Differential Diagnosis of Lower Quarter Conditions

1. Differential Diagnosis of Lower Quarter Conditions International Spine and Pain Institute Kansas City Evening Series 18 September 2014 Rockhurst University Marcie Swift, PT, PhD, FAAOMPT,and Carol Hobbs, PT

2. Why Are We Here?

3. Learning Objectives Upon completion of this presentation, attendees will have gained: • The ability to streamline the subjective and objective examination of patients who present with lower quarter dysfunction. • The ability to identify those patients who need an outside referral before initiating physical therapy treatment. • An understanding of when to incorporate neurological examination tests into the physical therapy examination.

4. Our Agenda Tonight • Body Chart • Introduction to Ruth, George, Julie and Ken • 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. How This Course Works • PowerPoint Presentation has flow of information • Links from PPT presentation to Google Doc for Case Study Application • PT Diagnosis Worksheet for each case • Participants will work in groups to “solve” one of four case studies • At the end of the course, the diagnoses* for each case will be revealed *as determined by the course instructors

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

12. Ruth P4: ache, constant, variable P1: ache, constant P2: ache, constant ✓ ✓ P3: sharp, crampy, intermittent ✓ ✓ P1 ≠ P2, P3, P4 P2 = P3 P4≠ P1, P2, P3 ✓ ✓ ✓ ✓ ✓ ✓

13. George P2: sharp, intermittent P3: throbbing P1: ache, constant, variable P4:burning, intermittent ✓ ✓ ✓ P2 P4 P2 = P3 P1 ? P2,P3 and P4 ✓ ✓

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

15. P4: deep ache, constant Ken P1: ache, constant, variable ✓ ✓ ✓ ✓ P1 P2, P3 P4 ? P1, P2, P3 P5 ≠ P1-P4 ✓ ✓ ✓ ✓ P2: pulling, intermittent ✓ P5: fatigue/ SOB ✓ ✓ P3: tingling, intermittent ✓ ✓ ✓ ✓

16. Disorder Recognition

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

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

19. 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.

20. Possible Non-Musculoskeletal Sites Capable of Referring Pain to the Low Back • 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

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

22. 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)

23. 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.

24. 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

25. 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

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

27. Back to the Case Studies!!

28. “Answers” to Your Questions

29. How does this change your diagnoses lists?

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

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

32. 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.

33. Tests and Measures: LQ Exam **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.

34. Examination: Standing 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 • [Vertical Compression] (Boissonnault, 2011, Ch 13)

35. Examination: Sitting Non-musculoskeletal Tests and Measures Posture/Observation Neurological Testing Segmental Neuro Exam Neurodynamic Testing (Slump) Musculoskeletal Tests and Measures • Percussion of kidneys • Lower Thoracic-Cage Excursion • [Vertical Compression] (Boissonnault, 2011, Ch 13)

36. Location of Kidneys meded.ucsd.edu

37. Practice Time! • Form groups of four • Each group will have a patient, practitioner, recorder and observer; roles will rotate for each technique • Practice kidney percussion in sitting • http://youtu.be/tyRt_1TKwps (for review at your convenience)

38. BREAK!! BREAK!!

39. 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)

40. Observation of Abdomen meded.ucsd.edu

41. Hiatal and Umbilical Hernia www.wikidoc.org www.webmd.com

42. Examination: Supine Non-musculoskeletal Tests and Measures 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) • 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)

43. Abdominal Auscultation • Bowel motility: lightly in all four quadrants with diaphragm • Vascular sounds using bell • aorta (approximately 2 inches superior to umbilicus) • renal arteries (2 inches lateral to aorta) • iliac arteries (ASIS level, 2 inches lateral to midline) • femoral arteries (femoral triangle) (Boissonnault, 2011, Ch 13)

44. Examination: Supine Non-musculoskeletal Tests and Measures 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) • 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)

45. Abdominal Percussion • Purpose of percussion • determine the size and location of abdominal organs • detect accumulation of excessive fluid • contraindicated in persons with AAA and transplants • Percuss over 4 quadrants • Normal sounds are tympanic or dull (Boissonnault, 2011, Ch 13)

46. Abdominal Percussion • Liver percussion • determining vertical span of organ • begin @ mid-clavicular line on right at umbilicus • percuss up toward liver • tympany (air in abdomen) then dullness noted (liver) • [go to below nipple and percuss down] • [note tympany first (lung fields) then dullness (liver)] • normal span is 6-12 cm at mid-clavicular line (Boissonnault, 2011, Ch 13)

47. Examination: Supine Non-musculoskeletal Tests and Measures 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) • 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)

48. Four Quadrants • RUQ • liver and gallbladder • pylorus • duodenum • head of pancreas • potions of the ascending and transverse colon • RLQ • cecum • portions of ascending colon • LUQ • left lobe liver • stomach • body of pancreas • portions of the transverse and descending colon • LLQ • sigmoid colon • portions of descending colon (Moore, p.177; Boissonnault, 2011, Ch 13)

49. 9 Quadrant Terms (Boissonnault, 2011, Ch 13)

50. STAND-IN-PLACE BREAK