"Red Flags" Article by Ross, Boissonnault

Question 1

True of false: A single red flag is useful for screening and determining the need for a referral

Answer 1

False - many patients will have at least one red flag, not all patients with a disease will exhibit all or any red flags; one must consider the full patient presentation when making this decision

Question 2

What are the possible harms that may come to a patient as a result of using red flags as a trigger to order further investigation?

Answer 2

Overmedicalizing a benign usually self-limiting
disorder

Harmful effects of radiation from obtaining unnecessary radiographs and computed tomography scans

Consequences of these investigations themselves producing false-positive results

Question 3

What is an alternative method to screening using red flags?

Answer 3

Consider a small number of disorders in which early diagnosis and treatment might make a big difference (ie, cauda equina syndrome, major intra-abdominal pathology, focal infections, and fractures), and use time as a diagnostic tool for the remainder.

If, in the clinician’s judgment, based upon skills and experience, the patient may have one of these serious conditions, appropriate investigation and treatment are indicated.

Question 4

Name a scenario in which cancer as a cause of low back pain can be ruled out.

Answer 4

Patient is less than 50 years old, does not exhibit unexplained weight loss, does not have a history of
cancer, and is responding to conservative
intervention

Question 5

What are the arguments for using red flag screening?

Answer 5

In primary care practice settings, there is a low rate of routine examination for red flag findings.

Symptoms associated with serious conditions can develop between the physician
consultation and the initial physical
therapy evaluation.

Some serious conditions, like a fracture, would contraindicate routine physical therapist inter-
ventions, like spinal manipulation.

There is therapeutic value in early diagnosis of serious conditions, like metastatic cancer, because specific treatment can be initiated.

Without some level of screening for red flag symptoms for each patient, how would a clinician
begin to even consider whether or not serious pathology is present and if referral is warranted?