Screening for Physical Therapy and Differential Diagnosis

Introduction to Screening and Flags

  • As healthcare professionals, physical therapists are often the first point of contact for patients with musculoskeletal pain or dysfunction.
  • Vigilance in screening for underlying medical conditions is crucial, as these can significantly impact a patient's recovery.
  • Key areas of focus include:
    • The diagnostic process within the physical therapist's scope of practice.
    • Red and yellow flags in patient history, signs, and symptoms that may necessitate further evaluation.
    • The interplay between a patient's medical history, comorbidities, demographics, and risk factors.
    • Differentiating between systemic and musculoskeletal pain patterns.
    • Understanding the mechanisms of referred visceral pain.
    • Screening for emotional and psychological overlay and its impact on pain experience and treatment response.
  • Screening Tools:
    • PHQ-2 and PHQ-9.
    • Oswestry Disability Index (ODI).
    • OSPRO-YF.
    • CAGE Questionnaire.
    • Alcohol Use Disorders Identification Test (AUDIT).
    • Chemical/Occupational Exposure CH2OPD2.
    • FABQ.
    • TSK-11.
    • Chronic Pain Acceptance Questionnaire.
    • Depression Screening Questions.
    • Örebro Musculoskeletal Pain Questionnaire.
    • Keele STarT Back Tool.
  • Reasons to screen:
    • Direct Access.
    • Early Detection.
    • Disease Progression.
    • Referral Source.
  • Patients are coming in 'quicker and sicker' than before.
  • Physical therapists are responsible for determining if an issue is within their scope of practice, viewing the individual as a whole.

Screening Tools and Outcome Measures

  • Screening Tools:
    • Brief triage instruments.
    • Are used to identify patients at risk for poor clinical outcomes.
  • Outcome Measures:
    • Used to assess a patient’s current status.
    • To track functional changes over time.
    • Improve the efficiency and effectiveness of care.
    • Types: Performance-Based and Self-Reported.
    • Performance-Based: Timed Up and Go (TUG).
    • Self-Reported: Oswestry Disability Index (ODI).
  • Constitutional Signs:
    • Fever.
    • Diaphoresis.
    • Sweats.
    • Nausea.
    • Vomiting.
    • Diarrhea.
    • Pallor.
    • Dizziness/syncope.
    • Fatigue/Weakness.
    • Weight loss.

Red Flags

  • Serious medical pathology that warrants referral to another qualified healthcare practitioner.
  • Examples:
    • Cauda equina.
    • Fracture.
    • Malignancy.
  • Red flags do not implicate the presence of psychosocial factors.
  • Most screens are located in the appendix of the electronic version of the textbook.
  • Follow-up Screening Questions (George et al., 2015):
    • A 23-item tool with 100% accuracy for screening non-musculoskeletal pathology.
    • Example for nervous system screen: "Have you recently experienced (1) abnormal sensations (e.g., numbness, pins and needles, burning) or (2) weakness?"
  • Pilot study by Boissonault et al. (2016):
    • Interview screening tool for PT students called ECHOWs.

Orange and Yellow Flags

  • Orange Flags:
    • Presence of psychiatric disorders that warrant referral.
    • Examples: Clinical depression, mental health disorders, post-traumatic stress disorder.
    • Physical therapy intervention may still be warranted.
    • Screen for orange flags using PHQ-2; if >3, complete PHQ-9.
  • Yellow Flags:
    • Overt psychological risk factors that do not rise to psychiatric disorders.
    • Findings in patient history that may require further inquiry or examination and includes psychosocial factors.
    • May create barriers to rehabilitation progress.
    • Facilitate the development of chronic pain and disability.
    • Physical therapists are front-line musculoskeletal healthcare professionals.
    • Identify and address yellow flags as part of a holistic approach to PT management.
    • OSPRO-YF (Yellow Flags) Louw et al. (2022).
  • APTA statement on screening tools for anxiety for adults is under review.
  • Correlating Factors:
    • Comorbidities.
    • Patient's Medical History.
    • Risk Factors.
    • Demographics.

The Interview Process

  • The interview process is a key skill to develop when screening for physical therapy and referral.
  • Follow-up questions to ask during interviews:
    • "Are you having any other symptoms of any kind anywhere else in your body we have not talked about yet?"
    • "Is there anything else you think is important about your condition that we have not discussed yet?"
    • "Are you better, the same, or worse today?"
  • System-specific questions are located in the e-book version of the textbook.
  • Diagnosis by the Physical Therapist:
    • Scope of Practice: Interpretation of all relevant data; consider all components from the examination.
    • Evaluation.
  • The process requires evaluation of all the data from an individual’s examination including radiographs, labs, and all results of the full examination process.
  • Physical therapist diagnostic labels are not specific to a pathologic or pathophysiologic level like a physician, rather they are at the level of the movement system or at the level of the whole person.
  • The movement system is defined in the textbook.
  • During the process, we must determine the need for a potential referral.
  • When is a referral needed?
    • No apparent movement dysfunction.
    • Lack of causative factors.
    • No identifiable syndrome.
    • Findings inconsistent with physical therapy diagnosis.
    • Flags and risk factors.
  • Guidelines for physician referral are listed in the textbook.

Establishing a Screening Process for Yellow Flags

  • When first introduced to the patient, the physical therapist can begin to screen for potential yellow flag signs.
  • Direct observation: Posturing, Movement patterns, Verbalizations.
  • Subjective exam.
  • Does the patient make any statements that would suggest they possess hypervigilance like “just thinking about all the pain I have keeps me up at night”, or fear avoidance like “ I don’t even try to lift weights anymore because I’m worried, I’ll make it worse” .
  • Standardized screening tools.
    • Tool advantages vs disadvantages:
    • Unidimensional tools:
      • FABQ.
      • TSK-11.
      • Chronic Pain Acceptance Questionnaire.
      • Depression Screening Questions.
      • Only provide data regarding a specific domain.
      • Need to conduct multiple outcome measures.
    • Multidimensional tools:
      • OSPRO-YF.
      • Örebro Musculoskeletal Pain Questionnaire.
      • Designed to provide preliminary data over multiple dimensions.
      • May not be robust enough to identify presence of yellow flags.
      • False negative.
      • Does not provide enough detail when yellow flags identified.
  • Which Patients to Screen?
    • Screening all patients increases workload and false positives but reduces the risk of missing a referral need.
    • Waiting and seeing approach delays informed rehabilitation principles and reduces benefits.
    • Recommended: two-step screening process:
    • Use of multidimensional tools at initial assessment.
    • Use specific unidimensional tools based on findings.
  • How Often to Screen?
    • Screening yellow flags throughout plan of care recommended.
    • Assesses progress with psychologically informed PT.
    • Need to continue, modify, or cease therapy.
    • Identify emerging yellow flags not present at the time of initial patient encounter.
    • Reassessment every two weeks recommended.
    • Balance between barriers to screen administration and minimal detectable changes.
  • Initial Screening:
    • Implement two-step screening process:
    • Multidimensional tools followed by unidimensional tools.
    • OSPRO-YF.
    • Örebro Musculoskeletal Pain Questionnaire (short form).
    • Keele STarT Back Tool.
  • Two-step process informed by subjective interview and clinical observations.
  • Subjective Exam and Observation:
    • Clinical interview provides valuable information not assessed on standardized outcomes.
    • Patient’s affective behaviors, verbalizations, body-language.
    • Avoiding use of questions beginning with “why”:
    • "Why do you think you are not getting better?"
    • "Why do you think your back hurts?"
    • Places patient on the defensive and reinforces previously established unhelpful psychosocial beliefs.
    • Use questions that begin with “what,” “when,” or “how”:
    • "What are you hoping to get out of the consultation today?"
    • "How do you usually respond to your pain?"
    • Often provides more detailed answers than "why" questions.
    • Socratic interviewing (disciplined and thoughtful dialogue).

Common Psychosocial Yellow Flags

  • Behaviors:
    • Extended rest.
    • Withdrawn from social life.
    • Alcohol consumption.
    • Smoking.
    • Sleeping disturbances.
    • Excessive reliance on passive modalities.
    • Reports of extremely high pain levels (e.g., 15/10).
  • Work issues:
    • Job dissatisfaction.
    • Problems with peers/supervisors.
    • High physical demands.
    • Low socioeconomic status (low SES).
  • Emotions:
    • Fear of increased pain with activity/therapy.
    • Depression.
    • Irritability.
  • Diagnosis and treatment:
    • Conflicting diagnoses.
    • Language promoting fear and catastrophizing in expectation of a “quick-fix”.
  • Overt Pain Behaviors:
    • Individuals may demonstrate any number of specific behaviors when experiencing pain.
    • Guarding – abnormally stiff or rigid movement when changing positions.
    • Bracing – maintaining a fully extended limb for weight bearing/acceptance.
    • Rubbing – any contact between hand and injured area.
    • Grimacing – obvious facial expressions including narrowed eyes, brow furrow, tightened lips, grimacing.
    • Sighing – obvious exaggerated exhalation of air, exemplified by shoulders rising and falling, may see cheeks puff.

Pain Types and Referred Pain

  • Sources of Pain:
    • Cutaneous.
    • Somatic.
    • Visceral.
    • Neuropathic.
    • Referred.
  • Cutaneous:
    • Related to the skin.
    • Localized with one finger.
    • Associated with referred or somatic pain.
  • Somatic:
    • Bone, nerve, muscle, tendon, ligament, arteries, joints, spongy or cancellous bone, periosteum.
    • Poorly localized.
    • Often Referred.
  • Visceral:
    • Internal Organs, heart muscle.
    • Poorly localized because of multi-segmental innervation.
    • Pain corresponds to dermatomes from which the organs receives its innervations.
    • ANS response.
  • Referred Pain:
    • From all structures cutaneous, somatic, or visceral.
    • Pain felt in an area far from the site of the lesion but supplied by the same or adjacent neural segments.
    • Usually well localized.
    • Can spread or radiate from point of origin.
    • Can occur alone but usually preceded by visceral pain when an organ is involved.
    • The client/patient just doesn't connect the two – and the therapist hasn't asked.
  • Common Sites of Referred Visceral Pain:
    • Anterior:
    • Heart.
    • Lung and diaphragm.
    • Esophagus.
    • Liver and gallbladder.
    • Stomach.
    • Pancreas.
    • Ovary.
    • Urinary bladder.
    • Posterior:
    • Gallbladder.
    • Kidney.
    • Small intestine.
    • Appendix.
    • Colon.

Mechanisms of Referred Visceral Pain

  • Embryologic Development.
  • Multi-segmental Innervation.
  • Direct Pressure and Shared Pathways.
  • Multi-segmental Innervation:
    • Pain of a visceral origin can be referred to the corresponding somatic areas.
    • Cardiac pain is not felt in the heart but is referred to areas supplied by the corresponding spinal nerves.
    • Cardiac pain occurs in any structure innervated by C3-T4: the jaw, neck, upper trap, shoulder and arm.
    • Note that this is the sympathetic division of the ANS.
  • Direct Pressure and Shared Pathways:
    • Pain of cardiac and diaphragmatic origin is often felt in the shoulder because the heart and the diaphragm are supplied by the C5-6 spinal segment.
    • Direct pressure from any inflamed, infected, or obstructed organ that can come in contact with the diaphragm can refer pain to the ipsilateral shoulder.
    • The spleen is tucked up under the diaphragm on the left side, the tail of the pancreas can also come in contact with the diaphragm on the left side, so any impairment of these organs can cause left shoulder pain.
    • The gallbladder is located up under the liver on the right side (though neither are shown here) so it can refer pain to the right shoulder which is shown in the image.

Characteristics of Pain

  • During the subjective history, the physical therapist will gather information about the patient's pain.
  • The following topics need to be fully explored by the physical therapist to gather the data/information needed to proceed with their reasoning process:
    • Location/Onset.
    • Description.
    • Intensity.
    • Duration.
    • Frequency.

Pain Patterns

  • Physical Therapist Looks for Patterns:
    • Vascular.
    • Neurogenic.
    • Musculoskeletal.
    • Neuromuscular.
    • Emotional.
    • Visceral.
  • Visceral Pain Pattern:
    • Gradual, progressive, cyclical.
    • Constant.
    • Intense.
    • Unrelieved by rest or change of position.
    • Does not fit the expected mechanical or neuromusculoskeletal pattern.
  • The Organ Dependent Pain Pattern Follows the Following Criteria:
    • Relieving:
    • Gallbladder – Lean Forward.
    • Kidney – lean to the affected side.
    • Pancreas – sit upright/lean forward.
    • Aggravating:
    • Esophagus – swallowing.
    • GI – Peristalsis (eating).
    • Heart – Cold/exertion/stress.
  • When Evaluating Night Pain Patterns Consider:
    • Systemic.
    • Associated signs and symptoms (shortness of breath, cough, wheezing).
    • What makes it better/worse?
    • For example: sitting up decreases venous return to the heart.
    • Effects of eating on back or shoulder pain.
    • If pain is musculoskeletal, then it should follow the patterns below:
    • Acute --> Subacute --> Chronic.
    • Bone Pain at night should be carefully considered and screened.
    • For example, cancerous neoplasms are highly vascularized at the expense of the host causing pain from ischemia (decreased blood flow).
  • Myofascial Pain Types:
    • Trauma.
    • Muscle Spasm.
    • Muscle Tension.
    • Muscle Deficiency (weakness/stiffness).
    • Trigger points (elaborated below).
  • Trigger Points (TrPs) are:
    • Found with palpation of tender points.
    • Pain is produced or increased with palpation.
    • There is a presence of a taut band of soft tissue.
    • Pain is reproduced by resisted motions.
    • There is a history of:
    • Immobility.
    • Prolonged or vigorous activity.
    • Forceful abdominal breathing.

Other Considerations

  • Physical therapists should complete a Review of Body Systems.
    • An inclusive list of systems is provided below.
    • For clarity, a systems review is objective testing of a specific system.
    • General Questions.
    • Integumentary.
    • Musculoskeletal.
    • Neurological.
    • Rheumatologic.
    • Cardiovascular.
    • Pulmonary.
    • Psychologic.
    • Gastrointestinal.
    • Hepatic/Biliary.
    • Hematologic.
    • Genitourinary.
    • Gynecologic.
    • Endocrine.
    • Cancer.
    • Immunologic.
  • Screening for Substances:
    • There are three more considerations a physical therapist must ponder. These include screening for substance use, emotional overlay and psychological considerations.
    • Alcohol use can be screened with:
    • CAGE Questionnaire.
    • Alcohol Use Disorders Identification Test (AUDIT).
    • Caffeine.
    • Tobacco.
    • Chemical/Occupational Exposure use can be screened with: CH2OPD2.
  • Emotional Overlay:
    • Psychological Components:
    • Anxiety.
    • Depression.
    • Panic Disorder.
  • Recognizing pain patterns that are characteristic of systemic disease is a necessary step in the screening process.
  • Understanding how and when diseased organs can refer pain to the neuromuscular, skeletal system helps the physical therapist to identify specific suspicious pain patterns.
  • Careful, sensitive, and thorough questioning regarding the multi-faceted experience of paint can elicit essential information necessary when making a decision regarding treatment or referral.