MOVE ED

Red Flag Screening Tool

Clusters, not checklists. Bayesian clinical reasoning for ruling in or out serious spinal pathology. Based on the ICF model of assessment.

ICF Assessment Model — Red Flags are Step 1

1. Red Flags 2. AROM 3. Control 4. Strength Endurance 5. Strength 6. Power 7. Pain 8. Other Objective

Reason backwards: Participation → Activity → Body Structure & Function → Contextual Factors (WHO, 2001; Escorpizo et al., 2010)

The Key Principle

Clusters, not individual flags. A single red flag in isolation rarely changes management. The question is: does this cluster of findings raise the pre-test probability of serious pathology above the threshold that requires action? This is Bayesian clinical reasoning — not box-ticking. (Finucane et al., 2020; IFOMPT International Framework)

Spinal Red Flag Categories

IFOMPT framework (Finucane et al., 2020). Screen at first visit for each category. Click each card to expand.

Cauda Equina Syndrome

EMERGENCY

Sounds Like (Subjective)

  • "My legs feel like they're not my own"
  • "I can't feel when I need to go to the toilet"
  • "My saddle area feels numb"
  • New onset bilateral leg symptoms
  • LL weakness or gait change
  • Rapid onset of symptoms with history of back pain
  • Urinary retention or faecal smearing

Rule In / Rule Out (Objective)

  • Bilateral lower limb neurological exam: Power > Reflexes > Sensation
  • Saddle anaesthesia testing
  • Bladder/bowel dysfunction confirmed
  • Progressive bilateral weakness
  • Mechanical lower back assessment
  • Gait assessment

Action

  • SAME-DAY EMERGENCY
  • Do not treat
  • Send directly to ED
  • Call triple zero if needed
  • Refer on for imaging
  • Full documentation immediately
This is your highest priority red flag. Never assume. Always ask. CES needs to be in your working hypothesis the moment someone mentions bilateral leg symptoms or bladder/bowel change alongside back pain. The threshold for action is low.

Spinal Malignancy

URGENT REFERRAL

Sounds Like (Subjective)

  • Age >50 or <20 with new onset back pain
  • "The pain doesn't change with position or movement"
  • Pain waking from sleep — unremitting, 8-9/10
  • "I've lost weight without trying"
  • Previous history of cancer
  • Malaise, fatigue, "I'm just so exhausted"
  • Failure to improve with therapy >1 month

Rule In / Rule Out (Objective)

  • Spine tenderness on palpation
  • Decreased LL strength
  • Gait/balance disturbance
  • Sensation changes
  • Non-mechanically responsive AROM/pain
  • Normal outcomes for central sensitisation (rules out nociplastic)
  • X-ray, PET scan, bloods

Action

  • 2+ features: urgent referral to GP or ED
  • 1 feature: caution, monitor closely
  • Refer to GP for imaging and bloods
  • Do not dismiss — document everything
  • Urgent if known previous malignancy
NAS case example: 74yo male, sudden onset LBP, CT showed increased lucencies in L3 — escalated same day for bone scan and CT chest/abdo/pelvis. Result: Paget's disease, not malignancy. Always investigate, never assume. (Barwon Health NAS, 2022)

Vertebral Fracture

URGENT REFERRAL

Sounds Like (Subjective)

  • "I felt something go in my back"
  • Sudden onset severe pain in older adult
  • Pain after a fall, even minor
  • "My back has never hurt like this"
  • Trauma — moment in time
  • History of osteoporosis or corticosteroid use
  • Bone conditions, myeloma history

Rule In / Rule Out (Objective)

  • Central tenderness on palpation — exquisite
  • Imaging (X-ray, CT)
  • C-spine rules / criteria-led assessment
  • Age >70 with new onset back pain
  • Known trauma (even seemingly minor)
  • Prolonged corticosteroid use confirmed

Action

  • Urgent imaging before loading
  • No manual therapy to spine
  • No exercise until cleared
  • Refer to GP same day
  • Refer on for X-ray
Do not load an uncleared suspected fracture. Imaging first. In Clinical Pilates, this means STOP — no reformer, no chair, no loading until cleared by imaging.

Spinal Infection / Sepsis

URGENT REFERRAL

Sounds Like (Subjective)

  • Fever, high respiratory rate, low BP
  • Confusional state
  • Recent infection, surgery or dental work
  • IV drug use
  • Immunosuppression / recent chemotherapy
  • Non-blanching rash
  • Acute functional change
  • Decreased urine output

Rule In / Rule Out (Objective)

  • O2 sats
  • Blood pressure
  • Urine output
  • Orientation questions
  • Temperature
  • Elevated CRP/ESR
  • Local spinal tenderness

Action

  • Urgent medical review
  • Do not exercise until cleared
  • Refer on for IV antibiotics, IV fluids, blood cultures
  • Document and follow up
Sepsis can mimic MSK presentations. If systemic features are present alongside spinal pain, act immediately. Do not rationalise systemic signs as part of a musculoskeletal picture.

Vascular (AAA)

URGENT REFERRAL

Sounds Like (Subjective)

  • Age >65, male, smoker
  • Sudden severe onset abdominal/back pain
  • Pulsating abdominal mass
  • Buttock claudication
  • "It came on out of nowhere and it's the worst pain"

Rule In / Rule Out (Objective)

  • Abdominal palpation (pulsating mass)
  • Blood pressure assessment
  • Non-mechanical pain pattern
  • Not reproduced with spinal loading

Action

  • Urgent medical review if AAA suspected
  • Call triple zero if acute rupture suspected
  • Do not treat — refer immediately

Progressive Neurological Deficit

HIGH PRIORITY

Sounds Like (Subjective)

  • "The weakness/numbness is getting worse week to week"
  • Rapidly worsening neurological symptoms over days to weeks
  • Increasing numbness, weakness, reflex loss
  • Foot drop developing or worsening

Rule In / Rule Out (Objective)

  • Serial neurological exam: power, reflexes, sensation
  • Track weekly with objective testing
  • Compare to baseline — is it getting worse?
  • Gait assessment changes

Action

  • Urgent neurological referral
  • Track weekly with objective markers
  • Refer for MRI and specialist review
  • Document progression timeline
NAS case: 58yo male with foot drop due to L4/5 radiculopathy — unchanged symptoms for 6 months. Referred for MRI, nerve root injection, and consultant review. Track and document progression. (Barwon Health NAS, 2022)

Cervical Red Flags

Apply to ALL cervical presentations. IFOMPT framework (Rushton et al., 2014). Screen separately from spinal red flags.

Cervical Arterial Dysfunction (CAD)

URGENT REFERRAL

Sounds Like (Subjective)

  • 5D's + 3N:
  • Dizziness
  • Diplopia (double vision)
  • Drop attacks
  • Dysarthria (slurred speech)
  • Dysphagia (difficulty swallowing)
  • Numbness
  • Nausea
  • Nystagmus
  • Onset with neck movement

Rule In / Rule Out (Objective)

  • HiNTS exam
  • Oculomotor exam
  • Vestibular assessment (to rule in peripheral cause)
  • Gait assessment
  • Coordination testing
  • Reflexes, power, visual field assessment

Action

  • Any positive 5D → caution
  • Two or more positive → urgent referral before manual therapy
  • No cervical manipulation until cleared
  • Refer for imaging
Rules out vertebrobasilar insufficiency and internal carotid dissection. Always screen before manual therapy or exercise involving cervical rotation/extension.

Upper Cervical Instability (UCI)

URGENT REFERRAL

Sounds Like (Subjective)

  • Myelopathic features: hand clumsiness, gait ataxia
  • Bilateral symptoms
  • Bladder changes
  • Sharp neck pain with flexion
  • History of RA, Down syndrome, trauma
  • Odontoid fracture history

Rule In / Rule Out (Objective)

  • Sharp Shooter Test (C1/C2 instability): sharp pain from occiput to vertex on cervical flexion
  • Upper limb coordination testing
  • Gait ataxia assessment
  • Babinski / clonus
  • Cervical flexion ROM with symptom monitoring

Action

  • Suspected UCI → urgent imaging before exercise or manual therapy
  • Positive Sharp Shooter → refer for imaging before any treatment
  • No loading, no manipulation
Rules out atlantoaxial instability. Key populations: rheumatoid arthritis, Down syndrome, post-trauma. Always screen before cervical exercise in Clinical Pilates.

Central / Brain Pathology

EMERGENCY

Sounds Like (Subjective)

  • Thunderclap headache
  • Progressive worsening headache
  • Headache with systemic illness
  • Neck stiffness
  • Visual disturbance
  • Ataxia, nausea, numbness
  • Dizziness, diplopia, dysarthria, dysphagia
  • Drop attacks, head strike

Rule In / Rule Out (Objective)

  • HiNTS exam
  • Oculomotor exam
  • Vestibular assessment (rule in peripheral)
  • Gait assessment & coordination
  • Reflexes & power
  • Visual field assessment
  • Sensation

Action

  • Refer on for imaging
  • Thunderclap headache = emergency
  • Multiple central signs = same-day referral
  • Do not treat cervically until cleared

SNOOP10 Headache Red Flags

The SNOOP10 mnemonic screens for secondary (sinister) headache. Apply to ALL headache presentations. Rule out sinister causes before attributing to primary headache or cervical driver.

SNOOP10 Mnemonic

SCREEN ALL HEADACHES
S
Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, cancer, immunosuppression)
N
Neurological symptoms or abnormal signs (confusion, altered consciousness, focal neuro)
O
Onset sudden / thunderclap (peak intensity in <5 seconds)
O
Older age (new onset headache >50 years)
P
Pattern change or recent onset of new headache type
P
Positional headache (worse lying, better standing or vice versa → raised ICP or CSF leak)
P
Precipitated by sneezing, coughing, or Valsalva
P
Papilloedema (on fundoscopy — refer if suspected)
P
Progressive headache and atypical presentations
P
Pregnancy or postpartum period
In hypermobility populations, always screen headaches with SNOOP10 first. Postural headache (positional component) may indicate CSF leak — common in EDS/HSD. Do not assume cervicogenic until sinister causes are excluded. (Do et al., 2019)

Action

  • Any positive SNOOP10 → medical referral before physiotherapy treatment
  • Thunderclap headache → EMERGENCY — same-day imaging
  • Positional headache in hypermobile client → investigate CSF leak
  • Once cleared: then determine primary headache type (migraine vs TTH vs cervicogenic)

Headache screening is part of the cervical assessment module

Week 5 covers upper body, thoracic and cervical assessment — including headache screening, CAD, and clinical reasoning for the cervical spine in Clinical Pilates.

Join the Collective →

Hypermobility Red Flags

Hypermobile clients present unique red flags that go beyond standard spinal screening. Screen for multi-system involvement at every initial assessment. (Malfait et al., 2017; Castori et al., 2017)

The Hypermobility Spectrum

Classification Features Clinical Pilates Approach Red Flags
Asymptomatic hypermobility Beighton ≥5/9. No pain. No functional impact. Preventive: control and strength training Onset of pain → reassess and reclassify
HSD Symptomatic hypermobility. Pain/functional impact. Does not meet hEDS criteria. Control-first Clinical Pilates. Strength endurance. Long timeline. POTS symptoms. Worsening autonomic features.
hEDS Meets 2017 nosology criteria. Systemic connective tissue involvement. Individualised MDT approach. Clinical Pilates as one component. POTS, MCAS, significant autonomic dysfunction → MDT referral
Hypermobility + POTS Orthostatic intolerance + hypermobility + often MCAS. Reclined-first exercise (Levine protocol). Hydration, salt, compression. Postural HR increase ≥30 bpm standing → cardiology / autonomic specialist

Hypermobility Assessment Battery

  • Beighton Score (≥5/9 = generalised hypermobility)
  • 5-part Questionnaire (Hakim & Graham 2003 — captures historical hypermobility)
  • SPIDER Questionnaire
  • Bristol Impact of Hypermobility Score
  • Single-leg squat quality (control deficit)
  • Joint position error test (proprioception)
  • Mid-range control test
  • POTS screen — 10-min stand test or NASA Lean Test (HR increase ≥30 bpm = refer)
  • BP Testing

Red Flags in Hypermobility

SCREEN ALL

Sounds Like

  • POTS symptoms (lightheadedness on standing, fatigue, brain fog, palpitations)
  • MCAS symptoms (flushing, GI issues, skin reactions)
  • Multi-system involvement (gut, pelvic organs, vascular/cardiac, vision)
  • Frequent cancellations/rebookings (fatigue pattern)
  • Headaches (screen with SNOOP10 first)

Rule In / Rule Out

  • NASA Lean Test or 10-min stand (HR ≥30bpm)
  • Beighton + 5-part questionnaire
  • EDS diagnostic criteria form
  • BP testing
  • Functional assessment “show me what bothers you”
  • Extra-articular manifestation screen

Action

  • POTS confirmed → refer cardiology/autonomic specialist before loading
  • MCAS suspected → refer immunology/allergy
  • Multi-system → MDT approach
  • You cannot treat these patients with strength alone — pushing through makes symptoms worse
  • Use mini treatments within session if required
You cannot treat these patients with strength alone, and pushing through makes symptoms worse. Use mini treatments within session if that is required. (Simmonds et al., 2019; Malfait et al., 2017)

Connective Tissue Red Flag Screen

REFER FOR FURTHER ASSESSMENT

Screen for features that may indicate a rarer type of EDS or other Hereditary Disorder of Connective Tissue. Any positive finding in the patient OR a first/second-degree relative should trigger referral for further assessment including consideration of genetic testing. (Malfait et al., 2017; Hakim, 2026)

Differential diagnosis includes: Marfan syndrome, Loeys-Dietz syndrome, Osteogenesis Imperfecta, Stickler syndrome.

Family & Systemic

  • Family history of EDS or other hereditary connective tissue disorder
  • Unexplained sudden death in a relative <50 years
  • Recurrent pneumothorax
  • Unexplained tears or ruptures of hollow organs (bowel, uterus)

Cardiovascular & Skeletal

  • Dilated aorta or large arteries (<50 years)
  • Arterial dissections or severe unexplained bleeding
  • Thoracic aortic pathology or carotid-cavernous fistula
  • Bilateral club foot or congenital hip dysplasia
  • Contractures or severe kyphoscoliosis
  • Low-trauma fractures <40 years, short stature

Skin, Eye & Dental

  • Skin hyperextensibility ≥2cm stretch
  • Atrophic papyraceous scars or premature aged appearance
  • Bilateral varicose veins <30 years
  • Recurrent large hernias (abdominal wall or groin)
  • Lens subluxation, retinal detachments, corneal scarring
  • Severe periodontal disease / tooth loss <40 years
  • Dentinogenesis imperfecta
Any positive finding should trigger referral for further assessment, including consideration of genetic testing to determine or exclude the presence of a rarer type of EDS or other HDCT. (Hakim AJ, 2026. In Hochberg et al., Rheumatology 9th Ed, Elsevier, Ch 230)

hEDS Diagnostic Criteria (2017)

3 CRITERIA MUST BE MET

The clinical diagnosis of hypermobile EDS requires the simultaneous presence of all three criteria. (The International Consortium on EDS & Related Disorders; The Ehlers-Danlos Society)

CRITERION 1 — Generalised Joint Hypermobility

Beighton Score cut-offs:

  • ≥6 — pre-pubertal children and adolescents
  • ≥5 — pubertal men and women to age 50
  • ≥4 — men and women over age 50

If Beighton is 1 point below cut-off, 2+ of the 5-part questionnaire must also be positive (hands flat on floor, thumb to forearm, contortions as a child, recurrent dislocations, considers self “double jointed”)

CRITERION 2 — Two or more of Features A, B, or C

Feature A (5 of 12 must be present):

  • Unusually soft or velvety skin
  • Mild skin hyperextensibility
  • Unexplained striae distensae
  • Bilateral piezogenic papules of the heel
  • Recurrent or multiple abdominal hernias
  • Atrophic scarring at ≥2 sites
  • Pelvic floor / rectal / uterine prolapse
  • Dental crowding and high or narrow palate
  • Arachnodactyly (Walker sign / Steinberg sign)
  • Arm span-to-height ratio ≥1.05
  • Mitral valve prolapse (MVP)
  • Aortic root dilatation Z-score >+2

Feature B:

Positive family history — one or more first-degree relatives independently meeting hEDS criteria

Feature C (at least one):

  • MSK pain in ≥2 limbs, recurring daily for ≥3 months
  • Chronic widespread pain for ≥3 months
  • Recurrent joint dislocations or frank joint instability (absence of trauma)

CRITERION 3 — All prerequisites must be met

  1. Absence of unusual skin fragility (which should prompt consideration of other EDS types)
  2. Exclusion of other heritable and acquired connective tissue disorders, including autoimmune rheumatologic conditions
  3. Exclusion of alternative diagnoses that may include joint hypermobility via hypotonia and/or connective tissue laxity (e.g. neuromuscular disorders, other EDS types, Loeys-Dietz, Marfan, skeletal dysplasias, osteogenesis imperfecta)
This checklist is for doctors across all disciplines to diagnose hEDS. Physiotherapists should use this to identify clients who may need medical referral for formal diagnosis. The diagnosis requires all three criteria to be met simultaneously. (The International Consortium on EDS & Related Disorders; The Ehlers-Danlos Society)

Hypermobility is covered in depth in the Foundations course

Assessment batteries, treatment maps, POTS screening protocols, and how to programme Clinical Pilates for the hypermobile client — all inside the Clinical Pilates Collective.

See the full course →

Interactive Red Flag Screen

Use this during your subjective assessment. Weave these into conversation — not as a checklist on a form. Tick what applies and the tool will suggest a risk level.

Cauda Equina Syndrome

Spinal Malignancy

Vertebral Fracture

Infection / Sepsis

Vascular (AAA)

Progressive Neurological Deficit

Cervical: CAD Screening

Headache: SNOOP10

Hypermobility Red Flags

Clinical Risk Level

LOW RISK — PROCEED

No cluster present. Proceed with assessment, document, and monitor.

Learn the full Move ED assessment framework

Red flags are Step 1 of 8. The Foundations course teaches the complete ICF-based assessment order, clinical reasoning, and treatment mapping for Clinical Pilates.

Explore Move ED Foundations →

How to Ask These Questions

Weave red flag questions into your subjective naturally — it's a clinical conversation, not a questionnaire.
Not: "Do you have any red flags?" (clients can't answer this)
Instead: "How has your sleep been — any pain that wakes you at night?" / "Have you noticed any changes in your bladder or bowel?" / "Any unexplained weight loss recently?" / "Any recent illness, infection or fever?"

Clinical Decision Framework

Use this to decide: reassure, monitor, refer urgently, or refer as emergency.

LOW RISK
Proceed
Features: Single isolated flag. Young patient. No systemic features. Improving with conservative care.
Decision: Continue Clinical Pilates. Monitor and document.
Documentation: Note the flag and the reasoning for proceeding.
MEDIUM
Monitor
Features: 1–2 flags. Some systemic features. Patient not deteriorating.
Decision: Continue with caution. Weekly objective monitoring. Low threshold to refer.
Documentation: Document flags, monitoring plan, patient informed.
HIGH RISK
Refer Urgently
Features: Multiple clustered flags. Any CES feature. Progressive neurology. Any vascular suspicion.
Decision: STOP Clinical Pilates. Same-day urgent referral. Notify GP.
Documentation: Full documentation. Follow-up to confirm referral acted on.
CRITICAL
Emergency
Features: Any cauda equina symptom. Suspected AAA. Signs of myelopathy.
Decision: Call triple zero or direct to ED. Do not continue assessment.
Documentation: Document emergency action immediately.

When in Doubt

Refer first, treat later. Your documentation protects your client and your registration. The decision framework is not about fear — it is about appropriate threshold-setting. Most of your clients will be low risk. But the one who isn't needs you to catch it.

CES Safety Netting

For any client with LBP, always provide CES safety net information: "If you develop any numbness in your groin or saddle area, any changes to your bladder or bowel control, or any sudden worsening of leg weakness — go directly to the emergency department. Do not wait." Document that you provided this advice.

Download CES Safety Netting Card ↓ — Give this to every client with LBP.

Want to see what this looks like in the treatment room?

Join the Clinical Pilates Collective on Skool — frameworks, case studies, and a community of clinicians who reason through rehab, not just prescribe exercises.

Join the Collective →

Evidence Base & References

Primary Sources

Finucane LM, Downie A, Mercer C et al. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic and Sports Physical Therapy, 50(7), 350–372. [IFOMPT Framework]

Rushton A, Rivett D, Carlesso L, Flynn T, Hing W & Kerry R. (2014). International Framework for Examination of the Cervical Region for Potential of Cervical Arterial Dysfunction Prior to Orthopaedic Manual Therapy Intervention. IFOMPT.

World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). WHO Press, Geneva.

Escorpizo R, Stucki G, Cieza A, Davis K, Stumbo T & Riddle DL. (2010). Creating an interface between the ICF and physical therapist practice. Physical Therapy, 90(7), 1053–1063.

Jones MA & Rivett DA. (2019). Clinical Reasoning in Musculoskeletal Practice. 2nd ed. Elsevier.

McKenzie R & May S. (2020). The Lumbar Spine: Mechanical Diagnosis and Therapy. Spinal Publications.

May S & Aina A. (2012). Centralisation and directional preference: a systematic review. Manual Therapy, 17(6), 497–506.

Kosek E, Cohen M, Baron R et al. (2016). Do we need a third mechanistic descriptor for chronic pain states? Pain, 157(7), 1382–1386.

Smart KM, Blake C, Staines A & Doody C. (2012). Mechanisms-based classifications of musculoskeletal pain. Clinical Journal of Pain, 28(8), 667–675.

Do TP, Remmers A, Schytz HW et al. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134-144.

Malfait F, Francomano C, Byers P et al. (2017). The 2017 international classification of the Ehlers-Danlos syndromes. American Journal of Medical Genetics Part C, 175(1), 8-26.

Castori M, Tinkle B, Levy H, Grahame R, Malfait F & Hakim A. (2017). A framework for the classification of joint hypermobility and related conditions. American Journal of Medical Genetics Part C, 175(1), 148-157.

Simmonds JV, Herbland A, Hakim A et al. (2019). Exercise beliefs and behaviours of individuals with Joint Hypermobility Syndrome/Ehlers-Danlos Syndrome. Disability and Rehabilitation, 41(4), 445-455.

Hakim A & Grahame R. (2003). A simple questionnaire to detect hypermobility. Rheumatology, 42(12), 1726-1727.

Hakim AJ. (2026). Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorder Syndromes. In Hochberg MC, Gravallese EM, Smolen JS et al. (eds), Rheumatology 9th Edition, Elsevier, Chapter 230.

The International Consortium on Ehlers-Danlos Syndromes & Related Disorders / The Ehlers-Danlos Society. (2017). Diagnostic Criteria for Hypermobile Ehlers-Danlos Syndrome (hEDS). Checklist v9.