Many patients attend physiotherapy by self referral without medical review. The history and examination of a patient by a physiotherapist needs to cover the possibility that there might be an underlying condition of a more serious nature than a benign musculoskeletal one. Musculoskeletal conditions represent the vast majority of presenting conditions but a thorough and detailed review of the patient's medical status is essential. Urgent referral to a physician is vital if any significant problem is identified. Red flags is the description given to the questions to be asked and to the warning signs elicited once a positive result is obtained.
Red Flags is the term given to the identification of dangerous or potentially dangerous findings in the history or examination. Physicians, physiotherapists and all other medical, para-medical and alternative practitioners should be aware of these warning signs and know where to send the patients next. While it is impossible to spot all serious conditions in patients, going through the list of red flags systematically greatly reduces the risk of missing anything which could be important. There is no substitute for going through a checklist as it is very easy to forget something even though one is familiar with the process.
Loss of weight: If someone has lost a lot of weight in a short time then the reason for this should be explored as there may be many valid explanations for this. Being on a diet can explain this, or the unwillingness to eat of people who are very depressed, upset or anxious. Heavy workers who suddenly have to stop work can also lose significant muscle mass. Red flags should be reported as positive if no defined reason for the weight loss can be found.
Losing one's appetite: This can have many causes but if the patient has these signs it is useful to refer to the weight loss remarks above.
Feeling unwell: If you ask people with chronic pain problems if they feel well in themselves they often answer yes. Anyone who complains of persistently feeling unwell, especially with loss of appetite and weight loss, should be regarded with suspicion.
Pain at Night: Back pain and many other conditions are painful during the nights but any pain which is worse at night or on lying down should be regarded with suspicion and recorded as a potential red flag.
Early Morning Stiffness: Most musculoskeletal injuries or joint problems have some stiffness early in the mornings after they have not been moved for a while. Stiffness lasting for an hour or more could be due to a rheumatoid condition.
A history of cancer: Any previous history of cancer could be important as the presenting condition could involve a recurrence of the disease.
Control of Bladder and Bowel: Incontinence can be caused by many conditions from having had children to irritable bowel syndrome to neurological conditions. However, any new incidence of incontinence or retention (difficulty passing urine) should be flagged up for medical review.
Perineal loss of sensibility: The perineal area is between the legs and includes the skin round the genitals and the anus. Certain important medical conditions can change this area, leading to loss of feeling or pins and needles.
Increased Tone: This can be apparent on walking but is more often noticed by testing the limbs to assess any increased muscle tone. Clonus, increased reflexes and heightened tone point towards a problem with the central nervous system.
Loss of muscle power: Injuries and damage to structures such as muscles or joints can give weakness but it is usually localised and explained. Weakness which is more generalised is harder to explain on simple anatomical grounds and should be noted.
Pain in the Thoracic Region: The cervical, sacral and lumbar regions are the typical areas which present with painful musculoskeletal syndromes. Thoracic pain is less common and associated with an increased risk of medical conditions.
Thoracic Pain: Most musculoskeletal spinal pains occur in the lumbar, sacral or cervical areas and are benign. Thoracic pain is associated with a higher risk of serious conditions such as tumours and this should be taken into account. - 16650
Red Flags is the term given to the identification of dangerous or potentially dangerous findings in the history or examination. Physicians, physiotherapists and all other medical, para-medical and alternative practitioners should be aware of these warning signs and know where to send the patients next. While it is impossible to spot all serious conditions in patients, going through the list of red flags systematically greatly reduces the risk of missing anything which could be important. There is no substitute for going through a checklist as it is very easy to forget something even though one is familiar with the process.
Loss of weight: If someone has lost a lot of weight in a short time then the reason for this should be explored as there may be many valid explanations for this. Being on a diet can explain this, or the unwillingness to eat of people who are very depressed, upset or anxious. Heavy workers who suddenly have to stop work can also lose significant muscle mass. Red flags should be reported as positive if no defined reason for the weight loss can be found.
Losing one's appetite: This can have many causes but if the patient has these signs it is useful to refer to the weight loss remarks above.
Feeling unwell: If you ask people with chronic pain problems if they feel well in themselves they often answer yes. Anyone who complains of persistently feeling unwell, especially with loss of appetite and weight loss, should be regarded with suspicion.
Pain at Night: Back pain and many other conditions are painful during the nights but any pain which is worse at night or on lying down should be regarded with suspicion and recorded as a potential red flag.
Early Morning Stiffness: Most musculoskeletal injuries or joint problems have some stiffness early in the mornings after they have not been moved for a while. Stiffness lasting for an hour or more could be due to a rheumatoid condition.
A history of cancer: Any previous history of cancer could be important as the presenting condition could involve a recurrence of the disease.
Control of Bladder and Bowel: Incontinence can be caused by many conditions from having had children to irritable bowel syndrome to neurological conditions. However, any new incidence of incontinence or retention (difficulty passing urine) should be flagged up for medical review.
Perineal loss of sensibility: The perineal area is between the legs and includes the skin round the genitals and the anus. Certain important medical conditions can change this area, leading to loss of feeling or pins and needles.
Increased Tone: This can be apparent on walking but is more often noticed by testing the limbs to assess any increased muscle tone. Clonus, increased reflexes and heightened tone point towards a problem with the central nervous system.
Loss of muscle power: Injuries and damage to structures such as muscles or joints can give weakness but it is usually localised and explained. Weakness which is more generalised is harder to explain on simple anatomical grounds and should be noted.
Pain in the Thoracic Region: The cervical, sacral and lumbar regions are the typical areas which present with painful musculoskeletal syndromes. Thoracic pain is less common and associated with an increased risk of medical conditions.
Thoracic Pain: Most musculoskeletal spinal pains occur in the lumbar, sacral or cervical areas and are benign. Thoracic pain is associated with a higher risk of serious conditions such as tumours and this should be taken into account. - 16650
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic issues and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Leeds.
