Screening for Red Flags by an Orthopedic Manual Physical Therapist

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

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
Medical emergency

Deep Vein Thrombosis - Wells criteria (≥2 points DVT likely, <2 DVT unlikely) [10, 18]:

Active cancer (treatment ongoing, within 6 mo, or palliative) +1
Paralysis, paresis, or recent plaster immobilization of lower extremities +1
Recently bedridden for 3 d or more, or major surgery within 12 wk requiring general or regional anesthesia +1
Localized tenderness along distribution of deep venous system +1
Entire leg swollen +1
Calf swelling at least 3 cm larger than asymptomatic side +1
Pitting edema confined to symptomatic leg +1
Collateral superficial veins (non-varicose) +1
Previously documented DVT +1
Alternative diagnosis at least as likely as DVT -2
Medical emergency. D-dimer testing is first recommended step. If positive, ultrasound is required. If negative, DVT is unlikely.

Pulmonary Embolism

Signs and symptoms
SOB/cough
Chest pain
Dizziness, fatigue
Loss of lung sound(s)
Cyanosis
Excessive sweating
Irregular heartbeat
History
Recent surgery
Family history of PE
Recent history of traveling / flying
Medical emergency

Myocardial Infarction / Angina

Pain in left upper quarter, i.e. neck, chest, jaw – or right biceps area in females)
Chest or abdominal pain / tightness
Heartburn
Heart palpitations
Difficulty breathing / shortness of breath
Pale, clammy, sweating
Pain worse with exertion, after heavy meals, or with arm / trunk movement
Not relieved with rest
Nausea / vomiting
Vision / speech impairments
Chest pain in a patient with a history of stent
Medical emergency

Pericarditis

Sharp pain in similar location pattern to MI
History of fever / chills
Pain worse with deep breathing, laughing, belching, coughing, swallowing, neck / trunk movements, lying down
Pain eased with holding breath, leaning forward, sitting upright
Medical emergency

Legg-Calve-Perthe’s

Hip avascular necrosis, more common in pediatric (aged 4-14) males
Hip, knee, or groin pain
Leg length inequality
Pain with hip range of motion, especially internal rotation
Antalgia
Refer to physician for X-ray, bone scan, or MRI

Slipped Capital Femoral Epiphysis (SCFE)

Most common adolescent hip disorder in prepubescent (aged 10-17) males
Obesity is significant risk factor
May have knee pain, hip pain or buttock pain
Leg length inequality
Decreased hip range of motion, especially internal rotation
May maintain hip in external rotation while weight bearing
Immediately make patient non-weight bearing and refer to surgeon

Femoral Neck Stress Fracture

Overuse or after initiating / increasing activity
Groin, thigh, or knee pain
More common in females
Family history of osteoarthritis
History of smoking
Pain in end-ranges of motion, with weight bearing, positive hop test, positive FABER, positive fulcrum test
Need to refer to physician for bone scans with recent onset (100% sensitivity and almost 100% specificity) as plain films will not detect fractures for 3-4 weeks

Septic Arthritis

History of fever
Non-weight bearing gait
Increased sedimentation rate (>40mm/hr)
Increased serum WBC (>12,000)
Deadly. Need bacteria culture for definitive diagnosis; may need antibiotics and/or invasive procedures

Inflammatory Arthritis

Severe morning stiffness >1 hr
Pain not relieved (or worse) with rest
Improvement in pain with exercise
Chronic duration
Decreased spinal range of motion
Decreased chest wall expansion
Fever
Weight loss
Fatigue

Ankylosing Spondylitis

Morning stiffness >30 minutes
Improvement in pain with NSAIDs
Night pain (during second half of night)
Alternating buttock pain

Digestive System Disorders

Difficulty swallowing
Heartburn
Indigestion
Specific food intolerances
Changes in appetite
Bowel dysfunction (dark, tarry stools are typically suggestive of upper GI involvement but may involve lower GI as well – possibly Crohn’s disease, prolonged use of NSAIDs; blood in the stool may indicate colon cancer, anal fissures, hemorrhoids)
Urinary dysfunction (hematuria, pain, change in frequency)
Abdominal distension
Fevers / chills / sweats
Nausea / vomiting
Rebound tenderness
Pain relieved by sitting forward (pancreatic etiology)
Pain not relieved with rest or positioning
Change in symptoms after eating (0-30 minutes implicate stomach, duodenum, upper GI; 2-4 hours implicate intestines, colon, lower GI)
Refer to physician (or ask if physician is aware of these symptoms and if the symptoms have changed in any way since seeing the physician)

Reproductive Organ Disorders

Change in menstruation (frequency, pain, discharge)
Change in bladder function (frequency, hesitancy, blood)
Sexual dysfunction, pain, or bleeding
Abdominal, thoracic, or lumbosacral pain

Major Depressive Disorder

Depressed mood most of the day, nearly every day for 2+ wks
Diminished interest or pleasure in most activities
Significant weight loss or gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue / loss of energy
Feelings of worthlessness / excessive guilt
Diminished ability to concentrate or make decisions
Recurrent thoughts of death or suicide
Use PHQ-2 first to screen for it (Kroenke 2003 Medical Care)
Use PHQ-9 to rule it in – high sensitivity and specificity (Kroenke 2002 Psychiatric Annals)
If score >10 on PHQ-9, 7-13.6x more likely to have major depression
Refer for psychiatric evaluation

Suicide Risk

History of major depression
History of substance abuse
Expressed suicidal ideation
Giving away of personal possessions
Recent calmness (do not prematurely conclude that depression is resolving)
Plan to take life and/or taking steps to enact a plan
Family history of suicide attempts
Previous suicide attempt
History of progressive illness
Recent loss (family member, job, financial)
Presence of firearms at home
Contact emergency department to arrange for transport

There is a low percentage of red flags presenting as common orthopedic conditions as noted in this systematic review that considered the prevalence of red flags in patients seen in the Emergency Department for low back pain:

"We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings." [17]

However, I cannot overemphasize the fact that not only is this list not all-inclusive, there still remains considerable uncertainty around the identification of red flags for serious pathologies, and each health care professional must weigh each patient's unique presentation carefully when deciding how to proceed. [11-18]

Further Information on Orthopedic Manual Physical Therapy

Click on any of the following links for more information:

Would you like a brief overview of the basics of orthopedic manual physical therapy?
Are you curious about the scientific mechanisms behind how orthopedic manual physical therapy works?
Have you ever wondered how pain works?
Do patients need an MRI or X-ray before beginning physical therapy?
What should you consider when choosing a physical therapist for an orthopedic condition?
What's an evidence-informed approach to the examination and treatment of sacroiliac joint pain?
How should one perform manual therapy for spondylolisthesis?

Dr. Damon Bescia is a fellowship-trained Doctor of Physical Therapy, board certified in orthopedics and sports physical therapy, who specializes in Orthopedic Manual Physical Therapy and serves Naperville and its surrounding communities by way of his Concierge Practice, providing private one-to-one orthopedic manual physical therapy for his clients. For more information, please visit https://www.napervillemanualphysicaltherapy.com.