L8 - CLINICAL FLAGS SYSTEM Flashcards
Definition of flags framework
- System used to assess various factors impacting patient’s recovery & guide clinical decisionmaking
- Classifies potential barriers to rehabilitation & recovery into different flags, each representing
category of BPS factors - Framework helps PT identify & address not just physical issues but also psychological, social &
environmental factors affecting patient’s treatment outcomes
Relevance direct access to flag framework
- Removal of physician referral to access physical therapist services for evaluation & treatment
- Available & well accepted in 40 countries
- Represents new model of care:
o Improve health status
o Decrease cost services
o Increase patient satisfaction
o Improve professionalization
Brief history of red flags
Red flags
- Red flags used by battle ready military forces
- In medical practice, first associated with backpain
- 1st catalogue of red flags for back pain appeared in literature in early 1980s as physical risk factors
- Comprehensive lists 1994
Brief history of yellow flags
Yellow flags
- Introduction study of non-organic signs & BPS model in LBP
- Started research interest in psychological risk & prognostic factors
- Introduced psychological, social & environmental risk factors for long-term disability & work loss
adopted in some guidelines
- Original list contained many domains about back pain & work:
o Attitudes & beliefs about back pain
o Behaviors
o Compensation issues
o Diagnosis & treatment
o Emotion
o Family
o Work
Brief history of blue and black flags
Blue and black flags
- Blue for individuals (subjective) perceptions about work issues
- Black for workplace organizational (objective) conditions
Brief history of orange & green flags
Orange & green flags
- Orange: to identify signs of more serious mental disorder requiring referral to psychiatric
treatment center
- Green: not as formally, indicate positive factors to enhance recovery & adherence to treatment
Implications of red flags
Red flags:
- Sources of information
- Documenting / communicating
- Screening / decision pathway
Implications of yellow flags
Yellow flags:
- Features
- Multidimensional screening
- Uni-dimensional screening
Implications of other flags
Other flags:
- Features
- Screening
Definition of red flags
RED FLAGS
= highest warning level. Indicate pathology & require further medical examination
- Indications of possible serious health problems requiring further investigation
Sources of red flags information
Sources of red flags information
- Screen for general & specific risk factors by complete review of systems & detailed physical
examination
Documenting red flags
Documenting red flags
Varied responses as to constituents of red flags list. Overall findings support combination of red flags
questions increased probability of serious finding
Reasons for omissions
Reasons for omissions:
- Patients may not realize thus omit relevant detail in history / cognitive errors
- Issues with standard patient intake questionnaire/screening/overlooked signs & symptoms
- Competency/awareness of PT/knowledge gaps
Communication red flags
Communicating red flags
Rationale: effect of wrong diagnosis/false alarm unnecessary worry, affects decision
Early identification can lead to reduction in damage & substantial litigation costs
- Clear & open
- Body language, facial expression, tone of voice
- Ensure sufficient time for patients to consider answers
- Provide reason for questions
- Few red flags, when used in isolation, are informative. Combinations of red flags demonstrate
promise - Red flags remain best tools at clinician’s disposal to raise suspicion of serious spinal pathology,
when used within context of thorough subjective patient history & physical examination - Clinicians should consider both evidences to support red flags & individual profile of person’s
determinants of health to decide level of concerns for presence of serious spinal pathology
Definition of yellow flags
Similar to coloring of traffic lights, yellow apply as lower warning level
- Perceptions about diagnosis, treatment & attitudes to pain
- Indications of existence of risks of chronicity
- Have consequences for own therapy design
- Does not change in course of therapy
Perceptions, behavior, cognition, emotion and beliefs
Screening & adaptation for MSK patients of multidimensional measures
Multidimensional measures
Screening: start-back tool
- Developed at Arthritis Research UK primary care center
- Available in > 40 languages
- Focused on primary care
- Short: psychosocial subscale (5 items) & modifiable risk factors
Adaptation for MSK patients
- Adaptation of SBT for identification of prognostic factors in patients with varying MSK complaints
- 10 items, self & clinician administered versions
- Developed & validated by Keele in 2017
- Cross-culturally developed & validated by Karstens
Screening: Orebro MSK pain screening questionnaire
- 10 item questionnaires
- Predicts long-term disability & failure to return to work when completed between 4 to 12 weeks
- Worsening condition: scores of 130 or above predict those who failed to return to work in studies
- Improvements: scores of 105 or below predict recovery & those who will not take sick leave
Description of uni-dimensional measures
Kinesiophobia
- TSK developed in 1990, 17 items scale originally developed to measure fear of movement related
to chronic lower back pain
- Alternatively: Fear Avoidance Beliefs Questionnaire (FABQ)
Physical activity (FABQ-PA) & work (FABQ-W)
- Variants: TSK PT & TSK-HC
Catastrophizing
- Pain Catastrophizing Scale (PCS): 13-item self-report questionnaire used to quantify patient pain
catastrophizing
- Rated using 0 (not at all) scale. Total score is yielded (from 0-52), along with 3 subscale scores
assessing rumination, magnification & helplessness
- Alternatively: pain vigilance & awareness questionnaire
Depression
- Beck Depression Inventory (BDI = 21-item self-reporting questionnaire for evaluating severity of
depression in normal & psychiatric populations
- Relied on theory of negative cognitive distortions as central to depression
- Other tools to measure depression:
o Geriatric Depression Scale
o 9-question Patient Health Questionnaire (PHQ-9)
o 2-question Patient Health Questionnaire (PHQ-2)
Self-efficacy
- Pain self-efficacy questionnaire / general self-efficacy scale = 10-item questionnaire developed to
assess confidence people with ongoing pain have in performing activities while in pain
- PSEQ = applicable to all persisting pain presentation
- Self-efficacy: chronic pain self-efficacy scale
Enablement
- Patient enablement instrument (PEI) = 6-item questionnaire, addressed to patient immediately
after consultation
- Items in PEI questionnaire enquire degree to which patients feel able to understand problems,
cope with it, keep themselves healthy, cope with life, be confident about health & help
themselves after consultation
Definiton of orange flags
- Psychiatric disorders such as depression may require referral for pharmacological and/or
behavioral therapy & may hinder rehabilitation process in any rehabilitation setting when not
managed appropriately - Screening for orange flags is performed by asking questions regarding clinical depression or other
personality disorders - Patient Health Questionnaire-2 (PHQ-2)
- Cutoff score for screening purposes = 3. If individual scores > 3, continue with PHQ-9 for further
assessment of depression
Description and tools for assessment of blue flags
BLUE FLAGS
- Subjectively perceived workplace stresses (physical or psychological)
Key examples: heavy physical demands, inability to modify work, lack of workplace support, increased job
stress, job dissatisfaction & poor expectations for return to work
Tools for blue flags assessment
- Preliminary development of Short Clinical Primary Care Questionnaire focusing on work-related
psychological risk factors. Satisfactory in content validity, structural validity & concurrent validity
Rationale: existing blue flag screening tools were not suitable for primary care settings, do not identify &
highlight psychological risk factors for work disability
- General Nordic Questionnaire (51 items) content areas considered most relevant: job demands,
social interactions, quantitative demands, equality bullying & harassment
- Alternatives:
o Back disability risk questionnaire
o Occupational role questionnaire
o Obstacles to return-to-work questionnaire
o Psychosocial aspects of Work questionnaire
Description of black flags
BLACK FLAGS
- Objectifiable social conditions on part of employers / care systems & objectively measurable
workplace factors
- Key examples:
o Employer & insurance system characteristics
o Financial issues and/or claims procedures
o Lack of training / injury prevention / health promotion / occupational health support
o Poor or unhelpful company policies
o Sick policy, sick pay entitlement & disciplinary procedures
Description of green flags
GREEN FLAGS
- Powerful predictor of improvement
- Patients will likely benefit from directional preference exercises
o Clinical prediction rules: manipulation & stabilization
Challenges & limitation of flags framework
CHALLENGES & LIMITATION OF FLAGS FRAMEWORK
- Potential difficulty in differentiating certain flags
- Limitations in environments with restricted access to actionable interventions
- Need for cultural sensitivity when assessing flags, as cultural backgrounds can influence
perceptions of pain, work & health
