Differential diagnosis for Physical Differential diagnosis for Physical therapist ... Physcial ththerapists,

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  • 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

  • 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

  • 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 rela