Red flags need more evaluation: reply

Abstract

The response by Henschke and Maher to our review article on ‘The role of physiotherapy for non-specific back pain and neck pain’ presents a useful opportunity for a discussion on an important topic. Red flags are clearly important as ignoring them can, in rare cases, result in severe disability (such as cauda equina lesion) whilst on the other hand accepting them uncritically, can result in many unnecessary referrals and investigations. The latter could raise anxiety, increase reliance on health care professionals and be wasteful of limited resources. Unfortunately, the evidence for red flags is under-developed and, as Henschke and Maher point out, there is a dearth of primary research in this area. Many red flags cited may indeed be red herrings, as discussed in a recent review presented at the Society for Back Pain Research [1]. In particular, some red flags listed in national guidelines, such as thoracic pain or night pain, are contentious and should be considered in context. Henschke and Maher are right in warning that clinicians should not uncritically accept any one red flag in isolation—the context is crucial. It might therefore be wiser to recommend that a physiotherapist who identifies any red flags should consider whether a referral to a specialist is appropriate. As we stated in the article, any signs indicating a cauda equina lesion or widespread/progressive neurology would necessitate an urgent referral. The subject of the review article was ‘non-specific low back pain and neck pain’. We feel that there is a fine balance between the amount of attention that needs to be given to red flags and the physiotherapist's subsequent management of non-specific back pain. It is important that we do not unnecessarily over-medicalize back pain and make sure that the emphasis is on helping the individual as far as possible to return to usual activities. The authors have declared no conflicts of interest.