Red Flags in Spinal Conditions

Red Flags in Spinal Conditions - Physiopedia 25/12/22, 5:08 PM
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Red Flags in Spinal Conditions

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Original Editor - Anna Butler, Fiona Stohrer and Katherine Moon as part of the Nottingham University Spinal Rehabilitation Project
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Claire Knott, Jess Bell, Gunilla Buitendag, Tarina van der Stockt, Simisola Ajeyalemi and Shaimaa Eldib
Contents
1 Introduction
2 History of Red Flags
3 Epidemiology of Red Flags
4 Subjective Assessment
4.1 Age
4.2 History of Cancer
4.3 Unexplained Weight Loss
4.4 Pain[8]
4.5 Responsiveness to Previous Therapy
4.6 Other[8]
5 Objective History
5.1 Physical Appearance
5.2 Deformity of the spine
5.3 Muscle Spasm
5.4 Neurological Assessment
6 Diagnostic Tests
6.1 Fracture
6.1.1 Lumbar Spine
6.1.2 Cervical Spine
6.2 Cancer
6.3 Ankylosing Spondylitis
6.4 Cauda Equina
7 Clinical Reasoning
8 Management of Red Flags
9 Documentation
10 References
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Introduction
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Clinical findings that increase the level of suspicion that there is a serious medical condition presenting as common, non-serious,
musculoskeletal conditions, are commonly described as red flags.[1]
International guidelines, for example the assessment of lower back pain[2] and neck pain,[3] recommend using red flags to identify
serious pathology. Red flags are features from a patient's subjective and objective assessment which are thought to put them at a
higher risk of serious pathology and warrant referral for further diagnostic testing[4]. They often highlight non-mechanical conditions
or pathologies of visceral origin and can be contraindications to many Physiotherapy treatments.
Although red flags have a valid role to play in assessment and diagnosis they should also be used with caution as they have poor
diagnostic accuracy[5] and red flag questions are not used consistently across guidelines[5]. Some guidelines even recommend
immediate referral to imaging if any red flag is present, which could lead to many unnecessary referrals if clinicians did not clinically
reason their referral[6]. The International Framework for Red Flags for Potential Serious Spinal Pathologies was developed to create
some consensus amongst healthcare workers identifying possible red flags in patients presenting with musculoskeletal complaints.
See also Spinal Masqueraders
History of Red Flags

The role of Physiotherapists in identifying red flags has changed as Physiotherapists increasingly become the patients first point of
contact with a healthcare professional. In McKenzies' 1990 book he states that “the patient once screened by the medical
practitioner, should have any unsuitable pathologies excluded.” Within today’s healthcare system patients may not have even been
seen by a doctor before they present to a Physiotherapist as there is more scope for self referral and private clinics. The term ‘red
flag’ was first used by the Clinical Standards Advisory Group in 1994.[7] However, similar high risk markers date back to Mennell in
1952 and Cyriax in 1982.[8]
Epidemiology of Red Flags

It is hard to get an exact picture of the epidemiology of red flags as it depends heavily on the level of documentation by clinicians.
One study of low back pain suggested that “the documentation of red flags was comprehensive in some areas (age over 50, bladder
dysfunction, history of cancer, immune suppression, night pain, history of trauma, saddle anaesthesia and lower extremity
neurological deficit) but lacking in others (weight loss, recent infection, and fever/chills)”[9].
Table showing breakdown of the conditions lower back pain patients present with
Figures in brackets indicate estimated percentages of patients with these conditions among all adult patients with signs and
symptoms of low back pain. Percentages may vary substantially according to demographic.[10]
Subjective Assessment
Clinicians must be aware of the key signs and symptoms associated with serious medical conditions that cause spinal pain and
develop a system to continually screen for the presence of these conditions.[11] They should also consider the context of the red
flag.[1] It is important to communicate clearly and effectively the reasons for asking these questions with the patient. Provide
reassurance to the patient if they are likely at low risk for a serious pathology.
Age
In the UK, age above 55 years is considered a red flag, this is because above this age, particularly above 65, the chances of being
diagnosed with many serious pathologies, such as cancers, increase[8].
History of Cancer
A patient history of cancer and also family history of cancer should be established, particularly in a first degree relative, such as a
parent or sibling[8]. The most common forms of metastatic cancer are: breast, lung and prostate.
The most common warning signs of cancer are:
Change in bowel or bladder habits

Sores that do not heal
Unusual bleeding or discharge
Thickening or lump in breast elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Unexplained Weight Loss

This should depend on a patient's previous weight and it is sometimes more useful to consider percentage weight loss. A weight loss
of 5% or more within a 4 week period is a rough indicator of when unexplained weight loss should cause alarm[8].
Pain[8]
1. Constant Pain - This needs to be true constant pain that does not vary within a 24 hour period.
2. Thoracic Pain - The thoracic region is the most common region for metastases.
3. Severe Night Pain - This can be linked to be objective history if the patient's symptoms are brought on when they are lying down
or non weight bearing.
4. Abdominal pain and changed bowel habits but with no change of medication - A change is bowel habits can be a red flag for
cauda equina.
Responsiveness to Previous Therapy

This can also be considered a yellow flag and should be taken with caution as many patients suffer episodic lower back and neck
pain. However, patients who initially respond to treatment and then relapse may be a cause for concern[8].
Other[8]
Systemically unwell
Bilateral pins and needles
Trauma , fall from height, road traffic accident or combat
Past medical history of tuberculosis or osteoporosis
Smoking - Has adverse effects on circulation, therefore decreasing the nutritional supply getting to the intervertebral disk and
vertebrae. Over time this leads to degeneration of these structures and therefore instability which can cause lower back pain. It
has also been suggested that regular coughing, which if often associated with smoking, can also lead to increased mechanical
stress on the spine
Cauda Equina Symptoms: urinary retention, fecal incontinence, unilateral or bilateral sciatica, reduced straight leg raise
and saddle anaesthesia
Objective History
The subjective assessment will provide the therapist with the majority of the information needed to clarify cause of symptoms.
[12]
The objective assessment needs to be sufficiently thorough to ensure that if present, red flags are managed appropriately[13]. It
is suggests that a total of 44 items in the objective examination can be considered as red flags[13]
Physical Appearance
The therapist should determine if the patient is unwell objectively however this is a very subjective concept. The following signs may
indicate that the patient has a systemic serious pathology[8].
Pallor/flushing
Sweating
Altered complexion: sallow/jaundiced
Tremor/shaking
Tired
Disheveled/unkempt
Halitosis
Poorly fitting clothes
Deformity of the spine

Deformity of the spine with muscle spasm and severe limitation of movement are suggested to be key indicators of serious spinal
pathology.[8] A rapid onset of a scoliosis may be indicative of an osteoma or osteoblastoma however this may not be
apparent in standing. Physiological movements are often required to determine a rapid onset scoliosis. Some spinal tumors can be
large enough to be seen or felt. Swelling and tenderness may be the first sign of a tumour.[8] It is also common for spinal tumours to
limit physiological movements.
Muscle Spasm
This is suggested to be synonymous with spinal pain and is therefore difficult to determine if it is associated with a red flag
pathology. If a serious spinal pathology is present, the muscle spasm may be severe enough to be a cause of scoliosis in the spine.[8]
The correlation between muscle spasm, pain and other objective clinical measurements however, are poorly supported by strong
evidence.[8]
Neurological Assessment
Patients who report neurological signs in the subjective assessment require a neurological assessment.[14] A neurological deficit is
rarely the first presenting symptom in a patient with serious spinal pathology however 70% of patients will have a neurological deficit
at the time of diagnosis.[8] Dermatomes, myotomes and reflexes should be examined. The upper motor neuron pathways should also
be examined via extensor plantar reflex (Babinski), clonus and hoffmans. If brisk, it may indicate a upper motor neuron pathology.[8]
Diagnostic Tests
In differential diagnosing serious spinal conditions we should understand the best tests for each spinal pathology and/or clusters of
tests. The best tests are: reliable, low cost, have validated findings and high diagnostic accuracy i.e. specifictit and sensitivity).
Specificity - Is the percentage of people who test negative for a specific disease among a group of people who do not have the
disease [15]
Sensitivity - Is the percentage of people who test positive for a specific disease among a group of people who have the disease
[15]
Likelihood ratio = The Likelihood Ratio (LR) is the likelihood that a given test result would be expected in a patient with the
target disorder compared to the likelihood that that same result would be expected in a patient without the target disorder [16]
High sensitivity and LOW LR = RULE OUT people who don’t have the disease
High specificity and HIGH LR = RULE IN people who have the disease
Fracture
Lumbar Spine
Table to show sensitivity, specificity, and likelihood ratios of subjective information in the diagnosis of lumbar
fracture[17][18][19][20][21][22][23]
Subjective Index Sensitivity Specificity Positive likelihood Ratios Negative likelihood Ratios
(%) (%) (%) (%)
History of major 0.65 0.95 12.8 0.37

trauma
0.36 0.90 3.42 0.72
1 0.51 1.93 0.12
Pain and tenderness 0.60 0.91 6.7 0.44
Tenderness 0.50 0.73 1.88 0.68
0.72 0.59 1.76 0.47
Age >50 years 0.79 0.64 2.2 0.34
0.79 0.64 2.16 0.34
Age >52 0.95 0.39 1.55 0.13
Female 0.47 0.80 2.3 0.67
0.72 0.43 1.26 0.65
Corticosteroid use 0.06 0.99 12.0 0.94
0 0.99 3.97 0.97
Clustered Results Sensitivity (%) Specificity (%) Positive likelihood Ratio (%) Negative likelihood ratio (%)
1 of 5 0.97 0.06 1.04 0.43
2 of 5 0.95 0.34 1.43 0.16
3 of 5 0.76 0.69 2.45 0.34
4 of 5 0.37 0.96 9.62 0.66
5 of 5 0.03 1 7.63 0.98
To objectively test for a compression fracture in the lumbar spine the examiner stands behind the patient. The patient stands facing a
mirror so that the examiner can gauge their reaction. The entire length of the spine is examined using firm, closed-fist percussion. It
is positive when the patient complains of a sharp, sudden pain.
Diagnostic Test Sensitivity (%) Specificity (%) Positive Likelihood ratio (%) Negative Likelihood Ratio (%)
Percussion Test 87.5 90.0 8.8 0.14
Cervical Spine
In the cervical spine the Canadian C-Spine Rule can be used to identify when people should be sent for radiography.
Cancer
Shows sensitivity, specificity and likelihood ratios for signs and symptoms that could indicate cancer [24][25][26][27][28][29]
Subjective Index Sensitivity Specificity Positive likelihood ratio Negative likelihood ratio
(%) (%) (%) (%)
Age >50 0.77 0.71 2.5 0.36
0.75 0.70 1.92 0.68
0.50 0.74 1.66 0.06
1 0.41 0.86 1.27
0.55 0.35
Previous history of cancer 0.31 0.98 15.27 0.71
0.31 0.98 31.67 0.06
1 0.97
Failure to improve in one month of 0.31 0.90 3.08 0.77

therapy 0.31 0.90
No relief from bed rest >0.90 0.46
Duration more than one month 0.50 0.81 2.63 0.62
0.50 0.81
Unexplained weight loss 0.15 0.94 2.59 0.90
Ankylosing Spondylitis
Shows sensitivity and specificity of information from subjective assessment in regards to Ankylosing Spondylitis [25]
Subjective Index Sensitivity (%) Specificity (%)
Age of onset <40 1.00 0.07
Pain not relieved by supine 0.80 0.49
Morning back stiffness 0.64 0.59
Pain duration >3 months 0.71 0.54
Chest expansion < or equal to 2.5cm 0.09 0.99
4 out of 5 of the above 0.23 0.82
Cauda Equina
Shows sensitivity and specificity of the signs and symptoms associated with cauda equina[30][31].
Subjective Index Sensitivity (%) Specificity (%)
Rapid symptoms within 24 hours 0.89
History of back pain 0.94
Urinary Retention 90
Loss of sphincter tone 80
Sacral sensation loss 85
Lower extremity weakness or gait loss 84
Abnormal anal tone 1 0.95
Altered perineal sensation 1 0.67
Clinical Reasoning
The use of red flags should not replace clinical reasoning but used as an adjunct to the process.[32] A lone red flag would not
necessarily provide a strong indication of serious pathology. It should be considered in the context of a person's history and the
findings on examination.[33][34]
Patients’ inappropriate misattribution of insidious symptoms to a traumatic event is common and can be misleading. Clinical
reasoning is only as good as the information on which it is based indicating the importance of thorough questioning in the subjective
assessment.
The three types of errors that can occur in clinical reasoning include:
Faulty perception or elicitation of cues

Incomplete factual knowledge
Misapplication of known facts to a specific problem
Within the clinical reasoning process, the therapist should determine if there are logical inferences in regards to the information they
are receiving from the patient. The therapist should not be reassured by previous investigations being reported on as normal. In the
early stages, serious spinal pathology is difficult to detect and weight loss will not always be evident in these early stages.[35]
Red Herrings for serious spinal pathology may include spinal stenosis, lower limb edema, nerve root compression, peripheral
neuropathy, cervical myelopathy, alcoholism, diabetes, MS and UMND.[13] Due to the abundance of red herrings that can be present,
it is important the therapist interprets the red flags in the context of the patient's current presenting condition and not singularly.[13]
Management of Red Flags

If red flags are identified in the spine, the should first consider if onward referral is appropriate.[36] If serious enough, the therapist
may refer to Accident and Emergency such as in the case of cauda equina syndrome and fractures.[37] Otherwise further specialist
medical opinions can be gained,[38] this may be referral onto a specialist spinal clinic.[38]
Failure to improve after one month is a red flag and the patient can be referred back to the GP for continued management and further
diagnostic tests as required.[8] The GP will be able to refer the patient on to have x-rays, CT/MRI, blood tests or nerve conduction
studies.[39] It has been suggested that to reduce the rate of false alarms, the patient should be referred back to the GP in the first
instance to undertake further investigations as required before more advanced imaging is undertaken[40].
Documentation
After onward referral red flags must be acknowledged in the notes as this will indicate contraindication to physiotherapy.
Physiotherapist documentation of red flags in the USA has demonstrated that 8 of 11 red flags were documented 98% of the time as
seen below:
Age over 50
Bladder dysfunction
History of cancer
Immunosuppression
Night pain
History of trauma
Saddle anaesthesia
Lower extremity neurological deficit
Red flags that were not documented routinely included:[38]
Weight loss
Recent infection
Fever/chills
In comparison to this data in the USA, Scotland undertook a review of the documentation of red flags on 2147 episodes of care. The
investigation took place in two phases, between May and June 2008 and January and February 2009). The therapists were given an
online tool to prompt them in respect to the most common red flags [32] Results reported that in the first phase, 33% of red flags
were documented and of those 33%, 54% were cauda equina symptoms. In comparison, within phase two, the rate of
documentation rose to 65% for red flags and within those, 84% recorded cauda equina [32]. Despite documentation improving, this
still left 1 in 5 therapists not documenting red flags. Of all the red flag questions investigated, HIV/drug abuse was the least
documented red flag [32]
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An Introduction to Red Flags in Serious Pathology - Physiopedia

Introduction Only around 1% of all musculoskeletal presentations in primary care will be due to serious pathology.[1][2] Such pathologies include spinal infection, cauda equina,
fracture, and malignancy.[3] Yet despite the low incidence rates, these conditions should be considered as differential diagnoses when individuals present with back pain - particularly
Remote
if the patient Screening
is not responding for Lumbar in an expected Spine way RedorFlags is starting - Physiopedia
to worsen.[1] Identifying serious pathology early on is very important for a number of reasons: Prognosis improves
with early diagnosis Patients tolerate treatment better Outcomes are better Quality of life is better maintained[1] However, it can be challenging identifying serious pathologies as they
Introduction Red flags are clinical findings that are identified from a patient's medical history and the clinical exam and can increase the suspicion of serious pathology such as an
often
infection,masquerade
cancer, orasa musculoskeletal
fracture[1]. The presence conditions, of particularly
red flags from in the early stages
a patient's subjectiveof disease. and objectiveAs a disease assessment progresses, it becomes
are thought to put easier
themto atidentify
a higherasrisk patients
of serious become systemically
pathology and
unwell.[1] What are Red Flags?[edit | edit source] "Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal
Thoracic Back Pain Red Flags - Physiopedia
warrant referral for further diagnostic testing.[2] It is vital that practitioners are aware of these red flags as they form a key component of the assessment and management of low
pain."[4] Red flags are specific attributes derived from a patient's medical history and the clinical examination that are usually linked with a high risk of having a serious disorder like
back pain whilst increasing patient safety.[3] Red Flags and Low Back Pain[edit | edit source] The role of physiotherapists as primary identifiers of red flags has grown owing to the
Introduction
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diagnostic testsany underlying
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spread of self‐referral services.[4] Physiotherapists often exist without input or review.[5] [6]Therefore, there is a need toare ensure rather that clinical
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have aTheir good
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understanding of individual red flags, understand their importance, and can ask these questions in a clear and unambiguous manner. Similarly, physiotherapists must have a clear
Serious
more serious Cervical
pathological Spine Conditions
conditions and - Physiopedia
differential diagnosis should be performed
black. Clinical flags are common to many areas of health – for example, red flags are indicators of possible serious pathology such as inflammatory or neurological conditions,to exclude other pain sources and, most importantly, emergent situations[1] Thoracic spine pain
understanding and agreed pathways of care dependent on these findings. Failure to do so raises issues around patient safety and professional reputation.[3] One study by Feguson
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including symptom progression and co-morbidities.[12] Decision[edit | edit source] The clinician needs to decide if there is a level of concern. If there is none, management
suggestion based
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scan’.[18]
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beliefs, is necessary of CEStowith review the additional
most common details beingrelated thatto ofthisa lumbarinteraction. spine Kendall
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potential metastases, which could wait a few days, but still requires urgent
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et7.al.flexible
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the
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“During theofpast the month cauda have equina.[21] you been Published
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per 100 pathways.[12]
000
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Summary[edit
population.[22]
diagnostic properties In a primary| edit source]care setting,
(Specificity
It is important
(Sp)Table .57-.67), 1 to considerthe
highlights
improve ourincidence
serious pathology
ability to screen of diagnosed as a differential
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presence of
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8. Greenhalgh,
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Likelihood ratio| (LR)
edit source]
S. and
17.5) orThehelp Selfe,
prognosis
in the futureJ. for Red ((+)Flags:
complete LR 7.9) A
for guide
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Churchill
fear severity
avoidance Livingstone:
and duration of compression
beliefs questionnaire Elsevier. (FABQ)upon the
damaged
have beennerve(s).
associated Generally,
with an the longer theperception
exaggerated time before of the
painintervention
and an elevated to remove risk for thechronic
compression causing nerve
LBP symptoms[5]. damage, the
Specifically, a FABQ greater Work the scoredamage >34caused
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<29 produces
Similarly,
a (+) LR 2006. Kennedy
3.33 and (-) et LR
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(1999)respectively,
describe thefor most the important
development factor identified
of chronic LBP in asymptoms.
series of predictors Calley et al. for reported
a favorable theoutcome
utilizationinofCES a two was an early
question diagnosis.[24]
screen for fear avoidance This highlights behaviors the
9. Leerar,
importance
including “Are P J,
of understanding
you afraidBoissonnault,
physical activityW,
and identifying willred Domholdt,
cause flags. an increase E and
Clinical Indicators[edit
in your Roddey,LBP?”| and T. source]
Documentation
edit “Are youThe afraid subjective
that moving ofhistory
red your flags
is back
the most
by be
will physical
important
harmfulaspect totherapists
you?” of can befor
the examination,
patients
effective with early
particularly
for identifying low in
the presentation
patients requiringoffurther a patient with CES
education on as theirtheLBP imperceptible
symptoms[3]. andAn possible
education vague sessionsymptoms devoted related to early CES
to improving a patient’sneed to be identified of
understanding usingpainclear and unmistakable
neurophysiology including methods of
nociception
and backsensitization,
communication.[25]
central pain. [26] ThePremkumar
asJournal of
well as, understanding Manual
et al. (2018) reported and Manipulative
that theand
their thoughts combination
beliefs Therapy. of recent
regarding 2007;
their of 15
losssymptoms bladder (1):can 42improve
control – and 49.outcomes
recent lossinofthese bowel control produced a specificity
patients[4][7][1][5][8]. Clinician’sofshould 97.4%[27]. aim
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masqueraders.ppt. Accessed 13/01/14. 2013.
13. Greenhalgh, S. and Selfe, J. A qualitative investigation of Red Flags for serious spinal pathology. Physiotherapy. 95, pp: 223 –
226. 2009.
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Livingstone. 2001.
15. Sackett, D.L., Straws, S.E., Richardson, W.S., et al. (2000) Evidence-based medicine: How to practice and teach EBM.(2nd ed.)
London: Harcourt Publishers Limited.
16. Centre for evidence based medicine, Critical appraisal, Likelihood ratios, August 2012, (accessed January 2014)
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19. Patrick JD, Doris PE, Mills ML, Friedman J, Johnston C. Lumbar spine x-rays: a multihospital study. Annals Emergency Medicine
1983;12:84-7.
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1981;246:1105-8.
21. Gibson M, Zoltie N. Radiography for back pain presenting to accident and emergency departments. Archives Emergency
Medicine 1992;9:28-31.
22. Deyo RA, Diehl AK. Lumbar spine films in primary care: current use and effects of selective ordering criteria. Journal General
Internal Medicine 1986;1:20-5.
23. Langdon J, Way A, Heaton S, Bernard J, Molloy S. Vertebral compression fractures: new clinical signs to aid diagnosis. Annals
Royal College Surgeons England 2009 Dec 7.
24. Reinus WR, Strome G, Zwemer FL. Use of lumbosacral spine radiographs in a level II emergency department. AJR American
Journal Roentgenology 1998;170:443-7.
25. Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-97.
26. Jacobson AF. Musculoskeletal pain as an indicator of occult malignancy. Yield of bone scintigraphy. Archives of International
Medicine 1997;157:105-9.
27. Frazier LM, Carey TS, Lyles MF, Khayrallah MA, McGaghie WC. Selective criteria may increase lumbosacral spine roentgenogram
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28. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. Journal General
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Red Flags in Spinal Conditions - Physiopedia 25/12/22, 5:08 PM

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Online Course: Introduction to Cervicogenic Headaches

See also Spinal Masqueraders

History of Red Flags

Epidemiology of Red Flags

The most common warning signs of cancer are:

Change in bowel or bladder habits

Unexplained Weight Loss

Responsiveness to Previous Therapy

Deformity of the spine

History of major 0.65 0.95 12.8 0.37

1 0.51 1.93 0.12

Pain and tenderness 0.60 0.91 6.7 0.44

Tenderness 0.50 0.73 1.88 0.68

0.72 0.59 1.76 0.47

Age >50 years 0.79 0.64 2.2 0.34

0.79 0.64 2.16 0.34

Age >52 0.95 0.39 1.55 0.13

Female 0.47 0.80 2.3 0.67

0.72 0.43 1.26 0.65

Corticosteroid use 0.06 0.99 12.0 0.94

0 0.99 3.97 0.97

1 of 5 0.97 0.06 1.04 0.43

2 of 5 0.95 0.34 1.43 0.16

3 of 5 0.76 0.69 2.45 0.34

4 of 5 0.37 0.96 9.62 0.66

5 of 5 0.03 1 7.63 0.98

Percussion Test 87.5 90.0 8.8 0.14

Age >50 0.77 0.71 2.5 0.36

0.75 0.70 1.92 0.68

0.50 0.74 1.66 0.06

1 0.41 0.86 1.27

Previous history of cancer 0.31 0.98 15.27 0.71

0.31 0.98 31.67 0.06

Failure to improve in one month of 0.31 0.90 3.08 0.77

No relief from bed rest >0.90 0.46

Duration more than one month 0.50 0.81 2.63 0.62

Unexplained weight loss 0.15 0.94 2.59 0.90

Subjective Index Sensitivity (%) Specificity (%)

Age of onset <40 1.00 0.07

Pain not relieved by supine 0.80 0.49

Morning back stiffness 0.64 0.59

Pain duration >3 months 0.71 0.54

Chest expansion < or equal to 2.5cm 0.09 0.99

4 out of 5 of the above 0.23 0.82

Subjective Index Sensitivity (%) Specificity (%)

Rapid symptoms within 24 hours 0.89

History of back pain 0.94

Loss of sphincter tone 80

Sacral sensation loss 85

Lower extremity weakness or gait loss 84

Abnormal anal tone 1 0.95

Altered perineal sensation 1 0.67

Faulty perception or elicitation of cues

Management of Red Flags

Red flags that were not documented routinely included:[38]

Practical Assessment and Treatment of Cervicogenic Headaches

Learn more on this topic