IDENTIFICATION OF SERIOUS PATHOLOGY: THE IMPORTANT ROLE OF PHYSIOTHERAPISTS
N. Hutting1, L. Finucane2,3,4, C. Paling5, W. Hing6
All authors, affiliations and abstracts have been published as submitted.
1HAN University of Applied Sciences, Research Group Occupation & Health, Nijmegen, Netherlands, 2Sussex MSK Partnership, Brighton, United Kingdom, 3International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), Albany, New Zealand, 4St Georges University London, London, United Kingdom, 5Wiltshire Health and Care, Outpatient Physiotherapy, Wiltshire, United Kingdom, 6Bond University, Physiotherapy, Gold Coast, Australia
Learning objective 1: Participants will become aware of the importance of - and their role in - identification of serious pathology in people presenting with musculoskeletal conditions.
Learning objective 2: Participants will gain knowledge, practical insights and strategies regarding the identification of serious pathology.
Learning objective 3: Participants will be better equipped to identify serious pathology in people presenting with musculoskeletal conditions (i.e. back pain or neck pain).
Description: Background: Musculoskeletal conditions are one of the leading contributors to disability worldwide and include conditions that affect the spine, such as back and neck pain. Many people receive treatment for low back pain, neck pain or headache by a physiotherapist. However, although considered rare, serious pathology can be present in people presenting with musculoskeletal conditions. Serious pathology is a term used to describe a variety of conditions that may present as benign musculoskeletal conditions, but are due to more serious underlying conditions. These conditions include fractures, malignancy, infections, and craniocervical vascular pathologies.
The ability to screen for a serious pathology that masquerades as a benign musculoskeletal condition is important to ensure that people receive the right management in a timely manner. Missed or delayed diagnosis of serious pathology can have devastating consequences for individuals and in rare cases, can be fatal. Therefore, the focus of all physiotherapy consultations should encompass assessment to determine a level of concern for potential serious pathology.
Red flags have historically been used to help clinicians identify serious spinal pathology, and the majority of guidelines recommend the use of red flags. However, there is lack of agreement between guidelines regarding which red flags should be considered when examining people seeking care for musculoskeletal conditions. This has led to confusion and lack of consistency in the management of people when there is suspicion of serious pathology, including spinal serious pathologies such as cauda equina syndrome (CES), spinal fractures, spinal malignancies, spinal infections and vascular pathology of the neck.
Physiotherapists working in musculoskeletal services can play an important role in early identification of serious pathology, ensuring that people achieve the best possible outcome. However, identifying an underlying serious pathology as the cause of a person’s musculoskeletal presentation is complex and challenging. Moreover, research suggests that physiotherapists encounter barriers and lack contemporary clinical reasoning skills regarding the identification of potential serious pathology.
Recently, two frameworks have been developed to help guide clinicians and provide a more standardised approach in the identification of serious pathology; the International Framework for Red Flags for Potential Serious Spinal Pathologies and the International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention. However, it is likely that many physiotherapists are still unaware of these frameworks or do not use these frameworks in practice. Moreover, preliminary evidence suggests that not all components of the framework are adequately implemented in educational programmes.
It is important that all physiotherapists involved in the treatment of people with musculoskeletal conditions, have up-to-date knowledge about the identification and management of serious pathology. Therefore, in this focused symposium, a contemporary approach regarding the identification of potential serious pathology (i.e. spinal serious pathology and craniocervical vascular pathology) will be presented. Topics that will be addressed include characteristics of serious pathology, clinical pathways, safety netting, clinical reasoning and recommendations regarding the patient history and physical examination.
Implications/conclusions: Physiotherapists play an important role in the identification and screening out of individuals that have serious pathology. This will insure that only individuals who are suitable will proceed to receive appropriate musculoskeletal management. This focused symposium will contribute to the awareness and knowledge of physiotherapists regarding (the identification) of serious pathology.
Keywords: Physiotherapy, serious pathology, serious spinal pathology, craniocervical vascular pathology
The ability to screen for a serious pathology that masquerades as a benign musculoskeletal condition is important to ensure that people receive the right management in a timely manner. Missed or delayed diagnosis of serious pathology can have devastating consequences for individuals and in rare cases, can be fatal. Therefore, the focus of all physiotherapy consultations should encompass assessment to determine a level of concern for potential serious pathology.
Red flags have historically been used to help clinicians identify serious spinal pathology, and the majority of guidelines recommend the use of red flags. However, there is lack of agreement between guidelines regarding which red flags should be considered when examining people seeking care for musculoskeletal conditions. This has led to confusion and lack of consistency in the management of people when there is suspicion of serious pathology, including spinal serious pathologies such as cauda equina syndrome (CES), spinal fractures, spinal malignancies, spinal infections and vascular pathology of the neck.
Physiotherapists working in musculoskeletal services can play an important role in early identification of serious pathology, ensuring that people achieve the best possible outcome. However, identifying an underlying serious pathology as the cause of a person’s musculoskeletal presentation is complex and challenging. Moreover, research suggests that physiotherapists encounter barriers and lack contemporary clinical reasoning skills regarding the identification of potential serious pathology.
Recently, two frameworks have been developed to help guide clinicians and provide a more standardised approach in the identification of serious pathology; the International Framework for Red Flags for Potential Serious Spinal Pathologies and the International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention. However, it is likely that many physiotherapists are still unaware of these frameworks or do not use these frameworks in practice. Moreover, preliminary evidence suggests that not all components of the framework are adequately implemented in educational programmes.
It is important that all physiotherapists involved in the treatment of people with musculoskeletal conditions, have up-to-date knowledge about the identification and management of serious pathology. Therefore, in this focused symposium, a contemporary approach regarding the identification of potential serious pathology (i.e. spinal serious pathology and craniocervical vascular pathology) will be presented. Topics that will be addressed include characteristics of serious pathology, clinical pathways, safety netting, clinical reasoning and recommendations regarding the patient history and physical examination.
Implications/conclusions: Physiotherapists play an important role in the identification and screening out of individuals that have serious pathology. This will insure that only individuals who are suitable will proceed to receive appropriate musculoskeletal management. This focused symposium will contribute to the awareness and knowledge of physiotherapists regarding (the identification) of serious pathology.
Keywords: Physiotherapy, serious pathology, serious spinal pathology, craniocervical vascular pathology
References:
- Hutting N, Kerry R, Kranenburg R, Mourad F, Taylor A. Assessing Vascular Function in Patients With Neck Pain, Headache, and/or Orofacial Pain: Part of the Job Description ofAllPhysical Therapists. J Orthop Sports Phys Ther. 2021 Sep;51(9):418-421.
- Hutting N, Wilbrink W, Taylor A, Kerry R. Identifying vascular pathologies or flow limitations: Important aspects in the clinical reasoning process. Musculoskelet Sci Pract. 2021 Jun;53:102343.
- Paling C. The complex problem of identifying serious pathology in Musculoskeletal care: Managing clinical risk during the COVID pandemic and beyond. Musculoskelet Sci Pract. 2021 Aug;54:102379.
- Paling C, Hebron C. Physiotherapists' experiences of managing persons with suspected cauda equina syndrome: Overcoming the challenges. Musculoskeletal Care. 2021 Mar;19(1):28-37.
- Greenhalgh S,Finucane LM, Mercer C, Selfe J. Safety netting; best practice in the face of uncertainty. Musculoskelet Sci Pract. 2020 Aug;48:102179.
- Finucane LM, Downie A, Mercer C, […]. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020 Jul;50(7):350-372.
- Rushton A, Carlesso LC, Flynn T, Hing WA, Kerry R. Rubinstein SM, Vogel S. International IFOMPT Cervical Framework (2020). IFOMPT, 2020.
- Yusuf M, Finucane L, Selfe J. Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskelet Disord. 2019 Dec 13;20(1):606.
- Taylor A, Kerry R, Mourad, F, Hutting N. Vascular flow limitations affecting the cervico-cranial region: Understanding haemodynamics. Submitted for publication.
- Hutting N, Kranenburg HA, Taylor A, Wilbrink W, Kerry R, Mourad F. Implementation of the International IFOMPT Cervical Framework: a survey among educational programmes. Submitted for publication.
All authors, affiliations and abstracts have been published as submitted.
