Lorenzo Storari

Introduction: While low back pain (LBP) is most often associated with musculoskeletal issues, in a minority of cases, it can be caused by serious underlying conditions such as cancer. Recognizing malignancy early remains a major clinical challenge, as the warning signs, known as red flags (RFs), are often vague and inconsistent. Methods: A comprehensive search of six databases (PubMed, Scopus, Google Scholar, Web of Science, Cochrane Library, and SciELO) and grey literature was conducted for studies published from January 1999 to March 2025. Eligible sources included studies describing adult patients with cancer presenting with LBP. Study selection and data extraction were independently performed by two reviewers. Results: We included 70 studies, most of which were case-based, along with reviews and observational research. In these studies, cancer prevalence among patients with LBP ranged from 0.1% to 1.6%, with metastatic disease being the most common finding. A prior history of cancer emerged as the most reliable red flag (specificity up to 0.99), while other signs and symptoms were less consistent. Notably, combining multiple RFs, such as a history of cancer and unexplained weight loss, significantly improved the diagnostic accuracy (LR+ = 10.25 in one study). Conclusions: While current evidence is limited and largely based on case-based studies, some RFs, particularly a history of cancer, show greater diagnostic value. In patients with LBP associated with underlying malignancy, RFs seem to be more useful for ruling in rather than ruling out (i.e., screening) serious pathologies. Most RFs have poor standalone accuracy; however, considering combinations of RFs within the broader clinical context may improve early detection of spinal malignancy in patients with LBP.

Background and Objectives: The aging population and the COVID-19 pandemic have led to a rise in severe conditions, including musculoskeletal (MSK) disorders. Although MSK conditions are often managed in primary care, they may sometimes mask serious illnesses requiring urgent diagnosis. The red flag (RF) concept is essential for identifying signs and symptoms of potentially severe disease. However, RF criteria vary across clinical guidelines and lack consistency. With the growing role of direct access to physiotherapy—bypassing physician referral—physiotherapists must develop strong differential diagnostic skills to identify serious pathologies that mimic MSK disorders. This review aims to systematically map how RFs are defined in MSK clinical practice guidelines (CPGs), supporting the move toward a standardized definition for clinical and research use. Materials and Methods: A comprehensive literature search was conducted in PubMed, Web of Science, Scopus, and Cochrane databases. Included studies were CPGs and systematic reviews (SRs) of CPGs addressing MSK disorders and incorporating the RF concept. Data extraction followed a rigorous process, and RF definitions were synthesized and compared in table format. Results: Out of thirteen-thousand three-hundred and ninety-three articles identified, fourteen met inclusion criteria (seven CPGs and seven SRs of CPGs), spanning both physiotherapy and medical fields. All definitions described RFs as signs or symptoms indicating possible serious pathology requiring further investigation or referral. Some definitions referred broadly to “patterns of signs or symptoms”, while others offered more precise criteria. Conclusions: This review highlights the lack of a standardized RF definition in MSK care, leading to inconsistencies in clinical decision-making and diagnosis. To improve patient safety and guide clinicians—especially in direct-access contexts—a unified, internationally recognized definition of RFs is needed in future guidelines.

This study explored the effect of knee range of motion (ROM) restrictions on lumbar spine kinematics and posterior chain muscle activity during squat and stoop lifting tasks. This relationship reflects the concept of regional interdependence, where impairments in one anatomical area may influence others, a key principle in the kinetic chain approach. Fifteen healthy adults performed squat and stoop lifting tasks under three knee ROM conditions (squat: free/0–60°/0–90°; stoop: free/0°/0–30°) using optoelectronic motion capture and electromyographic (EMG) systems. One-way analysis of variance was applied to analyze lumbar spine angles in flexion/extension, side bending, and rotation and to assess muscle activation patterns for five posterior chain muscles. No significant effects of knee ROM restrictions were observed for lumbar flexion/extension or side bending (p>0.15), but pelvic rotation differed significantly (p=0.0103). EMG analysis showed increased activation of the Gastrocnemius Lateralis and Biceps Femoris (p<0.001), while Gluteus Maximus and Latissimus Dorsi activation remained unchanged. Knee ROM restrictions influenced EMG muscle activation in distal posterior chain muscles and altered pelvic rotation, suggesting localized compensatory mechanisms. Results highlight the variation in muscle activation patterns and kinetic adjustments during squat and stoop lifting tasks in healthy individuals simulating knee ROM deficits, osteoarthritis, or low back pain conditions.

Background: Pelvic girdle pain (PGP) is described in the literature as a subgroup of low back pain (LBP), characterized by pain localized between the posterior iliac crest and the gluteal fold, particularly near the sacroiliac joints. This condition can manifest in different forms non-specific PGP, occurring during pregnancy or postpartum (pregnancy-related PGP), which represents the most prevalent form and non-pregnancy-related PGP, resulting from mechanical alterations caused by trauma or microtrauma. Specific PGP, associated with identifiable causes such as fractures, infections, or arthritis. Over the years, research has focused on identifying the most effective approaches for managing this condition and addressing its associated biopsychosocial impairments. The aim of this narrative review is to determine the types of motor control exercises (MCEs) used to reduce short-term pain in patients with PGP and to assess whether these exercises are designed in accordance with the principles of motor control (MC) theories. Methods: A narrative review was conducted through searches in various medical and rehabilitation databases, including MEDLINE (via PubMed), PEDro, Scopus, and Web of Science. The inclusion criteria of the review encompassed case studies, case reports, editorials, original research articles, randomized controlled trials (RCTs), and systematic reviews (SRs). Results: Six articles met the eligibility criteria, comprising two SRs and four RCTs, all of which were included in the qualitative analysis. Among these, two studies examine MCEs for non-pregnancy-related PGP, while all the other studies focus on pregnancy-related PGP. The exercises described focused on lumbar–pelvic stabilization or deep spinal muscle activation. Among the six included studies, five did not report statistically significant changes in pain outcomes, while only one study demonstrated a statistically significant improvement. Conclusions: The analysis highlighted that the exercises currently employed are generally unspecific and not systematically structured according to the principles outlined in MC theories. The available evidence, combined with the incorrect design of these exercises, does not allow for definitive conclusions regarding the efficacy of MCEs in reducing short-term pain in patients with both pregnancy-related and non-pregnancy-related PGP.

Objective: To investigate the most common physical examination tests (PET) for the screening for referral of patients with back or chest pain caused by serious pathology. Methods: A systematic review was conducted. Searches were performed on seven electronic databases between June 2020 and December 2021. Only studies evaluating patients with back and/or chest pain with clear reporting of PETs and prompt patient referrals were included. Results: 316 full texts were included, and these studies had a total of 474/492 patients affected by a serious disease. Only 26 studies of them described suspicion of serious disease due to at least one positive PET. Cardiac/pulmonary auscultation and heartbeats/blood pressure measurements were the most frequently reported tests. None of the reported studies included physiotherapists and chiropractors who reported the use of various tests, such as: cardiac and pulmonary auscultation, lung percussion, costovertebral angle tenderness, and lymph node palpation, highlighting a lack of attention in measuring vital parameters. On the contrary, doctors and nurses reported the assessment of the range of motion of the thoracolumbar spine and hip less frequently. Conclusions: Appropriate reporting of PETs is sparse, and their utilization is heterogeneous among different healthcare professionals. Further primary studies are needed to describe PETs results in patients suffering from back and/or chest pain.

We want to thank you for the opportunity to respond to the issues raised in the letter to the Editor of Dr. Moretti et al.

Osteoid osteoma (OO) is a relatively common, benign bone-forming tumour, which mainly occurs on the long tubular bones of the limbs in adolescents. Usually, the OO is classified based on its localisation. Night-time pain is the major symptom of OO, which is commonly relieved using non-steroidal anti-inflammatory drugs, while surgery is required only for those patients with severe pain or in case of failure of previous conservative treatments. Our case report describes a 56-year-old male basketball player who self-referred to our outpatient physical therapy with a shoulder pain complaint. Considering the anamnesis and the physical examination, the physical therapist referred the patient to an orthopaedic surgeon, who suggested a detailed imaging investigation. The peculiarity of this clinical case is the overlapping of two clinical presentations: the symptomatology of the OO and the concurrent mechanical disorder due to a rotator cuff tendinopathy.

Direct access to physical therapy (DAPT) is the patient’s ability to self-refer to a physical therapist, without previous consultation from any other professional. This model of care has been implemented in many healthcare systems since it has demonstrated better outcomes than traditional models of care. The model of DAPT mainly focuses on the management of musculoskeletal disorders, with a huge epidemiological burden and worldwide healthcare systems workload. Among the healthcare professionals, physical therapists are one of the most accessed for managing pain and disability related to musculoskeletal disorders. Additionally, the most updated guidelines recommend DAPT as a first-line treatment because of its cost-effectiveness, safety, and patients’ satisfaction compared to other interventions. DAPT was also adopted to efficiently face the diffuse crisis of the declining number of general practitioners, reducing their caseload by directly managing patients’ musculoskeletal disorders traditionally seen by general practitioners. World Physiotherapy organization also advocates DAPT as a new approach, with physical therapy in a primary care pathway to better control healthcare expenses. Thus, it is unclear why the Italian institutions have decided to recognize new professions instead of focusing on the growth of physical therapy, a long-established and autonomous health profession. Furthermore, it is unclear why DAPT is still not fully recognized, considering the historical context and its evidence. The future is now: although still preliminary, the evidence supporting DAPT is promising. Hard skills, academic paths, scientific evidence, and the legislature argue that this paradigm shift should occur in Italy.

Background: Glioblastoma is the most frequent and aggressive malignant brain tumor among adults. Unfortunately, its symptoms can vary considerably depending on the size, location and the anatomic structures of the involved brain. Case report: A 58-year-old male amateur cyclist who suffered from sharp arm pain was examined for a thoracic outlet syndrome due to a previous clavicle fracture. Because of ambiguous results of the neck and nerve plexus imaging, he was referred to a neurosurgeon who properly suspected a brain tumor. The neuroimaging of the brain shown a 3 cm disploriferative mass with a blood enhancement within the left parietal lobe. The mass was urgently removed, and its histologic analysis stated a grade 4 glioblastoma. Conclusion: This case report highlights the differential diagnosis process and the teamwork approach needed to diagnose a rare presentation of a brain glioblastoma, which started its symptoms mimicking a thoracic outlet syndrome caused by a previous bone fracture.