A Refresher in Cultural Competence

[David Brown]

As I enter my third month of my career as a DPT, I am constantly trying to evolve and refine my cultural competence by remaining open minded in all of my encounters and trying to stay informed of cultural differences and what I can do to mitigate biases and ignorance. I had a cervical/shoulder patient last week that had been dealing with significant neck pain with associated pain traveling into her shoulders along the upper traps for over 6 months. She said that, in efforts to be closer and take better care of a newborn infant (the patient works full time from home), she transitioned her laptop from the desk where she was sitting to the floor where she was sustaining a cervical flexed position for hours at a time This pain was bilateral in nature but far worse on the right side of her neck and traveling into her right shoulder. The patient denied any radicular symptoms. The patient was middle eastern and wore a hijab, which was an immediate challenge in my mind because I knew at some point I was going to need to get my hands on the patient but I also knew that this was not something, like a jacket, I could just ask the patient to remove so I can more easily access a certain body part. Moreover, because of the hijab, I was unable to confidently assess the resting position of her cervical spine. I was able to do the best I could and infer, but I knew it was a shot in the dark.
The patient had clear tendencies for fear avoidance and catastrophization as the patient feared her pain was permanent and it impeded her ability to perform any ADLs that involved cervical flexion. Before I could calm her fears, I had to confidently assess her neck and shoulder symptoms, but I knew this is going to be difficult with only using subjective responses to head and shoulder positions and what I can feel with my hands on assessment. The patient had full active cervical motion with pain at end range movements that were predominantly right sided with right rotation, and left and right sidebending. This discomfort was relieved with placing her arm onto her contralateral shoulder reinforcing my thinking that the primary pain driver was myofascial in nature.
The most challenging aspect of this exam was when I asked the patient to lay supine so I could assess her cervical spine. I, of course, did not ask her to remove her hijab, but I did ask her if it were ok for me to place my hands on her neck and and shoulders by running my hands up her hijab. This conversation was quick and easy and I was relieved that she felt comfortable with this as I was prepared to offer for a female clinician to be present or to have a female clinician perform the remainder of the hands-on exam. This was luckily not necessary as the patient immediately said it was fine for me to perform the exam and found there to be no arthrokinematic restrictions in the neck and was able to comfortably conclude that this was a primarily myofascial problem secondary to persistent postural faults. I was momentarily frustrated with myself that I built up the situation so much in my head in terms of what to expect for the objective exam. I think this was largely due to my inexperience with these types of situations and perhaps a lack of education on what is to be expected of patients from differing cultural backgrounds. I think it is important to always remain open minded to what the patient might prefer and I was prepared to not perform a hands-on exam at all as a worst case scenario. I think it is especially important to have an intimate understanding of what is typical to expect with patients of different cultural backgrounds so that the Physical Therapist can be well prepared and be able to properly respond to any wishes the patient might have.

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