K. Jeffrey Miller, DC, MBA
| DIGITAL EXCLUSIVE
In health care, the term red flag is used to describe signs and symptoms that can indicate the presence of serious health conditions. These conditions generally carry an increased likelihood for serious complications, disability or even death.
Each field typically has a list of red flags specific to its scope of practice, and lists of universal red flags also exist. Since most red flags have a definite effect on the pathway to diagnosis and treatment, they must be identified early, usually during the history-taking process.
In recent years, additional flags have been described to accompany red flags. Like red flags, these flags must be identified early, as they also affect the pathway to diagnosis and treatment. Five types of flags are now described in health care:
- Red flags: indicators of possible serious pathology
- Yellow flags: indicators of emotional and behavioral influences
- Orange flags: indicators of psychiatric elements
- Black flags: indicators of occupational issues
- Blue flags: indicators of social and economic circumstances
Most health care providers will recognize the indicators for these flags as conditions and situations with which they have always dealt. Now, the conditions and situations have been organized to assist the clinical process.
Red Flags
From the perspective of spinal care, some of the most concerning indicators are patients over the age of 50 or under age 10, severe night pain, a history of cancer, tuberculosis, HIV or osteoporosis, loss of bladder and/or bowel control, and severe trauma. The presence of these indicators is a forewarning for the provider to proceed slowly with evaluation and treatment.
Yellow Flags
The emotional and behavioral influences related to yellow flags are pain behaviors. This is not the same as the psychiatric problems related to orange flags (see below). Patients exhibiting emotional indicators usually have actual organic physical conditions. Patients exhibiting psychiatric indicators usually do not have physical conditions. Psychiatric patients are most likely to have a problem that will be described as "all in their head."
Patients with actual problems are often affected emotionally by their condition. Long-term pain, disability, financial problems, family issues, legal difficulties and other struggles that accompany some long-term health conditions can be emotionally fatiguing and frustrating. This can result in patients having trouble coping with their situation, exaggerating (not faking) their symptoms, doctor hopping, developing dependencies and other complicating behaviors.
These factors can make patients with yellow flags difficult to manage. Referral to a mental health professional is often necessary for yellow-flag patients.
Orange Flags
Patients exhibiting psychiatric indicators usually describe conditions that do not fit known anatomical or physiological dysfunctions. Examination of these patients is usually unfruitful due to an absence of findings, the presence of bizarre findings or both.
Patients with psychiatric indicators are also difficult to manage. They do not follow directions well, can be unreasonable and/or may have lost touch with reality. Patients with orange flag indicators definitely warrant referral to a mental health professional.
Black Flags
Indicators for black flags are associated with occupational issues. What a person does for a living can play an important role in both the mechanisms of injury and healing for many conditions.
Occupations involving prolonged sitting, lifting, vibration, and other taxing postures and activities are common causes of injury. If these factors help generate a problem, returning to them during or after healing affects long-term prognosis.
Occupational issues must be considered in other situations. A stay-at-home spouse, significant other, mom or dad can encounter postures and activities that are as hazardous as many other occupations outside the home.
Patients may have more than one job, multiplying and complicating their situation. Patients removed from work for extends periods also can begin to experience emotional indicators related to yellow flags, as mentioned above.
Blue Flags
Many patients have social and economic difficulties during their course of treatment. A lack of family support, transportation problems, minimal or no insurance coverage and financial hardships are sometimes routine. These circumstances can make it difficult for the patient to fully participate in care and may cause them to terminate care.
Note: This flag category is often the most difficult for patients and doctors to address.
Take-Away Points
Note that the negative indicators encountered in practice have been organized in literature. Classification in literature is a good starting point for efforts to educate practitioners about the indicators and their related flags. Organizing the indicators can lead to improved documentation of patients' conditions and situations – documentation that is often lacking in chiropractic.
Organizing and documenting indicators can lead to more effective referrals to other health care professionals when warranted.
Resources
- Greenhalgh S, Selfe J. Red Flags: A Guide to Solving Serious Pathology of the Spine. London: Churchill Livingstone / Elsevier, 2006.
- Greenhalgh S, Selfe J. Red Flags II: A Guide to Solving Serious Pathology of the Spine. London: Churchill Livingstone / Elsevier, 2006.
- Waddell G. The Back Pain Revolution. Edinburgh: Livingstone, 2004.
