There are many countries in which direct access to physiotherapy is possible. This means that patients do not have to see a general practitioner or specialist first in order to be referred for physical therapy.For this reason, an important first step for a physiotherapist during the intake procedure of a new patient especially without referral is to screen for serious pathology which might make a referral to the GP or specialist necessary.
During the screening procedure you should ask closed questions that the patient can mainly answer with yes or no.A typical screening procedure consists of the following 6 steps:
- Health seeking question
Ask your patient to briefly summarize his complaint, his goals with physiotherapy and his expectations from you. An example could be: I have pain in my right shoulder. “I would like to be able to play tennis again as soon as possible. I’m expecting that you show me exercises that I can do myself at home in order to speed up my recovery.” The health seeking question has to fall into the domain of the physiotherapist, otherwise the patient should be referred to a healthcare specialized that better fits the patient’s needs.
Be aware, that it’s important to give a patient space and time to tell their story, but this should be done during patient history taking and not during screening.
2. General red flags
The table below shows an overview of the questions that need to be asked during general screening. When screening for general red flags, you are trying to recognize a pattern of the following serious pathologies:
| Cancer | Infection | Fracture | CNS pathology |
| -Pain at rest/at night -Movement- independent pain -General malaise -Unexplained weight loss of >5kg in 1 month -Previous episode of cancer in history |
-Pain at rest/at nigh -Movement- independent pain -General malaise – Unexplained fever – Night sweats |
-Pain at night -Recent trauma -Severe pain that does not improve -Prolonged use of corticosteroids in history |
– Widespread loss of sensation in arms/ legs -WidespreaD loss of strength in arms/ legs -Dizziness -Problems with balance and vision |
3. Specific red flags
These are serious pathologies that are specific to a certain body region or joint. An example would be cauda equina syndrome for the low back or avascular necrosis in the shoulder or hip. In order to be able to screen for specific red flags you will have to obtain knowledge about signs & symptoms.
4. Tract anamnesis
Organ systems of the human body can cause visceral referred pain to a remote location which could be interpreted as somatic pain. For this reason it’s important to exclude that your patient’s complaints are of visceral nature.The following table derived from Snyder & Goodman gives you an overview about which organ dysfunctions can cause visceral referred pain to the respective body parts:
| Viscera | Afferent innervations | Referred pain |
| Liver, diaphragm, pericardium | n. Phrenicus (C3-C5) | Shoulder, neck |
| Gallbladder, stomach, pancreas small intestine |
n. Splanchnicus major (T6-T9) | Mid back, scapular region |
| Colon, appendix, pelvic viscera | n. Splanchnicus minor (T10-T11) | Mid back |
| Sigmoid colon, rectum, urethers, testes | n. Splanchnicus minor (T10-T11) Pelvis splanchnicus nerves (S2-S4) |
Pelvis, flank, low back, sacrum |
5. Course: normal or abnormal?
Depending on the complaint, a normal course is generally marked by a gradual decrease in pain and increase in activity level and participation. If this is not the case, we are talking about an abnormal course as most injuries are healed after 3 months at max. If your patient presents with an abnormal course, you assess for negative prognostic factors which could explain the delayed recovery. These factors are often found in the psychosocial domain, work-related or can be explained by inadequate coping. If the abnormal course cannot be explained, you should be suspicious of a serious pathology.
6. Movement-related complaint?
Complaints that are of musculoskeletal origin can be aggravated or eased by movement. Even if your patient complains about constant pain or pain at night, you should establish a clear link with specific body movement. If this link is absent, it might be an indication of an underlying serious pathology.
Note that serious pathologies usually never establish themselves in just one red flag, but you will recognize red flags in all steps of the screening procedure. If you are confident that there is no pattern that could indicate a serious pathology after all of the 6 steps, you can continue with patient history taking. If you would like to further investigate individual red flags, you could also decide to use orthopedic or neurological screening tests for which you can find an extensive list on our channel. On the contrary, if you recognize a pattern indicating a serious pathology, probably coupled with a bad gut feeling, you should contact a GP or specialist or write a referral letter. Note that you should also refer a patient if another health provider is better equipped to treat the patient’s condition, even in the absence of red flags.
It’s important to keep in mind that your screening process basically never stops. Even during your treatment you should stay alert, especially as time and response to conservative treatment can be used as diagnostic tools as well.