Red Flags For Spinal Pain

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Category: Blog

Published on Tuesday, 23 March 2010 16:51

Written by Devdeep Ahuja

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As physiotherapists have evolved from practising as technicians under the guidance of medical professionals to being autonomous first contact professionals, greater stress has been placed on exclusion of serious pathologies, which cannot be treated with physiotherapeutic interventions. This is to decide whether physiotherapy or manual therapy is unsuitable and not recommended and can even be harmful.

Initially, it was Mennel and Cyriax who promoted manual therapy, but recognised the need for a cautious approach in certain conditions. More recently, Clinical Skills Advisory Group (1994) and Agency for Health Care Policy and Research (1994) have provided information on potentially serious conditions presenting as spinal pain. Grieve (1994) in his classic paper, ‘Masqueraders’ has provided ample example of systemic conditions mimicking spinal pain.

The following is a list of red flags which needs to be considered in assessment of each patient.

• Presentation less than age 20 or onset over age 55 years
• Violent Trauma: eg fall from a height, RTA
• Constant, progressive, non-mechanical pain
• Thoracic pain
• Past Medical History - Carcinoma
• Systemic steroids
• Drug abuse, HIV
• Systemically unwell
• Sudden Unexplained Weight loss
• Persisting severe restriction of lumbar flexion
• Cauda equina syndrome/widespread neurological disorder
  • Difficulty with micturition
  • Loss of anal sphincter tone or faecal incontinence
  • Saddle anaesthesia about the anus, perineum or genitals
  • Widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance
  • Sensory level
• Inflammatory disorders (ankylosing spondylitis and related disorders)
  • Gradual onset before age 40
  • Marked morning stiffness
  • Persisting limitation spinal movements in all directions
  • Peripheral joint involvement
  • Iritis, skin rashes (psoriasis), colitis, urethral discharge
  • Family history
• Pain that worsens when supine

Thus it is imperative that each physiotherapist understands and recognises these red flags and the need for referral to appropriate consultant for further assessment and management. It is important that these red flags are seen in the context of the presentation and used with appropriate reasoning.

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