The One-Percenters

Posted by Terry Pratt, MS, PT, COMT, FAAOMPT on Nov 14, 2020 9:09:20 AM

Since PT school we have all been taught to be wary of serious pathology masquerading as musculoskeletal pain. We learn about the red flag, the 5 Ds, and the 3 Ns, etc. In fact, research has presented 163 possible signs and symptoms which can be reported as red flags for spinal pathology alone! There are some who disregard the screening for serious pathology as an unnecessary impediment to proving the intervention they prefer. Also, in their opinion, these signs and symptoms are so rare, they should not be a major concern for your average therapist. I would like to stress that even though these conditions are atypical for most patients, for those who have the pathology, the diagnosis is “devastating and life changing.” I call these patients the one-percenters, because although serious pathology is rare, they deserve appropriate screening.

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) in March of this year published an “International Framework for Red Flags for Potential Serious Spinal Pathology,” which is worth reviewing and implementing into clinical practice. It is thoroughly researched and has taken the best available evidence and combined it with clinicians who routinely work in the care of patients. With this information they formed a consensus statement which can be applied to everyday practice. Here you can access the framework which summarizes patient centered care with consideration of red flags and is well worth reviewing.

Serious spinal pathology can present in the form of upper motor neuron signs. Metastasis to the spinal cord from cancer are the 2nd most common serious pathology of the spine after fracture and presents as 0.6% to 1.6% of cases entering clinics. Knowing how these signs present can be challenging since they only are rare. The video below demonstrates how a patient presents who has actual UMN signs.


At NAIOMT we have always emphasized safety through clinical reasoning and this framework from IFOMPT is well worth reading to provide a guide for safe clinical practice. Our courses emphasize shared decision making and clinical reasoning with patient safety as our number one priority.

Please consider the information above and feel free to share it with your colleagues. I have had countless class participants thank me, because they had a patient who had a serious pathology that they identified because they learned how to screen for red flags.




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