Screening of Head, Neck and Back

Physiotherapy notes using the Goodman and Snyder screening model

Important: A red flag is not a diagnosis. One isolated red flag may not mean serious disease, but a cluster of flags, worsening symptoms, or abnormal neurological findings should lower the threshold for referral.

---

The 5-step screening model

1. Past medical history

• Previous cancer, infection, inflammatory disease, osteoporosis, fracture
• Neurological disorders, seizures, stroke, migraine
• Rheumatoid arthritis, ankylosing spondylitis/spondyloarthropathy
• Diabetes, cardiovascular disease, hypertension
• Recent surgery, injections, spinal procedure, hospital admission
• Current medication, especially:
  • corticosteroids
  • anticoagulants
  • immunosuppressants
  • long-term analgesics
• Previous episodes, imaging, treatment response

---

2. Risk-factor assessment

---

3. Clinical presentation

• When did it begin? Sudden or gradual?
• Was there trauma?
• Is pain constant, progressive, or severe at night?
• Is it linked clearly to movement, posture, loading, or rest?
• Does it improve with mechanical treatment or activity modification?
• Is the pattern changing or worsening despite treatment?
• Is pain local, referred, radicular, widespread, or non-mechanical?

Likely mechanical pattern

• Clear relationship to movement, posture, position, or load
• Symptoms change predictably with repeated movements or rest
• No systemic illness features
• No progressive neurological deficit
• Gradual improvement with appropriate conservative care

Suspicious non-mechanical pattern

• Constant and not altered by position or movement
• Progressive and unremitting
• Severe at night or at rest
• Accompanied by constitutional or neurological symptoms
• Not behaving as expected for a musculoskeletal disorder

---

4. Associated signs and symptoms

• Fever, chills, night sweats
• Unexplained weight loss, fatigue, malaise
• Nausea, vomiting, dizziness, fainting
• Visual disturbance, speech difficulty, facial weakness
• Dysphagia, dysarthria, drop attacks
• Chest pain, breathlessness, sweating
• New bowel/bladder dysfunction
• Saddle numbness
• Progressive weakness, altered gait, loss of hand function
• Skin rash, bruising, swelling, masses
• Severe night pain or pain not relieved by rest

---

5. Review of systems

---

Region-specific screening

A. Head screening

Key subjective questions

• New headache or a change in a usual headache pattern
• “First” or “worst” headache
• Sudden onset reaching maximum intensity quickly
• Head injury
• Dizziness, vertigo, syncope, seizures
• Visual loss, diplopia, speech or swallowing difficulty
• Facial numbness/weakness
• Fever, neck stiffness, rash
• Pregnancy/postpartum period
• Cancer or immune suppression
• Scalp tenderness or jaw claudication

Headache red flags

• Thunderclap headache: sudden, severe headache
• New focal neurological deficit
• Altered consciousness, confusion, seizure, or collapse
• Headache with fever and neck stiffness
• New headache after head trauma
• New or progressive headache in a person with cancer or immunosuppression
• New headache after age 50
• Headache with visual disturbance, temporal artery tenderness, or jaw pain while chewing
• Severe headache during pregnancy or postpartum
• Headache aggravated by cough, exertion, or Valsalva
• Worsening or progressively changing headache pattern

Head-related PT examination

• Observe general appearance, distress, gait, speech, cognition
• Check vital signs
• Screen cranial nerve-related function if symptoms suggest involvement
• Basic neurological examination: strength, sensation, reflexes, coordination, balance
• Cervical examination only after excluding urgent findings

---

B. Neck screening

Important conditions not to miss

• Cervical fracture or instability
• Cervical myelopathy
• Cervical artery dysfunction
• Infection or malignancy
• Inflammatory arthropathy
• Cardiac referral
• Neurological emergency

Cervical myelopathy red flags

• Bilateral arm or leg symptoms
• Progressive weakness, clumsiness, or loss of hand dexterity
• Gait imbalance, frequent falls, broad-based gait
• Hyperreflexia, clonus, pathological reflexes
• New bowel or bladder change
• Progressive sensory loss

Cervical artery or serious vascular concern

• Sudden unusual neck or head pain
• Severe headache unlike previous headaches
• Dizziness with neurological symptoms
• Diplopia, dysarthria, dysphagia
• Ataxia, drop attacks, facial numbness, visual disturbance
• Nausea/vomiting not explained by a benign cause
• New Horner syndrome symptoms such as drooping eyelid and unequal pupils

Other neck red flags

• Recent major trauma or high-risk mechanism
• Severe midline cervical tenderness
• Fever, immune suppression, IV drug use, recent infection
• History of cancer or unexplained weight loss
• Neck pain with chest pain, sweating, nausea, or dyspnoea
• Rheumatoid arthritis, spondyloarthropathy, or Down syndrome with neck symptoms
• Severe unremitting night pain

---

C. Back screening

Serious pathologies to consider

1. Fracture
2. Malignancy
3. Infection
4. Cauda equina syndrome
5. Severe or progressive neurological compromise
6. Inflammatory spinal disease
7. Visceral referral, for example renal, abdominal, pelvic, or gastrointestinal disease

Back pain red flags

1. Cauda equina syndrome: emergency

• New urinary retention or overflow incontinence
• New faecal incontinence
• Saddle/perineal numbness
• Bilateral sciatica
• Severe or progressive bilateral leg weakness or numbness

2. Fracture

• Significant trauma
• Minor trauma in an older adult or person with osteoporosis
• Long-term corticosteroid use
• Sudden spinal pain with local bony tenderness
• Pain aggravated by loading/percussion

3. Cancer

• Previous or current cancer
• Unexplained weight loss
• Constant progressive pain
• Night pain or pain at rest
• Failure to improve as expected
• New neurological deficit

4. Infection

• Fever/chills/night sweats
• Recent infection, surgery, injection, or invasive spinal procedure
• IV drug use
• Diabetes or immunosuppression
• Severe constant pain with systemic illness

5. Inflammatory spinal disorder

• Younger onset
• Gradual onset
• Morning stiffness
• Improvement with exercise but not rest
• Night pain, especially second half of night
• Alternating buttock pain
• Personal/family history of psoriasis, uveitis, inflammatory bowel disease

6. Visceral referral

• Renal: flank pain, urinary symptoms, fever
• Abdominal/aortic: abdominal or pulsatile pain, vascular risk factors
• GI: abdominal symptoms, nausea, altered bowel habits
• Pelvic/GU: pelvic symptoms, menstrual or urinary changes

---

Brief physical screening sequence for the physiotherapist

1. Observe
   • General appearance, distress, posture, gait, ability to transfer
   • Skin changes, scars, swelling, muscle wasting, bruising, rash
2. Measure vital signs when indicated
   • Blood pressure, pulse, respiratory rate, temperature, oxygen saturation
3. Neurological screen
   • Myotomes/strength
   • Dermatomes/sensation
   • Reflexes
   • Upper motor neuron signs where indicated
   • Coordination, balance, gait
   • Cranial-nerve-related screen when head/neck symptoms indicate it
4. Spinal examination
   • Active movement and symptom response
   • Functional movements
   • Palpation only as appropriate
   • Neural tests only when safe and clinically indicated
5. Reassess
   • Does the examination support a musculoskeletal hypothesis?
   • Is there a mismatch between symptoms and mechanical findings?
   • Are symptoms worsening, systemic, progressive, or unexplained?

---

Clinical decision: treat, refer, or emergency referral

---

Quick memory aid

HEAD

• H: History of cancer, immune suppression, head trauma
• E: Exertional or thunderclap headache
• A: Altered consciousness, age >50 with new headache
• D: Deficit, diplopia, dysarthria, dysphagia
• S: Stiff neck, scalp tenderness, systemic fever

NECK

• Trauma, vascular symptoms, myelopathy, infection, cancer, inflammatory disease, cardiac symptoms.

BACK

• Bowel/bladder dysfunction
• Anaesthesia in saddle area
• Cancer/infection/constitutional symptoms
• Kinetic trauma or osteoporosis/steroid use

Screening of the Head, Neck and Back

Simplified notes based on Goodman and Snyder’s Screening Model

1. Past medical history
2. Risk-factor assessment
3. Clinical presentation
4. Associated signs and symptoms
5. Review of systems

---

1. First decide: Mechanical or non-mechanical?

Likely mechanical musculoskeletal pain

• Has a clear injury, postural, movement, or loading relationship
• Changes with movement, position, activity, or rest
• Is reproducible during examination
• Has no major systemic symptoms
• Has no progressive neurological signs
• Improves as expected with conservative care

Possible non-mechanical or systemic source

• Is constant, progressive, or unexplained
• Is not changed by movement or position
• Is severe at night or at rest
• Is associated with fever, weight loss, fatigue, or malaise
• Is accompanied by neurological, vascular, visceral, or constitutional symptoms
• Does not improve as expected

---

A. Screening the Head

Step 1: Past medical history

• Previous migraine, headache, seizure, stroke, head injury
• Hypertension or vascular disease
• Cancer
• Immune suppression, HIV, diabetes, long-term steroid use
• Recent infection, especially sinus, ear, dental, or systemic infection
• Pregnancy or recent childbirth
• Anticoagulant medication
• Previous neurological disease

---

Step 2: Risk factors

• Age above 50 years with a new headache
• Cancer history
• Immune suppression
• Recent head trauma
• Hypertension or vascular disease
• Pregnancy/postpartum period
• Anticoagulant use
• Recent infection

---

Step 3: Clinical presentation

• Is this the first headache or the worst headache?
• Did it start suddenly or gradually?
• Is it different from the patient’s usual headache?
• Is it aggravated by cough, exertion, straining, or change of posture?
• Is it becoming more frequent or more severe?
• Is there a history of trauma?

Suspect a serious headache when it is:

• Sudden and severe
• New and progressive
• Associated with neurological signs
• Associated with fever or neck stiffness
• Different from the patient’s normal headache pattern

---

Step 4: Associated signs and symptoms

Red flags for headache

• Sudden severe “thunderclap” headache
• “First” or “worst” headache
• Headache after trauma
• Fever, rash, and neck stiffness
• Seizure, confusion, reduced consciousness, or fainting
• New weakness, numbness, facial droop, speech difficulty, or visual disturbance
• Persistent vomiting
• Headache with cancer or immune suppression
• New headache after age 50 years
• Headache with jaw pain on chewing, scalp tenderness, or visual loss
• Headache during pregnancy or postpartum
• Progressively worsening headache

Possible serious conditions

• Stroke or transient ischaemic attack
• Meningitis/encephalitis
• Subarachnoid haemorrhage
• Brain tumour or raised intracranial pressure
• Giant cell arteritis
• Intracranial infection
• Cervical artery pathology

---

Step 5: Review of systems

• Fever, chills, weight loss, fatigue
• Visual change, double vision, vision loss
• Speech or swallowing difficulty
• Facial weakness or numbness
• Dizziness, ataxia, collapse, or seizure
• Jaw claudication and temporal tenderness
• Nausea/vomiting
• Neck stiffness

Referral decision for head symptoms

---

B. Screening the Neck

Step 1: Past medical history

• Trauma, fall, road traffic accident, whiplash
• Rheumatoid arthritis
• Ankylosing spondylitis or other spondyloarthropathy
• Down syndrome
• Cancer, infection, osteoporosis
• Previous cervical surgery
• Cardiovascular disease
• Previous stroke, transient ischaemic attack, or vascular disorder
• Current drugs: anticoagulants, steroids, immune-suppressing drugs

---

Step 2: Risk factors

• Recent significant trauma
• Older age with a fall or osteoporosis
• Rheumatoid arthritis or inflammatory disease
• Cancer history
• Fever, recent infection, immune suppression, IV drug use
• Vascular disease, smoking, hypertension
• Long-term corticosteroid use

---

Step 3: Clinical presentation

Mechanical neck pain

• Is related to posture, movement, sustained positions, or load
• Is reproducible with cervical movement
• Improves or changes with unloading, exercise, or postural correction
• Has no serious systemic or neurological symptoms

Non-mechanical neck pain

• Constant or progressive pain
• Severe night pain
• Pain unrelated to movement
• Severe neck pain with unusual headache
• Neck pain with chest pain, shortness of breath, sweating, or nausea
• Neck pain with progressive neurological symptoms

---

Step 4: Associated signs and symptoms

Cervical myelopathy red flags

• Bilateral arm or leg symptoms
• Progressive weakness
• Hand clumsiness, dropping objects, difficulty with buttons/writing
• Gait disturbance, poor balance, repeated falls
• Hyperreflexia or clonus
• New bowel or bladder disturbance
• Progressive sensory loss

Cervical artery/neurological warning signs

• Diplopia
• Dysarthria
• Dysphagia
• Drop attacks
• Dizziness or severe disequilibrium
• Ataxia
• Numbness around the face
• Visual disturbance
• Nausea/vomiting with neurological symptoms
• New severe unusual headache

Other neck red flags

• Fracture risk after trauma
• Severe midline cervical tenderness
• Fever, chills, night sweats
• Unexplained weight loss
• History of cancer
• Severe unremitting pain
• Neck mass, persistent hoarseness, difficulty swallowing
• Neck pain with chest pain, sweating, dyspnoea, or nausea

---

Step 5: Review of systems

• Fever, weight loss, fatigue
• Balance and walking difficulty
• Hand function and dexterity
• Bowel/bladder changes
• Visual, speech, facial, or swallowing symptoms
• Chest symptoms
• Inflammatory symptoms: morning stiffness, psoriasis, eye inflammation, bowel disease

Referral decision for neck symptoms

---

C. Screening the Back

Step 1: Past medical history

• Previous cancer
• Osteoporosis, fracture, or long-term steroid use
• Recent trauma or fall
• Diabetes, infection, immune suppression
• IV drug use
• Recent spinal surgery, injection, or invasive procedure
• Kidney, urinary, bowel, abdominal, pelvic, or gynaecological disease
• Inflammatory arthritis, psoriasis, uveitis, inflammatory bowel disease
• Previous neurological symptoms or episodes of bowel/bladder dysfunction

---

Step 2: Risk factors

---

Step 3: Clinical presentation

Mechanical back pain

• Is altered by bending, lifting, sitting, standing, walking, or position
• May be linked to an injury or overload
• Has predictable aggravating and easing factors
• Shows a mechanical movement pattern
• Improves gradually with appropriate management

Non-mechanical back pain

• Is constant and unrelieved by rest
• Is severe at night
• Is progressive
• Is not changed by movement or posture
• Is associated with systemic signs
• Does not improve as expected
• Is accompanied by neurological deficit or bowel/bladder symptoms

---

Step 4: Associated signs and symptoms

1. Cauda equina syndrome: emergency

• New difficulty starting urination
• Urinary retention
• Overflow urinary incontinence
• Loss of bowel control
• Saddle or perineal numbness
• Bilateral sciatica
• Severe or progressive bilateral leg weakness

---

2. Fracture

• Major trauma
• Minor trauma in an older adult
• Osteoporosis
• Long-term steroid use
• Sudden severe back pain
• Focal bony tenderness
• Pain with percussion or loading

---

3. Cancer

• Previous or current cancer
• Unexplained weight loss
• Constant progressive pain
• Severe night or resting pain
• Failure to improve with treatment
• New neurological deficit
• General fatigue or malaise

---

4. Infection

• Fever, chills, or night sweats
• Recent bacterial infection
• Diabetes or immune suppression
• IV drug use
• Recent surgery, injection, or spinal procedure
• Severe constant pain with systemic illness

---

5. Inflammatory spinal disease

• Gradual onset, usually at a younger age
• Morning stiffness
• Improvement with activity or exercise
• Little improvement with rest
• Pain in the second half of the night
• Alternating buttock pain
• History of psoriasis, uveitis, inflammatory bowel disease, or family history

---

6. Visceral causes of back pain

• Urinary pain, blood in urine, fever, or flank pain: renal/urinary source
• Abdominal pain, pulsation, dizziness, or vascular risk: abdominal vascular source
• Nausea, altered bowel function, abdominal pain: gastrointestinal source
• Pelvic pain, menstrual change, urinary/reproductive symptoms: pelvic/gynaecological source

---

Step 5: Review of systems

• Fever, chills, night sweats
• Weight loss, fatigue, malaise
• Cancer history
• Urinary/bowel symptoms
• Saddle numbness
• Progressive weakness/numbness
• Abdominal, pelvic, or flank pain
• Inflammatory symptoms
• Skin changes or rashes
• Recent infection, surgery, or invasive procedure

Referral decision for back symptoms

---

Quick summary: treat, refer, or emergency

Treat and monitor

• Symptoms are mechanical and reproducible
• There are no important red flags
• Neurological findings are stable
• The patient responds appropriately to treatment

Refer for medical review

• Pain is constant, progressive, unexplained, or non-mechanical
• There are constitutional symptoms
• There is suspected cancer, infection, fracture, inflammatory disease, or visceral referral
• Symptoms fail to improve as expected

Emergency referral

• Thunderclap headache
• Suspected stroke or vascular event
• Altered consciousness, seizure, or meningitis-type symptoms
• Acute visual loss
• Cervical myelopathy with progressive neurological loss
• Severe trauma or suspected spinal fracture
• Cauda equina syndrome
• Rapidly progressive weakness or neurological deficit

Screening of Head, Neck and Back

Simplified physiotherapy notes using Goodman and Snyder’s screening model

1. Past medical history
2. Risk-factor assessment
3. Clinical presentation
4. Associated signs and symptoms
5. Review of systems

• Is this likely a mechanical musculoskeletal disorder suitable for PT?
• Does the patient need medical review?
• Does the patient require urgent or emergency referral?

---

1. General PT screening approach

A. Past medical history

• Previous cancer
• Diabetes, hypertension, vascular or heart disease
• Osteoporosis or long-term corticosteroid use
• Autoimmune/inflammatory disease, such as rheumatoid arthritis or ankylosing spondylitis
• Infection, recent surgery, injection, or hospital admission
• Neurological conditions, stroke, seizures
• Current medications, especially steroids, anticoagulants, immunosuppressants, and analgesics
• Recent trauma, falls, accidents
• Previous imaging, surgery, and response to treatment

B. Risk-factor assessment

• Fracture: trauma, older age, osteoporosis, steroid use
• Cancer: prior malignancy, unexplained weight loss, constant night pain
• Infection: fever, diabetes, immune suppression, IV drug use, recent procedure
• Vascular disease: hypertension, smoking, diabetes, cardiovascular history
• Inflammatory disease: younger onset, morning stiffness, psoriasis, uveitis, inflammatory bowel disease

C. Clinical presentation

• What caused the symptoms?
• Is pain related to posture, movement, loading, or activity?
• Is it constant or intermittent?
• Does it wake the patient from sleep?
• Is it getting worse or failing to improve?
• Is there numbness, weakness, imbalance, bladder/bowel disturbance, fever, weight loss, or fatigue?

Mechanical pattern

• Symptoms change with movement, posture, loading, or rest.
• Pain can be reproduced by examination.
• There are no constitutional or progressive neurological signs.
• Symptoms improve over time with appropriate management.

Non-mechanical/systemic pattern

• Pain is constant, progressive, severe at rest, or severe at night.
• Symptoms are unrelated to movement or posture.
• There are constitutional symptoms.
• There is a major mismatch between the patient’s pain severity and musculoskeletal findings.
• The patient does not respond as expected to PT.

D. Associated signs and symptoms

• Fever, chills, night sweats
• Unexplained weight loss
• Severe fatigue or malaise
• New neurological deficit
• Visual, speech, swallowing, or balance changes
• Chest pain, breathlessness, sweating
• Abdominal, urinary, bowel, or pelvic symptoms
• Skin rash, swelling, bruising, or palpable mass

E. Review of systems

• Constitutional system
• Neurological system
• Cardiovascular and respiratory system
• Gastrointestinal system
• Genitourinary system
• Musculoskeletal/inflammatory system

---

2. Screening of the Head

Main aim

---

A. Past medical history

• Previous headaches or migraines
• Recent head trauma
• Stroke, seizure, hypertension, vascular disease
• Cancer
• Immune suppression, HIV, diabetes, steroid use
• Recent infection, including sinus, dental, ear, or systemic infection
• Pregnancy or postpartum status
• Use of anticoagulants
• Medication overuse, including frequent analgesic use

---

B. Risk factors

• New headache after age 50
• History of cancer
• Immune suppression
• Recent trauma
• Hypertension or vascular disease
• Pregnancy/postpartum state
• Anticoagulant use
• Recent infection

---

C. Clinical presentation questions

• Is this the first headache or the worst headache?
• Was onset sudden or gradual?
• Did pain reach maximum intensity very quickly?
• Is this headache different from usual headaches?
• Is the headache worsening over days or weeks?
• Is it aggravated by cough, exertion, straining, or position?
• Is there neck pain, fever, visual change, dizziness, vomiting, or neurological symptoms?

---

D. Head red flags

---

E. Systemic causes of head pain: examples

PT message

---

3. Screening of the Neck

Main aim

---

A. Past medical history

• Road traffic accident, fall, sport injury, or other trauma
• Rheumatoid arthritis, ankylosing spondylitis, Down syndrome
• Cancer history
• Fever, infection, immune suppression, diabetes
• Previous cervical surgery
• Cardiovascular disease, smoking, hypertension
• Stroke or transient ischaemic attack history
• Anticoagulants, steroids, or immunosuppressant medication

---

B. Risk factors

• Major trauma or high-risk mechanism
• Osteoporosis or chronic steroid use
• Rheumatoid arthritis or inflammatory arthritis
• Cancer history
• Immune suppression or recent infection
• Smoking, hypertension, diabetes, vascular disease
• Recent cervical manipulation or unusual neck trauma

---

C. Clinical presentation questions

• Did symptoms begin after trauma?
• Is pain related to posture or neck movement?
• Is pain constant, severe, or worse at night?
• Is there arm pain, numbness, weakness, or altered reflexes?
• Are both arms or legs affected?
• Is there gait imbalance or loss of hand coordination?
• Is there dizziness, diplopia, dysarthria, dysphagia, or visual disturbance?
• Is there chest pain, sweating, nausea, or breathlessness?

---

D. Neck red flags

1. Possible cervical myelopathy

• Bilateral arm or leg symptoms
• Hand clumsiness or dropping objects
• Difficulty writing, buttoning, or using keys
• Progressive weakness
• Gait imbalance, falls, or broad-based gait
• Hyperreflexia, clonus, pathological reflexes
• Bowel, bladder, or sexual dysfunction

2. Possible vascular pathology

• Diplopia
• Dysarthria
• Dysphagia
• Dizziness or severe disequilibrium
• Ataxia
• Drop attacks
• Facial numbness
• Visual disturbance
• Unexplained nausea/vomiting
• Sudden unusual headache

3. Other red flags

• Fever, chills, night sweats
• History of cancer or unexplained weight loss
• Severe night pain or unremitting pain
• Severe midline tenderness following trauma
• Neck pain with chest pain, sweating, dyspnoea, nausea
• Persistent hoarseness, dysphagia, neck lump
• Progressive neurological symptoms

---

E. Systemic causes of neck pain: examples

PT message

---

4. Screening of the Back

Main aim

---

A. Past medical history

• Cancer history
• Osteoporosis, fracture, steroid use
• Recent fall or trauma
• Diabetes, immune suppression, recent infection
• IV drug use
• Recent surgery, injection, or spinal procedure
• Kidney stones, urinary tract infection, bowel disease
• Abdominal aortic aneurysm or vascular disease
• Gynaecological, prostate, bladder, or pelvic conditions
• Psoriasis, uveitis, inflammatory bowel disease
• Previous bowel, bladder, or saddle sensory change

---

B. Risk factors

---

C. Clinical presentation questions

• Did pain begin after trauma?
• Is it related to loading, bending, sitting, walking, or position?
• Is pain constant or progressively worsening?
• Is pain worse at rest or at night?
• Does the patient have fever, weight loss, fatigue, or malaise?
• Are there urinary, bowel, abdominal, pelvic, or menstrual symptoms?
• Is pain associated with bilateral leg symptoms?
• Is there saddle numbness or new bladder/bowel dysfunction?

---

D. Back red flags

1. Cauda equina syndrome: emergency

• Difficulty starting urination
• Urinary retention
• New urinary or faecal incontinence
• Loss of perineal/saddle sensation
• Bilateral leg pain, numbness, or weakness
• Rapidly progressive neurological deficit

2. Fracture

• Significant trauma
• Minor trauma in an older adult
• Osteoporosis
• Steroid use
• Sudden pain with focal spinal tenderness
• Pain with loading, percussion, or movement

3. Cancer

• Previous cancer
• Unexplained weight loss
• Constant, progressive, unremitting pain
• Night pain
• Failure to improve as expected
• New neurological symptoms

4. Infection

• Fever, chills, night sweats
• Recent systemic infection
• Immune suppression, diabetes, or IV drug use
• Recent spinal injection/surgery
• Severe constant pain and malaise

5. Inflammatory spinal disease

• Gradual onset at a younger age
• Morning stiffness
• Improvement with activity, not rest
• Night pain, especially in the second half of night
• Alternating buttock pain
• Psoriasis, uveitis, inflammatory bowel disease

---

E. Systemic causes of back pain: examples

---

5. Simple PT decision guide

---

6. Key exam points

• Screen every patient, not only those who appear unwell.
• A single red flag does not confirm serious disease.
• A cluster of red flags, worsening symptoms, abnormal neurological signs, or a non-mechanical pattern increases concern.
• Always ask specifically about bladder/bowel function and saddle sensation in back pain.
• In neck complaints, screen for myelopathy, vascular symptoms, and cardiac referral.
• In head complaints, screen for sudden onset, neurological deficit, systemic infection, giant cell arteritis features, trauma, cancer, and immune suppression.
• Document findings, the advice given, referral decisions, and communication with other healthcare professionals.