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Finger Reset After Dislocation

3 Weeks after a DIP Dislocation in a gymnastics injury, swelling, pain, and weakness remained in the PIP more than DIP of that digit. She was unable to grip or hang/swing on bars without pain. In order to restore threat free grip, compression plus lateral rotation held enabled full pain-free passive end range flexion of the PIP. For the DIP, which was also limited in flexion, end range repeated extension restored pain-free flexion. Just a little experimentation and you can easily find desensitizing repeated loading strategies. She was prescribed to do these resets hourly and gradually work on grip strength.

[UPDATE]: Just followed up, after 4 days of the reset and grip strengthening, she was able to complete a bars routine and prior she was unable to even hang from the bar. Swelling is down, but still present, and grip strengthening needs to continue.

What a Pain in the Groin!

 

I watch a lot of hockey….like A LOT of hockey.  It seems like every offseason there are at least a handful of players having surgery for femoral acetabular impingement (FAI), “hernia” repairs and/or abdominal “tears.”

Whenever there is a huge increase in certain procedures, I’m always a little suspect whether it’s just the latest trendy thing to be done or truly necessary.  In June of 2018, the Journal of Orthopedic Sports Physical Therapy even dedicated their whole issue to FAI occurrence and treatment. 

It was an interesting issue that didn’t just address FAI, but a large number of complex groin pain.  I realized much is the same as it was 20 years ago, but the understanding of the concurrent injury has improved.

What’s In A Name? 

Complex and difficult to treat groin pain has gone by a lot of names over the years. Gilmore’s Groin, Sports Hernia, Core Muscle Injury, Athletic Pubalgia.  All these different terms complicate literature searches and lead to poorly defined anatomy definitions.

It is now agreed upon to leave the term “hernia” behind because the injury usually involves the various structures that compromise the pubic and abdominal aponeurosis, but rarely a deficiency of the posterior wall. 

The literature also doesn’t agree whether surgical intervention or conservative treatment is best. These patients may seek you out for pain management or while waiting for a diagnosis.

Who’s At Risk?

Males are at higher risk than females due to the narrow pubic arch angle.  As well as athletes that involve high frequency of deceleration and acceleration particularly with cutting/pivoting such as ice hockey, soccer, rugby, and our military personnel.

71% can relate the pain to a reproducible, specific activity that usually involves hyperextension of the trunk and hip hyperabduction.  And there is a high incident with a co-existing FAI. Athletes with limited ROM due to FAI will rely more on trunk extension and the pivot point of the pubic symphysis perhaps making them more at risk to develop tears of the aponeurosis. Repetitive pelvic motion against a fixed extremity with decreased range due to CAM or Pincer lesions may result in rectus abdominus sheath and oblique muscle fiber injuries (Strosberg et al 2016). Studies have shown if the athlete has their abdominal/groin tear repaired, but not FAI, only 25% return to sport.

However, if both are repaired 89% return to sport (Larson et al 2014).

What Do I Need To Look For? 

We are not going to diagnosis an athlete with FAI or athletic pubalgia.

But what if our athlete comes to us with groin pain and we aren’t sure if it’s something muscular to treat? 

What makes this diagnosis difficult is there is no great test or exam that is specific for these injuries.  And studies have shown that there are potentially 17 different structure that can be involved!  Common Hallmark Signs include:

  • Deep going or lower abdominal pain
  • Pain exacerbated by very specific sports activity that is relieved by rest
  • Palpable tenderness over a conjoined tendon or rectus abdominus insertion near pubic tubercle
  • Pain with resisted abdominal curl up
  • Pain with resisted hip abduction at 0, 45 and 90 degrees of hip flexion

And of course, if your patient isn’t responding to treatment, it’s always time to investigate further.

To Treat Or Not To Treat?  

Most guidelines agree to always treat conservatively.

However, only 27% of athletes return long term to sport with conservative treatment.

Also, the length of a conservative treatment trial is somewhat controversial and inconsistent.  Nature of injury, level of performance of the athlete and length of time before return to pre-injury play all need to be considered when deciding how long to have a trial of conservative treatment.

I think back to my college athletic training days and I realize there were quite a few “sports hernia” surgeries being done.  So maybe this isn’t a new trend after all! However, it’s always good to remind myself of signs and symptoms and anatomy so we all make sure we are treating our patients effectively. It will, of course, be crucial for you to do your own assessment and use your critical thinking on how to progress with treatment, along with how to manage it as a conservative treatment as recommended. But at least after this hockey season is done, I’ll have my own answers as to how necessary the treatments on my favourtie players are.

 

References:

Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding Athletic Pubalgia: A Review. Rhode Island Medical Journal (2013)[serial online]. October 4, 2016;99(10):31-35.

Copperthite K. Athletic Pubalgia, Part 1: Anatomy and Diagnosis. Athletic Therapy Today[serial online]. September 2010;15(5):4-

Harris-Hayes M, Steger-May K, van Dillen LR, Schootman M, Salsich GB, Czuppon S, Clohisy JC, Commean PK, Hillen TJ, Sahrmann SA, Mueller MJ. Reduced Hip Adduction Is Associated With Improved Function After Movement-Pattern Training in Young People With Chronic Hip Joint Pain.  J Orthop Sports Phys Ther. 2018 Apr;48(4):316-324. doi: 10.2519/jospt.2018.7810. Epub 2018 Mar 16.

Heerey J, Risberg MA, Magnus J, Moksnes H, Ødegaard T, Crossley K, Kemp JL.  Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol for the HIP ARThroscopy International Randomized Controlled Trial.  J Orthop Sports Phys Ther. 2018 Apr;48(4):336-342. doi:10.2519/jospt.2018.8002.

Hopkins J, Brown W, Lee C. Sports Hernia: Definition, Evaluation, and Treatment. JBJS Reviews[serial online]. September 2017;5(9):e6

Larson CM. Sports Hernia/Athletic Pubalgia: Evaluation and Management. Sports Health. 2014;6(2):139-144. doi: 10.1177/1941738114523557

Munegato D, Bigoni M, Gridavilla G, Olmi S, Cesana G, Zatti G. Sports hernia and femoroacetabular impingement in athletes: A systematic review. World Journal Of Clinical Cases[serial online]. September 16, 2015;3(9):823-8

Strosberg D, Ellis T, Renton D. The Role of Femoroacetabular Impingement in Core Muscle Injury/Athletic Pubalgia: Diagnosis and Management. Frontiers In Surgery[serial online]. February 12, 2016;3:6.

Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, HÖlmich P.  Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management.  J Orthop Sports Phys Ther. 2018 Apr;48(4):239-249. doi: 10.2519/jospt.2018.7850. Epub 2018 Ma

Articles Of The Week March 11, 2018

Is yoga effective for managing chronic pain? Maybe, but then again maybe we just need to look at safe, non-threatening movement as a way to cure or manage chronic pain.

“Yoga, Mice, Pain and Your Brain” – Sarah Haag

There are some great points in this article about doing aggressive psoas work on patients, but there’s some things I don’t like about the article. To say that only those trained in visceral work should be doing this kind of work (because there’s not much evidence to say visceral manipulation is effective), is a bit of a stretch. However, I like the overall gist, that only trained professionals should be doing the work, and to be careful, there’s no need to do “aggressive” work.

“Serious Warning – If You Do Any Releases To Your Psoas or Abs, You Must Read This” – Antony Lo

Load management in athletes is an important factor in making athletes available for, and being in the best shape possible for competition. This post reviews three factors related to load management to help your athletes.

“Load Management Is Not About Decreasing Minutes” – Tim Gabbett

I love sleep, so I hate this part of the year where I lose an hour of it putting the clocks forward (why are we still doing this!?). A lack of sleep can lead to a host of health conditions and can affect brain health. Fortunately, massage therapy helps with sleep, so this could be a good article to share with your patients as another reason to get a massage!

“Why Are We So Sleep Deprived And Why Does It Matter?” – The Conversation

I’ve been asked many times if I would ever open up a practice at home and while it’s not for me, I know plenty of therapists who do. This post lays out several things to consider if you are wanting to open a home-based practice.

“Opening A Home Based Massage Business” – Allissa Haines

The Adolescent Female And The Athlete Triad

 

Many RMTs, Athletic Therapists and Physios start their career wanting to work with athletes, I know I did.

I had dreams of spending my days in the locker room and on the field, being part of a team and sharing in the glory of winning (having never been talented enough to compete myself!).

For many years, I did just that.

I worked in a sports clinic with my physical therapy “hat” on treating sports injuries and my evenings and weekends covering athletic events wearing my athletic trainer “hat.”  During my time at an all-girls high school, I became involved in female athlete triad research and bone stress injuries.

It opened my eyes to how athletics can affect females differently than males.

Since then, how we view the triad and how we treat it has changed.

Can you recognize and screen for the signs of the triad?  Do you know who is at risk?

What Is The Triad, And How Do We Recognize It?

Adolescent girls should participate in sports.  I want that to be clear.

Girls participating in sports have better communication with their parents, are less likely to get pregnant, have more positive body image and are 20% less likely to get breast cancer later in life.

But they are at risk for injury,  48% of female athletes will have injury severe enough for them to miss playing time.

Bone stress injuries are common in adolescent females, occurring in up to 21% of competitive females.  Injuries can range from a stress reaction to a stress fracture and occurs from a disturbance in osteoblastic bone formation and osteoclastic resorption.  The most common places are the foot, lower leg and pars in the spine.  Risk factors include endurance sports, sudden changes in training (duration, intensity, equipment) and inadequate recovery time.

90% of peak bone mass is gained by 18 years of age and research shows athletes have approximately 10% more bone density than non-athletes.  So any non-traumatic bone injury is cause for concern.  

It is imperative that the underlying cause is investigated and treatment includes resolving more than just the fracture.

Any time there is a bone stress injury, the other components of the Female Athlete Triad should be considered.

The Female Athlete Triad was first described in 1992 as disordered eating, amenorrhea (specifically missing more than 3 periods in a row) and osteoporosis.  The triad has now been expanded to include a spectrum of each pathology.  Screening should include having less than 6 periods a year (not necessarily consecutive missed cycles), dietary counselling and a DEXA bone density scan that compares the Z-scores, which matches the athlete to others her age. A  -2.0 standard deviation or greater is concerning.

The crux of the triad seems to be low energy availability due to disordered eating.

The athlete doesn’t necessarily try to restrict their calories, although some do in body-conscious sports, or if they are concerned about their weight.  Many are just unaware of the amount of food it takes to fuel their daily activity.  Sometimes they are just eating poorly: fast food, processed food, you know….they are teenagers!  This low energy availability leads to hypoestrogenism and disrupts menstrual cycles.

Estrogen normally inhibits bone turnover and maintains a balance between resorption and formation.  When there is a nutritional deficit and a lack of estrogen, this balance is disrupted.

Back when we started the research, we thought the best thing to do was replace the estrogen. Makes sense right?  Studies now show that using oral birth control does not change the bone density, even with prolonged use.  The first treatment should be nutritional counselling and improving caloric intake.  There are great resources online at www.femaleathletetriad.org that includes a nutritional calculator to get you started.

Also, find a nutritional counsellor in your area used to working with athletes.

Photo by: KeithJJ

What Can We Do?

So what do you do as a healthcare professional?

Know the signs….an athlete presenting with even one component has a 3x greater risk to develop one of the other components.  The Female Athlete Triad Coalition has a great screening tool that is non-confrontational and can easily be done as part of pre-participation screens.

Have information available.  Adolescent females need 1300mg of calcium a day and the best source is spread out throughout the day with food.  Raw green leafy vegetables, broccoli, almonds, canned sardines with bones, low-fat milk products are the best sources.  Certain medications can also impact bone health and may predispose your athlete to bone injuries.

Antiseizure medications (also used for migraine control), prednisone, SSRIs, thyroid medications are common medications for adolescents to be taking for a variety of disorders.

Female Athlete Triad is primarily hormonal and dietary driven.  It’s important to have a multidisciplinary approach to diagnosis and treatment.  It’s also important to be a nonjudgmental place for your athlete.  Athletes are a lot of fun to work with and you are part of a much larger team, especially when dealing with the triad.

 

References:

  • Goolsby M, Boniquit N. Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones. Sports Health[serial online]. November 7, 2016
  • Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985-996
  • De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43:140-14
  • Liu SL, Lebrun CM. Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review. Br J Sports Med. 2006;40:11-24
  • Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4:302-311
  • O’Connor D, Blake J, Bell R, Bowen A et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause and Beyond. J Obstet Gynaecol Can 2016;38(6):508-554
  • femaleathletetriad.org

Travelling In Sport As A Massage Therapist

 

When I decided to go back to school to be a Massage Therapist, the one thing that made me decide on this new profession was the chance to work with athletes and sports teams.

The whole idea of working with teams always had a certain lure to me, getting to be part of that team environment always seemed more appealing than strictly working in a clinic.

While in college I was lucky enough to start working with our local Junior A hockey club and continued working with them for seven years, even being the head trainer and medical director for one season. During that season, I did some travel with the team to other parts of the province and got the feel of what it’s like to be on the road with a team, dealing with transport, setting up dressing rooms, loading and reloading the bus with equipment and all the other issues that happen on the road.

Because of putting in the time volunteering with that team, some other great opportunities have come my way. I got to spend a year working with our Rugby 7’s men’s national team, and in 2016 I got my first opportunity to work with our national women’s development program in hockey.

Since working with the women’s development program, I’ve had two opportunities to travel internationally with them. I thought I knew the work and effort it takes to work with a team from my past experience, but working and travelling internationally takes on a whole other level of work and work ethic to be successful.

I know many of our readers are interested in this type of work, so I’ll try to outline what an average couple of days looks like work-wise, so you’ll know what you’re getting into if this is your chosen area of interest.

Daily Schedule

While I’m sure it’s different for every sport and probably every venue, it takes a ton of work to get things set up at hotels, dressing rooms, and whatever venue you are using to help the athletes throughout a tournament.

You aren’t doing strictly massage therapy when you’re on the road, you’re helping out wherever is needed, plus covering some aspects you may not have thought of (keep in mind this is just three days of a three-week trip).

Pretournament Game

5:00 amLight snack

5:30 amAthlete exercise routine  

6:00 amTeam meetings/presentations

6:30 amTeam practice/dryland

7:00 amRegular breakfast

7:30 amMorning session with S&C coach

7:45 – 9:10amPractice session for some athletes  

10:00am – 12:00pmPhysio & Massage Therapy treatments

1:30 pmPregame Meal

3:10 pmAthletes and coaches meeting

3:45 pmDryland warmup

4:30 pmOn ice warmup for both teams

5:00 pmGame time

5:10 pmAthlete cool down  

8:20 pmDinner

9:00 pmStaff meeting

Travel Day

5:00 amLight snack

5:30 amAthlete exercise routine

5:45 amTeam meetings/presentations

6:30 amBreakfast

6:50 amAthletes and coaches meeting

7:15 amDryland warmup

8:00am – 9:15amTeam practice

9:30 amAthlete cooldown 

9:30 am – 10:15 amHelp equipment manager pack up the dressing room and load all equipment on the bus

10:30 amLunch

12:15 pmLoad all team luggage on the bus

12:30 pmLeave for airport

1:45 pmCheck all baggage and equipment in through airport security

5:05 pmFlight leaves

6:30 amLand for connecting flight

10:10amConnecting flight departs

3:25 pmLand in destination, collect luggage, load bus

6:00 pmCheck into hotel

6:30 pmDinner

7:00 pmAll support staff (medical, logistics, equipment manager etc) set up athletes dressing room, medical room, and all associated equipment.

9:10 pm Staff meeting (time depending on dressing room setup completion)

Pre-competition

8:15 amBreakfast

8:45 amAthlete and coaches meeting

9:30 amDryland warmup

10:00 am – 11:45 amPractice

12:00 pmAthlete cool down

12:40 pmLunch

1:15 pmTeam meetings/presentations

2:00 pm – 4:00 pmPhysio and Massage Therapy treatments

4:30 pmLight meal

5:30 pmDryland warmup

6:00 pm – 7:15pmPractice

7:25 pmAthlete cool down

8:30 pmDinner

9:00 pm – 10:00 pmTreatment window for Physio and Massage

10:10 pmStaff meeting

Gameday

7:15 amBreakfast

7:45 am – Athlete and coaches meeting

8:15 amDryland warmup

9:00 am – 9:45 amPregame Skate

9:55 amAthlete cool down

11:00 amLight lunch

12:00 pm – 2:00 pmPhysio and Massage Therapy treatments

3:30 pmPregame Meal

4:50 pmAthlete and coaches meeting

5:45 pmDryland warmup

6:30 pmOn ice warmup for both teams

7:00 pmGame time

9:10 pmAthlete cool down

10:30 pmDinner

11:00pmStaff meeting

So when you look through this schedule, everywhere it talks about dryland warmup, athlete cool down, and practices, at least one member of the medical team is expected to be in attendance. Typically one member attends while the other therapist tends to some other tasks like filling game water bottles, getting ice, making up ice bags, or helping the equipment manager if needed (essentially doing the background work that isn’t typically thought about). Sometimes the practices and warmups etc. overlap each other depending on how the schedule is set, so you could be covering one practice and another medical staff member is covering the other one.  

During game times I would go up and help the video coach by shooting video during the game, while the physiotherapist is on the bench. Essentially everyone has a job description, so each members time is utilized and productive. 

If you’ve followed this blog for very long, you’ve seen articles stressing the need for us as a profession to be certified in First Aid training. In sports, it’s even more important to be trained as a First Responder. In cases like this, anytime there is an emergency with one of the athletes, the Massage Therapist is part of the emergency action plan and is expected to take part in the injury or emergency, whether it’s on the ice, or off. 

I can’t stress enough how important it is to get this training if working in sports is your interest!

The Team Within The Team

All of the staff are literally another team, within a sports team, it’s not just about the athletes working together.

As I mentioned before, you could be tasked with some menial work (filling water bottles etc.) while another member of the medical staff is working directly with the athletes at a warm up or cool down.

You can’t have an ego about this! 

Even if you work with a team at home and you’re the head trainer, that may not be your role when you travel with a national team. They will have a specific job description for you, and it’s important you adhere to it. There are some really long days where you could be setting up a dressing room, or loading equipment for travel (and not actually do any massage), while the coaches are doing their prep work, logistics are organizing travel, and other members are filling the role for whatever their responsibility is.

But just like the athletes who may be playing a smaller role on the team than they play at home, everyone comes together as a team to accomplish a goal. EVERYONE is filing a different role than they are used to. There will be days you get frustrated, you’ll be tired, and maybe even annoyed with other staff members. But part of being on a team is the ability to put that aside, come together, and work for the benefit of the athlete, it’s about them, not you. 

However, if you are willing to work, put your ego aside and do this kind of work, the benefits are phenomenal. The friendships you’ll make, the pride of not only helping the athletes performance but also representing your country (or whatever organization you’re working with) is incomparable. Plus, you may even end up with a cool picture and a medal at the end of it all.

 

Red Flags For Low Back Pain, Or Clinical Decision Making?

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital. 

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

  • Mechanism of injury
    • Fall from greater than 20ft
    • High-speed accident
    • Pedestrian struck at speeds higher than 30 km/hour
    • Broken windshield damaged steering wheel, or airbags deployed
    • A rollover accident
    • Severe crush injuries
    • Any other people involved in the accident that result in a fatality
    • Electrical injuries (we always assume spinal damage with electrocution)
  • Anatomy of injury
    • Severe brain injury
    • Penetrating injuries to anything but the limbs
    • Depressed skull fracture
    • Pregnant woman with fairly moderate trauma
  • Findings in the Primary Survey
    • Decreased level of consciousness
    • Cardiac arrest
    • Suspected heart attack
    • Poisoning
    • Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening. 

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

  • Fever/chills
  • Use of corticosteroids or immunosuppressant therapy
  • IV drug use
  • Pain worse at night
  • Night and rest pain
  • Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness)  and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

  • A belief that back pain is harmful or disabling
  • Fear of pain and movement avoidance
  • Tendency to low mood and withdrawal from social interaction
  • Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.