However, Cook et al. (2018) have identified several reasons red flags are sometimes not able to detect serious pathology including: ● The absence of red flag symptoms does not necessarily rule out a condition, nor does the presence of red flag symptoms necessarily identify it. ● There is great variability in how red flags are identified, which limits their utility in both clinical and research settings. ● At least 80% of patients have at least one red flag, but most guidelines recommend extensive (and expensive) diagnostic testing even if only one red flag is present. Healthcare consideration: Given that so many red flags have been identified and the fact that almost every client has at least one, it can be a challenge for the assessing clinician to decide how and when to act upon them. One strategy that can be helpful is this: First rule out the presence of any condition that requires immediate attention, things like very high blood pressure, sudden onset of very severe headache, or the possibility of fracture. Next, begin treatment based on your clinical findings. If no progress is made and the treatment is ineffective (another red flag), this can serve as a trigger for referral to another healthcare provider. In other words, every red flag does not necessitate referral or further diagnostic testing. Often, we have time to weigh their importance. The second question we are answering via differential diagnosis is “What neuromuscular or musculoskeletal diagnosis best explains this patient’s signs and symptoms?” This involves a critical analysis of medical history, subjective findings, objective findings, and physical examination. Physical examination often involves completing special tests to help hone in on a specific diagnosis or symptom source. Arriving at an accurate diagnosis empowers the therapist set up the most effective treatment plan. Healthcare consideration: Two important questions that need to be answered at the initial physical therapy assessment are: (1) Is this client appropriate for physical therapy? and (2) What neuromuscular or musculoskeletal diagnosis best explains this patient’s signs and symptoms?
pain and depression correctly, and 43.2% managed the patient with low back pain and fear-avoidance behavior correctly. The author concluded that physical therapists need further education regarding warning flags. Healthcare consideration: Red flags are warnings that certain features of the client’s examination or medical history are associated with high risk of serious disorders or conditions. Orange flags are psychiatric disorders such as depression, anxiety, or somatoform disorder that can hinder treatment progress. Yellow flags are maladaptive pain coping strategies that are predictors of long-term disability. Clinicians who are treating clients via direct access should be highly skilled in differential diagnosis, including familiarity with systemic and viscerogenic conditions that mimic musculoskeletal problems. Viscerogenic and systemic origins of the clients’ symptoms should be considered because these structures can be sources of musculoskeletal issues. In these instances, the client’s presenting problem will look like a musculoskeletal issue that would be appropriate for physical therapy evaluation and treatment when, in reality, the client’s signs and symptoms are stemming from a medical condition that needs attention from a physician. This situation is rare. According to Cavallaro Goodman (2018), osteopaths suggest that approximately 1% of cases seen by physical therapists are systemic or viscerogenic in origin, although this has not been statistically confirmed. Despite the infrequency of this situation, differential diagnosis to eliminate viscerogenic and systemic origins of symptoms is necessary for patient safety. The presence of a single yellow or red flag is often not cause for immediate medical attention. These findings should be evaluated in the context of the whole person, their medical history, known risk factors, and medication use. The focus is looking for a pattern of systemic or viscerogenic origin of pain and/or symptoms. Certain red flags have been shown to have good accuracy. For example, recent trauma and age greater than 50 years is associated with vertebral fracture, and a history of cancer with relevant clinical signs is associated with malignancy (physiopedia.com). Risk factors Risk factors are elements that increase the likelihood of a person having a disease ( NCI Dictionary of Cancer Terms , n.d.) Risk factors vary depending on the disease or condition under consideration. For example, the risk factors for osteoporosis are older age, female gender, white or Asian descent, positive family history of osteoporosis, and small body frame. If a small older woman presents to physical therapy with back pain from falling on ice, you are much more likely to consider the possibility of an osteoporosis-related back injury than you would be if the patient who fell on ice were a young athletic male. Most diseases and conditions have multiple risk factors, and the presence of just one factor may not be cause for concern (Heick et al., 2023). Familiarity with the main risk factors for major diseases and conditions is an important part of screening for systemic or viscerogenic causes of symptoms and/or pain. Healthcare consideration: Cardiac conditions such as myocardial ischemia (heart attack) or angina can produce pain in the left side of the neck. Knowing the risk factors for heart disease can help rule in or rule out a possible cardiac condition. According to the Centers for Disease Control and Prevention (CDC), the leading risk factors for heart disease are high blood pressure, high cholesterol, diabetes, smoking and secondhand smoke exposure, obesity, an unhealthy diet, and physical inactivity (Know Your Risk for Heart Disease cdc.gov, 2019).
Self-Assessment Quiz Question #1 At times, pain with viscerogenic and systematic origins can mimic musculoskeletal problems. Osteopaths estimate that approximately _____ of cases seen by physical therapists are systemic or viscerogenic in origin.
a. 1%. b. 5%. c. 10%. d. 25%.
Both headaches and neck pain can have systemic origins. This course will take an in-depth look at possible viscerogenic and systemic origins of pain in the head and neck. In addition, we will look at how to confirm your suspicions that a client’s condition is neuromuscular and/or musculoskeletal in origin so that you can proceed in setting up and administering the patient’s plan of care with confidence.
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Book Code: PTNY1024
EliteLearning.com/ Physical-Therapy
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