Guidelines for Physician Referral | Health Guidelines


Guidelines for Physician Referral:

• While following guidelines for Physician Referral immediate. Medical attention is required for anyone with risk factors for and clinical signs and symptoms of rhabdomyolysis.

•  Ask about recent (last 6 weeks) skin lesions or rashes of any kind anywhere on the body, urinary tract infection, or respiratory infection. 

Guidelines for Physician Referral Required:

• Proximal muscle weakness accompanied by change in one or more deep tendon reflexes. In the presence of a previous history of cancer.

• Diffuse pain that characterizes some diseases of the nervous system and viscera may be difficult to distinguish. From the equally diffuse pain so often caused by lesions of the moving parts. Look for significant risk factors for cardiovascular involvement. Check vital signs. Refer for medical evaluation if indicated.

immediate referral guidelines

Pain as Red flag Features:

Characteristics of systemic pain compared to musculoskeletal pain are presented, including a closer look at joint pain. Pain with the following features raises a red flag to alert the therapist of the need to take a closer look:• Pain of unknown cause• Pain that persists beyond the expected time for physiologic healing• Pain that is out of proportion to the injury• Pain that is unrelieved by rest or change in position• Pain pattern does not fit the expected clinical presentation for a neuromuscular or musculoskeletal impairment• Pain that cannot be altered, aggravated, provoked, reduced, eliminated, or alleviated• There are some positions of comfort for various organs (e.g., leaning forward for the gallbladder or side bending for the kidney), but with progression of disease the client will obtain less and less relief of symptoms over time

• Pain, symptoms, or dysfunction are not improved or altered by physical therapy intervention• Pain that is poorly localized• Pain accompanied by signs and symptoms associated with a specific viscera (e.g., GI, GU, GYN, cardiac, pulmonary, endocrine)• Pain that is constant and intense no matter what position is tried and despite rest, eating or abstaining from food; a previous history of cancer in this client is an even greater red flag necessitating further evaluation• Pain (especially intense bone pain) that is disproportionately relieved by aspirin. • Pain in the absence of any positive Waddell’s signs (i.e., Waddell’s test is negative or insignificant)

Case Study and Guidelines for physician referral:

Listen to the client’s choice of words to describe pain. Systemic or viscerogenic pain can be described as deep, sharp, boring, knifelike, stabbing, throbbing, colicky, or intermittent (comes and goes in waves)• Pain accompanied by full and normal range of motion• Pain that is made worse 3 to 5 minutes after initiating an activity and relieved by rest (possible symptom of vascular impairment) versus pain that goes away with activity (symptom of musculoskeletal involvement); listen for the word descriptor “throbbing” to describe pain of a vascular nature• Pain is a relatively new phenomenon and not a pattern that has been present over several years’ time.•  Observe the client for signs and symptoms of anxiety, depression, and/or panic disorder. In the absence of systemic illness or disease and/or in the presence of suspicious psychologic symptoms, psychologic evaluation may be needed.

Manual Therapy:

Manual therapy to correct an up slip is not successful and the problem has returned by the end of the session or by the next day; consider a somato-visceral problem or visceral ligamentous problem.• Back, shoulder, pelvic, or sacral pain that is made better or worse by eating, passing gas, or having a bowel movement• Night pain (especially bone pain) that awakens the client from a sound sleep several hours after falling asleep; this is even more serious if the client is unable to get back to sleep after changing position, taking pain relievers, or eating or drinking something• Joint pain preceded or accompanied by skin lesions (e.g., rash or nodules), following antibiotics or statins, or recent infection of any kind (e.g., gastrointestinal, pulmonary, genitourinary); check for signs and symptoms associated with any of these systems based on recent client history.

Careful General History

A careful general history and physical examination is still the most important screening tool; never assume this was done by the referring physician or other staff from the referring agency. Visceral problems are unlikely to cause muscle weakness, reflex changes, or objective sensory deficits (exceptions include endocrine disease and paraneoplastic syndromes associated with cancer). If pain is referred from the viscera to the soma. Challenging the somatic structure by stretching, contracting, or palpating will not reproduce the symptoms.


A 44-year old male was referred to physical therapy with a report of right-sided thoracic pain.

Past Medical History:

The client reported a 20-pack year smoking history (one-pack per day for 20 years). Patient denied the use of alcohol or drugs. The client’s symptoms began following chiropractic intervention to relieve left-sided lower extremity radiating pain. Within 6 to 8 hours after the chiropractor manipulated the client’s thoracic spine, he reported sharp shooting pain. On the right side of the upper thoracic spine at T4.  No imaging studies were done prior to physical therapy referral. The client rated the pain as a constant 10/10 on the Numeric Rating Scale (NRS) during sitting activities at work.


The client was described as slender in build (ectomorph body type) with forward head and shoulders and kyphotic posturing as observed in the upright and sitting positions. There were no significant signs of inflammation or superficial tissue changes observed or palpated in the thoracic spine region. There was palpable tenderness at approximately the T4 costotransverse joint and along the corresponding rib.


The client obtained gradual relief from painful symptoms after 8 treatment sessions. Session incuded stretches and costotransverse joint mobilization (grade 4, non-thrust progressive oscillations at the end of the available range). Pain was reduced from 10/10 to 3/10 and instances of night pain had decreased. The client’s thoracic pain returned on the 10th and 11th treatment sessions.  Red flags in this case included: Age over 40. History of smoking (20 pack years). Symptoms persisting beyond the expected time for physiologic healing. Pain out of proportion to the injury. Recurring symptoms (failure to respond to physical therapy intervention). Pain is constant and intense; night pain. The client was returned to his primary care physician for further diagnostic studies and later diagnosed with metastatic lung cancer.


Working with clients several times a week allows the therapist to monitor their symptoms and the effectiveness of interventions. 

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