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Despite being one of the most important things you’ll ever learn, screening for red flags is a very challenging and sometimes confusing task. It is something that all physiotherapists must be able to do, requiring you to not only remember what questions you need to ask and what pathology they relate to, but also to use your clinical judgement to have an appropriate threshold for concern. As a student or new graduate physiotherapist you will never have to make these decisions alone, but clinical judgement is something that will only develop with experience. So how can you as an inexperienced student physiotherapist learn to use red flags safely and effectively?
Lets start with what a red flag is. In healthcare, red flags are signs or symptoms that could suggest that an individual has a serious pathology, and therefore may require a referral onwards to another medical professional, or in the most serious cases A & E [1, 2]. As a physiotherapist, this basically means knowing when we can’t manage a condition ourselves or would need another professional to be involved a patients care. Examples might include things like fractures, infections or even general health problems such as kidney stones or endometriosis – all of the above could present as spinal pain and therefore we need to be able to distinguish between the usual ‘musculoskeletal’ bone, joint and muscle pain from the more medical conditions. So does this mean you have to be a doctor as well as a physiotherapist?
There is a reason that it takes around 10 years to become a GP and 3 years to become a physiotherapist. Over time, your knowledge and awareness of non-musculoskeletal conditions will develop, but initially you will find yourself learning key screening questions to ask patients, and escalating any patients with these symptoms to your supervisor. So whilst you may not know much about the condition you are screening for, you should be able to start identifying symptoms that are concerning. Sometimes you will just get a ‘gut feeling’ when something isn’t right. It may be something hard to quantify, but you will see some patients who’s symptoms just ‘don’t seem right’, or fit with what you would expect. There is evidence that a clinicians gut feeling that something is wrong should not be ignored, and may be a valid means of identifying more concerning conditions [3, 4]. It’s important to note that this might not be something that happens at your first session with the patient, but may be something that happens over time. You may notice that your patient isn't getting better as quickly as you thought they would, or starts to report some new symptoms that don’t really fit with what you expect. So is it just a matter of memorising a list of screening questions to ask patients?
There are 163 signs of red flag pathology in the spine alone [1], and even if you did memorise them all most patients would not be overly thrilled with sitting through the full interrogation. So if there are 163, how many should we ask? And how many questions do we need the patient to say ‘yes’ to before we refer them to their GP? And then how many more positives do we need to send them to A & E? This is where most people start to get confused. Shall we look at an example?
Cervical arterial dysfunction (CAD), refers to numerous vascular problems which can affect the blood supply to the brain and cause pain in the neck, including conditions such as stroke, thrombosis, haemorrhage, giant cell arteritis, aneurysm or dissection [5, 6]. This means that a patient may come to see a physiotherapist for neck pain, but the problem may actually be with their cardiovascular system. If so, we don’t necessarily need to be able to know the pathophysiology, epidemiology and signs and symptoms of each pathology in detail, rather we just need to be able to be confident that the cardiovascular system is not involved. Whilst we can rarely rule anything out with 100% certainty, we can be more or less confident. Commonly students are taught the ‘5 D’s and 3 N’s’ of cervical ischaemia – dizziness, diplopia, dysphagia, dysarthria, drop attacks, nausea, nystagmus and numbness [5]. The first challenge is to translate these symptoms for your patients – for example asking patients if they have double vision rather than ‘diplopia’. But if the patient has none of these symptoms you can probably be quite confident the neck is not involved in most cases. But what if they answer yes to half and no to half?
Let’s suppose that an 18 year old male (patient 1) comes to see you with a 6 week history of neck pain. They are generally healthy and active, with no other medical conditions, and noticed their pain gradually develop since starting university, and is generally worse when they sit studying on their bed and better when they are up and moving. Contrast this with a 50 year old (patient 2) who has started to develop neck pain over the last 2 weeks. They have high blood pressure which is poorly controlled, have a high BMI and have a very sedentary life. Without any further information, which patient are you more concerned about?
The truth is that red flag symptoms are just not very good. Whilst they are the best tool that we have, there is not a lot of evidence to support their use, and in isolation they are quite poor [1]. Red flag questions may be more closely related to prognosis than diagnosis, and the absence of any red flags does not actually allow us to confidently rule out serious pathology in patients as many serious conditions have a ‘preclinical’ phase, where the pathology is present but they have no outward symptoms [7]. So does this mean that we shouldn’t even bother screening patients?
It's easy to be frustrated at this point. As I said above, despite their limitations they are still the best tool we’ve got. Suppose patient 1 and 2 above both have dizziness – which one are you most worried about? Dizziness in isolation on the background of an otherwise healthy individual with postural neck pain would probably not be concerning enough to warrant an onward referral, however patient 2’s history alone may be enough to justify an onward referral to their GP even without any of the 5 D’s or 3 N’s, depending on the history of their symptoms and current presentation. If they had any 5 D or 3 N symptoms as well, you may be more concerned and want more urgent investigation depending on the severity of their symptoms, and may even refer them to A & E. What this shows is that our threshold for onward referral is influence by a variety of factors rather than just being able to memorise the screening questions. So how do you manage this as a student with very limited experience or background knowledge?
The most important thing to remember at the early stages is that you are not expected to do this alone. You will always report your assessment findings to your educator as a student, and they will help you to make sense of the information that you have gathered. Ultimately it is your job to ask the screening questions and then feed the information back to your educator. Most patients that you see will not have a serious pathology [1], but if the patient does have any ‘red flag symptoms’ or things just don’t ‘feel right’ (remember your gut feeling above), discuss this with your educator and see how they manage this. If a patient does answer ‘yes’ to any questions, your educator will likely ask some follow up questions. For example, if a patient says that they have dizziness, your educator will want to know how long they have had dizziness for, if it has been investigated, does it only come on with neck pain, and if there are any other triggers for it, amongst other questions. The more information you can gather, the easier it is for you and your educator to analyse that information. The patient may say that they’ve had dizziness for several years before their neck pain, and it only happens if they stand up too quickly and goes away after a few seconds, in which case it is very unlikely that their dizziness is related to CAD if this is the only symptom.
Ultimately, your first job is to ask the questions. Conduct a thorough subjective assessment including the history, presenting condition, past medical history and medication, and find out if your patients have any of the signs, symptoms or risk factors relevant to serious pathology for the region you are assessing. Before feeding this back to your educator, try to think about if the signs and symptoms all make sense, or if there is anything unusual about their presentation – what is the most likely diagnosis based on all the evidence? Then discuss this with your educator. The only way you will start to get good at this is with practice, and remember if you are ever unsure always seek advice. The cost of missing something can be catastrophic for the patient, and also mean serious repercussions for you as a therapist, and it is normal for clinicians at all levels to seek advice from more senior clinicians – from new graduate physiotherapists right up to band 8 advanced practitioners. There is a lot of uncertainty with red flags at any level, and so if in doubt, get it checked out. Despite this, over time you will become more and more comfortable with separating out the concerning from the less concerning.
The information in this blog does not replace your training. If you have any concerns about a patient, always discuss these with your supervisor or educator immediately.
References
2 – Evaluation of red flags minimizes missing serious diseases in primary care - PMC
3 – GPs’ use of gut feelings when assessing cancer risk: a qualitative study in UK primary care
4 – Clinicians’ gut feeling about serious infections in children: observational study | The BMJ
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