The Flag System

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Introduction

This article will discuss the management of patients with yellow flags in physiotherapy practice. Yellow flags are psychosocial indicators suggesting increased risk of progression to long-term distress, disability and pain.

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 (Waddell & Watson, 2004).

Stepped care approach

Von Korff and Moore (2001) 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.

Predictors of chronic disability

A biopsychosocial assessment should seek to identify the following:

• Bio (triage and identification of the pathology)
• Psycho (psychological distress, fear/avoidance beliefs, current coping methods and attribution)
• Social (work issues, family circumstances and benefits/economics)

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
  

Recent Related Research (from Pubmed)

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References

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