Red Flags in Spinal Conditions

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What are red flags?

Part of the UK guidelines of an assessment for lower back pain is too rule out serious pathology and identify red flags (Koes et al 2010). Red flags are features from a patients subjective and objective assessment which is thought to put them at a higher risk of serious pathology and warrant referral for further diagnostic assessment (Henschke et al 2013). Red flags are often a contraindication to many Physiotherapy treatments.

Although red flags have a valid role to play in assessment and diagnosis they should also be used with caution. Some guidelines contain no information on diagnostic accuracy for individual red flags, so it is the responsibility of individual practitioners to make themselves aware of these. Other guidelines even recommend immediate referral to imaging if any red flag is present, which could lead to many unnecessary referrals if clinicians did not clinically reason their referral (Downie et al. 2013).

Objective History

Physical Appearance

Determine if the patient is unwell however this is a very subjective concept. The following signs may indicate that the patient has a systemic serious pathology (Greenhalgh and Selfe, 2006).

General Signs to indicate that a patient is unwell:
• Pallor/flushing
• Sweating
• Altered complexion: sallow/jaundiced
• Tremor/shaking
• Tired
• Dishevelled/unkempt
• Halitosis
• Poorly fitting clothes

Observation

Posture

It is important to note any posture alterations as this can give the therapist some indication of levels of pain (Greenhalgh and Selfe, 2006).

Deformity of the spine

Observe any deformities of the spine. A deformity with associated muscle spasm and severe limitation of movement are suggested to be key indicators of spinal pathology (Greenhalgh and Selfe, 2006). A rapid onset of a scoliosis is indicative of an osteoma or osteoblastoma. This may not appear when standing straight and the patient may need to flex forwards first (Greenhalgh and Selfe, 2006). It may also affect the patients’ ability to move into physiological movements (Greenhalgh and Selfe, 2006).

Some tumors can be large enough to be seen or felt. Swelling and tenderness may be the first sign of a tumour (Greenhalgh and Selfe, 2006).It is also common for tumours to restrict movement eg. restricting spinal flexion.

Muscle Spasm

This is suggested to be synonymous with low back pain and is therefore difficult to determine if it is associated with a red flag pathology (Greenhalgh and Selfe, 2006). If a serious spinal pathology is present, the muscle spasm may be so severe to cause a scoliosis in the spine. The correlation between muscle spasm, pain and other objective clinical measurements however, are poorly supported by strong evidence (Greenhalgh and Selfe, 2006).

Neurological Assessment

Patients who report neurological signs in the objective assessment require a neurological assessment (Petty and Moore, 2001). A neurological deficit is rarely the first presenting symptom in a patient with serious spinal pathology however 70% of patient will have a neurological deficit at the time of diagnosis (Greenhalgh and Selfe, 2006).

The dermatomes, myotomes and reflexes should be examined. The upper motor neurone should also be examined via extensor plantar reflex (Babinski), clonus and hoffmans. If it is gained easily, it may indicate MS (Greenhalgh and Selfe, 2006). There should be a high index of suspicion if the patient has two or more affected nerve roots (Greenhalgh and Selfe, 2006).

Clinical Reasoning

Clinical Reasoning is integral to physiotherapy practice. It has been suggested that as a concept, clinical reasoning is quite a simple one however in practice, it is difficult and fraught with errors. The aim of clinical reasoning is to prevent misdirection (Jones, 1995).
Clinical Reasoning can strongly influence how the case is interpreted by the therapist. This has implications as to how the clinician views the red flags presented therein (Greenhalgh and Selfe, 2004).

The most common form of clinical reasoning within the physiotherapy profession is hypothetico-deductive reasoning (Doody and McAteer, 2002). Hypothetico-deductive reasoning, the clinician gains initial clues in regards to the patients problem (from the subjective assessment) which forms initial hypothesis in the therapists mind. Further data is collected in the objective assessment and the hypothesis is tested (special tests) and interpreted. This may confirm on negate the hypothesis. Continual hypothesis generation occurs during management and reassessment (Edwards, Jones, Carr et al. 2004).

Reflection after the assessment and also after the subsequent sessions will provide the clinical with patterns and their reasoning practice will increase. Without reflection, clinician’s will have no progress in their clinical reasoning (Jones, 1995, Greenhalgh, 2008).

References

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