approximately 50% of the subjects with low back pain reported that they experienced night pain, more than 80% of those subjects reported relief of symptoms with a simple change in position, 20% of the subjects got relief with walking, and 10% got relief with medication. Fewer than 5% of the subjects reported that nothing relieved their night pain. Therapists should be concerned if a patient reports that his or her worst pain is at night and he or she has not found anything that relieves the night pain. These findings are unusual, not consistent with a mechanical basis for the problem, and constitute part of an atypical cluster of signs and symptoms that warrant communication with a physician or another healthcare provider. Therapists should recognize, however, that the absence of night pain does not rule out the possibility of cancer or another serious medical condition (Slipman et al., 2003). A summary of atypical symptoms for patients with mechanical low back pain can be found in Table 4. Some of these factors are consistent with the presence of a serious medical disorder. Visceral diseases often produce pain that shows no relationship to mechanics (i.e., the pain is neither relieved with rest nor aggravated with activity). Symptoms that migrate or are symmetrically distributed are more often associated with medical problems than mechanical disorders. The presence of symptoms that are not constant in duration and intensity does not rule out visceral disease. An ulcer is a visceral disorder that presents with intermittent pain, and that pain can be aggravated and eased with various factors such as eating (Goodman et al., 2018). In summary, the therapist should consider that any single factor as an isolated finding is generally not justification for referring the patient to the physician or another healthcare provider (Ross & Boissonnault, 2010). Red and yellow flags Therapists must consider potential viscerogenic or systemic origins or explanations for pain and other symptoms that do not appear to be of a mechanical origin. Some authors use the terms yellow flags and red flags to describe signs and symptoms that suggests the etiology of the patient’s problem is not mechanical (Goodman et al., 2018). In this scheme yellow flags are signs and symptoms that are cautionary, suggest a need to progress slowly and suggest the need for additional screening through questioning or examination (e.g., patient belief that pain is harmful resulting in fear avoidance behavior). Red flags are signs and symptoms associated with a high risk of serious medical pathology and/or adverse drug reaction. In this classification scheme some red flags require immediate medical attention whereas other red flags require further questioning and/or examination. For example, the onset of chest pain and diaphoresis suggestive of a myocardial infarction is a red flag requiring immediate medical attention but the presence of night pain, a red flag finding, does not require immediate medical attention but does require follow-up questioning and/or examination. Other authors prefer to describe all of the signs and symptoms that do not appear to be of mechanical origin as red flags and then categorize the findings as level I, II, or III (Sizer, 2007). In this classification scheme level I findings require immediate medical attention whereas level II & III findings suggest further questioning and/or testing procedures are needed (i.e., level
More than 80% of patients with low back pain report at least one red flag finding (Henschke et al., 2009), while the incidence of cancer and other serious pathology as a cause of low back pain has been reported to be less than 1% to 2% (Deyo & Diehl, 1988; Henschke et al., 2009). The preferred practice pattern is to place any unusual findings in the context of the entire presentation by the patient. For example, a patient’s low back pain that includes night pain as an isolated finding is not considered significant. However, a patient over the age of 50 who has a history of cancer and states that night pain is his or her worst pain over a 24-hour period, that the pain is constant, and that there are no aggravating or easing factors for the symptoms is demonstrating a cluster of findings that should generate concern and warrants a referral to a physician or another healthcare provider. Table 4: Summary of Atypical Findings for a Patient with Mechanical Low Back Pain 1. Pain that is constant in duration and intensity (i.e., there are no aggravating and no easing factors). 2. Pain that is unaffected by a change in position. 3. Pain that is worse in the recumbent or other nonweight- bearing position. 4. Pain that is the worst at night. 5. Night pain that cannot be relieved or reduced by any means. 6. Pain that changes location, especially from side to side or between limbs. 7. Pain that is symmetrically distributed. Note . Adapted from “Pain profile of patients with low back pain referred to physical therapy,” by W. G. Boissonnault and R. D. Di Fabio, 1996, Journal of Orthopaedic & Sports Physical Therapy, 24(4), pp. 180-191. II and III findings are comparable Goodman’s use of the term yellow flags and red flags not requiring immediate medical attention). The presence of a single yellow or red flag (e.g., the presence of night pain) is rarely adequate justification for a referral to another healthcare provider or to seek immediate medical attention. The presence of a single yellow or red flag must be considered in the context of the entire person that includes consideration of the medical history, age, gender and medication use. Therapists should be more concerned about a cluster (multiple) of findings indicative of a serious medical condition and/or adverse drug reaction than a single red flag finding. Red flag findings that require immediate medical attention include chest pain suggestive of myocardial infarction, signs and symptoms consistent with a transient ischemic attack or blood in the urine. Common yellow flag and/or red flag findings that do not require immediate medical attention include the presence of night pain that is the worst pain in a 24-hour cycle, an insidious onset of pain of unknown etiology (especially with back and shoulder pain), and signs and symptoms that do not respond to physical therapy interventions or initially get better then worse following physical therapy intervention (APTA, 2014; Goodman et al., 2018). Some additional signs and symptoms that require further questioning and/or examination can be found in Table 5.
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