What’s your favorite question to ask of patients?
Here’s the scenario…your patient presents with a diagnosis of low back pain and you can only ask them one question…what would it be? If your goal is to come up with a preliminary hypothesis, what question could you ask that would garner the most information?
So what is your question? Mine would be, “if I asked you to sit, stand, or walk for 30 min, which would bother you the most?” This question gives us so much information. If the patient says that sitting increases their pain, we are thinking they have a disc injury. If they say that standing increases their pain we are thinking they might have an instability. Finally, if they say that walking increases their pain we are thinking they might have stenosis.
Now let us talk about the “whys” behind each answer.
Sitting = Disc
If the patient had a disc injury then sitting would be painful due to the increased inflammatory response from the injury. When we “herniate a disc,” or more accurately suffer from an endplate avulsion lesion, it creates an inflammatory response. When looking at work by Bogduk we see that the resulting inflammatory exudate raises the osmotic pressure within the zone of tissue damage. This inflammatory response is what sensitizes the dura and causes the subsequent peripheral symptoms. When we sit we have an increase in our lumbar flexion posture which also increases the intradiscal pressure. The resultant of the increased osmotic pressure from the injury and the added increase in pressure from sitting is why disc patients do not like to sit.
Standing = Instability
Have you ever heard of the “mommy sway”? A lot of moms sway from side to side to rock their babies to sleep…for those that have a lumbar instability they also rock from side to side because standing still increases their lumbar pain. When you look at the work done by Farfan he shows that when you injury your disc it affects the multifidus of the level that was injured. The muscle is no longer able to perform its job of segmental lumbar stabilization. If the lesion is not properly rehabbed then this becomes chronic and the patient winds up with decreased muscular control of a specific segment. These patients will often sway from side to side to activate the large stabilizers of the lumbar spine to provide the stabilization that the multifidus is not able to do.
Walking = Stenosis
If an initial disc injury is left untreated the natural sequella of events that often occurs is that the disc injury will progress to an instability and eventually stenosis of the segment. Often osteophytes will form and decrease the foramen space. Exiting from the foramen space are vascular and neural structures. If a patient is standing in an upright position the lumbar spine should be in more lumbar lordosis(or extension). This position further compresses the foramen space. This is why they say the longer I am up and walking the worse the pain/paraesthesia gets but if I lean forward (on grocery cart) the pain/paresthesia goes away. This is also why riding a bike does not increase their pain because they are leaning forward in a lumbar flexion position. By leaning forward they are opening up the foramen space and decreasing the compressing force.
If, as a profession, our reimbursement continues to decrease we are going to have to see more patients in shorter periods of time to pay our bills. We need to make sure that we are specific and intentional with what we are asking our patients to keep our assessment moving forward and not stalling out. By asking pointed specific questions we can zero in on the patient’s dysfunction more quickly and move into treatment, which is really what the patient came for.
So that’s my favorite question, what is yours? Do you have one that you like to ask that quickly helps you form a potential hypothesis as to the cause of the patient’s pain/dysfunction?
-Stacy Soaoppman, PT, DSc, COMT, FAAOMPT
Join Stacy for Manip Like A Girl course August 16 in Colorado Springs, CO (males welcome too!)
naiomt.me 
I would say that is a great question and that would definitely be high on my list due to the statistical utility of this question (Fritz 1998 shows that a patient reporting no pain with sitting had the highest specificity of .93 compared to a list of other data gained from the history. This resulted in a 6.6 +LR which is a quite large shift in statistical probability of having the condition.) Perhaps the question how long have you had these symptoms may be a helpful question as well. If they say 40 years and they are 70 years old, the liklihood of it being related to a stenotic or degenerative process is high. If they say it just happened yesterday, then you can infer that they are in the acute phase and thus their irritability level is high so we must proceed with caution so as to avoid a significant flare up. If they say one to two months and they don’t know why, our radar should be on high suspicion of a non-musculoskeletal cause.
Another question that may be helpful is: what do you think is going on with your back? If they lead into the common misbeliefs that they had a disc bulge 20 years ago and now I have this permenantly weak and bad back.. Or yeah I injured my back 3 years ago and so it’s not probably arthritis back there.. It sheds some light on where they are at with their beliefs and we can integrate best practice for that subgroup by integrating a biopsychosocial approach to deal with these “thought viruses” and steering away from another pathoanatomical label that they will cling onto for the years to come. Perhaps explaining more about pain to ease their anxiety and help them gain control over their pain would be more indicated at that time in addition to evidenced based manual therapy and exercise
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Great questions and points Steve!
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Stacy & Steve,
From a differential dx perspective, pattern recognition, and reasoning process, the “sitting, standing, walking” line of questioning is, IMO, an excellent route to take. It offers the clinician a route to assist the patient in his or her painful complaint quickly and effectively. And, should the patient respond positively to the treatment based on the answer to the question, the clinician AND patient now have rapport, trust, and buy-in.
And from Steve’s post, and a question I use often, is,” What do you think is wrong?” This question opens the door to what the patient has been told by previous healthcare professionals, offers us a chance to gauge potential nocebo involvement, and dispel misinformation and misguided advice. One caveat to pain education is that I think we ought to be careful just how much we hang our hats on pain education and its effects on the patient in front of us. I’ve seen new grads and students miss important signs and symptoms because they’ve seen the issue at hand (pain) is persistent and as such, are quick to dispel much of the scan & biomechanial exam in favor of pain education; this is dangerous. and most patients are left just as frustrated with this explanation as they are with overly biomechanical talk.
Lastly, there exists a litany of blogs out there that write of the frustration of both the clinician and the patient in regards to patient buy-in, outcomes, and satisfaction with TNE/pain education. As it is with any therapeutic intervention like ASTYM, manipulation, DN, taping, whatever, we cannot count one intervention as a stand-alone answer to all. Just like many of the aforementioned treatment modalities were fancy, sexy, new & cool ways to treat patients in their infancy, this is what TNE/pain education is now in the PT world, and the PT profession is best served adapting and incorporating it into the best, current, and evidenced-informed practice patterns.
Off soap-box…Keep up the excellent work Stacy & Steve! I enjoy following you both.
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Thanks for the kind words and for jumping into the conversation Austin. It’s so valuable for everyone to hear how other PTs are approaching this, and discuss best practices.
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Austin, totally agree with a lot of what you said. Hear me when I say that I don’t use TNE exclusively, but rather as a lead in to then go ahead and utilize manual therapy and exercise and active interventions. You say that there are lots of blogs about the PT and patients frustration regarding TNE, what are those? I would love to read them. I know that I have been frustrated in my own skill with TNE in my infancy with using the intervention and I know also that early on I was off-putting to some patients who didn’t understand where I was coming from. I feel that that wasn’t because the intervention isn’t useful, but that I wasn’t doing it right. Just like when we teach manips, the technique is everything.. the amplitude, the speed, the vector, the locking.. They all have a great to do with the barrier developed and the outcome achieved. Same with TNE, if it’s not working, it may be our verbiage, our analogies, are stories, they don’t strike a bell with the patient and therefore they have a tough time with but in. But if we develop our tool box of various analogies and stories then we can pick and choose so that we can effectively teach (with analogies that are specific to every patient) anyone from the stay at home mom to long haul trucker. I wrote a blog post a while ago discussing how important te actually words that we choose are. Believe me, I love biechanics and I want to fogure out what is going on and utilize a scan and biomechanical exam to try and make sense of what is going on and develop a framework with which to treat, but I still stand firm in the fact that we must watch what comes out of our mouth. If we use terms like “herniated disc” “locked facet” “torn muscle fiber” “sprained capsule” “slipped vertebrae” we can instill a great degree of fear which essentially shoots ourselves in the foot with progress. That’s why I personally love TNE.. Even if I feel fairly certain that someone is dealing with a disc bulge as we think of them, if I can use terms like “not moving well” or “your back is sensitive because you had/have an injury but we’re are going to do X, Y, and Z and make it less sensitive” then I can reduce the fear that I myself might create with my biomechanical lingo. I think the real place to be is to marry the two as much as possible, which I think is where you are at too. Eclectic is key. I just wanted to make sure you don’t think all I do is TNE or that I forfeit a sound physical exam in exchange to sit and talk with people. We’re PTs and I know we need to utilize manual therapy and exercise to work with people effectively, I guess I am in the camp that we can and should do both TNE and OMT/exercise.
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