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The flag system in physiotherapy: a biopsychosocial approach to pain assessment

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Paper title:

The flag system in physiotherapy: a biopsychosocial approach to pain assessment
DOI: https://doi.org/10.4316/SAM.2025.0223
Published in: Volume XVIII issue 2/ 2025
Publishing date: 2025
Pages:
Author(s): Gabriela Iuliana Cazac
Abstract. Musculoskeletal pain is a major contributor to disability and reduced quality of life, requiring assessment strategies that extend beyond a purely biomedical perspective. Contemporary physiotherapy practice increasingly emphasizes the biopsychosocial model, which considers biological, psychological, and social factors influencing pain and functional outcomes. Within this framework, the flag system represents a structured approach for identifying risk factors associated with serious pathology, psychosocial distress, occupational challenges, and systemic barriers that may affect recovery.

The aim of this article is to present and synthesize the flag system, including red, yellow, orange, blue, and black flags, and to underline its relevance in physiotherapy clinical reasoning and decision-making. A narrative literature review approach was employed, including relevant scientific articles and clinical guidelines, with the aim of analyzing key concepts related to pain screening, risk stratification, and interdisciplinary collaboration in physiotherapy practice.

The findings highlight the importance of early recognition of red flags that require urgent medical referral, as well as the identification of psychosocial and occupational factors that contribute to pain chronicity. Screening tools such as the Örebro Musculoskeletal Pain Questionnaire and the STarT Back Tool support individualized treatment planning. Integrating the flag system into physiotherapy assessment enhances patient-centered care, promotes multidisciplinary collaboration, and contributes to more effective and personalized therapeutic interventions.
Keywords: musculoskeletal pain, biopsychosocial model, flag system
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