Differential Diagnosing for the Physical Therapist: A Case Report

1. Differential Diagnosingfor the Physical Therapist:A Case Report William Nixon, SPT Cleveland State University-Doctor of Physical Therapy Program Class of 2017

2. What is it? • The process of differentiating between two or more conditions that share similar signs and symptoms. • Often ambiguous and requires clinical experience and practice.

3. Why is it so important? http://www.clipartbest.com/confused-people-pics

4. Direct Access1 • New and exciting but can be overwhelming! • Added responsibility to make accurate clinical decisions related to physical therapy patient care. • Save time and money • Decrease risk for malpractice • Patient centered care

5. Case Example

6. Background2 • 22-70% of the population will experience neck pain • 10-20% report neck pain at any given time • 54% in the last 6 months • Increases with age • Most common in women age 50 and > • Make up 25% of PT visits

7. Chart Review Patient Demographics + Initial presentation • 60 year old male identifying R scapular/neck pain  R pinky • Insidious onset of about 3 months • History of DM II • Occupation-Risk Manager • Physician Script: “M 54.12-Cervical Radiculitis-Evaluate & Treat”

8. Subjective History • No history of injury or heavy lifting • Numbness + decreased sensation in R pinky • Clumsiness • Difficulty sleeping especially on the R side • Occupation-Risk Manager • Sitting long hours on computer • Heat + arm cradling ↓ symptoms • Arm hanging at side + side sleeping ↑ symptoms

9. Common Clinical Presentations3

10. Initial Impressions?? • Cervical Spondylosis? • Cervical Radiculopathy? • Cervical Disc? • Central Stenosis/myelopathy? • Other??

11. Objective • Aching, constant pain • Current: 5 • Worst: 8 • Interrupted Sleep • Unable to sleep on right side • Palpation • Mild TTP Upper Trapezius on the right • Posture • Seated slouched posture

12. Objective

13. Myotomes Dermatomes

14. Special Tests • Spurling’s Test • Negative Bilaterally • UE Nerve Tension Testing • Negative-Ulnar, Median, Radial • Quadrant Testing • Positive on R Ext • s/s in neck + R shoulder blade

15. Review • Unilateral neck pain R + Scapula • C7 Myotome- R Triceps • C8 Dermatome- R Pinky + Ulnar border of hand • + R Ext Quadrant • Limited ROM: • Flex & Ext • SB L>R

16. Second Impressions? • Cervical Spondylosis? • Cervical Radiculopathy? • Cervical Disc? • Central Stenosis/myelopathy? • Other??

17. Second Impressions2 • Cervical Spondylosis? • Cervical Radiculopathy?** • Cervical Disc? • Central Stenosis/myelopathy?*** • Other??

18. Initial Exercises • Chin Tuck*** • Levator Stretch • Upper Trapezius & Scalene Stretch • Posterior Shoulder Rolls • External Rotation ISO

19. 1st Follow-Up Visit • Pre-treatment pain @ 2/10 • Objective finding • Hypomobile Thoracic segments with PA mobilizations. • Treatment • Thoracic PA mobs. • C/s flexion w/UT & Levator TPR • C/s Extension*** ↑ symptoms to 5/10 • C/s SB w/scalene depression*** s/s ↓, less diffuse, more pinpoint • Mechanical Traction • ↑ pain to 3-4/10 after

20. 2nd Follow-Up Visit • Pre-treatment pain @ 4-5/10 in the arm • Objective finding • - Ulnar nerve tension test • C/s rotation with suboccipital STM • Upper cervical flexion with manual traction • Supine shoulder ER with tube • Supine c/s SB L with scalene stripping • Mechanical Traction

21. 3rd Follow-Up Visit • Pre-treatment pain @ 2/10-no longer constant, not all the way to pinky • Objective findings: • Inc. pain w/manual scapular depression. Dec. pain w/scapular elevation • + Adson’s test • - Roo’s test • Ant + Lateral Scalene stripping • Prone T/s PA mobs + Rib mobs • Sidelying thoracic rotation stretch.

22. Roos or “EAST” Test4 • Test description • Arms abducted to 90, shoulders laterally rotated, elbows bent to 90 • Open + Close fingers • + test if patient can not hold the position for 3 minutes d/t ischemic pain, profound weakness, or n/t • Sensitivity=84% • Specificity=30%

23. Adson’s Maneuver5 • Test Description • Patient upright, arm passively extended, abducted, and externally rotated. • Palpate the radial pulse • Have patient take deep breath in + hold • Head is then SB and rotated toward the testing side • + sign if pulse is markedly decreased or obliterated • Specificity=18-87% • Sensitivity=94%

24. 4th Follow-Up Visit • Pre treatment-pain: limited and only in shoulder area • Scalene stripping w/cervical side bending • Prone thoracic mobilizations • Scalene + SCM stretch

25. Thoracic Outlet Syndrome6 • A group of disorders that occur when the blood vessels or nerves get compressed in the thoracic outlet.(Site mayo clinic) • Thoracic Outlet Boundaries • Median=Scalenes+1st Rib • Posterior=Upper Trap • Anterior=Clavicle • Laterally=Axilla • Controversial diagnosis

26. A Closer Look http://www.slideshare.net/jasminmagdy/thoracic-outlet-syndrome-52508525

27. 3 Types of TOS7 • Neurogenic • 95% of cases • Brachial Plexus becomes compressed • Most common • Venous • 3-5% of cases • Subclavian vein becomes compressed resulting in thrombosis • Paget-Schroetter Syndrome • Arterial • 1-2% • Friction of the subclavian artery on the first rib can cause fibrosis and stenosis of the artery • Typically requires surgery to remove part of the rib and repair the artery

28. Signs & Symptoms11 • Numbness & Tingling in arms + fingers • Neck, shoulder, or hand aches/pain • Weak grip • Discoloration of the hand • Cold fingers/hand • Weakened pulse • Swelling

29. Causes of TOS • Anatomical defects • Poor Posture • Traumatic Accident • Repetitive Activity

30. TOS Treatment8 • Physical Therapy is 1st choice for treatment • Botox injection in the anterior & middle scalene • Surgery

31. Conservative Treatment3-6 months9 • Patient education • Ergonomics • Posture • Scapular positioning exercises • Stretching • Upper Trapezuis • Scalenes • SCM • 1st Rib Mobilizations • TENS • Conservative treatment appears to be effective at reducing symptoms, improving function, and facilitating return to work.

32. Surgical Options • Most often indicated for arterial TOS • Excision of 1st rib • Scalenectomy • Ultimate goal is to open the interscalene space • A study of 588 participants who underwent a first rib resection found that 96% of the cases experienced improved or fully resolved symptoms10

33. Risks of Surgical Approach • Nerve Injury • Bleeding • Pneumothorax

34. Prognosis • Most cases have complete to near complete resolution of symptoms with conservative measures • Approximately 10-20% require surgery • Venous • Arterial

35. TOS Review • Difficult to diagnose • Patient history • Tests • Often mimic other conditions such as impingement, cervical disc, rotator cuff injuries, radiculopathy etc • Physical Assessment • Can respond to conservative treatment • Sometimes requires surgery

36. References • Direct Access in Practice. American Physical Therapy Association website. http://www.apta.org/DirectAccess/. Updated June 20, 2016. Accessed July 19, 2016. 2. Childs, J. D., Cleland, J. A., Elliott, J. M., Teyhen, D. S., Wainner, R. S., Whitman, J. M., American Physical Therapy, Association. (2008). Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther, 38(9), A1-A34 3. Magee, D. Orthopedic Physical Assessment6th edition. Elsevier Saunders. 2014. 4. Roos Stress Test. Physiopedia Website. http://www.physio-pedia.com/Roos_Stress_Test. Accessed July 19, 2016. 5. Adson’s Test. PhysiopediaWbsite. http://www.physio-pedia.com/Adsons_Test. Accessed July 19, 2016.

37. References 6. Kisner C, Kolby LA. Therapeutic Exercise: Foundations and Techniques. 6th edition. F.A. Davis Company. 2012. 7. Freischlag J, Orion K. Understanding Thoracic Outlet Syndrome. Scientifica [serial online]. January 2014;:1-6. Available from: Academic Search Complete, Ipswich, MA. Accessed July 20, 2016. 8. Grunebach H, Arnold M, Lum Y. Thoracic outlet syndrome. Vascular Medicine [serial online]. October 2015;20(5):493-495. Available from: Academic Search Complete, Ipswich, MA. Accessed July 20, 2016. 9. Hooper T, Denton J, McGalliard M, Brismée J, Sizer Jr. P. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. Journal Of Manual & Manipulative Therapy (Maney Publishing) [serial online]. September 2010;18(3):132-138. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed July 20, 2016. 10. Orlando M, Likes K, Freischlag J, et al. A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. Journal Of The American College Of Surgeons [serial online]. May 2015;220(5):934-939 6p. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 20, 2016. 11. BoezaartA, Haller A, Laduzenski S, Koyyalamudi V, Ihnatsenka B, Wright T. Neurogenic thoracic outlet syndrome: A case report and review of the literature. International Journal Of Shoulder Surgery [serial online]. April 2010;4(2):27-35. Available from: Academic Search Complete, Ipswich, MA. Accessed July 20, 2016.

38. Questions?