L2: Patient Interview

Question 1

What are 6 characteristics of triage?

Answer 1

1. Recognition of red flags,
2. Contraindications or precautions in assessment or management
3. Pain mechanisms and stage of the disorder
4. Patho-anatomical diagnosis if possible
5. Confirm a musculoskeletal disorder
6. Assess systems

Question 2

What are the 3 “Bio” characteristics of the biopsychosocial approach/ICF?

Answer 2

1. Impairments
2. Activity limitations
3. Cervical spine rule? Need for imaging

Question 3

What are 13 aimsof patient interview and history?

Answer 3

1. Establish relationshipbetween cervical or thoracic pain and a mechanical Musculoskeletalcondition
2. Identify Red Flags/ Yellow Flags
3. To establish functional activity and participation limitations
4. To gather all relevant information re: site, nature,behaviourof symptoms, their onset and past history
5. To assess and analyse provocative factors eg. work, sport activities, posture/motor function
6. To understand the patient’s concerns about their condition
7. To elicit restrictions/contraindications to Rx
8. To interpret information:
   
   • physical and functional diagnosis
   • provisional pathoanatomicaldiagnosis
9. To appreciate the impact on the patient’s work and lifestyleconcerns, coping strategies -participation levels
10. To establish patient relevant functional outcome measures
    
    • VAS; PSFS; NDI (Neck disability index)
11. To identify prognostic factors
12. To formulate next step of physical examination
13. Use clinical reasoning process throughout the examination

Question 4

What are red flags?

Answer 4

Contraindications for treatment or inappropriateness of physiotherapy management (partic. manual therapy)

Question 5

What are cervical spine red flags?

Answer 5

1. Non-musculoskeletal pain-lesscommon in Csp(egangina pectoris)
   
   • Cardiac cause of neck pain = pain gets worst with exercise
2. Inflammatory arthritides(eg. RA, AS, polymyalgia rheumatica)
3. Spinal infection (generally unwell, raised temperature)
4. Tumours (non-mechanical pain eg. Constant, past history of cancer, unwell, ? wtloss)
   
   • Eg. meningitis
5. Myelopathy/ cord compression (neurological signs, weakness, ataxia)
6. Acute onset mod-severe, unusualpain (arterial dissection VA or ICA)
7. Craniovertebralanomalies (Downs syndrome, congenital absence of odontoid peg)
8. Craniocervical(upper Csp) instability (egtrauma, whiplash, RA)

Question 6

What are precautions?

Answer 6

Conditions which dictate that special care is required in examination and management

Question 7

What are 7 cervical spine precautions?

Answer 7

1. Vertebral Artery Insufficiency/ vertebrobasilarinsufficiency (VBI), Atherosclerosis
2. Gross foraminalor spinal canal encroachment on X-ray
3. Acute and severe nerve root pain, irritation or compression; Presence of involvement of more than one nerve root
4. Recent major trauma egmotor vehicle accident, sport, substantial fall –x-rays may not be sensitive enough to detect ligamentous injuries, fine fractures. Substantive fractures or dislocations can usually be imaged.
5. Post-surgical spinal fusion –the adjacent segments may become hypermobile and potentially unstable
6. Osteoporosis
7. Long term medication eg. steroids for respproblem(bone de-mineralisation)

Question 8

What are 6 precautionary questions for any precautions/contra-indication to management for cervical spine?

What is the interpretation?

Answer 8

1. General Health, including stable weight, previous surgery, previous serious illnesses
2. RA
3. Medication (analgesics, NSAID’s, steroids, medications for other conditions)
4. X-rays and other medical evaluations
5. Presence of dizziness (VBI; cervical vertigo, vestibular)
6. Cord signs (bilateral paraesthesia/anaesthesia hands and feet, gait disturbances, balance)- Bladder and bowel disturbances

InterpretationElicit any information that may suggest that the patient’s condition is not musculoskeletal in origin, factors that may indicate serious pathology or factors that may guide the nature of treatment given

Question 9

What are 4 pain mechanisms?

Answer 9

1. Nociceptive?
2. Neuropathic?
   
   • Neurological signs (eg. P&Ns, spreading pain, paraesthesia)
3. Altered pain processing egcentral sensitisation(Nociplastic)
   
   • Allodynia, hyperalgesia, disproportionate wide-spread pain
4. What are the features of these?
   
   • How might you recognise?
   • Any screening questionnaires you might use?

Question 10

What are the 3 stages of disorders? What is the diagnosis and irritability?

Answer 10

1. Diagnosis: specific diagnosis v mechanical or non-mechanical
2. Irritability: implications for physical examination

Question 11

What are 8 features of the patient interview?

Answer 11

Question 12

What are the 3 preliminary questions in the patient interview?

Answer 12

1. What is the problem bringing you to physiotherapy?
2. What is your occupation?
3. History: duration of condition, history and mode of onset
   
   • how long have you had neck pain?
   • how did it begin? Further questions…
     
     • insidious –predisposing factors, progress of condition
     • incident –mechanism –progress
4. current status –better, the same, getting worse?
   
   • Need to re-asses treatment and beware for red flags
5. Previous history –how many episodes?
   
   • progress of condition?
   • previous treatment?

Question 13

What are the clinical reasoning summary from the patient interview?

Answer 13

Question 14

What are the 5 hypothesis for the physical examination?

Answer 14

Question 15

What are 6 clinical reasoning for treatment planning?

Answer 15

1. Correct her work practices and work at home (stop the adverse loading)
2. Teach correct spinal and scapular postural positions, encourage to get out of end range postures regularly at work
3. Specific exercises to re-educate cervical and scapular control, later strength
4. Manual therapy for C2-3 joint pain, hypomobility, any C/Thhypomobility
5. Active joint mobilisingexercises (C2-3 and C/Thregion)
6. Lifestyle advice: increase general exercise , modify/ decrease computer work at night

Question 16

What are 8 responses?

Answer 16

1. Neck/arm pain and stiffness is present on waking.
2. The neck and arm pain gradually increase through the day.
3. Unable to do normal household activities because of arm pain, difficult to get relief.
4. Gets ‘showers’of pins and needles down arm if moves her neck the wrong way.
5. Uses panadeineforte and nurofenfor pain, helps a bit, not much.
6. Is having trouble getting comfortable at night.
7. Is frequently waking with pain.
8. Is quite anxious as it has gone on for so long. She cannot sleep and she and her husband are due to travel again

Question 17

What are 3 clinical reasoning? What are 5 implications for physical exmination?

Answer 17

1. Biological
   
   • Pathoanatomical/structural hypotheses
     
     • (L) C5-6 Zygapophyseal joint
     • C5-6 Discallesion
     • C6 NR compromise
     • Neural tissue mechanosenstivity
2. Mechanisms
   
   • Neuropathic pain state
   • Severe and irritable
3. Psychosocial
   
   • increasing level of anxiety/general distress
4. Limit examination, do not provoke symptoms
5. Limited active movement examination
6. Neurological examination
7. Distal components of ULNT (if at all)
8. Non-provocative manual examination

Question 18

What are 7 clinical reasoning in treatment planning?

Answer 18

1. Communicate with GP to ensure patient has adequate pain management (eg. mediation for nerve pain)
2. Explain the nature of pain and her condition, assure, relieve anxiety
3. Treatment approach will be gentle, respecting pain and pathology
4. Monitorany neurological signs carefully
5. Help her to find positions of ease and any other pain relieving strategies –for household activities, for sleep at night
6. Manual therapy –traction, gentle mobilisation(openingthe intervertebral canal)
7. ?? Possible gentle nerve tissue mobilisation(movement, distal region)