Asking Better Questions Gets Better Results

What you focus on during the initial consultation can either set you up for success, or fast-track a path to treatment failure.

One of the most common mechanisms leading to a treatment plan derailing, is clinicians wasting precious time during the initial consultation on the theatrics of objective assessments.

A big caveat to this statement is that I'm referring to the initial consultations of more chronic & longer-term musculoskeletal presentations. When it comes to acute injuries, post-op rehab &/or return-to-sport/play assessments I'm all about objective & functional assessments.

What are the 'theatrics of objective assessments'?

Essentially this is focusing on elements that likely won't have much, if any impact on the underlying problem relating to the clinical presentation.

Often clinicians will default to looking at a clinical presentation through a purely biomedical lens (as opposed to the biopsychosocial). This may be due to habit, a lack of understanding of how to approach chronic injury management through a biopsychosocial lens, or it may be a default approach when there is uncertainty of how to assess and/or manage a complex musculoskeletal presentation.

ie: All musculoskeletal pain requires a biomechanical assessment
because the 'problem' must be biomechanical in nature.

Not true...

Whilst there certainly are exceptions to this rule, when it comes to those clients we see who are experiencing a musculoskeletal pathology of chronicity, more often than not it's the subjective we should be focusing on initially.

In chronic musculoskeletal pathologies/presentations, the subjective history will often give you >80% of the information you need to formulate your treatment plan*.

 Arguably one of the MOST important questions to explore with your patients,
is WHY are they seeking your help?

Where you can shortchange both yourself and your client, is not exploring their answer to this question sufficiently.

Often the most common response by a client is "My *whatever body part* hurts."

Yes, that's a good starting point, BUT in order to unpack what's really going on, you will likely need to dig deeper.

People often don't seek help simply because of pain.
They seek help because pain is disrupting an aspect of their life. 

THIS is what we need to explore.

Why do I need to dig deeper?

Humans are complex, often highly resilient creatures and we can tolerate and lot of discomfort, IF it is not disruptive. Once disruption begins and uncertainty creeps in, this is where the pain/discomfort becomes problematic and advice is sought.

If we stop at simply identifying and addressing a symptom, it's like placing a bucket under a leaking tap to stop the puddle forming, instead of addressing why the tap is leaking in the first place.

Again, there are exceptions to the rule and simply decreasing someone's pain may allow them to achieve their goals. However, there are many instances where we see the problem they are concerned with extending far beyond a symptom itself.

By exploring their 'WHY' more, we are able to identify a number of pieces of highly relevant information that are essential for us to create meaningful, successful rehabilitation programs.

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Better Management comes from Better Questions

The Symptom ** This is what is impacting an activity in my life **

Identifying the primary symptom can guide clinicians in respect to what treatment interventions may be required initially, to help the client begin to overcome their problem. ie: open the treatment window.

Remember Greg Lehman's words:

Calm sh*t down - Build sh*t up.

The Problem ** This is the activity that the symptom is interfering with **

By identifying the problem (ie: what the symptom is impacting/causing), we are able to set the overarching goal of our management plan. This may be returning to running, engaging in ADLs, walking the dog... Whatever it is, this is the goal that will create meaning of our interventions with our client. Not to mention will be out metric of success.

A client doesn't come in saying I want your help to get my pain from 8/10 to 0/10.

They come in saying I want your help so I can do *this* activity.

Achieving 0/10 pain is meaningless if we haven't helped them achieve their goal.

The Concern ** This is what I am worried about the symptom creating **

Identifying and addressing a client's concerns is how we develop and refine our management strategy. Elements we may identify by exploring a client's concerns may be; reinforcing what their goals are, identifying possible gaps in previous treatment, identifying what education we may need to provide and also how we foster engagement of the client, in regards to our management plan & our treatment interventions.

Goals: I'm worried I'll never be able to do **activity** again.

Gaps: I stopped the exercises because it didn't feel like I was getting any better. I'm worried this will just be more of the same.

 Education: I'm worried that the tendon will rupture or it will never heal.

The Need ** This is what I need from you to address my concerns **

The need is how a client tells us what we should be focusing on initially, in addition to what we can do to foster engagement in the treatment. In the case of chronic musculoskeletal pathologies, there may often be a number of elements that require our attention, but we can only focus on a small number of things at a time.

By asking a client what they feel they need at this point in time, it allows you to triage what you focus on. The answer to this question may also be uncovered when you explore their concerns.

Are they more concerned the problem will never go away as opposed to the problem itself? Educate about the pathology, prognosis etc and reassure.

Remember Louis Gifford's words: Effective reassurance is a bloody good pain killer.

Are they confused from receiving countless conflicting bits of information? Educate and focus on their understanding, to (hopefully) give a sense of clarity.

Are they primarily concerned with a heightened level of pain? If you are able to, you may implement an intervention that may be able to improve their pain in the short-term, to open the treatment window so you can introduce the longer-term solutions.

For example, in a highly reactive plantar fasciopathy presentation where strain loads are quite pain provocative, low-dye strapping may be what's needed to help alleviate some pain before you begin working on the other elements required for their successful management (eg: high-load plantar fascia strengthening and gradual re-exposure to loading activities).

??? = WHY the symptom is there - ie: the leaky tap.

Why I have put this last is that oftentimes the questions we ask when we are exploring the above elements will lead to you this answer.

Has the pathology been correctly identified but the management plan/treatment interventions have fallen short of solving the problem, addressing their concerns and meeting their needs?

I hope this article has given you some useful insights into how we can better approach our initial consultations, when dealing with those clients who have rather chronic and complex musculoskeletal injury histories.