Differential Diagnosis for Physical Therapists Screening for
Referral, 6th Edition
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DIFFERENTIAL DIAGNOSIS FOR PHYSICAL THERAPISTS,
SIXTH EDITION ISBN: 978-0-323-47849-6
Copyright © 2018 by Elsevier, Inc. All rights reserved.
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than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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contraindications. It is the responsibility of the practitioner, relying on their own experience and the knowl-
edge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
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Previous editions copyrighted 2013, 2007, 2000, 1995, and 1990.
International Standard Book Number: 978-0-323-47849-6
Executive Content Strategist: Kathy Falk
Content Development Manager: Billie Sharp
Associate Content Development Specialist: Samantha Dalton
Publishing Services Manager: Jeff Patterson
Book Production Specialist: Bill Drone
Design Direction: Ryan Cook
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Catherine…this edition is dedicated to you. We do stand on
the shoulders of giants as physical therapists. You have contributed
significantly to our profession by emphasizing differential diagnosis
through your clinical and academic work as well as your creation of
all six editions of this text. Thank you for all that you do!
JH and RTL
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CONTRIBUTORS
Sherman Auyeung, PT, DPT, OCS, FAAOMPT Jeannette Lee, PT, PhD
Physical Therapist Assistant Professor
Kaiser Permanente Graduate Program in Physical Therapy
San Francisco, California San Francisco State University
San Francisco, California
Annie Burke-Doe, PT, MPT, PhD
Professor and Assistant Director, Residential DPT Beth Shelly, PT, DPT, WCS, BCBPMD
University of St. Augustine for Health Sciences Physical Therapist
San Marcos, California Board Certified in Women’s Health and Pelvic Muscle
Dysfunction Biofeedback
Brian J. Hickman, PT, DPT, NCS, GCS Moline, Illinois
Physical Therapist
Acute Rehabilitation and Skilled Nursing Units
Fairmont Hospital
San Leandro, California
ix
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AUTHOR’S INTRODUCTION: A BRIEF HISTORY OF THE BOOK
It has been 30 years since the concept of this textbook was first the student handout was almost 350 pages, an employee at
hatched. It seems a good time for a walk down memory lane Kinkos suggested that “perhaps desktop publishing might be
to give our readers a better understanding of how this text- a good idea.”
book (and the concept behind it) came into being. This may That summer was spent writing a sample chapter to sub-
be especially important now for our future physical therapists mit to 12 different publishers. Six rejected the idea outright.
who will study this material as part of the core curriculum of Three expressed interest but noted that the references were
their education without any understanding of its roots. woefully outdated. The most recent references for this mate-
In the early 1980s, while at Fort Bliss, Texas, as a U.S. rial were dated in the 1950s. This was because the concept was
Army Reservist, I was present when Cpt. Steve Stratton, P.T. well known to medical doctors and was accepted as a matter of
came into the clinic one day all excited about something he course. There was no ongoing research to substantiate the fact
had found in a medical textbook. that systemic disease and medical conditions can refer pain
“Listen to this,” he said. “Back pain can be caused by kid- (and other symptoms) to a wide range of somatic locations.
ney disease, liver problems, and heart conditions.” That was In other words, there would be no newer references possible!
his (and my) first inkling that medical problems could be Eighteen draft revisions later (no kidding!), three publish-
referred to the areas most commonly evaluated and treated ers contacted me and offered a contract. I enlisted the help of
by physical therapists (i.e., back and shoulder). Teresa Snyder, a nursing and clinical instructor at the Univer-
Although this concept was well documented in the medi- sity of Montana. She had been a guest lecturer who provided
cal literature, it was not one included in the curriculum of excellent instruction for our students in the area of diabetes,
physical therapist programs. Back in my home state of Mon- but she also had a wealth of academic/medical information
tana, my colleagues and compatriots in the Montana chapter in her head.
of the American Physical Therapy Association (APTA) were Between teaching classes, clinical practice, pregnancies,
launching a campaign to pass unrestricted Direct Access in and raising babies together, we managed to put together the
our state. first edition of Differential Diagnosis in Physical Therapy:
Working as a physical therapist in the military was the Musculoskeletal and Systemic Conditions (now called Differ-
most Direct Access (at that time referred to as “Indepen- ential Diagnosis for Physical Therapists: Screening for Referral).
dent”) practice in the United States (with privileges to order The title originally submitted was Clinical Signs and Symp-
radiographs and prescribe Class I pain relievers). With this toms for the Physical Therapist. The Differential Diagnosis
experience, I was very concerned about the lack of prepara- name (assigned by the publisher) brought me much grief for
tion for our students heading into a Direct Access practice. many years by those who took exception to the use of the
Based on what I learned about referred pain patterns while word diagnosis linked with physical therapist. This was not
under the mentorship of Cpt. Stratton, it appeared to me that considered acceptable by the medical community. Indeed,
we were not ready for this challenge. while some physical therapists raised their eyebrows at that
At the same time, I was an adjunct professor at the Univer- time, many others were up in arms. Diagnosis was a word
sity of Montana School of Physical Therapy teaching Clinical strictly used by physicians.
Medicine as a core course in the curriculum. The more expe- But we have Z. Annette Iglarsh, PT, PhD, MBA, FNAP,
rienced therapists among us will remember that this course FAPTA (2015 Catherine Worthingham Fellow) and Jan
was often taught by a collection of community and hospital K. Richardson, PT, PhD, OCS, FAPTA (2011 Catherine
physicians. The course content often included a wide range Worthingham Fellow, 2011 Duke Medicine Professor Emeri-
of topics unrelated to physical therapy (e.g., we heard lectures tus, and former President of the APTA, 1997-2000) to thank
on stomach stapling, surgical techniques for urologic prob- for the title and their visionary insights for our profession
lems, descriptions of endoscopic procedures). behind it. Evidently, there was some conversations with the
So, I rolled up my proverbial sleeves and started research- editor that led to this title being adopted. I am forever grate-
ing the topic. While at the best military libraries in the United ful to them!
States, I found all the available information and articles and These two individuals have both been “change agents” in
brought them home to Montana. Remember, at that time, the physical therapy profession. Although Teresa and I wrote
the Internet was not a part of our daily lives, PubMed did not this text, Drs. Iglarsh and Richardson must receive some
exist, and there was no such thing as scanning or electroni- credit for their part in moving us toward developing a physi-
cally transferring information. Everything was painstakingly cal therapist’s diagnosis within the scope of our practice—a
photocopied, carried home, and then reorganized for class- seed planted with the singular title of an obscure textbook
room lectures presented on overheads and in handouts. published in 1989 (with a 1990 copyright date).
I put it together for the “new-and-improved” Clinical Two other individuals who have been very influential in
Medicine course designed to prepare our students for an the process of moving our profession toward developing the
unrestricted Direct Access practice. (Direct Access was passed concept of diagnosis and finding a way to standardize it are
in Montana in 1987—well ahead of many other states). When Shirley Sahrmann and Barb Norton (Washington University
xi
xii Author’s Introduction: A Brief History of the Book
in St. Louis). Their work to create the Diagnosis Dialog plat- through four of the editions (Margaret [Peg] Waltner, in
form for conversation and collaboration must be acknowl- memoriam), Laurita (Laurie) M. Hack (my physical therapy
edged (and lauded!) as well. advisor at the University of Pennsylvania way back when!),
No textbook that has gone through six revisions is accom- and the many, many people on the publishing side (from the
plished in isolation. I owe a debt of gratitude to many people original publisher W.B. Saunders to the present day Elsevier).
who supported the work or participated in a major way: Steve And a final thanks to my family who bring love, light, and
Stratton, Teresa E. Kelly Snyder (my coauthor through four laughter into my life.
editions), Margaret Biblis (the original editor who brought
the book on board), our tireless Developmental Editor Catherine Cavallaro Goodman
PREFACE
In the profession of physical therapy, we are similar to other neuromusculoskeletal presentation. Each system is presented
professions in that we are mere dwarfs standing on the shoul- with the common conditions that occur within it, as well as
ders of giants. This metaphor dates back to the twelfth century red flags, risk factors, clinical presentations, and signs and
but still applies today. That is, we are not brighter than our pre- symptoms. Clinical practice guidelines and helpful screening
decessors, but we have learned from them and are able to see clues supported by evidence at all levels are also presented for
further because of their efforts and persistence. This concept each system.
can also be applied to the updated edition of this book. The Section III covers the axial and appendicular regions of the
focus of the sixth edition is to continue to look forward with body and reviews the systemic origins to consider when treat-
the goal of improving the abilities of both physical therapy stu- ing a patient/client with a condition in these regions.
dents and clinicians to consider the three options when evalu- At the end of each chapter, the reader is presented with
ating a patient or client: 1) treat, 2) treat and refer, or 3) refer. practice questions to check for understanding and further
These three options must be carefully considered through- facilitate learning. In this edition, we updated the practice
out every episode of patient/client care and should follow the questions and added several new items for review.
standards of competency established by the APTA related A comprehensive index can be found at the end of the
to conducting a screening examination. Throughout this book to allow the reader to more easily locate content in the
text, we present a screening model that includes the criti- text.
cal parts of the screening process. This model is an accepted A guide to additional resources called quick response (QR)
part of standard clinical practice and reflects the patient/cli- codes is provided at the beginning of this book. These codes
ent management process in the updated edition of the Guide can be scanned on a digital device allowing readers quick and
to Physical Therapist Practice. This screening process has also easy access to valuable screening tools such as lists of ques-
contributed to the movement toward a diagnostic classifica- tions for screening specific problems (e.g., headache, depres-
tion scheme for our profession. sion, substance use/abuse, bladder function, and joint pain),
Differential diagnosis is an area of concentration that has checklists, intake forms, and assessment tests. Instructions
vastly grown over the past decade and is well represented on for using the codes can be found on page xvii. These tools
the physical therapist licensure examination. In addition, are also provided in the Appendices, which can be found on
screening for medical referral continues to be an increas- the Evolve website. See page 713 for more information about
ingly important component of physical therapy practice in accessing the Appendices, including the alphabetical list of
all clinical settings owing to direct access to physical therapy screening questions, which is a special feature of this book
by patients, the complexity of medical issues being encoun- (see Appendix B).
tered by therapists, and the limitations in health care reim- We encourage readers to take advantage of the many addi-
bursement. As we updated the literature for the new edition tional resources offered on the Evolve website to enjoy a more
of this text, we found even stronger evidence supporting the complete learning experience. These resources include forms
role of the physical therapist in the screening process, show- that can be used in clinical practice, practice questions, and
ing how the ability of the therapist to identify the need for reference lists. For instructors, there are a number of addi-
referral to other health professionals not only saves lives, but tional resources to support the use of the text in your courses,
also optimizes the quality of life for individuals under the including selected images, updated PowerPoint presenta-
therapist’s care. Information contained in this text is there- tions, and a comprehensive test bank.
fore immensely important in all clinical practice settings in It is our intention to provide the physical therapist (both
the contemporary and future practice of physical therapy. students and clinicians) with evidence-based approaches to
This text is divided into three sections: Section I intro- screen for systemic conditions that mimic neuromusculo-
duces the screening process and focuses on interviewing the skeletal conditions and to assist them with optimal decision-
client with clarity. Chapters 3 and 4 dive deeper into pain pre- making practices that will benefit the patient/client.
sentations and physical assessment of the patient/client.
Section II follows a systems approach that focuses on John Heick
the nine viscerogenic causes that may masquerade as a Rolando T. Lazaro
xiii
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CHAPTER 8 Screening for Gastrointestinal Disease xv
ACKNOWLEDGMENTS
We knew when we started editing the sixth edition of this To the staff at Elsevier, thank you for the help and support
book that it was going to be a major undertaking, but we behind the scenes:
really did not realize how complex it would be until we were Penny Rudolph, Professional Reference Director
knee-deep into the process. We are very fortunate to have had Kathy Falk, Executive Content Strategist
the expertise and support of several individuals who made the Jolynn Gower and Billie Sharp, Content Development
task easier and more enjoyable. Your immense contribution Managers
to the text is very much appreciated. Samantha Dalton, Associate Content Development Specialist
To the following content experts who provided support Bill Drone, Book Production Specialist
and/or edited chapters: Ryan Cook, Designer
Sherman Auyeung Our Developmental Editor, Linda Wood, deserves special
Bill Boissonnault mention. Thank you for your excellent work and attention to
Annie Burke-Doe detail. We very much appreciate your guidance and patience
Kevin Helgeson throughout the process.
Brian Hickman To Sherrill Brown, Michael Pritchett, and Elizabeth Van
Trish King De Grift at the University of Montana College of Health Pro-
Jeanette Lee fessions and Biomedical Sciences Drug Information Service:
Barbara Norton thank you for helping us update several tables related to drug
Beth Shelly information in the text.
Teresa Kelly Snyder
John Heick
Rolando T. Lazaro
xv
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ENHANCE YOUR LEARNING AND PRACTICE EXPERIENCE
The images below are QR (Quick Response) codes. Each What you need:
code corresponds to one of the appendices or reference lists • A mobile device, such as a smartphone or tablet, equipped
at the end of each chapter. Appendices can be accessed on with a camera and Internet access
your mobile device for quick reference in a lab or clinical • A QR code reader application (if you do not already have
setting. References are linked to the Medline abstract where a reader installed on your mobile device, look for free ver-
available. sions in your app store)
How it works:
For fast and easy access, right from your mobile • Open the QR code reader application on your mobile
device, follow these instructions. device.
• Point the device’s camera at the code and scan.
• Each code opens an individual URL for instant viewing of
the appendices and the references where you can further
access the Medline links—no log-on required.
APPENDIX A: SCREENING SUMMARY
APPENDIX A-1 APPENDIX A-3 APPENDIX A-4
Quick Screen Checklist Systemic Causes of Joint The Referral Process
Pain
APPENDIX A-2
Red Flags
APPENDIX B: SPECIAL QUESTIONS TO ASK (SCREENING FOR)
APPENDIX B-1 APPENDIX B-5 APPENDIX B-9
Alcohol Abuse: AUDIT Bladder Function Depression/Anxiety (see
Questionnaire also APPENDIX B-10)
APPENDIX B-2 APPENDIX B-6 APPENDIX B-10
Alcohol Abuse: CAGE Bowel Function Depression in Older Adults
Questionnaire
APPENDIX B-3 APPENDIX B-7 APPENDIX B-11
Assault, Intimate Partner Breast Dizziness
Abuse, or Domestic Violence
APPENDIX B-4 APPENDIX B-8 APPENDIX B-12
Bilateral Carpal Tunnel Chest/Thorax Dyspnea (Shortness of
Syndrome Breath [SOB]; Dyspnea on
Exertion [DOE])
(continued next page)
xvii
xviii Enhance your Learning and Practice Experience
APPENDIX B: SPECIAL QUESTIONS TO ASK (SCREENING FOR) (cont.)
APPENDIX B-13A APPENDIX B-22 APPENDIX B-31
Eating Disorders Lymph Nodes Psychogenic Source of
Symptoms
APPENDIX B-13B APPENDIX B-23 APPENDIX B-32A
Resources for Screening for Medications Taking a Sexual History
Eating Disorders
APPENDIX B-14 APPENDIX B-24 APPENDIX B-32B
Environmental and Work Men Experiencing Back, Taking a Sexual History
History Hip, Pelvic, Groin, or
Sacroiliac Pain
APPENDIX B-15 APPENDIX B-25 APPENDIX B-33
Fibromyalgia Syndrome (FMS) Night Pain Sexually Transmitted
Diseases
APPENDIX B-16 APPENDIX B-26 APPENDIX B-34
Gastrointestinal (GI) Problems Nonsteroidal Shoulder and Upper
Antiinflammatories Extremity
(NSAIDs) (Side Effects of)
APPENDIX B-17 APPENDIX B-27 APPENDIX B-35
Headaches Odors (Unusual) Sleep Patterns
APPENDIX B-18 APPENDIX B-28 APPENDIX B-36
Joint Pain Pain Substance Use/Abuse
APPENDIX B-19 APPENDIX B-29 See APPENDIX B-19
Kidney and Urinary Tract Palpitations (Chest or Urinary Tract Impairment
Impairment Heart)
APPENDIX B-20 APPENDIX B-30 APPENDIX B-37
Liver (Hepatic) Impairment Prostate Problems Women Experiencing Back,
Hip, Pelvic, Groin, Sacroiliac
(SI), or Sacral Pain
APPENDIX B-21
Lumps (Soft Tissue) or Skin
Lesions
