Doi:10.1016/s0031-9406(03)00008-7

Margaret: a tragic case of spinal Red Flags and Red Herrings a Bolton PCT, Ashburner St, Lever Chambers, Bolton, UK b Allied Health Professions Unit, University of Central Lancashire, Preston, UK c Satakunta Polytechnic, Pori, Finland Abstract
Objective This case illustrates how easily patient misattribution can influence the clinical reasoning process and it alerts physiotherapists to
safeguard from the influences of Red Herrings.
Design It is the second in a series of case studies considering patients with serious spinal pathology.
Setting This paper considers the case of a 49year old lady who was referred to a Spinal Assessment Clinic in a district general hospital. The
clinic was established specifically to deal with more complex spinal patients, identifying those at risk of chronicity, surgical cases or those
with more complex pathology. Unfortunately this case was subsequently diagnostically triaged as serious spinal pathology.
Conclusion As misattribution of symptoms by the patient is common, it is essential that the clinician considers a thorough subjective and
objective assessment. When drawing inferences from the findings it is vital to stand back and consider if the attributed cause and effect is an
inherent likelihood and consider whether there may be important information missing.
2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Serious pathology; Spine; Red Flags; Misattribution Introduction
• Violent trauma (road traffic accident); A previous paper highlights the difficulty faced • Constant progressive non-mechanical pain; by therapists in detecting serious spinal pathology in the early stages. The following case also serves to illustrate • Past medical history of carcinoma (family history of breast this problem, especially when the clinical presentation is complicated by misattribution of symptoms. In the late stage of this case the serious pathology emerged clearly • Persistent severe restriction of lumbar flexion.
but unfortunately progressed very rapidly, Margaret firstattended for physiotherapy in September and had died In addition she had also developed two breast lumps, which by the end of January. It is very likely that Margaret she did not report to the physiotherapist.
would have died even with earlier identification of her When faced with this list of symptoms most therapists cancer as it progressed so rapidly, however earlier iden- would agree that this appears as a very clear-cut case of a tification could have decreased her level of suffering and patient with serious pathology. However it is important to consider how the symptoms developed over time and alsoto consider how the clinical reasoning process was stronglyinfluenced by the initial presentation of the case. To illustrate The patient
Prior to serious pathology being diagnosed, at her first 1. A patient with no significant past medical history or attendance at physiotherapy, Margaret had the following spinal problems attends for physiotherapy following a symptoms, which appear on the Clinical Standards Advisory road traffic accident with thoracic and rib pain.
2. A patient with a lump in the left breast and a family history of breast cancer (mother and sister) attends for physiotherapy with thoracic and rib pain.
0031-9406/$ – see front matter 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/S0031-9406(03)00008-7 S. Greenhalgh, J. Selfe / Physiotherapy 90 (2004) 73–76 The physiotherapists interpretation and subsequent clin- Rehabilitation consisted of a home exercise program, ical reasoning in response to each of these two scenarios which included daily brisk walking and core stability exer- is likely to be quite different. Both scenarios are aspects of cises, advice on the use of heat and posture correction, a Margaret’s case, which is used to illustrate how misattribu- review appointment was given for 2 weeks later on 10 Oc- tion of symptoms influences patients’ behaviour and subse- tober. At this appointment Margaret still described sleeping in a chair and continued to complain of the mid-thoracicdiscomfort, gentle manual therapy was applied locally tothe thoracic spine. Six days later, 16 October, Margaret had shown some improvement and was now sleeping in bed,post-treatment soreness had been present for 3 days fol- On 25 September a referral for Margaret was received in lowing the previous appointment. By the next appointment the Physiotherapy Department. Margaret was a 49-year-old however, Margaret had taken to sleeping on the sofa and de- office worker, who 5 weeks earlier had been involved in a scribed increased thoracic pain. Temporary relief was con- road traffic accident (23 August), where she had been the sistently achieved following each of the treatment sessions driver in a stationary vehicle and a motorcyclist had crashed however the overall clinical presentation was one of deteri- into the drivers door. Margaret described being in shock for oration, this continued until 29 November when a second 2 days but then noticed right sided rib pain, she attended Ac- opinion was sought from another senior physiotherapist.
cident & Emergency Department the day after first noticing At that consultation Margaret, for the first time, reported the rib pain and was prescribed rest, analgesics and 1 week finding a lump in the left breast, this she had already reported off work. The following week (2 weeks post-road traffic ac- to her GP, and was waiting for further investigation by the cident) she noticed a constant dull ache in the mid-thoracic surgical team at an appointment on 4 December. By this spine, with associated morning stiffness. She returned to a stage Margaret was not eating due to the pain, this was different Accident & Emergency Department on 25 Septem- attributed to her medication, the patient described feeling at ber, at this visit she had urine tests, which proved nega- the end of her tether and stated that she wanted: tive, received an anti-inflammatory injection into the buttock,and was prescribed dihydrocodeine and diclofenac. On 27 To go to sleep and not have to wake up and feel the pain.
September Margaret attended for her first physiotherapy ap- The specialist spinal physiotherapist was contacted and pointment. By this time her pain had generally become a lit- an urgent referral to the spinal assessment clinic followed.
tle easier, but she still reported a dull ache in the mid-thoracic On the 4 December appointment at the surgical unit the region. She was much worse first thing in the morning and initial entry in the medical notes is as follows: found that sleeping upright in a chair helped. Margaret re-ported that litigation concerning the accident was ongo- Road traffic accident 3 months and then noticed lump 1 ing. No previous back problems were reported there was no medical history of note and she did not smoke or drink It was also noted that a second lump had appeared the week before in November. An isotope bone scan revealedwidespread metastatic disease and interestingly on the rightnineth rib posteriorly there was an area highly suggestive of Patient assessment and management
an expansive rapidly growing destructive lesion. During theremainder of December and January, Margaret was managed At the first physiotherapy appointment Margaret clearly by a specialist oncology team and died on 30 January.
identified pain in the mid-thoracic region with radiating painaround the right chest wall into the ribs. She demonstratedpoor sitting posture, but had a full range of lumbar spine Discussion
movements; all thoracic spinal movements were restrictedto 3/4 range. All neurological testing was consistently neg- It is easy to understand the initial clinical reasoning of the ative, however palpation revealed tenderness centrally and physiotherapist. Margaret was 49 years old, not an age iden- unilaterally to the right over the fifth to nineth thoracic tified by the Clinical Standards Advisory Group guidelines vertebrae. Following a subjective and objective examina- as being at risk from serious pathology (<20 or >55). Mar- tion the physiotherapist classified Margaret’s problem using garet attributed symptoms to her road traffic accident and the Clinical Standards Advisory Group diagnostic triage as indeed the site of symptoms was consistent with mechani- simple (thoracic) back pain and embarked on a course of cal injury, where Margaret was in the driver’s seat and the driver’s door was the point of impact of the motorcyclist.
Clinical Standards Advisory Group triage: This highlights the importance of vigilance and an aware- ness that breast cancer is frequently described as the most • Nerve root pain (<5% of patients); common cancer in females in western countries Ac- • Possible serious spinal pathology (<1% of patients).
cording to Wiesel et al. patients with a history of breast S. Greenhalgh, J. Selfe / Physiotherapy 90 (2004) 73–76 cancer have an 85% chance of developing bony metastases themselves against being influenced by Red Herrings?” It before death. They also suggest that one of the earliest sites is important in clinical history taking to probe deeply with for these metastases is the spine, in particular the thoracic questioning and listen carefully to the response. When draw- spine, this is also confirmed by the Clinical Standards Advi- ing inferences it is vital at this stage to stand back and con- sory Group guidelines With particular reference to this sider if the attributed cause and effect is an inherent likeli- case it is also interesting to note that one of the important hood and to consider whether there may be any information risk factors that has been identified is family history missing. This process should continue throughout the whole It is very interesting to consider why Margaret did not patient management episode. In view of the current high lev- mention her breast lump to the physiotherapist earlier, a els of cancer in Western Society and predicted increases in number of alternative explanations exist. The breast lump its incidence, including those with a genetic component, it was on the left but the impact from the road traffic acci- would be prudent for physiotherapists not only to routinely dent and the pain was on the right. Was there a perception investigate the patients history of cancer but any previous that the breast lump was related to the accident or was there an element of fear/denial owing to her experiences with her It is also interesting to consider Margaret’s early and per- mother and sister? Unfortunately in Margaret’s case the an- sistent report of an inability to lie supine. The Clinical Stan- swer to this question will never be known.
dards Advisory Group do not list this clinical Leventhal and Crouch suggest that a patient’s be- feature as a Red Flag. However, the more recent New haviour is determined by their own self-diagnosis. This self- Zealand Low Back Pain list of Red Flags in- diagnosis is determined by mapping the signs and symptoms cludes patients with spinal problems whose pain gets worse of the health problem against five attributes, described by when they lie down. The clinical experience of the lead au- thor (S.G.) would tend to concur with the opinion of the NewZealand guidelines, in that a patients persistent report of an inability to lie supine should be considered as a Red Flag.
The final questions to consider in this case are why fol- 3. Consequences (prognosis/likely outcome); lowing the road traffic accident the previously asymptomatic cancer became painful and would it have progressed so 5. Controllability (is intervention necessary?).
rapidly without the “trigger” of the accident. Unfortunately, In Margaret’s case it appears that misattribution occurred however these questions are beyond the scope of this paper.
in her self-diagnosis concerning disease identity and cause,in that she incorrectly attributed her breast cancer symptomsto her road traffic accident, misattribution of this type is Key messages
• Misattribution of symptoms by the patient is common.
According to Jones reasoning refers to the • In clinical history taking physiotherapists need to con- thought processes used in patient diagnosis and manage- sider the possibility of alternative causes of the pre- ment. He goes on to suggest that this reasoning is only as good as the information on which it is based. Scott • Physiotherapists need to consider family history of that three types of error can occur in clinical reasoning: 1. Faulty perception or elicitation of cues; Persistent inability to lie supine should be considered 3. Misapplication of known facts to a specific problem.
In Margaret’s case there appears to have been an error in perception, although there is one set of symptoms there References
are two potential causal factors that coexist, the breast can-cer and the road traffic accident, the physiotherapist was [1] Greenhalgh S, Selfe J. John: a case of malignant myeloma of the only aware of one of these factors, the road traffic accident.
spine. Phyiotherapy 2003;89(8):486–8.
As deductive reasoning involves logical inference [2] Clinical Standards Advisory Group. Back pain. HMSO; 1994.
physiotherapists clinical reasoning was appropriate under [3] Karki A, Simonen R, Malkia E, Selfe J. Efficacy of physical therapy methods and exercise after a breast cancer operation: a systematic review. Crit Rev Phys Rehabil Med 2001;13(2/3):159–90.
[4] Wiesel SW, Weinstein JN, Herkowitz H, Dvorak J, Bell G. The lumbar spine. The international society for the study of the lumbar Implications for practice
spine, vol. 1, 2nd ed. Philadelphia, PA: WB Saunders; 1996.
[5] Kelsey JL. Breast cancer epidemiology: summary and future direc- tions. Epidemiol Rev 1993;15:256–63.
This case illustrates how easily misattribution can in- [6] Spicer DV, Pike MC. Epidemiology of breast cancer. In: Loboa RA, fluence physiotherapists clinical reasoning processes. This editor. Treatment of post menopausal women: basic and clinical poses the question “How can physiotherapists safeguard aspects. New York: Raven Press; 1994.
S. Greenhalgh, J. Selfe / Physiotherapy 90 (2004) 73–76 [7] Leventhal E, Crouch M. Are there differences in perceptions of illness [9] Wilson A. Effective management of musculoskeletal injury. Edin- across the lifespan? In: Petrie KJ, Weinman JA, editors. Perceptions of health and illness. Australia: Harwood Academic Publishers; 1997 [10] Jones MA. Clinical reasoning in manual therapy. Phys Ther 1992; [8] Leventhal H, Benyamini Y, Brownlee S, Diefenbach M, Leven- [11] Scott I. Teaching clinical reasoning: a case based approach. In: Jones thal E, Patrick-Miller L, et al. Illness representations: theoretical MA, Higgs J, editors. Clinical reasoning in the health professions, foundations. In: Petrie KJ, Weinman JA, editors. Perceptions of 2nd ed. Oxford: Butterworth Heineman; 2000 [chapter 34].
health and illness. Australia: Harwood Academic Publishers; 1997

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