screening for
Red flags
associated to spinal conditions
a pragmatic adaptation of the 2020 IFOMPT framework
Creation: Yannick Tousignant-Laflamme, PT, Ph.D
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
STEP 1: Determine your level of concern in regards to the presence of a serious pathology
Sous-titre
Level of concern
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Based on the prevalence of the different pathologies in your context of practice, on the presence of risk factors/signs/symptoms associated to a high probabiliy of serious pathology and the profile of your patient.
RED FLAGS: clinical features associated with a high level of suspicion that a fracture is the cause of spinal pain ?
Clinical signs
symptoms
RISK Factor
History of osteoporosis*
Neurological signs
Thoracic pain*
History of ostooporotic facture + presence of other osteoporosis risk factors
Back pain with a history of cancer, myeloma or osteoporosis
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
corticosteroid*
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Steroid use (>5mg) for >3 months
Severe and unfamiliar pain
history of cancer
relevant investigations to confirm the hypothesis fracture?
Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid
Describes pain that is unfamiliar and possibly worsening pain
spinal deformity
Sudden changes in anatomical structures associated with trauma or in a patient with known osteoporosis
severe trauma*
Immediate pain during a severe traumatic event
Neurological symptoms
Female sex*
Spine tenderness
Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Menopause that started at a young age
Tenderness or reproduction of symptoms on palpation or percussion/vibration
older age*
Women: >65 y.o.; Men > 75 y.o.; for all patients > 80 y.o.
Previous spinal fracture*
contusion/abrasion
*these elements have a high level of Evidence
Signs of contusion/abrasion to the spinous processes following trauma
History of spinal atraumatic fracture (low impact event)
History of falls
History of falls or comorbidities that increase the risk of falls
Creation: Yannick Tousignant-Laflamme
RED FLAGS: clinical features associated with a high level of suspicion that a cancer is the cause of spinal pain ?
symptoms
clinical signs
Risk factor
Neurological signs
past history of cancer*
Severe pain
Severe, constant and progressive pain; described as band-like pain, and inability to lie flat
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid
Night pain
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
People who report having to walk the floors or sit in a chair or lie on the floor, with minimal relief
relevant investigations to confirm the hypothesis of cancer?
Systemically unwell
The patient reports characteristics of hypercalcemia, such as fatigue, nausea, stomach pain and fever. These also tend to be progressive in nature
Altered sensation from the trunk down
Thoracic pain
Evidence of loss of sensation in the trunk and/or lower limbs (quadrant)
Back pain, may be painful on percussion over the area of pain. May not be a mechanical pain pattern
neurlogical symptoms
Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Spine tenderness
Tenderness or reproduction of symptoms on palpation or percussion/vibration
*these elements have a high level of Evidence
Unexplained weight loss*
> 5% loss of body weight in < 3 months
Unfamiliar back pain
Pain described as unfamiliar and possibly worsening
Creation: Yannick Tousignant-Laflamme
RED FLAGS: clinical features associated with a high level of suspicion that a cauda equina syndrome is the cause of spinal pain ?
symptoms
clinical signs
Sensory change
Abnormal lower-limb neurology
Back pain+ typical signs
History of sensory disturbances in the lower limbs
Neuro examination shows significant deficits in the lower limbs
Back pain WITH: saddle anesthesia, age<50 years, bilateral and/or alternating lower limb symptoms, new motor weakness, obesity
Motor weakness (lower limbs)
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
History of weaknesses (motor) in the lower limbs
Sensory defecit in saddle to light touch and pinprick
Urinary and/or bowel incontinence
relevant investigations to confirm the hypothesis of cauda equina syndrome?
Saddle sensory disturbance
History of disturbed sensations (tingling) in the perineum
Reports incontinence for no other reason
Changes and sensory loss in the perineum
Unilateral/bilateral leg pain
erection/ejaculation disorders
Reduced anal tone
Unilateral symptoms that have progressed to bilateral symptoms
Recent changes/disorders related to symptom onset
A rectal examination shows a loss of tone
loss of sensation during sexual intercourse
constipation
Associated with other signs and symptoms and the onset of clinical presentation
risk factors
Loss of sensation during sexual relations
Herniated intervertebral disc
Urinary function
Urinary frequency and retention
Clinical evidence of disc herniation
History of falls
lumbar spinal stenosis
History of falls or comorbidities that increase the risk of falls
Clinical evidence of lumbar stenosis
Creation: Yannick Tousignant-Laflamme
Red flags: clinical features associated with a high level of suspicion that an infection is the cause of spinal pain ?
Clinical signs
symptoms
Risk factors
Neurological signs*
spinal pain*
Comorbidities
Unexplained and progressive pain in the spine, limiting ++ mobility
Presence of comorbidities (poorly controlled) that cause immuno-supression + history of infection
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
neurological symptoms
Surgery: invasive
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
relevant investigations to confirm the hypothesis of infection?
Recent spinal surgery, especially a revision
Radiculopathy
Intravenous drug use
fatigue
Progressive and significant neurological deficits (weakness <3/5)
ANORMAL fatigue and limiting usual activities
IV drug user with intravenous drug abuse
Fever*
social deprivation
Fever (and chills) consistent with the onset of painful symptoms
Material and social disadvantage, health determinants + unfavorable living conditions, alcoholism
Spine tenderness on palpation
Unexplained weight loss
tuberculosis
Tenderness or reproduction of symptoms on palpation or percussion/vibration
> 5% loss of body weight in < 3 months
Exposure to tuberculosis, without immunization
Recent infection
History of recent infection +progressive symptoms (degenerate)
*classic triad of Evidence of Infection
Creation: Yannick Tousignant-Laflamme
Treat or refer?
STEP 2: Determine your action
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Based of your level of concern, should you begin a trial of therapy, treat with a safety net or refer out for medical/urgent investigation?
STEP 3: Establish a trajectory for patients referred out
Trajectory for medical referral
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Medical emergency or need a medical consultation? Know your local resources to support patients in need of medical care.
CLINICAL DECISION SUPPORT-TOOL
Patient presenting with S & S consistent with MSK condition
MAJOR evidence of red flags
NO evidence of red flags
Provide care guided by best practice+ monitoring of S & S
SOME evidence of red flags
Medical emergency
Re-evaluation
Appearance of new signs or symptoms that worsen
Normal/expected progress
NO improvement / new signs or symptoms
Refer for further invensitatioins
progress as expected
VIGILENCEbegin trial of treatment WITH safety net
goals attained + discharge
Creation: Yannick Tousignant-Laflamme
Red Flags for potential serious spinal pathologies
Yannick Tousignant-L
Created on June 21, 2022
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Transcript
screening for
Red flags
associated to spinal conditions
a pragmatic adaptation of the 2020 IFOMPT framework
Creation: Yannick Tousignant-Laflamme, PT, Ph.D
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
STEP 1: Determine your level of concern in regards to the presence of a serious pathology
Sous-titre
Level of concern
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Based on the prevalence of the different pathologies in your context of practice, on the presence of risk factors/signs/symptoms associated to a high probabiliy of serious pathology and the profile of your patient.
RED FLAGS: clinical features associated with a high level of suspicion that a fracture is the cause of spinal pain ?
Clinical signs
symptoms
RISK Factor
History of osteoporosis*
Neurological signs
Thoracic pain*
History of ostooporotic facture + presence of other osteoporosis risk factors
Back pain with a history of cancer, myeloma or osteoporosis
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
corticosteroid*
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Steroid use (>5mg) for >3 months
Severe and unfamiliar pain
history of cancer
relevant investigations to confirm the hypothesis fracture?
Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid
Describes pain that is unfamiliar and possibly worsening pain
spinal deformity
Sudden changes in anatomical structures associated with trauma or in a patient with known osteoporosis
severe trauma*
Immediate pain during a severe traumatic event
Neurological symptoms
Female sex*
Spine tenderness
Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Menopause that started at a young age
Tenderness or reproduction of symptoms on palpation or percussion/vibration
older age*
Women: >65 y.o.; Men > 75 y.o.; for all patients > 80 y.o.
Previous spinal fracture*
contusion/abrasion
*these elements have a high level of Evidence
Signs of contusion/abrasion to the spinous processes following trauma
History of spinal atraumatic fracture (low impact event)
History of falls
History of falls or comorbidities that increase the risk of falls
Creation: Yannick Tousignant-Laflamme
RED FLAGS: clinical features associated with a high level of suspicion that a cancer is the cause of spinal pain ?
symptoms
clinical signs
Risk factor
Neurological signs
past history of cancer*
Severe pain
Severe, constant and progressive pain; described as band-like pain, and inability to lie flat
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid
Night pain
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
People who report having to walk the floors or sit in a chair or lie on the floor, with minimal relief
relevant investigations to confirm the hypothesis of cancer?
Systemically unwell
The patient reports characteristics of hypercalcemia, such as fatigue, nausea, stomach pain and fever. These also tend to be progressive in nature
Altered sensation from the trunk down
Thoracic pain
Evidence of loss of sensation in the trunk and/or lower limbs (quadrant)
Back pain, may be painful on percussion over the area of pain. May not be a mechanical pain pattern
neurlogical symptoms
Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Spine tenderness
Tenderness or reproduction of symptoms on palpation or percussion/vibration
*these elements have a high level of Evidence
Unexplained weight loss*
> 5% loss of body weight in < 3 months
Unfamiliar back pain
Pain described as unfamiliar and possibly worsening
Creation: Yannick Tousignant-Laflamme
RED FLAGS: clinical features associated with a high level of suspicion that a cauda equina syndrome is the cause of spinal pain ?
symptoms
clinical signs
Sensory change
Abnormal lower-limb neurology
Back pain+ typical signs
History of sensory disturbances in the lower limbs
Neuro examination shows significant deficits in the lower limbs
Back pain WITH: saddle anesthesia, age<50 years, bilateral and/or alternating lower limb symptoms, new motor weakness, obesity
Motor weakness (lower limbs)
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
History of weaknesses (motor) in the lower limbs
Sensory defecit in saddle to light touch and pinprick
Urinary and/or bowel incontinence
relevant investigations to confirm the hypothesis of cauda equina syndrome?
Saddle sensory disturbance
History of disturbed sensations (tingling) in the perineum
Reports incontinence for no other reason
Changes and sensory loss in the perineum
Unilateral/bilateral leg pain
erection/ejaculation disorders
Reduced anal tone
Unilateral symptoms that have progressed to bilateral symptoms
Recent changes/disorders related to symptom onset
A rectal examination shows a loss of tone
loss of sensation during sexual intercourse
constipation
Associated with other signs and symptoms and the onset of clinical presentation
risk factors
Loss of sensation during sexual relations
Herniated intervertebral disc
Urinary function
Urinary frequency and retention
Clinical evidence of disc herniation
History of falls
lumbar spinal stenosis
History of falls or comorbidities that increase the risk of falls
Clinical evidence of lumbar stenosis
Creation: Yannick Tousignant-Laflamme
Red flags: clinical features associated with a high level of suspicion that an infection is the cause of spinal pain ?
Clinical signs
symptoms
Risk factors
Neurological signs*
spinal pain*
Comorbidities
Unexplained and progressive pain in the spine, limiting ++ mobility
Presence of comorbidities (poorly controlled) that cause immuno-supression + history of infection
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
neurological symptoms
Surgery: invasive
Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance
relevant investigations to confirm the hypothesis of infection?
Recent spinal surgery, especially a revision
Radiculopathy
Intravenous drug use
fatigue
Progressive and significant neurological deficits (weakness <3/5)
ANORMAL fatigue and limiting usual activities
IV drug user with intravenous drug abuse
Fever*
social deprivation
Fever (and chills) consistent with the onset of painful symptoms
Material and social disadvantage, health determinants + unfavorable living conditions, alcoholism
Spine tenderness on palpation
Unexplained weight loss
tuberculosis
Tenderness or reproduction of symptoms on palpation or percussion/vibration
> 5% loss of body weight in < 3 months
Exposure to tuberculosis, without immunization
Recent infection
History of recent infection +progressive symptoms (degenerate)
*classic triad of Evidence of Infection
Creation: Yannick Tousignant-Laflamme
Treat or refer?
STEP 2: Determine your action
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Based of your level of concern, should you begin a trial of therapy, treat with a safety net or refer out for medical/urgent investigation?
STEP 3: Establish a trajectory for patients referred out
Trajectory for medical referral
Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy
Medical emergency or need a medical consultation? Know your local resources to support patients in need of medical care.
CLINICAL DECISION SUPPORT-TOOL
Patient presenting with S & S consistent with MSK condition
MAJOR evidence of red flags
NO evidence of red flags
Provide care guided by best practice+ monitoring of S & S
SOME evidence of red flags
Medical emergency
Re-evaluation
Appearance of new signs or symptoms that worsen
Normal/expected progress
NO improvement / new signs or symptoms
Refer for further invensitatioins
progress as expected
VIGILENCEbegin trial of treatment WITH safety net
goals attained + discharge
Creation: Yannick Tousignant-Laflamme