There are packs of inspirations to make custom flags or standards. From the famed childrens museum to the several parks, there is plenty of space to let them run around and burn off their endless energy. However, it is still unknown whether more bending energy can be generated when coupled inverted flags are arranged properly. Third, there is therapeutic value in early diagnosis of serious conditions, like metastatic cancer, because specific treatment can be initiated. There are also other conditions that are more prevalent than cancer, infections, or fractures that can influence the outcome of patients with low back pain that physical therapists should be aware of when evaluating history and physical examination data. First, in primary care practice settings, there is a low rate of routine examination for red large yard flag holder findings.2 Additionally, symptoms associated with serious conditions can develop between the physician consultation and the initial physical therapy evaluation. Second, some serious conditions, like a fracture, would contra-indicate routine physical therapist interventions, like spinal manipulation.
For example, night pain has long been taught to be red flag finding for serious medical conditions, such as cancer, but research shows that not all patients with musculoskeletal cancers experience night pain.23 In addition, night pain has also been associated with osteoarthritis and mechanical low back pain.9,29 So when should a physical therapist be concerned about a patient complaining of night pain? For example, cancer causing low back pain can be ruled out with 100% sensitivity if the patient is less than 50 years old, does not exhibit unexplained weight loss, does not have a history of cancer, and is responding to conservative intervention.11 If a red flag is present, a spine specialist referral is not immediately indicated; rather, evidence-based screening strategies suggest that completing lumbar spine radiographs and laboratory testing (erythrocyte sedimentation rate) is the next appropriate step, as this can rule out cancer causing low back pain with 100% sensitivity.11 One exception would be in a patient with low back pain with a recent history of cancer, as early referral and advanced diagnostic imaging may be warranted in this case.
Although the prevalence of serious medical pathology, such as cancer, infection, or fracture, causing low back pain is extremely low, we still believe it is the physical therapist’s responsibility to utilize a management model for each patient that allows for the evaluation of red flag findings to make clinical judgments regarding the need for patient referral. Therefore, we suggest that physical therapists utilize a consistent management model for each patient that allows for the evaluation of red flag findings. Furthermore, without some level of screening for red flag symptoms for each patient, how would a clinician begin to even consider whether or not serious pathology is present and if referral is warranted? Given the importance of red flag screening in determining the appropriateness of physical therapy4 and the goal of physical therapists to be the provider of choice for patients with musculoskeletal disorders, we believe that taking a less than adequate red flag screening approach for patients with low back pain will not facilitate optimal patient outcomes.
Through the evaluation of risk factors and red flag screening questions from the history and physical examination, such as patient demographics, social and health habits, medical/surgical history, medications, family history, systems review, and review of systems, physical therapists have the examination data necessary to identify the need for medical referral.1 A lack of response to conservative management is also key in identifying those patients with potentially serious disorders which require medical referral.11 Several published case reports have described how physical therapists have used history and physical examination findings, as well as response to intervention, in patients with signs and symptoms related to the lumbar spine to determine that physician referral was necessary.3,6-8,10,14,15,20,21,25,27 As seen in these case reports, the level of red flag screening for an individual patient may vary based on the medical complexity of the patient, emerging data from the patient history and physical examination, response to intervention, and the directions taken in the clinical decision-making process.1 In some of these cases, red flag findings were present early in the case, which led to the initiation of early referral.6,7,10,15,20,25 In other cases, overt red flag findings were not evident; rather, a cluster of findings that were atypical for nonspecific low back pain emerged through the course of care that prompted referral.3,6,8,14,15,21,27 Using a cluster of history and physical examination findings is also consistent with evidence-based screening strategies for serious conditions like cancer,11 fractures,17 and abdominal pain that is non-musculoskeletal in nature.24 For example, in an individual with low back pain, advanced age, corticosteroid use, or pain caused by a traumatic incident may not be concerning when each finding is considered in isolation.
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