page 20 | the osteopath magazine | Oct/Nov 2012

Osteopaths are familiar with the concept of red and yellow flags in clinical practice, but other flagsexist which also have a bearing on practice. This article describes the different types of flags that exist,their significance to clinical practice and the limitations of the flag system.

What is the relevance of coloured flags toosteopathic practice? Carol Fawkes (NCOR Research Officer) and Dawn Carnes (NCOR Director)

T raditionally the treatment of lowback pain had focussed on the useof the biomechanical and

biomedical models alone1. Longitudinalstudies emphasised the impact ofpsychosocial factors and their impact onoutcome, or the development of chronicpersistent problems. The concept ofyellow flags was introduced and has beenwidely adopted. This has been followedby the introduction of blue flags whichdescribe the workplace itself, and blackflags which address the wider context inwhich an individual functions includingother personnel, systems, and policies2,3,4,5.More recently orange has been added tothe spectrum, with pink included alsoalthough not officially recognised inmainstream healthcare.

The Accident Compensation Corporationof New Zealand highlighted in 2004 theimportance of using a holistic approach

when assessing patients presenting withspinal pain3. The biopsychosocialapproach views pain and disability as acomplex and dynamic interaction amongphysiological, psychological, and socialfactors, which perpetuates and mayworsen the clinical presentation.Historically, the two most commonlyrecognised flags have been physiological(red flags), and psychosocial (yellow flags)risk factors associated with theprogression from acute to chronic lowback pain disability1,2. The use of the flagframework and its screening tools hashad widespread application in clinicalpractice since its creation. However, it hasbeen argued that they need to beregarded critically and considered notonly in terms of their validity andreliability, but also for the effect their usemight have on patient-clinicianinteraction and the clinical reasoningprocess6.

Good case historytaking is an implicit part of

professional practice for all osteopaths. Itcan help to identify signs of seriouspathology including tumour, fracture,infection, cauda equina syndrome whichrequire onward referral for investigationand treatment. Additional red flags withwhich all osteopaths are familiar includethe presence of significant trauma,unexplained weight loss, previous historyof cancer, fever, intravenous drug use,long-term steroid use, severe, unremittingnight pain, and pain that gets worse whenlying down7,8. This list is not exhaustivebut illustrative, and the presence of anyred flag should be considered inconjunction with appropriate clinicalexamination.

These are salientpsychosocial risk factors

involved in impeding the ability of anindividual to improve and/or recover fromacute pain episodes, and increasing therisk of developing chronic pain anddisability. The presence of yellow flags isnot indicative of malingering, and shouldbe regarded as one of a range ofinteracting factors affecting the healingand recovery process1.

In practical terms, yellow flags include thepresence of catastrophising thoughts

Red flags

Yellow flags

Key messages> Flags are not a diagnosis

> They are not definitive and should be used as part of a wider clinical picture

> They should not be used to label patients

> They are relevant to identify potential reasons for the persistence of a problem

> Flags are not present exclusively, and a patient mayrequire help in more than one area concurrently

> They are relevant to identify when certain types of treatment may not be suitable for the best long-term patient outcome.

research|NCO

R|

What is the relevance of coloured flags to osteopathic practice?

the osteopath magazine | Oct/Nov 2012 | page 21

research|NCO

R|

What is the relevance of coloured flags to osteopathic practice?

which focus on the worst possibleoutcome; avoidance of activities due toexpectations of pain and re-injury; havingnegative expectations of recovery; beingpreoccupied with health, havingdysfunctional beliefs and expectationsconcerning pain, work, and healthcare; fearof movement; uncertainty concerning theonset of symptoms; concern regardingpossible interventions to help symptomsand what to expect in the future. Thesefactors can be accompanied by feelings ofworry and distress; low mood (which mayor may not be accompanied by adiagnosis of depression or anxiety);withdrawal from social contact; extremesymptom reporting behaviour; overreliance and positive expectations ofpassive coping strategies (e.g. hot packs,cold packs, and/or analgesia) and negativeexpectation of treatment outcome. Thesespecific beliefs, behaviours, and moodhave been associated with the risk ofdevelopment of chronic pain1,2,3,4,9.

Trying to identify an individual’s beliefsconcerning their spinal pain is key toassessing the presence or absence ofyellow flags. A variety of measures havebeen used to accomplish this, but the useof questionnaires has been found toconstrain patients’ responses7. Identifyingpatients who are at risk of developingchronic pain is an essential part ofeffective practice. However, it is importantnot to take an overly-simplified approachwhich fails to recognise an individualpatient’s experience of pain and themeaning they may attach to such pain6.

Blue flags have beendefined as “an individual’s

perceptions about work, whetheraccurate or inaccurate, that can affectdisability”9. Clinical psychologist ChrisMain has been very influential inincreasing awareness that certain workingconditions and adverse workplacecharacteristics may place an individual atincreased risk of disability, and presentobstacles to recovery with associateddelay in return to work9,11. Prolonged leaveof absence from work can be problematicsince the longer an individual is out ofwork, the more likely it is that they will fail

to return to work. Bigos and colleagueshave suggested that this is influenced byperception about symptoms, the safety ofreturning to work, and the impact ofreturning to work on an individual’spersonal world12.

Items included within blue flags arelargely based upon literature relating toworkplace stress and control and theperception of how occupational factorscan impact on recovery. Issues consideredas blue flags include:

> A high demand/low control workenvironment in which workersperceive they are in a stringent,inflexible environment where theyhave little control over what is goingon but, at the same time, are expectedto be highly productive;

> The perception that the style ofmanagement is unhelpful;

> The belief that work is taking placeunder a perceived time pressure;

> The belief that poor social support isreceived from their colleagues;

> The belief that return to work will bringre-injury;

> The belief that return to work will notbe possible;

> The belief that work is harmful;

> The perception that work is stressful;

> Dissatisfaction with current job;

> Dislike for the current job13,14,15,16.

Factors including a work history thatincludes patterns of frequent job changesand lack of vocational direction, areconsidered also secondary to the abovefeatures.

The development of blue flags is relativelynew and currently there are no standardguidelines available to assess them(although initial attempts are being madeto rectify this situation15). The strongestconstruct to arise from factors listed asblue flags relates to recovery expectations.Systematic reviews have concludedconsistently that there is strong predictiveevidence that low expectation of return towork or recovery from symptoms isparticularly important for prognosticinformation16.

These refer to moreobjective occupational

factors that affect all workers equally.However, it may be difficult todifferentiate between subjective andobjective occupational stress factors,since they can be present independentlyor in combination with other factors.Black flags include nationally establishedpolicies concerning the conditions ofemployment and sickness policy, as wellas working conditions that are specific toindividual organisations.

Nationally these can include items suchas salary rates, shift patterns, the numberof work hours, ergonomic considerations(e.g. the necessity to lift items, andsustained working postures), nationwidenegotiated entitlements related tosickness certification, benefit systems andwage reimbursement rates. At the level ofan individual organisation, these caninclude items such as sickness policy,workers’ entitlement to sick leave, the roleof occupational health personnel and“signing off” and “signing on”requirements for full fitness. In addition,black flags can includemisunderstandings between keypersonnel, issues relating to financial andcompensation problems, negativeexpectations, fears or beliefs fromspouse/partner or other family membersand social isolation and/or dysfunction.

Black flags identify the need to involveother personnel (including otherhealthcare professionals) in an integratedapproach to care2,5,9.

These have been added tothe flag framework recently.

Orange flags represent the equivalent ofred flags for mental health andpsychological problems. They can help toalert clinicians to potentially serious issuesthat could be psychiatric in nature andrequire appropriate referral to a specialist.

Black flags

Orange flags

Blue flags

research|NCO

R|

What is the relevance of coloured flags to osteopathic practice?

page 22 | the osteopath magazine | Oct/Nov 2012

This replaces the normal course ofmanagement that could be followed formild mental health conditions such asanxiety. Orange flags can includeexcessively high levels of distress, majorpersonality disorders, post-traumatic stressdisorders, drug and alcoholabuse/addictions or clinical depression17.

Pink flags are relativelynew and are not officially

recognised by many healthcareprofessionals since there has been littleresearch to provide an evidence base.They were described originally in 2005 byLouis Gifford, a pain specialistphysiotherapist to reflect his concern atthe constant focus of medicine onaggravating factors associated with acondition at the expense of looking atrelieving/improving factors18. Pink flagsare positive factors that clinicians can tryand identify and emphasise to promotethe chance of a better outcome forpatients. Pink flags can be influenced bygiving reassurance, and educatingappropriately to avoid the developmentof inaccurate and unhelpful beliefs18.

References

1. Kendall NAS, Linton SJ, Main CJ. Guide toassessing psychosocial yellow flags in acutelow back pain: risk factors for long-termdisability and work loss. Wellington, NewZealand: Accident Rehabilitation &Compensation Insurance Corporation; 1997

2. ACC and the National Health Committee.(1997). New Zealand Acute Low Back Guide.Wellington, New Zealand.

3. Accident, Compensation Corporation. NewZealand acute low back pain Guide.Incorporating the Guide to assessingpsychosocial ‘yellow flags’ in acute low backpain; 2004. Wellington: New Zealand.

4. Tackling health problems at work.http://www.kendallburton.com/Flags/flagsindetail.html. (Accessed 30-07-2012).

5. Burton AK, Bartys S, Wright IA et al. (2005).Obstacles to recovery from musculoskeletaldisorders in industry. HSE Books, London.

6. Stewart J, Kempenaar L, Lauchlan D.Rethinking yellow flags. Manual Therapy.2011;16:196e198

7. Greenhalgh S & Selfe J. (2006). Red Flags: aguide to identifying serious pathology of thespine. Churchill Livingstone, Edinburgh

8. The New Zealand Acute Low Back Pain Guide(1999 review) and Assessing Yellow Flags inAcute Low Back Pain: Risk Factors forLongterm Disability and Work Loss (1997).

9. Main CJ, Sullivan MJL, Watson PJ. Painmanagement: practical applications of thebiopsychosocial perspective in clinical andoccupational settings. London: Elsevier;2008.

10. Sutton S, French D, Hennings S, et al.Eliciting salient beliefs in research on thetheory of planned behaviour: the effect ofquestion wording. Current Psychology.2003;22:234e51.

11. Shaw W, van der Windt DA, Main CJ, et al.The “Decade of the flags”, working group.Early patient screening and intervention toaddress individual level occupationalfactors (“Blue flags”) in back disability.Journal of Occupational Rehabilitation.2009a;19(1):64e80.

12. Bigos SJ, Battie MC, Nordin M, et al. (1990).Industrial Low Back Pain. In J. Weinstein & S.Wiesel (Eds.), The Lumbar Spine.Philadelphia: W.B. Saunders and Co.

13. Gatchell RJ. Musculoskeletal disorders:primary and secondary interventions.2009. http://dspace.uta.edu/bitstream/handle/10106/1918/MUSCULOSKELETAL%20DISORDERS.pdf?sequence=1

14. Gray H, Adefolarin AT, Howe T. A systematicreview of instruments for the assessment ofwork-related psychosocial factors (BlueFlags) in individuals with non-specific lowback pain. Manual Therapy. 2011;16:531e-543e.

15. Jocksimovic L, Starke D, Knesebeck, O, et al.Perceived work stress, overcommitment,and self-reported musculoskeletal pain: Across-sectional investigation. InternationalJournal of Behavioural Medicine. 2002;9:122-138.

16. Turner JA, Franklin G, Fulton-Kehoe D,Sheppard L, Wickizer TM,Wu R, et al. Workerrecovery expectations and fear-avoidancepredict work disability in a populationbased workers’ compensation back painsample. Spine. 2006;31(6):682e9.

17. Main CJ, Philips CJ, Watson PJ. Secondaryprevention in healthcare and occupationalsettings in musculoskeletal conditions(focusing on low back pain) in Handbook ofcomplex occupational disability claims: Earlyrisk identification, intervention andprevention. I Z Schultz & R J Gatchel, (eds)(2005), Springer Science & Business Media,New York.

18. Gifford L. Now for pink flags. PhysiotherapyPain Association Journal. 2005;20:1.

Pink flags

Thank you ... N C O ROsteopathic Research

National Council for

... to everyone who participated in the first roundof the research priorities exercise and contributedtheir ideas.

As you may be aware, we are currently carrying out aDelphi study to establish the profession’s views on what thepriority areas should be for osteopathic research. We haveasked osteopaths like you to complete an initialquestionnaire to identify the priority topic areas and therationale for these. Based on this information, the research

team will produce a list of topics which osteopaths will beasked to rank in order of importance.

The data from the first round is currently being analysed,and the second round of the survey will be circulated laterin the autumn. Further information concerning theprogress of the study will continue to be published in thissection of The Osteopath.

For more information about the project, please contactc.fawkes@qmul.ac.uk