A new episode in “Old Man Shouting At Clouds” on the back of my tweet yesterday and to fulfill a request I am going to do a tweetorial on Synergistic History and examination in a symptom modification and classification paradigm. It wil include my ACTIVE/INACTIVE model...
And BIG PICTURE history assessment model. I have proposed numerous times on twitter that there is really no difference in a History and an Examination in a patient centered paradigm, other than the tense. 
A History (receiving) and an examination doing and receiving are synergistic. The history should always drive the examination intent. This exemplifies the use of a Bayesian system of clinical reasoning. Receiving a history in a symptom modification paradigm requires...
Questioning with intent, based on understanding that the patient has all the answers & the clinician needs to listen and structure the interview.The BIG PICTURE history format is like the markings on a tennis court it allows a format to understand the patients current experience
Utilizing the BIG PICTURE assessment will allow verbal “examination” of various parts of the patients History, hence there is no difference between history and exam. Each section gives a valuable group of pieces to the patient picture.
boxes in the BIG PICTURE history give information that is relevant to the person and their current condition. The body chart gives a pictorial view of the symptom presentation. The “Nature” of symptoms speaks to the presence and rhythm of the symptoms
Important words and terms to listen for and to question for are symptoms that are “Always, sometime, last, never last, change location, vary in intensity.” These are clues to symptom modification in the History. As you go through receiving a history there are two types...
Of common clinical reasoning, hypothetico-deductive and pattern recognition. Utilizing s symptom modification model, the clinician is trying to identify common symptomatic and mechanical presentations. Mckenzie suggested three Syndrome Posture, dysfunction and derangement......
I will propose a simpler and more efficient model the ACTIVE/INACTIVE model.This model is simply based on the mechanical and symptomatic responses to loading, historically reported or under exam reporting. Simply put under loading & ACTIVE condition is one that has a symptomatic
& mehanical response to loading, that once loading stops or changes, the effect lasts. This would include increased, decreased symptoms, ROM changes and changes in location of symptoms. INACTIVE conditions are those that under loading there maybe a symptom response and mechanical
Presentation, but after loading the response does not last. This is a new model and is explained in more detail here retlouping.blogspot.com/2008/02/eviden… The model uses three models of causation, inflammation, Trauma and Over/Under-stress of tissue, the latter speaks to my Rule of Toos
The right side of the model shows a cycle from ACTIVE to INACTIVE moderated by healing, natural resolution ( including remodeling, adaptation,& maladaption) & treatment/management . I propose that every clinical test you use even special tests and nerve tension tests....
Can be done verbally. If you can’t trust a patinets ability to give you a history, then why would your exam be any better? Trust your patients, learn to question and listen effectively.
Remember there is nothing more subjective than a clinician who believes his testing is truly objective. Proposal if we can rely on a patinet to report the cardinal red flag signs of Cauda Equina, we can surely rely on them to report their own symptomatic and mechanical responses
Play the following manual game. For every test you want to do to a patient, can you verbalize the test to the patient in daily functinal terms? Most test are looking for symptoms, mechanical changes ie ROM, deformities, blockages, catching points and strength. All can be reported
Examples are seen on the Mckenzie assessment form where in the history section the static and repeated movement tests are asked historically. The question then arises, why would you re-test them during an examination? Remember most patients come to see us for answers & solutions
If you are choosing to do pain provocation tests on them during the examination, maybe we should be giving them a choice and informing them, before doing such testing? As I stated in a previous episode, I rarely if ever choose to provoke a patients symptoms, they are good at this
I have covered this in the past and will briefly say, if you need to test it should be to reduce symptoms and find a self treatment procedure, rather than provoke. The patient is your guide and reps will be based on the history information. TEN is rarely if ever enough.
Thanks for reading as always. It’s hard to briefly outline a complex process. Stay safe.
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