Asking Special Questions In Your Subjective Assessment

It is our professional responsibility to be able to identify patients who require further medical examination or treatment.  Identifying these patients begins during the subjective assessment through the use of special questions to identify Red Flags.  A common list of Special Questions are as follows:

  • Age of onset of pain less than 20 years or more than 55 years
  • Recent history of violent trauma
  • Questioning of dizziness (5D's & 3N's)
    • 5D's
      • Dizziness
      • Diplopia (blurred vision or transient hemianopia)
      • Drop Attacks (loss of power or consciousness)
      • Dysphagia (problems swallowing)
      • Dysarthria (problems speaking)
    • 3N's
      • Nystagmus
      • Nausea or Vomitting
      • Other Neurological Symptoms
  • Constant progressive, non mechanical pain (no relief with bed rest)
  • Thoracic pain
  • Past medical history of malignant tumour
  • Prolonged use of corticosteroids as well as other long term medications
  • Drug abuse, immunosuppression, HIV
  • Systemically unwell
  • Unexplained weight loss
  • Widespread neurological symptoms
  • Structural deformity
  • Fever and night sweats
  • General Health - 'do you have any other medical conditions?' 'how is your general health?'
  • Investigations - 'have you had or been referred for any scans?'

Red Flag Screening

The term red flags refers to clinical features that help to identify the presence of potentially serious conditions.  Such conditions include tumours, infection, fractures and neurological damage.

Screening for serious conditions must occur during history taking at initial assessment and may be followed up with specific physical tests during examination.

Red flags indicate the need to consider further investigation and/or referral to an appropriate specialist.

Types of clinical red flags

Clinical red flags for your patient include:

  • Cauda Equina Syndrome: features include some or all of: urinary retention, faecal incontinence, widespread neurological symptoms and signs in the lower limb(s), gait abnormality, saddle area numbness and a lax anal sphincter.  Acute Cauda Equina Syndrome is a medical emergency and requires urgent hospital referral.
  • Weight Loss
  • History Of Cancer
  • Fever
  • Intravenous Drug Use
  • Steroid Use
  • Age Of Onset 20yrs < Or > 55yrs
  • Severe, Unremitting Night-Time Pain

Recommended approach for red flags

  • all patients with symptoms or signs of Cauda Equine Syndrome should be referred urgently to a hospital for orthopaedic or neurosurgical assessment
  • patients with Red Flags should be investigated appropriately and referred to a specialist if indicated by clinical findings and test results
  • investigations in an episode of cause low back pain do not provide clinical benefit, unless there are red flags.  Radiological imaging (x-rays and CT scans) carry the risk of potential harm from radiation-related effects and should be avoided if not necessary for diagnosis or management
  • a full blood count and ESR should usually be performed only if there are red flags.  Other tests may be indicated depending on the clinical situation
  • remember, red flag pathology may lie outside the lumbar region and may not be detected by radiology.

Yellow Flag Screening

Yellow Flags are psychosocial factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain.

Kendall et al. (1997) developed guidelines for assessing 'yellow flags' in acute low back pain, outlining factors that should be assessed particularly when progress is slower than expected.  The presence of such factors is a prompt for further detailed assessment and early intervention.  'Red Flags' and 'Yellow Flags' are not mutually exclusive and intervention may be required to address both clinical and psychosocial risk factors.

Poor Outcome Predictors

There is good agreement that the following factors are important and consistently predict poor recovery outcomes:

  • The presence of beliefs that back pain is harmful or potentially severely disabling
  • Fear-avoidance behaviour (avoiding a movement or activity due to misplaces anticipation of pain) and reduced activity levels
  • Tendency to low mood and withdrawal from social interaction
  • An expectation that passive treatments rather than active participation will help

Questions To Ask Your Patient

Below are some questions to assist you in identifying potential psychological barriers to recovery.  these questions are to be phrased in your own words.

  • Have you had time off work in the past with back pain?
  • What do you understand is the cause of your back pain?
  • What are you expecting will help you?
  • How is your employer responding to your back pain?
  • Your co-workers?  Your family?
  • What are you doing to cope with back pain?
  • Do you think that you will return to work?  When?

The Keele Start Back Screening Tool

The Keele STarT Back Screening Tool is a brief, validated tool (Hill et al 2008), designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making.

The instrument is being used by a range of clinicians to systematically identify patients 'at risk' or persistent symptoms.

The 9-item tool is designed to classify patients into one of three subgroups for targeted primary care management:

  • low risk
  • medium risk (physical indicators)
  • high risk (physical and psychosocial indicators)

Early behavioural management of lumbar disorders

Suggested steps to better early behavioural management of low back pain include:

Be positive and realistic

  • Provide a positive expectation that the individual will return to work and normal activity.  If the problem persists beyond two to four weeks, provide a reality-based warning of what is going to be the likely outcome (for example loss of job, the need to begin reactivation from a point of reduced fitness)
  • Be directive in scheduling regular reviews of progress.  When conducting these reviews shift the focus from the symptoms (pain) to function (level of activity).  Instead of asking 'How much do you hurt?' ask 'What have you been doing?'.

Provide expectations of continued activity

  • Keep the individual active and at work if at all possible, even for small part of the day.
  • Acknowledge difficulties with activities of daily living, but avoid making the assumption that these indicate all activity or any work must be avoided.
  • Help to maintain positive cooperation between the individual, empower, compensation system and health professionals.
  • Make a concerted effort to communicate that having more time off work will reduce the likelihood of a successful return to work.
  • Be alert for the presence of individual beliefs that he or she should stay off work until treatment has provided a 'total cure'.

Promote self-management and self-responsibility

  • Encourage people to recognise, from the earliest point, that pain can be controlled and managed so that a normal, active or working life can be maintained.   Provide encouragement for all 'well' behaviours - including alternative ways of performing tasks, and focusing on transferable skills.
  • Encourage the development of self-efficacy to return to work.

Involve multidisciplinary services if required

  • Be prepared to ask for a second opinion, provided it does not result in long and disabling delay, especially if it may help clarify that further diagnostic work up is unnecessary.  Be prepared to say 'I don't know' rather than provide elaborate explanations based on speculation.
  • Avoid confusing the report of symptoms with he presence of emotional distress.  Distressed people seek more help, and have been shown to be more likely to receive ongoing medical intervention.  Exclusive focus on symptom control is not likely to be successful if emotional distress is not dealt with.
  • If barriers to return to work or accustomed activity are identified and the problem is too complex to manage, referral to a multidisciplinary team is recommended.