differential diagnosis for physical therapist · differential diagnosis for physical therapist ......

Differential diagnosis for

Physical therapist

陳昭瑩物理治療師

臺大醫院物理治療中心

BACKGROUND KNOWLEDGE

Introduction

DIFFERENTIAL DIAGNOSIS AND

CLIENT MANAGEMENT MODEL

Client Management Model

Intervention

Diagnosis

Prognosis Evaluation

Examination

Outcomes Outcome

Phase 1 Phase 2

Diagnosis • Data organized into defined clusters, syndromes or categories

Differential diagnosis

A. Refer/Consult B. Diagnose and treat C. Treat and refer

Evaluation

Examination

Prognosis

Intervention

Outcome

A

B

C C

The therapist’s responsibility

• To make sure that each client is an appropriate candidate for PT, To determine: – Biomechanical problem?

– Neuromusculoskeletal problem is present?

• To rule out: – Signs/Symptoms of systemic disease that can

mimic neuromuscular or musculoskeletal dysfunction

– Cancer screening

8

Key factors to consider

• Side effects of medications

• Comorbidities

• Visceral pain mechanisms

OR

• Client does not get better with PT intervention

• Client gets better, then worse

• Other associated signs/symptoms develop.

9

Side effect of medication on

Musculoskeletal system

• Weakness, fatigue, cramps, arthritis, decrease exercise tolerance, osteoporosis

• Medication – Corticosteroids – 心臟血管疾病

• β-blocker: ↓血壓與心跳 • Calcium channel blocker: ↓血壓與心跳, ↑心臟血管舒張 • ACE inhibitors: ↓血壓 (congestive heart failure) • Diuretics • Digoxin

– 精神狀態 • Antianxiety: (BZD, 放鬆安眠) • Antidepressants • Neuroleptics (精神抑制劑 , sedative)

– Antiepileptics agents

10 drug side-effect

BACKGROUND KNOWLEDGE ABOUT LOW BACK PAIN

Etiology of LBP

• Specific etiology (Serious spinal pathology, less than 5%)

– Tumor, Spinal instability/Fracture, Infections, Cauda equina syndrome

• Degenerative disc disease and spondylotic process (Nerve root problems,5% )

• Nonspecific LBP (more than 90% )

1.Waterman, Spine, 2012 2.Savingy, 2009

• The clinician’s initial aim is to distinguish the small proportion of patients with specific underlying from the vast majority with non-specific mechanical LBP.

Balague, Lancet 2012

• Clinicians should consider diagnostic classifications associated with serious medical conditions or psychosocial factors and initiate referral to the appropriate medical practitioner when: 1. the patient's clinical findings are suggestive of serious

medical or psychological pathology, or 2. the reported activity limitations or impairments of body

function and structure are not consistent with those presented in the diagnosis/classification section of these guidelines, or

3. the patient's symptoms are not resolving with interventions aimed at normalization of the patient's impairments of body function.

Delitto A, JOSPT, 2012

SYSTEM APPROACH

Part I

First step

Quick screen checklist

Quick screen checklist • Past history

• Risk factor assessment – Age, Life style, medication…

• Part of patient education for disease prevention!

• Clinical presentation – Effect of position/Night pain

– Source of pain

• Associated signs and symptoms – Additional s/s, anywhere else!

• Review of systems

• Aggravating/relieving factor

Past history

• ?

• 病人自填問卷 – Family/personal history

–過敏/胸痛/恐慌/焦慮/關節炎/氣喘/癌症/肝病/飲食障礙/高血壓/心臟相關/腎臟病/骨鬆/中風/結核病等等

• Age less than 20 or over 50 (malignancy)/ over 70 (fracture) • Previous history of cancer • Constitutional symptoms: Fever, chills, unexplained weight loss • Failure to improve with conservative care (4-6 weeks) • Pain

– Not relieved by rest or recumbency – Severe, constant night time pain – Back pain accompanied by abdominal, pelvic, or hip pain

• History of falls or trauma • Recent urinary tract infection, blood in urine or stools, difficulty with

urination • Progress neurologic deficit; saddle anesthesia; urinary or fecal

incontinence • History of injection drug use • Immunocompromised condition: prolonged use of corticosteroids,

transplant recipient, autoimmune disease. • Significant morning stiffness with limitation in all spinal movements

(ankylosing spondylitis or other inflammatory disorder) • Skin rash (inflammatory disorder, e.g. Crohn’s disease)

Aggravating/Relieving factor

• Aggravating

– What kinds of things affect the pain?

• Eating, exercise, rest, specific position, excitement, stress

• Relieving

– What make it better?

• Systemic disease: unrelieved by change in position or by rest.

– Hoe dose rest affect the pain?

RED FLAGS

Red flags of oncologic back pain

• Screening for oncologic cause of back pain

– Age:50 or older

– Previous history of cancer

– Unexplained weight loss

– more than 10% of body weight in 10–21 days

– Failure to improve

after 1 month of conservative care.

Red-flag for back - related infection

• Recent infection (urinary tract or skin)

• Intravenous drug user/abuser

• Concurrent immunosuppressive disorder

• Deep constant pain, increase with weight bearing

• Fever, malaise, and swelling

• Spine rigidity

Red flags for spinal fracture

• History of trauma

– Including minor falls or heavy lifts for osteoporotics or elderly individuals

• Age> 70 years

• Prolonged use of systemic steroid

• Point tenderness over site of fracture

• Increase pain with weight bearing

S/S of femoral head/neck

insufficiency/stress fracture

• Insidious onset of pain, in groin, great trochanteric,

and/ or buttock regions

• Might referring to anterior-medial thigh and knee

• Pain increased with weight bearing

• Might only minor or no impairment in hip motion

• 4-12 weeks delay in diagnosis for non-displaced

fracture

Red flags for Cauda equina syndrome

• Urine retention

• Fecal incontinence

• Saddle anesthesia

• Sensory or motor deficits in the feet (L4, L5, S1 areas

Referred pain patterns from

viscerogenic pain

Screening for renal and urologic system

• Usually, no limitation of back motion

• Renal and urethral pain if felt through T9-L1 dermatomes; pain is constant but may crescendo (kidney stones)

• Associated signs and symptoms: blood in urine, fever, chills, increased urinary frequency, difficulty starting or continuing stream of urine, testicular pain in men, painful ejection and/or ejaculation.

• Side bending to the involved side and pressure at that level is ‘more comfortable’.

Screening for gastrointestinal disease

• Presence of GI signs and symptoms: – Nausea, vomiting, diarrhea, constipation

– Blood in stool

• Headaches, sweats, fever?

• Is there abdominal pain and is it at the same level as the back pain?

• Dose the abdominal/back pain change with food intake (assess from 30 minutes to 2 hours after eating)

• Is there relief of back pain with passing gas or having a bowel movement?

• Is there a recent (chronic ) history of antibiotic and /or

NSAID use?

• Any skin rashes anywhere? Any joint pain anywhere else in the body? (enteric-induced arthritis, red rash usually preceding the joint- sacral or hip joint, or back pain.)

Abdominal aneurysm

• Back, abdominal, or groin pain and symptoms not related to movement stresses

• Presence of peripheral vascular disease or coronary artery disease and associated risk factors (age over 50, smoker, hypertension, diabetes mellitus)

• Smoking history

• Family history

• Age over 70

• Palpation of abnormal aortic pulse

EXERCISE

Case 1

61 y/o male Patient with

diagnosis of HIVD

Patient profile

• 61 y/o male Patient with diagnosis of HIVD

• Chief Complaint

– Low back pain and pain radiate to left lower leg for more than 1 month.

Observation

• Walk-in PT clinic with regular cane, trunk shifting to right, antalgic gait with shortened stance phase of left side.

Symptom-based approach

Part II

Symptom-based approach

• Identify the patient’s chief concern

• Create a symptom timeline

• Create a diagnostic hypothesis list from a database of possible causes

• Sort and resort the list by epidemiology, specific case characteristics, and response to specific questioning

• Decide on a diagnostic impression

• Refer/ Consult /Treat

Create a diagnostic hypothesis list

• Trauma

• Inflammation: septic/aseptic

• Metabolic:

DM/gout/toxic/endocrine(pregnancy)/ethanol

• Vascular

• Degenerative: tendinoses/arthroses

• Tumor

• Congenital

• Neurogenic/ Psychogenic

TIM VaDeTuCoNe

EXERCISE

Case 2

55 yrs male patient

diagnosis with knee contusion

Patient profile

• A 55 year old Caucasian male presented to an PT clinic with chief complaints of:

– Right hip and knee pain after falls (hit on knee) 2 weeks ago

– Referred by Neurologist.

Case 1

• Walking independently with wide board base and antalgic gait

• Mild swelling bruise over right knee

Observation

Narration by his wife

• Blurry vision, sometime confusion and short-term memory loss were also noted recently, before fall event.

• After fall, he presented with a limping gait and difficulty in performing functional activities such as climbing stairs and squatting.

• Stroke was suspected by Neurologist.

– No special finding after Brain CT scan.

• Keep medication for HTN and glucose

Medical History • 55 y/o male, Developmental hip dysplasia (DDH)

was diagnosis since he was a boy.

– 15 years ago, right THA with ceramic-on-ceramic hip prosthesis due to joint degeneration secondary to DDH.

– 1.5 years ago, revision with a metal-on-polyethylene prosthesis for the broken of ceramic THA.

• Other medical history

– DM type II and HTN for about 5 years, under regular control.

Create a diagnostic hypothesis list

TIM VaDeTuCoNe

• Trauma

• Inflammation

• Metabolic

• Vascular

• Degenerative

• Tumor

• Congenital

• Neurogenic/ Psychogenic

View patient as

a whole person

not just the lesion site!

References • Goodman CC, Snyder TEK. Differential Diagnosis for

Physcial therapists, screening for referral. 5th ed, 2013.

• Davenport CA, Kulig K, Sebelski CA, et al. Diagnosis for

Physical Therapists: A Symptom-Based Approach. 1st ed,

DavisPlus, 2013.

• Balague F, Mannion AF, Pellise F, et. al..Non-specific low

back pain. Lancet 2012;379:482-91.

• DELITTO A, GEORGE SZ, DILLEN LV, et. al. Low back pain:

clinical practice guidelines linked to the International

Classification of Functioning, Disability, and Health from the

Orthopaedic Section of the American Physical Therapy

Association. J Orthop Sports Phys Ther. 2012.

• Kisner C, Thorp JN. The spine: management guideline. In

Therapeutic exercise, foundations and techniques. 6th ed,

2012; Chapter 15.

THANKS FOR YOUR ATTENTION

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