"Importance of Screening Red Flags"
MDT Connect | Volume 1, Issue 2 | September 2024
“IMPORTANCE OF SCREENING THE RED FLAGS”
- Dr Hitesh Rohra, BPT, Dip MDT, CMP
Musculoskeletal conditions are a significant burden in primary care, with primary care physical therapy playing a key role in their management. Physiotherapists, experts in assessing, diagnosing, and treating these conditions, must determine whether physiotherapy is appropriate for each patient, requiring a thorough understanding of contraindications and precautions. Their ability to effectively screen for serious pathologies is crucial in the clinical reasoning process, as accurate identification of conditions needing specialist referral ensures timely treatment and enhances patient safety.
The prevalence of serious pathology varies depending on the clinician's point of contact within the clinical pathway.1 Spinal surgeons are likely to encounter more cases of serious pathology compared to general practitioners, while physiotherapists generally see a number of cases between these two extremes, depending on their role in the clinical pathway.1 Physiotherapists at an advanced practice level are expected to encounter more serious pathology due to the more complex nature of the populations they serve.
Red flags are signs and symptoms from a patient’s history, physical exam, and follow-up evaluations that raise suspicion of serious pathology. Although individual red flags are weak indicators on their own, a combination of them should alert the clinicians.2,3 However, there has been limited guidance on their use, leaving it to individual interpretation.2 High-quality evidence for the diagnostic accuracy of red flag tests is scarce, supporting only a few red flags as indicators of serious pathology.4 There is no consensus on the most useful red flags or their application in clinical settings.2,4 Despite these issues, red flags remain the best tool available for raising suspicion of serious pathology.1
Managing patients with potential serious pathology can be challenging, and a collaborative approach is essential. A diagnosis of serious pathology can be deeply distressing for individuals and their families, making it vital for patients to be actively involved in their care decisions. Shared decision-making ensures that patients receive support to make choices aligned with their own needs and preferences.2 Through a collaborative process, clinicians should present treatment options, evidence, risks, and benefits, and work with the patient to understand how these align with their personal circumstances, goals, values, and beliefs.
Effective communication with patients facing potential serious pathology is essential.2 It should be respectful, meaningful, and sensitive to the gravity of the situation to be truly effective.5 Patients may come to appointments feeling anxious, especially if they've heard concerning information about their symptoms from others. It is important to reassure them about the purpose of assessing for red flags, particularly if their risk of serious pathology is low. Paying attention to your choice of words, body language, tone of voice, and mannerisms when asking questions is crucial. Ensure that patients have ample time to reflect on and respond to questions about potentially unfamiliar topics. If a serious pathology is suspected, referring the patient for further investigation without providing a definitive diagnosis, such as saying: “Based on your symptoms, further investigation by a specialist may be necessary”, can be a consideration.
A clinician may decide to refer a patient with multiple red flags from their history without even conducting a physical examination. For instance, a 55-year-old patient with worsening back and leg pain who has recently developed a foot drop and reports new bladder or bowel symptoms might be referred immediately. In contrast, if the patient has a similar presentation but without bladder or bowel symptoms, the clinician might opt to proceed with performing a thorough physical examination. To aid in the evaluation and investigation of red flags, Sizer et al.3 suggest a categorization approach as illustrated in Figure 1, and Finucane et al.3 propose a similar categorization method for early identification and referral of patients with potential serious pathology, as shown in Figure 2.
(Figure 1: 2007 Sizer et al.)
(Figure 2: 2020 Finucane et al.)
Challenges:
Physiotherapists lacking experience in non-musculoskeletal domain.6
Clinicians often fail to recognize the limitations of physiotherapy in a timely manner.6
Patients referred by medical doctors or surgeons are assumed to have been thoroughly screened.6
Cultural and linguistic barriers6
Musculoskeletal pain of serious origin may temporarily improve due to movement's physiological effects, but as the pathology progresses, the patient's condition will worsen regardless of movement.7
Distribution of referred pain.5
Extreme pain, contextual and cognitive factors.5
Clinical Message:
There is insufficient evidence supporting the usefulness of most commonly used red flags in clinical practice.
While few red flags are informative on their own, combining them shows potential but needs further validation.
Red flags remain the most reliable tool available.
The absence of red flag responses does not lower the risk of serious pathology.
Combining evidence with the individual’s profile determines the level of concern.
References:
1) Budtz CR, Rønn-Smidt H, Thomsen JNL, Hansen RP, Christiansen DH. Primary Care Physical Therapists' Experiences When Screening for Serious Pathologies Among Their Patients: A Qualitative Study. Phys Ther. 2022 May 5;102(5):pzac026. doi: 10.1093/ptj/pzac026. PMID: 35302642; PMCID: PMC9155951.
2) Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020 Jul;50(7):350-372. doi: 10.2519/jospt.2020.9971. Epub 2020 May 21. PMID: 32438853.
3) Sizer Jr P, Brismée JM, Cook C, Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain 2007 World Institute of Pain, 1530-7085/07/$15.00 Pain Practice, Volume 7, Issue 1, 2007 53–71
4) Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red flags for low back pain are not always really red: a prospective evaluation of the clinical utility of commonly used screening questions for low back pain. J Bone Joint Surg Am. 2018;100:368-374. https://doi.org/10.2106/ JBJS.17.00134
5) Lewis J. & Fernandez-de-las-Penas C: THE SHOULDER Theory and Practice
6) Kimber D, Pigott T. Cauda equina screening in Physiotherapy: A qualitative study of physiotherapists in a community musculoskeletal service: Are we asking the right questions and are we asking the questions right? Musculoskelet Sci Pract. 2023 Jun;65:102773. doi: 10.1016/j.msksp.2023.102773. Epub 2023 May 10. PMID: 37201228.
7) Goodman CC, Snyder TEK. Screening for immunologic disease. In: Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St Louis, MO: Elsevier/ Saunders; 2013:ch12.
CASE STUDY: SERIOUS PATHOLOGY - CAUDA EQUINA SYNDROME (CES) REQUIRING URGENT REFERRAL TO EMERGENCY DEPARTMENT
- Kavya Parekh, MSc, HCPC, MCSP
Clinical reasoning for suspecting CES:
· Intense LBP 10/10, worsening in nature, with radiating pain to both the lower limbs with pins and needles and numbness.
· Loss of feeling between legs – saddle anesthesia.
· Recent urinary incontinence and increased urinary frequency with constipation.
· Loss of libido.
· Loss of balance (feelings of dizziness, nausea, lightheaded and lose legged) and reduced lower limb strength and power.
· Back pain not relieving while lying down.
Telephonic follow-up on same day evening: Patient was at the emergency department and grateful for the referral. The professionals were also suspecting CES. He underwent several investigations including blood tests and MRI scanning and was waiting for the results.
Bottom line:
This case demonstrates the significance of being vigilant for serious pathology presentation and of screening each patient through thorough questioning for red flags.
Clinical reasoning was based on the paper by Lavy C et al, 2022 and NICE guidelines, 2016.
The McKenzie Institute India would like to congratulate our most recent Cert. MDT clinicians
“ABOUT MDT FREE CAMPS”
- Dr Madhavi Gadhvi, BPT, Cert MDT
MDT Free Camps is a public health initiative by McKenzie Institute India, honoring the legacy of Robin McKenzie. This initiative aims to provide evidence-based, cost-effective, and patient-empowering therapy to those in need. Sometime before the MI India’s branch formation in 2013, this charity work of free camps was started by Certified McKenzie Therapists in India with Dr Asha Menon and after the branch formation, MI India’s first camp was conducted in 2013 which had excellent support of all Certified McKenzie Therapists and all those who were in their MDT education journey. Following the branch's establishment, the first official camp was held in 2013 with strong support from certified McKenzie therapists and those on their MDT education journey. Since then, the MDT India community has continued to organize these camps annually across various cities, hosted at personal clinics of Certified and Diploma Therapists or within tertiary care hospitals where they are employed.
Here are a few key points about these camps:
Timing: The free camps are typically scheduled on a Sunday close to World Physiotherapy Day.
Eligibility and Support: Certified and Diploma MDT clinicians listed on MI India’s reference list can host these camps. MI India provides full support, including publicity materials such as social media ads, pamphlets, banners, mini assessment forms, and home instruction papers for patients.
Preparation: All hosts and volunteers (those undergoing MDT education) receive detailed instructions on how to conduct the camps prior to the event.
Standards: Throughout the camp, hosts and volunteers are reminded that they represent MI India and must use MDT in its pure form when assessing and treating patients.
What sets MI India's MDT Free Camps apart is the inclusion of two free follow-up sessions, totaling three free sessions. This comprehensive approach allows for accurate MDT classification and effective treatment with Direction Preference exercises, optimizing patient outcomes.
We proudly celebrate World Physiotherapy Day by offering these valuable services, which are truly in the best interest of the patients. To date, thousands of patients have benefited from this initiative, saving over 1.5 million rupees. As awareness of McKenzie therapy grows, more medical professionals are recommending it, confident that their patients will achieve better results in fewer sessions.
Here's a memorable highlight from the 2018 MDT camps:
In 2018, we had a remarkable year for our MDT camps with some notable achievements:
Largest Reach: A total of 23 hosts and 45 enthusiastic volunteers came together to assist 469 patients across various camp venues in India, marking the highest number of patients served to date.
Certified McKenzie Clinics: Four clinics in Mumbai hosted the camps:
Dr. Devang Dharek’s Rudraksh Physiotherapy Clinic
Dr. Asha Menon’s Shree Giridhari Physiotherapy Clinic
Arogyanidhi Hospital’s Certified McKenzie Clinic
Lilavati Hospital’s Physiotherapy Department with Dr. Heena Garude
Tertiary Care Hospitals: Two Mumbai hospitals collaborated with MI India to host camps:
Arogyanidhi Hospital with Dr. Asha Menon
Lilavati Hospital with Dr. Heena Garude
Teaching Institute: Krishna College of Medical Sciences in Karad partnered with MI India to host a camp at its Physiotherapy Department, led by Dr. Khushboo Bathia, a certified MDT therapist.
Patient Impact: 160 patients took advantage of free follow-up sessions, and out of them 103 were discharged after their 3 free sessions.
Cost Savings: The total savings for patients at these camps amounted to ₹4,37,380, demonstrating a significant financial benefit.
These accomplishments reflect the immense impact of our MDT camps and the ongoing commitment to providing valuable care to our communities.
This year, we are excited to host our MDT camps on September 15th. We look forward to seeing even more MDT clinicians and students actively participate and contribute their expertise.
Offering your skills in service to society is one of the most meaningful contributions you can make and MDT therapy stands out as a powerful way to not only treat patients but also to educate them about preventing recurrences and empowering them to manage their own health.
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