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Bread and butter: Differential Diagnosis

Differential diagnosis is the bread and butter of PT. PT is not supported by some insurance companies to state a diagnosis, but we all know we have to diagnosis to provide proper treatment. We are orthopedic and musculoskeletal and neurologic experts. We base our findings on imaging, clinical findings, and patient report. Differential diagnosis is an experience and skill based part of our exam.

A novice clinician has the basics, but an expert can more quickly create a differential list. A huge part of my experience is training newer clinicians how to create the list, narrow it down using their exam techniques, and either come up with the one answer or a short list of possible answers. This is critical to determine the goals, prognosis, and treatment. Often referrals to physical therapy are vague because other providers expect us to use our skills to determine the precise diagnosis. Even though "we don't diagnose."

Vestibular disorders require the clinician to step back and see the whole picture to make a diagnosis. No exam finding stands alone (unless it is the dix hallpike!).

Here is a case example:

54 year old male presents with unsteadiness for 1 year. He reports a bout of vertigo that lasted 3 days a year ago. He went to the emergency room and was prescribed anti-biotics and went home. He hasn't been able to drive, coach soccer, and is having a really difficult time keeping his balance at work. He has daily headaches now that he never had before. He tried PT but it didn't help.


1) What was the diagnosis 1 year ago?

2) Has he ever had headaches in the past?

3) Is he falling?

4) Has his hearing been checked?

5) What did he do in the previous PT?

6) What does the unsteadiness feel like?

7) Is there a history of concussion?

1-nothing; 2-migraine history; 3-yes, every other week; 4-no, but hasn't noticed any issues; 5-high level balance drills; 6-like he suddenly loses his balance, can't walk a straight line, worse when he turns his head; 7-many from soccer

After the Q/A my differential diagnosis included neuritis or labyrinthitis without compensation, central balance issue from the concussion history and/or chronic migraines that were untreated and led to balance disorder. Could it be BPPV? Did he have BPPV originally a year ago?

The likelihood is about zero. BPPV wouldn't last for days and the person wouldn't have been prescribed antibiotics. Meclizine perhaps, but not anything else.

Without a diagnosis from the previous year, it is hard to determine what happened but often a short course of vertigo that self resolves (stroke was ruled out) is vestibular neuritis or labyrinthitis (acute vestibular syndrome). If the person doesn't adapt on their own, they need PT to help resolve their balance issues.

My exam was consistent with a right vestibular hypofunction. The concussion history and migraine history were of concern and I took this into consideration as we started treatment. He was referred to headache clinic and his headaches decreased. His balance improved. He was able to walk a straight line. He returned to driving short distances in his neighborhood.

He didn't get better the first time in PT because he was only prescribed balance exercises. I was so disgusted that the PT he saw told him he treated vestibular issues but didn't treat him with the right exercises. There are only a handful of tools in vestibular rehab and they always work. If this patient had started them earlier, he would have been better earlier.

Find the right PT - one who really knows what they are doing with vestibular rehab. If you aren't getting better, look elsewhere.

Ashley Stanley PT, DPT

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