Physiotherapists assess and treat people independently from medical referral or advice in many cases, and so have a responsibility to perform a thorough history and examination of the patient. The overwhelming majority of patients will present with musculoskeletal conditions of various kinds but some could have a serious illness or disease to at least partly explain their symptoms. Physiotherapists need to identify patients with medical conditions and to refer them urgently to the relevant physician for a consultation. Warning signs elicited during the history and examinations are referred to as red flags, indicating danger and the necessity for immediate actions.
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.
Bodyweight loss: The reasons for losing weight should always be explored as this can have a serious condition underlying it. Severe, unexpected or sudden weight loss should be discussed to explore potential explanations such as dieting or a loss of appetite secondary to anxiety or depression. Even people who normally work in heavy jobs can lose a lot of muscle bulk if they are unable to work for a few months. A red flag should be suspected if the reason for the weight loss is not clear.
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.
Being unwell: Most people suffering from musculoskeletal and pain conditions do not record themselves as unwell if they are asked about this. Feeling persistently unwell can be a suspicious sign, and fits with loss of weight and loss of appetite.
Night Pain: While many pain problems are troublesome at night as well as during the day, in some cases the pain is particularly bad on lying down at night. This should be noted as a red flag.
Morning stiffness: Musculoskeletal conditions are often stiff in the morning after a night without much movement of the joints. However, if the stiffness is severe and lasts for more than an hour or most of the day if could indicate an arthritic disease.
A history of cancer: Any previous history of cancer could be important as the presenting condition could involve a recurrence of the disease.
Bladder and bowel function. Bladder and bowel control is disturbed in many conditions from childbirth to irritable bowel. Any incontinence not previously present or an inability to pass water (retention) is important and should be immediately reported.
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.
Heightened Tone and Spasticity: As assessment should be performed to include reflex testing, clonus elicitation and movement of the limbs passively to check that tone is normal. Central nervous system conditions cause alteration in tone, heightened reflexes and clonus.
Weakness: Isolated areas of weakness are common in many different kinds of pathology. More widespread weakness not easily explained by local changes to a joint, muscle, disc or a nerve should be regarded as potentially serious.
Age: Most musculoskeletal conditions such as low back pain or neck pain come on between the ages of 20 and 55 years. Anything which comes on earlier or later than these ages may be perfectly straightforward but there is a higher risk of a serious underlying cause.
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. - 14130
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.
Bodyweight loss: The reasons for losing weight should always be explored as this can have a serious condition underlying it. Severe, unexpected or sudden weight loss should be discussed to explore potential explanations such as dieting or a loss of appetite secondary to anxiety or depression. Even people who normally work in heavy jobs can lose a lot of muscle bulk if they are unable to work for a few months. A red flag should be suspected if the reason for the weight loss is not clear.
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.
Being unwell: Most people suffering from musculoskeletal and pain conditions do not record themselves as unwell if they are asked about this. Feeling persistently unwell can be a suspicious sign, and fits with loss of weight and loss of appetite.
Night Pain: While many pain problems are troublesome at night as well as during the day, in some cases the pain is particularly bad on lying down at night. This should be noted as a red flag.
Morning stiffness: Musculoskeletal conditions are often stiff in the morning after a night without much movement of the joints. However, if the stiffness is severe and lasts for more than an hour or most of the day if could indicate an arthritic disease.
A history of cancer: Any previous history of cancer could be important as the presenting condition could involve a recurrence of the disease.
Bladder and bowel function. Bladder and bowel control is disturbed in many conditions from childbirth to irritable bowel. Any incontinence not previously present or an inability to pass water (retention) is important and should be immediately reported.
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.
Heightened Tone and Spasticity: As assessment should be performed to include reflex testing, clonus elicitation and movement of the limbs passively to check that tone is normal. Central nervous system conditions cause alteration in tone, heightened reflexes and clonus.
Weakness: Isolated areas of weakness are common in many different kinds of pathology. More widespread weakness not easily explained by local changes to a joint, muscle, disc or a nerve should be regarded as potentially serious.
Age: Most musculoskeletal conditions such as low back pain or neck pain come on between the ages of 20 and 55 years. Anything which comes on earlier or later than these ages may be perfectly straightforward but there is a higher risk of a serious underlying cause.
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. - 14130
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 conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.
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