Red Flag Commentary

[Aaron Hartstein]

Here is a new commentary on Red Flags by the folks at Duke. What are your thoughts and how does this influence your practice?

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[Justin Pretlow]

Thanks for the article, Aaron –
This is interesting because it touches on the self doubt one may have when trying to decide if a “red flag” is worthy of a referral. Their explanation of how red flags were initially used as a screening tool or at least proposed as screening tools but morphed into part of clinical diagnosis/management is persuasive in that I found myself agreeing with the rest of their commentary. If many of these screening tools are very poor at ruling out a serious pathology, then it makes sense to weigh them less heavily in clinical decision making. In other words, I’m likely to be more cautious in interpreting red flags after reading this article. Or a better way to state this may be – Red flags should be considered as a small piece of the overall clinical picture, and thus guide decision-making, but not dictate decision making(ie. this patient needs an x-ray right away because of this one red flag).

[Katie Long]

Thanks for this Aaron. I don’t know how I feel about this article. They bring up a lot of good points in this article, and it makes sense, but I feel like I have spent so much time learning red flags and screening and feel conflicted. The article that comes to mind is one published in 2007, which Chad Cook was also on (attached). This most recent article has definitely given me a lot to think about but I did like that they proposed recommendations along with their points regarding issues with utility of red flags. I liked the quote of “Watchful waiting may also improve patient–provider relationship, improve clinician clinical reasoning/decision-making, improve patient satisfaction and anxiety” and addressing the potential benefit to excessive healthcare costs. After all, these are many of our goals as therapists.

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[Justin Pretlow]

Hi Katie,
I see what you mean about feeling conflicted after giving the 2007 article a quick scan. I interpret the recent commentary by Chad Cook et al as an attempt to swing the pendulum back the other way. Perhaps their thought process has evolved over the last 10 years and they’ve realized we are putting too much weight on red flags, rather than using that information more discerningly to guide decision-making.
I like the watchful waiting quote as well. It makes sense to me that a watchful waiting approach can in some ways improve clinical reasoning skills and patient/therapist communication naturally by the monitoring and interpreting of changes in symptoms.

[Tyler France]

I agree with Justin’s point that red flag screening should be used as a piece of the larger picture and not the end-all be-all of determining whether or not a patient needs further imaging. One point I found interesting from the article was the suggestion that red flags are likely more indicative of poor prognosis than they are of actual serious pathology. However, this leads me to a gray spot in my practice. At what point do I refer a patient with LBP for further imaging? Do I refer if they have certain red flag symptoms and do not improve with a reasonable course of PT? Do I refer for further imaging anyway if they have a certain number of red flags? Is it a “gut feel” type of thing? I’m curious to see if anyone has any other thoughts about when we should actually refer these patients out.

[Jennifer Boyle]

Building on Tyler’s questions as to when we should actually refer these patients out would be based on the “closely monitor for changes in symptoms over time”. I feel like red flag questions are still relevant and it gives us a great baseline at initial eval to be able to monitor any changes in the time we spend with these patients. One of the main reasons I became a therapist was because we are the medical provider that spends the most one-on-one time with our patients. With this being said we will be the first to recognize a status change on these patients in regards to the red flags and this is then the time to possibly refer out. I feel like this article has a great point about diagnostic imagine showing “abnormal” findings on 94% of MRI findings with only 3% being a serious pathology. Just like imaging, our red flag questions may show abnormal findings but in many of these cases it will be a horse rather then a zebra. This is when monitoring is the key and a referral is indicated with + clusters/ status changes.

[Sarah Bosserman]

The quote in this article: “Rarely does the literature outline a definitive set of signs or symptoms that are unique to serious pathology of the low back—for either the screening OR the diagnostic phase” resonated with me for this patient population. I think the red flags are important to be aware of, and as Jen said, have a baseline of symptoms and information to monitor over time. We get to chance to see our patients more frequently than most other healthcare providers, so we have the opportunity to closely monitor symptoms over the course of time and refer as indicated. In reading one of the references listed in this review for primary care providers – it can be difficult to manage patient fears…”Primary care education also aims to help the clinician learn how to handle uncertainty when further pursuit of a disease diagnosis is unlikely to influence the choice of treatment or alter the patient’s outcome” and this uncertainty can often lead to unnecessary imaging or “overdiagnosis”. To follow what Tyler said, I think the “gray area” makes this aspect of practice challenging – there is not a simple answer and potentially why people like Chad Cook continue to question and research this topic.

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