DPT 880 DIFFERENTIAL DIAGNOSIS IN PHYSICAL THERAPY Units: 3, Clock Hours: Lecture 45 Spring 2013 Monday and Wednesday: 4:00-5:15 p.m.

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1 DPT 880 DIFFERENTIAL DIAGNOSIS IN PHYSICAL THERAPY Units: 3, Clock Hours: Lecture 45 Spring 2013 Monday and Wednesday: 4:00-5:15 p.m. Location: PG 174 Instructor: Michael D. Rosenthal, PT, DSc, SCS, ECS, ATC Office: ENS 125 Phone: Office hours: Monday and Wednesday 5:20-6:00; or by appointment Course Prerequisites DPT 750, DPT 710, DPT 725 Course Materials Required: McKinnis LN. Fundamentals of Musculoskeletal Imaging, 3rd Ed. F.A. Davis Co; 2010 Goodman CG, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral 5th Ed. W.B. Saunders Co.; 2013 Dutton, Orthopedic Examination, Evaluation, and Intervention, 3 rd Ed. McGraw Hill; 2012 Groopman J. How Doctors Think. Boston: Houghton Mifflin; 2007 Haggman S, Maher CG, Refshauge KM. Screening for Symptoms of Depression by Physical Therapists Managing Low Back Pain. Physical Therapy. 2004; 84(12): Riddle DL, Wells PS: Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients. Physical Therapy 2004; 84(8): Sahrmann S: Are Physical Therapists Fulfilling Their Responsibilities as Diagnosticians? J Orthop Sports Phys Ther 2005; 35(9): Patient case studies and research articles from professional journals may be assigned throughout the course to supplement key topics. Reflex hammer, goniometer, stethoscope, and blood pressure cuff Additional or Recommended Text and Readings Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St Louis: Elsevier Saunders; 2005 Robinson AJ, Snyder-Mackler L. Clinical Electrophysiology, 3 rd Ed. Philadelphia: Williams and Wilkins; Boissonnault WG, Badke MB: Collecting Health History Information: The Accuracy of a Patient Self- Administered Questionnaire in an Orthopedic Outpatient Setting. Physical Therapy 2005; 85(6): Goodman CG, Boissonnault WG. Pathology: Implications for the Physical Therapist. Philadelphia: WB Saunders; Magee DJ. Orthopedic Physical Assessment, 3 rd Ed, WB Saunders Co; Swain J, Bush KW, Brosing JW. Diagnostic Imaging for Physical Therapists. St Louis: Elsevier Saunders; 2009 Purpose/ Course Overview The focus of this course will be on differentiating: 1) Less common musculoskeletal pathology that might require referral to a physician. These musculoskeletal conditions may be disorders related to the following pathological categories: acquired, genetic, developmental, metabolic, infectious and neoplastic 2) Systemic medical conditions that can mimic and /or complicate common musculoskeletal conditions. This course will provide information for the physical therapist student to differentially diagnose the significant overlaps between common musculoskeletal conditions and other medical pathological problems and/or co-morbidities that can affect clinical decision-making.

2 The knowledge and clinical skills necessary for the appropriate and accurate screening of these patients will be emphasized. The purpose of the course is not to have the student be able to make a differential medical diagnosis; that is beyond the scope of physical therapy practice. In an attempt to improve the physical therapy student s differential assessment capabilities, this course will also emphasize basic interpretation of imaging studies, electroneuromyography and selected laboratory test results. Teaching Methods and Learning Experiences The format of this course will be a combination of lecture, class discussion, demonstration, role-playing, and small group learning exercises. This course builds upon the information and techniques learned in the first semester of the Doctor of Physical Therapy program at San Diego State University. Students will therefore be expected to apply the information and techniques previously learned. The use of patient case studies and role-playing will be used to reinforce the principles being taught. Class participation as both a listener and contributor are expected. The course website can be accessed through Blackboard at This will be the primary area to review your assignments and receive announcements pertaining to this class. Although students will have an opportunity to practice the skills taught during the laboratory, additional time outside of the classroom will be necessary for students to gain entry-level proficiency. Students may be called upon to demonstrate tests previously covered in a class or laboratory session. Student Learning Outcomes At the completion of this course, the student will be able to: 1. Recognize medical conditions whose symptoms mimic and/or complicate musculoskeletal problems. 2. Develop skills in problem solving strategies necessary to plan an effective and time-efficient basic patient evaluation of the musculoskeletal, neuromuscular, cardiopulmonary, or integumentary system. 3. Demonstrate the ability to integrate the various historical, observational and physical signs gathered from a physical therapy assessment in the analysis of various patient case studies. 4. Demonstrate a working understanding of the Decision-Making process, and the skills required to make a well-informed clinical decision, leading to a choice between treatment and referral. This process includes client history, pain patterns and types, systems review, and signs and symptoms of systemic diseases. 5. Appraise examination data to determine the need for further examination or consultation by a physical therapist or for referral to another health care professional. 6. Independently examine a patient by obtaining a pertinent medical history from the patient and other relevant sources. 7. Independently conduct all relevant systems review as part of a comprehensive physical therapy examination. 8. Collect examination data in order to synthesize and complete the physical therapy evaluation. 9. Recognize the responsibility for communication or discussion of diagnoses or clinical impression with other practitioners. 10. Evaluate all pertinent patient or client information in order to arrive at an appropriate prognoses based on the evaluation of results as well as medical and psychosocial information. 11. Discuss the etiology and pathophysiology, signs, symptoms and functional limitations of selected, less common musculoskeletal acquired, genetic, developmental, metabolic, infectious and neoplastic conditions. 12. Discuss the etiology and pathophysiology, signs, symptoms and functional limitations of selected neuromuscular diseases such as neuropathies, myelopathies, myopathies and neuromuscular transmission disorders. 13. Discuss the etiology and pathophysiology, signs, symptoms and functional limitations of selected systemic medical disorders that mimic and/or complicate musculoskeletal problems. 14. Describe the basic anatomy/physiology, rationale and results of electrodiagnostic testing. 15. Describe the principles and techniques involved in measuring EMG and motor and sensory nerve conduction velocity. 16. Describe and understand the probable electrophysiological findings with common neuromuscular disorders. 17. Evaluate imaging studies such as: X-ray, MRI, CT scan, Bone scan, and Ultrasound tests that utilize contrast mediums for common musculoskeletal conditions.

3 18. Demonstrate professional behavior in all interactions with fellow students, instructors, colleagues, and other health professionals and payers. 19. Interpret a written report from imaging studies such as X-ray, MRI, CT scan, Bone scan, and Ultrasound tests. 20. Assess a patient's pain level using various instruments and discuss the advantages and disadvantages of each test. 21. Interpret a written report from an EMG/NCV diagnostic examination. 22. Conduct a physical examination of the cranial nerves as well as of the peripheral nervous system. 23. Recognize emergency situations and respond appropriately Course Outline I. Introduction to Differential Diagnosis II. Review of PT examination a. History b. Subjective Examination c. Physical Examination i. Active and Passive Movement ii. Resisted Movements iii. Special Tests III. Review of Systems a. Cardiovascular b. Pulmonary c. Gastrointestinal d. Genitourinary IV. Common Features of Musculoskeletal Disorders a. Muscle Disorders b. Joint Disorders c. Ligament Disorders d. Bone Disorders V. Common Features of Neuromuscular Disorders a. Peripheral Nerve Disorders b. Complex Regional Pain Syndrome VI. Medical Diagnostic Testing a. Basics of Radiology, MRI, CT, Nuclear Medicine b. EMG / NCV VII. Decision Making in Physical Therapy Evaluation and Medical Screening TENTATIVE SCHEDULE Date Topic Readings*/References Jan 23 Course Introduction Overview of Diagnosis in Physical Therapy Sahrmann editorial; Goodman:Ch 1 28 History Taking, Symptom Investigation and Identification of Health Risks Goodman: Ch History Taking, Symptom Investigation and Identification of Health Risks Haggman article; Goodman Ch2-4 Feb 4 Musculoskeletal Injuries and Disorders (Upper Extremity) Dutton Ch 16-18

4 6 Musculoskeletal Injuries and Disorders (Lower Extremity) Dutton Ch Musculoskeletal Injuries and Disorders (Spine) Dutton Ch 25, 27, Lab: Musculoskeletal injuries and Differential Diagnosis 18 Principles of Medical Imaging Plain radiographs and special studies McKinnis:Ch 1-6; Boyles Article 20 Radiographic Assessment of the Spine McKinnis:Ch 7,9,11; Jarvik Article 25 Radiographic Assessment of the Lower Extremity McKinnis:Ch 13, Radiographic Assessment of the Upper Extremity McKinnis:Ch MAR 4 Examination #1 (through Radiographic Assessment) 6 Neuromuscular Disorders Electrodiagnostic Testing 11 Electrodiagnostic Testing 13 Electrodiagnostic Testing 18 Review of Systems Goodman Ch Review of Systems Goodman Ch 8, Review of Systems/Screening for Neurological Conditions Goodman Ch 12-13, Riddle article 27 Discussion How Doctors Think APR 1-5 Spring Recess 8 Screening for Neurologic Conditions 10 Lab on Systems Screening and Neurologic Conditions 15 Examination 2 17 MOCK PHYSICAL THERAPY MALPRACTICE TRIAL-Medical-Legal Considerations (McKinnis Ch18, 22 Role Play Scenario #1 24 Role Play Scenario #2 29 Role Play Scenario #3 May 1 Role Play Scenario #4

5 6 Final exam review** 8 Guest lecture 13 or 15 FINAL EXAMINATION (comprehensive) FINALS WEEK *Additional course readings (journal articles) may be added to complement lecture material and textbook information. **Class time TBD. Grading Criteria Evaluation will be based upon three (3) written examinations, patient evaluation role-playing activities, and class participation. All examinations will be based upon both lecture material and assigned readings. Approximately 10% of the total points for the class are reserved for attendance, professional behavior and participation. There are 30 class sessions; each class you attend is worth 1 point for attendance and participation. Tardiness is calculated as 0.5 points deducted per 15 minutes of lateness. The breakdown of points for the above assessment activities is as follows. Possible le points Exam #1 100 (25%) Exam #2 100 (25%) Final Exam (comprehensive) 100 (25%) Patient Evaluation Role-Play 60 (15%) Class Participation 40 (10 %) % Grading Scale A = 93% - 100% A- = 90% % B+ = 87% % B= 80% % C+ = % C = 70% % F = < 70% Patient Evaluation Role-Playing Activities This semester, role-playing of patient examination scenarios will be used to not only illustrate, emphasize and reinforce material covered in lecture, but will also be used to assess the student s ability to perform an appropriate physical therapy examination and to differentially diagnose a neuromuscular condition that is consistent with their level of education. As such, students will need to use their didactic knowledge and psychomotor skills that they learned in the first semester of the curriculum. Students will be graded on role-playing activities, which will be conducted at the end of the semester. For these graded activities, students will be assigned to groups of three or four (see group assignments) and each group will be given information about the patient scenario ahead of time. The patient in these cases will be an instructor. The evaluation conducted should include all appropriate aspects of the examination process, including history taking, review of systems, joint screening, muscle testing, goniometry and any appropriate special tests. All students in the group will be evaluated based upon the collective performance of the group. The portion of the examination that each group member performs, however, will be determined at the time of the actual exercise. The score assigned will be related to 1) the overall organization of the evaluation, 2) the quality of questions asked during the evaluation, 3) the tests selected to be performed, 4) the psychomotor skill exhibited in performing the tests, and 5) the accuracy and rationale for the final diagnosis. Because all members of the group will receive the same grade and their role will not be pre-determined, it is

6 important that each of them is as prepared as possible. The criteria and rubric used to grade these assignments is available on blackboard. Prior to participating in the role-playing experiences, information related to the particular patient case will be made available on the class web site so that students can come prepared to perform the examination. To this end, students will likely find it helpful to do the following: Generate a list of possible tissues or structures that are likely involved. Generate a list of possible impairments or problems that should be examined. Outline how they feel the examination should proceed, including the questions that they would like to ask and the tests that will likely be performed. Don t forget that your plan will likely change as the examination process proceeds so be flexible. Each group will have approximately 45 minutes to conduct a patient history and perform the desired physical examination and arrive at their final diagnosis. An additional minutes will be used for instructor feedback and discussion about the particular case. Although this experience may invoke some feelings of anxiety, it is hoped that you will look at it as an opportunity to learn and solidify your examination skills. Course Policies 1. Regular attendance is expected and each student is responsible for all lecture and demonstration material provided in class and via Blackboard. 2. All class activities will start promptly at the designated time. If you are late, please wait for an appropriate time to come in and take a seat near the back of the classroom so you do not disrupt others. If you are late for one of the role-playing activities, you will not be permitted to participate and will receive a zero for that particular assignment. 3. Be respectful of other students and the learning environment. Please do not talk unnecessarily in class and remember to turn your cell phone off or place it in its vibrate mode. 4. It is expected that all reading assignments will be completed prior to the start of class. 5. It is expected that course materials for each class will be reviewed prior to the start of class. 6. Examinations must be taken on the day and time specified unless prior arrangements have been made. No make-up examinations will be given. 7. All students should complete assignments independently of other individuals or materials unless specifically directed by the course instructor. Class activities in which students may work together or assignments where notes, texts and other material may be used will be specifically announced in class. 8. I am committed to treating you in a professional manner as well as making this course a meaningful experience for you. If you need any help or further explanation of presented material, please see me as soon as possible! Professional Behavior Statement Entrance into the program of study in physical therapy at San Diego State University signifies a commitment to a doctoring profession, which entails a consistent demonstration of specific knowledge, skills and attitudes. Professional behaviors are a defining element of a doctoring profession. Thus, integration of professional behaviors is a key aspect of the professional socialization process, which begins in the educational program. The following professional behaviors (adopted from objectives 1-6 of the APTA Clinical Performance Instrument) are expected of all doctoral physical therapy learners: Practice in a safe manner that minimizes risk to the patient, self, and others; Demonstrate professional behavior in all situations; Practice in a manner consistent with established legal and ethical practice standards; Communicate in ways that are congruent with situational needs; Adapt delivery of physical therapy services with consideration for patient s differences, values, preferences, and needs; Participates in self-assessment to improve clinical and professional performance.

7 Statement on Cheating and Plagiarism Cheating is the actual or attempted practice of fraudulent or deceptive acts for the purpose of improving one s grade or obtaining course credit; such acts also include assisting another student to do so. Typically, such acts occur in relation to examinations. However, it is the intent of this definition that the term cheating not be limited to examination situations only, but that it include any and all actions by a student that are intended to gain an unearned academic advantage by fraudulent or deceptive means. Plagiarism is a specific form of cheating which consists of the misuse of the published and/or unpublished works of others by misrepresenting the material (i.e., their intellectual property) so used as one s own work. Penalties for cheating and plagiarism range from a 0 or F on a particular assignment, through an F for the course, to expulsion from the University. For more information on the University s policy regarding cheating and plagiarism, refer to the General Catalogue or the Graduate Bulletin section Students with Disabilities The University is committed to providing reasonable academic accommodation to students with disabilities. The Student Disability Services Office provides university academic support services and specialized assistance to students with disabilities. Individuals with physical, perceptual, or learning disabilities as addressed by the Americans with Disabilities Act should contact Student Disability Services office for information regarding accommodations at (619) ( Moreover, you should notify me so that reasonable efforts can be made to accommodate you. This syllabus and schedule are subject to change in the event of extenuating cir