I thought that the chart that Dr. Boissannault provided us with is a great tool to utilize in the clinic. It is very simple and it highlights the most important questions to ask patients and listen for when we have red flag concerns. Something I have been working on is asking the right questions depending on which red flag pathology I am concerned with, rather than asking the patient every red flag question I can think of, with no clinical judgement as to why I am asking each question. The chart helps clinicians be succinct yet thorough and cover our bases. I also really like that it provides the medical tests you may want to recommend if you are referring back to the physician – that way it helps avoid unnecessary testing and may help speed up the referral process.

I’ve already incorporated using the chart into my clinical practice, here are two examples from today. I have a patient who has been diagnosed with b/l knee OA and back pain whose pain is 10/10 and can’t find any positions of comfort. She speaks Spanish which makes communication difficult, but she said she had gone to her physician and had lab work done. When I called her physician’s office, I was able to voice my concerns and ask specifically which tests had been completed, and helped initiate a POC for the patient. I was also able, to the best of my ability, ask her red flag questions that I was able to document in the note I sent to the physician.

I have another patient who insidiously but quickly had a large increase in RLE pain > LBP. He has a positive Slump and SLR, but what concerns me is that he has very noticeable, multilevel myotomal weakness L2-5. He also has N/T that goes into his anterior thigh and shin. I was most concerned with cauda equina, due to age, weakness, N/T, aggs and alleviating factors. Using what I learned in the class and the chart to help, I was able to ask him very specific questions about the numbness and tingling, and B/B changes (and I was more specific than just asking if he had B/B changes, as Dr. Boissannault said that urinary retention was the most significant finding). Luckily the patient had already had an MRI, but it has helped keep me on my toes to what to look, listen, and ask for.

There is a joke in my clinic that I think all of my patients are dying of cancer. I think being a new grad and being in a residency where red flags are talked about often raises my concerns maybe more than they should be (better than the opposite I suppose). The class and the article helps me be more confident in my ability to detect red flags and ask the right questions to ensure that my patients are appropriate for PT.

I believe the chart that Dr. Boissannault provided is super helpful in assisting us as clinicians to organize some common red flag pathologies that we may come across in the clinic. My biggest take away from his presentation was that red flag symptoms need to be clustered much like we would with any other orthopaedic examination; of course with certain questions carrying more weight than others. With the direct access growing in the Physical Therapy profession it is imperative for us to be able to recognize when patients symptoms are not mechanical in nature and/or outside our scope of practice requiring referral to other medical professionals. Even if my patient does not fall into category I red flags, I am constantly clearing category II or III red flags before performing other objective orthopaedic tests.

I have a patient earlier today who was s/p MVA ~1 month ago with complaints of neck and low back pain. I happened to be the first medical professional she had seen after the accident and immediately my red flag radar was elevated. Even though her main complaint was low back pain my first line of questioning mainly pertained to her neck and head symptoms and the mechanism of the MVA. Luckily for this patient she was negative for upper cervical ligamentous tests and denied any signs or symptoms of underlying concussion or potential fracture. After those were clear I felt more comfortable addressing her main complaints of low back pain.

Jeff to your point about being over cautious with our patients is not a bad trait. I definitely am along the line of thinking better to be over safe than sorry, even if the incidence of true red flag pathologies presenting to the clinic are relatively small.

I really enjoyed Dr. Boissannault education course. I think he did an amazing job of taking patient examples and showing how efficient screening for red flags in a subjective patient interview can be. Especially if you know what you are looking for. Dr. Boissannault continues to be another example of how I truly believe our profession is both an art and a science. Knowing the red flags questions is not skillful, ascertaining information from the patient that captures the overall risk of this patient having a rare pathology with skillful questioning is. Asking blanket questions of red flags is not all that helpful? Is it relevant or not, will the answer change your clinical decision to evaluate, treat, or refer? This course did a good job of navigating those questions for me. For example, if a patient that meets a lot of the risk factors for cancer, but they just followed up with their oncologist and had imaging 2 months ago you should feel better that serious pathology might not be the cause of their pain (obviously being confirmed by other subjective and objective measures). I took away that being skeptical but being thorough with appropriate /relevant questions (specific for what you are trying to rule out) are where we as health care providers have the unique opportunity and time advantage to screen for red flags. After reading this article is confirms just that, with primary care providers only screening 5% of the time. I think we should consider ourselves the first line of defensive for screening for these pathologies until proven otherwise, or at minimum understand how well this patient has been evaluated by the system.

I also really enjoyed his emphasis on educating the patient on how they should relay concerning findings to their health care providers. He gave examples of how he would tell the patients how he wanted them to explain their symptoms to their health care provider, not something I think ever really considered. He wanted them to avoid the broad pain complaint “shoulder pain” or “toe pain” but get them to relay the signs and symptoms that may indicate pathology not musculoskeletal in nature he was wanting to rule out. Seems intuitive however don’t know that I have been that skillful when I have asked patients to follow up with their healthcare provider, I just assumed these physicians would understand. Wrong assumption. I can hear his voice “Now Joe, I want you to call your doctor, don’t tell them you have back pain, but you have flank pain that has progressively gotten worse over the past 2 weeks and is constant and unlike any back pain you’ve had before and that you are have noticed an increase in urination frequency” The man was great, I could go on and on!

Dr. Boissannault’s course did a great job of helping me think about the purpose of each red flag question. It’s my job to ask pointed questions, aimed at gathering information much like I would in my objective examination to guide my “treatment” (which may be a referral). “Recent infection” is a good example; I hadn’t thought of what constitutes a “recent” infection. It made me start to think more about the questions and what kind of information I’m attempting to gather.. what does the information tell me? These broad, often blanket-style questions are actually more specific than I’d originally interpreted and help shift the needle of a hypothesis much like a component of an objective exam might.

A good example is my 55yo male patient who’d finished his final round of chemo 6 weeks ago. He was reporting to my office with “LBP and Sciatica.” We spent 20 minutes laying out what stage cancer, location, surgical procedures, visit history/ schedule with the oncologist and PCP, and other all-of-a-sudden meaningful information to include in my initial examination. Nerve pain can be vague and broadly distributed, but it was important to me to demonstrate that his low back pain was mechanical and that his “sciatic” pain was reproducible with nerve sensitivity tests. 1 week in, I noticed his ankle was asymmetrically swollen affected side > unaffected. He hadn’t realized his leg had swollen until that moment and actually recalled thinking he’d gained weight because of the cancer when he’d felt like his pant leg didn’t fit as well about a month ago. Here, I was able to educate the patient on what to describe to his oncologist (and get an appointment sooner than his scheduled visit in 3 months).

Dr. Boissannault’s course and the attached article help me interpret more fluently the information at my doorstep; they help me speak to patients as a Doctor of Physical Therapy rather than Kinesiologist; they help me be a better case manager and provider for my patients.