The Flag System

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Introduction

Flags can be split into two distinct categories: clinical flags and psychosocial flags.

Clinical flags are common to many areas of health – for example, red flags for musculoskeletal disorders, which are indicators of possible serious pathology such as inflammatory or neurological conditions, structural musculoskeletal damage or disorders, circulatory problems, suspected infections, tumours or systemic disease. If suspected, these require urgent further investigation and often surgical referral. There are certain signs and symptoms that when observed in a patient’s examination or history alert us to the fact that something could be seriously wrong. In the case of musculoskeletal disorders, physiotherapists are highly trained to identify or rule out red flags. If you suspect any red flags the patient must seek urgent medical attention and it is better to send the patient to A&E rather than risk any permanent, life changing pathology.

Recently, orange flags were added to the spectrum, and represent the equivalent of red flags for mental health and psychological problems – alerting the clinician to serious problems that could be psychiatric in nature, and therefore require referral to a specialist in that field, rather than following the normal course of management for mild mental health conditions such as anxiety. Orange flags can include excessively high levels of distress, major personality disorders, post-traumatic stress disorders, drug and alcohol abuse/addictions or clinical depression.

Psychosocial flags allow us to identify aspects of the person, their problem and their social context, and how those factors affect the recovery and return-to-work process. The concept was introduced in 1997 by Kendall et al and looked at factors that identified patients who were at risk of developing chronic disability, and did not recover as was expected for their condition.

Psychosocial flags enable us to work from a biopsychosocial model and give a framework for assessment and planning. These flags are not a diagnosis or a symptom, but an indication that someone may not recover as expected, and may need additional support to return to work. These flags are often referred to as obstacles to recovery. Psychosocial factors determine outcomes such as activity levels and participation and work, but appear to be less relevant to the reporting of symptoms.

Below is a table with some examples of a flag colour, the nature of the flag and examples of clinical signs to look for on assessment:

Flag	Nature	Examples
Red	Signs of serious pathology	Cauda equina syndrome, fracture, tumour, unremitting night pain, sudden weight loss of 10pounds over 3 months, Bladder & Bowel incontinence
Orange	Psychiatric symptoms	Clinical depression, personality disorder
Yellow	Beliefs, appraisals and judgements	Unhelpful beliefs about pain: indication of injury as uncontrollable or likely to worsen. Expectations of poor treatment outcome, delayed return to work.
	Emotional Responses	Distress not meeting criteria for diagnosis of mental disorder. Worry, fears, anxiety.
	Pain behaviour (including pain and coping strategies)	Avoidance of activities due to expectations of pain and possible reinjury. Over-reliance on passive treatments.
Blue	Perceptions about the relationship between work and health	Belief that work is too onerous and likely to cause further injury. Belief that workplace supervisor and workmates are unsupportive.
Black	System or contextual obstacles	Legislation restricting options for return to work. Conflict with insurance staff over injury claim. Overly solicitous family and health care providers. Heavy work, with little opportunity to modify duties.

Psychosocial flags

Psychosocial flags have been subdivided over the years to reflect the different interactions that can affect recovery. As a result, they are now referred to as yellow, blue and black flags. Briefly, yellow flags cover the features of the person which affect how they manage their situation with regard to thoughts, feelings and behaviours. Blue flags concern the workplace and the employee’s perceptions of health and work. And black flags are about the context and environment in which that person functions, which includes other people, systems and policies. Black flags can block or limit the helpful activity of healthcare providers and workplace support.

Yellow flags

Obstacles that can be classed as yellow flags include many aspects of thoughts, feelings and behaviours. Some common examples include:

• Catastrophising – thinking the worst
• Finding painful experiences unbearable, reporting extreme pain disproportionate to the condition
• Having unhelpful beliefs about pain and work – for instance, ‘if I go back to work my pain will get worse’
• Becoming preoccupied with health, over-anxious, distressed and low in mood
• Fear of movement and of re-injury
• Uncertainty about what the future holds
• Changes in behaviour or recurring behaviours
• Expecting other people or interventions to solve the problems (being passive in the process) and serial visits to various practitioners for help with no improvement.

Assessing for yellow flags

While performing a Yellow Flag assessment, the following should be acknowledged:

• • Attitudes/Beliefs – What does the patient think to be the problem and do they have a positive or negative attitude to the pain and potential treatment?
  • Behaviour – Has the patient changed their behaviour to the pain? Have they reduced activity or compensating for certain movements. Early signs of catastrophising and fear-avoidance?
  • Compensation – Are they awaiting a claim due to a potential accident? Is this placing unnecessary stress on their life? .
  • Diagnosis/Treatment – Has the language that has been used had an effect on patient thoughts? Have they had previous treatment for the pain before, and was there a conflicting diagnosis? This could cause the patient to over-think the issue, leading to catastrophising and fear-avoidance.
  • Emotions – Does the patient have any underlying emotional issues that could lead to an increased potential for chronic pain? Collect a thorough background on their psychological history.
  • Family – How are the patient’s family reacting to their injury? Are they being under-supportive or over-supportive, both of which can effect the patient’s concept of their pain
  • Work – Are they currently off work? Financial issues could potentially arise? What are the patient’s thoughts about their working environment?
    

Clinical Assessment of Psychosocial Yellow Flags

Treating yellow flags

The early treatment of patients at risk of developing chronic pain has been found to be effective at preventing long-term disability and chronicity.

Stepped care approach

People with pain require:

• a rationale for returning to activity
• an appropriate strategy to manage their symptoms
• a safe environment to engage in physical exercise to restore confidence in movement
• the opportunity and encouragement to return to normal physical activity

In addressing the factors above, the difference between treatment and rehabilitation becomes clearer but must still take into account the barriers to rehabilitation. These are the non-physical or clinical factors that are important to determine recovery and failure to address them can lead to a suboptimal outcome, no matter how technically good you are as a clinician.

Von Korff and Moore advocate a stepped care approach, evident in the following table:

1	Most patients who are at the acute stage	Identify and address the common worries of patients with back pain using simple, symptomatic measures. Provide information and advice to encourage the resumption of ordinary activities.
2	The substantial minority of patients who do not resume ordinary activities by 3-6 weeks with simple advice.	Provide brief, structured interventions that help patients to identify obstacles to recovery, set functional goals and develop plans to achieve them. Provide support for physical exercise and return to ordinary activities
3	The small minority of patients who have persisting disability in work or family life and who require more intensive intervention.	Address dysfunctional beliefs and behaviour. Provide a progressive exercise or graded activity programme. Enable and support patients to return to ordinary activities.

Cognitive behavioural approach

Cognitive Behavioural Therapy (CBT) is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner  .

It is not just psychologists or psychiatric nurses who specialise in CBT as some ESP physiotherapists, mainly in a MSK setting, have been trained in this specialist area so it is worth investigating who you could refer a patient to.

Blue flags

Blue flags can be considered in terms of the employee and the workplace. The employee often has fears and misconceptions about work and health based on their own previous experiences or those of others in the company they work for, or stories from the neighbours. Blue flags can include:

• Concerns about whether the person is able to meet the demands of the job
• Low job satisfaction
• Little or poor support at work
• A perception that the job is very stressful
• An accommodating approach in the workplace to providing altered duties or modified work options to facilitate a return to work
• Poor communication between employer and employee.

Black flags

There is some overlap between blue and black flags, but they can be primarily distinguished by the black flags being those that are outside the immediate control of the employee and/or the team trying to facilitate the return to work. Black flags include:

• Misunderstandings among those involved
• Financial issues and/or claims procedures
• Sensationalist media reports
• Family and friends with strong unhelpful beliefs influencing the employee
• Social isolation and becoming disconnected from the workforce

Poor or unhelpful company policies. Often company policies can take two forms: either there is no policy or inadequate policy surrounding sickness absence management and return to work, or there is rigid management of absence within a disciplinary policy system that does not allow sufficient flexibility to deal with genuine injury and illness rehabilitation needs.

Key Resources

1. Kendall NA, Linton SJ, Main CJ. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss]. Wellington, New Zealand: Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee; 1997.
2. Nicholas MK1, Linton SJ, Watson PJ, Main CJ; "Decade of the Flags" Working Group. Early identification and management of psychological risk factors ("yellow flags") in patients with low back pain: a reappraisal. Phys Ther. 2011 May;91(5):737-53. doi: 10.2522/ptj.20100224. Epub 2011 Mar 30.
   

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