While objective clinical testing is important and is given a lot of focus within clincal training programs, subjective assessment and history taking is one of the key aspects of the clinical reasoning process. A detailed subjective assessment will help a physiotherapist form provisional hypotheses as to the potential causes of the patient’s presentation and therefore form the basis of the subsequent objective assessment.


Additionally, subjective history taking provides the first opportunity to establish the direct therapeutic relationship with patients and listen to their story with an unfolding of symptoms, problems and feelings. Epstein et al (2008) proposed that an accurate history taking will provide 80% of the information required for developing a diagnosis. On the other hand, a vague history and unclear description of the issues patient is experiencing will only lead to poor planning of objective examination and subsequently leading to poor clinical outcomes. But what makes a good subjective examination? 

Pre-session preparation

While as busy clinicians, and as we gain more experience, it may be tempting to just go cold into an initial assessment, reviewing any available medical notes/ history of the patient is an important first step to gain an understanding of the patient. This can provide some insight into their presenting condition and therefore may provide useful guide to subsequent assessment planning. 

Catching the patient’s wavelength

Therapeutic relationship is the key to sucess of a clinical consultation. In fact, it is one of the most important elements of achieving clinical outcome and ensuring optimal adherence. I have discussed therapeutic relationship in the article below. 

Do they trust you enough? The role of therapeutic relationship in rehabilitation adherence

But developing rapport can be achieved through simple strategies such as a welcoming greeting at the start of assessment, providing the patient with your name, role and brief summary of how the consultation is likely to proceed. Non-verbal gestures such as smiling, hand-shake and eye contact are also considered important. Maintaining appropriate distance where you do not invade their personal space by being too close or appear too aloof by sitting behind a big desk is also an important element. Trying to understand their tone and behaviour and responding appropriately is important to ensuring the patient is able to develop a trusting relationship and feel comfortable in discussing their problems with you. 

Just a little pause

The first important skill for undertaking a good subjective history is to remember the basic tenet of interviewing. Ask open ended questions which give the patient a chance to provide detailed answers and rather than rushing to ask more questions when patient pauses, leave the gaps which the patient will then feel the need to fill in psychologically. In the early minutes of the consultation the physiotherapist should leave as much space as possible for the patient to talk without interruption. 

An example of an open ended question would be “Tell me more about your shoulder pain”  which a patient can not answer in a Yes or No as opposed to a closed question such as “Do you have pain at night”? 

Generally, as soon as the patient pauses, we start to ask more questions, but the skill is in just leaving the gap a little longer which gives the patients time to reflect and elaborate further on the topic which they are discussing.  Now before you say that with the pressure of time and long waiting lists, it is impossible to let the patient’s continue to talk and ramble on (which does happen!!), remember I am not talking about long gap in conversation but just developing the skill to just leave a couple of seconds before you ask the next question to ensure that the patient has completed their thought process before moving on to the next topic. Research indicates that patients who are allowed to carry on talking until they stop usually do so within two minutes and, by this time, they have usually provided the clinician with most of the relevant information.

This is a skill I have seen some clinicians use expertly to gain a detailed psycho-social perspective of the patient’s presentation which then enhances their overall understanding of the patient’s condition and develop treatment plans which are truly patient centred.

A common mistake is to stop the patient to focus on the first issue which the patient has mentioned. While this may lead them to elaborate on that aspect, that may not be the most important for them. Gask (2002) have shown that once interrupted, patients may not highlight other important issues which may lead to failure to disclose important aspects of their presentation. 

Summarising

Summarising the patient’s history back to them has a two fold purpose. One, it helps to ensure that the physiotherapist has obtained the correct version of the events, facts and perceptions of the patient. Second, it also provides the patient with an opportunity to clarify aspects of history, make amendments to the physiotherapist’s understanding of patient’s condition as well as most importantly, further elaborate on an element which may have been overlooked. Through summarising, the patient and physiotherapist construct a shared version of patient’s problems which form the template for shared decision making and patient centred practice.  

The format for subjective assessment

As discussed above, it is important to have a plan for the subjective assessment to ensure all aspects are covered. Here I suggest a format which I feel provides the best opportunity for indepth exploration of the client’s issues. 

We started with an open ended question about what is the issue which brings them to the clinic. This allows the patient to explain their chief complaint as well as any other associated issues. Usually it is a good idea to cover off the areas of complaints which need to be addressed in a body chart. I prefer to use the chart like below which covers all aspect of the body. 

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We should try and spend some time on the body chart to explore the location and distribution, types of pain, severity, irritability, intensity and nature of pain. As we are discussing each region of complaint, we can also discuss the aggravating and relieving factors as well as the 24 hour pattern of pain. Body charts also serve the useful purpose of exploring the relationship between different symtpoms. It is also a useful indicator of RED FLAGS and should include discussion of the special questions (discussed separately). 

Along with this, I would then explore the rest of the history of present condition. What happened, when did the symptoms start, did they notice any specific incident/ injury which led to the onset of symptoms, what has been the course of progression of symptoms, are they worsening or getting better?

This then leads nicely to ask about any treatment they have had so far or any self-help strategies which they may have used and their impact on the condition.

Once any treatment they have been received has been discussed, I would then delve into the impact of the symptoms on their ADLs (this should generally include screening all the important ADLs like bathing, washing, cooking, cleaning, driving etc.), their leisure activities and hobbies. 

Subsequently, I also make it a point to discuss their work situation and whether they continue to work or have taken time off due to their presenting symptoms and whether they intend to return to work.

Once this has been discussed, it is then an opportune time to discuss their personal perception of what is wrong with them. While some patients may say that they don’t know or even that is why they are here because they want to find out, most will give some indication of what they consider is causing the symptoms they are experiencing. This can offer useful clues to the origin of condition, but more importantly to the mindset and psychological status of the patient. 

Finally, it is crucial to understand the patient’s expectations from your intervention. What are they hoping they will be able to do at the end of your intervention. Again this gives some insight into their cognition but also ensures that you are aware of their expectations. 

Conclusion

By the end of your subjective assessment, you should have a clear picture of what the client’s injury was, what intervention they have had so far, what their current issues are, how these are impacting their life and what they expect you to do about it. You should also use appropriate Patient Rated Outcome Measures which you can ask the patients to fill in prior to the appointment and then go through them during the assessment with them. Then the next step is to undertake a detailed objective examination which serves to confirm or refute your hypotheses which you have formed during the subjective assessment. But if the patient has engaged well and you have taken time to listen to the patient and explore the issues, you should have a very good idea of which specific tests to utilise to confirm your hypotheses. 

Do you have any other tips which physiotherapists can use to enhance their subjective assessment skills? Please post in the comments below.  

Cardiorespiratory, Clinical, MSK, Neuro, Sports

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