Red Flags Flashcards
Bio - Psycho - Social Model of Health - Components
Bio: Physiological pathology, Healing phases.
Psycho: Cognitive, emotional aspects, beliefs, behavior.
Social: Socio-cultural factors, participation.
Why is the Bio-Psycho-Social paradigm important for physiotherapy?
Physiotherapy operates most effectively within it.
Gives clinician opportunity to identify personal and environmental mediators which may contribute positively or negatively to recovery and assist in broader assessment of prognosis.
What is the Flag system in physiotherapy?
Tools used to predict prognosis. Guide the physical assessment. Contradictions to specific techniques.
Clinical Flags
Red ad orange flags.
Typical signs and symptoms.
Psychosocial Flags
Yellow, blue and black flags.
Check if there is something in environment or social context of patient that can affect recovery and back to work process.
Key role in transition form acute to chronic.
Not a diagnosis nor a symptom.
Yellow Flags - Components
Many aspects of thoughts feelings and behaviors. Beliefs Pain behavior Emotional response Perceptions and cognition
Yellow Flags - Examples
- Catastrophizing
- Finding painful experiences unbearable, reporting extreme pain disproportionate to the condition
- Having unhelpful beliefs about pain and work – ‘if I go back to work my pain will get worse’
- Becoming preoccupied with health, over-anxious.
- Fear of movement and of re-injury
- Uncertainty about what the future holds
- Changes in behavior or recurring behaviors
- Expecting other people or interventions to solve the problems (being passive in the process) and serial visits to various practitioners for help with no improvement.
Blue Flags - Components
Relation between work and health.
Employee often has fears and misconceptions about work and health based on previous experiences.
Need to ask: how is work affecting recovery? can you have time off to go to a physio? (if not, we need to adjust).
Blue Flags - Examples
• Concerns about whether the person is able to meet the demands of the job
• Low job satisfaction
• Little or poor support at work
• A perception that the job is very stressful
• An accommodating approach in the workplace to provide modified work options to facilitate return to work.
• Poor communication between employer and employee.
I might get fired if I am sick or if my recovery takes too long.
If I go back to work, I will get worse.
Black Flags - Components
- Overlap between blue and black flags, black flags being those that are outside the immediate control of the employee and/or the team trying to facilitate the return to work.
- Politics (therapist gives less care to those with opposite views)
Black Flags - Examples
- Misunderstandings among those involved
- Financial issues and/or claims procedures (insurance)
- Sensationalist media reports
- Family and friends with strong unhelpful beliefs influencing the employee
- Social isolation and becoming disconnected from the workforce
Psychosocial Flags: How to assess? - Questions
- What do you think has caused the problem?
- What do you expect is going to happen? How long do you think it’s going to take? (might have happened before)
- How are you coping with things? Do you need support at home with recovery and daily activities?
- Is it getting you down?
- When do you think you’ll get back to work?
- What can be done at work to help? (working from home, no travelling for work…)
Yellow Flags: How to assess? - ABCDEFW
Attitude and beliefs Behavior Compensation Diagnosis Emotions Family Work
Yellow Flags - Attitude and Beliefs
What does the patient think to be the problem and do they have a positive or negative attitude to the pain and potential treatment?
Yellow Flags - Behavior
Has the patient changed their behavior to the pain? Have they reduced activity or compensating for certain movements. Early signs of catastrophizing and fear-avoidance?
Yellow Flags - Compensation
Are they awaiting a claim due to a potential accident? Is this placing unnecessary stress on their life?
Yellow Flags - Diagnosis
Has the language that has been used had an effect on patient thoughts? Have they had previous treatment for the pain before, and was there a conflicting diagnosis? This could cause the patient to over-think the issue, leading to catastrophizing and fear-avoidance. Does patient understand his condition?
Yellow Flags - Emotions
Does the patient have any underlying emotional issues that could lead to an increased potential for chronic pain? Collect a thorough background on their psychological history.
Yellow Flags - Family
How are the patient’s family reacting to their injury? Are they being under-supportive or over- supportive? both of which can effect the patient’s concept of their pain. Can someone support you?
Yellow Flags - Work
Are they currently off work? Financial issues could potentially arise? What are the patient’s thoughts about their working environment?
Red Flags vs. Orange Flags
Red Flags: symptoms suggesting serious pathology. Contradiction to physical assessment and treatment.
Orange Flags: Equivalent of red flags for mental health conditions.
Red Flags and Clinical Reasoning - Stages (sub clinical, prodromal, clinical)
Subclinical stage: pathological changes with no signs/symptoms.
Prodromal stage: vague non-specific symptoms with few signs (don’t know exactly which condition it is).
Clinical stage: Signs and Symptoms (condition known).
Red Flags and Clinical Reasoning Within a Bio-Psycho-Social Context
Red flags are not always red flags.
Non-red flags ARE sometimes RED FLAGS!
Clinical Flags - Category I
- Serious pathology outside the domain MSK condition
* Requires immediate intervention by a specialist
Clinical Flags - Category II
• Requires further questioning
• Precautionary examination and treatment
• Used in cluster
Could be a trauma but symptoms could also suggest a serious pathology.
Clinical Flags - Category III
Further physical testing and differentiation analysis.
Clinical Flags - Fractures
• History of trauma
• Long term use of steroids (corticosteroids)
• Osteoporosis
• Female gender - Age > 50 (menopause, decreased bone density)
• Pain and tenderness (on a bony part, increases when palpated)
Stress fracture due to repeated impact - sports.
Clinical Flags - Malignancy/Cancer
• History of malignancies / cancer
• Age over 50
• Unexplained/unintentional weight loss (>10% in one month)
If yes, ask if they changed anything in daily activity that could explain it.
• Pain at night - Not eased by prone position
• Duration of condition > 1 month
If patient has the last two, don’t touch them, call their doctor.
Clinical Flags - Infection
- Fever > 38°c
- Long term use of corticosteroids / immunosuppressant
- Drug addiction
- Urinary tract infection
- Penetrating wound (insect bite, tick infected: lyme disease)
- Previous bacterial infection
- Reduce appetite
- Rapid fatigue
Clinical Flags - Cervical Artery Disfunction
• Compression • Inflammation • Occlusion • Vasospasm • Source of pain Cervical artery dissection Carotid artery dissection (+ high impact rotation: dead!) - Signs of brain not getting enough oxygen and blood. - Call and ambulance!
Cervical Artery Disfunction - 5D’s and 3N’s
Dizziness Dysarthria (talking not clear) Dysphagia (can't swallow saliva) Diplopia (double vision) Drop attacks (patient drops when assessing, rotating head)
Nausea
Nystagmus (eyes flickering when looking to sides)
Numbness of face
Ataxia (change in gate pattern)
Clinical Flags - Cauda Equina Syndrome
Linked to a herniated disc. • Compression of conus medullaris • Prolapsed disc • Metastatic disease • Sensory and motor neural dysfunction • Irreversible bladder and bowel dysfunction (can't hold in pee or poop)
Cauda Equina Syndrome - Signs and Symptoms
- (sudden onset) Bladder dysfunction
- Sphincter disturbance
- Progressive weakness in lower limb
- (wide) Spread sensory deficit (lower limb)
- Gait disturbance
- Fecal incontinence
- Pain (radiating) in both leg
- (Sciatica)
General Red Flag, Unrelated to Specific Disease - Pain
- <20 (if no history of trauma, refer to a pediatric doc or physio) or >50 years old
- Constant progressive nonmechanical pain
- No pain reliefs with bed rest
- Thoracic or abdominal pain
- Continuous pain at rest (see malignancy)
- Increasing pain at night (see malignancy, infection)
- Pain not eased by prone position/aggravated by supine (see malignancy)
Which is performed first, subjective examination or objective examination?
Subjective examination.
Special Questions
Do you have a recent injury?
Do you have a history of bone disease?
Have you been diagnosed with rheumatoid arthritis? Juvenile arthritis?
Have you ever been diagnosed with problems in the spine?
Have you had pins / needles in your hands ?
Do you have any paraesthesia / anaesthesia?
Do you feel weakness or numbness in your U.L (L.L) ?
Do you have a history of cancer? Unexplained recent weight loss?
