Why is the Subjective so Critical?

The subjective interview is the initial conversation between a physical therapist and a patient, aimed at gathering critical information about the patient’s condition, medical history, and functional limitations. This phase of the evaluation sets the foundation for clinical reasoning, differential diagnosis, and patient-centered care planning. For this reason, it is critical that PT’s can effectively lead and engage in a thorough subjective interview, where useful information will be gained and utilized in the evaluation and future treatment sessions. For the purposes of this edition, we will focus more specifically on leading a thorough subjective interview for the orthopedic patient population.

So if it has not stuck yet, here are the brief points that make the subjective so critical for high quality patient care:

• Guides the Objective Exam: The information gathered helps the therapist determine which tests and measures to prioritize during the objective examination, ensuring a more efficient and focused evaluation process. For example, if a patient reports difficulty with overhead reaching, shoulder mobility tests will be emphasized.

• Assists with Differential Diagnosis: Key details can help identify red flags and clarify the nature of the injury. By understanding the mechanism of injury and symptom behavior, the therapist can better differentiate between musculoskeletal issues and potential non-musculoskeletal contributors that may require referral to another healthcare provider.

• Enhances Patient-Centered Care: Listening actively fosters rapport and builds trust, which improves treatment adherence and outcomes. A patient who feels heard and understood is more likely to engage fully in their rehabilitation plan and follow through with prescribed exercises.

• Identifies Functional Limitations and Goals: The interview allows the therapist to understand how the injury impacts the patient’s daily life and provides a foundation for their personal goals. This knowledge enables the therapist to tailor interventions to what matters most to the patient, whether that’s returning to sport, work, or simply being able to perform daily activities comfortably.

Structuring the Subjective Interview for Orthopedic Patients

While every patient is unique, having a structured approach ensures consistency and completeness in gathering information. At a minimum I would recommend asking these questions to all orthopedic patients for initial treatment:

1. How did the injury occur? (Mechanism of Injury)

   • Understanding the nature of the injury helps formulate ideas about potential structures involved and how the tissue may have been stressed or damaged.

2. When did the injury occur? (Timeline and Chronicity)

   • Establishing a timeline helps determine the stage of healing (acute, subacute, or chronic), therefore influencing examination techniques and treatment approaches.

3. What are you feeling now? (Current Symptoms, Pain Descriptors)

   • Determining the current pain level and symptom severity provides insight into the patient’s irritability and pain behavior, guiding movement choices during assessment and treatment. Patient symptom irritability and their respective coping strategies are also crucial to guide exercise prescription and treatment intensity. Additionally, certain pain descriptors can be keys to determining specific tissue injury or emotional overlay associated with the injury. For example, if a patient is complaining of “excruciating” or “horrendous” these words can indicate that there could be an emotional component to their complaints and it should be investigated further.

4. What makes you feel better? (Relieving Factors)

   • Identifying positions or activities that reduce symptoms helps determine potential tissues affected and offers clues for early therapeutic interventions. Often, the simplest movements or comfortable positions described by the patient can serve as a valuable starting point for treatment. Therapists do not need to create complex exercises initially; rather, they can use these patient-reported relieving movements to reduce pain, initiate movement, and build trust. Establishing early success through simple, pain-relieving movements can also encourage patient engagement and confidence in the therapeutic process.

5. What makes you feel worse? (Aggravating Factors)

   • As you may imagine, the above question gives you similar information but for the opposite reason. Pinpointing aggravating factors helps identify movement patterns and structures that may be contributing to the patient’s pain. If a patient describes increased discomfort during specific activities or positions, this information can guide test selection and help identify the root cause of their symptoms. For example, if prolonged sitting worsens symptoms, it may indicate issues with lumbar flexion tolerance or nerve sensitivity. Understanding these patterns not only informs testing but also helps the therapist avoid unnecessary discomfort during assessments, preserving patient trust, and reducing the risk of symptom flare-ups.

Obviously, other questions can and should be asked based off of each unique patient you see. However, these are the five essential questions that should provide you with a starting point to gather the most necessary information for evaluation and treatment.

Using the Subjective Information Gathered in the Examination

I know this seems simple, but it’s easy to get into an evaluation routine and completely disregard the valuable information you have just gotten. So, here is a simple scenario of information gathered and how it can and should be utilized when evaluating an orthopedic patient.

PT: "Tell me about your back pain. When does it bother you the most?"

Patient: "It hurts the most when I'm sitting for long periods, like at my desk."

PT: "That makes sense. Let's see how your back responds to some movements. Try bending forward and let me know if it brings on the same discomfort."

(The patient bends forward and reports a similar pain.)

PT: "Got it. It seems like bending forward is reproducing your pain, which lines up with the discomfort you are feeling while sitting.”

Don’t overlook these small bits of information and don’t feel the need for a patient to push past excessive pain if they have already told you what bothers them most. This risks flaring up the patient's symptoms, just to gather information that is already known. Again, exercise common sense and make sure you're using the information gathered to guide your assessment and treatment decisions thoughtfully. Focus on reducing symptom flare-ups and building trust while encouraging safe, active movements, especially when pain or fear of movement is present. By asking the right questions and truly listening to patients we can provide high quality care simply and effectively.

Helpful Tips You Can Never Hear Enough Times

The following tips are things that I have been told over and over again, yet still can sometimes forget when performing a subjective interview. Please try and learn from mine and many others’ mistakes by taking the following ideas to heart. These are simple things that will enhance your ability to perform subjective interviews and gain the necessary information needed to evaluate and treat future patients.

1. Patients Are Literal:

   • Patients often answer only the specific question asked. This can lead to PT’s assuming they have gathered all necessary details when, in reality, patients may still be unknowingly withholding relevant information. It’s essential to ask follow-up questions and explore multiple aspects of their experience to avoid missing critical insights for assessment and treatment planning. It can be helpful to clarify by using broader language, e.g., instead of just asking about "pain," inquire about sensations like tingling or discomfort to capture a fuller picture.

2. Avoid Over-Reliance on Scripts:

   • While structured templates can be useful, avoid becoming overly dependent on them. When caught up in asking a list of questions, it can be easy to disregard patient information and repeat questions that have already been answered. This can create frustration for the patient and damage the therapeutic relationship. Truly listening to the patient's narrative instead of focusing solely on the next question in the EMR allows for a more meaningful interaction, where the patient feels heard and understood. By actively engaging with the patient’s story, therapists can better identify key concerns and provide a more effective and personalized care plan.

3. Health Literacy Matters:

   • Avoid medical jargon when explaining findings or treatments. The average American only reads at a 7th grade level, BE MINDFUL.

   • Clear, specific, and understandable language enhances patient buy-in and adherence to home exercise programs (HEP).

Parting Thoughts.

A well-conducted subjective interview is a powerful tool that informs the entire rehabilitation process. By using a structured, yet adaptable approach, physical therapists can gather essential information, build rapport, and guide effective treatment planning. Prioritizing this phase ensures a comprehensive understanding of the patient’s needs and sets the stage for successful outcomes.

Now I would love to hear from the audience! What strategies have you found most effective for gaining valuable subjective information? What’s one powerful insight you’ve gained from a patient’s narrative that changed your approach to their care? Share your insights, stories, and tips for creating meaningful connections during patient evaluations!

Disclaimer:

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.