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Appendix
APPENDIX A-2
Red Flags
The presence of any one of these symptoms is not cause for extreme concern, but it should raise a red flag for the alert therapist. The therapist is looking for a pattern that suggests a viscerogenic or systemic origin of pain and/or symptoms. Often, the next step is to look for associated signs and symptoms. The therapist will proceed with the screening process depending on which symptoms are grouped together.
PAST MEDICAL HISTORY (PERSONAL OR FAMILY)
Personal or family history of cancer
Recent (last 6 weeks) infection (e.g., mononucleosis, upper respiratory infection [URI], urinary tract infection [UTI], bacterial infection such as streptococcal or staphylococcal; viral infection such as measles, hepatitis), especially when followed by neurologic symptoms 1 to 3 weeks later (Guillain-Barr syndrome), joint pain, or back pain
Recurrent colds/flu with a cyclical pattern (i.e., the client reports that s/he just cannot shake this cold or the flu; it keeps coming back over and over)
Recent history of trauma such as motor vehicle accident or fall (fracture; any age) or minor trauma in older adult with osteopenia/osteoporosis
History of immunosuppression (e.g., steroids, organ transplant, HIV)
History of injection drug use (infection)
RISK FACTORS
Risk factors vary depending on family history, previous personal history, and disease, illness, or condition present. For example, risk factors for heart disease will be different from risk factors for osteoporosis or vestibular/balance problems. As with all decision-making variables, a single risk factor may or may not be significant and must be viewed in the context of the whole patient/client presentation.
Substance use/abuse
Alcohol use/abuse
Age
Occupation
Body mass index (BMI)
Domestic violence
Gender
Hysterectomy/oophorectomy
Race/ethnicity
Tobacco use
Sedentary lifestyle
Overseas travel
Exposure to radiation
Multiple sexual partners
CLINICAL PRESENTATION
No known cause, unknown etiology, insidious onset
Presence of symptoms that are unrelieved by physical therapy intervention is a red flag.
Physical therapy intervention does not change the clinical picture; client may get worse!
Presence of symptoms that get better after physical therapy but then get worse again is also a red flag indicating the need to screen further.
Significant weight loss/gain without effort (more than 10% of the clients body weight in 1021 days)
Gradual, progressive, or cyclical presentation of symptoms (worse/better/worse)
Unrelieved by rest or change in position (no position is comfortable)
If relieved by rest, positional change, or application of heat, these relieving factors no longer reduce symptoms in time.
Symptoms seem out of proportion to the injury.
Symptoms persist beyond the expected time for that condition.
Unable to alter (provoke, reproduce, alleviate, eliminate, aggravate) the symptoms during exam
Does not fit the expected mechanical or neuromusculoskeletal pattern
No discernible pattern of symptoms
A growing mass (painless or painful) is a tumor until proved otherwise; a hematoma should decrease (not increase) in size with time.
Postmenopausal vaginal bleeding (bleeding that occurs a year or more after the last period [significance depends on whether the woman is on hormone replacement therapy and which regimen is used])
Bilateral symptoms (see Chapter 1)
Numbness/tingling
Burning
Edema
Clubbing or other nail bed changes
Skin rash, lesions, or pigmentation changes
Weakness
Change in muscle tone or range of motion for individuals with neurologic conditions (e.g., cerebral palsy, spinal cord injury, traumatic brain injury, multiple sclerosis)
Pain Pattern
Pain of unknown cause
Back or shoulder pain (most common location of referred pain; other areas can be affected as well, but these two areas signal a particular need to take a second look)
Pain accompanied by full and painless range of motion (see Table 3-1)
Pain that is not consistent with emotional or psychologic overlay (e.g., Waddells test is negative or insignificant; ways to measure this are discussed in Chapter 3); screening tests for emotional overlay are negative
Night pain (constant and intense; see complete description in Chapter 3)
Symptoms (especially pain) are constant and intense [Remember to ask anyone with constant pain: Are you having this pain right now?]
Pain made worse by activity and relieved by rest (e.g., intermittent claudication, cardiac: upper quadrant pain with the use of the lower extremities while upper extremities are inactive)
Pain described as throbbing (vascular), knifelike, boring, or deep aching
Pain that is poorly localized
Pattern of coming and going like spasms, colicky
Pain accompanied by signs and symptoms associated with a specific viscera or system (e.g., gastrointestinal, genitourinary, gynecologic, cardiac, pulmonary, endocrine)
Change in musculoskeletal symptoms with food intake or increased pain with medication use (immediately up to several hours later)
Neurologic Signs and Symptoms
General
Confusion/increased confusion (most common in older adults)
Depression
Irritability
Drowsiness/lethargy/sleepiness
Blurred vision
Headache
Balance/coordination problems
Weakness
Change in memory
Change in muscle tone for individual with previously diagnosed neurologic condition
Cauda Equina Syndrome
Cauda equina syndrome is defined as compression of the lumbar nerves in the central canal causing sensory and motor deficit, saddle anesthesia, and bowel and bladder dysfunction.
Low back pain
Loss of sensation in the lower extremities
Muscle weakness and atrophy
Bowel and/or bladder changes
Urinary retention
Difficulty starting a flow of urine
Decreased urethral sensation
Fecal incontinence
Constipation
Loss of anal tone and sensation
Perineal pain
Saddle and perineal hypoesthesia or anesthesia
Unilateral or bilateral sciatica
Change in deep tendon reflexes (reduced or absent in lower extremities)
Cervical Myelopathy
Neck pain and/or shoulder pan, stiffness
Wide-based clumsy, incoordinated gait
Loss of hand dexterity
Paresthesias in one or both arms or hands
Visible change in handwriting
Difficulty manipulating buttons or handling coins
Hyperreflexia
Positive Babinski test
Positive Hoffman sign
Lhermittes sign (electric shock sensation down spine/arms with neck flexion/extension)
Urinary retention followed by overflow incontinence (severe myelopathy)
ASSOCIATED SIGNS AND SYMPTOMS
Recent report of confusion (or increased confusion); this could be a neurologic sign; it could be drug-induced (e.g., NSAIDs); usually it is a family member who takes the therapist aside to report this concern
Presence of constitutional symptoms (see Box 13) or unusual vital signs (see Chapter 4); body temperature of 100 F (37.8 C) usually indicates a serious illness
Proximal muscle weakness, especially if accompanied by change in deep tendon reflexes (DTRs) (see Fig. 133)
Joint pain with skin rashes, nodules (see discussion of systemic causes of joint pain, Chapter 3; see Table 36)
Any cluster of signs and symptoms observed during the Review of Systems that are characteristic of a particular organ system (see Box 419)
It is imperative at the end of each interview that the therapist ask the client a question such as the following:
Follow-Up Questions
Are there any other symptoms or problems anywhere else in your body that may not seem related to your current problem?
A2-PAGE 4
Appendix
Copyright 2013, 2007, 2000, 1995, 1990 by Saunders, an imprint of Elsevier Inc.
Copyright 2013, 2007, 2000, 1995, 1990 by Saunders, an imprint of Elsevier Inc.
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