A Review of Red Flags | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

A Review of Red Flags

This blog is a follow-up from the second episode of the "Untold Physio Stories" podcast where Erson discusses red flags and a clinical case of cancer.  During the podcast Jason and Erson discuss the keystone red flags for cancer:
  • recent unexplained weight loss
  • general malaise
  • unremitting night pain
  • pain in multiple spinal regions
  • night sweats
These five points are taught as key features that should alert our attention to a potential sinister pathology, but really they only just begin to scratch the surface in terms of differential diagnosis. This blog aims to expand on the special questions for the cervical, thoracic and lumbar spine that Physical Therapists can be including in their subjective examination to draw out more information about unusual pain presentations. 

Asking special questions is an important component of every patient examination and generally red flags are suspected when with the following features (Van Tulder et al., 2006, p. S172).
  • How old were they when the pain began? An age of onset of pain of less than 20 years or more than 55 years. 
  • Recent history of violent trauma (fracture). 
  • Dizziness - the presence of 5D's and 3N's (explained below).
  • Constant, progressing, unremitting and non-mechanical pain (which is not relieved with bed rest).
  • Thoracic spine pain. 
  • Past history of malignant tumour. 
  • Prolonged use of corticosteroids and other long term medications (changes in bone integrity, liver function and other body systems).
  • Drug abuse, use of immunosupressants and HIV (risk of infection). 
  • Systemically unwell.
  • Unexplained weight loss
  • Widespread neurological symptoms (including cauda equina syndrome).
  • Structural deformity
  • Fever and night sweats. 
  • General health "do you have any other medical conditions? How is your general health?".
  • Investigations - what scans have they had?
  • Changes in bladder or bowel disturbance (particularly urinary retention and faecal incontinence).
  • Cauda equina signs or symptoms of cord compression (numbness over the perineum, loss of control of continence, incompetence). 
So the list is quite extensive and it is our responsibility to check these areas when assessing patients with spinal pain. But have you ever wondered why you are asking them or what you should do if the answers come back positive? 

So what are we looking for?

We are looking for the prresence of serious pathology:
  1. Constant pain
  2. Pain that is not related to movement
  3. Presence of severe spasm
  4. Morning stiffness lasting more than 30 minutes
  5. Presence of severe night pain
  6. Presence of night sweats
  7. History of cancer
  8. Recent fracture or trauma.
We are looking for signs of spinal cord compromise: 
  • Non-dermatomal symptoms - 'glove or sleeve or stocking' like distribution. 
  • Ataxia during gait and clumbsiness with upper extremity tasks.
  • Increased reflexes.
  • Postive Babinski sign or clonus.
  • Non-myotomal muscle weakness.
  • Bladder and bowel disturbance. 
  • Saddle anaesthesia. 
  • Global/progressive upper or lower limb weakness.
We are looking for signs of nerve root compression:
  • Dermatomal pain, paraesthesia or anaesthesia.
  • Decreased reflexes.
  • Reduces strength in a myotomal pattern. 
  • Reproduction of neurological symptoms with spinal movements. 
We are questioning about the following conditions because they require special consideration for treatment modalities:
  • Active infection.
  • Active Scheuermann's disease. 
  • Pregnancy
  • Active diabetes. 
  • Inflammatory disorders.
  • Metabolica and endocrine disorders. 
  • With conditions where instability can result from loss of bone and joint integrety such as Rheumatoid Arthritis and Spondyloarthropathies. 
We are questioning for the following medications, which also require special consideration for treatment modalities and differential diagnosis:
  • Anti-depressants
  • Anti-coagulants
  • Oral steroids
  • Strong analgesia
  • Muscle relaxants
  • Opiates
Patient's with dizziness.

Dizziness is the most common complaint associated with vertebrobasilar insufficiency (VBI). When dizziness is present you should be questioning for 5D's and 3N's:
  • 5D's - dizziness, diplopia (blurred vision or even transient hemianopia), drop attacks (loss of power or consciousness), dysphagia (problems swallowing), dysarthria (problems speaking). 
  • 3N's - nystagmus, nausea (or vomiting) and other neurological symptoms. 
  • And the others we often forget - light headiness or fainting, disorientation, unexplained anxiety, disturbances in the ears (tinnitus), pallor, tremors, sweating, fascial paraesthesia or anaesthesia. 
The case that Erson presented on the podcast was of a lady with unexplained weight loss, multiple regions of spinal pain, poor response to treatment, general malaise and the outcome for this client was cancer. It fits the typical box which we all hear about but not often do you actually experience this case first hand. It was great to listen to Erson share his experience about the case and how he reacted when he felt "things weren't quite right". 

There definitely is a fine balance between being hypervigilent with referring patients for further investigation and also questioning enough to know you aren't overlooking a more sinister pathology. In my opinion, build these questions into assessment and make a commitment to regularly ask your special questions. Not often do a whole cluster of them come out positive and when this occurs, it generally warrants a second review. 


Sian Smale is an Australian-trained and APA-titled Musculoskeletal Physiotherapist. Sian has been writing a Physiotherapy evidence-based blog for the past 3 years called Rayner & Smale (www.raynersmale.com). Sian is based out of San Francisco and continues to write and teach Clinical Pilates while trying to gain her Californian Physical Therapy license. This blog is shared from a previous post on Rayner & Smale relating her knowledge of red flags to the recent Podcast of Untold Physio Stories. 

Van Tulder, M., Becker, A., Bekkering, T., Breen, A., Gil del Real, M. T., Hutchinson, A., ... & Malmivaara, A. (2006). Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal, 15, s169-s191.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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