RED FLAGS Flashcards
red flags
Red flags are signs and symptoms that raise suspicion of serious spinal pathology.
For spinal pathology, 163 signs and symptoms have been reported including -
119 symptoms from history
44 signs from the physical examination
Recent International Framework (IFOMPT) to guide application
Few red flags in isolation are informative
Consider both the evidence to support red flags and individual profile of determinants of health (eg, age, sex) to decide the level of concern (index of suspicion) for presence of serious spinal pathology
Shared decision-making
framework decision tool
1
evidence level of concern and clinical profile
prevalance of pathology
red flags
(in comibination)
urgency repeat visit comorbidities response to care symptom progression
framework decision tool: 2
decide clinical action based on level of concern
low - no concerning features
= begin trial of therapy
few concerning - begin with watchful waiting
+ revise mgmt
monitor progress closely
some concerning features
decision - urgent referral
DONOT begin Rx
further investigation needed
high concern
emergency refereal
do not begin
emergency referral
Step three framework decision tool
consider pathway for emergency / urgent referral if needed
few concerning featured
consider watchful wait
safety net patient
progress as expected = treat as planned and monitor symptmos
+ pt discharged from care once treated as planned
if not improving / new concerning feature - consider further investirgation / referral
if investigations are negative consider further referral / restart Rx
examples of red flags
age >50 histroy of cancer unexplained weight loss failure to improve after 1 month conservative Rx Tb HIV /AIDs CES severe night pain loss of sphincter tone and altered S4 sensation \+ babinski abdominal pain and changed bowel habits + not change in medications inability to lie supine bizarre neuro deficti spasm disturbed gait weight loss <5% in 3-6 months smoker systemically unell trauma cervical artery dysfunction bilater P+Ns previously failed Rx thoracic pain headache poor physical appearance partial articular restriction of movement upper cervical instability
risk factors for spinal fracture
high clinical suspicion H/o osteoporosis H/o trauma Corticosteroid use H/o ‘specific’ Ca Breast Prostate Lung Thyroid Kidney Female Older age H/o previous fracture Thoracic pain
low clincial suspicionNo family h/o osteoporosis or fracture
No previous fractures
No other osteoporotic risk factors
visceral referred pain
Consider segmental innervation for viscera to appreciate pain referral maps
Reported pain is often deep, diffuse, hard to localise
Pain behaviour will relate to
visceral function / load
Aggr. Factors -
CVS – exertion
GIT – digestion
Pattern doesn’t fit with MSK
CI to SMT joint mobs
Failure of bony structural integrity –
Fracture local to the area/spine
Unhealed fracture
Severe osteoporosis (high grade mobs)
Local malignancy
Spondylolisthesis/Spondylolysis (at specific level)
Failure of ligamentous structural integrity
Rheumatoid Arthritis in craniovertebral region
Neurological compromise
Spinal Cord Injury
Spinal cord compression
Cauda Equina Syndrome
Immediately post-op
Inflammatory joint disease- during acute flare up
Presence of fever, vomiting, diarrhoea
Presence of haemodynamic instability e.g. Aortic Aneurysm
Bleeding into joints
+ve red flags
If the patient cannot achieve the position for manual therapy due to pain, resistance or protective spasm
Lack of consent from patient or guardian
precautions to SMT
History of Cancer
Cognitive impairment
Severe/irritable pain
E.g. Radiculopathy - particular care not to aggravate radicular symptoms
Inflammatory joint disease
Analgesic or muscle relaxants taken prior to Rx.
Bony fragility e.g. osteoporosis (precaution) or Hx of fractures or on medication for bone health
Pregnancy
Vertigo
Hypermobility
Anticoagulants / long-term steroid user - may bruise easily.
Adverse reactions to previous manual therapy
Attachments e.g. colostomy bag
red flags key messages
Red flags occur in =1% spinal pain presentations in primary care
Physiotherapists’ Scope of Practice is limited to Diagnostic triage but not diagnosis of red flags
Communication around this is critical
To patient – Shared-decision making
To medical colleagues – urgent / emergency referral
Not all red flags are of equal clinical concern
Absence of high-quality evidence for the diagnostic accuracy of most red flags
See Framework for Case examples (Finucane et al, 2020)
