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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Rheumatoid Arthritis (RA) • Characterized by polyarthritic involvement of peripheral joints, but the cervical spine is often affected early. Deep aching pain in occipital or temporal areas may be present with pain referred to face, ear, or subocciput from irritation of the C2 nerve root Atlanto-axial (AA) Instability/Subluxation • Sensation of head falling forward during neck flexion or clunking sensation during neck extension. Symptoms of cervical radiculopathy are common with AA joint involvement • Radicular symptoms accompanied by weakness, gait disturbance, bladder, and bowel and sexual dysfunction can occur whenever cervical myelopathy occurs, whether from a mechanical or medical cause • The Babinski test may be the most reliable screening test Clinical Signs and Symptoms: Upper Cervical Ligamentous Instability • Neck pain and/or shoulder pain, stiffness • Wide-based, uncoordinated gait • Loss of hand dexterity • Paresthesia • Hyperreflexia • + Babinski test • + Hoffman sign • + Lhermitte's sign • Urinary retention followed by overflow incontinence (severe myelopathy) • Occipital headache and numbness • Severe limitation during neck active range of
INTRODUCTION Differential diagnosis is defined as the process of examination, evaluation, and medical screening to determine appropriateness of intervention within scope of practice—or need for referral to another practitioner. Provider responsibility is to determine what biomechanical or neuromusculoskeletal problem is present and then provide treatment. Clinicians must be able to identify signs and symptoms of systemic disease. Use of evidence-based practice will enable a provider to build their own screening tools. This course will review differential diagnosis screening the spine, upper extremities and lower extremities. CERVICAL SPINE History • Outcome measures ○ Neck Disability Index: Contains 10 items (7 related to activities of daily living (ADLs), 2 related to pain, 1 related to concentration); each item is scored 0–5, and the total score is expressed as a percentage ■ Higher scores correspond to greater disability – MDC =5 (10%) – MCID = 9.5 (19%) ○ The Patient-Specific Functional Scale- (PSFS): Asks patients to list three activities that are difficult as a result of their symptoms, injury, or disorder. Patient rates each activity on a scale of 0–10. The three activity scores are averaged for a final score – MCID = 2.0 Cervical Pain • Traumatic and degenerative conditions of cervical spine are major primary musculoskeletal causes of neck pain. Cervical pain with or without radiating upper extremity (UE) pain or symptoms may be caused by a local biomechanical dysfunction or systemic problem
motion (AROM) in all directions • Signs of cervical myelopathy • Post trauma • History of RA or down syndrome
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