Patient History

Clinical Cornerstone:

• Taking a patient's history goes beyond data collection; it's about forging and upholding a therapeutic relationship. Actively and empathetically listening to the patient's narrative offers insights into their condition and its optimal approach to management. The essence of history-taking lies in turning into the patient's story, discerning their non-verbal cues, and steering the conversation to ensure a comprehensive, yet seamless, patient history.

• Clinicians should exercise judgment during history-taking. Adopting principles of trauma-informed care (safety, trustworthiness, collaboration, choice and empowerment, culturally responsive) could help minimize potential barriers. This might involve reframing questions from "what's wrong with you" to "what happened". This might also involve explaining the rationale behind sensitive questions or tests.

• While history taking needs to be thorough, it does not need to be linear. Reports can be explored as the patient makes them, using care to ensure needed details are not subsequently missed. While certain topics like prior episodes of LBP, past care experiences, and recovery expectations are crucial, they might be broached at different times during the patient encounter, not just the initial history.

• When re-evaluating existing patients, especially those presenting with new complaints, a thorough assessment is just as imperative as with new patients. Delve into the new issue's onset, duration, and associated factors. Gauge the new LBP issue's influence on pre-existing conditions and their treatment.

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• Sociodemographic: Age, sex and gender, occupation.

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• Chief complaint: Main issues.

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• History of Present Condition: Mechanism, location, duration, frequency, character, alleviating/aggravating factors, radiation (e.g., pain, numbness, tingling or weakness), timing (e.g., constant/intermittent, morning/end-of-day/night pain, improving/staying-the-same/getting worse), severity, and associated symptoms.

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• Past Health History: Previous or concurrent conditions, medications, injuries, hospitalization, surgeries, and treatments. Includes orange flags: significant psychiatric symptoms or disorders (e.g., major depression, anxiety disorders, post-traumatic stress disorders [PTSD]).

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• Previous History of LBP: Including experience with previous treatments – effective or any adverse effects. Expectations of treatment and recovery.

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• Family History: Genetic and familial predispositions, familial major medical history (e.g., cancer, cardiovascular).

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• Social History: Family support, caregiver responsibilities, role of family or caregivers in care.

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• Review of Systems: Comprehensive review of body systems to identify any related or unrelated symptoms (neurologic, cardiovascular (including hypertension), genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health and orange flags, menstrual related, bone density, medications, pregnancy, children).

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• Psychosocial Assessment (yellow flags):

  • Beliefs and perceptions: Negative beliefs about the prognosis, fear of movement or re-injury, misconceptions about the nature of the pain, or poor expectations of recovery.

  • Emotional factors: Symptoms of depression, anxiety, or stress (recent life changes or stressors).

  • Behavioural factors: Avoidance behaviors, reduced activity levels, over-reliance on passive treatments, or high self-reported disability levels.

  • Social or environmental factors: Lack of social support, work-related issues, or family pressures.

  • Compensation or legal issues: Pending litigation or compensation claims.

  • Coping strategies: Maladaptive coping mechanisms (e.g., catastrophizing or relying heavily on medication).

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• Lifestyle Assessment: Nutrition, exercise (type, duration and frequency), hobbies, sleep, stress; smoking, alcohol, and recreational drug use.

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• Occupational History: Type of work they do (sedentary, physical labour, etc.), ergonomics of workplace, other work stressors (including social environment), any taken time off due to LBP, any work accommodations/modifications.

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• Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

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• Goals and expectations: Goals for treatment, expectations from intervention.