Subjective History & Evaluation Notes

HPPT 8425: Musculoskeletal Physical Therapist Practice I – Subjective History

Overview and Core Objectives

  • Subjective History Purpose: The subjective history process is utilized to accurately identify musculoskeletal pathology causing patient symptoms and to select appropriate assessment and treatment techniques for musculoskeletal disorders.
  • Pain Assessment Context: Pain must be evaluated comprehensively within the context of obtaining the subjective history of musculoskeletal disorders.
  • Diagnostic Yield: The subjective history provides >80%> 80\% of the information needed for an accurate diagnosis.
  • Patient Centeredness & Therapeutic Alliance: The history is where the therapeutic relationship begins as part of a comprehensive biopsychosocial approach.
    • Patients desire caregivers who communicate warmth, interest, and focused attention.
    • Patients require providers to understand the whole person, including emotional needs and treatment preferences.
    • Treatment should enhance a continuing relationship between patient and clinician.

Clinical Reasoning and Patient Evaluation Framework

Patient Evaluation Flowchart

  • Sequential Evaluation Process:
    1. Subjective History & Systems Review
    2. Observation & Movement Analysis
    3. Tests & Measures
    4. Evaluation & Clinical Reasoning
    5. Intervention Planning
    6. Reassess
  • Core Decision-Making Elements in Subjective Phase:
    • Red Flags Screening
    • Yellow Flags Screening
    • Risk Factors Assessment
    • S.I.N.S.S. Profile (Severity, Irritability, Nature, Stage, Stability)

11 Best Practice Recommendations for Care in Musculoskeletal Pain

11 Best Practice Recommendations Infographic Wheel

  • Scope: High-quality care recommendations across common pain sites encounterd in emergency and primary care, including:
    • Cervical and thoracic pain
    • Low back pain
    • Hip and knee pain (including osteoarthritis)
    • Shoulder pain
  • 11 Core Recommendations:
    1. Patient-Centred Care: Care should always be patient centred.
    2. Red Flag Screening: Screen for serious pathology and red flags.
    3. Psychosocial Assessment: Assess psychosocial factors.
    4. Radiological Imaging: Only use radiological imaging if specifically indicated.
    5. Physical Examination: Undertake a thorough physical examination, including neurological screening tests, mobility assessment, and/or muscle strength evaluation.
    6. Outcome Measures: Evaluate progress consistently using validated outcome measures.
    7. Patient Education: Provide patient education on the condition and available management options.
    8. Physical Activity: Provide management addressing physical activity and/or structured exercise.
    9. Manual Therapy: Apply manual therapy only as an adjunct to other evidence-based treatments.
    10. Non-Surgical Care: Unless specifically indicated otherwise, offer evidence-informed non-surgical care prior to considering surgery.
    11. Work Resumption: Facilitate the continuation or resumption of work.

Systems Review & Review of Systems (OSPRO-RS)

  • Optimal Screening for Prediction of Referral Outcome – Review of Systems (OSPRO-RS): A validated review-of-systems screening tool developed for orthopaedic physical therapists to identify red flags and systemic non-musculoskeletal medical conditions.

OSPRO-RS Item Bank Part 1

  • Cardiovascular System Screening Questions:
    • Chest pain with rest
    • Chest pain with exertion
    • Chest pressure
    • Upper-quarter pressure or tightness sensations
    • Upper-quarter pain when performing lower-quarter activity (e.g., walking)
    • Light-headedness
    • Loss of consciousness
    • Anxiety or apprehension
    • Sweating with chest pain
    • Sweating without exercise or activity (i.e., cold sweats)
    • Excessive sweating
    • Decreased sweating
    • Night sweats
    • Severe fatigue
    • Shortness of breath
    • Rapid breathing
    • Labored or difficult breathing
    • Breathlessness
    • Shortness of breath while lying down (orthopnea)
    • Difficulty in swallowing
    • Edema or weight gain
    • Heart palpitations
    • Heartbeat felt in abdomen when lying down
    • Leg cramps when walking several blocks
    • Swollen calves, ankles, or feet upon waking in the morning
    • Malaise (e.g., feeling lethargic as a result of illness)
    • Unexplained irritability
  • Pulmonary System Screening Questions:
    • Wheezing
    • Harsh, high-pitched noise on breathing (stridor)
    • Production of blood when coughing (hemoptysis)
    • Dry, hacking cough
    • Changes in typical cough pattern
    • Production of abnormally colored substances upon coughing
    • Decreased tolerance for physical activity

OSPRO-RS Item Bank Part 2

  • Gastrointestinal System Screening Questions:
    • Nausea
    • Vomiting
    • Constipation
    • Diarrhea
    • Abdominal pain
    • Change in stool color
    • Blood in stool
    • Changes in frequency of bowel movements
    • Excessive heartburn or indigestion
    • Specific food intolerance
    • Change in appetite
    • Excessive belching or flatulence
  • Urogenital System Screening Questions:
    • Pain or difficulty when urinating
    • Blood in urine
    • Dark-colored urine
    • Changes in urinary frequency and/or volume
    • Infection
    • Incontinence
    • Vaginal discharge
    • Urethral discharge
    • Abdominal bloating
    • Changes in menstruation patterns
    • Pain with sexual intercourse
    • Difficulty with sexual intercourse
    • Difficulties maintaining an erection
    • Breast tenderness
  • Endocrine System Screening Questions:
    • Excessive thirst
    • Excessive hunger
    • Heat or cold intolerance
    • Abrupt onset of cramps
    • Unexplained weight loss
    • Unexplained weight gain
    • Hoarseness of voice
    • Easy bruising

OSPRO-RS Item Bank Part 3

  • Nervous System Screening Questions:
    • Abnormal sensations (e.g., numbness, pins and needles)
    • Muscle weakness
    • Changes in coordination
    • Gait or balance disturbances
    • Changes in vision
    • Changes in hearing
    • Changes in smelling
    • Slurred speech
    • Changes in memory
    • Unexplained confusion
    • Frequent dizziness
    • Headaches
    • Facial pain
    • Tremors
    • Seizures
  • Integumentary System Screening Questions:
    • Changes in skin color
    • Changes in skin texture
    • Changes in wound healing time
    • Skin rash
    • Changes in hair on skin
    • Changes in integrity of nails
  • Musculoskeletal System Screening Questions:
    • Night pain
    • Pain with rest
    • Sustained morning stiffness
    • No symptom relief with position changes
    • Trauma (e.g., motor vehicle accident, fall)
    • Symptoms that travel to different body regions
    • Failure of conservative intervention
    • Prolonged use of corticosteroids

Psychosocial Screening (OSPRO-YF)

  • Optimal Screening for Prediction of Referral and Outcome - Yellow Flags (OSPRO-YF): A validated assessment tool for orthopaedic physical therapists to identify yellow flags across three key psychological domains.
  • Three Psychosocial Domains:
    1. Negative Mood Domain: Evaluates depression, anxiety, and anger symptoms.
    2. Fear-Avoidance Domain: Evaluates fear-avoidance beliefs regarding physical activity and work, pain catastrophizing, and pain somatization.
    3. Positive Affect/Coping Domain: Evaluates self-efficacy for pain management, pain acceptance, and positive coping strategies.
  • Assessment Tools: Available in concise 10-item10\text{-item} and 7-item7\text{-item} versions.

OSPRO-YF Item Bank Page 1OSPRO-YF Item Bank Page 2

Yellow Flags Clinical Framework Decision Pathways

  • Four Pathways for Management of Yellow Flags in Physical Therapy Practice:
    • Pathway 1: Standard Physical Therapy
      • Screening Criteria: Low impact of yellow flags; no symptoms of mental illness.
      • Plan of Care: Self-management; encouragement; advice to remain active.
    • Pathway 2: Psychological Informed Physical Therapy (PIPT)
      • Screening Criteria: Moderate impact of yellow flags; no symptoms of mental illness.
      • Plan of Care: Cognitive behavioral strategies; coping skills training; motivational interviewing; self-management.
    • Pathway 3: PIPT With Referral
      • Screening Criteria: Moderate or high impact of yellow flags; symptoms of mental illness present.
      • Plan of Care: Referral and active communication with healthcare providers; PIPT strategies; self-management.
    • Pathway 4: Immediate Referral
      • Screening Criteria: Signs of severe mental illness, including clinical depression or suicidality; physical therapy participation or self-management is not appropriate; emergency care is indicated.
      • Plan of Care: Referral and communication with other healthcare providers; initiate emergency care response.

Red Flag & Hypermobility Screening Variables

  • Cancer Screening Variables & Likelihood Ratios (+LR+\text{LR}):
    • Prior history of cancer: +LR=15.5+\text{LR} = 15.5
    • Age >50 years> 50\,\text{years}: +LR=2.7+\text{LR} = 2.7
    • Failure of non-surgical / conservative care: +LR=2.6+\text{LR} = 2.6
    • Unexplained weight loss: +LR=2.5+\text{LR} = 2.5

The Beighton Scoring System

  • Beighton Scale for Joint Hypermobility:
    • Cutoff Criteria: Various cutoffs exist, but >4/9> 4/9 is the most common threshold for hypermobility.
    • Scoring System Elements (9 points total9\,\text{points total}):
      • A. 5th Finger / "Pinkies" (1 point per hand1\,\text{point per hand}): Rest palm and forearm flat on surface with palm down and fingers straight. Test if the 5th finger can be bent/lifted upwards at the knuckle beyond 90∘90^\circ.
      • B. Thumbs (1 point per thumb1\,\text{point per thumb}): Arm straight out, palm facing down, wrist fully bent downward. Test if thumb can be pushed back to touch the forearm.
      • C. Elbows (1 point per arm1\,\text{point per arm}): Arms outstretched with palms facing upward. Test if elbow extends (hyperextends upwards) more than 10∘10^\circ beyond normal outstretched position.
      • D. Knees (1 point per leg1\,\text{point per leg}): Standing with knees locked (bent backwards as far as possible). Test if the lower part of either leg extends more than 10∘10^\circ forward (hyperextension).
      • E. Spine (1 point1\,\text{point}): Bend forward; test if palms of hands can be placed flat on the floor in front of feet without bending knees.

Components of the Subjective Examination

  • Nine Essential History Components:
    1. Location of symptoms
    2. Mechanism of injury / Onset of symptoms
    3. Severity
    4. Irritability
    5. Nature
    6. Stage / Stability
    7. Present & Past History of Condition
    8. Special Questions & Spontaneous Comments
    9. Patient Goals
  • Opening Questions for Consultation:
    • "Tell me about your symptoms" (not every patient has pain as primary complaint).
    • "What is your main concern?"
    • "What brings you in today?"
    • "What do you think is going on?"
  • Most Common Primary Complaints Encountered:
    • Pain
    • Stiffness
    • Weakness
    • Numbness / Tingling

Detailed Analysis of Subjective Components

1. Location of Symptoms

Pain Body Diagram Tool

  • Assessment Tools: Body diagrams where patients mark specific locations and qualities of pain.
    • Symptom Key Standard Examples: Pins and Needles = 000000, Stabbing = //////, Burning = XXXXX, Deep Ache = ZZZZZZ.
  • Local vs. Referred Symptoms:
    • Distal Symptoms: The further distal a symptom is located, the better and more specifically the patient can localize their pain.
    • Proximal / Deep Symptoms: Deep, dorsal, or proximal symptoms are harder to localize; patients can no longer put a finger directly on it.
    • Systemic Referral: Must consider non-musculoskeletal systems that can refer pain to specific anatomical regions, which guides and focuses the Systems Review.

2. Mechanism of Injury (MOI) & Onset

  • Traumatic Onset:
    • Differentiate between contact vs. non-contact injuries.
    • Assess force direction.
    • Evaluate temporal presentation: immediate pain (indicates mechanical injury) vs. delayed pain (indicates inflammatory response).
    • Determine if patient heard or felt a "pop".
  • Microtraumatic / Gradual Onset:
    • Repetitive microtrauma and predisposing structural/biomechanical factors.
    • Gradual onset still maintains a logical, identifiable underlying pattern and reason.
  • Insidious Onset:
    • No clear, true identifiable reason or trigger.
    • Neither patient nor clinician can establish a logical mechanical reason.
    • Clinical Consideration: Must evaluate for potential serious underlying non-musculoskeletal pathology.

3. S.I.N.S.S. Profile: Severity, Irritability, Nature, Stage, Stability

Severity
  • Definition: Impact of symptoms on social life, occupation, lifestyle, and activities of daily living (ADLs), comparing baseline function to current status.
  • Measurement Methods:
    • Visual Analog Scale (VAS): Patient marks symptom intensity along a 100 mm100\,\text{mm} line.
    • Numeric Pain Rating Scale (NPRS): Patient circles a number from 00 to 1010 (0=no pain0 = \text{no pain}, 10=most severe pain / worst possible pain10 = \text{most severe pain / worst possible pain}).
    • Wong-Baker FACES Pain Rating Scale: Visual scale ranging from 00 ("No Hurt") to 1010 ("Hurts Worst").

Wong-Baker FACES Pain Rating Scale

Irritability
  • Definition: The reactivity of symptoms based on aggravating and easing factors.
  • Three Key Irritability Questions:
    1. What specific activities "flare up" your condition?
    2. Once aggravated, how long does the "flare up" last?
    3. What do you have to do to calm the "flare up" down?
  • Frequency and Duration Patterns:
    • Intermittent: Pain comes and goes; drops completely down to zero (00) between episodes.
    • Constant: Pain is present continuously at all times; never fully drops to zero (00). Often exhibits no change where nothing helps significantly (frequently associated with acute or active inflammatory states).
    • Continuous: Pain is present at all times, but fluctuates in intensity. Pain is present, but the patient can perform specific easing actions to lessen it.
    • Episodic: Symptoms recur over extended timeframes (months or years) with periods of remission in between.
  • Comparable Sign:
    • The single ONE movement, activity, posture, or action that best reproduces the patient's chief complaint (e.g., climbing stairs, squatting, reaching overhead).
    • Used for baseline measurement and ongoing re-assessment throughout treatment.
    • Musculoskeletal vs. Non-Musculoskeletal Profiles:
      • Musculoskeletal: Typically mechanical in nature, reproducible with specific movements/postures, relieved by rest.
      • Non-musculoskeletal: Non-mechanical in nature, symptoms cannot be mechanically reproduced by physical examination, requires systemic review.
Nature
  • Pain Mechanisms / Phenotypes:
    1. Nociceptive (Somatic) Pain:
      • MSK Sources: Bone, ligament, tendon, muscle, dura mater.
      • Subjective Descriptions: Aching, sore, deep, cramping, dull, sharp with movement. Clear, specific aggravating and easing factors.
      • Objective: Mechanically reproducible during objective assessments.
      • Clinical Cluster for Nociceptive Pain (Smart et al., 2012):
        1. Pain localized to area of injury/dysfunction (with or without referral).
        2. Clear, proportionate, mechanical aggravating and easing factors.
        3. Intermittent pain with mechanical provocation.
        4. Absence of dysesthesia.
        5. Absence of night pain or sleep disturbances.
        6. Absence of antalgic postures or movement patterns.
        7. Absence of burning, shooting, sharp, or electric shock-like pain descriptions.
      • Dural Pain Referral: The dura is somatic tissue and is frequently the source of referred somatic pain into the leg (with lumbar pathology) or arm (with cervical pathology).
      • Clinical Distinction: Extremity pain is NOT always neuropathic/nerve pain!
    2. Neuropathic Pain:
      • Subjective Descriptions: Sharp, piercing, burning, hot, shooting, electrical, lancinating, stinging, zinging. Shoots down and follows specific neural paths.
      • Objective: Mechanically reproducible with specific neural tension or compression tests (e.g., Upper Limb Tension Tests [ULTT], Straight Leg Raise [SLR], Slump Test, Foraminal Compression).
      • Clinical Cluster for Peripheral Neuropathic Pain (Smart et al., 2012):
        1. Pain/symptoms referred in a dermatomal or peripheral cutaneous distribution.
        2. Symptom provocation with mechanical/movement tests that move, load, or compress neural tissue.
        3. History of nerve injury, pathology, or mechanical compromise.
    3. Nociplastic Pain (Central Sensitization):
      • Mechanism: Augmentation of responsiveness of central pain-signaling neurons to input from low-threshold mechanoreceptors.
      • Allodynia: Pain produced by a stimulus that does not normally provoke pain (hurts when it shouldn't; non-noxious stimulus causes pain).
      • Hyperalgesia: Increased pain from a stimulus that normally provokes pain (hurts more than it should; excess pain from a noxious stimulus).
      • Neurobiology: Altered sensory processing in the brain, malfunctioning pain inhibitory pathways, and activation of non-pain brain regions.
      • Clinical Cluster for Central Sensitization (Smart et al., 2012):
        1. Disproportionate pain relative to nature and severity of injury.
        2. Disproportionate, non-mechanical aggravating/easing factors.
        3. Presence of psychosocial symptoms.
        4. Diffuse distribution of pain with palpation.
  • Other Aspects of Nature:
    • Stiffness: Morning stiffness duration and tissue reactivity.
    • Paresthesia / Numbness: Delineate between subjective "pins & needles" sensations versus objective loss of sensation (numbness). Differentiate peripheral cutaneous nerve distribution vs. spinal nerve root (dermatomal) patterns.
    • Weakness: Differentiate global weakness vs. myotomal weakness vs. specific peripheral nerve distribution.
    • Dizziness: Assess vestibular, cervicogenic, or vascular causes.
Stage & Stability
  • Stage: Tissue healing phase (e.g., acute, subacute, chronic, acute-on-chronic) corresponding to pathologies like acute ligament partial tears, muscle strains, or disc herniations.
  • Stability: Current direction of condition trajectory:
    • Better
    • Worse
    • No different
    • Fluctuating

4. Present & Past History of Condition

  • Current Episode: New onset vs. acute recurrence vs. chronic/recurrent trajectory. Determine if current episode differs from past occurrences.
  • Past Medical History (PMH): Systemic illnesses, cardiovascular conditions, diabetes, and health lifestyle habits.
  • Past Surgical History (PSH): Specific operative procedures performed, surgical details, and outcomes of post-surgical rehabilitation.

5. Special Questions & Spontaneous Comments

  • Anatomical Region-Specific Questions: Red flag and systems screening tailored to body region.
  • Associated Systemic Symptoms: Bowel and bladder dysfunction, diaphoresis (excessive sweating), nausea, vomiting.
  • Spontaneous Closing Questions:
    • "Do you have any questions?"
    • "Is there anything I missed that you think is important?"
    • "What do you think is going on?"

Person-Centered Hypothesis Framework

  • Integration Process: Synthesizing subjective history findings into a holistic diagnostic framework.
  • Framework Components:
    1. Pain Phenotypes: Identify suspected predominant pain phenotype(s) (Nociceptive, Neuropathic, Nociplastic).
    2. Clinical Patterns: Recognize established symptom patterns of relevant conditions (e.g., knee pain with mobility deficits / knee osteoarthritis).
    3. Regional Contributors: Account for regional interdependence and co-existing mechanical drivers (e.g., hip motor control/strength deficits contributing to knee pain).
    4. Influencing Factors: Evaluate contextual drivers:
      • Emotional / Affective Factors
      • Cognitive / Belief Factors
      • Socioenvironmental Factors
      • Lifestyle Factors

Therapeutic Alliance

  • Definition: The positive working relationship and social connection established between therapist and client through active collaboration, effective communication, empathy, and mutual respect.
  • Three Primary Components:
    1. Goal Agreement: Mutual agreement on rehabilitation goals between therapist and patient.
    2. Intervention Agreement: Mutual agreement on intervention strategies between therapist and patient.
    3. Affective Bond: Establishing a strong interpersonal affective bond between therapist and patient.