Chapter 2: Differential Diagnosis for Headaches and Cervical Spine Pain 3 Contact Hours
By: Lorie Schleck, PT, DPT, MA Learning objectives After completing this course, the learner will be able to: Describe the fundamental role of differential diagnosis in the practice of physical therapy. Describe red flag and yellow flag conditions for headache and cervical spine conditions. Describe important subjective, objective, and physical examination findings to consider when accurately diagnosing headache and cervical spine problems. Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing
Outline potential viscerogenic and systemic origins of head and neck pain. Outline the subjective, objective, and physical findings that are important in confirming a neuromuscular or musculoskeletal source of a patient’s problem.
implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
INTRODUCTION
Differential diagnosis is a critical part of the initial physical therapy assessment. This involves using subjective, objective, and physical examination findings to answer two important questions. The first question is “Is this patient appropriate for physical therapy?” Direct access to physical therapy services means that we now see patients without a referral from a physician. Direct access to physical therapy is increasing because it has been associated with lower cost, less healthcare utilization, and higher patient satisfaction (George et al., 2018). Red and yellow flags When we are the first medical professionals to have contact with a client, we are responsible for screening for possible medical disease processes. This includes recognizing both red and yellow flag findings. Red flag findings are warnings that features of the client’s medical history or clinical examination are associated with a high risk of serious disorders such as cancer, inflammation, or fracture. Red flags require a medical specialist to evaluate the patient (Carvallaro Goodman et al., 2018). Orange flags Recently, physical therapy practitioners have differentiated orange versus yellow flags. Orange flags are associated with psychiatric disorders such as depression, anxiety, and somatoform disorders (Ladeira, 2018). In this schema, yellow flags are identified as maladaptive pain coping strategies such as fear-avoidance behavior, kinesiophobia, and catastrophic thinking (Ladeira, 2018). The prevalence of psychiatric disorders is high in patients with movement disorders, and these diagnoses may hinder treatment progress. Per Ladeira (2018), recognition of the presence and effect of psychiatric disorders and referral to the appropriate practitioner is essential to improving patient outcomes.
Healthcare consideration: All 50 states plus the District of Columbia and the U.S. Virgin Islands enjoy some form of direct access to physical therapy services. However, the exact provisions and limitations vary. The American Physical Therapy Association (APTA) has a list of each jurisdiction’s level of direct access (https://www.apta.org/advocacy/issues/direct-access- advocacy/direct-access-by-state). Yellow flags are cautionary and warn the therapist to think again about the presenting problem and perhaps to dig deeper into the screening process. Yellow flag findings are not warnings of high-risk issues but rather are factors that should be considered when devising a care plan for patients with headaches and neck pain. For example, you may evaluate a patient where, along with musculoskeletal elements, you conclude that there are psychogenic contributions to their headaches. This conclusion might influence how you communicate with this client as well as types of helpful education you can provide. Yellow flag factors such as maladaptive pain coping strategies are predictors of long-term disability (Ladeira, 2018), and management of these factors is critical to preventing chronic pain and long-term disability. A study by Ladeira (2018) assessed physical therapists’ ability to manage red, orange, and yellow flags in patients with low back pain. Participating physical therapists made clinical decisions based on three vignettes: Low back pain with red flag of ectopic pregnancy, low back pain with orange flag of concomitant depression, and low back pain with yellow flag of fear- avoidance behaviors. Of the 410 physical therapists who participated in the study, 53% managed the patient with low back pain and ectopic pregnancy correctly, 28.5% managed the patient with low back
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Book Code: PTNY1024
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