Framework helps clinicians identify serious spinal pathology

May 27, 2020

Rehabilitation clinicians and other health care professionals now have a framework for assessing and managing people who may have serious spinal pathologies. Detailed in a position statement about red flags for serious spinal injuries and disease, this new guidance for clinical practice was developed for the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) and Journal of Orthopaedic & Sports Physical Therapy® (JOSPT®).

"While rare, serious spinal pathology can have devastating and life-changing consequences, and must be identified early and managed appropriately," says Laura M. Finucane, MSc, BSc, FCSP, FMACP, lead author of the statement and vice president of IFOMPT. "This framework is intended to provide clinicians with a clinical-reasoning pathway to clarify the role of red flags in recognizing spinal injuries and disease."

IFOMPT drew on the expertise of 100 experts from 19 countries to synthesize current research and reach consensus on the framework. Seventy clinicians from 13 countries, supported by patient partners, reviewed the information and approved the final version of the framework and its decision tools.

The framework covers four serious spine pathologies: cauda equina syndrome, compression of the nerve roots at the base of the spinal cord; spinal fracture, which accounts for the largest number of serious pathologies of the spine; spinal malignancy, which includes cancers that have spread from a primary cancer site to bone; and spinal infection, which includes infectious disease affecting spinal structures. For each pathology, decision tools summarize the red flags; outline the risk factors, symptoms, signs, and initial investigations; and offer a series of scenarios illustrating how red flags may raise suspicion of that condition.

The framework identifies the level of concern clinicians should have and the clinical action they should take, based on available pathways for therapy or referral to specialist care.

"While they often lack high-quality empirical evidence, red flags remain the best tools available to the clinician to raise suspicion of serious spinal pathology when used in the context of a thorough, subjective patient history and physical examination," Finucane says. As a result, the framework's authors urge clinicians to consider both the evidence to support red flags and the individual profile of their patient to decide how concerned they are that a serious condition exists.
The position statement is titled "International Framework for Red Flags for Potential Serious Spinal Pathologies." Co-authors on the paper are Aron Downie, MPhil, BSc, MChiro, of Macquarie University and The University of Sydney in North Ryde and Sydney, Australia, respectively; Christopher Mercer, MSc, Grad Dip Phys, PG Cert (Clin Ed), FCSP, FMACP, of Western Sussex Hospitals NHS Foundation Trust, Chichester, United Kingdom; Susan M. Greenhalgh, PhD, MA, Phys FCSP, of Bolton NHS Foundation Trust and Manchester Metropolitan University in Bolton and Manchester, United Kingdom, respectively; William G. Boissonnault, PT, DPT, DHSc, of the American Physical Therapy Association, Alexandria, Virginia, United States; Annelies L. Pool-Goudzwaard, PT, PhD, MT, MSc Psych, of Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Jason M. Beneciuk, PT, DPT, PhD, MPH, of the University of Florida and Brooks Rehabilitation in Gainesville and Jacksonville, Florida, United States, respectively; Rachel L. Leech, MSc, BSc, of Manchester Metropolitan University, Manchester, United Kingdom; and James Selfe, DSc, PhD, MA, Grad Dip Phys, FCSP, Manchester Metropolitan University, Manchester, United Kingdom, and Satakunta University of Applied Sciences, Pori, Finland.

The position statement's full citation is: J Orthop Sports Phys Ther 2020;50(7). Epub 21 May 2020. doi:10.2519/jospt.2020.9971. The statement is available at: The framework will be published in print in JOSPT's July 2020 issue.

The following organizations provided financial support for the development and dissemination of this framework: the Canadian Academy of Manipulative Physiotherapy, Chartered Society of Physiotherapy, International Maitland Teachers Association, Musculoskeletal Association of Chartered Physiotherapists, Private Physiotherapy Educational Foundation, and Swiss Association for Orthopaedic Manipulative Physiotherapy.

For more information, please contact Ms. Finucane at, or JOSPT Editor-in-Chief Clare L. Ardern, PT, PhD, at

About the Journal of Orthopaedic & Sports Physical Therapy

The Journal of Orthopaedic & Sports Physical Therapy® (JOSPT®) publishes scientifically rigorous, clinically relevant content for rehabilitation clinicians, including physical therapists, and others in the health care community to advance musculoskeletal and sports-related practice globally. JOSPT is an independent, non-profit journal, published by JOSPT, Inc. d/b/a Movement Science Media. For more information, visit

JOSPT, Inc. d/b/a Movement Science Media

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