History taking – the unsung hero; Part 1.
Physio assessment - history taking
One of the questions I am frequently asked as a Physiotherapist is - “what is the most important part to getting someone better?”. This is obviously a loaded question with multiple key elements to successfully rehabilitating an individual. In the earlier days of my career I would have said “hands on treatment”. Fresh off trigger point, massage and manipulation courses I was eager to unleash my newly acquired skills on the general public. Some got better … some didn’t. The failures were frustrating and made me ask “what technique am I missing”.
The answer to this question is the same as to the original question - “what is the most important thing to getting someone better?”. The irony is that it’s something that I had been taught as an undergraduate, the bedrock of Physiotherapy assessment which is all too often glossed over. I am referring to history taking, also known as “subjective assessment”. Anybody reading this who has undergone Physiotherapy, should have received a subjective assessment at the first appointment. It’s a series of questions covering a wide range of topics including (but not limiting to) the following; -
· Existing medical or health conditions.
· Previous surgeries.
· Details of the injury sustained/ pain presented with.
· Details of any relevant previous injuries or pain.
· What aggravates and eases the pain.
· Medication.
· Daily pattern of the pain.
· Pain scores.
· Specific questions related to the area of injury.
· Social and recreational interests.
· Goals and expectations
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Each of these topics can be broken down into further topics. It is beyond the scope of this blog to explore all elements of the subjective assessment, however, key parts will be discussed below.
The critical part of the initial assessment is that the above questions are not rushed through to get to the physical assessment or “trendy” hands on stuff. Each of these topics holds the key to unlocking the patient’s recovery and quality time should be taken by the Physio to achieve this. In these questions lies key information about diagnosis, causative factors, prognosis, whether to refer on, factors that may hamper recovery, exercise prescription and what advice to offer. I will now run through some key topics illustrating its importance.
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Diagnosis
From a broad medical perspective, researchers way back in 1975 concluded that history taking determined 83% of diagnoses in medical outpatients. As diagnostic tests have developed throughout the years this finding has been constantly reviewed and challenged.
A study in 2008 explored history taking in the thick fibro cartilage of the knee, known as the meniscus. It found history taking to have diagnostic value, whereas physical examination did not add any diagnostic value for detecting meniscal tears.
1-0 history taking.
Sticking with the knee, researchers in 2010 explored the diagnostic importance of history taking and a physical examination test (anterior drawer test) in individuals with anterior cruciate ligament (ACL) injuries. They found patient reported “popping sensation” to be the most predictive factor in determining ACL injury. Furthermore, combining factors from history taking (2 of 3 positive results regarding swelling, popping sensation, and giving way) improved diagnostic accuracy.
2-0 history taking.
Finally, researchers in 2013 explored the diagnostic accuracy of history taking in low back patients with referred leg pain. This study did not compare history taking to physical examination, however, history determinants were correlated to MRI scan findings. They found several elements of the history taking to have significant diagnostic value for nerve compression including; “pain worse in leg than in back,”, “a non-sudden onset” and “sensory loss”.
As you can see, the scientific literature demonstrates that history taking is key to accurate diagnosis. If good treatment comes from an accurate diagnosis, then you can see why I feel good history taking is the most important part to getting someone better.
Serious Pathology
Another question frequently asked is “is online physiotherapy safe?”. The answer is “yes! - absolutely”. The main factor in solidifying its safety is history taking and, thankfully this is performed as equally effectively remotely as face to face.
During the history taking process we ask a series of specific questions depending on the area of pain. This allows us to screen for any rare but potentially sinister pathologies. For example, let’s take the low back and a rare type of arthritis called Ankylosing Spondylitis. It mostly causes pain and swelling in the spine and the joints that connect the bottom of the spine to the pelvis (sacroiliac joint). Other joints can be affected as well. It is a systemic disease, which means it may affect other body parts and organs.
The key to successfully identifying this disease are clues from taking a thorough history. Important clues are; age of onset < 40, pain duration > 3 months, pain not relieved by lying supine (on the back), pain and stiffness worse first thing on waking or after long periods of rest and back pain during the night.
Once again, taking a thorough history, combined with clinical experience, is vital to identifying this disease and referring on to appropriate specialists. Thankfully, PhysioHub’s therapist each have over 14 years clinical experience and our virtual physiotherapy services are subject to the same high levels of quality, safety and auditing as face to face clinics.
I will pause things for now, however, in part 2 we will cover topics of exercise prescription, offering accurate advice and onward referral to other services.
Physiohub is an online physiotherapy company. We offer a 100% virtual service providing remote physiotherapy assessments, online physiotherapy treatment and rehabilitation sessions and online DSE assessments.
To learn more about our online physiotherapy services click here. Or to learn a little bit more about the Online Physiotherapists from the PhysioHub team, click here.