Low back pain and physiotherapy use of red flags: the evidence from Scotland
Introduction
The overwhelming majority (approximately 90%) of low back pain referrals made to physiotherapy services are mechanical in nature and appropriate for conservative management [1]. However, in a small percentage (approximately 1%), serious spinal pathology can be the underlying cause; although rarely encountered, the assessment process needs to be sufficiently thorough to ensure that, if present, these are identified and managed timeously [2], [3], [4].
Results from a recent national initiative in Scotland identified that over 55 000 patients with low back pain were referred to National Health Service (NHS) outpatient physiotherapy services annually; based on this figure, 550 may have a serious underlying pathology [5].
These indicators of possible serious spinal pathology are known as ‘red flags’. Some of the most common are listed in Box 1, Box 2. Red flags have been used since 1949 by doctors and, more recently, physiotherapists to help identify symptoms which may indicate an underlying serious pathology [6]. Since the publication of the work of the Clinical Standards Advisory Group in 1994, their profile has evolved to become more formally recognised as key patient safety components of low back pain orthopaedic medicine [6], [7].
Clinical guidelines exist to aid clinicians in their management of patients by providing evidence about treatment considerations and options. With regard to the management of low back pain, red flags are recognised as a key component of assessment within the majority of guidelines [1], [2], [3], [4], [6], [8], [9], [10]. Despite being universally recommended for use, there remains a degree of controversy with regard to the indicative importance of individual red flags and the weight apportioned to them [11]. A systematic review of international guidelines found numerous red flags listed for back pain; however, only those red flags relating to weight loss, previous history of cancer and long-term use of systemic steroids were used consistently throughout [11]. Similarly, a systematic review also confirmed a previous history of cancer as one of the most accurate indicators of a potential presence of malignancy [12]. In addition to identifying cancer, the review also reported that clinical judgement was an accurate tool in identifying serious spinal pathology [12]. The use of red flags should not replace clinical judgement and reasoning, but should be used as an adjunct to the process. There is also evidence which supports the use of red flags within a hierarchy [6]. Individually, each red flag can be significant in its own right. In terms of caution, however, greater emphasis is placed on the presence of concurrent red flags [6]. For example, weight loss, history of cancer or age greater than 55 years would cause some concern individually, but the presence of all three has a sensitivity of nearly 100% for identifying an underlying cancer [13]. Red flags indicative of cauda equina syndrome (i.e. urinary incontinence, saddle anaesthesia or paraesthesia, and retention) are a potential surgical emergency and require urgent specialist review [2], [3], [4].
With such importance attached to red flags, it is surprising that there has been little evaluation about how the documentation of red flags compares against recommendations from guidelines. Two small studies of doctors’ practices and one of physiotherapists’ practices identified low levels of documented use [14], [15], [16]. All three studies identified the need for ongoing education and monitoring, and also the need for a more standardised assessment tool for red flags, within the small local population in which these studies were based.
Section snippets
Practice in Scotland
Similar to other countries worldwide, Scotland lacked a national view about whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. However, anecdotal evidence suggested that physiotherapy management of low back pain was neither consistent nor followed evidence- and consensus-based recommendations offered by guidelines.
NHS Quality Improvement Scotland (NHS QIS) is a special health board, the role of which is to provide advice and guidance,
Methods
Invitations were sent out to all providers of physiotherapy services for low back pain within Scotland to take part in the national initiative. A national physiotherapy low back pain core dataset was developed based on the evidence- and consensus-based recommendations from clinical guidelines for low back pain [2], [3], [4], [8], [9], [10]. The dataset was developed by the project steering group and reflected core assessment, management and discharge information including the red flags and
Results
Data were submitted on 2147 episodes of care. Results were collated by individual participating site and also by health board region. Results are presented below by health board region and private provider (referred to as ‘regions’). All regions were able to demonstrate improvements in all aspects of practice over the two audit cycles, with a mean improvement of 32% [from 33% (n = 709) to 65% (n = 1396)] in relation to general red flag documentation and 24% [from 60% (n = 1288) to 84% (n = 1804)]
Discussion
The purpose of this work was to capture and improve the extent to which red flags were being used by physiotherapists in the assessment of patients with low back pain. It was not designed to capture any associated or non-associated improvement in patient outcome. However, there is considerable evidence that links a direct association between process and outcome. Successful implementation of guidelines into practice relies on a number of issues including: provision of practical and human
Conclusion
This is the first attempt to examine physiotherapy practice in relation to the documented use of red flags in low back pain against guideline recommendations on a Scotland-wide scale. It has shown that such an approach, led by a central body but driven locally by physiotherapists, is possible. Results did improve between cycles; however, it is unclear if a similar improvement is transferrable to clinical care. The level of involvement with action planning by boards during this initiative
Acknowledgements
The authors would like to acknowledge the work of the regional representatives who gathered and encouraged local participation in this initiative: G. Grant, J. Furniss, A. Di Salvo, N. Aiken, K. Hildersley, T. Coulton, S. Cree, D. Brandie, R. Pitt, D. Kemp, C. Redmond, J. McNee, A. Green, A. Coffey, F. Smith, A. Grant, C. Wallace, S. Greenall, N. Groenedijk, N. Turvill, L. Platford. The authors also wish to thank the Project Steering Group: M. McMenemy, G. Grant, J. Graham, D. Falconer, I.
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