Low back pain and physiotherapy use of red flags: the evidence from Scotland

Measuring guideline adherence in physiotherapy: A scoping review of methodological approaches

RATIONALE

Clinical practice guidelines summarise the existing evidence on specific health conditions and aim to optimise quality of care by providing evidence-based recommendations. Studies have reported a gap between research findings and clinical practice in physiotherapy. Guideline adherence is often used as a measure of agreement between therapeutic care and guideline recommendations. However, there is currently no standardised methodological approach for measuring guideline adherence.

AIMS AND OBJECTIVE

The objective of this scoping review was to summarise the methods and results of studies that assessed guideline adherence in physiotherapy.

METHODS

MEDLINE, EMBASE, PEDro and CENTRAL databases were searched for relevant literature up to December 2022. Published reports of observational studies and controlled clinical trials that provided information on the assessment of guideline adherence in physiotherapists were included. The selection process was performed independently by two reviewers. The methodological quality of the identified reports was not assessed. Results were summarised narratively.

RESULTS

From a total of 2560 potentially relevant records, 53 reports were included in the analysis. Physiotherapists' adherence to guidelines was primarily assessed in the context of musculoskeletal conditions, such as low back pain (n = 25, 47.2%) and osteoarthritis (n = 8, 15.1%). A wide range of measurement approaches were used with the majority of reports using web-based surveys (n = 21, 39.6%), followed by chart reviews (n = 17, 32.1%). Most reports (n = 21, 39.6%) provided information on the level of adherence in terms of frequency dichotomising (self-reported) clinical practice as adherent or non-adherent. Adherence rates varied widely between included reports.

CONCLUSIONS

Although the large number of included reports indicates a high level of interest in the topic of guideline adherence, there is considerable heterogeneity between studies regarding the methodological approaches used to assess guideline adherence in physiotherapists. This reduces the comparability of the study results.

TRIAL REGISTRATION

INPLASY (registration no. 202250081). Registered on 12th May 2022.

Physiotherapists' awareness and use of red flags for the assessment of low back pain in Saudi Arabia

BACKGROUND

Physiotherapists must identify potential red flags that may impede recovery and function in individuals with low back pain (LBP) or put them at risk.

OBJECTIVES

This study aimed to (1) investigate physiotherapists' awareness and use of red flags for individuals with LBP in Saudi Arabia and (2) identify factors associated with their awareness and use of LBP red flags.

METHODS

This cross-sectional study collected data using an anonymous online questionnaire (February-July 2023). It included physiotherapists working in private/public hospitals in Saudi Arabia. The questionnaire asked about the participants' characteristics, their awareness of LBP red flags, and their use of red flags for LBP assessment.

RESULTS

A total of 643 participating physiotherapists (26.2 ± 3.8 years), 63.8% of whom were females, completed the survey. Most participants (94.4%) had adequate awareness of LBP red flags, and more than half (61%) had good utilization of red flags when assessing individuals with LBP. There was a positive correlation between the physiotherapists' awareness and use of LBP red flags.

CONCLUSION

The majority of the participating physiotherapists in Saudi Arabia were aware of LBP red flags, and many reported to have good use of red flags in clinical practice when assessing and managing individuals with LBP.

Cauda equina screening in Physiotherapy: A qualitative study of physiotherapists in a community musculoskeletal service: Are we asking the right questions and are we asking the questions right?

Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition. Thirty physiotherapists working in a community musculoskeletal service were purposively sampled and participated in semi-structured interviews. Data was transcribed and thematically analysed. All participants routinely asked bladder, bowel function and saddle anaesthesia screening questions although only 9 routinely asked about sexual function. Whether questions are asked in the correct way has never been studied. Sufficient depth of questioning, using lay terminology and explicit language was achieved by two-thirds of participants. Less than half of the participants framed the questions before asking them and only 5 participants combined all four dimensions. Whilst most clinicians felt comfortable asking general CES questions, half reported feeling uncomfortable when asking about sexual function. Issues around; gender, culture and language were also highlighted. Four main themes emerged from this study; i) Physiotherapists ask the right questions but frequently omit sexual function questions, ii) mostly, Physiotherapists ask CES questions in a way that patients understand however, there needs to be improvement in framing the context of the questions, iii) Physiotherapists generally feel comfortable with CES screening but there is some awkwardness surrounding discussion of sexual function and iv) Physiotherapists perceive there to be barriers to effective CES screening caused by culture and language.

Primary care physiotherapists ability to make correct management decisions - is there room for improvement? A mixed method study

Background

With increasing interest in direct access to physiotherapy, it is important to consider the physiotherapists (PTs) ability to make correct management decisions, because identification of differential diagnostic pathologies and timely referral for specialist care is vital for patient safety.

The aims of the study were to investigate PTs ability to make correct management decisions in patients presenting with musculoskeletal conditions and to identify explanatory factors associated with this ability. Furthermore, we wanted to explore the PTs views on the identified factors.

Methods

The study was a mixed methods study with an explanatory sequential design consisting of a questionnaire survey and semi-structured interviews. The questionnaire comprised 12 clinical vignettes describing patient scenarios for musculoskeletal conditions, non-critical medical conditions and critical medical conditions. Based on this, the PTs indicated whether the patient should be managed by the PT or were in need of medical referral. Associations between correct decisions and explanatory variables was analyzed by mixed- effects logistic regression. Interviews were performed with nine PTs to explore their reactions to the results. A directed content analysis was performed.

Results

A total of 195 PTs participated in the questionnaire survey and 9 PTs were interviewed. Overall, PTs were more likely to make correct management decisions in the musculoskeletal conditions category, whereas wrong decisions were more often chosen for underlying medical conditions categories. Positive associations between correct management decision in the critical medical category were found for experience: odds ratio (OR) 2.73 (1.33;5.57) and passed quality audit OR 2.90 (1.50;5.58). In the interviews, PTs expressed concerns about the differential diagnostic abilities. They all noted, that experience is immensely important in the clinical reasoning process because the ability to recognise diagnostic patterns evolves over time. Furthermore, the quality audit seems to address and systematize the clinical reasoning process and workflow within the clinics.

Conclusion

The lack of ability to make correct management decision in critical medical categories and the uncertainties expressed by PT’s should raise concern, as direct access to physiotherapy is already well-established and the results indicate that patient safety could be at risk. The findings that experience and passed quality audit was associated with correct management decisions highlights the need for ongoing awareness and education into differential diagnostics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01546-1.

Development of a Logic Model for a Programme to Reduce the Magnetic Resonance Imaging Rate for Non-Specific Lower Back Pain in a Tertiary Care Centre

Tertiary care centres continue to experience over-utilisation of diagnostic imaging services for lower back pain cases that may not be required. Moreover, these services may require additional time and consequently delay access to services that offer conservative management, i.e., physiotherapy, and hence, increase the direct and indirect costs with no added quality of care. A logic model was developed based on qualitative and quantitative studies that explains the plan and process evaluation strategies to reduce imaging for lower back pain in tertiary hospitals. Logic models are useful tools for defining programme components. The delivery of the components is ensured by well-defined process evaluations that identify any needed modifications. The proposed logic model provides a road map for spine clinics in tertiary care hospitals to decrease the number of patient referrals for magnetic resonance imaging and waiting times for consultations and services and promote early access to physiotherapy services.

The professional development and career journey into musculoskeletal first contact physiotherapy: a telephone interview study

(a)Background: Musculoskeletal (MSK) first contact physiotherapy (FCP) is being rolled out in the National Health Service, but limited research exists on career pathways into MSK FCP, or on pre-and-post-registration educational preparation for the knowledge and skills that are required for musculoskeletal first contact physiotherapy. (b) Objectives: From the perspectives of existing MSK FCPs, the study sought to understand the pre-and-post-registration professional developmental journey into musculoskeletal first contact physiotherapy. (c) Methods: Semi-structured interviews over the telephone were conducted with a self-selected and snowball sample of 15 MSK FCPs from across Britain. Framework analysis was used to analyze the interview transcripts. (d) Results: Four overarching themes were identified: (1) Decision to choose a career path as a MSK FCP; (2) Relevancy of pre-registration physiotherapy (PT) education for MSK FCP; (3) Relevancy of post-registration continuing professional development for MSK FCP, and; (4) Improving pre-registration PT education for the foundational knowledge and skills required to work in musculoskeletal first contact physiotherapy. Each overarching theme generated several subthemes. (e)Conclusion: The research contributes to understanding the career pathway into the MSK FCP role and showed what relevant knowledge and skills were acquired for this role at pre-and-post registration levels. Findings will inform guidance for pre-registration PT curriculum development.

Red flags for the early detection of spinal infection in back pain patients

BACKGROUND

Red flags are signs and symptoms that are possible indicators of serious spinal pathology. There is limited evidence or guidance on how red flags should be used in practice. Due to the lack of robust evidence for many red flags their use has been questioned. The aim was to conduct a systematic review specifically reporting on studies that evaluated the diagnostic accuracy of red flags for Spinal Infection in patients with low back pain.

METHODS

Searches were carried out to identify the literature from inception to March 2019. The databases searched were Medline, CINHAL Plus, Web of Science, Embase, Cochrane, Pedro, OpenGrey and Grey Literature Report. Two reviewers screened article texts, one reviewer extracted data and details of each study, a second reviewer independently checked a random sample of the data extracted.

RESULTS

Forty papers met the eligibility criteria. A total of 2224 cases of spinal infection were identified, of which 1385 (62%) were men and 773 (38%) were women mean age of 55 (± 8) years. In total there were 46 items, 23 determinants and 23 clinical features. Spinal pain (72%) and fever (55%) were the most common clinical features, Diabetes (18%) and IV drug use (9%) were the most occurring determinants. MRI was the most used radiological test and Staphylococcus aureus (27%), Mycobacterium tuberculosis (12%) were the most common microorganisms detected in cases.

CONCLUSION

The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

The skills, knowledge and attributes needed as a first-contact physiotherapist in musculoskeletal healthcare

OBJECTIVES

The provision of musculoskeletal assessment and pathway management by physiotherapists in primary care is an expanding innovation within the UK National Health Service. This new model of care is challenging physiotherapists to work in new ways, and so an understanding of these roles is timely and wil contribute to the growing knowledge regarding these practitioners and their impact.

METHODS

This qualitative study aimed to improve the understanding of the clinical practice of first-contact clinicians in musculoskeletal healthcare. The study used a think-aloud method to explore eight clinicians' views via a stage 1 semi-structured interview process. This was followed by a stage 2 focus group involving physiotherapists and a general practitioner trainer. A thematic analysis then followed, which involved the researcher and a research colleague coding the data and subsequently developing themes.

RESULTS

The themes identified were: medical assessment and systems knowledge; speed of thought in an uncertain environment; breadth of knowledge; people and communication skills; common sense/simplify; and responsibility and experience.

CONCLUSIONS

The identified themes should help to underpin the competence, capability and training requirements for these new roles, and should be considered when developing new services utilizing first-contact primary care physiotherapy practice.

Sensitivity and specificity of patient-entered red flags for lower back pain

BACKGROUND CONTEXT

Red flags are questions typically ascertained by providers to screen for serious underlying spinal pathologies. The utility of patient-reported red flags in guiding clinical decision-making for spine care, however, has not been studied.

PURPOSE

The aim of this study was to quantify the sensitivity and specificity of patient-reported red flags in predicting the presence of serious spinal pathologies.

STUDY DESIGN

This was a retrospective nested case-control study.

PATIENT SAMPLE

This study consisted of 120 patients with International Classification of Diseases, Ninth Revision, Clinical Modification codes for spinal pathologies and 380 randomly selected patients, from a population of 4,313 patients seen at a large tertiary care spine clinic between October 9, 2013 and June 30, 2014.

OUTCOME MEASURES

The presence of patient-reported red flags and red flags obtained from medical records was verified for chart review. The spinal pathology (ie, malignancy, fractures, infections, or cauda equina syndrome) was noted for each patient.

METHODS

The sensitivity and specificity of patient-reported red flags for detecting serious spinal pathologies were calculated from data obtained from the 500 patients. Youden's J was used to rank performance. Agreement between patient-reported red flags and those obtained from medical record review was assessed via Cohen's kappa statistic.

RESULTS

"History of cancer" was the best performing patient-reported red flag to identify malignancy (sensitivity=0.75 [95% confidence intervals, CI 0.53-0.90], specificity=0.79 [95% CI 0.75-0.82]). The best performing patient-reported red flag for fractures was the presence of at least one of the following: "Osteoporosis," "Steroid use," and "Trauma" (sensitivity=0.59 [95% CI 0.44-0.72], specificity=0.65 [95% CI 0.60-0.69]). The prevalence of infection and cauda equina diagnoses was insufficient to gauge sensitivity and specificity. Red flags from medical records had better performance than patient-reported red flags. There was poor agreement between patient red flags and those obtained from medical record review.

CONCLUSIONS

Patient-reported red flags had low sensitivity and specificity for identification of serious pathologies. They should not be used in insolation to make treatment decisions, although they may be useful to prompt further probing to determine if additional investigation is warranted.

Integration of musculoskeletal physical therapy care in the patient-centred medical home (IMPaC): protocol for a single-site randomised clinical trial

INTRODUCTION

Annually, >50% of the US population reports musculoskeletal (MSK) pain to a provider, with direct healthcare costs exceeding $185 billion. The number of MSK complaints and the associated costs are projected to rise, increasing demand for and burden on providers. Establishing new care models to decrease inefficiencies may lower costs and optimise care delivery. The purpose of the Integration of Musculoskeletal Physical Therapy Care in the Patient-Centred Medical Home (IMPaC) study is to compare initial evaluation by a physical therapist (PT) integrated into primary care versus initial evaluation by a primary care provider (PCP) for patients with an MSK complaint.

METHODS AND ANALYSIS

This single-site, randomised clinical trial will test the hypothesis that a PT within a primary care facility as the initial evaluating provider for patients with an MSK complaint will lower costs, improve utilisation (ie, reduced opioid prescriptions, imaging, physical therapy, emergency department visits and missed appointments) and increase patient satisfaction within 90 days of the index visit compared with PCP evaluation in the same location. Participants aged ≥18 years will be randomised with equal allocation and stratified by pain site (ie, back, knee, upper extremity and other). In the initial PT evaluation arm, patients will be assessed, treated and then instructed to complete a home exercise programme. The PCP cohort will undergo a usual PCP evaluation, and if a referral to physical therapy is made, patients will be randomised to onsite versus offsite physical therapy. Differences will be calculated and tested across the two arms.

ETHICS AND DISSEMINATION

Approval was received from the Duke University Institutional Review Board (01 May 2017) and the National Institutes of Health, National Centre for Advancing Translational Sciences (01 January 2017). Findings will be communicated via quarterly reports to funding bodies and disseminated through scientific publications.

TRIAL REGISTRATION NUMBER

NCT03110211; Pre-results.

Physical therapy clinical specialization and management of red and yellow flags in patients with low back pain in the United States

Objectives

Physical therapists (PTs) may practice in direct access or act as primary care practitioners, which necessitate patients' screening and management for red, orange and yellow flags. The objective of the project was to assess the American PT's ability to manage red, orange and yellow flags in patients with low back pain (LBP), and to compare this ability among PTs with different qualifications.

Methods

The project was an electronic cross-sectional survey. The investigators contacted 2,861 PTs. Participants made clinical decisions for three vignettes: LBP with red flag for ectopic pregnancy, with orange flag for depression and with yellow flag for fear avoidance behaviour (FAB). The investigators used logistic regression to compare management of warning flags among PTs with distinct qualifications: orthopaedic clinical specialists (PTOs), fellows of the AAOMPT (PTFs), PTOs and PTFs (PTFOs), and PTs without clinical specialization (PTMSs).

Results

A total of 410 PTs completed all sections of the survey (142 PTOs, 110 PTFOs, 74 PTFs and 84 PTMSs). Two hundred and seventeen PTs (53%) managed the patient with LBP and symptoms of ectopic pregnancy correctly, 115 PTs (28.5%) of them managed the patient with LBP and symptoms of depression correctly, and 177 (43.2%) managed the patient with LBP and FAB correctly.

Discussion

In general, PTs with specialization performed significantly better than PTMSs in all three clinical vignettes. PTs ability to manage patients with warning flags was relatively low. Based on our results, further education on patients with LBP and warning flags is needed. The survey had the potential for non-response and self-selection bias.

Level of Evidence

3b.

CareTrack: Toward Appropriate Care for Low Back Pain

STUDY DESIGN

Retrospective medical record review to assess compliance with low back pain (LBP) care indicators.

OBJECTIVE

To establish baseline estimates of the appropriateness of LBP care in the general Australian population provided by a range of healthcare providers in various real-world settings.

SUMMARY OF BACKGROUND DATA

LBP is a costly condition and accounts for the greatest burden of disease worldwide, yet the care provided is often at variance with guidelines. No baseline estimates of performance are currently available in Australia across various aspects of LBP care, practitioners, and settings.

METHODS

A population-based sample of patients with 22 common conditions was recruited by telephone; consents were obtained to review their medical records against indicators ("CareTrack"). Care for LBP was reviewed against 10 indicators used in a previous study and ratified by experts as representing appropriate LBP care in Australia during 2009 and 2010.

RESULTS

Of the 22 CareTrack conditions, LBP had the highest number of eligible healthcare encounters (6588 of 35,573, 19%), 125 to 884 per indicator among 164 LBP patients. Overall compliance with LBP indicators was 72% (range 42%-98%). Allied health practitioners and hospitals were the most compliant (82%-83% respectively), followed by general practitioners (54%). Some aspects of care were poor, such as documenting a thorough neurological examination, screening for serious diseases such as infection and inappropriate use of drugs such as steroids and treatments such as traction.

CONCLUSION

Over a quarter of LBP care was not appropriate despite the availability of guidelines. There is a need for national and, potentially, international agreement on clinical standards, indicators and tools to guide, document and monitor the appropriateness of care for LBP, and for measures to increase their uptake, particularly where deficiencies have been identified.

LEVEL OF EVIDENCE

N /A.

Physical Therapist Clinical Reasoning and Action for Individuals With Undiagnosed Lower Extremity Tumors: A Report of 3 Cases

Study Design Resident's case problem. Background Although rare in the general population, bone and soft tissue tumors may be more frequently encountered in patients seeking physical therapy because of the propensity of their initial symptoms to mimic those of commonly treated musculoskeletal disorders. Screening for tumors requires the physical therapist to be attentive to unexpected findings. The purpose of this paper was to describe the clinical-reasoning and screening processes of physical therapists who facilitated the timely recognition of bone and soft tissue tumors in 3 patients referred through medical channels. Diagnosis The referral diagnoses were lumbar spinal stenosis, calcaneal bursitis, and postexcisional quadriceps weakness. When comprehensively examined, each of the patients had either atypical examination findings or failed to respond to physical therapy treatment. After the physical therapists alerted the appropriate medical providers of the examination findings, diagnoses of high-grade osteosarcoma of the pelvis, chondroma of the knee, and liposarcoma of the thigh followed. Discussion Tumors of the lower extremity can initially mimic common musculoskeletal pathology. Physical therapists must remain alert for red flags, atypical signs and symptoms, and poor responses to treatment, even when patients are referred through medical channels. Particular attention is necessary in the case of unusual symptoms in the lower extremity, where over half of primary malignant tumors occur. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2017;47(5):359-366. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7037.

Urinary incontinence symptoms and impact on quality of life in patients seeking outpatient physical therapy services

OBJECTIVE

The objective of this study was to examine the frequency and types of urinary incontinence (UI) in patients seeking outpatient physical therapy for neuro-musculoskeletal conditions.

DESIGN

Retrospective cross-sectional analysis.

PATIENTS

A convenience sample of patients that positively responded to a UI screening question was included in this study.

METHODS

Data were collected for age, sex, and primary treatment condition classified into one of the following (i.e., urinary dysfunction, fecal dysfunction, pelvic pain, spine, neurological disorders, or extremity disorders); UI type (i.e., mixed, urge, stress, or insensible); UI symptom severity; and quality of life (QoL) impact.

MAIN OUTCOME MEASURES

Frequency of UI type, symptom severity, health-related quality of life (HRQoL) impact, and pad use were compared between treatment groups.

RESULTS

The mean age of the sample (n = 599) was 49.8 years (SD = 18.5) and 94.7% were female. The urinary dysfunction group comprised 44.2% of the total sample, followed by the spine group with 25.7% and pelvic pain with 17.2%. The urinary dysfunction group scored significantly higher on UI symptom severity and impact on QoL compared to the pelvic pain and spine groups, but not compared to the extremity disorders, fecal dysfunction, or neurological disorder group.

CONCLUSION

These preliminary data indicate that UI is a condition afflicting many individuals who present to outpatient physical therapy beyond those seeking care for UI. We recommend using a simple screening measure for UI and its impact on HRQoL as part of a routine initial evaluation in outpatient physical therapy settings.

Development of a Review-of-Systems Screening Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

STUDY DESIGN

Literature review and cross-sectional study.

BACKGROUND

Direct access to physical therapy necessitates greater responsibility to determine appropriateness of care by recognizing the potential for concomitant disease or systemic involvement. Recent research has identified excessive variability in the reporting of red flag symptoms. An initial step to improve the identification of red flag symptoms is the development of a standardized screening tool.

OBJECTIVE

To describe the development of a review-of-systems screening tool appropriate for use by orthopaedic physical therapists.

METHODS

First, a red flag symptom item bank was compiled from a systematic literature review to allow for further psychometric testing and development of a screening tool. Second, physical therapists in 11 outpatient clinics recruited patients presenting with primary complaints of neck, shoulder, low back, or knee pain. Patients completed the red flag symptom item bank and standard questionnaires for comorbidities, negative mood, quality of life, pain, and function. The development of the screening tool involved identifying and combining different 3-item sets that characterized the highest number of patients reporting at least 1 positive symptom response (operationally defined as "red flag symptom responder").

RESULTS

The literature search yielded 103 studies that met the inclusion criteria, and the final item bank consisted of 97 items representing 8 body systems. Four hundred thirty-one patients with primary complaints of neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) disorders contributed to the cross-sectional study. The number of red flag symptom responders was 393 of 431 (91.2%). These patients were older, more likely to be female, had lower income, and were more likely to report neck or back pain (all, P<.05). A 10-item review-of-systems screening tool correctly identified 372 of 393 (94.7%) responders, and a 23-item version identified all 393 (100%) responders. The review-of-systems screening tools and the complete 97-item bank had similar correlations with concurrent clinical measures, except for depressive symptoms.

CONCLUSION

Concise red flag symptom identification appears to be feasible in outpatient orthopaedic physical therapy settings. Future research will determine how this review-of-systems screening tool needs refinement for different patient populations and whether it predicts clinical outcomes or the need for referral to other providers.

Physiotherapists' understanding of red flags for back pain

INTRODUCTION

The expanding role of physiotherapists, with increasing use of services such as self-referral, means that demonstrating an ability to understanding and ask red-flag questions appropriately has never been more important. The present study investigated how physiotherapists define common red flags, how they ask red-flag questions, which red flags they routinely record and the importance that therapists attribute to individual red-flags.

METHODS

In this qualitative study, an online questionnaire survey was circulated to physiotherapists using various UK special interests networks. A total of 98 physiotherapists participated in the study, the majority of whom worked exclusively in the National Health Service.

RESULTS

In general, clinicians defined red flags for back pain in line with guidelines but there was little consensus on how therapists asked patients about red flags. Questioning often included undefined terminology and therapists not asking some red-flag questions. Additionally, the more recently recognized flags (vague, non-specific lower-leg symptoms; band-like trunk pain; decreased mobility) had less importance attached to them and were recorded less frequently.

CONCLUSIONS

If only certain red flags are being assessed, this may put patients at risk of having serious spinal pathologies going undetected. Thus, strategies encouraging therapists to ask all red-flag questions may be needed. The importance of the more recently recognized red flags may need to be emphasized to clinicians. Finally, the inconsistent way in which the red-flag questions were asked highlights a potential practical barrier to translating red-flag knowledge into clinical practice. There is a need to build on this work, using in-depth qualitative interviews, to gain a deeper understanding of how therapists understand and apply the red flags commonly used in back pain assessment.

Are we missing any patients with serious spinal pathology?

Background:

Due to its rarity, serious spinal pathology (SSP) is often missed or misdiagnosed. The consequence of missing the vital signs and symptoms can be devastating for patients, their families and clinicians. At present, there appear to be no available NHS statistics on the prevalence rates of missed or misdiagnosed conditions in the UK.

Aim:

To identify whether a specialist physiotherapy-led back pain service misdiagnosed any patients with SSP between 2004–2008.

Methods:

Subject data was extracted from a back pain service database and International Classification of Disease (ICD) codes were used to identify patients diagnosed with SSP. The two data sources were cross matched to identify patients assessed by the specialist service and later diagnosed with SSP.

Results:

The database search identified 25 patients (0.2% of the total number of patient records) who had been diagnosed with SSP. Four patients had been misdiagnosed. Clinicians should be aware that there appears to be a small cohort of patients in which it is almost impossible to differentiate between simple mechanical lower back pain (LBP) and SSP early in its evolution.

Conclusion:

SSP continues to be rare; however, the risk of misdiagnosis remains. The emergence of new red flags and a growing body of evidence emphasising the importance of combinations of red flags raises the question over whether an up-to-date review of the red flag recommendation list is warranted.

A treatment-based classification approach to examination and intervention of lumbar disorders

CONTEXT

Low back injuries are a common occurrence in athletes and often result in missed competition and practice time. The examination of athletes with low back pain commonly involves diagnostic imaging, which rarely guides the clinician in selecting the appropriate interventions.

DATA ACQUISITION

All years of PubMed, CINAHL, PEDro, and SPORTDiscus were searched in December 2010. Keywords included treatment based classification and lumbar with the following terms: rehabilitation, treatment, athlete, low back pain, sports, and outcomes.

RESULTS

A treatment-based classification approach is preferred for the management of the athlete with low back pain. The treatment-based classification approach involves 3 steps. First is to screen the patient for potentially serious conditions that are not appropriate for conservative management. Second is staging the athlete (based on current disability ratings and ability to perform functional activities). Finally, treatment interventions are selected on the basis of the athlete's signs and symptoms.

CONCLUSION

The treatment-based classification scheme provides the clinician with a reliable algorithm for matching an athlete's symptom presentation to the optimal intervention, potentially reducing participation loss. Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.

Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis

Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. In most health-care systems, the first person to see the patient with a musculoskeletal problem such as back pain is the general practitioner, and access to other professionals such as physiotherapists, chiropractors, or osteopaths is still either largely controlled by a traditional medical model of referral or left to self-referral by the patient. In this paper, we examine the arguments for the general practitioner-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.