Many patients attend physiotherapy by self referral without medical review. The history and examination of a patient by a physiotherapist needs to cover the possibility that there might be an underlying condition of a more serious nature than a benign musculoskeletal one. Musculoskeletal conditions represent the vast majority of presenting conditions but a thorough and detailed review of the patient’s medical status is essential. Urgent referral to a physician is vital if any significant problem is identified. Red flags is the description given to the questions to be asked and to the warning signs elicited once a positive result is obtained.
Medical practitioners have developed a series of flag systems to evaluate and categorise the risks involved in dealing with various conditions. Red flags refer to findings on examination or in the history which could indicate the presence of serious medical situation. It is vital that physiotherapists, medical practitioners and alternative therapists understand and apply the principles behind this idea when assessing patients. It is never possible to catch all potentially serious conditions at first assessment but having a checklist significantly decreases the chances of missing something that is there.
Weight loss: Any unexpected, sudden or severe weight loss should be noted and the reasons for this identified if possible. Dieting is an obvious cause and some people who are very anxious or depressed eat very little and can lose considerable amounts of weight. Stopping active work can also lead to a lot of muscle loss in heavy workers. If there is no apparent reason for significant weight loss it should be regarded as a red flag and reported accordingly.
Appetite loss/poor eating: Loss of appetite could indicate a serious problem and if this is apparent refer to the above remarks about loss of weight.
Being unwell: Most people suffering from musculoskeletal and pain conditions do not record themselves as unwell if they are asked about this. Feeling persistently unwell can be a suspicious sign, and fits with loss of weight and loss of appetite.
Pain at Night: Back pain and many other conditions are painful during the nights but any pain which is worse at night or on lying down should be regarded with suspicion and recorded as a potential red flag.
Stiffness in the Mornings: Stiffness is a common symptom after musculoskeletal injury or joint damage but persistent or severe stiffness which lasts over an hour or for the rest of the day could point towards an arthritic condition.
Previous Medical History of a Tumour: The examiner should enquire about this as a recurrence could be the presenting cause of the patient’s problems.
Bowel and Bladder Control: This can be altered by many things from IBS to multiple sclerosis to having had children. Any new symptoms either of retention (inability to pass water) or incontinence should be reported as potentially serious.
Perineal loss of sensibility: The perineal area is between the legs and includes the skin round the genitals and the anus. Certain important medical conditions can change this area, leading to loss of feeling or pins and needles.
Heightened Tone and Spasticity: As assessment should be performed to include reflex testing, clonus elicitation and movement of the limbs passively to check that tone is normal. Central nervous system conditions cause alteration in tone, heightened reflexes and clonus.
Muscle Weakness. Weakness may occur due to damage to a joint or muscle or due to one of the spinal nerve roots being affected. A condition which gives widespread weakness or weakness in more than one nerve root should be flagged as suspicious.
The Age of the Patient: Between twenty and fifty-five years of age is the typical age range for most musculoskeletal conditions to present initially. If a patient is seen with the onset of their condition in younger or older life there is an increased risk of a medical condition to explain their symptoms.
Importance of the Patient’s Age: Typically, painful conditions such as low back or neck pain come on in adult life between 20 and 55 years old. Anyone whose pain problem arises when they are much younger or much older has a higher risk of an underlying medical problem.
Tags: health, Frozen Shoulder, Piriformis Syndrome, Fitness
