Physical Therapists' Adherence to Red Flags Documentation for Low Back Pain | Study notes Physiotherapy

42 / The Journal of Manual & Manipulative Therapy, 2007

Documentation of Red Flags by Physical Therapists for Patients

with Low Back Pain

Pamela J. Leerar, PT, DHSc, OCS, COMPT

William Boissonnault, PT, DHSc, FAAOMPT

Elizabeth Domholdt, PT, EdD, FAPTA

Toni Roddey, PT, PhD, OCS, FAAOMPT

Abstract: The comprehensiveness of physical therapists’ adherence to the guidelines for red fl ag docu-

mentation for patients with low back pain has not previously been described. Therefore, the purpose of

this study was to describe that comprehensiveness. Red fl ags are warning signs that suggest that physi-

cian referral may be warranted. Clinic charts for 160 patients with low back pain seen at 6 outpatient

physical therapy clinics were retrospectively reviewed, noting the presence or absence of 11 red fl ag

items. Seven of the 11 red fl ag items were documented over 98% of the time. Most charts (96.3%) had

at least 64% of the red fl ag items documented. Documentation of red fl ags was comprehensive in some

areas but lacking in others. Red fl ags that were regularly documented included age over 50, bladder

dysfunction, history of cancer, immune suppression, night pain, history of trauma, saddle anesthesia, and

lower extremity neurological defi cit. The red fl ags not regularly documented included weight loss, recent

infection, and fever/chills. Factors infl uencing item documentation comprehensiveness are discussed,

and suggestions are provided to enhance the completeness of recording patient examination data. The

study results provide a red fl ag documentation benchmark for clinicians working with patients with low

back pain and they lay the groundwork for future research.

Key Words: Medical Screening, Clinical Guidelines, Differential Diagnosis, Physical Therapy, Low Back

Pain

The Guide to Physical Therapist Practice1 states that

“ . . . the initial patient examination is a comprehen-

sive screening and specifi c testing process leading to

diagnostic classifi cation or, as appropriate, to a referral to

another practitioner . . . ” Medical screening, associated with

the examination and evaluation processes leading to patient

referral by physical therapists to practitioners such as physi-

cians (e.g., medical and osteopathic doctors), is of particular

importance when treating patients with complaints of low

back pain (LBP) where serious medical disease may present

as a musculoskeletal complaint1-4. Several medical condi-

tions, such as cancer, infections, and fractures, have been

shown to cause LBP thereby mimicking a mechanical LBP

condition3-9. Additionally, mechanical LBP may co-exist with

a serious medical condition that warrants physician involve-

ment10-12. Considering that patients with LBP constitute the

largest outpatient population serviced by physical thera-

pists11,13-15, vigilance for red fl ag examination fi ndings (i.e.,

patient manifestations that suggest that physician referral

may be warranted) associated with these serious disorders by

therapists is imperative. The medical screening goal for pa-

tients with LBP is to identify those with high probabilities of

having serious medical conditions causing their back pain,

or those patients who have an unrelated health problem co-

existing with LBP1,2,16,17.

Experts have provided varied opinions as to what consti-

tutes a red fl ag fi nding for patients with LBP. For example,

several sources have indicated that duration of symptoms

over 1 month is a red fl ag 6,9,18,19 while others have reported

duration of over 1.5 to 3 months as a red fl ag20-24. Some

Address all correspondence and request for reprints to:

Pamela Leerar

29734 48th Avenue South

Auburn, WA 98001

E-mail: paml@ossrpt.com

The Journal of Manual & Manipulative Therapy

Vol. 15 No. 1 (2007), 42–49

Physical Therapists' Adherence to Red Flags Documentation for Low Back Pain, Study notes of Physiotherapy

Related documents

Partial preview of the text

Download Physical Therapists' Adherence to Red Flags Documentation for Low Back Pain and more Study notes Physiotherapy in PDF only on Docsity!

42 / The Journal of Manual & Manipulative Therapy, 2007

T

he Guide to Physical Therapist Practice^1 states that

“... the initial patient examination is a comprehen-

sive screening and specific testing process leading to

diagnostic classification or, as appropriate, to a referral to

another practitioner... ” Medical screening, associated with

the examination and evaluation processes leading to patient

referral by physical therapists to practitioners such as physi-

cians (e.g., medical and osteopathic doctors), is of particular

importance when treating patients with complaints of low

back pain (LBP) where serious medical disease may present

as a musculoskeletal complaint1-4. Several medical condi-

tions, such as cancer, infections, and fractures, have been

shown to cause LBP thereby mimicking a mechanical LBP

condition 3-9. Additionally, mechanical LBP may co-exist with

a serious medical condition that warrants physician involve-

ment 10-12. Considering that patients with LBP constitute the

largest outpatient population serviced by physical thera-

pists 11,13-15, vigilance for red flag examination findings (i.e.,

patient manifestations that suggest that physician referral

may be warranted) associated with these serious disorders by

therapists is imperative. The medical screening goal for pa-

tients with LBP is to identify those with high probabilities of

having serious medical conditions causing their back pain,

or those patients who have an unrelated health problem co-

existing with LBP1,2,16,17.

Experts have provided varied opinions as to what consti-

tutes a red flag fi nding for patients with LBP. For example,

several sources have indicated that duration of symptoms

over 1 month is a red flag 6,9,18,19^ while others have reported

duration of over 1.5 to 3 months as a red flag20-24. Some

Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain / 43

sources have included a history of trauma as a red flag

item22,25, while other sources have omitted this item from the

red fl ag list18,19^. In addition, very few symptoms by them-

selves are indicative of a serious medical condition. Night

pain has long been listed as a red flag finding for patients

with LBP 6,24-26 , yet studies have reported an association of

night pain with osteoarthritis especially when the lumbar,

hip, and knee regions are involved20,23,27,28. Probably more

clinically relevant is an examination that reveals a pattern or

cluster of red fl ag findings that raises the clinician’s suspi-

cion of serious medical conditions 5,10,16,24,26^. For example,

Deyo and Diehl^18 reported that patient age over 50 years, his-

tory of cancer, unexplained weight loss, duration of pain

greater than one month, or failure to improve with conser-

vative therapy was associated with increased probability of

cancer being present in patients with LBP. If present, these

fi ndings should lead to a further diagnostic work-up9,18. To

promote consensus, Bigos et al 25 delineated a list of red fl ag

fi ndings associated with potential fracture, tumor, infection,

and/or cauda equina syndrome for patients with acute LBP

that was presented in the U.S. Department of Health and Hu-

man Services Agency for Health Care Policy and Research

(AHCPR) Clinical Practice Acute Low Back Pain Guideline

(Table 1). Their recommendation was that all practitioners

involved in the management of this population should rou-

tinely investigate these red flags.

To what degree does this level of red flag screening for

patients with LBP occur in clinical practice? In physician

practices, the results are mixed. For example, in a study by

DiIorio^19 that investigated documentation of specific red

fl ags, physicians routinely asked about 2 (saddle anesthesia

and history of trauma) of 7 red flag items over 50% of the

time. They did not routinely inquire about 1) pain at rest, 2)

pseudo-claudication, 3) age over 50 years, 4) recent infec-

tion, and 5) pain duration over one month. Similarly, Ramsey

et al^29 documented deficiencies in the history-taking skills of

primary care physicians. Using audiotapes of the primary

care physicians’ evaluations of standardized patients with a

wide variety of complaints, the frequency of asking questions

(symptom description, medications, and review of systems)

designed to detect underlying medical conditions related to

the primary patient complaint was monitored. The results

revealed that in total 59% of these essential history items