L8 - CLINICAL FLAGS SYSTEM

Question 1

Definition of flags framework

Answer 1

• 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

Question 2

Relevance direct access to flag framework

Answer 2

• 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

Question 3

Brief history of red flags

Answer 3

Red flags
- Red flags used by battle ready military forces
- In medical practice, first associated with backpain
- 1
st catalogue of red flags for back pain appeared in literature in early 1980s as physical risk factors
- Comprehensive lists 1994

Question 4

Brief history of yellow flags

Answer 4

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

Question 5

Brief history of blue and black flags

Answer 5

Blue and black flags
- Blue for individuals (subjective) perceptions about work issues
- Black for workplace organizational (objective) conditions

Question 6

Brief history of orange & green flags

Answer 6

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

Question 7

Implications of red flags

Answer 7

Red flags:
- Sources of information
- Documenting / communicating
- Screening / decision pathway

Question 8

Implications of yellow flags

Answer 8

Yellow flags:
- Features
- Multidimensional screening
- Uni-dimensional screening

Question 9

Implications of other flags

Answer 9

Other flags:
- Features
- Screening

Question 10

Definition of red flags

Answer 10

RED FLAGS
= highest warning level. Indicate pathology & require further medical examination
- Indications of possible serious health problems requiring further investigation

Question 11

Sources of red flags information

Answer 11

Sources of red flags information
- Screen for general & specific risk factors by complete review of systems & detailed physical
examination

Question 12

Documenting red flags

Answer 12

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

Question 13

Reasons for omissions

Answer 13

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

Question 14

Communication red flags

Answer 14

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

Question 15

Definition of yellow flags

Answer 15

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

Question 16

Screening & adaptation for MSK patients of multidimensional measures

Answer 16

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

Question 17

Description of uni-dimensional measures

Answer 17

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

Question 18

Definiton of orange flags

Answer 18

• 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

Question 19

Description and tools for assessment of blue flags

Answer 19

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

Question 20

Description of black flags

Answer 20

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

Question 21

Description of green flags

Answer 21

GREEN FLAGS
- Powerful predictor of improvement
- Patients will likely benefit from directional preference exercises
o Clinical prediction rules: manipulation & stabilization

Question 22

Challenges & limitation of flags framework

Answer 22

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