Red Flags, Yellow Flags, Blue Flags, Black Flags


This page was originally posted on September 21, 2006. It has been the most viewed page on this blog. Updated February 22, 2013.  

The other day a student asked me where the phrase “red flag” originated. He had also heard of yellow flags, and suspected that there were other colours of flags to indicate barriers to recovery. Well, we looked in various glossaries of medical and medical education terms, without success. So I e-mailed Dr. Shawn Thistle, and, sure enough, he helped. It is difficult to find where these terms originated (try Googling blue flags!) and Dr. Thistle thinks they may just be part of every doctor’s vocabulary. (Ever since I wrote the title above, I can’t get Dr. Seuss’s One fish two fish red fish blue fish out of my head.)


Red flags/clinical red flags (biomedical factors) ~
These help identify potentially serious conditions, and are often listed in practice guidelines. Here is a description from Chapter 13 of the
Clinical guidelines for chiropractic practice in Canada [Glenerin Guidelines]:
The main focus for the prevention of complications is the recognition of well-known and established indicators or “red flag” signs and symptoms which may require careful assessment and reassessment, changes in treatment plan, or other appropriate action, such as emergency care or referral to another health care specialist. Ignoring these “red flag” indicators increases the likelihood of patient harm. 

Yellow  flags/clinical yellow flags (psychological or behavioural factors/predictors) ~
These indicate psychosocial barriers to recovery. Here is a definition from

New Zealand acute low back pain guide: incorporating the Guide to assessing psychosocial yellow flags in acute low back pain:
Yellow Flags are factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain … Before proceeding to assess Psychosocial Yellow Flags it is important to differentiate between acute, recurrent and chronic presentations. Evidence suggests that treating chronic back pain as if it were a new episode of acute back pain can result in perpetuation of disability. 

Blue flags/occupational blue flags (social and economic factors) ~
These refer to conditions in the workplace that may inhibit recovery. Examples are
monotony, low degree of control, poor relationships or high work demands. 

Black flags/socio-occupational black flags (occupational factors) ~
These are also used for workplace issues, but refer to organizational issues such as financial reliance on disability benefits, workers’ compensation issues, or employer attitudes to the sick worker.


Helliwell PS, Taylor WJ. Repetitive strain injury. Postgrad Med J 2004;80(946):438-43.See An Approach to Diagnosis
Main CJ, Williams AC.  ABC of Psychological Medicine. Musculoskeletal pain. BMJ 2002;325(7363):534-7.

Click on the image below for The clinical flags approach to obstacles to recovery from back pain and aspects of assessment.

From:  Main CJ, Williams AC.  ABC of Psychological Medicine. Musculoskeletal pain. BMJ 2002 Sep 7;325(7363):534-7. PMC version

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Web Sites, Facebook, Twitter and LinkedIn ~ What I’m doing now

Hello, everyone out there ~
I haven’t been keeping this blog up to date but I am still very much involved in continuing health education and chiropractic. This is what I am doing now, and you can see the twitter feeds from this site ~

I am the Web editor for ICL and still have involvement with CACHE:


Twittering for chiropractic, continuing health education and fun

I maintain three Twitter accounts, one for CACHE/ACEMC, one for the Index to Chiropractic Literature, and one just for fun stuff I find on the Internet. You can follow them from any page on this blog (right and left sides of the screen) at

Index to Chiropractic Literature is on facebook!

Since mid-October 2010, ICL has had a facebook page, and as of mid-December, we have over 200 friends! These people live in Canada, the United States, Australia, the United Kingdom, Spain, India, Japan, Mexico and Singapore. If you would like to receive regular updates on what’s being added to the database or the Web site, click on one of the icons on this page and “friend” us.

Check out the page at   

The new Index to Chiropractic Literature (ICL)

In July 2009 we launched the latest version of ICL – There are many new features, including improvements to the search interface, an Open Access Library, links to RSS feeds for relevant journals, lots of help pages, and a blog. ICL is a high quality product developed and maintained by librarians, and it’s free!

To find out how to search the database and find all the resources on the site, please see the help pages (second menu item from the left). 

See how far we’ve come since 2001!


Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007

nccam  According to a national survey, in the United States in 2007, 38% of adults and 12% of children used complementary and alternative medicine. The survey is posted on the Web site of NCCAM (National Center for Complementary and Alternative Medicine):   PDF version

This report presents selected estimates of complementary and alternative medicine (CAM) use among U.S. adults and children, using data from the 2007 National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS).

Read the press releasePubMed abstract.

Neck Pain and the Decade of the Bone and Joint 2000–2010 – Open Access!

The special supplement published in Spine in February 2008 has been republished with permission elsewhere. The European Spine Journal has published the Bone and Joint Decade articles on neck pain as v. 17, Supplement 1. The great news is, the whole supplement is available on PubMed Central.

European Spine Journal Volume 17 (Suppl 1);  April 2008

From the Editorial Preface:
In this supplement of Spine [republished with permission in this supplement], the results of a unique project, The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders, is published. This multidisciplinary, international Task Force, which was formed in 2000, has consisted of an executive committee, a scientific secretariat, an advisory committee together with research associates and graduate students. These groups involved more than 50 people. Committee members were based in 9 countries and represented 14 different clinical and scientific disciplines. Moreover, the Task Force was affiliated with 8 universities and research institutes in 4 different countries. Eleven professional organizations have been non-financial sponsors. Thus, the Task Force represents a unique gathering of international expertise covering all relevant aspects related to neck pain and its associated disorders. The Task Force has made an impressive systematic review of the vast literature in this field and a best evidence synthesis, which has resulted in 21 chapters in this supplement.

Neck pain and the Bone and Joint Decade 2000-2010

The February 2009 supplement of the Journal of Manipulative and Physiological Therapeutics is a Neck Pain Task Force Special Supplement, containing reprints of articles from the February 2008 supplement of  Spine See also this post. And for an Open Access version, see this post.

From the editorial by Claire Johnson:

These are some of the most important documents published recently on the topic of neck pain and it is important that the broader community of clinicians and policy makers have access to these documents. Traditionally it is the JMPT policy not to allow duplicate or redundant publications. However the content of this supplement is an exceptional case. For this series of articles, we felt that these works are so important that they needed to be accessible to the current and future readership of the JMPT. Therefore, with the kind permission from Spine and the support from The Task Force on Neck Pain and Its Associated Disorders, we are able to reprint in its entirety this special supplement issue focused on neck pain. This supplement issue is provided to our readers at no extra charge through the generous support from The Task Force on Neck Pain.

This is good news for people with a subscription to JMPT.    PubMed Records

Who uses chiropractic?

back.jpg Here are a few studies examining the populations of patients who visit chiropractors. Click on Related Articles in PubMed to retrieve more records.

Blum C, Globe G, Terre L, Mirtz TA, Greene L, Globe D. Multinational survey of chiropractic patients: reasons for seeking care. JCCA: J Can Chiropr Assoc 2008 August;52(3):175-84. [Open Access]
INTRODUCTION: This study explores the extent to which consumers seek wellness care when choosing chiropractors whose practice methods are known to include periodic evaluative and interventional methods to maintain wellness and prevent illness.
METHODS: Using an international convenience sample of Sacro-Occipital Technique (SOT) practitioners, 1316 consecutive patients attending 27 different chiropractic clinics in the USA, Europe and Australia completed a one-page survey on intake to assess reason for seeking care. A forced choice response was obtained characterizing the patient’s reason for seeking chiropractic care.
RESULTS: More than 40% of chiropractic patient visits were initiated for the purposes of health enhancement and/or disease prevention.
CONCLUSION: Although prudence dictates great caution when generalizing from this study, if confirmed by subsequent research among other similar cohorts, the present results may lend support to continued arguments of consumer demand for a more comprehensive paradigm of chiropractic care, beyond routine musculoskeletal complaints, that conceptualizes the systemic, nonspecific effects of the chiropractic encounter in much broader terms.

Hurwitz EL, Chiang LM. A comparative analysis of chiropractic and general practitioner patients in North America: Findings from the joint Canada/United States Survey of Health, 2002-03. BMC Health Serv Res 2006 April 6;6:49.:49. [Oopen Access]
BACKGROUND: Scientifically rigorous general population-based studies comparing chiropractic with primary-care medical patients within and between countries have not been published. The objective of this study is to compare care seekers of doctors of chiropractic (DCs) and general practitioners (GPs) in the United States and Canada on a comprehensive set of sociodemographic, quality of life, and health-related variables.
METHODS: Data are from the Joint Canada/U.S. Survey of Health (JCUSH), 2002-03, a random sample of adults in Canada (N = 3505) and the U.S. (N = 5183). Respondents were categorized according to their pattern of health-care use in the past year. Distributions, percentages, and estimates (adjusted odds ratios) weighted to reflect the complex survey design were produced.
RESULTS: Nearly 80% of respondents sought care from GPs; 12% sought DC care. Compared with GP only patients, DC patients in both countries tend to be under 65 and white, with arthritis and disabling back or neck pain. U.S. DC patients are more likely than GP only patients to be obese and to lack a regular doctor; Canadian DC patients are more likely than GP only patients to be college educated, to have higher incomes, and dissatisfied with MD care. Compared with seekers of both GP and DC care, DC only patients in both countries have fewer chronic conditions, take fewer drugs, and have no regular doctor. U.S. DC only patients are more likely than GP+DC patients to be uninsured and dissatisfied with health care; Canadian DC only patients are more likely than GP+DC patients to be under 45, male, less educated, smokers, and not obese, without disabling back or neck pain, on fewer drugs, and lacking a regular doctor.
CONCLUSION: Chiropractic and GP patients are dissimilar in both Canada and the U.S., with key differences between countries and between DC patients who do and do not seek care from GPs. Such variation has broad and potentially far-reaching health policy and research implications.

Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS. Patterns and perceptions of care for treatment of back and neck pain: Results of a national survey. Spine 2003 February 1;28(3):292-7.
STUDY DESIGN: We conducted a nationally representative random household telephone survey to assess therapies used to treat back or neck pain.
OBJECTIVES: The main outcome was complementary therapies used in the last year to treat back or neck pain.
SUMMARY OF BACKGROUND DATA: Back pain and neck pain are common medical conditions that cause substantial morbidity. Despite the presumed importance of complementary therapies for these conditions, studies of care for back and neck pain have not gathered information about the use of complementary therapies.
METHODS: Our nationally representative survey sampled 2055 adults. The survey gathered detailed information about medical conditions, conventional and complementary therapies used to treat those conditions, and the perceived helpfulness of those therapies.
RESULTS: We found that of those reporting back or neck pain in the last 12 months, 37% had seen a conventional provider and 54% had used complementary therapies to treat their condition. Chiropractic, massage, and relaxation techniques were the most commonly used complementary treatments for back or neck pain (20%, 14%, and 12%, respectively, of those with back or neck pain). Chiropractic, massage, and relaxation techniques were rated as “very helpful” for back or neck pain among users (61%, 65%, and 43%, respectively), whereas conventional providers were rated as “very helpful” by 27% of users. We estimate that nearly one-third of all complementary provider visits in 1997 (203 million of 629 million) were made specifically for the treatment of back or neck pain.
CONCLUSIONS: Chiropractic, massage, relaxation techniques, and other complementary methods all play an important role in the care of patients with back or neck pain. Treatment for back and neck pain was responsible for a large proportion of all complementary provider visits made in 1997. The frequent use and perceived helpfulness of commonly used complementary methods for these conditions warrant further investigation.

Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: Who are they, and why are they in chiropractic care? Spine 2002 February 1;27(3):291-6.
SUMMARY OF BACKGROUND DATA AND OBJECTIVES: Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why.
METHODS: The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patient’s reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors.
RESULTS: More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care.
CONCLUSION: These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care 2001 September;39(9):956-67.
BACKGROUND: Neck and low back pain are leading causes of morbidity and health care utilization. However, little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain.
OBJECTIVES: The objectives of this study were to: 1) describe health care utilization for neck and back pain; 2) determine the characteristics of individuals seeking health care for neck and back pain; and 3) identify the characteristics of patients who consult medical doctors, chiropractors, or both.
DESIGN: Population-based cross-sectional mailed survey. SUBJECTS: Subjects were randomly selected adults from the Saskatchewan Health Insurance and Registration File.
MEASURES: Demographic, socio-economic, general health, comorbidity, health-related-quality-of-life, pain severity and health care utilization data were collected. The main outcome was whether subjects with prevalent neck or low back pain visited a health care provider in the previous month.
RESULTS: Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. Compared with medical patients, fewer chiropractic patients lived in rural areas or reported arthritis, but they reported better social and physical functioning. More patients consulting both providers reported disabling neck or back pain.
CONCLUSIONS: Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.

How can chiropractic become a respected mainstream profession? The example of podiatry

The debate continues. Here is a new article from the Open Access journal Chiropractic & Osteopathy:

Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteopat 2008 Aug 29;16(1):10. [Epub ahead of print]  HTML version

BACKGROUND: The chiropractic profession has succeeded to remain in existence for over 110 years despite the fact that many other professions which had their start at around the same time as chiropractic have disappeared. Despite chiropractic’s longevity, the profession has not succeeded in establishing cultural authority and respect within mainstream society, and its market share is dwindling. In the meantime, the podiatric medical profession, during approximately the same time period, has been far more successful in developing itself into a respected profession that is well integrated into mainstream health care and society.

OBJECTIVE: To present a perspective on the current state of the chiropractic profession and to make recommendations as to how the profession can look to the podiatric medical profession as a model for how a non-allopathic healthcare profession can establish mainstream integration and cultural authority.

DISCUSSION: There are several key areas in which the podiatric medical profession has succeeded and in which the chiropractic profession has not. The authors contend that it is in these key areas that changes must be made in order for our profession to overcome its shrinking market share and its present low status amongst healthcare professions. These areas include public health, education, identity and professionalism.

CONCLUSION: The chiropractic profession has great promise in terms of its potential contribution to society and the potential for its members to realize the benefits that come from being involved in a mainstream, respected and highly utilized professional group. However, there are several changes that must be made within the profession if it is going to fulfill this promise. Several lessons can be learned from the podiatric medical profession in this effort.


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