Patient history

The following points should be considered during the history taking process:

  • Age: spondylosis occurs more often with increasing age.
  • Severity of symptoms: (clinimetrics: severity scales).
  • Mechanism of injury: trauma, stretching or overuse; such as sustained posture.
  • Patient’s usual activity: activities, movements, positions or postures that bother the patient. What kind of work and hobbies does the patient do?
  • Blow to the head or loss of consciousness during trauma.
  • Onset and duration of symptoms: sudden pain onset or slow progression of symptoms.
  • Sites and boundaries of pain: location, unilateral or bilateral, involvement of dermatomes and myotomes.
  • Radiation of pain: dermatomes and sensory peripheral nerve involvement.
  • Laughing, coughing, sneezing, straining affect pain behavior (increase in intra thoracic or abdominal pressure).
  • Headaches: occurrence, frequency, location and intensity.
  • Positions that change the pain or headache: alleviation or aggrevation of symptoms.
  • Presence of paresthesia “pins and needles”: might indicate increased pressure on nerve root.
  • Experience of tingling sensation in extremities.
  • Symptoms in lower limbs.
  • Difficulties with walking or balance: might indicate cervical myelopathy.
  • Experience of dizziness, fatigue, seizures.
  • Presence of sympathetic symptoms: sympathetic hypertonia, tinnitus, dizziness, blurred vision, photophobia, rhinorrhea, sweating, lacrimation, loss of strength.
  • Progression of symptoms: improving, worsening, staying the same.
  • Activities that aggravate and ease the problem: certain head or neck positions.
  • Restriction of movements.
  • Breathing technique: mouth breathing encourages forward head posture.
  • Difficulties with swallowing or voice changes: might indicate neurological problems, mechanical pressure or muscle incoordination.
  • Patients sleeping position: type of pillow and mattress.
  • Cognitive dysfunctions.

Always be aware of red and yellow flags!

Red flags     Yellow flags

(Magee 2007)


Observation
Active range of motion
Passive range of motion
Resisted isometric movements
Neurological testing