Patients often present with yellow flags. Are we as Physiotherapists prejudice towards this type of patient? Do we manage them appropriately?

Over recent months, I have had an influx in patients that present with biopyschosocial factors. Although I feel somewhat confident in recognising such factors, what I continually ask myself is whether or not I manage this type of patient correctly. I also question whether there is any truth in the prejudice belief that I have towards this type of patient based on my past clinical experiences in the development of chronic pain and that patients like these don’t respond particularly well to treatment.
Through the purpose of this blog I aim to determine whether biopyschosocial factors play a role in the development of chronic pain, how we as clinicians assess the likelihood of this occurring in these type of individuals and based on the current literature and available evidence what we should be doing in order to best manage this type of patient.

Teaching grandmother to suck eggs…

As clinicians we use the term ‘flags’ to highlight a concern. Typically flags are split into two main categories clinical flags and psychosocial flags.

Clinical flags are used widely within healthcare. In the musculoskeletal setting, red flags are indicators of possible serious pathology, and highlight the need for further urgent investigation if something serious is suspected (Greenhalgh & Selfe 2006).
Orange flags are also clinical flags and refer to mental health and psychological issues that may be psychiatric in nature, they alert the clinician that there may be the need for onward referral to someone who is expert in that field. Orange flags include major personality disorders, post traumatic stress disorders and clinical depression and should not be confused with mild mental health issues such as anxiety (Main et al 2005).

Previously the term yellow flags was used to describe psychological risk factors and social and environmental risk factors for the development of chronic disability and failure to return to work following the onset of musculoskeletal pain (Kendell et al, 1997).
However, the focus more recently has been further subdividing this term and differentiating between the different factors that can affect recovery. Main and Burton (2000) argued that the term yellow flags should be reserved for more apparent psychological risk factors such as fears and negative beliefs. Social/environmental (workplace) risk factors should be divided into two further categories: blue and black flags.
Blue flags being the perceptions that a person holds regarding their environment/workplace that it is a stressful environment, excessively demanding etc and black flags referring to the more observational characteristics of the workplace, the nature of work, and the insurance and compensation systems and procedures that are in place that manage injuries that occur within the workplace.

That thing called pain…

Pain previously understood purely as a biophysical response to noxious stimulus to protect the body from harm is now more thought of as a biophysical response shaped by a whole host of psychological factors (Engel,1954). In my subsequent post I aim to elaborate on this new found understanding and wish to discuss the link that many studies suggest there is between psychological factors and the chronicity of pain.


Engel, G (1959) “Psychogenic” pain and the pain-prone patient. The American Journal of Medicine 26, (6), 899–918

Greenhalgh, S & Selfe, J. (2006) Red Flags: a guide to identifying serious pathology of the spine. Churchill Livingstone, Edinburgh

Kendall, NA, Linton, SJ, Main, CJ. (1997) Guide to Assessing Psychosocial yellow flags in acute low back pain: Risk factors for Long-Term Disability and Work Loss. New Zealand: Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee. Wellington

Main CJ, Burton AK. Economic and Occupational influences on pain and disability. Pain Management: An Interdisciplinary Approach. Edinburgh, Scotland; Churchill Livingstone: 63-87

Main, C.J., Philips, C.J., & Watson, P.J. (2005) Secondary prevention in healthcare and occupational settings in musculoskeletal conditions (focusing on low back pain) Handbook of complex occupational disability claims: Early risk identification, intervention and prevention. I, Z Schultz & R J Gatchel, (eds) Springer Science & Business Media, New York.


Linton, S & Shaw, W (2011) Impact of Psychological Factors in the Experience of Pain. Physical Therapy, 91, (5), 700-711

Bergamot, S, Boersma, K, Overmeer, T, Linton, S (2011) Pain Catastrophizing, Depressed Mood, and Outcomes in Physical Therapy Treatments. Physical Therapy 91, (5), 754-764

One thought on “Patients often present with yellow flags. Are we as Physiotherapists prejudice towards this type of patient? Do we manage them appropriately?

  1. I can say absolutely, physiotherapists are profoundly, offensively , and detrimentally prejudiced against to ‘this type of patient’ and I will never see another physiotherapist for my chronic pain issues. Physiotherapists all too often presume they are entitled to express the arrogance of both the medical knowledge of a doctor and the clinical knowledge of a psychotherapist when they are at best glorified massage therapists set on trivializing the chronic pain patients’ experiences and circumstances.
    Granted, I am speaking harshly to some one I have no personal knowledge of, but if you wish to be effective in your work, you must first seek some empathy in your practice. That is severely lacking in the field as well as in this post.

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