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). 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. 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.
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? 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. Self-Assessment Quiz Question #2 A patient presents for evaluation of neck pain related to a car crash that happened four weeks ago. She describes severe pain, rating it a 12 on a scale of 1 to 10. She reports that this neck pain has ruined her life and she is no longer able to work. Both x-rays and magnetic resonance imaging (MRI) were negative, but she insists that her doctor was a “quack.” Her medical history is significant for hypothyroidism and hypertension. She is hoping that you, her physical therapist, can find out what is wrong with her neck. Is this a red, orange, or yellow flag situation, and what should the evaluating therapist consider as a helpful next course of action? a. This is a red flag, and the client should be immediately referred back to her physician. b. This is an orange flag, as the client obviously has a psychiatric disorder. c. This is a yellow flag, and the client should be referred back to her physician. d. This is a yellow flag, and the physical therapist should proceed with treatment, incorporating the appropriate pain education strategies to address the patient’s maladaptive coping strategies.
a. 1%. b. 5%. c. 10%. d. 25%.
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