The Flag System

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Introduction

Yellow flags are psychological (fear/avoidance beliefs, current coping methods and attribution) and social (work issues, family circumstances and benefits/economics) indicators suggesting increased risk of progression to long-term distress, disability and pain.  

The term was coined by Kendall and colleagues coined to encompass psychological risk factors and social and environmental risk factors for prolonged disability and failure to return to work as a consequence of musculoskeletal symptoms .

Key predictors include:

• The belief that pain is harmful or severely disabling
• Fear-avoidance behaviour (avoiding activity because of fear of pain)
• Low mood and social withdrawal
• Expectation that passive treatment rather than active participation will help

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

The developing concept

However, more recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables.

In recent years, the focus of research on yellow flags has been more specifically applied to occupational contexts. Main and Burton have argued that, in these contexts, the term “yellow flags” should be reserved for more overtly psychological risk factors, such as fears and unhelpful beliefs, whereas the social/environmental (workplace) risk factors could be divided into 2 categories:

1. Workers' perceptions that their workplace is stressful, unsupportive, and excessively demanding, which they termed “blue flags,” and
2. The more observable characteristics of the workplace and nature of the work, as well the insurance and compensation system under which workplace injuries are managed, which they termed “black flags.”

More recently, a distinction has been drawn between psychological risk factors that might be considered essentially “normal,” but unhelpful, psychological reactions to musculoskeletal symptoms (eg, the belief that pain necessarily implies damage) and clearly “abnormal” psychological or psychiatric factors or disorders (eg, posttraumatic stress disorder, major depression) suggestive of diagnosable psychopathology. It has been suggested that the normal but unhelpful psychological reactions should be described as yellow flags, and those meeting criteria for psychopathology should be termed “orange flags.”  The primary significance of this distinction is to differentiate yellow flag factors, which might be amenable to change by suitably trained health care providers such as general medical practitioners and physical therapists, from orange flag factors that probably require specialist mental health referral.

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.
Yellow	Emotional Responses	Distress not meeting criteria for diagnosis of mental disorder. Worry, fears, anxiety.
Yellow	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.

If you suspect any “RED FLAG” pathology there 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.

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.

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.
   

Recent Related Research (from Pubmed)

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