LMNOPQRST Framework for History Taking in Musculoskeletal Rehabilitation

Original Editor - Ewa Jaraczewska based on the course by Shala Cunningham

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Taking a detailed patient history is an essential part of a patient evaluation. It provides crucial insights on a person's condition, highlights potential red flags, and guides the overall management approach. The LMNOPQRST mnemonic provides a framework for the subjective interview. Adopting this approach helps ensure that clinicians obtain all relevant information during the initial evaluation, including red flags that warrant referral and further investigation.

This article explains each component of the LMNOPQRST framework. It provides examples of dialogues between Sarah, a fictional 45-year-old office manager, who has a three-week history of right-sided shoulder pain and her physiotherapist to show how this approach can be used in musculoskeletal practice.

LMNOPQRST Framework

The LMNOPQRST mnemonic is as follows:

• L: location of symptoms and level of functional impairment
• M: medical factors (including medications) and mechanism of injury
• N: neurological symptoms
• O: occupation, including limitations
• P: palliating and provoking symptoms
• Q: quality of symptoms
• R: radiation of symptoms
• S: severity of symptoms
• T: timing of symptoms

Location of Symptoms and Level of Functional Impairment (L)

Clinicians need to determine exactly where a person has symptoms. When asking about the location of symptoms, find out if the pain is localised to a particular area, or if it is more generalised or diffuse. Does the pain radiate or refer to other areas, or do symptoms move between different locations? Using a body chart can help patients show clinicians exactly where all their symptoms are located.

It is also important to determine a person's level of functional impairment—i.e. how symptoms impact their daily activities. Is the patient avoiding activities or tasks because of their symptoms? Are they adapting activities because of their condition? This might include using assistive devices or avoiding activities. Find out how functional limitations change based on symptom severity.

Examples of questions related to the location of symptoms:

Physiotherapist: "Sarah, can you show me exactly where you feel the pain?"

Sarah: "It's right here, on the top of my shoulder, and sometimes it feels like it goes down about halfway to my elbow."

Physiotherapist: "Is the pain always in the same spot, or does it move around?"

Sarah: "It's mostly in that top area, but when it's really bad, it shoots down my arm like I mentioned."

Physiotherapist: "How is this affecting your daily activities?"

Sarah: "Well, I can no longer reach up to get things from high shelves. I have been asking my husband to help with things I used to do myself. I stopped going to my yoga class because I could not do the poses where I lifted my arms overhead. And at work, I have had to ask colleagues to help me lift files from the top shelf."

Physiotherapist: "Have you made other changes to accommodate the pain?"

Sarah: "I have been sleeping with an extra pillow under my right arm because lying on that side is too painful. I also switched my computer mouse to my left hand, which is awkward, but it hurts less."

Medical Factors and Mechanism of Injury (M)

Medical Factors

In this part of the assessment, clinicians need to find out about all prescribed medications and over-the-counter supplements a patient is taking. They also need to find out about any comorbidities. Understanding a patient's medical history helps clinicians identify how other conditions might be contributing to current symptoms and if there are any potential medication interactions.

Examples of questions related to medical factors:

Physiotherapist: "What medications are you currently taking?"

Sarah: "I take a multivitamin and vitamin D daily. Since this started, I have taken ibuprofen, usually two tablets twice daily, which helps a little."

Physiotherapist: "Do you have any other medical conditions or have you been diagnosed with anything else?"

Sarah: "I have hypothyroidism, so I take levothyroxine every morning. My doctor also told me I have slightly elevated blood pressure, but we are monitoring it rather than treating it with medication right now."

Mechanism of Injury

The mechanism of injury refers to the specific circumstances, forces, and movements that led to the patient's current condition. It helps physiotherapists understand the biomechanical forces involved in the injury, the tissues likely to be affected based on the mechanism, the severity and nature of the injury, and potential complications or red flags. Understanding the mechanism of injury guides the clinician's physical examination and treatment planning process.

Red flag symptom: sudden onset of severe pain or weakness with no incident or accident.

Examples of questions related to the mechanism of injury:

Physiotherapist: "Can you describe the specific movement or activity you were doing when you first felt the pain? Take me through it step by step."

Sarah: "I was reaching up to put some heavy binders on the top shelf of our filing cabinet. The shelf is quite high—I had to really stretch my arm up and forward to reach it."

Physiotherapist: "So you were reaching overhead and forward. Were you using both hands, or primarily your right arm?"

Sarah: "Mainly my right arm. I was holding about three thick binders—they were quite heavy, probably around 5 kilograms total. I was stretching up and slightly across my body to reach the far end of the shelf."

Physiotherapist: "Was there a specific moment when you felt something happen in your shoulder, or did the pain come on gradually?"

Sarah: "There wasn't really a sharp moment. It was more like I felt a deep ache starting while I was holding the position. But then, when I tried to lower my arm afterwards, that's when I really felt it. It was like a sharp, catching sensation."

Neurological Symptoms (N)

We need to determine if a patient has any neurological symptoms. Neurological symptoms include numbness, tingling, crawling, burning or electric-shock-like sensations. It is important to identify the exact location and pattern of these symptoms, as this can help identify which nerve or nerves might be involved. Also, find out if symptoms are constant or intermittent and whether they are associated with specific positions or activities.

Red flag symptom: symptoms that suggest multiple nerves are involved, such as a stocking-glove distribution.

Examples of questions related to neurological symptoms:

Physiotherapist: "Are you experiencing any numbness or tingling?"

Sarah: "No, I only have the aching and then sharp pain in my shoulder."

Physiotherapist: "And no other unusual sensations?"

Sarah: "No, nothing like that."

Occupation (O)

"Occupation" includes all activities that fill a person's day. During this part of the interview, it's important to determine if there are specific activities that may be contributing to a person's pain, considering activities such as repetitive tasks or tasks that involve considerable vibration (e.g., driving a truck, using a jackhammer, etc.).

Examples of questions related to occupation:

Physiotherapist: "Tell me about your work activities and what you do during a typical day?"

Sarah: "I am an office manager, so I spend most of my day at a computer. I probably type and use the mouse for 6-7 hours daily. I also have to reach up to filing cabinets frequently and carry heavy binders and files. I have been having trouble with overhead reaching and lifting anything heavy recently."

Physiotherapist: "What about activities at home?"

Sarah: "I enjoy cooking and used to garden on weekends. I also do – or did – yoga twice a week. I have two teenage kids and am pretty active with household tasks. Lately, I have been avoiding anything that requires lifting my arm high."

Palliating and Provoking Factors (P)

The next part of the history considers what activities make symptoms better or worse (e.g., physical or emotional stress, prolonged postures, changes in position, exercise, heat or cold). We also need to find out how long it takes for symptoms to decrease once they are aggravated, as this provides insight into the patient's irritability and helps guide the assessment and management approach.

Red flag symptom: constant and unrelenting symptoms—nothing makes the symptoms better or worse, including medication.

Examples of questions related to palliating and provoking symptoms:

Physiotherapist: "Is there anything that makes your pain better?"

Sarah: "Rest helps. It feels better when I take a break from the computer and just let my arm hang by my side. Ice sometimes helps too, especially at the end of the day. The ibuprofen takes the edge off."

Physiotherapist: "What makes it worse?"

Sarah: "Definitely reaching overhead—that is the worst. Using the computer mouse for extended periods makes it ache. Carrying my purse on that shoulder is painful. Even washing my hair is difficult now."

Physiotherapist: "When you do something that aggravates your shoulder pain, how long does it take to settle down?"

Sarah: "If I reach up high, I get this sharp pain immediately, and it takes about 20-30 minutes to calm down to its baseline level. But if I have been typing all day, it can take a few hours of rest before it feels better."

Quality of Symptoms (Q)

Patients may describe their pain in different ways, such as sharp and stabbing, or dull and aching, or shooting. These descriptions help differentiate between different types of pain. For example, burning, tingling, shooting, or electric shock-like sensations can be associated with neuropathic pain, while sharp, aching, or throbbing pain may be nociceptive. For more information on the quality of different types of pain, please see Principles of Pain Management: Pain Mechanisms.

Examples of questions related to the quality of symptoms:

Physiotherapist: "How would you describe the pain?"

Sarah: "Most of the time, it is a deep, aching pain. But when I reach overhead or lift something, it becomes very sharp."

Radiation of Symptoms (R)

Clinicians must also establish if a patient's symptoms stay in one location or if they radiate/refer to other areas. If symptoms do radiate to another area, it is essential to map their exact path. Clinicians must establish if radiating symptoms are constant or intermittent, how long they last and what causes changes in radiating symptoms (e.g., changes in posture or specific activities).

Red flag symptoms: symptoms that radiate down multiple dermatomes or multiple peripheral nerves if a peripheral nerve lesion is suspected.

Examples of questions related to the radiation of symptoms:

Physiotherapist: "You mentioned the pain goes down your arm. Can you trace exactly where it travels?"

Sarah: "It starts here on top of my shoulder and goes down the outside of my arm, stopping about halfway between my shoulder and elbow."

Physiotherapist: "Does the pain always go to the same spot, or does it vary?"

Sarah: "It's pretty consistent. When it's mild, it stays in my shoulder. It goes down to that same spot on my arm when it's severe."

Severity of Symptoms (S)

"One of the key components of severity is how the patient’s symptoms affect their activities of daily living (ADLs)."

The next component in the evaluation is determining the severity of symptoms. Pain scales such as the Visual Analogue Scale and Numeric Pain Rating Scale can help clinicians objectively categorise symptoms. However, while these scales provide helpful information, pain is a subjective experience. It's also important to determine how symptoms affect functional activities (e.g. self-care activities, work, participation in social events) for a more complete clinical picture.

Red flag symptoms: sudden onset, severe pain with no preceding incident or accident; and constant, unchanging, severe pain.

Examples of questions related to the severity of symptoms:

Physiotherapist: "On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, how would you rate your pain right now?"

Sarah: "Right now it's about a 3. But when I reach overhead, it shoots up to about a 7 or 8."

Physiotherapist: "How does the pain affect your ability to do things?"

Sarah: "The constant ache does not stop me from doing things, but it is distracting. The sharp pain when I reach up makes me stop what I'm doing immediately. I'd say it's preventing me from doing about 30% of my normal activities."

Timing of Symptoms (T)

Timing considers symptom behaviour over a 24-hour period. It considers the progression of a person's symptoms over the day, and relates symptoms to activities.

Red flag symptoms: pain that interrupts sleep (unrelated to changes in position) or gets worse at night; and constant pain that doesn't change throughout the day.

Examples of questions related to the timing of symptoms:

Physiotherapist: "Take me through how your symptoms behave over a typical day."

Sarah: "I wake up and it is usually pretty mild, maybe a 2 out of 10. But as I get ready for work—showering, doing my hair, getting dressed—it starts to increase. By the time I get to work, it is noticeable. It gets progressively worse throughout the workday, especially in the afternoon after hours of computer work. By evening, it is usually at its worst, around a 5 or 6. It is generally better on weekends when I am not at the computer as much."

Physiotherapist: "Does it affect your sleep?"

Sarah: "I can no longer sleep on my right side because it's too painful. Sometimes I wake up if I accidentally roll onto it during the night. But the pain itself does not keep me awake—it is just the position that is problematic."

Physiotherapist: "Has the pain changed since it started three weeks ago?"

Sarah: "Initially, my shoulder was just a mild ache. Over the past week, it's become more intense. The pain going down my arm has also become more frequent."

Note: Based on Sarah's history, the physiotherapist would also ask about constitutional symptoms to help rule out systemic pathology.

Key constitutional symptoms include:

• fever
• unintentional weight loss
• fatigue that is not relieved by rest
• night sweats
• day sweats
• shortness of breath
• syncope, dizziness or vertigo
• change in sleep pattern
• nausea and vomiting
• change in bladder and bowel habits

Examples of questions related to constitutional symptoms:

Physiotherapist: "Have you experienced any fever, night sweats, unexplained weight loss, or changes in your bowel or bladder habits?"

Sarah: "No, nothing like that."

Physiotherapist: "Any nausea, vomiting, or unusual fatigue?"

Sarah: "No, I feel fine otherwise."

Clinical Reasoning

The example interaction between Sarah and her physiotherapist highlights how the LMNOPQRST framework can be used in clinical practice. The questions and answers given suggest that Sarah has a musculoskeletal condition, likely involving the rotator cuff. The absence of red flag symptoms and the clear relationship between activities and symptoms all support a musculoskeletal diagnosis appropriate for physiotherapy intervention.

Conclusion

The history is an invaluable part of the musculoskeletal examination. Information obtained from the subjective assessment guides the objective examination and shapes treatment planning. The LMNOPQRST framework provides a systematic approach to history-taking that ensures clinicians can capture all relevant clinical information, which sets the foundation for a focused assessment, accurate diagnosis, and effective treatment.

Resources

• Patient Clinical History
• ICF Beginner's Guide: Towards a Common Language for Functioning, Disability and Health