MSK Red Flags + Nerve testing

Clinical Reasoning Framework includes:

What we know → Interpretation [Additional info] → Action

It is iterative, contextual and developmental

MSK Clinical Translation Framework includes….

Specific diagnosis: well-defined + labelled

Red flags

Non-specific presentation: no label

Special considerations: contextual factors

Red Flags Defined by MSK Clinical Translation Framework

MSK pain driven by serious, non-MSK pathology requiring escalation

• masked as MSK issue

Red Flags defined by International Framework

• S & S from history + physical exam raise suspicion of serious spinal pathology

• Tools to raise suspicion, not tests that rule out

How legit are red flags?

Limited evidence in isolation

• Combination is more promising but still requires validation

+ evidence tgthr (age, other health determinants)

IT IS NOT A CHECKLIST!

4 serious spinal pathologies

1. Cauda equina syndrome

2. Spinal fx: rare

3. Spinal malignancy

4. Spinal infection: fever, chills, sweat, heat, pain, abscess, recent surgery

Cauda Equina Syndrome S&S

• Compressed/impaired conduction

• Sensory, bowel, bladder control

  • Change in bathroom habits?

• Saddle anaesthesia

• Sexual dysfxn

• Bilat. or alternating leg pain, new or progressing motor weakness

• Nerves can heal if decompress early on.

Spinal malignancy Symptoms/signs

Cancerous growth

Abnormal mechanical finding in combination w/ low energy, rapid weight loss

History of cancer

> 50 yrs old

Night pain not eased by position change

Pain not improving

Spinal Fx Risk factors/Signs

• Old age

• Female

• Significant/minor trauma (w/ osteoporosis)

  • Low force can cause fx

• Prolonged corticosteroid use

• Sudden severe pain

• Low bone density

Decision Tool Steps for Red Flags

1. Level of concern: dial, NOT a switch.

   1. Take into account age, sex, past medical history, meds, other hlth determinants.

   2. # red flags checked off?

2. Match action w/ concern

3. Know your pathway + safety net

What do I know? How do I interpret? What do we do?

#2 Match Action w/ Concern

Low: start a trial of therapy. Revise if changes unexpectedly.

Few: start a trial, but closely monitor. Talk to a colleague or send a note to dr.

Some: URGENT REFERRAL. DO NOT start therapy. Further investigation needed.

HIGH: ER referral

#3 Know your pathway + safety net

Know referral pathway: imaging, specialists, speed, emerg plan

Safety netting: warning signs to watch for if it escalates, not bad enough to call 911, give tools in case it escalates.

• Signs + symptoms to look for

• What to do if things get worse

• Time frame for acting

3 Principles for all of practise

1. Screen

2. Screening is ongoing: keep checking

3. Evidence + profile informs action

Types of neuro assessments

Nerve conduction: myotomes, dermatomes, deep tendon reflexes assess nerve root conduction

Pathological reflexes: babinski + hoffman → Upper motor neurons

Neurodynamic tests: ULTT, Slump, SLR asses NS response to load

Nerve Conduction Tests

1. Myotomes

2. Dermatomes

3. Deep tendon reflex

Grading for Deep Tendon Reflex

0: absent (abnormal)

1: diminished

2: normal

3: brisk, exaggerated

4: brisk, clonus (abnormal)

Neurodynamic Test +ve Signs

Normal: pulling, pain, tingling

+ve: reproduces symptoms, ROM differences btwn L vs R

Diff in resistance