Finucane et al 2020 Jospt International Framework For Spinal Red Flags PDF

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2,3 LAURA M. FINUCANE, MSc, BSc, FCSP, FMACP1 • ARON DOWNIE, MPhil, BSc, MChiro 4 CHRISTOPHER MERCER, MSc, Grad Dip Phys, PG Cert (Clin Ed), FCSP, FMACP• SUSAN M. GREENHALGH, PhD, MA, Phys FCSP 5,6 WILLIAM G. BOISSONNAULT, PT, DPT, DHSc 7 • ANNELIES L. POOL-GOUDZWAARD, PT, PhD, MT, MSc Psych 8 JASON M. BENECIUK, PT, DPT, PhD, MPH 9,10 • RACHEL L. LEECH, MSc, BSc6 • JAMES SELFE, DSc, PhD, MA, Grad Dip Phys, FCSP6,11

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International Framework for Red Flags for Potential Serious Spinal Pathologies

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dentifying serious pathology as the cause of a person’s musculoskeletal presentation is complex. Red flags have historically been used to help clinicians identify serious spinal pathology, and the majority of guidelines recommend the use of red flags. However, guidelines are not consistent about which red flags should be considered when examining people seeking care for musculoskeletal disorders. This has led to confusion and inconsistency in the management of people

skeletal services can play an impo role in early identiication of se thology, ensuring that people achiev best possible outcome. The prevalenc serious pathology will vary dependi where in the clinical pathway the cian has contact with the person. Sp surgeons likely see more cases of ser can masquerade as musculoskeletal spi-pathology than general practitioner when there is suspicion of serious pathology, and, in some cases, to unnecessary nal conditions. The framework has beenand physical therapists probably informed by available evidence and augand worrying medical tests or false reasnumber in between, depending on wh surance that there is no serious pathology.mented by a formal consensus process they are on their clinical pathway. that aincluded academics and clinicians We aim to provide clinicians with pists working at an advanced-prac more standardized and consistent ap- involved in the management of musculolevel are likely to see more serio conditions. proach to identifying people with skeletal pothology, as the populations they se This framework aims to support aare likely to have more complex pre tential serious spinal pathology. This 86 framework has been developed by re- variety of health professionals, irrespectations. Clinicians must consid searchers and clinicians to providetive a of experience, who provide care for context within which red lags exi with musculoskeletal spinal conpragmatic approach for clinicianspeople to clinically reason the relevance of ditions. Clinicians working in musculoscreen for serious spinal pathology that formation gathered to determine wh er any action is required.

U SYNOPSIS: The International Federation of Ortho-historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of paedic Manipulative Physical Therapists Person-Centered Care high-quality evidence for the diagnostic accuracy of (IFOMPT) led the development of a framework to help clinicians assess and manage people who most red lags. This framework is intended to provide Working with people with possib a clinical-reasoning pathway to clarify the role of red ous pathology can be challenging, may have serious spinal pathology. While rare, serious spinal pathology can have devastating and lags.J Orthop Sports Phys Ther 2020;50(7):350a collaborative approach is essent 372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971 life-changing or life-limiting consequences, and possible diagnosis of serious pa must be identiied early and managed appropri- U KEY WORDS: cauda equina syndrome, clinical can be extremely worrying for peopl ately. Red lags (signs and symptoms that might reasoning, malignancy, spinal fracture, spinal regard to their families and career raise suspicion of serious spinal pathology) haveinfection

ple must be involved in decision 1

2 3 Sussex MSK Partnership, Brighton, United Kingdom. Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, North Ryde, Institute Australi fo 5 Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney,4Western Australia. Sussex Hospitals NHS Foundation Trust, Chichester, United Kingdom. Bolton 6Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom. 7 American Physical Thera NHS Foundation Trust, Bolton, United Kingdom. Association, Alexandria,8Department VA. of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the 9Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, 10 11Physical Gainesville, Brooks Rehabilitation, FL. Jacksonville, FL. Therap Department, Satakunta University of Applied Sciences, Pori, Finland. The following organizations provided inancial support for the development and dissemi the Canadian Academy of Manipulative Physiotherapy, Chartered Society of Physiotherapy, International Maitland Teachers Association, Musculoskeletal Assoc Physiotherapists, Private Physiotherapy Educational Foundation, and Swiss Association for Orthopaedic Manipulative Physiotherapy. The authors certify that th with or inancial involvement in any organization or entity with a direct inancial interest in the subject matter or materials discussed in the article. Address ® Finucane, Sussex MSK Partnership, 177 Preston Road, BN1 6AG Brighton, UK. E-mail: [email protected] U Copyright ©2020 Journal of Orthopaedic & Sports Physical Therap

350 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy

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about their care, even when faced with atentially life-changing conditionsand has been coordinated by researche and, serious diagnosis. Shared decision makat Manchester Metropolitan Unive in some cases, being sent for further ining is essential to ensure that individuvestigations. When asking about subjectsDue to a paucity of primary evidenc als are supported to make decisions thatsuch as previous history of cancer, it is framework has been developed by expe are right for them. Using a collaborative clinicians’ interpretation of the particularly important to ofer appropriprocess, the clinician should highlight ate emotional support and, when needed, quality evidence available. the treatment options, evidence, risks,help people ind other services that can Key Term: Red Flags and beneits and, together with the per- ofer further support. Red lags are signs and symptoms th son, seek to understand how these it raise suspicion of serious spina with that person’s circumstances, goals,How an International Framework 56 Can Help Clinicians ogy. Until now, there has been little values, and beliefs. ance on their use and they have been l This is an internationally agreed-on Experts by Experience: How framework to aid early assessment and to individual interpretation. Fo to Use This Framework pathology, 163 signs and symptoms h initial management of people who prebeen reported as red lags, 32 inclu sent with potential serious spinal patholClear and open communication with ing 119 symptoms from the indivi ogy. These conditions, while considered people with potential serious pathology history and 44 signs from the phy rare, can lead to devastating and lifeis vital. People presenting with spinal examination. for pain may have no concept that their changing/life-limiting consequences people. The neurological function and The high number of red lags p bladder or bowel function might be afsents a challenge in terms of their quality of life of people with metastatic fected, or that the spinal pain could be spinal cord compression (MSCC) can beday practical utility. Few red lags caused by serious pathologies such as inused in isolation, are informati preserved with early diagnosis, by facilifection or malignancy. Providing the reatating rapid access to appropriate treat-lags used in combination have p son for the questions in the framework is 35 but further validation studi an important aspect of the consultation,ment, reduction in nerve damage, and ise, 32 Sub- required. There is a lack of highas some of these questions may seem ir-maintenance of spinal stability. evidence for the diagnostic accura relevant to a person who presents with stantial litigation costs can be incurred red lag tests, 20,34 and the evidence su by health care providers if serious spiback pain. ports only a limited number of red Efective communication about rednal pathology is not identiied early and managed appropriately. Litigation to re-raise suspicion of serious pat lags is vital. People can become worried before an appointment, especially if they lating to cauda equina syndrome (CES)There is no consensus on which red l are most useful to identify seriou have seen something worrying on televialone accounted for £25 million ($40 pathology or how they should be used sion or the internet, heard a story from amillion) in claims against the National 82 the clinical setting. friend or relative, or experienced medical Health Service in the United Kingdom 54 Despite the problems, red lag te misdiagnosis. from 2010 to 2015. remain the best tools that health Provide reassurance about why you This international framework has are assessing for red lags, especially been developed on behalf of the Interna- practitioners have to raise suspic serious spinal pathology when us when the person is likely at low risktional of Federation of Orthopaedic Manipcombination with a thorough pa having severe pathology. Consider theulative Physical Therapists (IFOMPT) wording of your questions, your body language, tone of voice, and mannerisms Key Clinical Messages when asking the questions. • There is a lack of evidence to support the informativeness of the majo People must feel at ease when anred lags commonly used in clinical practice. swering questions and not judged (eg, • Few red lags, when used in isolation, are informative. Combinatio intravenous drug use, poor social and lags demonstrate promise, but this work requires further validation. environmental factors). Ensure people have suicient time to consider and com- • Red lags remain the best tools at the clinician’s disposal to raise sus serious spinal pathology, when used within the context of a thorough su municate their answers about something tive patient history and physical examination. that they may never have considered before (eg, their toilet habits and how those • Clinicians should consider both the evidence to support red lags and th vidual proile of the person’s determinants of health (eg, age, sex) to deci may have changed). level of concern (index of suspicion) for presence of serious spinal p Provide support regarding the emotional impact of being assessed for pojournal of orthopaedic & sports physical therapy | volume 50 | number 7 | july 2020 |

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history and an appropriate physical exTABLE 1): CES, spinal fracture, malignanrious spinal pathologies and outl amination. Serious spinal pathology cy,is and spinal infection. factors, symptoms, signs, and initi associated with increasing age, althoughThe following sections summarize the vestigations. Each section conclude 33 serious pathology can afect all ages. red lags for each of the 4 prioritized sea series of clinical-reasoning sc Populations around the world are aging, which presents challenges, as people with increased medical complexity Evidence and morbidities present more often to musculoskeletal services. Consequently, Red flags Red flags therapists may see more patients with (supported by (supported by high- versus serious pathology. Prevalence consensus only) quality evidence) Red flags of pathology

in combination

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Goal of the International Framework Given the paucity of high-quality evidence to guide practice, we built this framework on multiple perspectives, including synthesizing the current research data, expert consensus and opinion, and steering-group consensus, to relect an evidence-based practice approach.77 The framework is intended to provide clinicians with a clear clinicalreasoning pathway to clarify the role of red lags in identifying serious spinal pathology.

Decision Tool for Early Identiication of Serious Spinal Pathology

Level of concern Symptom progression Urgency (consequence of delay)

Response to care

Comorbidities

Clinical profile Consider within the context of the patient profile (eg, sex, age, race)

FIGURE 1. Decision tool for early identiication of potential serious spinal pathology, step 1. Consid to support red lags, together with the clinical and patient proiles, when determining your level of con serious pathology.

The basis of our framework is a decision tool to help clinicians identify serious spinal pathology. The tool has 3 steps: 1. Determine your level of concern. Consider the evidence to support red lags and the individual proile of the perLOW son’s health determinants (eg, age, sex) to decide your level of concern (your inNo dex of suspicion) about the presence of concerning serious pathology (FIGURE 1). features 2. Decide on your clinical action, based Decision: on your level of concern determined Begin a trial of in step 1 (FIGURE 2). therapy 3. Consider the pathway for emergency/ Revise management if urgent referral. Know your local referclinical features change unexpectedly ral pathways and pathways to access specialist care if indicated (FIGURE 3).

Prioritize Serious Spinal Pathologies

Repeat visit?

Level of Concern HIGH Few concerning features Decision: Begin a trial of therapy with watchful waiting Begin a trial of therapy Revise management if clinical features change unexpectedly

Some concerning features

Some concerning features

Decision: URGENT referral

Decision: EMERGENCY referral

DO NOT begin a trial of therapy

DO NOT begin a trial of therapy

Further investigation or referral is warranted

Emergency referral is warranted

In 2016, the member organizations of IFMonitor progress closely (vigilance) OMPT, a subgroup of the World Confederation for Physical Therapy, identiied 4 FIGURE 2. Decision tool for early identiication of potential serious spinal pathology, step 2. Decid priority areas for discussion and research action based on your level of concern. on red lags (incidence data presented in 352 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy

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3 (For all the key deinitions used in this opment of clinical guidelines. Phase 2 Jisc Online Surveys (Jisc document, see APPENDIX A, available at Phase 1 We reviewed systematic reviewstol, UK) was used to administer t www.jospt.org). and other key papers summarizing availseparate questionnaires developed able evidence related to red flags in 1 phase or 1. The international expert g Method: Haute Autorité de more of the 4 key spinal pathologies (see (100 experts from 19 countries) rated APPENDIX B, available at www.jospt.org, flag statements based on the evide Santé Consensus Method This framework combines an evidence for an evidence summary table). Thispresented (phase 1) and their own exp synthesis and international expert conled to the formulation of 4 international rience. Each section reports separatel sensus. We followed the Haute Autoritéexpert consensus questionnaires, 1 forhow many experts were involved in de Santé recommendations for the devel- each key pathology. consensus process for that section. A

Person referred with musculoskeletal condition No concerning features

Some concerning features

Few concerning features Consider watchful wait Initiate treatment and safety neta patient

Treat as planned and monitor symptoms

Progress as expected

Consider further investigation/referral The timing of this will depend on the specific pathology, but may be urgent Not improving or new concerning features or same day/emergency. Refer to condition-specific sections for details. If investigations are negative, consider further referral or restart treatment

Progress as expected Treatment proceeds as expected and patient is discharged from care

a Safetyif FIGURE 3. Decision tool for early identiication of potential serious spinal pathology, step 3. Consider the pathway for emergency/urgent referral netting indica is management strategy used for people who may present with possible serious pathology. These strategies should include advice on which signs and symptoms to 37 which action to take if symptoms deteriorate, and the time frame within which action should be taken.

TABLE 1

Prevalence Estimates for Key Pathologies When Presenting With Back Pain a Primary Care

Secondary Care

CES

31 Estimated incidence (UK): 0.002% 17 Back pain: 0.04%

Fracture: OCF

LBP: 0.7%, 35 3.0%,73 4.0%,414.1%, 80 4.5% 16

Fracture: traumatic

Tertiary Care: ED

Tertiary Care: Spine Center LBP: 0.4%66

Left X-ray: 2.6%69

Back pain: 6.5%29 Left X-ray: 7.3%,65 11.0%68

LBP: 5.6%66

LBP:...