Differential diagnosis for

Physical therapist

陳昭瑩 物理治療師
臺大醫院 物理治療中心
 Introduction
BACKGROUND KNOWLEDGE
 DIFFERENTIAL DIAGNOSIS
AND
CLIENT MANAGEMENT MODEL
Client Management Model
Diagnosis

Evaluation Prognosis

Examination Intervention

Outcome
Outcomes
 Differential diagnosis

Phase 1 Phase 2
A
A. Refer/Consult Diagnosis
B
B. Diagnose and treat • Data organized into defined clusters,
C. Treat and refer syndromes or categories
C C

Prognosis

Evaluation
Intervention

Examination Outcome
 Differential diagnosis

Phase 1 Phase 2
A
A. Refer/Consult Diagnosis
B
B. Diagnose and treat • Data organized into defined clusters,
C. Treat and refer syndromes or categories
C C

Prognosis

Evaluation
Intervention

Examination Outcome
 Differential diagnosis

Phase 1 Phase 2
A
A. Refer/Consult Diagnosis
B
B. Diagnose and treat • Data organized into defined clusters,
C. Treat and refer syndromes or categories
C C

Prognosis

Evaluation
Intervention

Examination Outcome
 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 agentsdrug side-effect 10
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

 Part I
SYSTEM APPROACH
 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 • Relieving
– What kinds of things affect – What make it better?
the pain? • Systemic disease:
• Eating, exercise, rest, unrelieved by change in
specific position, position or by rest.
excitement, stress – 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.
 Part II
Symptom-based approach
 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 TIM VaDeTuCoNe
• Neurogenic/ Psychogenic
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
 Observation
• Walking independently with wide board base
and antalgic gait
• Mild swelling bruise over right knee
 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
ccypt@ntu.edu.tw