Prevalence and “Red Flags” Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice

Enthoven, Wendy T. M.; Geuze, Judith; Scheele, Jantine; Bierma-Zeinstra, Sita M A; Bueving, Herman; Bohnen, Arthur M.; Peul, Wilco C.; Tulder, Maurits W. van; Berger, Marjolein Y.; Koes, Bart W.; Luijsterburg, Pim A J

doi:10.2522/ptj.20140525

Cited by 44 publications

(40 citation statements)

References 36 publications

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“…We found two systematic reviews presented in 5 articles [13][14][15][16][17]. Furthermore, we found 2 narrative reviews [10,18], 7 prospective cohort studies [19][20][21][22][23][24][25][26], 9 retrospective cohort studies often collecting data from medical records [27][28][29][30][31][32][33][34][35], and 8 case reports [36][37][38][39][40][41][42][43]. Six studies provided diagnostic test accuracy data related to red flags for detection of malignancy for patients with LBP and were included in the assessment of diagnostic accuracy using the QUADAS-2 (Table 1) [20,21,22,24,26,29].…”

Section: Search Resultsmentioning

confidence: 99%

“…For example, 202 patients (17.2%) had an 'insidious onset, 46 patients (3.9%) had 'a history of cancer', and 3 (0.3%) had 'unexplained weight loss'. The other study did not present accuracy data and is described above [25].…”

Section: Studies With Accuracy Datamentioning

confidence: 98%

“…Lastly, a primary care prospective cohort included 669 patients with LBP of 55 years or older [25]. After a 12-months follow-up 4 patients were found with malignancy, but no data on the diagnostic accuracy of red flags for malignancy were reported.…”

Section: Studies Without Accuracy Datamentioning

confidence: 99%

“…Two more recent replication studies were conducted [24,25]. One prospective cohort study included 1172 patients with a new episode of LBP in primary care [24].…”

Section: Studies With Accuracy Datamentioning

confidence: 99%

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Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Verhagen

Downie

Maher

et al. 2017

Pain

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Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.

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Section: Search Resultsmentioning

confidence: 99%

Section: Studies With Accuracy Datamentioning

confidence: 98%

Section: Studies Without Accuracy Datamentioning

confidence: 99%

“…Two more recent replication studies were conducted [24,25]. One prospective cohort study included 1172 patients with a new episode of LBP in primary care [24].…”

Section: Studies With Accuracy Datamentioning

confidence: 99%

See 2 more Smart Citations

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Verhagen

Downie

Maher

et al. 2017

Pain

Self Cite

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“…LBP not affiliated with a serious pathology will often exhibit symptoms that are similar to competing diagnoses such as fracture, cancer and other red flags. Many of the red flags associated with LBP are more prevalent in older individuals,21 a subset of individuals who will also frequently have concomitant orthopaedic-related LBP 22. In a study designed to identify movement examination features unique to metastatic spinal cancer, 61 of 66 individuals with LBP were diagnosed with metastatic bone cancer and (concomitantly) were diagnosed with a condition such as lumbar stenosis, spondylosis or degenerative disc disease 22.…”

Section: Introductionmentioning

confidence: 99%

Red flag screening for low back pain: nothing to see here, move along: a narrative review

2017

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Screening for red flags in individuals with low back pain (LBP) has been a historical hallmark of musculoskeletal management. Red flag screening is endorsed by most LBP clinical practice guidelines, despite a lack of support for their diagnostic capacity. We share four major reasons why red flag screening is not consistent with best practice in LBP management: (1) clinicians do not actually screen for red flags, they manage the findings; (2) red flag symptomology negates the utility of clinical findings; (3) the tests lack the negative likelihood ratio to serve as a screen; and (4) clinical practice guidelines do not include specific processes that aid decision-making. Based on these findings, we propose that clinicians consider: (1) the importance of watchful waiting; (2) the value-based care does not support clinical examination driven by red flag symptoms; and (3) the recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis.

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Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: a network meta-analysis

Bagg

McLachlan

Maher

et al. 2018

Cochrane Database of Systematic Reviews

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This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To answer the clinical question: 'what analgesic medicine shall I prescribe this patient with chronic low back pain to reduce their pain? '. The objectives are to determine the analgesic effects, safety, effect on function, and relative rank according to analgesic effect, safety and effect on function of a single course of opioid analgesics, NSAIDs or paracetamol or combinations of these medicines. B A C K G R O U N D Description of the condition Low back pain (LBP) presents an enormous global health problem. It is the leading cause of disability (GBD Collaborators 2017a), 1 Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: a network meta-analysis (Protocol)

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Prevalence and “Red Flags” Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice

Abstract: In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

Cited by 44 publications

References 36 publications

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Red flag screening for low back pain: nothing to see here, move along: a narrative review

Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: a network meta-analysis

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