Symptoms for which a patient has presented to Physiotherapy treatment may be associated with a medical condition. Sometimes pain referred can be from another body part.
It is well established that what seems like pain in our back can come from our kidney, or pain in our shoulder can be actually caused by lung cancer.
The Physiotherapist is expert in treating pain from muscles, joints and nerves that tends to be related to movement.
But, how does a Physiotherapist determine if the problem is something really serious??
One of the early things that is drilled into us as Physiotherapy university students, is that we should always have our “antennae up and alert for serious pathology”.
In the medical profession there are a system of “flags”:
Red Flag
Sign of serious pathology
Orange Flag
Psychiatric symptoms; clinical depression, personality disorder
Yellow Flag
Pain beliefs, emotional response, pain coping strategies
Blue Flag
Perceptions about the relationship between work and health
Black Flag
Contextual obstacles; litigation, heavy work that cannot be modified
If a red flag is suspected, seek urgent medical attention.
As Physiotherapists, to determine if there is a serious problem we clarify topics such as:
Cord/Cauda Equina Syndrome
Pins and Needles or numbness in hands or feet in both sides at once and especially if there are associated Bladder/Bowel changes.
Bowel or Bladder Dysfunction
Not being able to urinate, not being able to open the bowels or losing control of either function
Fracture
If the trauma involves a collision, rotation or at high speed we suspect a bone break so refer the patient for an XR. This is particularly important in a woman who has been through menopause as their bones are generally weaker.
Cancer
There are certain cancers that are common in certain populations.
Osteosarcoma- in boys in long bones.
Breast Cancer – can present as shoulder pain however the shoulder doesn’t follow usual joint/muscle pain patterns.
Brain Cancer – can present as a headache but the headache tends to be sudden onset, severe and unrelenting pain.
Unremitting night pain
Sudden and significant weight loss
Previous History of Cancer
In Summary
At Active Solutions Physiotherapy we always refer you back to your GP for further investigations of we identify a red flag. The occasions for these referrals do not occur often. Anecdotally, our staff with a combined working experience of 50 years have described having a patient with a red flag that needs a medical referral on average 1 x 3 years.
These are some of our stories of red flags in our careers:
- TUMOUR: Patient had back pain and was referred by an Orthopaedic Surgeon for treatment. However he described how he couldn’t walk very well and had to hold onto the wall for balance – He was immediately referred to his GP for spinal cord imaging, which revealed a tumour in the spine pressing on the spinal cord.
- PREVIOUS CANCER: A patient had bladder cancer a few years ago. When he developed an unrelenting pain in his leg that wasn’t caused by any trauma, before we started treatment, he was referred for an XR to check for any bone cancer. As the XR was clear, we could then treat the muscle weakness problem.
- TUMOUR: A 10-year-old boy had thigh pain for 12 months that started when his sister kicked him in the leg. Osteosarcoma (cancer in the long bones, particularly prevalent in young boys) needed to be excluded (and thankfully was) by an XR before we could confidently treat him.
- PREVIOUS CANCER: A patient was referred to us for low back pain. She had full movement of the spine with no pain. She was however severely constipated and had a history of Lymphatic Cancer. Treatment focused on pelvic floor management, tactics to reduce constipation and following up closely with the GP’s investigations. Sure enough the pain eased with the constipation relief, however the constipation was there because the cancer was back.
- CAUDA EQUINA SYNDROME CAUSED BY SPINAL STENOSIS: A patient developed bladder weakness 10 years previously and was treated surgically by a urologist. His bladder had worsened and he had been self-catheterising for 2 years. Physiotherapy was treating his stiff back, however when his back symptoms worsened as well, we referred him for an MRI. The MRI showed his spinal cord was being compressed which is why his bladder function was worse and the back was stiffer despite treatment. He had a back operation for Spinal Stenosis and he improved.
Physiotherapists are experts at treating musculoskeletal pain but are well aware that sometimes serious pathology can be present.
Therefore, we have a set of screening questions that we always ask which help us identify if a patient might have a serious illness. In addition to this, injuries have common pain and movement patterns. If these patterns are unusual and do not respond to treatment, we are immediately concerned. In these circumstances we refer the patient back to their GP for further investigations. These events are very serious and require careful and prompt action, however thankfully they are rare.
You can trust Active Solutions Physiotherapy to perform an accurate assessment of your pain. If there is a positive response to the screening questions or an injury doesn’t follow the usual pattern, we will refer for a medical review.
