says it hurts, they flinch, or you can see  discomfort  register  in  their  face  –  always  keep  a  watch  on  your patient’s face  when  testing  for tenderness. The maximum  pressure  you should  exert should  be sufficient to make  your nails blanch  before  you say there is no tenderness.”

“If the  patient’s joint  seems  very tender  then  obviously  examine  them very gently.  Moving  a joint  can  be  very painful,  not  only  in the  joint you’re examining, but  you  could  also  be  moving  other  joints  that  are painful.”

“You  also  need  to  feel  for swelling.  If  there  is swelling  you  need  to characterise if it is hard or soft swelling. If it’s soft, is it soft tissue or fluid? If it’s hard,  is it bony enlargement of the joint or a rheumatoid nodule?”

“Now  you need to move the joint to test its range of motion with active or  passive  movement and  looking  at  how  the  function  of the  joint  is affected:

Is it painful?

• Is there a full or restricted range of movement, or does the joint move beyond the normal  range into hypermobility?”

“Ask the patient  to move  their joint as far as they can in comfort to see how they manage  [active range of movement]. Then you can gently move the joint and see if it will move any further [passive range of movement] – remembering the  joints  could  be  very  painful.  There  may  be  times when   you  do  these   movements  separately,  as  the  active   range   of movement  involves   muscles   and   tendons   and   the  passive   range   of movement is just moving  structures.    When  you  move  a joint  against resistance  this can detect  lesions in the tendons  and  test muscle  power. Differences  in the pattern  of pain on these movements can help identify the cause.”

“When  you are moving a joint you can also take the opportunity to feel and listen for sounds of crepitus.”

“Use  stress tests, where  the joint is physically  tested  against  resistance, such  as  the  examiners  hand,  to  assess  stability  and  establish  whether stressing the joint allows movement in planes  that are abnormal for that joint.”

Feedback

Once  the examination has been  completed the doctor  should  be able to make a diagnosis.  Once  the nature  of a problem  has been  established it is important  that there is feedback  and exchange of information  between the  patient  and  the  doctor.  The doctor  must  be  aware  of the  patient’s expectations about his or her condition and how it will progress, and the doctor  must explain  carefully  the nature  of the patient’s complaint and likely  outcome.  If   the   doctor   you   are   training   does   not   do   this spontaneously, then  you must ask appropriate questions  to start up this dialogue  and  may even  remind  the doctor  that the patient  will want  an explanation.

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The inability to flex a joint is called  fixed flexion deformity and the inability to extend  a joint is called fixed extension deformity.

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Screening assessment

Please note:

– Please DO  NOT  attempt  to  demonstrate anything  that  might  cause you pain or any damage. Ask members of your audience to ‘volunteer’ and use them  to model  the movements.

– If you  are unsure  what  moves  might  not be safe for you  to perform, please check  with your doctor  or specialist first.

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“Having  established the principles  of history taking and joint examination, we are now going to put theory into practice. First we will look at a quick screening assessment and then go more specifically  into a full mock consultation that will tell you about my problem, using the principles we have just talked about.”

“First, I will show you the screening  assessment.”

“The  screening  assessment  we  are  going  to  use  today  is based  on  a validated  and  widely  used  method.  The questions  asked  will identify if there is a problem  affecting the musculoskeletal system. The movements of this assessment  are the first to show evidence of problems  affecting the joints or spine, so it is a sensitive test of early disease.”

“This screening assessment can be used to check over the whole musculoskeletal   system  as  a  routine  check,   as  you   might   screen someone’s heart and lungs, or it can be used to investigate if someone’s problem is localised or generalised. The full screening  assessment  should only take a few minutes”

“To start with,  as your  patient  enters  the  room,  you may already have noticed  they have a problem with how  they move,  how  they look and whether  they have any trouble  walking. Screening  questions  you should ask at this stage are:

• Do you have any pain or stiffness in your arms, legs, back or neck?
• Do you  have  any  difficulty  with  activities,  such  as  washing  and dressing, or in going up and down  stairs?
• Do you have any swelling of your joints?

These will establish  if they have  any problem  with the musculoskeletal system.  You should  also  ask  “How  is your  general  health?”  as  many musculoskeletal problems  are associated with systemic illness.”

“You may have  to ask additional questions, depending on the answers you  receive.  For example,  if the  patient  says they  have  pain,  you  will need  to ask them to tell or show  you exactly  where  the pain  is situated in their arms, legs or back. As this is a screening  assessment  you would not want to ask more detailed  questions  at this stage.”

“When  you’re doing  a screening  assessment  you  will need  to tell the patient what to do and you may need to demonstrate some of the movements. You can  record  your  findings  on  the  screening  check  list provided.” [You can provide  the Screening Assessment Checklist here].

“Please  could  I have a volunteer to help me with this demonstration?”

“First let’s look at how your patient   walks  without   shoes on. [Observe the patient walking a few meters and then turning and walking back again].”

“What are you looking for?”

• Abnormalities  of heel strike / stance phase / toe off and swing phase.
• Abnormalities of move-ment of arms, pelvis, hips, knees,  ankles and feet during these phases.

“Now ask the patient to stand to check their posture from the front, side and back.”

“Examine  for tenderness by applying  pressure  in the  midpoint  of each supraspinatus and rolling an overlying skin fold.”

“What are you looking for?”

• Normal muscle bulk/knee alignment/appearance of forefoot, midfoot and arches.
• Normal muscle  bulk  in the gluteal and calf muscles  and appreance of the paraspinal muscles.
• Alignment and positioning of the shoulder girdle, spine and the levels of the iliac crest.
• Swivel of the hind foot or popliteal area.
• Tenderness  of the supraspinatus  muscle.

“Ask the patient  to flex their neck laterally to each  side. [Touch ear to shoulder  on each side].”

“What are you looking for?”

• Lateral flexion of the cervical spine to each side.

“To check  the lumbar spine, place  several fingers on successive  lumbar spinious   processes   and  ask  the  patient   to  bend   forward  slowly   and attempt  to touch  their toes with their legs fully extended.”

“What are you looking for?”

• Hip and  lumbar  spine  flexion,  observing   and  feeling  for  normal movement as flexion occurs. 

[The patient  can remain standing,  or you  could  invite them  to sit down to perform the next tests if this would  be more comfortable for them.]

“Moving  on  to  the  shoulders,  ask  your  patient  to  place  their  hands behind  their head  with their elbows  out and to push their elbow  back.”

“What are you looking for?”

• Full shoulder  abduction and external rotation
• Elbow flexion, steroclavicular and acomicoclavicular joints

“Looking at hands and wrists, ask your patient  to straighten  their arms down  the sides of their body  and  bend  their elbow  at a 90o   angle  with their  palms  up  and  fingers straight. Then  ask them  to turn  their  palms downwards and make a tight fist with each  hand.”

“Now ask them to touch the tip of each finger in turn with the tip of their thumb.”

“Ask the  patient  to squeeze your  fingers with  each  hand.  And finally, gently squeeze the 2nd   – 5th   metacarpal joints.”

“What are you looking for?”

• Joint swelling of wrists and fingers, any changes,  e.g. nails.
• Suprination, pronation,  proximal and distal radius-ulnar joints.
• Palm muscle  bulk.
• Hand  joint movement.
• Fine motor coordination.
• Pinch dexterity and strength.
• Flexion of finger joints.
• Grip strength (writs and hand joints).
• Tenderness  (inflammation).

“To test their hips, knees and feet,  ask your patient  to lie down  on an examination couch. Note their ability to get onto the examination couch and inspect  their legs for asymmetry  and wasting.”

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Please note:

If an examination couch is not available these moves can be done sitting.

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“Flex and  turn each  hip and  knee  whilst holding  and  feeling the knee. Then passively rotate the hip internally.”

“With the leg extended and resting on the examination couch, examine for tenderness or swelling  of the knee by pressing  down  on the patella while cupping  it proximally.”

“What are you looking for?”

• Flexion of the hip.
• Flexion of the knee.
• Tenderness  or swelling of the knee.

“Moving on to the feet, gently squeeze the metatarsal  heads  and inspect the soles of the feet for callosities.”

“What are you looking for?”

• Tenderness  and callosities.

“You should  now  record  it as shown  on your screening  assessment  fact sheet.”

“In  practice   it might  not  be  necessary  to  do  a  full screening, if your patient  has specified  their problem  lies in one particular  area. However, even if the problem  is restricted  to one joint, you should  always test one joint  above  and  one  joint  below  the  affected  area,  as  pain  might  be referred,  or another  joint might be involved.”

“Do you have any questions about the screening assessment?”

Individual Problems

“With these joint examination principles  in mind, we can now move on to  assess  certain   individual   joints.  Today  we  will  be  reviewing   the …………. joints. At each  joint, we will review  the relevant  anatomy  and discuss  further  specific  history-taking  questions. You will then  have  an opportunity  to  examine   my  joints   whilst   I   guide   you   through   the process.”

The following  sections  will consider  musculoskeletal problems  for each of the following:

• Neck pain.
• Shoulder and upper  arm pain.
• Hand and wrist pain.
• Low back pain.
• Hip pain.
• Knee pain.
• Foot and ankle pain.

For each  section  there will be:

• An introduction.
• A description of the anatomy of the region.  A pronunciation guide will be provided  to help you learn the terms as you encounter them but pronunciations are also repeated in the glossary provided.
• The symptoms that a person  might experience in this region.
• The possible causes  of the problem.
• An explanation of the symptoms and  impact  on quality  of life that you,  the  Patient  Partner,  may  encounter because of  the  problem. This will help you role play giving a history.
• A script describing  how  the  region  should  be  examined using  the techniques explained in the previous section: look, feel, move, stress, listen and special  tests.

[Move into individual joint examination  script/s]