Red Flags

Red Flags:

VBI, CVA, MI, Infection, DVT, Cervical Fx/Instability, Myelopathy, Cancer

• Red-flag findings are symptoms or conditions that may require immediate attention and supersede physical therapy being the primary provider of service.

• They are typically indicative of non-mechanical (non-neuro musculoskeletal) conditions or pathologies of visceral organs

• Common red-flags are reports of trauma, fever or chills, unremitting night pain, bilateral symptoms and unintentional, substantial weight loss.

• An affirmative response to a single red-flag question may not be a reason for an immediate referral but a cluster typically would be

  • 1 red flag is not enough to be suspicious.

Pathology Requiring Referral

• Fevers, chills, or night sweats

  • Associated with systemic disorder such as an infection

• Recent unexplained weight changes

  • An unexplained weight gain could be caused by congestive heart failure, hypothyroidism or cancer.

  • An unexplained weight loss could be the result of a gastrointestinal disorder, hyperthyroidism, cancer, or diabetes.

• Malaise or fatigue

  • These complaints, which can help determine the general health of the patient, may be associated with a systemic disease.

• Unexplained nausea or vomiting

  • This is never a good symptom or sign, needs medical work up

  • GI, neurological, vertigo

• Unilateral, bilateral, or quadrilateral paresthesias

  • The distribution of neurologic symptoms can give the clinician clues as to the structures involved

  • Quadrilateral paresthesia always indicates the presence of central nervous system (CNS) involvement.

• Shortness of breath

  • Shortness of breath can indicate a myriad of conditions. These can range from anxiety and asthma to a serious cardiac or pulmonary dysfunction.

• Dizziness

  • The differential diagnosis of dizziness can be quite challenging. Patients often use the word “dizziness” to refer to feelings of lightheadedness, various sensations of body orientation, blurry vision, or weakness in the legs.

• Nystagmus

  • Rhythmic movement of the eyes, with an abnormal shifting away from fixation and rapid return. 14 failure of any one of the main control mechanisms for maintaining steady gaze fixation (the vestibuloocular reflex and a gaze-holding system) results in a distraction of steady fixation

• Bowel and Bladder Dysfunction

  • May indicate compromise of the cauda equina

    • Compression of the spinal nerve roots that supply neurologic function to the bladder and bowel

    • Inability to urinate while sitting down, because of the increased levels of pressure.

    • Occurs over the buttocks, posterior-superior thighs, and perinatal regions (saddle anesthesia)

  • A massive disk herniation may cause spinal cord or cauda equina compression

  • Rapid diagnosis and surgical decompression of this abnormality are essential to prevent permanent neurologic dysfunction

• Severe pain

  • An insidious onset of severe pain with no specific mechanism of injury

• Pain at night that awakens the patient from a deep sleep

  • Usually at the same time every night, and which is unrelated to a movement.

    • This finding may indicate the presence of a tumor

• Painful weakness

  • Almost always indicates serious pathology, including a complete rupture of contractile tissue or nerve palsy

• A gradual increase in the intensity of the pain

  • Indicates that the condition is worsening, especially if it continues during rest

• Radiculopathy

  • Neurologic symptoms associated with more than twolumbar levels or more than one cervical level

  • With exception of central protrusions or a disk lesion at L4 through L5, disk protrusions typically only affect one spinal nerve root.

  • Multiple-level involvement could suggest the presence of a tumor or other growth, or it may indicate symptom magnification.

  • The presence or absence of objective findings should help determine the cause.

MI

§  Myocardial Infraction: occurs with a complete blockage of blood supply to the heart muscle, resulting in coronary artery occlusion.

o   In contrast to angina pectoris, where are the symptoms are typically described as a feeling of heaviness or pressure, an MI typically has a crushing or gripping over the sub, sternal region, left, neck, and jaw.

o   Angina pain with nausea, sweating, and profuse sweating

o   Patient is hypotensive and has a week, rapid poles, and occasionally a low-grade fever

o   Mi symptoms last longer than angina pectoris, lasting 15 minutes or more, and are not relieved by rest or nitroglycerin.

Different symptoms of MI

Infection

§  Osteomyelitis: patients usually present with fever, malaise, irritability, pain, and localized tenderness at the infection site. Muscle guarding and decreased movement and pain of the affected. Limb and adjacent joints may also be a feature. These symptoms may be accompanied by edema and erythema over the involved area.

§  Cat-Scratch Disease: is generally up benign, self limited, infectious disease in immuno competent patients. It is caused by Bartonella henselae, a small, gram-negative, argyrophilic, no acid-fast, pleomorphic bacillus.

§  Tumors: differential diagnosis of all painful shoulders includes various tumors. The typical clinical features of a bone tumor include variable pain, which is often worse at night and market Lee unresponsive to NSAIDs. Thorough evaluation of suspected. Patient requires routine, radiography, radionuclide, imaging, CT scanning, MRI, and angiography. Surgical treatment of shoulder tumors depends on the patient’s age and the type, extent, and aggressiveness of the tumor.

o       Infective Diseases

·        Osteomyelitis: is an acute or chronic inflammatory process of the bone and its marrow secondary to infection with pyogenic organisms or other sources of infection, such as tuberculosis or specific, fungal, infections, parasitic infections, viral infections or syphilitic infections.

o   Hematogenous osteomyelitis: Is an infection caused by bacterial seeding from the blood. Most common site is the rapidly growing and highly vascular metaphysis of growing bones

o   Direct or contiguous inoculation: This type of osteomyelitis is caused by direct contact between the tissue and bacteria during surgery, a penetrating wound, or poor dental hygiene.

·        Predispose patients to osteomyelitis include: diabetes mellitus, sickle-cell disease, acquired immune deficiency syndrome, drug abuse, alcoholism, chronic steroid use, immunosuppression, and chronic joint disease. Clinical signs include fever, fatigue, edema, erythema, tenderness, and reduced extremity use.

·        Constant pain with marked tenderness over the involved bone

Deep Venous Thrombosis

·        Muscle veins drain into the deep veins of the lower extremity.

·        Thrombosis usually develops from venous stasis or slow-flowing blood around venous valve sinuses.

·        Extension of the primary thrombus occurs within or between the leg’s deep and superficial veins, and the propagating clot causes venous obstruction, damage to valves, and possible venous thromboembolism (VTE).

·        The most common cause of leg swelling is edema, but an expansion of all or part of a limb may result from an increase in any tissue component (muscle, fat, blood, etc)

·        The clinical features of DVT include:

o   Calf pain, tenderness, or both;

o   Swelling with pitting edema;

o   Swelling below the knee (distal DVT) or up to the groin (proximal DVT);

o   Increased skin temperature;

o   Superficial venous dilation; and

o   Cyanosis in patients with severe obstruction

·        The main complications of DVT are pulmonary embolism, post thrombotic syndrome, and recurrence of thrombosis

Cervical Spine

• Cervical Stenosis, Cervical Myelopathy

  • Cervical myelopathy refers to compression on the cervical spinal cord

  • Any space occupying lesion within the cervical spine that narrows the spinal canal (spinal stenosis) has the potential to compress the spinal cord can cause cervical myelopathy.

  • Spinal Stenosis is predominantly caused by cervical spondylosis (degenerative changes in the cervical spine) but can also be the result of traumatic (fractures and instability) and inflammatory conditions or caused by herniated discs or tumors.

• Cervical Fractures

  • When a patient with neck pain reports of history, need to be alert for spinal fracture and the potential for cervical instability and/or spinal cord or brain stem injury.

  • Canadian C-Spine Rule can be used to determine when to refer for radiography in individuals following trauma where fracture of the cervical spine is a concern.

• Cervical Arterial Dysfunction (CAD)

  • Range from pre-existing underlying anatomical anomalies, vasospasm, atherosclerosis, through to giant cell arthritis (i.e. temporal arthritis) or arterial dissection

  • All of these may lead to potential cranio-cerebral ischemia which may originate and manifest in a variety of ways

  • Presentations

    • Pain

    • Cranial nerve dysfunction (e.g. Horner’s Syndrome)

    • Blindness

    • Stroke

    • Death

  • Care must be taken to differentiate vascular sources of pain from musculoskeletal sources.

  • Urgent medical investigation is indicated if frank vascular pathology is identified. (5 D’s, 3 N’s, 2A’s)

• Cervical Instability

  • Inability of the spine under physiological loads to maintain its normal pattern of displacement so that there is no neurological damage or irritation, no development of deformity, and no incapacitating pain.

  • With cervical instability (particularly in the Upper Cervical Spine) there is potential for serious neurological injury so the cause and extent of instability should be investigated before physiotherapy treatment commences,

Cancer

§  Colorectal Cancer: it’s the third, most common cancer, in both men and women in the United States.

o   Risk factors include age, a diet rich, and fat and cholesterol, inflammatory, bowel disease, and genetic predisposition.

o   The most common metastatic presentation of colon cancer is in the thoracic spine and rib cage.

o   The five-year survival rate is different for each stage; the staging classification of colon cancer can prognosis

Table 5-11: TNM Staging of Cancer

Red Flags:

·        Each greater than 50 years

·        History of colon cancer in an immediate family member

·        Bowel disturbance (e.g., rectal bleeding, or black stools)

·        Unexplained, weight loss; and

·        Back or pelvic pain that is unchanged by position or movement

Thoracic Spine & Ribs

Vertebral Compression Fractures

• Occurs when the body block or vertebral body in the spine collapses, which can lead to severe pain, deformity and loss of height. Most common in lower thoracic spine

• Causes:

  • Severe osteoporosis: may be caused by simple daily activities, such as stepping out of the shower, sneezing forcefully or lifting a light object

  • Moderate osteoporosis: usually takes increased force or trauma, such as falling down or attempting to lift a heavy object

• It is the most common fracture in patients with osteoporosis, affecting about 750,000 people annually. VCFs affect an estimated 25% of all postmenopausal women in the U.S.

• The occurrence of this condition steadily increases as people age, with an estimated 40% of women age 80 and older affected.

• People with healthy spines most commonly suffer a VCF through severe trauma, such as a car accident, sports injury or a hard fall.

  • Metastatic tumors should be considered as the cause in patients younger than 55 with no history of trauma or only minimal trauma. The bones of the spine are a common place for many types of cancers to spread. The cancer may cause destruction of part of the vertebra, weakening the bone unit it collapses.

• The main clinical symptoms of VCFs may include any of the following, alone or in combination:

  • Sudden onset of back pain

  • An increase of pain intensity while standing or walking

  • A decrease in pain intensity while lying on the back

  • Limited spinal mobility

  • Eventual height loss

  • Eventual deformity and disability

Lumbar/Lower

Cauda Equina Syndrome

·        Space occupying lesion of the Cauda Equina

·        Distal emergent symptoms:

o   Urine retention or incontinence

o   Fecal incontinence

o   Saddle anesthesia

o   Global or progressive weakness in the lower extremities

o   Sensory deficits in the feet (i.e., L4, L5, and S1 areas)

Pelvis, Hip, and Thigh

Table 4.9

Signs and Symptoms Requiring Immediate Medical Referral

Table 5-17

Origin and Location of Shoulder Pain