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Flagging patient safety in massage therapy.


It is estimated that approximately 34% of clients will consult massage and other natural medicine practitioners for treatment of a condition that has not been previously assessed by a medical practitioner. (1,2) Consequently all natural medicine practitioners have a responsibility to be able to determine whether their client is a suitable candidate for their treatment or whether they need to be seen by a medical or other health practitioner first. Taking a comprehensive case history from a client is usually the first step in massage therapy consultations and the best way to understand the reason for their client's visit. A system of coloured flags has been developed over the past two decades to help practitioners identify cues in the information gathered from clients that may indicate referral or other guidance for safe and effective treatment. Five flags are currently in use:

* Red flags--indicate serious underlying pathology

* Yellow flags--indicate psychosocial factors

* Orange flags--indicate psychological problem or drug abuse

* Blue flags--refer to the patient's perception of the relationship between health and work

* Black flags--indicate work issues that could inhibit recovery and ability to return to work

Although it is helpful to be vigilant for all flags, the most useful flags for massage therapists are likely to be the red flags for indentifying the possibility of serious underlying pathology, and yellow ones for identifying the importance of addressing a psychosocial influence on health.

Red flags

Lists of red flags have been developed for many conditions that commonly present to massage therapy clinics. For example, red flags are available for low back pain, neck pain, headache and thoracic spinal pain. Red flags for low back pain were published in a previous issue of JATMS (see 20(2): 100-104). Lists of red flags for common musculoskeletal conditions are readily available, including those previously published by The Acute Musculoskeletal Pain Guidelines Group. (3) These lists of red flags should be referred to whenever a history is being taken. Although many of the conditions are rarely encountered in clinical practice, checking for red flags every time a client history is taken enhances the safety and quality of care. Clients with identified red flags should be referred for further investigation. It is beyond the scope of massage therapists (and not necessary) to label or name potential medical conditions but it is important to know that some symptoms (e.g. joint pain with fever, or unexplained weight loss) always require referral for further investigation.

Neck pain is a common reason why people consult massage and other health professionals. One year prevalence of neck pain in the general population has been reported to be between 15% and 44%. (4-6) Most neck pain is classified as non-specific, that is, it is not associated with underlying pathology or abnormal anatomy. (7) However, all practitioners need to be vigilant for those rare occasions when serious underlying pathology does exist. Checking for red flags is an easy and useful way to do this. Table 1 is an example of red flags for acute neck pain.

Yellow flags

Yellow flags are indicators of psychological factors that can influence health (2). For example, a student studying for a major exam may experience a great deal of stress and anxiety apart from muscle strain associated with long hours at a desk or in front of a screen. Massage therapy to the neck and upper back is likely to bring relief from sore shoulders and upper back muscles, and even headaches that arise from overly tight neck musculature. However, while the stress of the exam persists, the client is unlikely to experience long-lasting relief from treatment. The yellow flag, in this case the stress of an impending examination, can interfere with the client's response to treatment.

A similar patient with similar treatment but without the same stress is likely to have faster or more sustained relief from neck pain and headache. Yellow flags, then, are indicators of factors that can interfere with the client's response to treatment and consequently the normal course of recovery. In some cases, clients may need referral for assistance in dealing with the psychological factors that are influencing their health.

Yellow flags have been categorised in a number of ways, including the following (Table 2): Many massage therapists will have encountered these yellow flags in clients in their practices.

Orange flags

Orange flags refer to psychiatric symptoms that clients may manifest. They alert practitioners to the possibility of serious mental health problems like clinical depression and personality disorders. Clients identified with orange flags require referral to a medical or other health practitioner for further assessment and care. Examples of orange flags that could indicate an underlying psychological problem include. (10)

* Recent social withdrawal and loss of interest in others

* An unusual drop in functioning, especially at school or work, such as quitting sports, failing at school, or difficulty performing familiar tasks

* Problems with concentration, memory, or logical thought and speech that are hard to explain

* Heightened sensitivity to sights, sounds, smells or touch; avoidance of over-stimulating situations

* Loss of initiative or desire to participate in any activity; apathy

* A vague feeling of being disconnected from oneself or one's surroundings; a sense of unreality

* Unusual or exaggerated beliefs about personal powers to understand meanings or influence events; illogical or 'magical' thinking typical of childhood in an adult

* Fear or suspiciousness of others or a strong nervous feeling

* Uncharacteristic, peculiar behavior

* Dramatic sleep and appetite changes or deterioration in personal hygiene

* Rapid or dramatic shifts in feelings or 'mood swings' (10)

Blue and black flags

Blue flags relate to clients' expectations about recovery. If clients have low expectations they are less likely to recover from symptoms. (11) Black flags refer to how work-related issues like wages, shift patterns and ergonomics influence health. Examples of black flags include a child care worker with a lumbar disc problem whose work involves moving furniture and lifting children; an office worker who spends prolonged hours at a fixed height work station; and a worker who is required to drive long distances in a vehicle with a poorly designed driver's seat. Clients can feel caught between wanting to pursue their chosen career or source of income on the one hand and difficult or untenable circumstances in the workplace on the other.

Screening questions for workplace factors were suggested by the working group at the Decade of the Flags conference in 2008. (12) These screening questions may be of use to massage and other natural medicine practitioners who are assessing and treating clients with work-related complaints:

* Are you concerned that the physical demands of your job might delay your return to work?

* Do you expect your work could be modified temporarily so you could return to work sooner?

* Are there stressful elements to your job that might be difficult when you first return to work?

* What kind of response do you expect from co-workers and supervisors when you return?

* Is this a job you would recommend to a friend?

* Are you concerned that returning to your work may be difficult given your current circumstances?


* Are you worried about any repeat episodes of (back) pain once you return to work?


The flag system is a useful tool that can be used by massage and other natural medicine practitioners to enhance the safety and quality of their practices. Although the vast majority of massage therapy clients will have non-life threatening conditions, it remains the responsibility of all health practitioners who see clients who may not have been previously screened by a medical or other health practitioner to screen for red flag conditions. It is not necessary to name the potential pathological condition; all that is required is that flags are identified so that clients can receive the most appropriate care.

The presence of other flags (e.g. yellow and blue) can interfere with a client's response to treatment. Often these clients continue their treatment but supported by treatment from other health workers (e.g. psychologists, occupational therapists, work-place rehabilitation consultants). Table 3 summarises the flag system and includes actions for practitioners to take should flags are identified in their clients.

The following key messages about the use of flags in health assessment were provided by Fawkes and Carnes: (11)

* Flags are not a diagnosis

* They are not definitive and should be used as part of a wider clinical picture

* They should not be used to label patients

* They are relevant to identify potential reasons for the persistence of a problem

* Flags are not present exclusively, and a patient may require help in more than one area concurrently

* They are relevant to identify when certain types of treatment may not be suitable for the best long-term patient outcome.

Sandra Grace | Southern Cross University


(1.) Grace S, Vemulpad S, Beirman ft. Training in and use of diagnostic techniques among CAM practitioners: an Australian study.

J Aitern Complement Med. 2006 Sept 2006;12(7):695-700.

(2.) Nicholas M, Linton S, Watson P, CJ M. "Decade of the Flags" Working Group. Early identification and management of psychological risk factors ("yellow flags") in patients with low back pain: a reappraisal. Physical Therapy 2011;91(5):737-53.

(3.) Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Bowden Hills, Queensland: Australian Academic Press Pty Ltd; 2004.

(4.) Cote P, Cassidy J, Carroll L, Kristman V. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 2004;. Pain. 2014;112:267-73.

(5.) Croft P, Lewis M, Papageorgiou A, Thomas E, Jayson M, Macfarlane G, et al. Risk factors for neck pain: a longitudinal study in the general population Pain. 2001;93:317-25.

(6.) Sim J, Lacey ft, Lewis M. The impact of workplace risk factors on the occurrence of neck and upper limb pain: a general population study. BMC Public Health. 2006;6:234-44.

(7.) Tsakitzidis G, Remmen ft, Dankaerts W, Van Royen P. Non-specific neck pain and evidence-based practice. European Scientific Journal January 2013;9(3).

(8.) Teichtah IA, McColl G. An approach to neck pain for the family physician. Aust Fam Physician. 2013;42(11)774-7.

(9.) Chartered Society of Physiotherapy. How useful are flags for identifying the origins of pain and barriers to rehabilitation? Allison Carvalho investigates. 2015 [cited 2015 August 8); Available from: http://www.csp.

(10.) American Psychiatric Association. Warning Signs of Mental Illness 2015; Available from: more-topics/warning-signs-of-mental-illness.

(11.) Fawkes C, Carnes D. What is the relevance of coloured flags to osteopathic practice? The Osteopathic Magazine. 2012;Oct/Nov:20-2.

(12.) Shaw WS, van der Windt DA, Main CJ, Loisel P, Linton SJ. Decade of the Flags Working Group. 2008. Early patient screening and intervention to address individual level Occupational Factors ("Blue Flags") in Back Disability. Journal of Occupational Rehabilitation. 2009;19(1):64-80.
Table 1: Red flags for neck pain (adapted from Non-
specific neck pain and evidence-based practice (8))

Red flag                              Possible pathological process

Significant trauma (e.g. fall by an   Bony/ligamentous disruption of
osteoporotic patient, motor vehicle   the cervical

History of rheumatoid arthritis       Atlanto-axlal disruption

Symptoms of infection (e.g. fever;    Infection (e.g. epidural abscess,
meningism like neck stiffness,        subarachnoid haemorrhage)
photophobia and headache; history
of immunosuppression or intravenous
drug use)

Constitutional symptoms (e.g.         Malignancy/infiltrative process;
fevers, weight loss, anorexia, past   rheumatological disease
or current history of malignancy)

Neurological symptoms (e.g. signs     Cervical cord compression,
or symptoms of upper motor neuron     demyelinating process
pathology such as stroke, multiple
sclerosis, traumatic brain injury,
cerebral palsy including muscle
weakness, slowness, spasticity,
Babinski sign)

Concurrent chest pain, shortness of   Myocardial ischaemia
breath, diaphoresis

Table 2: Yellow flags (9)

Yellow flag                          Possible pathological process

Beliefs, appraisals and judgements   Unhelpful beliefs about pain:
                                     indication of injury as
                                     uncontrollable or likely to worsen

Emotional responses                  Expectations of poor treatment
                                     outcome, delayed return to work

Pain behaviour (including pain       Distress not meeting criteria for
and coping strategies)               diagnosis of mental disorder

Table 3 Flag Action (adapted from How useful are flags for
identifying the origins of pain and barriers to rehabilitation?
Allison Carvalho investigates (9))

 Flag            Indicator of                       Action

Red      Serious underlying pathology    Refer for medical or other

Yellow   Psychological issue             Biopsychosocial management

Orange   Psychiatric problem             Refer to mental health

Blue     Perceptions about the           Identify modifiable work
         influence of work and health    perceptions/refer to AA
                                         practitioner (who will
                                         further refer for appropriate

Black    Workplace of system-wide        Refer to employer/workplace
         factors that influence health   health and safety
                                         consultant for alternatives
                                         or modifications to work
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Author:Grace, Sandra
Publication:Journal of the Australian Traditional-Medicine Society
Date:Sep 1, 2015
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