Tue, Jun 25, 2024

Colour-Coded Care: A Closer Look at Flags in the Field of Physiotherapy


      The Flag System in the field of Physiotherapy is categorized into three main types that are

  1. Clinical flags
  2. Psychosocial flags
  3. Efficient flag system

1. Clinical flags

           Clinical red flags are indications of potential severe abnormalities such as caused by inflammation or neural diseases, structural musculoskeletal damage or disorders, circulatory issues, suspected diseases, malignancies, or systemic conditions. Best example for this are the red flags for musculoskeletal issues. If present, these call for an immediate referral for surgery and additional research.

           There are some symptoms and signs that, when seen during a patient's examination or medical history, make us aware that there may be a severe problem. Physiotherapists are well-versed in musculoskeletal disorders and can spot warning signs or rule them out. 

2. Psychosocial flags

           It allows us to pinpoint the individual, their issue, and their social setting, as well as how those elements influence the healing process and returning to work. The idea was first presented in 1997 by Kendall, who examined variables that helped identify patients who were at risk of acquiring chronic handicaps and did not heal as was anticipated for their disease.

           Using psychosocial flags, we can evaluate and plan using a biopsychosocial model. These warning signs are neither diagnostic nor symptoms; instead, they are signs that a person might not recover as quickly as anticipated and may require more help to resume employment. A common term for these warning signals is recovery barriers. Psychosocial variables determine activities and involvement levels.

3. Efficient flag system

           As we observe, the flag system addresses a variety of problems. On the one hand, it's implemented to spot problems like a malignancy requiring an oncology referral for a patient. It also enables the detection of crucial psychosocial elements for a successful recovery.

           The flag system is significant because it incorporates how an injury affects a person's physiological and emotional aspects. We now know that worry or fear of experiencing pain while engaging in a therapeutic activity might hinder healing. Treating patients as living things rather than merely as a collection of joints and muscles is crucial.

Types of flags

           The flag system is further divided into various types depending on the severity of the patient's condition, emotional distress, behaviour changes and all other aspects are also observed that will be discussed further in detail of these types.

  1. Red flags
  2. Yellow flags
  3. Orange flags
  4. Blue flags
  5. Black flags

1. Red flags

           Red flags are conditions with severe pathologies that physiotherapists can not treat but must immediately refer to the respective physician to treat them properly. A physiotherapist should strictly not even that patient at all. Some of the examples of these red flags are as follows.

  • Malignancy
  • Fractured bone
  • High-grade fever
  • Cauda equina syndrome
  • Tumour/cancer, even with a previous history of cancer
  • Bladder and bowel incontinence
  • Saddle anaesthesia
  • Sudden unexplained weight loss of up to 10 pounds 
  • Seizures
  • Ataxia
  • Visual/speech/Hearing changes
  • Progressive dementia
  • Dizziness
  • Severe pain
  • Nausea
  • Diarrhoea 
  • Vomiting
  • Severe abdominal pain
  • Unexplained swelling without any injury 
  • SOB

2. Yellow flags

           In physiotherapy, yellow flags are those conditions that can be treated by physiotherapists but under great observation. They must continuously check on the patient to prevent worsening the situation. Yellow flags indicate the characteristics related to the patient's thoughts, beliefs and attitude. Some examples are as follows.

  • Bilateral symptoms
  • Peripheral symptoms
  • Abnormal pattern of sensation
  • Involvement of multiple nerve roots
  • Unusual pattern of pain
  • Spinal cord involvement 
  • Drop attacks
  • Dizziness
  • Fainting
  • Vertigo
  • Multiple inflamed joints
  • ANS symptoms
  • Gait disturbance
  • Skin changes
  • Circulatory changes
  • Progressive weakness
  • Fear of re-injury

3. Orange flags

           Orange flags indicate the psychiatric conditions of the patient. While dealing with patients with orange flags, physiotherapists may give 100% to the patient according to treatment. Still, patients complain that their pain is the same and don't trust anyone easily. Some examples are below.

  • Depression
  • Stress 
  • Anxiety
  • Personality disorder
  • Mood changes
  • Lack of trust
  • Dementia-related disorders
  • Schizophrenia

4. Blue flags

           Blue flags indicate the relationship between employees and the workplace. The employee's perception about their work and health issues that their health can cause difficulties in their work. In blue flags, as a physiotherapist, PT can create some changes at their workplace to change the environment according to their condition, such as changing their table height and asking other employees to be supportive and create a happy surrounding. However, the patient has a fear of blue flags.

  • Patients have a fear that their workplace is too demanding and can cause further injury and worsen the condition.
  • Have a belief that other employees are not supportive
  • Less job satisfaction
  • That their job is too stressful
  • Poor communication with others
  • Can not fulfil company's demands
  • Physiotherapists make an accommodation approach at patients' workplaces for modification to avoid any further damage

5. Black flags

           Black flags indicate the obstacles between the system and the employees' requirements for immediate modifications. When the changes cannot be done according to patients' needs, just like if a person lives on the 2nd floor and must climb stairs in any condition, they can not be modified; this is a black flag. Some of the red flags patients face at work are as follows.

  • The sick leave policy, ill pay eligibility, and disciplinary processes of the company, 
  • Plans for 'Phased Return to Work' are available, 
  • The requirement to return to work completely fit, 
  • A lack of variation or rotation, 
  • A lack of training, support for occupational health, injury prevention, health promotion, 
  • Reorganization or job security 
  • A lack of risk management or health and safety, 
  • Hours, shift schedules, and flexibility.



Kainat Ashiq

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