Enhanced History Taking for

Spinal Assessment
7082SOH
Week 1 – Spinal Assessment
 To generate hypotheses for the source of the symptoms

To estimate the severity and irritability of the presenting

condition

Aims of To identify any precautions / contraindications to physical

examination and treatment

subjective To estimate the prognosis

examination
To develop a broad management plan

To be aware of the patient’s preferences

  General subjective assessment includes the following sections
 Body chart
 Area & depth of symptoms
 Nature & behaviour of symptoms
 Any other of symptoms & linkage of symptoms
 24 hour pattern , night pain
 Improving , worsening , ISQ
Components of  Aggravating and easing factors

generic  PC (presenting complaint)

subjective
 what is the patients main reason for coming to physiotherapy?

 HPC (history of present condition)

examination  When did it start, how did it start, have they had previous episodes, how has it progressed
since, what have they done about it, have they seen their GP or other HCP, have they had
any imaging or investigations, have they had any previous treatment & what was the result

 PMH (previous medical history) – screen systems & conditions

 DH (drug history) – screen for steroids / anticoagulants / other medications & why
 SFH (social/family history) – occupation, currently working , live alone/family,
hobbies/sports, age
Flag system
used in MSK
  Step 1 of red flag screening is ‘diagnostic triage’ (CSAG,
1994)
 Recommended by majority of international guidelines
 Aim is to sub-classify the presenting condition into one of
3 categories through careful questioning
Red Flag Screening  Serious spinal pathology

for Spinal Conditions  E.g. spinal metastases, spinal infection, osteoporosis, space
occupying lesion, cord compression
– identification of  Nerve pathology
physical risk factors  E.g. Sciatica, radiculopathy
 Non-specific spinal pain
 non-specific neck pain e.g. facet joint dysfunction
 Non-specific back pain e.g. disc herniation
 1. Age of onset
 < 20 years
 > 50 years
2. Constant progressive pain
3. Unremitting night pain
4. Unexplained, significant weight loss
General spinal  > 5-10% of normal body weight

red flags 5. Widespread neurology

6. Thoracic pain
7. Structural deformity
8. Violent trauma
9. Systemic steroids
10. Systemically unwell
11. Drug abuse, HIV
12. PMH of cancer
  Clumsiness of extremities

Red flags for  Stumbling gait

Cord
 L‘Hermitte’s sign
 Unilateral or bilateral paraesthesia/anaesthesia
Compression  Bowel or bladder dysfunction
 Red Flags for Spinal Metastases
 Most commonly occurring cancer in men & women all have high rate of metastasis to
spine (85%) - Breast / prostate / lung

 Combination of 4 red flags has very high diagnostic accuracy / index of suspicion for
spinal cancer
 History of significant unexplained weight loss
 Previous history of cancer
 Age > 50
 Failure of 1/12 conservative treatment

 (Deyo & Diehl, 1988; Greenhalgh & Selfe, 2006)

  Age > 50 yrs
 Trauma (Bogduk & McGuirk, 2002)
 Medical h/o osteoporosis
 Current h/o systemic steroids (Greenhalgh & Selfe, 2006)

Red Flags for  Consider Canadian cervical (C)-spine rule (Eyre, 2006)
Spinal fracture  99.4% sensitivity & 45.1% specificity
 Osteoporosis Risk Assessment Instrument (ORAI) – Cadarette et
al (2000) – based on age + weight + oestrogen use
 Scores of >9 : sensitivity = 93.3% & specificity = 46.4% for
osteopenia & sensitivity = 94.4% for osteoporosis
 Score of <9 reduced likelihood of suspected osteoporotic fracture in
female
 Marked morning stiffness

Gradual onset before age 40

Red Peripheral & spinal joint stiffness in all

directions
Flags for Spinal
Skin rashes / collitis / irritis
Inflammatory
Disorders Family history

High Erythrocyte Sedimentation Rate (ESR)

mm/hour – blood test
 Systemically unwell - fever or night sweats, exhaustion/fatigue,
generally unwell
 Recent bacterial infection
 UTI (frequency / dysuria)
 IV drug abuse
 Immunosuppression (steroid use / transplant / HIV/AIDs) Red Flags
 Medical h/o (Greenhalgh & Selfe, 2006)
 TB for Spinal


HIV / AIDS
Injection drug abuse Infection
 Catheterization
 Diabetes mellitus
 DH - Systemic steroids (Bogduk & McGuirk, 2002)
  Signs of Cervical Arterial Dysfunction (CAD)
(ischaemia to the brainstem and/or forebrain)
 Dizziness
 Diploplia
 Dysarthria
Special Questions  Dysphagia

– Cervical Spine  Drop attacks

(Greenhalgh & Selfe, 2006)  Nausea

 Numbness (facial)
 Nystagmus
 Headaches
 Visceral causes of
thoracic/trunk pain
 Pleurisy
 Pancoast’s tumour
 Neoplasm
 TB
 Aortic aneurysm
 Hiatus hernia
 Angina pectoris
 Gall bladder, kidney, stomach, ureter,
spleen, bronchi/lungs
 Yellow flag screening

 Screening to identify any

psychosocial risk factors that may
act as a barrier to recovery and lead
to persistent pain
 Psychosocial influence
on pain perception

 Response to pain is affected by your psychology

(thoughts, beliefs, emotions, behaviours) and
social environment
 Psychosocial context is very powerful
 Unhelpful or negative thoughts beliefs & emotions
have been shown to increase & maintain pain,
affect response to treatment & delay recovery
 Waddell (2004) or Linton (2000)
 The presence of unhelpful psychosocial factors is
a risk factor for persistent pain

GFG - EFFECTIVE HISTORY TAKING 2018

 Unhelpful/ Maladative Psychosocial factors

 Important influencing psychosocial factors are

 Fear Avoidance
 Catastrophising
 Pain Behaviours

GFG - EFFECTIVE HISTORY TAKING 2018

 FearAvoidance

 Fear of activity induced pain

 Belief that pain indicates harm or damage
 Belief that pain must be abolished before engaging in
activity eg. RTW / hobbies etc
 Patient example
 “Exercise hurts my back, I’m worried about doing further
damage so I should not do any”
 “Bending is dangerous for my back”

 Leads to  activity levels

 Use of extended rest
 Avoidance of normal activity

 Often have
 High VAS score eg.10/10
 Passive attitude to rehabilitation
 Boom or Bust cycle
 Hypervigilence
GFG - EFFECTIVE HISTORY TAKING 2018
Catastrophising

 Severe, irrational, negative belief about the situation -when negative

thinking spins out of control.
 Patient examples
 “Of course, I have a slipped disc so I can’t bend”
 “I have a crumbling spine and should not sit for
long periods”
 “My discs are degenerative and I have bone
rubbing on bone”
 “Every time I bend my discs slip out”
 “This back pain is so bad I’m going to end up in a
wheelchair, I’ll never walk again”
 Leads to feelings of hopelessness about future prospects, hinders
activity & can lead to fear avoidance & chronic issues

GFG - EFFECTIVE HISTORY TAKING 2018

  Screen every patient on initial assessment
 Have you had any time off work because of your neck/back pain?
 What do you think is the cause of your neck/back pain?
 Are you worried or concerned about anything?
 How are you expecting physiotherapy to help you?
 How are your employers / family/ co-workers responding to your neck/back

Yellow Flag
pain?
 What are you doing to cope with it?
 Are you expecting to go back to work/normal duties – when?

Screening in  Have you been bothered by feeling down, depressed or hopeless in the last
month?

Practice  Have you been bothered by little interest or pleasure in doing things in the last
month?

 Explore using ICE (Impression / concerns / expectations)OR /ABCDEF initially

 Is any intervention required? Can it be included in management plan?

 Is further assessment required? Re-assess in 2-3 weeks;

 Implement psychosocial assessment questionnaires if need be eg. FABQ, IES, TSK, HAD
  Analysis of patients functional complaint
 Determine any influences of work on the patients presenting complaint
 Are there occupational drivers of neck pain?
 Analyse provocative work postures/ activities

 Determine if changes to work posture / working habits / work tasks /

Blue & black flag working environment can change pain state

screening (socio-
occupational)
  Please ask in the face to face session about anything raised in

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