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Red flag screening for low back pain: nothing to see here, move along: a narrative review
  1. Chad E Cook1,2,
  2. Steven Z George2,3,
  3. Michael P Reiman2,4
  1. 1Division of Physical Therapy, Duke MSK, Duke Clinical Research Institute, Durham, North Carolina, USA
  2. 2Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
  3. 3Duke MSK, Duke Clinical Research Institute, Durham, North Carolina, USA
  4. 4Division of Physical Therapy, Duke University, Durham, North Carolina, USA
  1. Correspondence to Dr Chad E Cook, Department of Physical Therapy, Duke University, Durham, NC 27708, USA; chad.cook{at}


Screening for red flags in individuals with low back pain (LBP) has been a historical hallmark of musculoskeletal management. Red flag screening is endorsed by most LBP clinical practice guidelines, despite a lack of support for their diagnostic capacity. We share four major reasons why red flag screening is not consistent with best practice in LBP management: (1) clinicians do not actually screen for red flags, they manage the findings; (2) red flag symptomology negates the utility of clinical findings; (3) the tests lack the negative likelihood ratio to serve as a screen; and (4) clinical practice guidelines do not include specific processes that aid decision-making. Based on these findings, we propose that clinicians consider: (1) the importance of watchful waiting; (2) the value-based care does not support clinical examination driven by red flag symptoms; and (3) the recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis.

  • low back pain
  • red flags
  • orthopaedic
  • screening

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  • Contributors CEC, SZG and MPR all worked together for the concept of the study, participated in the full writing and approved the final manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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