Progression and escalation

Throughout the physiotherapy management if a patient is not responding to treatment as expected then consideration should be given to:

• Presence of serious pathology (red flags)
• Psychosocial factors (yellow, orange, blue, black flags)
• Potential for other pathology/structures/atypical presentations
• Assessment findings (subjective and objective)
• Diagnosis
• Pain control
• Supported self management (communication and education)
• Appropriateness of treatment approach

Escalation within physiotherapy may include

• Self reflection
• Peer review
• Discussion/reassessment with senior colleague and/or relevant Extended Scope Physiotherapy Practitioner (ESP Physio)

Orthopaedics

Referral to local orthopaedic departments for further investigations and management can be made in accordance with local procedure after discussion and reassessment by senior colleagues in the following circumstances:

• The patient presents with persistent debilitating arm pain with progressive neurological deficit (e.g. loss of power/sensation/altered reflexes) and they are not responding to treatment
• A myotomal weakness of 3/5 is detected at any one nerve root, in the absence of pain
• Myotomal weakness is detected at more than one spinal nerve root
• The patient wants a further opinion/investigation, or is unable to accept the self-management philosophy
• Patients with persistent non-specific neck pain and significant yellow flags that hamper their ability to engage in an active rehabilitation process should also be discussed with a senior colleague. Where appropriate, these patients should then be referred to the pain management team for a multidisciplinary biopsychosocial assessment.

GP Referral

Communication with or referral back to a GP should be made when:

• Appropriate analgesics are required
• Systemic inflammatory disease is suspected
• A non-mulsculoskeletal pathology is suspected as a source of the symptoms (e.g. visceral referral)
• A patient exhibits severe levels of distress with the possibility of clinical levels of anxiety and depression