Clinical Reasoning

What is a red flag, and why is it important to screen for them?

Signs and symptoms that may suggest a severe pathology, or that can place a patient at risk for serious medical consequences or deter a patient's recovery and function

Are screening tests designed to rule in or rule out selected conditions? Would they need to have a high specificity or high sensitivity to accomplish this?

Rule out

Need to have high sensitivity

What are category I, II, and III red flags, according to Sizer et al.?

Category I: factors requiring immediate attention

Category II: factors requiring subjective questioning and precautionary examination and treatment procedures

Category III: factors requiring further physical testing and differentiation analysis

General category I red flags

Blood in sputum

Loss of consciousness or altered mental status

Neurological deficit not explained by monoradiculopathy

Numbness/paresthesia in perianal region

Pathological changes in bowel and bladder

Patterns of symptoms not compatible with mechanical pain (on physical examination)

Progressive neurological deficit

Pulsatile abdominal mass

General category II red flags

Age >50

Clonus

Fever

Elevated sedimentation rate

Gait deficits

History of a disorder with predilection for infection or hemorrhage

History of a metabolic bone disorder

History of cancer

Impairment precipitated by recent trauma

Long-term corticosteroid use

Long-term worker's compensation

Nonhealing sores or wounds

Recent history of unexplained weight loss

Writhing pain

General category III red flags

Abnormal reflexes

Bilateral or unilateral radiculopathy or paresthesia

Unexplained referred pain

Unexplained significant upper or lower limb weakness

Category I red flags for cervical spine

Neurological deficits

Cervical spine fracture

Dislocation

Laxity, especially atlantoaxial laxity

Category II red flags for cervical spine

Upper cervical instability

Vertebrobasilar insufficiency

Common causes and symptoms of upper cervical instability

Causes: rheumatoid arthritis, Down syndrome, trauma, infection, congenital and hereditary bone dysplasias, Marfan syndrome

Symptoms: nonspecific neck pain, limited ROM, torticollis, nausea, dizziness, history of worsening symptoms (i.e. headache, fatigue, transient UE paresthesia) with neck flexion

Common symptoms of vertebrobasilar insufficiency

Vertigo (swimming/swaying sensation)

Visual disturbances (diplopia)

Sudden sensorineural hearing loss

Facial numbness/paresthesia

Dysphagia

Dysarthria

Syncope (drop attacks)

Symptoms are reproduced with sustained passive end-range cervical rotation

Category III red flags for cervical spine

Radiculopathy

Myelopathy

Category I red flags for thoracic spine

Visceral referred pain

Category II red flags for thoracic spine

Metabolic disorders and their sequelae (i.e. osteoporosis)

Category III red flags for thoracic spine

Intervertebral disc lesions

Fractures

Category I red flags for lumbar spine

Cauda equina syndrome

Radiculopathy from upper lumbar spine in younger patients (rare in younger patients, which makes it a big deal)

Category II red flags for lumbar spine

Osteoporosis

Pyogenic infectious conditions

Category III red flags for lumbar spine

Cord compression

What is a yellow flag, and why is it important to screen for them?

Psychological and social factors that impede patient's recovery

They serve as prognostic indicators and play a critical role in development of chronicity of pain and disability

Reasons to screen for yellow flags

Depression, anxiety, or emotional distress

Poor coping strategies and catastrophizing behaviors

History of psychological trauma or abuse

Poor support system or job dissatisfaction

Over-reliance on passive treatments

In litigation for current condition or disability claim

Long-term worker's compensation

Lack of knowledge about current status

What are the two screening tools used to look at yellow flags in orthopedic PT?

STarT Back risk stratification tool (stratifies pts into low risk, medium risk, or high risk)

OSPRO-YF

What are your three objectives during the subjective exam?

Screen for red flags

Screen for yellow flags

Differential diagnosis of musculoskeletal conditions

What are your two main objectives during the objective exam?

Determine tissue differentiation and tissue irritability

What are your three main objectives when coming up with treatment and plan of care?

Patient-focused treatment

Selection of best approaches individualized to each patient

Address physical, physiological, psychological, and social factors

What is the difference between screening and differential diagnosis?

Screening: process of dichotomously ruling in/out presence of red or yellow flags

Differential diagnosis: process of integrating and evaluating subjective and objective findings to distinguish various conditions

When should you screen a patient for red or yellow flags?

Screen a patient for red flags when indicated

Screen every patient for yellow flags

What are the three main mechanisms of pain?

Nociceptive

Neuropathic

Centrally evoked

Nociceptive pain

Normal process that results in noxious stimuli being perceived as painful

Is inflammatory, mechanical, ischemic, or visceral

Described as dull/sharp pain, catching, and intermittent pain

Neuropathic pain

Pain originating from the CNS or PNS

Is mechanical, viral, metabolic, or resulting from a lesion

Described as sharp pain, radicular symptoms, numbness/tingling

Centrally evoked pain

Abnormal pain processing in the brain

Associated with other CNS-derived symptoms, such as fatigue, mood, sleep or cognitive issues, affective/psychological stress

Can be seen in isolation (fibromyalgia), as a part of chronic pain conditions, or from to autonomic nervous system

Described as bizarre, latent, widespread with no particular pattern

Examples of possible structures as sources of symptoms (local, referred, psychological and social)

Local pain sources: joint, bone, disc, cartilage, meniscus, capsule, ligament, bursa, muscle, fascia, blood vessels, lymph, nerves

Referred pain sources: other areas/joints, viscera, nerve roots, somatic tissues

Psychological and social pain sources: yellow flags

Guiding questions to help formulate our SINSS statement and classification category

Is the disorder mechanical, inflammatory, visceral, neuropathic, or centrally driven?

Do the symptoms appear to fit a particular syndrome?

To what degree is psychological stress driving the patient's symptoms?

What other potential contributing factors are there?

Questions to ask yourself when planning your objective exam

Does the subjective exam indicate a red flag or caution?

Will you limit the exam and why?

Do the symptoms indicate need for specific clinical or imaging tests?

Is a neurological exam necessary? Why or why not?

Do you expect reproduction of symptoms to be easy or hard?

Any clues for treatment ideas?

Anticipated exam results and treatment options for someone with nociceptive symptoms

Exam results: likely to reproduce or ease symptoms with ROM, palpation, joint or soft tissue assessment, and specific tests

Treatment: responds well to manual therapy, exercises, and patient education

Anticipated exam results and treatment options for someone with neuropathic symptoms

Exam results: likely to reproduce or ease symptoms in a preferred direction with ROM, neuro exam, and neurodynamic testing

Treatment: responds well to manual therapy, exercises with directional preference, neurodynamic exercises, and patient education

Anticipated exam results and treatment options for someone with centrally evoked symptoms

Exam: variable response; may see reproduction of symptoms with each test

Treatment: movement based approaches, graded approach to exercises and activities, biopsychosocial treatment strategies, pain education, address worries/converns, distraction, breathing, meditation, lifestyle modifications, manual therapy, psychological referral

What is the caveat to using manual therapy for someone with centrally evoked symptoms?

Some may become too reliant on it

As you are going through the subjective exam, when should you take the three planned pauses and what do you do in each?

After filling out profile and body chart, formulate initial hypothesis based on mechanisms of symptoms

After completing the history and reprioritizing hypotheses as needed, revise and confirm initial hypotheses

After planning physical exam tailored to subjective exam, SINSS and classification, determine the need for screening, limited vs comprehensive objective exam, symptom response during objective exam, inclusion of specific tests/approaches, and referral to other providers

Basic objective exam sequence

1. AROM (with or without overpressure)

2. Repeated motion

3. PROM

4. Accessory glides

When testing AROM and PROM, what are you looking for?

Seeing if motion is normal or limited, and if pain is present

Seeing if limitations are in one direction or multiplanar (capsular pattern of restriction)

How do you identify capsular restriction? What pathologies are related to this?

Limitation in motion in multiple directions

Overpressure feels different in different directions

Pathologies: synovitis, arthrosis, muscle shortening (i.e. casting after surgery, major trauma)

What is the clinical significance of capsular vs non-capsular patterns of restriction?

Helps us to understand the underlying pathology, exam, and treatment

Assists with formulation of hypothesis and prognosis

Synovitis - causes, symptoms, objective exam, treatment

Causes: trauma, overuse, or systemic conditions (i.e. RA)

Symptoms: pain, swelling, limited motion; symptoms are usually intense

Objective exam: minimum

Treatment: need for anti-inflammatory medications, joint injections, modalities, exercises done in pain-free range with high reps and low load

Arthrosis - causes, symptoms, objective exam, treatment

Causes: degeneration of joint surfaces, fibrotic changes

Symptoms: less intense symptoms of pain than synovitis, swelling, limited motion and function

Objective exam: complete

Treatment: joint mobilizations, muscle flexibility, high rep low load exercise, focus on regaining function

Muscle shortening/guarding - causes, treatment

Causes: acute trauma, post-immobilization

Treatment: joint glides, neuromuscular techniques, soft tissue mobilization, high rep exercises

How do you identify a non-capsular pattern of restriction?

Limitation of active and/or passive ROM in a single plane

Altered end-feel

Altered glides

Need for special tests, tissue-specific testing, or imaging

Considerations for peripheral joint testing

Isometric muscle testing can be used as a pain provocation test

Palpation has greater sensitivity in distal joints, because there is more sensory overlapping and convergence of sensory input from the spine to proximal joints

Ligament tests are done with initial swelling decreases, and you are assessing for amount of motion, end-feel, and pain

Findings when doing a ligament test on a partial tear

Excessive motion, normal end-feel, pain

Findings when doing a ligament test on a full tear

Excessive motion, lack of firm end-feel, no pain

Considerations for spinal joint testing

Localization of pain generators is difficult

Use pattern recognition to guide clinical reasoning

Focus on addressing psychological contributors, movement-based treatment, and muscle endurance training

In a highly irritable condition, how much special testing should you do and why?

Minimal testing

Use the most sensitive test to rule out alarming diagnoses

In a moderately irritable condition, how much special testing should you do and why?

Minimal to moderate amount of special testing

Use to rule out competing diagnoses; treatment response confirms your hypothesis

In a minimally irritable condition, how much special testing should you do and why?

Extensive testing

Organize tests to rule in the primary hypothesis, followed by tests to rule out competing hypotheses

Regardless of diagnosis, what factors do you need to consider before planning treatment?

Address psychological contributors

Identify underlying issues (inflammation, mobility, stability, neurological component)

Recognize contributing joints and factors

Determine qualitative and quantitative findings to be treated (asterisk signs)

Identify access to resources

Tailor treatment to what the patient can accomplish

Considerations for manual therapy

Manual therapy has a neurophysiological effect

Consider both joint and soft tissue techniques

Use direct or indirect techniques based on tissue tolerance (acute = indirect, subacute/chronic = direct)

Considerations for therapeutic exercise prescription

Selection of exercises (tissue specific, symptom specific, or function specific)

Training goals (what I want to achieve physiologically to help the pt meet their goals)

Dosage and type of contraction

When to progress an exercise

When should you progress an exercise?

Decrease in pain

Less fatigue

Less compensatory activity

Improved quality of motion

Four stages of exercise prescription and progression for nociceptive pain and neuropathic pain

Stage 1: symptom focus

Stage 2: tissue focus

Stage 3: strength focus

Stage 4: function focus

Stage 1 of exercise prescription and progression (symptom focus) - training goals, exercise concept, things to avoid

Training goals: minimize acute symptoms, decrease irritability

Exercise concept: limit exercise selection to 3-5, minimal resistance (40-60% 1RM), high reps broken into sets, slow speed of movements, concentric contractions to help pump out swelling and improve neurological adaptation

Avoid: overexertion and reproduction of pain

Stage 2 of exercise prescription and progression (tissue focus) - training goals, exercise concept, things to avoid

Training goals: improve tissue tolerance and mobility

Exercise concept: tissue-specific exercise providing optimal stimulus, increase exercise selection to 5-10 exercises, increase reps with additional sets, increase speed of movement but not weight, combine concentric and eccentric movements, add isometrics with short hold duration, initiate balance training

Avoid: adding too much resistance, reproduction of pain

How do you know when to progress from stage 2 to stage 3?

Being mindful of typical timeline of specific tissue healing to determine when to progress, along with patient's progress and subjective reports

Stage 3 of exercise prescription and progression (strength focus) - training goals, exercise concept, things to avoid

Training goals: increase strength and endurance

Exercise concept: increase resistance to 60-80% 1RM, decrease # of reps, change work order to eccentric-to-concentric, isometrics in multiple ranges with increased hold duration, diagonal patterns, progress toward functional motion

Avoid: delayed onset of muscle soreness and fatigue

Stage 4 of exercise prescription and progression (function focus) - training goals, exercise concept, things to avoid

Training goals: improve function

Exercise concept: increase resistance to 80% 1RM, begin functional exercises including hypertrophy, speed, and power, make exercises specific to patient goals

Avoid: early return-to-sports, overloading, and reinjury

Tips to improve patient compliance

Understand your patient, what motivates them and what doesn't

Involve patient in their POC and their intervention program

Give choices of exercises modes and types

Be realistic and keep things concise and simple

Have patient keep track of their progress and relapses

Acknowledge gains

Treatment strategies for yellow flags

Provide additional education about the biopsychosocial nature of pain and address negative beliefs and maladaptive behavior

Use relaxation approaches, imagery, or meditation

Focus on graded exposure to exercises and activities

Identify activities that are fearful to the patient and introduce fearful activity at an intensity that does not increase fear

Acknowledge functional gains with positive reinforcement

Progress activity as fear decreases

Focus on behavioral modification and problem solving