Differential Diagnosis for Low Back Pain

Patients may or may not be aware, but since 2006 in New York State, a prescription is not needed to see a physical therapist. Direct access allows physical therapists with 3 or more years of experience to see patients for 10 visits or 30 days without obtaining a prescription from a doctor. This is great for PT from a professional standpoint, as it allows us to be at the forefront of diagnosis, planning and care for individuals with acute conditions. With more power though, comes more responsibility.

Our licenses are on the line if we miss those “red flags” and potentially misdiagnose, mistreat and fail to refer a patient that needs more medical care.

My advice to fellow physical therapists is to frequently think outside the “PT” box. We are frequently taught to think in a musculoskeletal and postural dysfunctional framework when looking and listening to a patient. Sometimes this can get us in to trouble if we miss something important. It is therefore imperative to know of other conditions which sometimes masquerade as musculoskeletal problems.

Know pain referral patterns on the body of, for example, the diaphragm, gall bladder and kidneys. Know the signs and symptoms of an AAA. Know why fever, recent flu and joint pain is important to refer out to a medical doctor for more testing.

I can think of one recent example of a patient whom I had recently treated who had lower back pain for 5+ years. He had lower back pain and joint stiffness relieved at times by gentle exercise, but was taking Percoset daily to make it through the day. His MRI revealed a tiny disc herniation at a lower lumbar level that was not consistent with his pain levels. He had seen orthopaedic surgeons, neurologists, and pain management specialists all of whom told him to continue PT. All health professionals had failed to see patches of severe psoarasis over his body from head to toe. Joint pain, stiffness, psoariasis = psoriatic arthropathy. I refered this patient to a rheumatologist who took blood and Xrays of his sacroiliac joint and confirmed my diagnosis. He is now on disease modifying anti-rheumatic drugs and different NSAIDS which have helped his joint pain and stiffness significantly.

The most important patient we treat is not one that has returned to soccer, running or basketball, but rather one whose life we have prolonged by not missing those red flags. I try to read as much as I can from other related health professions – neurology, orthopaedics, rheumatology, radiology, general practise. Only by doing so can I be comfortable that my differential diagnosis is not only within the PT framework, but also within a greater medical framework.

I refer you a very interesting case review by Dr Stephen Paget is last week’s Medscape, titled “Low Back Pain with GI Complaints: Don’t Miss the Diagnosis.”

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