Red flag screening questionnaire, is it necessary?
Harry Herrewijn
Last year I attended William Boisonnault`s , `screening methods `course.
A very interesting and practical course, with a lot of aspects I wasn`t aware of enough, or at all.Here he presented a questionaire, that he uses for the patient intake. It takes the patient about ten minutes to fill out. At the course Boisonnault told that it is a big help for him, also for legal issues.
In Switzerland, in a physiotherapy intake, this isn`t common practice. I was curious and was wondering in what way it would be an extra help to me for the C/O and also if it would be influencing my clinical reasoning.
I started to hand out the german questionaire, translated by Kerstin Lüdtke, to patients. Ideally before the first treatment, when this wasn`t possible at the end of it and they had to bring it at the second treatment.
A 33 year old patient attended the praxis with the diagnosis `Thoracic pain syndrom`
He complained of Thoracic pain, especially on the right side.
He also had tension in the cervical spine and complained of left sided frontal headache.
He sometimes suffered from dizzyness and slight swalloing problems.
Cauda Equina and spinal cord were o.k.
No symptoms in his arms, legs or feet.
Aggravating factors were lying flat on his back, lifting something heavier than 5 kilo`s and .sitting for more than 45 minutes.
Relieving factors were lying on his back in flexion and walking around.
He wasn`t sleeping very well and woke up every morning between 4 and 5 o`clock because of the pain.
In the morning he was stiff, which got better 1 hour after he got up.
His profession is mechanic. He does a lot of representation for his company. Which means of a lot of cardriving and sitting in the office. At the moment he was 100% on sick leave
Five Months ago he had to lift a 60 kg barrel at work.
He felt a stinging pain on the right thoracic side and the pain was so intense that he had to stop working.
He went to his GP. He got pain medication and went for treatment to a osteopath and to a chiropractor, who both diagnosed a blocated rib. He was treated in the thoracic spine with mobilisation and manipulation. He had some relieve from it, but most of the pain didn`t go away. He said he had a `funny stomach`since the treatment.
With 16 and 19 years old he has had two major roadtraffic accidents.
The only medication he takes is optifen when neccesary. He had some weight loss but that was deliberately, he said. General health was ok
After the C/O the clinical pattern wasn`t clear to me. A blocated rib which doesn`t get better after 5 months with mobilisation and manipulation? Still at sick leave? Dizzynes and swallowing problems? A. vertebrae? A `funny stomach`? Cord signs? waking up every morning between 4 an 5 o`clock? Internal Organs? Mulidirectional pain with movement but also without with morning stiffness? Something inflammatory? Some weight loss ? Are there some maligne processes going on? Two aggrevating car accidents in the past? Instability? Pain for 5 Months with no clear clinical pattern? Was there already some pain centralisation? Was it just the vegetative nervous system? A very mixed picture where the features didn`t fit to me.
Because he was treated only at the thoracic spine until now, I decided to just take a quick look at the movements of the Tx and than concentrate on the cervical spine, with the hypothesis that something in the Cx could irradiate to the Tx or maybe even give some irritation of the Spinal cord.
Main findings were: limited rotation to the left, less movement and quality with flexion, a lot of extension mid cervical spine. With all the movements no pain, just tension.
The PPIVM`s showed an increased Extension in C4-5 and stiffnes in the upper and lower CX.
Linear Movents to the left appeared to have more movement at C4-5.
I treated the stiffnes at the Cx – Tx junction for 5`with accesory movements grades IV-.
The reassement showed more movement at the Cx and more movement and less pain at the TX.
The only thing I knew now that there was an instability and I could influence the Tx problem with treatment of the Cx. But was that the cause of his problems? Was the change a mechanical reaction? Was it more reflectory? Was this instability I found really causing all these problems?
While he had no time to fill out the questionaire before the treatment, I had to give the red flag screening questionaire at the end of the first treatment.
At the second session he reported that he had had a lot of pain after the treatment, he have had some dizzynes and problems with concentration,.When I looked at the questionaire he brought, there were a few points he crossed which I didn`t expect:
He complained of tiredness, weakness, sleeping problems, sexual dysfunction, obstipation, some urine incontenency and a lot of stress.
Even though I asked for problems with going to the bathroom and sensibility loss in the pelvic floor region, which he denied in the first session, apparently it wasn`t so good after all.
With more detailed questioning he said that the incontenency was just slightly and not always. Once in a while he was stumbling and a lot of times hit his leg with walking stairs. He also confirmed sometimes having problems with his balance
Even though he had no signs on the bodychart in arms and legs, I did a neurological exam and found in the upper extremity: hypersensibility I, II an V on the left side, loss of force of every kennmuscle and BTR and TTR were less.
ULNT 1 was ok.
Lower extremity: SLR right R1 at 20° R2+P1 40°, SLR left R1 20°, P1 30° P+N whole leg and foot.
Babinsky negative. No clonus. Force, sensibiliy and reflexes of the lower extremity were normal.
This wasn`t fitting in any pattern for me at all and I was worried about some spinal cord involvation in some way or maybe some neurological disease (MS?)
I send him back to his GP, called her and told her my findings an worries..
She was very surprised to hear al those findings. Until now apperently nobody had asked for those informations and nobody had done a neurological examination until now.
She send him to a specialist, where blood was taken, an MRI was made and tests for ms were done. They found some older, discrete vertebral plate fractures at T5 an T7 but all the other findings were negative. Was it then only stress causing this?
He was send back to me for further Treatment.
After nine sessions he estimated the problem 60% better. Slight pain on the right Tx remained.
A lot of the signs were gone, but the tiredness, no appetite , weakness in the arms and some neurological signs remained.
I send him back again to the GP for fürther investigation.
Retrospectively this was a clinical presentation I hadn`t seen before.
I thought I had done a fairly complete c/o.
After receiving back the questionaire, some very important information about his problem apeared which I had missed before.
That could have several reasons; maybe I didn`t ask thouroughly enough?,maybe I used the wrong wording?, maybe Ididn`t ask explicilitly enough? or maybe had a wrong understanding of his wording? Maybe reading something at home on paper is different than being asked?
In the end, because of the questionnaire,, I had a much more complete information and because of that I could adapt my reasoning in this situation, which I was very thankful for.
I had a more complete picture of this patient, I could give very detailed information to the GP and most of all with all this in mind, I could adapt my treatment .Though there weren`t any severe findings until now, I still was, and I still am, not reassured about his situation.
A red flag screening questionaire is maybe not necessary, but to me, it is a very good extra tool which I, definitely after this example, continue to use in my daily praxis.
It doesn`t cost me any extra time and it helps me to reflect even more on my findings and my clinical reasoning.
Références :
Kerstin Lüdtke, Lucia Grauel, Daniela Laube: `Screening in der Physiotherapie`
William Boissonnault: Screening methods Course script
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