Review our list along with a video tutorial on how to master the clinical “20 questions” game.
The art of diagnosis is essentially a game of elimination; and a missed question can lead to a missed diagnosis. Check out our list of twelve potentially game-changing questions that you’ll not want to overlook.
1. How long does your morning stiffness last?
One of the key clues in differentiating OA from inflammatory arthropathy is “how long does it take to get moving in the morning?” Inflammatory arthropathy patients experience stiffness that lasts longer than the expected ~15 minutes with OA.
Research suggests that systemic inflammatory arthropathies are responsible for a significant percent of back and joint pain. The classic presentation includes: gradual onset LBP that started before age 40 with pain at rest that improves with exercise. (1) While these symptoms may mimic osteoarthritis or simple mechanical dysfunction, there may be a few other clues to help identify systemic arthropathies:
- Multiple joint involvement
- Warmth and swelling
- Skin rashes or mouth sores
- Fatigue or flu like symptoms
Check out the ChiroUp inflammatory arthropathy synopsis for a handy 1-page guide to identifying systemic problems.
2. Does the pain wake you at night? If so are you able to reposition and go back to sleep or do you need to get out of bed?
Not all night-time pain represents something sinister. Problems like chronic tendinopathies and neuropathies involve local tissue ischemia and generally feel worse when blood flow slows during sleep. While these problems can wake a patient, they will also generally improve with simple repositioning to temporarily enhance circulation. Pain that does not dissipate with care or requires someone to “get out of bed” deserves a closer look at question #3.
Use nighttime discomfort as a gauge for progressive loading tendinopathy rehab; an increase in nighttime symptoms means that you have pushed too hard.
3. Do you have anything more serious going on?
Wouldn’t it be nice if our patient had a check engine light for serious problems? Until human bodies evolve include that luxury, the obligation to uncover those pathologies is on us.
The ongoing campaign to limit avoidable imaging only enhances our responsibility to identify red flags and concerns arising from non-MSK systems. Red flags help direct our imaging decisions, however a 2018 Spine journal study found that imaging was inappropriately NOT performed in nearly two-thirds of patients who presented with red flags. (3) Red flags can be consistently identified only by asking LOTS of questions about many systems.
Pro tip from ChiroUp advisor Dr. David Flatt:
“As we all know, it is an art form to get accurate, honest, and truthful information from patients – not easy by any stretch. In the red flag realm, I present a quick series of yes or no questions ( from the ChiroUp review of systems ). Obviously, if the patient answers yes to any of these, we are obligated to follow up with more exacting questions.”
4. Do you have any weakness?
This weakness question is not answered verbally or with a single test, but rather by performing repeated muscle testing. While some patients will report pain-induced “weakness”, very few patients will recognize true motor weakness. And neither will we if we don’t adequately challenge the muscle. Bodies find ways to compensate for weakness and those mechanisms can mask underlying deficits. Performing a single repetition of a toe raise or heel lift will sometimes fail to expose weakness. So, consider 10 repetitions next time you suspect a motor deficit- it will help you with the next question.
5. Are your sciatic symptoms chemical or compressive?
Spinal radiculopathy presents in two basic varieties:
- Chemical radiculopathy– This is where the belligerent bar patron called the disc nucleus is introduced to a bouncer called the immune system. Because of the vulnerability of the posterior annulus, the ensuing fight usually takes place next to a nerve root. Chemical radiculopathies irritate the outermost nerve fibers, and hence generate sensory disturbances (i.e. pain and paresthesia), but generally do not trigger reflex or motor deficits.
- Compressive radiculopathy– In this significantly less common variety, the nerve root is physically compressed by a disc, spur, or other stenotic lesion. This triggers an ischemic reaction that can affect the entirety of the nerve including the deeper motor and reflex fibers. Loss of motor or reflex function is a significantly more concerning problem because basically someone is being choked out and the permanent impairment clock is ticking. This presentation almost always warrants immediate advanced imaging and consideration for neurosurgical referral or co-management.
Pro tip from some doc named Brandon: “Mechanical compression patients can often find positions of relief. However, many patients can present with both a chemical and mechanical component. Never be afraid to try a trial of care, however, motor deficits warrant further investigation to minimize the risk of lasting neurologic deficit.”
6. Do you ever feel a “hitch” or joint locking?
Palpating a tender spinal segment indicates something’s wrong, probably intersegmental joint dysfunction. But that doesn’t necessarily mean the joint is hypomobile. Hypermobile joints demonstrate palpatory tenderness too. The management of hypo- vs. hyper-mobility is divergent, so how do you tell the difference? Here are four clinical signs of lumbar segmental instability that will likely respond to a stability program (2):
- Age under 40
- Aberrant movement that might include a “hitch” or “catch”
- Active straight leg raise > 90 degrees
- Positive prone instability test
Check out this recent Facebook live tutorial for details about identifying and managing spinal instability.
7. If you had hold one position all day, would you prefer to sit or stand?
More than any other single question, this one helps to define a lumbar or cervical directional preference. Patients who prefer to stand are telling you they like extension. Those who like to sit, generally prefer flexion. Knowing the directional preference allows you to accurately answer a myriad of options:
- Sphynx extension vs knee to chest exercises?
- Should the patient use a lumbar roll when sitting?
- Are early morning toe touches acceptable?
- Should the patient lie prone or supine during lumbar traction?
- Recommend a sitting or standing workstation?
- Perform or skip the levator stretch?
Knowing the directional preference takes the guesswork out of many treatment, exercise, and ADL suggestions. If you’re not completely sure what directional preference means, then you’ll want to check out a class from the chiropractic division of the McKenzie Institute.
8. How long has this tendon been hurting?
While the management of some conditions changes minimally in acute vs chronic situations, that’s not the case with tendons. Like most any other tissue, initial insults to a tendon generate inflammation, however ongoing tendon stress (beyond a few days) leads to a failed healing response.
The etiology of chronic tendinopathy is more degenerative than inflammatory- wherein a classic inflammatory reaction is histologically absent in lieu of thin, degenerated, and disorganized collagen fibers, along with other signs of a failed healing response. Knowing how long the tissue has been irritated will allow you to choose between suppressing inflammation with anti-inflammatory techniques (rest, ice, modalities, etc.) vs. stimulating a controlled inflammatory reaction (IASTM, shock wave therapy, laser, dry needling, and progressive loading.)
Pro tip from ChiroUp advisor Dr. Tom Hyde:
In my opinion, once a soft tissue sustains injury, treatment should be initiated as quickly as possible, but first, you must determine if the tendon is intact or has sustained a partial tear. Diagnostic Ultrasound (DU) can often provide an answer quickly IF you have access to this equipment. Many hospitals as well as diagnostic radiology centers, and many universities have this equipment. It offers a quick method of assessing soft tissue injury, not just tendon injuries, and allows you to follow the progress, or lack thereof, your therapy.
As with any injury, it is important to know the date of injury. Are you dealing with an acute injury, subacute, or chronic injury? Providing manual or IASTM to an acute injury is often applied by sports health care providers and others. There was also a time when RICE and later PRICE came into the picture, however, it has been shown that ice should not be utilized in the acute phase. There are several references questioning the use of ice on an acute injury and injuries to soft tissues. (1,2) There appears to be what is alluded to as a paradigm shift related to the use of ice in the treatment of soft tissue injuries which includes tendons.
9. Does your pain change with movement?
This question differentiates mechanical from chemical pain. Unwavering pain suggests an inflammatory origin which requires further workup to exclude underlying pathology. Manual/ movement therapy works best for problems that change with movement. Most cases of chemically-mediated pain benefit from a chemical solution, or at least co-management.
Pro tip from ChiroUp advisor Dr. Jess Brower:
“I always ask the patient to point to their pain and put their finger on it, and then I have them “show me a movement that hurts.” This leads to a lot of additional findings or clues that I could easily overlook. We all know that someone’s “Hip” could be somewhere between their knee and their shoulder.”
10. Are you happy and at ease?
As practicing providers, we’re all keenly aware of how attitude affects outcome. Patients who exhibit unhealthy beliefs or interpretations about pain and recovery will certainly not respond as favorably – or at all. The following biopsychosocial inventories can help qualify and quantify the corresponding yellow flags.
- Fear-avoidance (FABQ)
- Catastrophizing (PCS)
- Kinesiophobia (TSK-11)
- Passive coping/ Reliance on passive care (CAPQ)
- Excessive stress (PSS)
- Anxiety (STAI, PASS-20, GAD-7)
- PTSD (PC-PTSD-5, SPRINT)
- Depression (PHQ-9)
- Workplace fears (FABQ-W)
- Central sensitization (CSI)
Use the yellow flag questionnaire as a screening tool to narrow your biopsychosocial focus.
11. Are you doing your home exercises? …correctly?
The literature clearly shows that rehab is a crucial component of MSK recovery. Patients who are active participants in their own recovery tend to have better outcomes. And those who participate correctly recover even better. Worthwhile rehab entails identifying functional deficits, then progressively challenging the patient with exercise slightly beyond their current comfort zone.
Prescribing an exercise that the patient cannot complete correctly, or does not know how to perform properly, leads to frustration and failure at best – and potentially an even stronger pattern of dysfunction. Choose quality over quantity. Select the most appropriate exercise(s), equip the patient with the skills to perform those exercises correctly, then insure they are participating…correctly.
Want to help automate the process? Check out this sample ChiroUp lay condition report on carpal tunnel syndrome that includes video demonstrations of the essential exercises and ADL’s. (Created in 14 seconds.)
12. Can I forward my findings to your primary care physician?
Teamwork and communication are essential elements of quality care, so our intake form includes this question. Plus, sending summarized initial reports and release reports is probably your most effective practice building tool.
Although US laws do not require treating providers to obtain permission to communicate with other treating providers, we still obtain permission to avoid surprises. We insist upon forwarding an initial visit summary and discharge report to EVERY patient’s primary provider. In the rare instance that a patient denies permission, we take that opportunity to explain why it is in their best interest for all providers to be on the same team. And finally, if they’re looking for someone who practices in isolation, they’ll need to find another office.
Want to learn more about harvesting MD referrals through simple communication? Check out this prior blog for details.
Our clinical toolbox has two sides; one filled with various treatment tools and the other with questions to ask in order to choose which tool to employ. While there is no effective way to eliminate this task, there are ways to automate it.
And that happens with ChiroUp.
If you’re ready to see how this can work for your unique practice, I’d encourage you to schedule a call today with our team. It’s 20 minutes of your time that I can assure you will be worth your time.
“ChiroUp has greatly improved our office processes as a whole. Patients love the app they can download with all their exercise videos, and we love the backend automation for things like PCP letters and Google reviews. Don’t know how we ever practiced without it!”
“We are so happy to work with ChiroUp! Every member of their team has gone above and beyond to make our user experience the best. We even received customer support on a Sunday afternoon! It’s nice to know you are working with real, live people. 🙂 The ChiroUp resources are helping us better educate our patients and to build our relationships with the area MDs. Thank you ChiroUp!”
– Active Health Chiropractic & Wellness
“Chiroup has been a game changer for my practice. I use it on a daily basis to help improve my patient care. I have been able to effectively treat more conditions in a patient centered, evidence informed way. Highly recommended!! Thank you to the Chiroup team!”
- Sieper J et al. New Criteria for Inflammatory Back Pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of Spondyloarthritis inernational Society (ASAS). Ann Rheum Dis 2009; 68: 784-8.
- Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation. 2005 Sep 1;86(9):1753-62.
- Jenkins HJ, et al. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine 2018
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as past president of the executive board.
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