Purpose of the clinical interview
The interview is your first screening tool. It helps you (1) recognize a likely mechanical pattern (symptoms change with movement, posture, or load), (2) spot non-mechanical features (constant, progressive, systemic, or disproportionate), and (3) decide what to test physically and what to monitor. Use a consistent flow so you don’t miss key details.
Interview flow at a glance
| Step | Goal | Output |
|---|---|---|
| 1) Opening questions | Capture the main complaint, onset, and 24-hour behavior | Initial hypothesis + baseline severity |
| 2) Pain descriptors + location | Map symptoms and screen for referred/radicular patterns | Body chart + symptom quality |
| 3) Aggravating/easing factors | Differentiate mechanical sensitivity vs non-mechanical features | Mechanical pattern clues |
| 4) Functional impact | Identify region-specific limitations | Functional baseline + goals |
| 5) Risk screening prompts | Identify referral/medical review triggers | Safety decision |
| 6) Close with plan | Explain physical screening + monitoring instructions | Shared plan + symptom diary targets |
1) Opening questions: main complaint, onset, and 24-hour behavior
A. Start broad, then narrow
“What brings you in today?” (Let them speak uninterrupted for ~30–60 seconds.)
“Point with one finger to the main area.” (Establish primary region before chasing secondary symptoms.)
“What is the main problem you want help with?” (Pain, stiffness, weakness, pins/needles, headaches, sleep disruption, etc.)
B. Onset and timeline (mechanical clues often live here)
“When did it start?” (Exact date or approximate.)
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“How did it start?” Sudden (lift, twist, fall) vs gradual (desk work, training load).
“Was there a specific incident?” If yes: details of position, load, and immediate symptoms.
“Since it began, is it getting better, worse, or staying the same?” Progressive worsening without clear mechanical trigger is a caution signal.
C. 24-hour behavior (pattern recognition)
Ask for a simple day map. Mechanical problems often fluctuate with activity and posture; non-mechanical features may be constant or unrelated to movement.
“How is it in the morning?” (Stiffness duration, ease of getting going.)
“How is it through the day?” (Work posture, movement breaks, activity spikes.)
“How is it at night?” (Sleep positions, waking due to pain.)
“What’s your best time of day and worst time of day?”
Practical tip: Quantify quickly: “0–10 now, best, and worst in the last 24 hours.” This becomes your baseline for monitoring.
2) Pain descriptors and location diagrams
Use a body chart (or have the patient draw). Your job is to map: (1) location, (2) spread, (3) quality, and (4) symptom type (pain vs tingling vs numbness vs weakness). This helps you decide whether to emphasize cervical/thoracic/lumbar screening and whether to include neuro tests.
A. Symptom quality prompts (simple, beginner-friendly)
“How would you describe it?” Options: ache, sharp, burning, electric, throbbing, tight, heavy.
“Is it pain, or more like pins and needles/numbness?”
“Do you notice weakness or dropping things/leg giving way?”
“Is it one spot or does it travel?” Traveling symptoms can suggest nerve involvement or referred pain patterns.
B. Location diagram: neck and upper limb (cervical screening)
Ask the patient to mark:
Neck: midline vs one-sided; base of skull; between shoulder blades.
Shoulder/arm: upper arm, forearm, hand/fingers.
Associated symptoms: headache, dizziness, jaw/face symptoms (note and clarify).
Clarifiers:
“Which fingers?” (Specific distribution is useful.)
“Any change with coughing/sneezing/straining?” (May increase nerve root sensitivity.)
C. Location diagram: thoracic and rib region
Thoracic symptoms can be local (mid-back) or wrap around the rib cage.
Mark the area: midline thoracic spine, paraspinals, scapular region, costovertebral area, sternum/front chest wall.
“Does it wrap around like a band?” (Rib/intercostal distribution.)
“Is it linked to breathing, coughing, or sneezing?” (Mechanical rib/thoracic sensitivity vs other causes—use risk prompts later.)
D. Location diagram: low back and leg (lumbar screening)
Low back: central vs one-sided; above/below belt line; buttock.
Leg symptoms: thigh, calf, foot; front/back/side.
“Does it go below the knee?” (Useful for pattern recognition.)
“Any numbness in the groin/saddle area?” (This is a high-priority risk prompt—document clearly.)
3) Aggravating and easing factors: mechanical sensitivity vs non-mechanical features
This section is where you actively test the “mechanical hypothesis” through questions. You are looking for a consistent relationship between symptoms and movement/posture/load.
A. Mechanical sensitivity prompts (movement/posture/load)
Use a structured set of prompts and ask for specific examples.
Movement: “Which movements make it worse—bending, turning, looking up/down, reaching?”
Posture: “What happens if you sit still for 20–30 minutes? What about standing still?”
Load: “What happens with lifting, carrying, pushing, pulling?”
Repetition: “Does it build up after repeated tasks (typing, vacuuming, walking)?”
Relief: “What positions or movements ease it—lying down, walking, changing posture, heat?”
Step-by-step technique (beginner-friendly):
Ask for the top 3 aggravators: “Name the three things that most reliably flare it.”
Ask for the top 3 easers: “Name the three things that most reliably settle it.”
Confirm consistency: “If you repeat that activity, does it reliably reproduce the symptoms?”
Quantify irritability: “How long until it flares?” and “How long to settle?”
B. Non-mechanical feature prompts (constant, progressive, systemic)
These questions help you notice patterns that don’t behave like typical mechanical sensitivity.
Constancy: “Is it there even when you are completely still and supported?”
Progression: “Over the last days/weeks, is it steadily worsening regardless of what you do?”
Systemic feel: “Any fever, chills, feeling unwell, unusual fatigue?”
Night pattern: “Does it wake you at night? If you change position, does it ease?” (Pain that is severe at night and not position-responsive is more concerning.)
Unexplained weight change: “Any unexplained weight loss?”
Practical example: If a patient says “It’s constant and nothing changes it,” follow with: “Even lying down? Even after changing position? Even on days you don’t work?” This clarifies whether it is truly non-mechanical or simply highly irritable.
4) Functional impact questions tailored to each region
Functional questions translate symptoms into real-life limitations and guide your physical screening priorities. Keep them specific and measurable.
A. Cervical region: driving, desk work, and upper limb use
Desk/phone: “How long can you sit at a desk before symptoms start? What happens with laptop vs monitor?”
Driving: “Any difficulty checking blind spots or holding your head up while driving?”
Sleep: “Which positions are tolerable? Any pillow changes help?”
Arm function: “Any trouble with typing, mouse use, lifting overhead, or carrying bags?”
Fine motor: “Any clumsiness with buttons, handwriting, or dropping objects?”
B. Thoracic/rib region: rotation, breathing, and reaching
Rotation: “Does turning in bed or twisting to reach a seatbelt provoke it?”
Breathing: “Does a deep breath change the pain? What about coughing or sneezing?”
Reaching: “Any pain reaching overhead, across your body, or behind your back?”
Activity tolerance: “What happens with walking uphill, stairs, or carrying groceries?”
C. Lumbar region: lifting, sitting, and walking/standing tolerance
Sitting: “How long can you sit? Does it ease if you stand or walk?”
Standing: “How long can you stand still? Does leaning forward on a counter change it?”
Lifting: “Which part is hardest—picking up from the floor, carrying, or putting down?”
Walking: “Does walking help or worsen it? Any leg symptoms with walking?”
Daily tasks: “Shoes/socks, getting in/out of a car, rolling in bed—any of these limited?”
Practical tip: Choose one functional baseline measure per region (e.g., “minutes sitting,” “number of head turns while driving,” “deep breath tolerance”) to re-check after your physical screen.
5) Risk screening prompts that trigger referral or medical review
Ask these clearly and document the answers. If a patient answers “yes” to any high-risk item, pause and consider medical review/referral pathways according to your setting and scope.
A. Trauma and fracture risk
“Have you had a fall, accident, or direct blow?”
“Was it a minor incident that caused major pain?” (Higher concern in older adults or those with bone health issues.)
B. Systemic symptoms
“Any fever, chills, or recent infection?”
“Any unexplained weight loss?”
“Any night sweats or feeling generally unwell?”
C. Cancer history
“Do you have a history of cancer?”
“Any new, unexplained pain that is steadily worsening?”
D. Neurological progression (upper or lower limb)
“Are the numbness/tingling or weakness getting worse?”
“Any new difficulty walking, balance changes, or frequent tripping?”
“Any new problems with hand coordination?”
E. Bowel/bladder changes and saddle symptoms (urgent)
“Any new trouble starting or stopping urination, or new incontinence?”
“Any changes in bowel control?”
“Any numbness around the groin or saddle area?”
F. Severe night pain
“Is the pain severe at night and not relieved by changing position?”
How to phrase it calmly: “I ask everyone these questions because they help us decide whether it’s safe to proceed with a physical screen today.”
6) Close the interview: plan the physical screening and symptom-monitoring instructions
A. Summarize and confirm (teach-back)
Give a short summary and ask the patient to confirm accuracy.
“Let me check I’ve got this right…” (Location, main aggravators/easers, 24-hour pattern, key functional limits.)
“Is there anything important I missed?”
B. Set expectations for the physical screen
Explain what you will do next and why, using simple language.
“Next I’ll do a brief movement screen of your neck/thoracic spine/low back and a quick nerve check if needed.”
“We’ll look for movements that reproduce your symptoms and movements that reduce them.”
“You’re in control—tell me immediately if anything feels sharp, alarming, or unusually intense.”
C. Symptom-monitoring instructions (what to track between visits)
Give 2–3 simple tracking targets based on their presentation. Keep it practical and measurable.
Intensity: “Rate your symptoms 0–10 morning and evening for the next 3 days.”
Key trigger: “Note how long you can sit/drive before symptoms start.”
Distribution: “If symptoms travel further down the arm/leg or retreat back toward the spine, write that down.”
Safety instruction: “If you develop new or worsening weakness, new bowel/bladder changes, new saddle numbness, fever, or rapidly worsening night pain, seek urgent medical review.”
