Differential Diagnosis of Lower Quarter Conditions

1. Differential Diagnosis of Lower Quarter Conditions Marcie Swift, PT, PhD, FAAOMPT Assistant Professor in Physical Therapy Rockhurst University

2. What will I take away? • New students: Introduce concepts related to differential diagnosis through deliberate practice. • Seasoned students: Supplement and reinforce importance of differential diagnosis through deliberate practice.

3. Ultimately, I hope to… Provide you with some tools to practice confidently in a direct-access setting!

4. Agenda • Direct Access • Body Chart • Introduction to Julie • Directed Inquiry • Finish SE • Objective Exam Tests and Measures • Selected Tests and Measures • Triage

5. Direct Access • Unrestricted: 18 states AK, AZ, CO, HI, ID, IA, KY, MD, MA, MT, NE, NV, ND, OR, SD, UT, VT, WV • Restricted: 1 state MI (evaluation only) • Provisions: 31 states +District of Columbia AL, AR, CA, CT, DC, DE, FL, GA, IL, IN, KS, LA, ME, MN, MS, MO, OK, NH, NJ, NM, NY, NC, OH, PA, RI, SC, TN, TX, VA, WA, WI, WY • APTA--Advocacy http://www.apta.org/StateIssues/DirectAccess/ • Direct access by state https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf

6. Missouri: Provisions • Missouri Revised Statutes, Chapter 334(Physicians and Surgeons--Therapists--Athletic Trainers--Health Care), Section 334.506 • PTs must have RX to begin new course of treatment BUT • PTs can provide education, fitness/wellness programs, and screening/consultation services without a RX and • PTs can evaluate and treat a patient previously diagnosed by “an approved health care provider.”

7. Kansas: Provisions • May evaluate and initiate treatment on a patient without a referral. • If providing treatment without a referral and patient is not progressing toward documented treatment goals within 10 visits or 15 business days from the initial treatment visit following the initial evaluation visit, the PT shall obtain a referral from an appropriate licensed health care practitioner.

8. Bottom Line • A PT must “refer to an approved health care provider any patient whose medical condition at the time of examination or treatment is determined to be beyond the scope of practice of physical therapy” and • “No person licensed to practice, or applicant for licensure, as a physical therapist or physical therapist assistant shall make a medical diagnosis.”

9. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

10. “Science” “Practice” • PowerPoint Presentation has flow of information • Link to Google Doc for Case Study Application https://docs.google.com/document/d/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf_9L5FokKlzoC1M/edit?usp=sharing

11. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

12. Julie P1: ache, constant, variable; at its worst: 8/10 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ P1 = / ≠ P2 P2:sharp, constant, variable ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

13. https://docs.google.com/document/d/1yAotNgx4OLszKQkfAeCFbAYqw5aJgAlrmaox71BchUE/edit?usp=sharinghttps://docs.google.com/document/d/1yAotNgx4OLszKQkfAeCFbAYqw5aJgAlrmaox71BchUE/edit?usp=sharing Go to the case!

14. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

15. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

16. Remember to ask questions that will not only rule in your hypothesis (provisional diagnosis) but rule out other diagnoses. This process is known as differential diagnosis.

17. Possible Non-Musculoskeletal Sites Capable of Referring Pain to the Low Back/ Pelvis-SI region • liver, gallbladder, stomach (lower thoracic referral as well as shoulder area) • kidney/ureter/bladder/urethra • pancreas • abdominal aorta (abdominal aortic aneurysm) • prostate gland • uterus/ovaries • testes • small intestine/colon Moore, p. 243, 305; Goodman, p. 148-151, 156, 175-6, D’Ambrosia, p. 300-1, Boissonnault, p 68

18. Visceral Pain Referral Patterns (Boissonnault, 2011, pp. 182–192)

19. Visceral Pain Referral Patterns (Boissonnault, 2011)

20. Systemic Signs and Symptoms (Red Flags) Requiring Referral to a Physician • bloody diarrhea, light stools, melena • fecal incontinence or urinary incontinence • dark or foul-smelling urine • pain that is boring/stabbing, cutting/knifelike, or gnawing/burning • constant pain or pain unchanged by movement/position • dysphagia, odynophagia • early satiety • fever, chills • jaundice • positive McBurney’s point • migratory arthralgias • night pain or night sweats • skin lesions • sudden weight loss or gain • vomiting, nausea • Kehr’s sign (if unsupported by other glenohumeral signs &/or symptoms) • decreased pulses • intermittent claudication • fatigue • malaise • progressive sensory or motor loss (especially “saddle” anesthesia) • change in mentation (Goodman, p. 142, 153, 179)

21. Note to the Wise: Any “red flag” can become a “yellow flag” on further questioning; conversely, a “yellow flag” can convert to a “red flag” over time.

22. Directed Inquiry: Review of Systems 9 Great Questions • Fatigue • Malaise • Weakness • Fever/chills/sweats • Weight change • Nausea / vomiting • Dizziness / lightheadedness • Paresthesia / numbness • Change in cognition -General Health Component of Review of Systems Boissonnault, 2011, Ch 9, p 122

23. Directed Inquiry: All parts of SE! • Environmental Factors • Participation Factors • Aggravating and Easing Factors • 24 hour • History • Current Condition (current and past) • Medical History • Review of Systems MS ------ Non MS Non MS ------ MS

24. What additional questions will you ask to rule IN/ OUT your diagnoses?

25. Back to the Case!! https://docs.google.com/document/d/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf_9L5FokKlzoC1M/edit?usp=sharing

26. How does this change your diagnoses lists?

27. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

28. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

29. Remember to perform tests and/or measures that will not only rule inyour hypothesis (provisional diagnosis) but rule outother diagnoses. This process is known as differential diagnosis.

30. Directed selection of Tests and Measures **Assumption: the clinician is performing a Lower Quarter OE sequence so we will highlight non-musculoskeletal and musculoskeletal tests and measures the clinician should consider to perform depending on their clinical reasoning.

31. Examination: Sitting Non-musculoskeletal Tests and Measures Observation/Inspection Functional Test (squat, gait, balance) LS ROM Balance Neurological S1 myotome Heel/Toe Walking Balance Musculoskeletal Tests and Measures • Posture • Observation/Inspection (Boissonnault, 2011, Ch 13)

32. Examination: Sitting Non-musculoskeletal Tests and Measures Posture/Observation Neurological Testing Segmental Neuro Exam Neurodynamic Testing (Slump) Musculoskeletal Tests and Measures • Percussion of kidneys (Boissonnault, 2011, Ch 13)

33. Examination: Supine Non-musculoskeletal Tests and Measures Muscle strength and length tests Implicate/ Clear joints above and below Pelvis-SIJ, Thoracic Spine Hip, Knee, Ankle, Feet/Toes Neurological Testing Segmental (myotomes, dermatomes, reflexes) Central (Babinski, Clonus) Neurodynamic Testing (SLR, PNF) Musculoskeletal Tests and Measures • Abdominal Tests • Observation • Auscultation • Percussion • Palpation • Sensory Testing • Superficial Abdominal Reflex • Lymph Node Palpation (NAVeL) • Arterial Pulses of Lower Extremities (Boissonnault, 2011, Ch 13; Magee, p.405)

34. Examination: Prone Non-musculoskeletal Tests and Measures Muscle strength and length tests Implicate/ Clear joints above and below Pelvis-SIJ, Thoracic Spine Hip, Knee, Ankle, Feet/Toes Neurological Testing Segmental PKB Palpation ProneStability Test Repeated Extension in lying Musculoskeletal Tests and Measures • None

35. Examination: Sidelying Non-musculoskeletal Tests and Measures Muscle strength and length tests Implicate/ Clear joints above and below Pelvis-SIJ Palpation (PPIVMs) Anterior Stability Test Musculoskeletal Tests and Measures • None

36. What tests and measures will you select to perform to rule IN/ OUT your diagnoses?

37. Back to the Case!! https://docs.google.com/document/d/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf_9L5FokKlzoC1M/edit?usp=sharing

38. In addition to Non-MS tests… Consider the following MS tests and measures for differential diagnosis • Neurological Testing • Central Neurological Exam • Segmental Neurological Exam • SLR • Implicate/ Clear Tests for joints above and below • Lumbar Spine, Pelvis/ SI, Hip • Stability Testing MS ------ Non MS Non MS ------ MS

39. Back to the Case!! https://docs.google.com/document/d/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf_9L5FokKlzoC1M/edit?usp=sharing

40. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

41. What are your top 2 diagnoses?

42. Disorder Recognition (Maitland, Hengeveld, Banks, & English, 2011)

43. Triage Categories • Serious: medical referral trumps PT Intervention • Urgent: life- or limb-threatening condition; escort client to emergency room • Immediate: serious condition requiring medical referral within 1-2 days; “urgent care clinic” referral • Delayed: condition should be evaluated within a week or two by primary care physician • Minimal: treat presenting complaint but also refer • Expectant: unable to benefit from PT Intevention

44. Consider your case. What would YOU do?

45. Back to the Case!! https://docs.google.com/document/d/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf_9L5FokKlzoC1M/edit?usp=sharing

46. Errors in Clinical Reasoning • Over-emphasis on findings which support an existing hypothesis • Ignoring findings that do not support an existing hypothesis • Obtaining redundant information • Misinterpretation • Translation errors • The clinician accepts the terminology used by the patient as the diagnosis

47. Reminder: If what you think is a musculoskeletal condition does not respond to treatment in a reasonable amount of time, consider a non-musculoskeletal etiology and refer or return to the primary care manager.

48. Thank you so much for your participation and attention!!

49. References • Bates B (1991). A Guide to Physical Examination and History Taking, 5th ed. JB Lippincott Company. Chapter 11. • Boissonnault WG (2011). Primary Care for the Physical Therapist: Examination and Triage (2nd ed). Saunders Elsevier. Chapter 13 (pp 182-192). • D’Ambrosia RD (1977). Musculoskeletal Disorders: Regional Examination and Differential Diagnosis, Chapter 7. • Goodman CC, Snyder TEK (1990). Differential Diagnoses in Physical Therapy: Musculoskeletal and Systemic Conditions, Chapters 6, 7. • Magee DJ (1997). Orthopedic Physical Assessment, 3rd ed. Chap 9. • Maitland, GD, Hengeveld, E, Banks, K, & English, K (2011). Maitland’s Vertebral Manipulation Text and Evolve eBooks Package, 7e (7th ed.). Butterworth-Heinemann. • Moore KL, Dalley AF (1999). Clinically Oriented Anatomy, 4th ed. Chapter 2. • Oluwole O, Akinyemi R, Owolabi LF (2005). Superficial Abdominal Reflex Is Not Sensitive to Direction of the Moving Stimulus. African Journal of Neurological Sciences, 24(1), letters. • http://medicine.ucsd.edu/clinicalmed/abdomen.htm • Critical findings on abdominal plain films: http://www.medscape.com/features/slideshow/non-intestinal-xray?src=mp&spon=17&uac=126254DT