What do flags communicate
Anyone who, like me, works in a “field and meadow practice” usually has to deal with harmless complaints in their everyday life. The patient sometimes feels differently, but when measured against what can happen to you, many things are harmless.
It is therefore all the more important to be alert at all times, especially during the first examination, in order to find out those patients who are affected by serious pathologies.
To help with this, Red Flags are defined and also taught in the MT courses according to Kaltenborn-Evjenth. Red flags are not a diagnostic test. They are clinical prediction guides, meaning they are signs with a prognostic value in relation to a pathology
The IFOMT, which we also belong to as DGOMT, supports and distributes on their website a work by a group of scientists from all over the world who have created a manual on how therapists can proceed when red flags are present.
I would like to use this post to present some keypoints from this work.
First of all, a few thoughts on our communication with the patient: If there are suspicions during the examination, clear, open but also sensitive communication is important. Often the patients have already been examined and have received incomplete explanations or have misunderstood some things in the excitement. It is not uncommon for this information to be supplemented with “Dr. GOOGLE ". On the other hand, if we, as a physiotherapist, have any suspicions, further examinations with imaging procedures or a laboratory etc. are necessary. So we should think carefully about which information is important for the patient in this phase of the examination, without unsettling him. That is why we should think about verbal and non-verbal communication.
In the manual, as a first step in the detection of possible serious spinal pathologies, it is recommended to consider the scientific evidence (occurrence of the disease, recognized red flags) and the clinical profile of the patient (age, gender, previous illnesses, progression of symptoms) together. On this basis it is then decided how worrisome the symptoms are. Recommendations for the intervention are then given on a scale.
1. If the symptoms are of little concern, a trial treatment can be carried out after the examination.
2. If few of the symptoms cause concern, the trial treatment should be closely monitored with retest. We should see or speak to the patient again in a short time. Depending on how his symptoms develop, we then act as in 1 or 3.
3. If several symptoms are of concern, no treatment is given. The patient should promptly seek further clarification.
4. In the event of threatening signs, the patient should be referred to the emergency room immediately.
In the manual, various serious pathologies of the spine are evaluated according to the above model. I would like to explain two of them a little further
Cauda Equina Syndrome (CES)
The CES only makes up a small proportion of the patients who come with back pain, according to the literature in the range of 0.08 to 0.2%. The symptoms range from unilateral or bilateral radicular pain, sensory disorders, riding breeches paresthesia and loss of strength via disorders in the bladder, rectum and sexual function. The latter symptoms show the need for sensitive communication and the need to be informed about what the patient should be aware of. The clinical picture shows a low prevalence, few personal predictors but often symptoms that require quick action.
These symptoms can be used to understand the suggested action described above. In the group of LBP patients, CES is rare, age plays a role in the clinical profile, CES due to a disc hernia occurs more in people under 50 and in obese people. In older patients, CES is increasingly associated with spinal canal stenosis, but then does not occur so suddenly. If the LBP patient's symptom limits to unilateral radicular pain, if it falls below 1, we can investigate and conduct a trial treatment. If, for example, there is a conspicuous bladder dysfunction after a lifting dream, the highest point is that the patient must go to the MRI immediately. This urgency is always given in the case of functional and sensitive disorders in the urogenital area that suddenly occur, even if there is no LBP present
Non-traumatic fractures of the spine
Prevalence is very much related to age and gender and lifestyle. The symptoms are to be compared with these personal indicators. Further examinations are often necessary, and absolute urgency is seldom. So we are often at 2 or 3 of the above action.
If a 30-year-old man introduces himself to the practice, healthy and sporty, with pain in the thoracic spine after lifting the washing machine when moving, further examination and treatment can be carried out.
If a woman over 60 has spontaneous back pain after a long bike ride over uneven terrain, she is at a moderate level of concern. Further questions about the state of health, osteoporosis, deficiency, way of life, previous similar complaints, family belsung will follow. According to the literature, 12% of women between 50 and 79 have non-traumatic spinal fractures.
An increase in non-traumatic fractures is observed in younger people. Risk factors are accompanying diseases such as Crohn's disease, diabetes, rheumatism, eating disorders, but also smoking, corticosteroid use, and excessive alcohol
Furthermore, up to 60% of metastases are in the vertebral bodies. That should also be taken into account during the survey.
Symptoms that are to be evaluated as red flags are pounding pain, bilateral discharge in the arms and legs, unsteady gait, bladder and rectal disorder, sudden changes in vertebral incisions.
For me, deepening the topic has shown that red flags are not only the signs that indicate red alert, but that lighter symptoms can also be a start. The comparison of the symptoms with the personal predictors also shows that we in Germany need significantly more time for the anamnesis and standardized questionnaires that the patient needs to fill out before treatment.
Stay healthy, Else
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