Reading various articles on the subject of ‘clinical interviews’ published in national massage publications, convinced us that this important topic is greatly misrepresented and misunderstood. A correctly conducted clinical interview must follow the same basic template used by all other health practitioners (from MDs to PTs) with some important massage therapy additions.
The reader may ask the reasonable question: Why should the clinical interview follow one particular template? The clinical interview is a very personal matter and everyone is entitled to conduct it in the manner they think is right. If a practitioner practices stress-reduction massage, this is the correct approach. However, if he or she practices clinical or medical massage, then the practitioner is dealing with various pathological conditions. In such case, the only way to conduct a clinical interview is to follow the same template used by every health practitioner (MD, DO, DC, ND, PT). In this manner, the practitioner who uses a commonly accepted procedure of clinical interview is able to save time while making a preliminary but very important diagnosis about the new client and possible causes of his or her pathological condition(s). Thus, there is no reason to re-invent a procedure already tested and perfected over a long time by modern medicine.
Considering the practitioner deals with pathological conditions, we will use the term patient rather than client. The main purpose of the initial clinical interview as well as the follow-up patient’s examination is to find signs of somatic abnormalities (e.g. the active trigger point in the skeletal muscles or tension in connective tissue zones) rather than make diagnostic assumptions which are outside the scope of the massage profession. These signs and symptoms are critically important clues that the practitioner uses to formulate an effective medical massage protocol.
Thus, the first important step in the overall clinical success of any medical massage treatment is to correctly conduct a scientifically based clinical interview. The rules of such an interview are the subject of this article. We will go over each detail of this process and explain the meaning and value of each piece of information you as a therapist may collect during the clinical interview. Although this article is long, we encourage practitioners to read it carefully because it will greatly enhance their decision-making ability. In actuality, the practitioner can cover all questions in 15-20 minutes if he or she conducts the interview correctly.
The therapist has a very limited set of tools to evaluate each new patient. At the same time, every practitioner would like to be efficient during the patient’s evaluation and save time while obtaining the information necessary to formulate a correct medical-massage protocol from the very start.
We may split each new patient’s evaluation into three major steps: visual observation, clinical interview and physical examination (palpation, range of motion, etc.). Thus, the clinical interview is the second step of this process. The information the practitioner obtains during patient observation also should be used during the interview. The visual observation stage demands a separate article. Here we will concentrate on the components of the clinical interview.
There are several critically important components for a successful clinical interview.
1. INTERVIEW GOAL
The massage practitioner has only three tools to evaluate the patient: visual observation, clinical interview and physical examination. Very frequently, an incorrectly conducted clinical interview directly results in an erroneous interpretation of pathological symptoms and signs found during examination of the soft tissue. At the same time. the clinical interview must be conducted reasonably quickly so the practitioner does not waste his or her time. Thus, the main goal of the interview is to obtain as much clinical information as possible in the shortest time, and make correct preliminary assumptions about future examinations and treatment options.
2. HOW TO CONDUCT THE INTERVIEW
How the practitioner conducts the interview is the foundation for its success. After the mutual introduction, the practitioner must take the initiative and always maintain it during the entire interview. Thus, he or she must have a clear structure of the typical interview in mind and use it as a template. The practitioner should phrase as many questions as possible in a “yes” or “no” format in order to obtain accurate information from the patient. If the practitioner takes a passive position during the interview and lets the patient take charge, the patient will waste time on unnecessary information. Sometimes it is suggested that the practitioner should allow the patient to complain and express concerns while the practitioner listens, take notes and only asks questions to confirm details. However, the clinical interview for the possible application of medical massage as a treatment option conducted by massage practitioner is not the visit to a psychologist or life coach. If the practitioner wants to use medical aspects of massage therapy, he or she has to follow the rules of medical interview established and tested through a long history of successful application.
While the patient responds to interview questions, the practitioner should have the next question ready in mind, and ask it immediately after obtaining the information he or she is looking for. Do not be shy about politely interrupting the patient with a new question if the patient starts to move away from the subject of the original question. If you interrupt using a concerned voice and a genuine interest, the patient will never consider such interruptions as impolite behavior.
There is another very important fact to remember. During the interview, the practitioner must ask the patient about any history of previous pathological symptoms. For example, if you ask the patient if he currently has tingling sensations down his arm and he says that he does not, your next question must clarify if he ever experienced tingling in the same area in the past.
The correct way to conduct the interview has another benefit: it builds trust in the patient who now understands that this therapy room is the place where he or she will find help. Such trust obtained during the interview even before the examination and first treatment is priceless.
Make sure that the patient and you are comfortable. If the patient is in a lot of pain try to accommodate him or her in the most comfortable position even if this position is less comfortable for you. Be sure to take notes and use charts to compare information you obtained during the interview. For example, matching the areas of numbness with a map of dermatomes allows the practitioner to find out immediately which spinal and peripheral nerves are responsible for the innervation of the affected area.
The correct and efficient way to conduct a clinical interview in some degree is an art form, which we encourage practitioners to master. This is why we decided to provide a template with printed questions that readers can use during the interview. At the end of the article, we include all these questions into a Clinical Interview Form, which you may print, copy and use as a guide during the interview.
3. CONTENTS OF THE INTERVIEW
The clinical interview should clarify three major topics.
1. How acute is the condition the patient is experiencing at the moment of interview?
If during the interview, the practitioner realizes that the patient is suffering from acute symptoms (e.g., severe muscle spasms, peripheral nerve compression, migraine, etc.) the practitioner should approach the treatment much more carefully and expect that more time will be needed to help the patient. In the opposite scenario of a chronic condition, the treatment protocol may be more aggressive.
2. Does this condition have a local origin? or
Is the nervous system primarily responsible? or
Is there a combination of both factors?
We cannot stress enough the importance of this aspect of the clinical interview. Very frequently, the patient’s clinical symptoms are the results of mild irritation of the spinal or peripheral nerves. In these cases, widely recommended local treatment protocols are useless. Even in the best case scenario, local treatment will bring only temporary relief.
For example, the patient has an obvious case of Tennis Elbow or Medial Epicondylitis of the Humerus. Various educational sources such as DVDs, websites, even YouTube, will suggest the application of local massage protocols some of them more effective than others. However, it is rarely mentioned that the clinical picture of Tennis Elbow can be also triggered by mild irritation of the brachial plexus as a result of tension in anterior scalene or the pectoralis minor muscles. In these cases the patient will exhibit exactly the same clinical symptoms as Tennis Elbow caused by elbow overload or trauma. However, the patient never mentions that he experienced episodes of mild tingling on the lateral surface of forearm. He simply does not link severe pain in the elbow when he lifts any object with the occasional tingling in the forearm, which seems a minor inconvenience compared to the intense pain in the lateral elbow.
If the practitioner does not understand that the patient’s Tennis Elbow is a result of chronic overload or irritation of brachial plexus, the local treatment is doomed to fail in the long run and result in the patient suffering from the same clinical symptoms sometimes even days after the end of treatment.
The combination of a successful clinical interview and palpatory examination of the tissue allows the practitioner to isolate the real cause of the problem in the very beginning and choose the correct treatment protocol.
3. What exact symptoms and signs is the patient experiencing in each type of the soft tissue (skin, fascia, skeletal muscles, periosteum)?
The clinical interview does not provide all the answers to this question but it allows the practitioner to make important preliminary conclusions, which are very helpful during the palpatory evaluation of the tissue.
4. Clinical outcomes of the interview
After the practitioner finishes the interview and is about to examine the patient, he or she has the basic ideas about the patient’s condition, what areas should be examined and what tests should be conducted. Of course, in some cases, the physical examination may redirect assumptions already established during the clinical interview, but this is why both components are so important to balance and complement each other. Now let’s go over a typical template of the clinical interview and discuss the value and meaning of the questions the practitioner should ask the patient.
1. What brought you here?
This is a simple question to start the conversation. You are not interested in a detailed description of the symptoms yet. Your goal is to get the ball rolling and obtain the first very simple piece of information from the patient why he or she is here. “I have pain in the right shoulder, ” is a fair enough answer, Avoid any other details at this moment. You do not want to contaminate this basic information with any of the patient’s detailed descriptions or with his or her ideas or theories. Frequently, the symptoms he or she has at the moment of the interview are secondary, and you will clarify this later during the interview.
2. How long have you had this symptom(s)?
This question gives you picture of the case you are dealing with. Is it a freshly developed abnormality, which is easier to treat or is it a chronic case with a long-lasting history that will require longer treatment? You just need to know the average time the patient has experienced the symptoms and nothing more.
3. What symptoms do you have right now (at the moment of interview)?
This question allows you to evaluate patient’s current condition, and is important if you plan to treat your patient on the first day after the examination. In some cases, the patient feels much worse in the morning and feels better during the day and in some case it is vice versa. Knowing the nature of the current symptoms will help you to decide if you should be less or more aggressive with your treatment protocol during the first session.
4. When did everything start?
There are two issues you need to clarify and may require additional questions. Did any type of trauma or strain initiate the symptoms or did the symptoms appear and develop gradually? If patient has experienced trauma or strain as the initial trigger, he or she will always remember the circumstances. For example, “I helped my friend move into a new house,” or “I fell from my bicycle.” If your patient cannot remember a particular incident and the symptoms developed, let’s say, within a week, you are dealing with conditions that are a result of overload and/or the peripheral nervous system heavily involved in the development of pathological abnormalities. Do not allow the patient to go into a long description if you feel that information he or she provides is irrelevant. Control the pace of the interview by immediately posing additional questions.
5. Have you seen anyone especially your physician and has any diagnosis already been established? Were any tests (X-ray, MRI, CT, Nerve Conducting Study, etc.) done?
Despite the fact that these are very important questions, do not blindly follow the information your patient may provide you. Do not let it cloud your own judgment. In many cases, an already established diagnosis provides only partial information. For example, the patient was in car accident, he went to his family physician and was treated unsuccessfully for “Whiplash” for the past two months with pain medication and chiropractic care. Now he is in your office and telling you that he has “Whiplash”. Such diagnosis does not provide you with any guidance because it does not specify the patient’s actual abnormality. Was the trapezius traumatized? Did the splenius capitis develop active trigger points? Is there irritation of the greater occipital nerve? While the diagnosis of “Whiplash” helps physicians or massage practitioners obtain reimbursement from insurance companies, it is completely useless from a clinical point of view. Only after a successful clinical interview and examination, is the practitioner able to answer these questions and develop clinically effective medical massage protocol. In some cases, an already established diagnosis can even be completely wrong. The Case of the Month in this issue of JMS is an excellent example of that.
In another example, a diagnosis of Multiple Sclerosis (MS), which your patient says he has suffered from for the past two years is a great help. Now in your mind you immediately know that you will use a medical massage protocol for MS, and further interviews and examinations will focus on the goal of refining this protocol and make it more effective for this particular patient.
6. What treatments, if any, were used?
This question is of great importance. It helps you avoid those therapies that have already been used and were unsuccessful. The more ineffective treatments your patient has tried, the more difficult the case you are dealing with. There is other important information you may learn by asking this question. For example, your patient went through 15 sessions of chiropractic adjustments and felt no relief. In such case, there is chance of disk pathology or the patient has severe muscle spasms, which were not addressed properly before adjustments, and very tight muscles are responsible for the misalignment of the vertebrae. In such case, failure of chiropractic adjustments additionally justifies the application of medical massage protocol.
In another scenario, pain around the knee joint was not relieved by 10 sessions of physical therapy and actually made the symptoms worse. It is a good chance that your patient suffers from periostal reflex zones, and the medical exercise additionally traumatized the already inflamed periosteum.
7. Do any family members have similar problems?
It is a well-documented medical fact that intervertebral disk pathology as a result of Spondylosis runs in many families from generation to generation. Recent data shows that Fibromyalgia may also affect several members or generations of the same family. Another great example is Scoliosis.
By asking this question, the practitioner first of all may estimate how difficult it will be to treat this particular patient because family history is always a complicating factor. Additionally, the practitioner will have the chance to raise the awareness of the patient, and discuss important lifestyle changes that may play a dramatically important role in preserving the patient’s future health.
Let’s look at the three cases discussed above: The patient with a family history of disk pathology will receive great benefits from daily use of an inversion table. The patient with a family history of Fibromyalgia will benefit from regular exercise in the water. The daughter of a mother who has even mild Scoliosis must have her back checked regularly once she reaches age 10.
8. Were other health conditions or medications eliminated by the primary physician as potential causes of the patient’s symptoms?
For example, Hypothyroidism or decreased activity of the thyroid gland will cause muscle pain and spasms throughout different parts of the body. Hyperparathyroidism or increased activity of parathyroid glands will trigger bone and joint pain. The same symptoms can also indicate Lyme Disease.
Many medications may cause various somatic abnormalities as side effects. For example, one of the common side effects of birth-control medication is headaches. Widely prescribed Lipitor, which is one of the most popular medications to control cholesterol levels, may trigger Rhabdomyolysis that is a breakdown of myosin in the myofibrils and consequent damage of the skeletal muscles. Rhabdomyolysis is accompanied by local and generalized muscle pain. Some antibiotics (e.g., Ciprofloxacin) may trigger a clinical picture of tendinitis and joint pain. Amiodarone (a commonly used antihypertensive medication) may cause tingling and numbness. The list of side effects triggered by various medications is very long. This is why the practitioner must be sure that the patient discusses this subject with his or her primary care physician before the start of medical massage treatment.
9. Have you experienced any previous traumas?
If there is no direct history of trauma associated with the current symptoms, the practitioner should still ask about previous trauma since they may have a direct link with the symptoms the patient is currently experiencing. For example, a patient fractured his pelvis when he was young but since original trauma has not experienced lower back pain or hip pain. Now in his forties, he has started to complain about hip pain. The knowledge of that previous trauma obtained during the interview will direct the practitioner to measure the patient’s legs. Even a slight shortening of one leg as a result of pelvic trauma long ago will greatly contribute to pelvic misbalance and eventually to the hip pain. The combination of medical massage therapy and compensation in footwear will alleviate any future pain in the same area.
EVALUATION OF SYMPTOMS DURING THE INTERVIEW
1. Pain Evaluation
There is one critical piece of information the practitioner must always remember: Pain is not an abnormality itself. It is an essential part of the body’s function and our existence. Human kind would never have survived if the alarm system of the pain analyzer was not fully developed. The evolutionary evaluation of CNS shows that the fast-pain analyzing system developed later on the evolutionary scale than the original slow-pain analyzing system but both of them are equally important for the correct function of the human body. Thus the pain is a result of an existing and, in many cases, hidden pathological problem. If there is no history of trauma, the activation of the pain analyzer means that the body is no longer able to compensate for an already existing abnormality. This is why it is so important for the practitioner to correctly identify the initial cause at the very beginning and eliminate it using medical massage protocols. The clinical interview is the first important step on this path.
There are several aspects of pain evaluation that the practitioner should consider during the clinical interview: onset of pain, character of pain, type of pain, time of pain, correlation of pain and movement, and intensity of pain.
A. Onset of Pain
Information about the onset of pain has already been obtained from question #4.
B. Character of Pain
Question: How would you describe the pain you have or had (sharp, aching, burning, pulsating)?
Do not forget to mention all four patterns in the question. Here is what each pattern means for you as a practitioner.
Sharp pain in a patient is the most difficult to differentiate because it can be caused by various reasons from nerve compression by the herniated disk to muscle trauma and active periostal trigger points. Thus, when a patient complains about sharp pain, the practitioner should concentrate his or her questions on the evaluation of this pattern: its exact location, its spread, radiating pattern, etc. Use the questions we discuss below.
Aching pain is more frequently associated with hypertonic muscular abnormalities (hypertonus, trigger point, myogelosis). Other examples are Osteoarthritis, Fibromyalgia, and referred pain from abnormalities of inner organs (e.g. pain in the right upper shoulder in patients with liver diseases).
If the patient had or has even short episodes of burning pain, the practitioner can be 100% certain that the nerve that innervates this part of the body is under pressure. In such case, during palpatory evaluation of the tissue, the practitioner should examine the pathway of this nerve and find the area of its entrapment above the affected area. All other approaches are simply useless.
Usually pulsating pain is accompanied by two major conditions: acute inflammation and venous stasis as a result of insufficient drainage. In these cases, the practitioner should send the patient to the physician.
C. Type of Pain
Correct evaluation of the type of pain gives you the correct direction to determine the initial cause.
Question: Do you feel pain locally?
Ask patient precisely to indicate pain location. Even during the interview the practitioner can match the location of the pain with a map of dermatomes and determine which segment of the spinal cord innervates affected area. Also, remember that the location of the pain indicated by the patient does not indicate the actual location of the problem. For example, a frontal headache is frequently caused by irritation of the greater occipital nerve in the occipital area but the patient does not know that, because he or she does not feel pain on the back of the head. In such case, the treatment of the forehead headache will fail if the practitioner chooses local treatment on the forehead and temporal areas as a main therapeutic option.
Question: Do you feel pain radiating to any neighboring part of the body?
Pain radiation means that pain shoots to neighboring or in many cases to distant parts of the body. For example:
Local radiation – pain from an active trigger point in the rhomboideus major muscle radiates to the subscapular area, or pain from the periostal trigger points formed along the upper edge of tibia radiates into the joint triggering a clinical picture of Knee Osteoarthritis.
Distant radiation – pain from the gluteal area radiates down to the bottom of the foot as seen in cases of Sciatic Nerve Neuralgia as a result of Piriformis Muscle Syndrome. In another case, the tension in the pronator teres muscle will compress the median nerve and cause the Median Nerve Neuralgia (clinical picture of Carpal Tunnel Syndrome) in the hand.
Question: Do you have the sensation of spreading pain?
In this case, the patient may feel lower grade pain starting, let’s say, in the right side of the neck and upper shoulder and slowly spreading to the opposite shoulder, between the shoulder blades, shoulder joints and even the anterior surface of the upper thorax. The classic example is Fibromyalgia.
D. Visceral Pain
Acute visceral pain
A great example of acute visceral pain is kidney colic. Acute visceral pain is a medical emergency and practitioners never encounter these patients in the therapy room.
Chronic visceral pain
Chronic visceral pain is purely localized and usually is of low intensity. Frequently it is accompanied with various autonomic reactions: headache, nausea, sweating, “goose bumps”. This is why the practitioner must ask following question.
Question: “Did you notice if the pain you have is accompanied by headache, nausea, sweating, “goose bumps”, or changes in the body’s temperature?
There are medical massage protocols for inner organ abnormalities but massage therapy plays a supportive role, and the practitioner must be sure that the patient is under the supervision of a medical doctor.
E. Referred Pain
Questions: “Did you have the sensation that the original pain triggers pain in other parts of your body?” and
“Do you have pain in any other parts of the body?”
The pain in the area of the sternum felt by the patient when he has heartburn is common example of referred pain. The issue of referred pain is frequently misrepresented in massage literature because referred pain is described as a radiating pain and this is completely incorrect. The practitioner should clearly see the difference since this issue affects treatment plans.
Radiating pain will always spread along the pathway of the peripheral nerves. Here are two examples: the pain from the sciatic nerve compressed by piriformis muscle radiates to the foot, or pain from the upper-lower back radiates to the anterior thigh as a result of tension in the quadratus lumborum muscle and the following irritation of the L1-L2 spinal nerves, which gives origin to the femoral nerve.
Referred pain may be located along the pathway of the peripheral nerve (or cardiac pain radiates to the 4-5 fingers on the left hand) but in many cases it is reflected to distant areas, which are not directly linked to the affected areas by the same pattern of innervation. For example, tension in the temporomandibular joint triggers referred pain into the eye socket on the same as well as opposite side of the face. In another scenario, a patient with chronic gastritis feels pain and tension in the lower thoracic and upper lumbar paraveretebral muscles on the left side.
The main difference between radiating and referred pain is the fact that the patient feels that radiating pain travels from one area to another, i.e., pain in both areas is felt at the same time. In contrary, the patient with referred pain feels the pain areas are independently located, and he or she does not link them together.
Existence of referred pain should be confirmed when the patient’s pain pattern is compared to reflex zones diagrams (e.g. Map of Connective Tissues Zones, Glezer/Dalicho Zones, Map of Chapman’s reflexes, etc.).
F. Time of Pain
What part of the day the patient feels more intense pain is another helpful piece of information that should be obtained during the interview. There are three major pain patterns during the day: morning pain, late afternoon/evening pain and night pain.
Question: Do you feel rested in the morning after you wake up?
If the patient wakes up in the morning with pain and stiffness which gets significantly better after one or two hours, you are dealing with hypertonic muscular abnormalities. In such case, the muscle pump did not work at night and for the first couple of hours, and until it kicks in the patient continues to feel pain and stiffness, which significantly improves when the affected muscles fully start to operate.
Question: Do you feel the pain is getting worse by late afternoon/evening?
Late afternoon/evening pain
If the patient wakes up in the morning feeling rested but by the late afternoon or evening the pain appears or gets worse, it is more likely that the practitioner is dealing with a patient who has a bulged or moderately herniated disk. This occurs because during the night, the pressure in the affected disk decreases due to the lack of vertical compression but by the late afternoon or evening it builds up to the degree of irritation or compression of the spinal nerve. In case of a large herniation, the pain will appear as soon as the patient puts pressure on the leg and continues until the pressure is removed.
In both scenarios, (morning or evening pain) medical massage is a critically important treatment method but practitioner chooses different protocols for each case.
Questions: Do you have night pain? and
Do you have difficulties falling asleep or wake up during the night?
Any type of visceral or somatic disorder may trigger night pain. If the patient feels pain at night while he or she is turning or tossing, it is sign of severe muscle spasm or pressure on the nerve. Usually continuous night pain means that the practitioner is dealing with a difficult case. The pain stimuli are predominantly conducted through the parasympathetic nervous system that is much more active at night. This is why pain, which may be tolerable during the day, feels excruciating at night. Night pain perceptively means that the practitioner will need more sessions to help the patient.
G. Correlation of the Pain with Movement
Questions: How is the pain you feel affected by your movement?
Does movement increase, decrease or has no effect on the pain intensity?
Pain increases with movement
If movement increases pain intensity, it is sign of active trigger points in the skeletal muscles or periosteum, compression or irritation of the spinal or peripheral nerve or previous trauma. If the patient complains about pain that increases during active movement, the practitioner must remember to examine the range of motion (ROM) during the physical examination, which will greatly help guide the examination in the correct direction.
Pain decreases with movement
Repetitive movement decrease pain intensity if the initial cause of the pain is from inactive myogelosis, sleeping trigger point or various circulatory abnormalities (decrease or arterial circulation or venous and lymph drainage). In these cases, repetitive movement helps activate the muscle pump, which increases oxygenation, circulation and drainage.
Movement has no effect on the pain intensity
The best examples of such situation are the presence of cutaneous trigger points or referred pain. In these cases, movement or lack of movement has no effect on the pain intensity.
H. Pain Intensity
Question: How do you grade your pain intensity on a 1-to-10 grade scale?
The currently accepted 1-to-10 gradation of pain intensity allows the practitioner to initially evaluate pain intensity from the patient’s point of view. Regular pain gradation before each treatment session helps to estimate the effectiveness of the therapy while it is in progress.
2. Evaluation of sensory abnormalities
During the clinical interview, the practitioner should ask the patient about previously or currently present sensory abnormalities. The practitioner should ask following question.
Question: Have you had in the past or do you currently have sensations of tingling or numbness in any parts of the body?
This question is very important because it may point to the neurological nature of the clinical symptoms the patient is complaining about. The many patients will never mention the fact that they had tingling or episodic numbness, let’s say, a week ago. If the practitioner does not actively ask about it, this information may be missed, and practitioner will approach the physical examination with the idea that he or she is dealing with a local abnormality instead of concentrating on finding the initial neurological trigger.
For example, the clinical picture of an active trigger point in the pronator teres muscle will be the same if the initial trigger was this muscle overload or irritation of the brachial plexus by pectoralis minor muscle on the anterior surface of the shoulder. In the first scenario, the local treatment is a primary choice but in the second scenario, the anterior shoulder area must be addressed first with the following addition of local treatment of the pronator teres muscle on the anterior surface of the forearm. This is a prime example that the first step to a correctly formulated treatment protocol is the clinical interview.
The important advantage of asking the patient about sensory abnormalities is the fact that they usually appear first before motor abnormalities (muscle weakness, atrophy, etc.) develop. In such case, the practitioner has the chance to catch abnormalities in the early stages when treatment is especially effective.
3. Evaluation of motor abnormalities
The examination of motor abnormalities also starts at the interview. The practitioner should ask the patient following questions.
Questions: Do you feel any restriction in your ROM? and
Do you feel any muscle weakness?
The same way as the practitioner questions the patient about sensory abnormalities he or she must evaluate the patient’s motor abilities from his or her point of view. If the patient mentioned that, let’s say, his quadriceps got weak and at the same time he had episodes of tingling on the anterior surface of the thigh, the practitioner can be 100% certain that active trigger points in the quadriceps and consequent weakness are the result of irritation of the femoral nerve. The practitioner will make this correct decision in the stage of the clinical interview even before he or she conducts the physical examination and confirms the application of treatment protocol for the Femoral Nerve Neuralgia.
This is a very basic template of the clinical interview, and the practitioner may add or skip questions to ensure the interaction with the patient is as efficient as possible. Here is the link to the Clinical Interview Form we suggest practitioners use during their interviews:
Category: Medical Massage