Screening for Red Flags by an Orthopedic Manual Physical Therapist



Red Flag

How Does an Orthopedic Manual Physical Therapist perform Medical Screening for Red Flags?

Orthopedic manual physical therapy is performed with the goal of reducing pain and improving movement in the spine and/or at any location throughout the neuromusculoskeletal (or orthopedic) system. In rare cases, however, pain that seems to be of an orthopedic nature may have a different origin. Does this mean that prospective patients should seek out a medical physician before scheduling an examination with a doctor of physical therapy?

No, patients have direct access to physical therapists in Illinois and do not require a physician referral (though patients are advised to contact their insurance company to inquire about whether or not a referral is required for insurance reimbursement). Doctors of physical therapy are trained in differential diagnoses and will refer to more appropriate health care providers if there is suspicion that a patient's symptoms are not of an orthopedic origin. An orthopedic manual physical therapist is to be vigilant to signs and symptoms ("red flags") that either indicate a medical emergency or are suggestive of sinister pathology. As both lie outside of a physical therapist’s scope of practice, patients presenting with these signs and symptoms warrant a referral to a medical physician.

An orthopedic manual physical therapist must always inquire of the presence of any symptoms that may be suggestive of these red flags. Depending on each patient's unique presentation, the physical therapist would directly inquire about such things as severe trauma, unexplained weight loss, history of cancer, dizziness, loss of consciousness, clumsiness walking or handling objects, unexplained weakness, nausea, fever, chills, night sweats, change in bowel or bladder function, change in symptoms after eating or drinking, paresthesia or anesthesia, difficulty speaking, difficulty swallowing, and change in vision (though this is not all-inclusive). The following outline provides a brief overview of conditions that commonly present with pain or dysfunction that may be incorrectly interpreted as having an orthopedic origin or that may warrant further medical work-up.

  • Cancer[1]

  • History Cluster (sensitivity of 100%)

  • Age >50

  • Previous history of cancer (+LR 23.7)

  • Unexplained weight loss (>10 pounds in 3 months)

  • Failure to improve after 1 month of treatment

  • Relentless night pain

  • Non-mechanical pain – not relieved with positioning or rest

  • PB KTLL – “Lead Kettle” pneumonic for cancers likely to metastasize to bone: Prostate, Breast, Kidney, Thyroid, Lung, Lymph

  • Must refer to physician for ESR / hematocrit testing

  • Elevated ESR (+LR 18.0)

  • Reduced hematocrit (+LR 12.1)

  • Upper Cervical Instability[2] [3] [4]

  • Positive Sharp-Purser test

  • Positive alar ligamentous instability

  • Headaches

  • “Bobble head” that feels unstable – patient needs pressure/support to feel relief

  • History of Down’s Syndrome, Rheumatoid Arthritis, Ankylosing Spondylitis, throat infection, Ehlers-Danlos Syndrome

  • UCI tests have not been studied sufficiently, but seem to be highly specific. (Cannot rule out when negative, however.)

  • Refer to physician for open mouth, flexion/extension plain films

  • Cervical Arterial Insufficiency[5] [6]

  • Typically unilateral posterior neck pain with suboccipital pain or headache around temple (these symptoms may precede an ischemic event by a few days to several weeks)

  • Contralateral vertebral artery stressed with cervical rotation (In healthy adults, the cerebral vasculature can compensate for unilateral decrease of blood flow; strokes may be more resultant of decreased compensatory capacity of the system and not isolated VBI)

  • Assess for 5 D’s & 3 N’s (especially dizziness) and Ataxia

  • Dizziness

  • Diplopia

  • Drop Attack

  • Dysarthria

  • Dysphagia

  • Nystagmus

  • Nausea

  • Numbness

  • Cranial nerve palsy with Horner’s syndrome (pathognomonic for internal carotid artery)

  • Vomiting, hoarseness, memory loss

  • Hearing loss / tinnitus

  • Pupillary changes, photophobia

  • Facial numbness

  • Vision changes

  • Blood pressure changes (typically higher)

  • History: smoker, cardiovascular dysfunction, previous MVA, diabetes, blood clotting disorder, post-partum, long-term steroid use, recent infection, history of trauma, oral contraceptives

  • Medical emergency. May need Doppler assessment with rotation and extension or angiography.

  • Cervical myelopathy – Clinical Prediction Rule (>3 to rule in, <1 to rule out) [7]

  • Gait deviation

  • Hoffman’s

  • Inverted supinator sign

  • Babinski

  • >45 years of age

  • Though not a medical emergency, the physical therapist must refer to a physician if unchanged after a reasonable amount of treatment and discuss options based on presentation; MRI is best for suspicion of cord compression. (Myelopathy is the most common spinal disorder >55 years of age, and surgery is rarely needed.)

  • Pulmonary Dysfunction (Pneumothorax, Pulmonary Embolism)

  • Sharp, localized pain

  • Pain may also be present in abdomen, neck, shoulder, posterior thorax

  • Pain aggravated by breathing, coughing, sneezing, laughing

  • Better in upright position, worse recumbent

  • Dyspnea / Shortness of breath

  • Persistent cough

  • Fever / chills

  • Malaise

  • Weak, rapid pulse

  • Low blood pressure (pneumothorax)

  • Palpitations

  • Bloody sputum

  • Cyanosis

  • History of DVT, prior pulmonary embolism, COPD, CHF, oral contraceptives, hormone replacement, pregnancy, TKA/THA, lower extremity fractures, abdominal/pelvic surgery or malignancy.

  • Medical emergency

  • Infection / Osteomyelitis / Discitis

  • Increased temperature

  • Erythema / Streaking

  • Malaise

  • Disproportionate tenderness

  • Systemic changes

  • Chills / Night sweats

  • Severe night pain

  • Unexplained weight loss of >10 pounds in 3 months

  • Recent bacterial infection

  • Dental abscesses

  • Transplant

  • IV drug abuse

  • Prolonged steroid use

  • Age >50

  • Visible redness

  • Palpable increased warmth

  • Positive spinal percussion

  • "The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction." [xvi]

  • Must refer to physician for imaging and lab tests or send to emergency department as appropriate.

  • Cauda Equina Syndrome

  • Signs and symptoms

  • Urinary retention (Sp=0.95, +LR=18)

  • Bowel dysfunction

  • Saddle paresthesia / anesthesia

  • Ataxia

  • Hyporeflexia

  • Significant/progressive neurological changes in lower extremities at multiple spinal levels

  • Patients in their 40’s and 50’s

  • Reports of sciatica in one or both lower extremities

  • Reports of sexual dysfunction

  • Positive straight leg raise

  • Medical emergency. Patient must receive immediate evaluation and neurosurgery as appropriate within 48 hours.

  • Spinal Fracture[8] [9]

  • Positive Tap Test or Closed Fist Percussion Test

  • Unrelenting pain

  • Altered sensation from trunk down

  • Age >68

  • Trauma

  • History of osteoporosis, osteopenia, corticosteroid use

  • Unable to lie supine

  • Refer to physician for imaging

  • Abdominal Aortic Aneurysm

  • Pain in abdomen, chest, low back, groin, posterior thighs

  • Pain worse with exertion

  • Excruciating, sharp, pulsating, throbbing

  • Pain greater in supine

  • Non-mechanical back pain

  • Tearing sensation during rupture

  • Cold, pulseless lower extremities

  • Width of abdominal pulse >3cm to palpation

  • Neurological changes

  • Age >50

  • Symptom onset during exertion

  • Recent initiation of weight lifting program

  • Smoking, obesity, family history, high cholesterol, high blood pressure

  • Medical emergency

  • Thoracic Aortic Aneurysm

  • Knife-like, tearing, excruciating pain

  • Pain in thoracic spine, chest, neck

  • Sense a heartbeat in supine

  • Hoarseness

  • Difficulty swallowing

  • Difficulty breathing

  • Clammy skin

  • Nausea / vomiting

  • Elevated heart rate

  • Elevated blood pressure

  • Positive family history