Author: Rainer Smale



Asking ‘special questions’ is a component of every patient examination and generally include the following areas of questioning for symptoms related to the patient problem/history (Van Tulder et al., 2006, p. S172):

  • 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).
  • 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 (including cauda equina syndrome).
  • 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?”
  • Bladder and bowel disturbance.
  • Cauda equina sings or signs of cord compression.
  • … but have you ever found yourself wondering why we are asking them, how to interpret the responses given by our patients, and how to continue questioning deeper when we need to clarify the information gained?

I have written this blog to recap some key information regarding red flags.

Here are some fun statistics (Van Tulder et al., 2006, p. S172)…

  1. The lifetime prevalence of low back pain is reported as over 70% in industrialised countries.
  2. In over 85% of those suffering from lower back pain, the pain is not attributable to pathology or neurological encroachment.
  3. About 4% of people seen with low back pain in primary care have compression fractures and about 1% has a neoplasm.
  4. Ankylosing spondylitis and spinal infections are even more rare.
  5. The prevalence of prolapsed intervertebral disc is about 1% to 3%.

With regards to lower back pain, 97% of cases can be diagnosed as mechanical lower back pain, 2% visceral pain, and <1% from other non-mechanical causes (Jarvik & Deyo, 2012).

It is our professional responsibility to be able to identify those who required further medical examination or treatment. Identifying these patients begins during the subjective examination when we question for the presence of RED FLAGS.

“‘Red flags’ are risk factors detected in patients’ past medical history and symptomatology and are associated with a higher risk of serious disorders causing pain compared to patients without these characteristics. If any of these are present, further investigation (according to the suspected underlying pathology) may be required to exclude a serious underlying condition, e.g. infection, inflammatory rheumatic disease or cancer” (Van Tulder et al., 2006, p. S172).


Presence of signs/symptoms of serious pathology

  • Constant pain
  • Pain that is not related to movement
  • Presence of severe spasm
  • Morning stiffness >half hour
  • Presence of severe night pain
  • Present of night sweats
  • History of cancer
  • Recent fracture or trauma

Presence of symptoms of spinal cord compromise

  • Non-dermatomal symptoms
  • Ataxia or clumsiness
  • Increased reflexes
  • Positive Babinski sign or clonus
  • Non-myotomal muscle weakness

Presence of symptoms of the following conditions

  • Active infection
  • Active Scheuermann’s disease
  • Osteoporosis or osteopenia
  • Pregnancy
  • Advanced diabetes
  • Inflammatory disease
  • These conditions may have precautions or contraindications to manipulation

Signs of possible spinal instability in

  • Rheumatoid Arthritis
  • Spondylolisthesis

Symptoms of acute spinal nerve or nerve root compression

  • Dermatomal pain or paraesthesia or anaesthesia
  • Decreased reflexes
  • Decreased myotomal power
  • Production of neurological signs with spinal movements

Use of medication

  • Anti-depressants
  • Anti-coagulants
  • Oral Steroids
  • Strong analgesia
  • Muscle relaxants
  • Opiates


Cervical spine

Disorders that may stimulate spinal pain in the cervical spine include (Maitland, 2005):

  • Malignant lymphadenopathy.
  • Pancoast’s tumour.
  • Vertebral artery syndrome.
  • Subarachnoid haemorrhage.
  • Coronary artery disease.
  • Polymyalgia rheumatica.

Thoracic Spine

Disorders that may stimulate spinal pain in the thoracic spine include (Maitland, 2005):

  • Bronchogenic carcinoma.
  • Other lung disease.
  • Coronary artery disease.
  • Aortic aneurysm.
  • Massive cardiac enlargement.
  • Hiatus hernia.
  • Gall bladder disease – cholecystitis.
  • Herpes zoster.

Lumbar spine

Disorders that may stimulate spinal pain in the lumbar spine include (Maitland, 2005):

  • Peptic ulcer.
  • Renal disease.
  • Pancreatic carcinoma.
  • Obstruction of aorta or iliac arteries.
  • Carcinoma of colon or rectum.
  • Other pelvic carcinomas.
  • Endometriosis.
  • Pregnancy.
  • Disseminated sclerosis.
  • Spinal cord tumour.
  • Hip disease.


So just to look a step closer at the signs we are looking for and how to expand our questioning further….

Dizziness is the most common complaint associated with vertebrobasilar insufficiency (VBI). When dizziness is present you must assess for the presentation of the following symptoms (the presence of one of these symptoms is enough to warrant caution and further investigation).

  • 5D’s
    • Dizziness
    • Diplopia, blurred vision or transient hemianopia
    • Drop attacks (loss of power or consciousness)
    • Dysphagia (problems swallowing)
    • Dysarthria (problems speaking)
  • 3 N’s
    • Nystagmus
    • Nausea or vomitting
    • Other neurological symptoms
  • 5 others
    • Light headiness or fainting
    • Disorientation or anxiety
    • Disturbances in the ears – tinnitus
    • Pallor, tremors, sweating
    • Fascial paraesthesia or anaesthesia.

Emergency referral is required when a patient presents with cauda equina sings or signs of cord compression i.e

  1. Bladder dysfunction (usually urinary retention),
  2. Faecal incontinence,
  3. Saddle anaesthesia,
  4. Global / progressive upper or lower limb weakness, and
  5. Gait disturbance.
  6. Glove or stocking paraesthesia in the limbs.

Hopefully this blog expands on your current understanding of red flags or reminds you of the depth the questioning can go into when are trying to identify sinister pathology. I always find it helpful to know why I’m asking these questions to my patients and what answers I am hoping/not hoping to receive.



Hengeveld, E., & Banks, K. (2005). Maitland’s peripheral manipulation: Elsevier/Butterworth Heinemann.

Jarvik, J. G., & Deyo, R. A. (2002). Diagnostic evaluation of low back pain with emphasis on imaging. Annals of internal medicine, 137(7), 586-597.

Van Tulder, M., Becker, A., Bekkering, T., Breen, A., Gil del Real, M. T., Hutchinson, A., … & Malmivaara, A. (2006). Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal, 15, s169-s191.