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Michael D. Ross, PT, DHSc1
William G. Boissonnault, PT, DHSc2
J Orthop Sports Phys Ther 2010;40(11):682-684. doi:10.2519/jospt.2010.0109
T
he physical therapy profession has long recognized the
importance of physical therapists determining whether a need
for a patient referral to another healthcare practitioner exists.5-8
More specifically, during each initial patient evaluation and
subsequent reevaluation, physical therapists must decide whether
to treat the patient, refer the patient, or initiate both treatment and
referral.1,4 This clinical decision is based on physical therapists recognizing
patient history and physical examination red flag findings consistent
with pathology that requires physician consultation and examination.4
The challenge to physical therapists
is the current lack of evidence describing
what red flag findings are representative
of specific pathological conditions. For
example, night pain has long been taught
to be red flag finding for serious medical
conditions, such as cancer, but research
shows that not all patients with musculoskeletal cancers experience night pain.23
In addition, night pain has also been associated with osteoarthritis and mechanical low back pain.9,29 So when should a
physical therapist be concerned about a
patient complaining of night pain? Is it a
red flag finding or not?
This uncertainty was a topic of recent
publications that has appeared to call
into question the usefulness of red flag
questions for patients with low back pain.
Henschke et al17 reported on the performance of 25 commonly recommended
red flag questions in a prospective study
of 1172 consecutive patients presenting
with acute low back pain in a primary
care setting of general practitioners,
1
physical therapists, and chiropractors.
After 1-year follow-up, a serious cause
for back pain was identified in only 11
patients. The prevalence of spinal fractures was 0.7%, and no cases of malignancy were reported. The low prevalence
of serious pathology noted by the authors
is not necessarily surprising, considering
that their sample population’s mean age
was 44 years (SD,  15.1 years). Previously reported values for the prevalence
of osteoporotic fractures and malignancy
are approximately 4% and 0.7%, respectively.13 Despite the low prevalence of
serious pathology in the Henschke et al17
study, most patients (80.4%) had at least
1 red flag finding, suggesting that nearly
all red flag questions, when considered
individually, were uninformative.
The findings by Henschke et al17
prompted Underwood28 to write in the
editorial of that same issue of the journal Arthritis and Rheumatism that
“Too great a focus on addressing red
flag questions may distract the clinician
from delivering key information to the
patient: reassurance as to the benign nature of the disorder for the vast majority
of patients and the benefits of avoiding
bed rest and maintaining normal activity, including work.” He goes on to write
that “The indiscriminate use of red flag
symptoms as a trigger to order further
investigations will lead to unnecessary
investigations that are themselves harmful, through a combination of overmedicalizing a benign usually self-limiting
disorder, the harmful effects of radiation
from obtaining unnecessary radiographs
and computed tomography scans, and
the consequences of these investigations
themselves producing false-positive
results.”
Underwood28 recommends that rather
than recording an exhaustive list of red
flags, clinicians should 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.
We agree with Underwood28 that, with
this extremely low prevalence of serious
disease identified following a first consultation for a new episode of acute low
Associate Editor; Director, US Air Force Physical Medicine Training Programs, Fort Sam Houston, TX.
Associate Professor, Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI.
2
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[
back pain, the large number of patients
with at least 1 red flag symptom (80%)
is of considerable concern. As noted by
Underwood,28 if nearly everyone with
acute low back pain has a red flag, then
the presence of a red flag will not help the
clinician in deciding whether any further
investigation or treatment is needed. We
already are in the midst of a crisis when
it comes to managing low back pain.12
Costs are soaring due to unnecessary
diagnostic imaging, the prescribing of
opioid analgesic medications, injections,
and surgeries.12,19 These increased costs
could perhaps be justified if they were
associated with improved outcomes; but
patient outcomes are not improving.12,19
Indiscriminate use of red flag findings
would only delay the time for the indicated primary treatment of the patient’s
low back pain and place more unnecessary strain on an already overburdened
medical system.
For some serious medical pathologies mentioned by Underwood28 that can
potentially mimic mechanical low back
pain, there are evidence-based screening
strategies that may assist in ruling out pathology and avoid unnecessary physician
referrals. For example, cancer causing
low back pain can be ruled out with 100%
sensitivity if the 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. 11 If a red flag is present, a
spine specialist referral is not immediately indicated; rather, evidence-based
screening strategies suggest that completing lumbar spine radiographs and
laboratory testing (erythrocyte sedimentation rate) is the next appropriate step,
as this can rule out cancer causing low
back pain with 100% sensitivity.11 One
exception would be in a patient with low
back pain with a recent history of cancer,
as early referral and advanced diagnostic
imaging may be warranted in this case.
For patients older than 50 years who may
even have general health changes, such
as unexplained weight loss, response to
conservative management will be key in
guest editorial
]
identifying those patients that may have
potentially serious underlying disorders.
However, given the large number of
patients with nonspecific low back pain
who will have false-positive red flag findings, is it time to recommend that physical
therapists spend less time on screening
for red flags? Although the prevalence of
serious medical pathology, such as cancer, infection, or fracture, causing low
back pain is extremely low, we still believe
it is the physical therapist’s responsibility to utilize a management model for
each patient that allows for the evaluation of red flag findings to make clinical
judgments regarding the need for patient
referral. There are 3 primary reasons for
this. First, in primary care practice settings, there is a low rate of routine examination for red flag findings.2 Additionally,
symptoms associated with serious conditions can develop between the physician
consultation and the initial physical
therapy evaluation. Second, some serious
conditions, like a fracture, would contraindicate routine physical therapist interventions, like spinal manipulation. Third,
there is therapeutic value in early diagnosis of serious conditions, like metastatic
cancer, because specific treatment can
be initiated. Furthermore, 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?
Through the evaluation of risk factors
and red flag screening questions from the
history and physical examination, such as
patient demographics, social and health
habits, medical/surgical history, medications, family history, systems review, and
review of systems, physical therapists
have the examination data necessary
to identify the need for medical referral.1 A lack of response to conservative
management is also key in identifying
those patients with potentially serious
disorders which require medical referral.11 Several published case reports have
described how physical therapists have
used history and physical examination
findings, as well as response to intervention, in patients with signs and symptoms
related to the lumbar spine to determine that physician referral was necessary.3,6-8,10,14,15,20,21,25,27 As seen in these case
reports, the level of red flag screening for
an individual patient may vary based on
the medical complexity of the patient,
emerging data from the patient history
and physical examination, response to
intervention, and the directions taken in
the clinical decision-making process.1 In
some of these cases, red flag findings were
present early in the case, which led to the
initiation of early referral.6,7,10,15,20,25 In
other cases, overt red flag findings were
not evident; rather, a cluster of findings
that were atypical for nonspecific low
back pain emerged through the course
of care that prompted referral.3,6,8,14,15,21,27
Using a cluster of history and physical
examination findings is also consistent
with evidence-based screening strategies
for serious conditions like cancer,11 fractures,17 and abdominal pain that is nonmusculoskeletal in nature.24 For example,
in an individual with low back pain, advanced age, corticosteroid use, or pain
caused by a traumatic incident may not
be concerning when each finding is considered in isolation. However, when these
factors are clustered in an individual with
back pain, they are highly predictive of a
fracture.17
There are also other conditions that
are more prevalent than cancer, infections, or fractures that can influence the
outcome of patients with low back pain
that physical therapists should be aware
of when evaluating history and physical
examination data. For example, depression is a condition that can adversely
influence the prognosis for patients with
low back pain.18,22,26 Generally, depression
is underrecognized by physical therapists,
even in those cases when severe depression is evident.16 Additionally, the history
and physical examination may also identify health restoration and prevention
needs, as well as pre-existing medical
comorbidities that may have implications
for intervention and outcome.1
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[ editorial
] ]
[ guest
editorial
Given the importance of red flag
screening in determining the appropriateness of physical therapy4 and the goal
of physical therapists to be the provider
of choice for patients with musculoskeletal disorders, we believe that taking
a less than adequate red flag screening
approach for patients with low back
pain will not facilitate optimal patient
outcomes. Therefore, we suggest that
physical therapists utilize a consistent
management model for each patient
that allows for the evaluation of red flag
findings. Because a red flag finding will
most likely be present for most patients
with low back pain,17 physical therapists
should carefully evaluate the findings to
determine if a red flag finding is indeed
present that warrants referral, while
keeping in mind the low prevalence of
serious pathology in patients with low
back pain. t
The opinions expressed herein are those
of the authors and do not necessarily
reflect the opinions of the Department of
Defense, the United States Air Force, or
other federal agencies.
6.
7.
8.
9.
10.
11.
12.
13.
14.
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