In the next portion of our master class on the lower back, we’re going to teach you how to have an effective assessment flow, how to follow the o-HIP-MNRS DDx protocol and how to conduct key orthopedic tests for the low back.
Effective Assessment Flows for Successful Outcomes
What does o-HIP-MNRS look like? This is your clinical protocol you should follow for every single patient. Where do we start?
[Powerpoint o-HIP-MNRS graphic from 2nd video]
O is for Observation. You’re greeting the patient, but you’re already observing their body language. Are they slouched down and tired? Do the have poor posture? Have they been crying? All of these are things you’re going to take into consideration before you even start.
Next, you’ll get an informed consent for what you’re about to do. It might sounds something like this: “Hi, I’m Dr. Nik. Today, I’m going to take you through a little bit of a history. We’ll do an assessment. I want to know if you have any questions or concerns before we begin.” Start with a brief, informed consent so they know everything you’re about to do.
Now, the most important thing you do is take a good, detailed History. You are not looking for a chief complaint. This is one of the worst statements I hear made in medicine from all healthcare providers. Who wants to hear complaints all day? I don’t. I’m looking for a patient-centered approach, and that is looking for chief concerns where we can work together to make the ultimate benefit for the patient.
So, you get some history, chief concerns, outcome markers and things you can work on. Once you get the history, repeat it back and make sure everything is accurate, and nothing has been missed.
From there, you’ll go into the Inspection portion of your visit. This includes Palpation, range of Motion, and assessment of Neurovascular and any Referral concerns. These can really go in any order, depending on the individual patient and your preference.
Once all of that is complete, this is the point where you can order Special Tests to give you more information about potential areas of concern. These can include orthopedics, MRI, ultrasounds or bloodwork. Only do these tests if you really need to. Once you have a good idea of what’s going on, you’re going to proceed with some new outcome markers based on the physical assessment in conjunction with any special tests.
At this point, you’re going to give a Clinical Impression or differential diagnosis. This is where you say, “I think x, y and z might be going on with you.” You’re going to offer a treatment plan to that patient, with informed consent. I use the acronym PAR-Q for this. It is on every one of my chart notes for my patient, there is a PAR-Q box for every patient that we see. P for Procedures, A for Alternatives, R for Risks and expected outcomes and Q for any questions the patient has. This is fundamental for the patient-centered physical exam and the clinical relationship you’re trying to establish.
Then you move on to the treatment, and home care has to be a part of that. It’s not enough to just treat the patient in your office and send them on their way. You have to give them the information they need to continue that healing at home.
[Hand in Hand graphic: “If I is Replaced with We, even Illness becomes Wellness”]
So, who is the expert? The expert is actually you and the patient, working together. You are the expert with the clinical knowledge, but the patient is the expert in themselves. Those two things meld together in this therapeutic relationship that you’re creating.
If you want a worksheet with some detailed outcome markers, you can find them in your Low Back Pain book. We also have a copy online on our website as well at ProHealthSys.com.
What Tissue is Damaged?
The first thing you have to figure out is what tissue is damaged. Hopefully, by going through the following series of videos, you will understand it in detail. Is it muscle, ligament, tendon, bone, nerve, viscera? You need to figure that out because different tissues heal at different rates, and we follow slightly different treatment protocols for optimal healing.
Remember this: Assessment is Therapeutic. Your assessment is therapeutic. People want to have confidence in their healthcare providers that you know what’s going on, and you can help them to get better.
ROM Bias: A Great Start
One of the places that I always like to start with is range of motion testing. I’m just looking for a bias, and a baseline of function. Which way do you move that makes it feel better, or makes it feel worse? Which way do they move that makes it feel better or makes it feel worse? What can we do to challenge those areas and allow them to move in the ways that they currently associate with a little bit of avoidance or fear.
Fear Avoidance Model
That brings us to the Fear Avoidance Model that you want to make sure you overlay on all of this. If someone has an injury, what happens? They have pain, and they have a choice. They can decide to catastrophize – and, let’s face it, we all do that sometimes. Or, they can choose to approach it with low fear and a level of optimism.
[Fear Avoidance Graphic]
For our purposes, let’s follow the catastrophization path. When someone goes down this path, they’re not thinking about when they will get better. They’re wondering if they will get better. They have a fear of movement, fear of reinjury, disuse and potentially even a depressive episode out of this from the lack of physical ability. Our job is to take someone, and bring them into this lower fear area and into recovery safely, so they don’t reinjure themselves.
We need to listen, so we can cheer them on and bring them into this low fear path. Our job is to make sure we pay attention, so we can hear in their words and voices where they are on and encourage them. Someone who is catastrophizing is having trouble visualizing a future scenario where they are recovered and have regained their function.
Working with Pain
The key thing you want to focus on always is goals. Recovery is not instantaneous. It is a process, and there is often some pain along the way. So, we need to educate and inform our patients so they know how to work with and minimize the pain during recovery. What are the goals of the patient? What do they really want to accomplish with this treatment?
[Working with Pain graphic]
This includes a lot of practical but important aspects that can help your patient not only recover now, but avoid new injuries and reinjury in the future. They need to recognize, respect and challenge those movements that cause pain, when appropriate. They need to differentiate pain versus sensation, and bring awareness into the body. They need to recognize the biomechanics they use on a daily basis, and how they can change the way they move to be more effective and safer.
Next, we’ll be going over videos on all of the detailed lower back range of motion and muscle testing assessments. So, let’s get started!
