Assessing Red Flags

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.

Medical practitioners have developed a series of flag systems to evaluate and categorise the risks involved in dealing with various conditions. Red flags refer to findings on examination or in the history which could indicate the presence of serious medical situation. It is vital that physiotherapists, medical practitioners and alternative therapists understand and apply the principles behind this idea when assessing patients. It is never possible to catch all potentially serious conditions at first assessment but having a checklist significantly decreases the chances of missing something that is there.

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.

Appetite loss/poor eating: Loss of appetite could indicate a serious problem and if this is apparent refer to the above remarks about loss of weight.

Not feeling well: Asking a chronic pain patient how they feel in themselves will likely get the answer that they feel ok. A persistent feeling of being unwell is suspicious, particularly if combined 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.

Previous Medical History of a Tumour: The examiner should enquire about this as a recurrence could be the presenting cause of the patient’s problems.

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.

Saddle anesthesia: The saddle is the perineal area, the skin around the genitals and anus. An alteration or loss of feeling in this area, for instance when drying oneself with a towel, could be the indicator of a serious problem.

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.

Muscle Weakness. Weakness may occur due to damage to a joint or muscle or due to one of the spinal nerve roots being affected. A condition which gives widespread weakness or weakness in more than one nerve root should be flagged as suspicious.

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.

Importance of the Patient’s Age: Typically, painful conditions such as low back or neck pain come on in adult life between 20 and 55 years old. Anyone whose pain problem arises when they are much younger or much older has a higher risk of an underlying medical problem.

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