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 colleague in the following circumstances:

• The patient presents with persistent debilitating thoracic pain, not responding to treatment
• Undiagnosed structural deformity with associated pain symptoms (particularly in those aged 18 and under)
• 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

GP Referral

Immediate communication with GP is required when:

• Red flags are identified
• Serious pathology is suspected
• Except when CES is suspected (see appendix 1)

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

• Appropriate analgesics are required
• Systemic inflammatory disease is suspected (including suspected Scheurmann’s disease)
• A non-musculoskeletal pathology is suspected as a source of the symptoms (e.g. visceral referral)
• Myelopathy is suspected with/without presence of radiculopathy