Recognising Red Flags With Lower Back Pain Patients

Posted By: Andy Barker

You know the importance of your red flag questions.

They are asked to make sure you don’t miss any serious pathology and treat something you shouldn’t.

But despite what many therapists believe…

A positive answer does not mean instant referral to A & E or the need for a second opinion.

But it should raise suspicion.

A positive red flag question is something that will likely need further questioning.

Many New Grad’s often tell me they just feel like they go through the motions…

Asking ‘red flag’ questions for asking sake…

Unsure about what they might do if the patient did answer YES to any one of those red flag questions.

This blog post will help you make sense of your red flag questioning.

It will give you some easy tips to help you remember what questions, you need to ask, when you need to be cautious and ask further questions and when it is safe to treat.

Lets take a look…

What Questions To Ask?

Asking red flag questions is a necessity for any patient you see with lower back pain.

These are the questions you need to ask to attain if your patient has any of these symptoms;

Thoracic pain
Fever and unexplained weight loss
Bladder or bowel dysfunction
History of cancer
Ill health or presence of other medical illness
Progressive neurological deficit
Disturbed gait, saddle anaesthesia
Age of onset <20 years or >55 years

They are broad questions for a reason.

To ‘screen’ for every possible sinister pathology that could cause lower back pain is impossible.

As such no subjective history is going to be able to rule out every possible sinister cause.

The aim of red flag questioning is to identify the most common sinister pathologies.

And heighten your suspicion which would prompt you to ask more questions.

Context Is Key

Just because a patient has one or more red flags does NOT mean you can’t treat them.

The context of their symptoms or their responses is key.

Take for example, the history of cancer.

This is clearly a red flag.

It is a red flag because we know a history of cancer raises the risk of further episodes of cancer.

Also the presence of cancer contraindicates certain interventions, including certain manual therapy techniques.

However, even with a history of cancer you might still be able to treat this patient.

If a patient presented with lower back pain following a slip, trip or fall, there is a clear mechanism as to why they have presented with this injury.

This is very different to the same patient presenting with a previous history of cancer and insidious onset symptoms and the presence of other symptoms..

Like night pain…

Or symptoms not associated with movement or position.

These might suggest currently active cancer and something that might require onward referral.

The context of symptoms is key and will influence your management.

A red flag does not mean no treatment or rehab.

You need to take into consideration their symptoms and what they mean.

Make It Easy For Yourself

Trying to remember all your red flag questions can be tough.

There is no shame in not knowing them all ‘off my heart’ especially as a New Grad.

Make it easier for yourself.

If you struggle to remember things, write them down.

Have a list or have a ‘cheat sheet’ that has your red flag questions on it and place it somewhere where you can quickly refer to.

This will make sure you don’t miss any important questions and possibly miss some important patient information.

It will help your subjective questions flow and make you sound and feel more confident during your patient assessments.

It can be tough trying to remember everything you need to ask…

So make it easier for yourself and see your confidence in your assessments grow!

Key Take-Aways

What Questions To Ask? Any patient with lower back pain should be asked red flag questions. The same goes for patients with other spinal injuries.

Context Is Key: Just because you get a positive red flag response does NOT mean no treatment or rehab. You need to take into consideration the context of their injury, symptoms and the patients past medical history.

Make It Easy For Yourself: Make a ‘cheat sheet’ that you can quickly refer to during your assessments, so you don’t miss any of your important red flag questions.


The New Grad Physio Mentor

PS. Do you want to touch up on your red flag questions so you stop worrying you might miss a sinister injury during your assessments?

If so, let me know.

Email me at with the subject ‘Red Flags’ and I’ll get right back to you with some help.