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 GG+CBPS clinical specialist

Specialist Spinal Service

Discuss with or refer to Greater Glasgow and Clyde Back Pain Service (GG+C BPS) when:

• The patient presents with persistent debilitating leg 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
• Severe debilitating stenotic pain and the patient is not improving
• The patient wants a further opinion/investigation, or is unable to accept the self-management philosophy
• Patients with persistent LBP and significant yellow flags that hamper their ability to engage in an active rehabilitation process should also be discussed with a member of the GG+C BPS. Where appropriate, these patients should then be referred to the pain management team for a multidisciplinary biopsychosocial assessment via referral through patient’s GP
• Patient not responding as expected

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-musculoskeletal 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