Flag Systems

Reasons to screen

• direct access

• quicker and sicker patient (pts seen sooner after surgery)

• signed prescriptions - repeat PR

• medical specialization

• missing pt information

• disease progression - other DRs not seeing pts often enough

• presence of one or more yellow / red flags

A pt gives you a written prescription. The first screening question to ask is:

• what did the physician say is the problem

• did the physician examine you

• when do you go back to see the doctor

• how many times per week did the doctor suggest you come to therapy?

did the physician examine you?

Which 3 following activities are MOST effective for identifying red flags?

• effectiveness of treatment

• subjective exam

• functional movement screens

• physical exam

• self-report outcome measures

• effectiveness of treatment

• subjective exam

• physical exam

• (function screen too broad, self-report is more for yellow flags)

Red flags

• serious pathology

• require immediate attention

• supersede physical therapy as a provider

Red flag screening process

• appearance

• chief complaint/history

• physical exam

• response to treatment

Red flags - visual inspection

• unwell

• pale

• shivering

• anxiety

• muscle guarding/splinting

Red flags - chief complaint / history

• unexplained weight loss

• unexplained nausea / vomiting

• pain unaffected by movement and/or position - nonmechanical

• slide 11

red flags - visceral pain

• diffuse

  • poorly localized

  • deep

  • dull

• emotional response

• associated w/ autonomic symtpoms

  • nausea/vomiting

  • blood pressure

  • heart rate

• low receptor density

  • overlapping receptor fields

red flags - assess

physical exam

• temperature

• RR

• BP

• HR

• skin

• nails/nail beds

• pain unaffected during exam

• not consistently better/worse

red flags - response to treatment

• unusual response

• symptom magnification

• symptom behavior

  • improvement with unexpected return

  • unaffected by treatment

  • made worse by treatment

Early warning signs of cancer

CAUTIONS

• slide 15

which of the following is signified by the presence of yellow flags?

• a pt who is at risk for developing chronicity

• a pt wh is malingering

• a pt with increased psycho-social barriers

• a patient in need of emergency services

a pt with increased psycho-social barriers

Yellow flags

• potential confounding factors that may be warnings and require further investigation

• psychosocial factors

• mental health factors

• alter:

  • assessment (lack of motivation, emotions, education)

    • spend less time on subjective so pt doesn’t harp on pain

  • intervention

Yellow flag - patient characteristics

• attitudes

• beliefs

• emotions

• behaviors

• family

• work

yellow flags - key factors

• belief that pain is harmful and/or severely disabling

• fear avoidance behavior

• social withdrawal

• depression

• expectation of passive treatment

yellow flags - cycle

• attention

• cognition

• emotions

• behaviors

• slide 19

Yellow flags - things to avoid

• short term passive palliative care

  • quick fixes

  • no long term management plan - give pts HEP

• failing to educate and guide patients on self-care and self-management

  • alters focus of control - internal vs external

• focus on pain

  • something is “broken” - pathoanatomic explanations

  • reinforces disability

Yellow flags - psychosocial risk factors

• fear avoidance

• pain catastrophizing

yellow flags - mental health risk factors

• depression

• anxiety