Interviewing as a Screening Tool

Chapter 2


Interviewing as a Screening Tool


The client interview, including the personal and family history, is the single most important tool in screening for medical disease. The client interview as it is presented here is the first step in the screening process.


Interviewing is an important skill for the clinician to learn. It is generally agreed that 80% of the information needed to clarify the cause of symptoms is given by the client during the interview. This chapter is designed to provide the physical therapist with interviewing guidelines and important questions to ask the client.


Medical practitioners (including nurses, physicians, and therapists) begin the interview by determining the client’s chief complaint. The chief complaint is usually a symptomatic description by the client (i.e., symptoms reported for which the person is seeking care or advice). The present illness, including the chief complaint and other current symptoms, gives a broad, clear account of the symptoms—how they developed and events related to them.


Questioning the client may also assist the therapist in determining whether an injury is in the acute, subacute, or chronic stage. This information guides the clinician in addressing the underlying pathology while providing symptomatic relief for the acute injury, more aggressive intervention for the chronic problem, and a combination of both methods of treatment for the subacute lesion.


The interviewing techniques, interviewing tools, Core Interview, and review of the inpatient hospital record in this chapter will help the therapist determine the location and potential significance of any symptom (including pain).


The interview format provides detailed information regarding the frequency, duration, intensity, length, breadth, depth, and anatomic location as these relate to the client’s chief complaint. The physical therapist will later correlate this information with objective findings from the examination to rule out possible systemic origin of symptoms.


The subjective examination may also reveal any contraindications to physical therapy intervention or indications for the kind of intervention that is most likely to be effective. The information obtained from the interview guides the therapist in either referring the client to a physician or planning the physical therapy intervention.



Concepts in Communication


Interviewing is a skill that requires careful nurturing and refinement over time. Even the most experienced health care professional should self-assess and work toward improvement. Taking an accurate medical history can be a challenge. Clients’ recollections of their past symptoms, illnesses, and episodes of care are often inconsistent from one inquiry to the next.1


Clients may forget, underreport, or combine separate health events into a single memory, a process called telescoping. They may even (intentionally or unintentionally) fabricate or falsely recall medical events and symptoms that never occurred. The individual’s personality and mental state at the time of the illness or injury may influence their recall abilities.1


Adopting a compassionate and caring attitude, monitoring your communication style, and being aware of cultural differences will help ensure a successful interview. Using the tools and techniques presented in this chapter will get you started or help you improve your screening abilities throughout the subjective examination.



Compassion and Caring


Compassion is the desire to identify with or sense something of another’s experience and is a precursor of caring. Caring is the concern, empathy, and consideration for the needs and values of others. Interviewing clients and communicating effectively, both verbally and nonverbally, with compassionate caring takes into consideration individual differences and the client’s emotional and psychologic needs.2,3


Establishing a trusting relationship with the client is essential when conducting a screening interview and examination. The therapist may be asking questions no one else has asked before about body functions, assault, sexual dysfunction, and so on. A client who is comfortable physically and emotionally is more likely to offer complete information regarding personal and family history.


Be aware of your own body language and how it may affect the client. Sit down when obtaining the history and keep an appropriate social distance from the client. Take notes while maintaining adequate eye contact. Lean forward, nod, or encourage the individual occasionally by saying, “Yes, go ahead. I understand.”


Silence is also a key feature in the communication and interviewing process. Silent attentiveness gives the client time to think or organize his or her thoughts. The health care professional is often tempted to interrupt during this time, potentially disrupting the client’s train of thought. Silence can give the therapist time to observe the client and plan the next question or step.



Communication Styles


Everyone has a slightly different interviewing and communication style. The interviewer may need to adjust his or her personal interviewing style to communicate effectively.


Relying on one interviewing style may not be adequate for all situations.


There are gender-based styles and temperament/personality-based styles of communication for both the therapist and the client. There is a wide range of ethnic identifications, religions, socioeconomic differences, beliefs, and behaviors for both the therapist and the client.


There are cultural differences based on family of origin or country of origin, again for both the therapist and the client. In addition to spoken communication, different cultural groups may have nonverbal, observable differences in communication style. Body language, tone of voice, eye contact, personal space, sense of time, and facial expression are only a few key components of differences in interactive style.4



Illiteracy


Throughout the interviewing process and even throughout the episode of care, the therapist must keep in mind that an estimated 44 million American adults are illiterate and an additional 35 million read only at a functional level for social survival. According to the National Center for Education Statistics, illiteracy is on the rise in the United States.


Nearly 24 million people in the United States do not speak or understand English. More than one third of English-speaking patients and half of Spanish-speaking patients at U.S. hospitals have low health literacy.5 According to the findings of the Joint Commission, health literacy skills are not evident during most health care encounters. Clear communication and plain language should become a goal and the standard for all health care professionals.6


Low health literacy means that adults with below basic skills have no more than the most simple reading skills. They cannot read a physician’s (or physical therapist’s) instructions or food or pharmacy labels.7


It is likely that the rates of health illiteracy defined as the inability to read, understand, and respond to health information are much higher. It is a problem that has gone largely unrecognized and unaddressed. Health illiteracy is more than just the inability to read. People who can read may still have great difficulty understanding what they read.


The Institute of Medicine (IOM) estimates nearly half of all American adults (90 million people) demonstrate a low health literacy. They have trouble obtaining, processing, and understanding the basic information and services they need to make appropriate and timely health decisions.


Low health literacy translates into more severe, chronic illnesses and lower quality of care when care is accessed. There is also a higher rate of health service utilization (e.g., hospitalization, emergency services) among people with limited health literacy. People with reading problems may avoid outpatient offices and clinics and utilize emergency departments for their care because somebody else asks the questions and fills out the form.7


It is not just the lower socioeconomic and less-educated population that is affected. Interpreting medical jargon and diagnostic test results and understanding pharmaceuticals are challenges even for many highly educated individuals.





English as a Second Language


The therapist must keep in mind that many people in the United States speak English as a second language (ESL) or are limited English proficient (LEP), and many of those people do not read, or write English.10 More than 14 million people age 5 and older in the United States speak English poorly or not at all. Up to 86% of non–English speakers who are illiterate in English are also illiterate in their native language.


In addition, millions of immigrants (and illegal or unregistered citizens) enter U.S. communities every year. Of these people, 1.7 million who are age 25 and older have less than a fifth-grade education. There is a heavy concentration of persons with low literacy skills among the poor and those who are dependent on public financial support.


Although the percentages of illiterate African-American and Hispanic adults are much higher than those of white adults, the actual number of white nonreaders is twice that of African-American and Hispanic nonreaders, a fact that dispels the myth that literacy is not a problem among Caucasians.11


People who are illiterate cannot read instructions on bottles of prescription medicine or over-the-counter medications. They may not know when a medicine is past the date of safe consumption nor can they read about allergic risks, warnings to diabetics, or the potential sedative effect of medications.


They cannot read about “the warning signs” of cancer or which fasting glucose levels signal a red flag for diabetes. They cannot take online surveys to assess their risk for breast cancer, colon cancer, heart disease, or any other life-threatening condition.



The Physical Therapist’s Role


The therapist should be aware of the possibility of any form of illiteracy and watch for risk factors such as age (over 55 years old), education (0 to 8 years or 9 to 12 years but without a high school diploma), lower paying jobs, living below the poverty level and/or receiving government assistance, and ethnic or racial minority groups or history of immigration to the United States.


Health illiteracy can present itself in different ways. In the screening process, the therapist must be careful when having the client fill out medical history forms. The illiterate or functionally illiterate adult may not be able to understand the written details on a health insurance form, accurately complete a Family/Personal History form, or read the details of exercise programs provided by the therapist. The same is true for individuals with learning disabilities and mental impairments.


When given a choice between “yes” and “no” answers to questions, functionally illiterate adults often circle “no” to everything. The therapist should briefly review with each client to verify the accuracy of answers given on any questionnaire or health form.


For example, you may say, “I see you circled ‘no’ to any health problems in the past. Has anyone in your immediate family (or have you) ever had cancer, diabetes, hypertension …” and continue to name some or all of the choices provided. Sometimes, just naming the most common conditions is enough to know the answer is really “no”—or that there may be a problem with literacy.


Watch for behavioral red flags such as misspelling words, not completing intake forms, leaving the clinic before completing the form, outbursts of anger when asked to complete paperwork, asking no questions, missing appointments, or identifying pills by looking at the pill rather than naming the medication or reading the label.12


The IOM has called upon health care providers to take responsibility for providing clear communication and adequate support to facilitate health-promoting actions based on understanding. Their goal is to educate society so that people have the skills they need to obtain, interpret, and use health information appropriately and in meaningful ways.13,14


Therapists should minimize the use of medical terminology. Use simple but not demeaning language to communicate concepts and instructions. Encourage clients to ask questions and confirm knowledge or tactfully correct misunderstandings.13


Consider including the following questions:



image Follow-Up Questions





Resources


There is a text available specifically for physical therapists to help us identify our own culture and recognize the importance of understanding and communicating with clients of different cultural backgrounds. Widely accepted cultural practices of various ethnic groups are included along with descriptions of cultural and language nuances of subcultures within each ethnic group.15 A text on this same topic for health care professionals is also available.16


Identifying individual personality style may be helpful for each therapist as a means of improving communication. Resource materials are available to help with this.17,18 The Myers-Briggs Type Indicator, a widely used questionnaire designed to identify one’s personality type, is also available on the Internet at www.myersbriggs.org.


For the experienced clinician, it may be helpful to reevaluate individual interviewing practices. Making an audio or videotape during a client interview can help the therapist recognize interviewing patterns that may need to improve. Watch and/or listen for any of the guidelines listed in Box 2-1.



Box 2-1   Interviewing Do’s and Don’ts



DO’s


Do extend small courtesies (e.g., shaking hands if appropriate, acknowledging others in the room)


Do use a sequence of questions that begins with open-ended questions.


Do leave closed-ended questions for the end as clarifying questions.


Do select a private location where confidentiality can be maintained.


Do give your undivided attention; listen attentively and show it both in your body language and by occasionally making reassuring verbal prompts, such as “I see” or “Go on.” Make appropriate eye contact.


Do ask one question at a time and allow the client to answer the question completely before continuing with the next question.


Do encourage the client to ask questions throughout the interview.


Do listen with the intention of assessing the client’s current level of understanding and knowledge of his or her current medical condition.


Do eliminate unnecessary information and speak to the client at his or her level of understanding.


Do correlate signs and symptoms with medical history and objective findings to rule out systemic disease.


Do provide several choices or selections to questions that require a descriptive response.



DON’Ts


Don’t jump to premature conclusions based on the answers to one or two questions. (Correlate all subjective and objective information before consulting with a physician.)


Don’t interrupt or take over the conversation when the client is speaking.


Don’t destroy helpful open-ended questions with closed-ended follow-up questions before the person has a chance to respond (e.g., How do you feel this morning? Has your pain gone?).


Don’t use professional or medical jargon when it is possible to use common language (e.g., don’t use the term myocardial infarct instead of heart attack).


Don’t overreact to information presented. Common overreactions include raised eyebrows, puzzled facial expressions, gasps, or other verbal exclamations such as “Oh, really?” or “Wow!” Less dramatic reactions may include facial expressions or gestures that indicate approval or disapproval, surprise, or sudden interest. These responses may influence what the client does or does not tell you.


Don’t use leading questions. Pain is difficult to describe, and it may be easier for the client to agree with a partially correct statement than to attempt to clarify points of discrepancy between your statement and his or her pain experience.



















Leading Questions Better Presentation of Same Questions
Where is your pain? Do you have any pain associated with your injury? If yes, tell me about it.
Does it hurt when you first get out of bed? When does your back hurt?
Does the pain radiate down your leg? Do you have this pain anywhere else?
Do you have pain in your lower back? Point to the exact location of your pain.

Texts are available with the complete medical interviewing process described. These resources are helpful not only to give the therapist an understanding of the training physicians receive and methods they use when interviewing clients, but also to provide helpful guidelines when conducting a physical therapy screening or examination interview.19,20


The therapist should be aware that under federal civil rights laws and the Medicaid Act, any client with LEP has the right to an interpreter free of charge if the health care provider receives federal funding. But keep in mind that quality of care for individuals who are LEP is compromised when qualified interpreters are not used (or available). Errors of omission, false fluency, substitution, editorializing, and addition are common and can have important clinical consequences.10 Standards for medical interpreting professionals in the United States have been published and are available online.21


The American Physical Therapy Association (APTA) makes available a distance-learning course that provides listening and speaking skills needed to communicate effectively with Spanish-speaking clients and their families. Contact Member Services for information at 800-999-2782 and ask for Spanish for Physical Therapists: Tools for Effective Patient Communication.


The Joint Commission’s 2007 report, What did the doctor say? Improving health literacy to protect patient safety, is a must read. It is available online at www.jointcommission.org.



Cultural Competence


Interviewing and communication require a certain level of cultural competence as well. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.2,22 Multiculturalism is a term that takes into account that every member of a group or country does not have the same ideals, beliefs, and views.


Cultural competence can be defined as the ability to understand, honor, and respect the beliefs, lifestyles, attitudes, and behaviors of others.23 Cultural competency goes beyond being “politically correct.” As health care professionals, we must develop a deeper sense of understanding of how ethnicity, language, cultural beliefs, and lifestyles affect the interviewing, screening, and healing process.



Minority Groups


The need for culturally competent physical therapy care has come about, in part, because of the rising number of groups in the United States. Groups other than “white” or “Caucasian” counted as race/ethnicity by the U.S. Census are listed in Box 2-2. Previously these groups were referred to as “minorities,” but social scientists are looking for a different term to describe these groups. Terms such as “dominant” and “nondominant” have been suggested when discussing race and ethnicity.



Box 2-2   Racial/Ethnic Designations


Some individuals may consider themselves “multiracial” based on the combination of their father and mother’s racial background. The categories below are used by the U.S. government for census-taking but do not recognize multiple racial combinations. This grouping was adopted for use by the APTA in the Guide to Physical Therapist Practice, ed 2 (Revised), 2003.



This has come about because some minority groups are no longer a “minority” in the United States due to changing demographics. According to the U.S. Census Bureau, 31% of the U.S. population belongs to a racial/ethnic minority group. By the year 2042, Caucasians will represent less than 50% of the population (currently at approximately 75%).24 Hispanic Americans will comprise nearly a quarter of the American population (currently 12.5% and expected to reach 30% by 2042). African Americans make up 12.5% of the population (as of 1990). This will increase to approximately 15% so that Hispanic Americans will outnumber African Americans by 2 : 1. Asian/Pacific Island Americans will make up almost 10% in 2050.24



Cultural Competence in the Screening Process


Clients from a racial/ethnic background may have unique health care concerns and risk factors. It is important to learn as much as possible about each group served (Case Example 2-1). Clients who are members of a cultural minority are more likely to be geographically isolated and/or underserved in the area of health services. Risk-factor assessment is very important, especially if there is no primary care physician involved.



Case Example 2-1   Cultural Competency


A 25-year-old African-American woman who is also a physical therapist came to a physical therapy clinic with severe right knee joint pain. She could not recall any traumatic injury but reported hiking 3 days ago in the Rocky Mountains with her brother. She lives in New York City and just returned yesterday.


A general screening examination revealed the following information:



What Are the Red-Flag Signs/Symptoms?


How Do You Handle a Case Like This? 



With the combination of red flags (change in altitude, increased fatigue, increased urination, and stomach pain), there could be a possible systemic cause, not just life’s stressors as attributed by the client. The physical therapist treated the symptoms locally but not aggressively and referred the client immediately to a medical doctor.


Result: The client was subsequently diagnosed with sickle cell anemia. Medical treatment was instituted along with client education and a rehab program for local control of symptoms and a preventive strengthening program.


Communication style may be unique from group to group; be aware of groups in your area or community and learn about their distinctive health features. For example, Native Americans may not volunteer information, requiring additional questions in the interview or screening process. Courtesy is very important in Asian cultures. Clients may act polite, smiling and nodding, but not really understand the clinician’s questions. ESL may be a factor; the client may need an interpreter. The client may not understand the therapist’s questions but will not show his or her confusion and will not ask the therapist to repeat the question.


Cultural factors can affect the way a person follows through on instructions, interprets questions, and participates in his or her own care. In addition to the guidelines in Box 2-1, Box 2-3 offers some “Dos” in a cultural context for the physical therapy or screening interview.



Box 2-3   Cultural Competency in a Screening Interview





When Working with an Interpreter



• Choosing an interpreter is important. A competent medical interpreter is familiar with medical terminology, cultural customs, and the policies of the health care facility in which the client is receiving care.


• There may be problems if the interpreter is younger than the client; in some cultures it is considered rude for a younger person to give instructions to an elder.


• In some cultures (e.g., Muslim), information about the client’s diagnosis and condition are relayed to the head of the household who then makes the decision to share the news with the client or other family members.


• Listen to the interpreter but direct your gaze and eye contact to the client (as appropriate; sustained direct eye contact may be considered aggressive behavior in some cultures).


• Watch the client’s body language while listening to him or her speak.


• Head nodding and smiling do not necessarily mean understanding or agreement; when in doubt, always ask the interpreter to clarify any communication.


• Keep comments, instructions, and questions simple and short. Do not expect the interpreter to remember everything you said and relay it exactly as you said it to the client if you do not keep it short and simple.


• Avoid using medical terms or professional jargon.



Resources


Learning about cultural preferences helps therapists become familiar with factors that could impact the screening process. More information on cultural competency is available to help therapists develop a deeper understanding of culture and cultural differences, especially in health and health care.4,25,26


The Health Policy and Administration Section of the APTA has a Cross-Cultural & International Special Interest Group (CCISIG) with information available regarding international physical therapy, international health-related issues, and physical therapists working in third world countries or with ethnic groups.27 The APTA also has a department dedicated to Minority and International Affairs with additional information available online regarding cultural competence.23,36


Information on laws and legal issues affecting minority health care are also available. Best practices in culturally competent health services are provided, including summary recommendations for medical interpreters, written materials, and cultural competency of health professionals.36


The APTA’s Tips to Increase Cultural Competency offers information on values and principles integral to culturally competent education and delivery systems, a Publications Corner that includes articles on cultural competence, links to resources, resources for treating patients/clients from diverse background, and more.28 Also, there is a Blueprint for Teaching Cultural Competence in Physical Therapy Education now available that was created by the Committee on Cultural Competence.29 This program is a guide to help physical therapists develop core knowledge, attitudes, and skills specific to developing cultural competence as we meet the needs of diverse consumers and strive to reduce or eliminate health disparities.29


The U.S. Department of Health and Human Services’ Office of Minority Health has published national standards for culturally and linguistically appropriate services (CLAS) in health care. These are available on the Office of Minority Health’s Web site (www.omhrc.gov/clas).30


Resources on the language and cultural needs of minorities, immigrants, refugees, and other diverse populations seeking health care are available, including strategies for overcoming language and cultural barriers to health care.31


The American Academy of Orthopaedic Surgeons offers a free online mini-test of cultural competence for residents and medical students that physical therapist may find helpful and informative.32 For more specific information about the Muslim culture, visit The Council on American-Islamic Relations33 or the Muslim American Society.34,35


The Gay and Lesbian Medical Association (GLMA) offers publications on professional competencies in providing a safe clinical environment for Lesbian-Gay-Bisexual-Transgender-Intersex (LGBTI) health.37



The Screening Interview


The therapist will use two main interviewing tools during the screening process. The first is the Family/Personal History form (see Fig. 2-2). With the client’s responses on this form and/or the client’s chief complaint in hand, the interview begins.


The overall client interview is referred to in this text as the Core Interview (see Fig. 2-3). The Core Interview as presented in this chapter gives the therapist a guideline for asking questions about the present illness and chief complaint. Screening questions may be interspersed throughout the Core Interview as seems appropriate, based on each client’s answers to questions.


There may be times when additional screening questions are asked at the end of the Core Interview or even on a subsequent date at a follow-up appointment. Specific series of questions related to a single symptom (e.g., dizziness, heart palpitations, night pain) or event (e.g., assault, work history, breast examination) are included throughout the text and compiled in the Appendix for the clinician to use easily.



Interviewing Techniques


An organized interview format assists the therapist in obtaining a complete and accurate database. Using the same outline with each client ensures that all pertinent information related to previous medical history and current medical problem(s) is included. This information is especially important when correlating the subjective data with objective findings from the physical examination.


The most basic skills required for a physical therapy interview include:




Open-Ended and Closed-Ended Questions


Beginning an interview with an open-ended question (i.e., questions that elicit more than a one-word response) is advised, even though this gives the client the opportunity to control and direct the interview.38


People are the best source of information about their own condition. Initiating an interview with the open-ended directive, “Tell me why you are here” can potentially elicit more information in a relatively short (5- to 15-minute) period than a steady stream of closed-ended questions requiring a “yes” or “no” type of answer (Table 2-1).39,40 This type of interviewing style demonstrates to the client that what he or she has to say is important. Moving from the open-ended line of questions to the closed-ended questions is referred to as the funnel technique or funnel sequence.



Each question format has advantages and limitations. The use of open-ended questions to initiate the interview may allow the client to control the interview (Case Example 2-2), but it can also prevent a false-positive or false-negative response that would otherwise be elicited by starting with closed-ended (yes or no) questions.



Case Example 2-2   Monologue


You are interviewing a client for the first time, and she tells you, “The pain in my hip started 12 years ago, when I was a waitress standing on my feet 10 hours a day. It seems to bother me most when I am having premenstrual symptoms.


“My left leg is longer than my right leg, and my hip hurts when the scars from my bunionectomy ache. This pain occurs with any changes in the weather. I have a bleeding ulcer that bothers me, and the pain keeps me awake at night. I dislocated my shoulder 2 years ago, but I can lift weights now without any problems.” She continues her monologue, and you feel out of control and unsure how to proceed.


This scenario was taken directly from a clinical experience and represents what we call “an organ recital.” In this situation the client provides detailed information regarding all previously experienced illnesses and symptoms, which may or may not be related to the current problem.




False responses elicited by closed-ended questions may develop from the client’s attempt to please the health care provider or to comply with what the client believes is the correct response or expectation.


Closed-ended questions tend to be more impersonal and may set an impersonal tone for the relationship between the client and the therapist. These questions are limited by the restrictive nature of the information received so that the client may respond only to the category in question and may omit vital, but seemingly unrelated, information.


Use of the funnel sequence to obtain as much information as possible through the open-ended format first (before moving on to the more restrictive but clarifying “yes” or “no” type of questions at the end) can establish an effective forum for trust between the client and the therapist.




Paraphrasing Technique: A useful interviewing skill that can assist in synthesizing and integrating the information obtained during questioning is the paraphrasing technique. When using this technique, the interviewer repeats information presented by the client.


This technique can assist in fostering effective, accurate communication between the health care recipient and the health care provider. For example, once a client has responded to the question, “What makes you feel better?” the therapist can paraphrase the reply by saying, “You’ve told me that the pain is relieved by such and such, is that right? What other activities or treatment brings you relief from your pain or symptoms?”


If the therapist cannot paraphrase what the client has said, or if the meaning of the client’s response is unclear, then the therapist can ask for clarification by requesting an example of what the person is saying.



Interviewing Tools


With the emergence of evidence-based practice, therapists are required to identify problems, to quantify symptoms (e.g., pain), and to demonstrate the effectiveness of intervention.


Documenting the effectiveness of intervention is called outcomes management. Using standardized tests, functional tools, or questionnaires to relate pain, strength, or range of motion to a quantifiable scale is defined as outcome measures. The information obtained from such measures is then compared with the functional outcomes of treatment to assess the effectiveness of those interventions.


In this way, therapists are gathering information about the most appropriate treatment progression for a specific diagnosis. Such a database shows the efficacy of physical therapy intervention and provides data for use with insurance companies in requesting reimbursement for service.


Along with impairment-based measures therapists must use reliable and valid functional outcome measures. No single instrument or method of assessment can be considered the best under all circumstances.


Pain assessment is often a central focus of the therapist’s interview, so for the clinician interested in quantifying pain, some way to quantify and describe pain is necessary. There are numerous pain assessment scales designed to determine the quality and location of pain or the percentage of impairment or functional levels associated with pain (see further discussion in Chapter 3).


There are a wide variety of anatomic region, function, or disease-specific assessment tools available. Each test has a specific focus—whether to assess pain levels, level of balance, risk for falls, functional status, disability, quality of life, and so on.


Some tools focus on a particular kind of problem such as activity limitations or disability in people with low back pain (e.g., Oswestry Disability Questionnaire,41 Quebec Back Pain Disability Scale,42 Duffy-Rath Questionnaire).43 The Simple Shoulder Test44 and the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)45 may be used to assess physical function of the shoulder. Nurses often use the PQRST mnemonic to help identify underlying pathology or pain (see Box 3-3).


Other examples of specific tests include the



A more complete evaluation of client function can be obtained by pairing disease- or region-specific instruments with the Short-Form Health Survey (SF-36 Version 2).46,47 The SF-36 is a well-established questionnaire used to measure the client’s perception of his or her health status. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. It includes eight different subscales of functional status that are scored in two general components: physical and mental.


An even shorter survey form (the SF-12 Version 2) contains only 1 page and takes about 2 minutes to complete. There is a Low-Back SF-36 Physical Functioning survey48 and also a similar general health survey designed for use with children (SF-10 for children). All of these tools are available at www.sf-36.org. To see a sample of the SF-36 v.2 go to www.sf-36.org/demos/SF-36v2.html.


The initial Family/Personal History form (see Fig. 2-2) gives the therapist some idea of the client’s previous medical history (personal and family), medical testing, and current general health status. Make a special note of the box inside the form labeled “Therapists.” This is for liability purposes. Anyone who has ever completed a deposition for a legal case will agree it is often difficult to remember the details of a case brought to trial years later.


A client may insist that a condition was (or was not) present on the first day of the examination. Without a baseline to document initial findings, this is often difficult, if not impossible to dispute. The client must sign or initial the form once it is complete. The therapist is advised to sign and date it to verify that the information was discussed with the client.



Resources: The Family/Personal History form presented in this chapter is just one example of a basic intake form. See the companion website for other useful examples with a different approach. If a client has any kind of literacy or writing problem, the therapist completes it with him or her. If not, the therapist goes over the form with the client at the beginning of the evaluation. The Guide to Physical Therapist Practice49 provides an excellent template for both inpatient and outpatient histories (see the Guide, Appendix 6). Other commercially available forms have been developed for a wide range of prescreening assessments.50


Therapists may modify the information collected from these examples depending on individual differences in client base and specialty areas served. For example, hospital or institution accreditation agencies such as Commission on Accreditation of Rehabilitation Facilities (CARF) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) may require the use of their own forms.


An orthopedic-based facility or a sports-medicine center may want to include questions on the intake form concerning current level of fitness and the use of orthopedic devices used, such as orthotics, splints, or braces. Therapists working with the geriatric population may want more information regarding current medications prescribed or levels of independence in activities of daily living.


The Review of Systems (see Box 4-19; see also Appendix D-5), which provides a helpful chart of signs and symptoms characteristic of each visceral system, can be used along with the Family/Personal History form. The Guide also provides both an outpatient and an inpatient documentation template for similar purposes (see the Guide, Appendix 6).


A teaching tool with practice worksheets is available to help students and clinicians learn how to document findings from the history, systems review, tests and measures, problems statements, and subjective and objective information using both the SOAP note format and the Patient/Client Management model shown in Fig. 1-4.51



Subjective Examination


The subjective examination is usually thought of as the “client interview.” It is intended to provide a database of information that is important in determining the need for medical referral or the direction for physical therapy intervention. Risk-factor assessment is conducted throughout the subjective and objective examinations.



Key Components of the Subjective Examination


The subjective examination must be conducted in a complete and organized manner. It includes several components, all gathered through the interview process. The order of flow may vary from therapist to therapist and clinic to clinic (Fig. 2-1).



The traditional medical interview begins with family/personal history and then addresses the chief complaint. Therapists may find it works better to conduct the Core Interview and then ask additional questions after looking over the client’s responses on the Family/Personal History form.


In a screening model, the therapist is advised to have the client complete the Family/Personal History form before the client-therapist interview. The therapist then quickly reviews the history form, making mental note of any red-flag histories. This information may be helpful during the subjective and objective portions of the examination. Information gathered will include:




Family/Personal History


It is unnecessary and probably impossible to complete the entire subjective examination on the first day. Many clinics or health care facilities use some type of initial intake form before the client’s first visit with the therapist.


The Family/Personal History form presented here (Fig. 2-2) is one example of an initial intake form. Throughout the rest of this chapter, the text discussion will follow the order of items on the Family/Personal History form. The reader is encouraged to follow along in the text while referring to the form.



As mentioned, the Guide also offers a form for use in an outpatient setting and a separate form for use in an inpatient setting. This component of the subjective examination can elicit valuable data regarding the client’s family history of disease and personal lifestyle, including working environment and health habits.


The therapist must keep the client’s family history in perspective. Very few people have a clean and unencumbered family history. It would be unusual for a person to say that nobody in the family ever had heart disease, cancer, or some other major health issue.


A check mark in multiple boxes on the history form does not necessarily mean the person will have the same problems. Onset of disease at an early age in a first-generation family member (sibling, child, parent) can be a sign of genetic disorders and is usually considered a red flag. But an aunt who died of colon cancer at age 75 is not as predictive.


A family history brings to light not only shared genetic traits but also shared environment, shared values, shared behavior, and shared culture. Factors such as nutrition, attitudes toward exercise and physical activity, and other modifiable risk factors are usually the focus of primary and secondary prevention.




Follow-Up Questions (FUPs)


Once the client has completed the Family/Personal History intake form, the clinician can then follow-up with appropriate questions based on any “yes” selections made by the client. Beware of the client who circles one column of either all “Yeses” or all “Nos.” Take the time to carefully review this section with the client. The therapist may want to ask some individual questions whenever illiteracy is suspected or observed.


Each clinical situation requires slight adaptations or alterations to the interview. These modifications, in turn, affect the depth and range of questioning. For example, a client who has pain associated with a traumatic anterior shoulder dislocation and who has no history of other disease is unlikely to require in-depth questioning to rule out systemic origins of pain.


Conversely, a woman with no history of trauma but with a previous history of breast cancer who is self-referred to the therapist without a previous medical examination and who complains of shoulder pain should be interviewed more thoroughly. The simple question “How will the answers to the questions I am asking permit me to help the client?” can serve as your guide.53


Continued questioning may occur both during the objective examination and during treatment. In fact, the therapist is encouraged to carry on a continuous dialogue during the objective examination, both as an educational tool (i.e., reporting findings and mentioning possible treatment alternatives) and as a method of reducing any apprehension on the part of the client. This open communication may bring to light other important information.


The client may wonder about the extensiveness of the interview, thinking, for example, “Why is the therapist asking questions about bowel function when my primary concern relates to back pain?”


The therapist may need to make a qualifying statement to the client regarding the need for such detailed information. For example, questions about bowel function to rule out stomach or intestinal involvement (which can refer pain to the back) may seem to be unrelated to the client but make sense when the therapist explains the possible connection between back pain and systemic disease.


Throughout the questioning, record both positive and negative findings in the subjective and objective reports in order to correlate information when making an initial assessment of the client’s problem. Efforts should be made to quantify all information by frequency, intensity, duration, and exact location (including length, breadth, depth, and anatomic location).



Age and Aging


Age is the most common primary risk factor for disease, illness, and comorbidities. It is the number one risk factor for cancer. The age of a client is an important variable to consider when evaluating the underlying neuromusculoskeletal (NMS) pathologic condition and when screening for medical disease.


Age-related changes in metabolism increase the risk for drug accumulation in older adults. Older adults are more sensitive to both the therapeutic and toxic effects of many drugs, especially analgesics.


Functional liver tissue diminishes and hepatic blood flow decreases with aging, thus impairing the liver’s capacity to break down and convert drugs. Therefore aging is a risk factor for a wide range of signs and symptoms associated with drug-induced toxicities.


It is helpful to be aware of NMS and systemic conditions that tend to occur during particular decades of life. Signs and symptoms associated with that condition take on greater significance when age is considered. For example, prostate problems usually occur in men after the fourth decade (age 40+). A past medical history of prostate cancer in a 55-year-old man with sciatica of unknown cause should raise the suspicions of the therapist. Table 2-2 provides some of the age-related systemic and NMS pathologic conditions.



Epidemiologists report that the U.S. population is beginning to age at a rapid pace, with the first baby boomers turning 65 in 2011. Between now and the year 2020, the number of individuals age 65 and older (referred to by some as the “Big Gray Wave”) will double, reaching 70.3 million and making up a larger proportion of the entire population (increasing from 13% in 2000 to 20% in 2030).54


Of particular interest is the explosive growth expected among adults age 85 and older. This group is at increased risk for disease and disability. Their numbers are expected to grow from 4.3 million in the year 2000 to at least 19.4 million in 2050. As mentioned previously, the racial and ethnic makeup of the older population is expected to continue changing, creating a more diverse population of older Americans.


Human aging is best characterized as the progressive constriction of each organ system’s homeostatic reserve. This decline, often referred to as “homeostenosis,” begins in the third decade and is gradual, linear, and variable among individuals. Each organ system’s decline is independent of changes in other organ systems and is influenced by diet, environment, and personal habits.


Dementia increases the risk of falls and fracture. Delirium is a common complication of hip fracture that increases the length of hospital stay and mortality. Older clients take a disproportionate number of medications, predisposing them to adverse drug events, drug-drug interactions, poor adherence to medication regimens, and changes in pharmacokinetics and pharmacodynamics related to aging.55,56


An abrupt change or sudden decline in any system or function is always due to disease and not to “normal aging.” In the absence of disease the decline in homeostatic reserve should cause no symptoms and impose no restrictions on activities of daily living regardless of age. In short, “old people are sick because they are sick, not because they are old.”


The onset of a new disease in older people generally affects the most vulnerable organ system, which often is different from the newly diseased organ system and explains why disease presentation is so atypical in this population. For example, at presentation, less than one fourth of older clients with hyperthyroidism have the classic triad of goiter, tremor, and exophthalmos; more likely symptoms are atrial fibrillation, confusion, depression, syncope, and weakness.


Because the “weakest links” with aging are so often the brain, lower urinary tract, or cardiovascular or musculoskeletal system, a limited number of presenting symptoms predominate no matter what the underlying disease. These include:


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Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Interviewing as a Screening Tool

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