Physiotherapy Red Flags and Clinical Decision-Making in Back Pain

Role of a Physio (red flags)

Recognise conditions or comorbidities that could hinder recovery, impair function, or place the patient at risk of medical consequences.

Red flag concept

Clinical prediction guides that raise a clinician's suspicion for serious pathology (e.g. DVT presenting as a calf strain).

Examples of red flags

Cancer; fracture; infection; inflammatory neurological conditions; cardiopulmonary compromise; neurovascular compromise; mental health conditions.

Subjective interview - what to look for

Anything unusual; symptoms not fitting a typical MSK pattern; consider less common diagnoses; then consider a red flag.

Low back pain - possible patho‑anatomical diagnoses

Disc and facet degeneration; annular tears; IVD prolapse; spondylolisthesis; foraminal or spinal stenosis.

Low back pain - terminology‑related causes

Lumbar instability; postural dysfunction.

Neurophysiological causes to consider

Neuropathic pain; central sensitisation involving peripheral, spinal cord, and cortical changes.

Psychosocial contributors to back pain

Depression (can't work, pain won't go away); negative thoughts and emotions influenced by healthcare experiences.

Discussing mental health with patients

Using curious, patient‑centred language about their feelings towards their care and treatments.

Serious conditions to consider in back pain

Cauda equina syndrome; fracture; malignancy; infection (e.g. infective spondylitis).

Cancer red flags - key symptoms

Night pain worse when lying down; unexplained weight loss; non‑mechanical pain from bone destruction; progression from gradual to constant increasing pain.

Other conditions to be mindful of

Osteosarcoma; rheumatoid polyarthritis; muscular dystrophy; Marfan syndrome; shingles; osteomyelitis; fibromyalgia; DVT.

General red flag signs and symptoms

Age over 50; progressive symptoms; past cancer; unexplained weight loss; night pain; poor response to therapy; fever; night sweats.

Red flag decision tool - Step 1

Determine level of concern by assessing multiple symptoms, context, detailed history, and objective findings.

Red flag decision tool - Step 2

Decide action: watchful waiting with monitoring; urgent referral (within 5 days); or emergency referral (A&E).

Red flag decision tool - Step 3

Consider referral pathway, understand local systems, and build relationships with local GPs.

Contraindication (definition)

A scenario or feature where a particular assessment or treatment technique should not be used.

Manual therapy precautions - skin/sensation/oedema

Fragile skin; impaired sensation; generalised oedema (e.g. pregnancy, lymphoedema).

Manual therapy precautions - connective tissue/bleeding

Weakened connective tissue (long‑term steroids, osteoporosis, rheumatoid arthritis); clotting disorders such as haemophilia.

Manual therapy precautions - cardiovascular

Hypertension, heart disease, or heart failure requiring modified or avoided techniques.