Neurologic Differential Diagnosis for Physical Therapy

Journal of Neurologic Physical Therapy, Dec 2004 by Sullivan, Katherine J, Hershberg, Julie, Howard, Robbin, Fisher, Beth E

COURSE OF ACTION

If the physical therapist decides that the patient's neurologic presentation is not within the scope of physical therapy practice, then appropriate action must be taken. A clinical decision making algorithm to determine whether a patient presenting with neurologic findings is within the scope of physical therapy care or requires referral to a physician is presented in Figure 2. Of particular concern are emergent neurologic conditions that require immediate medical attention. Table 1 describes neurologic signs and symptoms that require immediate action. For example, severe headache with no previous history may be an early warning sign of hemorrhagic leakage from an intracerebral aneurysm.'8A flu-like illness with fever and neurologic signs such as nuchal rigidity (resistance to active or passive neck flexion accompanied by severe pain) may indicate bacterial meningitis. 19A rapid onset of focal neurologic signs such as unilateral weakness, visual changes, or inability to speak can indicate a stroke in progress.'" The physical therapist must have knowledge of the range of neurologic signs and symptoms that underlie serious neurologic conditions that are in process. Clearly, immediate medical referral is essential to ensure optimal patient management.

Trained to provide thorough musculoskeletal and neuromuscular evaluations, physical therapists are key practitioners for identifying changes in neurologic status or inconsistencies in patient presentation in relation to the working medical diagnosis. For example, the diagnosis of shoulder weakness due to rotator cuff tear may be called into question if the physical therapist notes severe atrophy and fasciculation during the examination. These neurologic signs are associated with lower motor neuron disease and would warrant further diagnostic investigation to rule out a more serious neurologic condition. An individual referred for deconditioning or unsteady gait could possibly be in the early stages of a progressive degenerative condition if other neurologie signs such as abnormalities in postural eontrol, muscle tone, or strength are present. Examples of signs and symptoms that may reflect a progressive neurologic process or compromise of a neurologic structure are listed in Table 1. While this grouping of signs and symptoms may not require emergency medical attention, referral to a physician would be warranted.

CASE STUDIES

Determining the medical differential diagnosis has traditionally been considered the sole responsibility of the physician. However, physical therapists are equipped to make important contributions to this process as a result of their education and training. The case studies presented below are actual clinical cases in which the neurologic examination performed by physical therapists provided critical information leading to a timely and accurate neurologic diagnosis.These cases illustrate the application of the neurologic differential diagnosis framework and clinical decision-making algorithm presented in this paper. The essential role that physical therapists can play in the neurologic differential diagnosis process that leads towards an accurate diagnosis and optimal treatment is illustrated.