Clinical Biomechanics for Podiatry Series (Post #4):Taking a Good (Biomechanics) History

This is where it all begins in the doctor/patient or therapist/patient relationship. The time spent here discussing the historical facts of an injury or pain syndrome, and important contributing factors, can be vital in the success or failure of treatment. Why is it so vital? Followup visits work off the success or failure of the treatment plan set on that first visit. If the information collected is inadequate, the entire sequence of events following may be subpar. I refer the reader to a post I did earlier on giving a good history. Please review it now before we go further.

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

The biomechanics history related to injuries is looking for patterns or facts that can cause injuries to occur. Here are some of the many questions that normally get asked, or at least you should add to your thoughts prior to seeing a doctor or therapist. These include:

1. Do you know if you have a short leg?
2. Do you believe you have weak or tight muscles in general, or around the injured part?
3. Do you have loose ligaments in general?
4. Are you right or left-handed?
5. When you were a child did you have to wear braces or shoe inserts?
6. Have you ever been prescribed shoe inserts?
7. Have people told you that you walk or run funny?
8. What has your history been of overuse injuries (nontraumatic)?
9. How all or most of your injuries been to one side of your body?
10. Do you have high arches, flat feet, bow legs, knock knees, bunions, hammertoes, or other abnormalities?
11. Do you have any arthritis from your hips downward and wear?
12. Do you feel unstable in any joints?

A skilled practitioner knows the relevancy of the answers. The answers will help point the course of treatment in the right direction. 

Giving a Good Sports Medicine History: Come Prepared (type if you can)

Giving Good Historical Information: Helping to Steer the Course of Treatment

I have watched ships and boats sail through the narrow channel between Portovenere and the Island of Palmaria along the Italian Riviera. They perform this task so effortlessly since they have done it so many times. In the medical arena, an important time to steer the ship/treatment plan in the right direction is by giving good historical information. Come prepared with the information typed (unless you have great handwriting typing in the best). Point your doctor or therapist along the right path/channel and it will help you get better faster. Think over each question carefully when answering. The process will clear your head and keep you focused on the most important aspects. While many of these questions can be the most helpful clues, it may also free the doctor/therapist to ask the key specific questions related to your specific injury (for example, does your painful knee lock where you can not bend it?)

I would like to introduce you to a mnemonic that I used in medical school for asking a great history. The basic questions over the years have remained the same and the hallmark of great history taking. I hope you can take these questions and make them paint an accurate picture of your problem for the doctor/therapist you see next. If they are not impressed by your organizational skills, I will be amazed.

The mnemonic goes like this---

F Family History of similar problem? Frequency of pain (how often)?

A What is your Assessment of the problem (what do you think it is)?

What part of your Anatomy is involved?

I How Intense (use Pain Scale) is the pain? What Irritates (makes it

worse)?

L With one finger, point to the exact Location of the worse pain?

E What Eases the Pain? Does the pain have an Electric sensation with it?

D What has been it’s Duration (how long has it been going on)?

O What were all the events surrounding the Onset of Pain? Are there

any Observable skin changes?

P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End

of the day?

Q What is the Quality of Pain (burning, tingling, dull ache, sharp,

numbness, throbbing, pulsating, etc)?

R Is there Redness? Does the pain Radiate and where to?

S How does Shoe gear or barefoot affect it (or high heels, or various

types of shoes)?

T What have you done to Treat the problem? What Treatment has

helped? What Treatment has made it worse?

U Are there Underlying Health Issues (diabetes, osteoporosis,

arthritis, poor circulation, etc.)?

V Does the pain Vary (better at different times, worse at other times)?

W Can you Work? Were you injured at Work? Does this affect your Work

shoes?

Listening is Great, But Sometimes you must Read Between the Lines

     I did tell this story today about listening and asking questions. My patient Deborah (real name from 1982) had injured her big toe joint and was in severe pain. I immediately recommended surgery which I thought was the correct call, but she resisted. For the next 4 months, Deborah and I tried shots, manipulations, casting, all in severe pain. Nothing worked. Deborah finally came in one day and agreed to have surgery. 

     After surgery, where a piece of fractured bone was removed, was all over, and she had completely recovered and was painfree, I was sitting with her one day in Physical Therapy. Then, and not before, I asked her why she had waited so long (as a 30 year old) in severe pain, to have surgery, knowing how much pain she was in. 

    Deborah said she had been afraid of doctors and surgery for a long time. When Deborah was 4, her 2 year old brother went to surgery for an emergency appendectomy, and died on the table. I learned a lesson that day. I had been a good listener, but I did not listen to what was between the lines. So, even though Deborah non-verbally was telling me to go deeper into her story, I was not ready to do so. To make matters worse, Deborah was really afraid of General Anesthesia where you are put asleep. My surgery was with a local block, and she was awake and comfortable. We had never talked about the type of surgery I would be performing, as we attempted some form of conservative treatment. If I had only told her that 4 months before. 

    So, I try to spend as much time with each patient. Listening to every word. Listening to the clues they provide in what they say and don't say. And times, it is what they don't say that is the most important.