Blue Flags Research Articles

Clinical Examination, Diagnosis, and Conservative Treatment of Chronic Low Back Pain: A Narrative Review.

Chronic low back pain is one of the most frequent reasons for medical consultation. It is important to make the correct diagnosis to select the most appropriate treatment in a stepwise approach. In this narrative review, we focus on the clinical examination, the diagnosis, and the conservative treatment of chronic non-specific low back pain. Belgian guidelines for low back pain were used as a basis, followed by a snowball search starting from two articles. Besides that, the Cochrane database was consulted using the following research areas: "multidisciplinary biopsychosocial rehabilitation", "physical examination of lumbar spine", and "rehabilitation back pain". Lastly, we took information from three handbooks. The diagnosis of low back pain starts with a thorough history, including red, yellow, orange, black, and blue flags. Physical, neurological, sensory, and motor testing is performed and complemented with specific tests for low back pain. With a focus on the conservative treatment, pharmacological and non-pharmacological treatments are possible. For CNSLBP, conservative management is advised, starting with reassurance and clear patient education about the condition. While additional treatments, such as manipulation, massage, and acupuncture, can be considered, their effectiveness is not well supported by evidence. Our center emphasizes exercise within a multidisciplinary biopsychosocial rehabilitation program, and although evidence for this approach is limited, we have seen positive outcomes, including improved mobility, strength, and higher return-to-work rates, particularly with the David Spine Concept (DSC).

“Blue flags” of pain such as an important factor, has been influenced in the chronification of the low back pain

BACKGROUND. Despite the widely discussed problem of pain chronification, the issues of assessing the relationship between emotional-affective disorders and the social status of patients with pain in the context of assessing the so-called blue flags of pain remain poorly understood.
 AIM. To determine the relationship between biopsychosocial factors, particularly socioeconomic status, and the quality of life of patients with back pain.
 MATERIAL AND METHODS. The study included 32 patients suffering with non-specific back pain of various localization. During of the study, the results of neuropsychological tests (HADS, SF-36, VAS) were analyzed to assess the mental state and social aspects of the patients lives. A specially designed questionnaire was used to assess the so-called blue flags of pain, which including the level of satisfaction with work and relationships in the workplace. The statistical processing of the data obtained was carried with using the programe Statistica 6.0 with the evaluation of Students criterion and Pearsons coefficient.
 RESULTS. Correlations were found between emotional-affective disorders and socio-economic aspects, namely: job satisfaction and relationships with colleagues. Emotional and affective disorders were found to have a significant impact on relationships at work. People with emotional-affective disorders and chronic pain syndrome are more likely to have an unsatisfactory self-assessment of their health. The relationship between emotional-affective disorders and the intensity of the pain syndrome and life impairment was also determined, and it was found that patients with psychological distress are more susceptible to life impairment due to back pain. In the process of determining the level of quality of life of the examined individuals, low values were found according to the SF-36 questionnaire due to a decrease in the psychological component of health in patients with chronic pain syndrome (r=0.64, p 0.05). Significant correlations were found between affective disorders and job satisfaction (r=0.46, p 0.05) and relationships with co-workers (r=0.44, p 0.05), as well as pain intensity according to VAS (r=0.37, p 0.05).
 CONCLUSION. Socio-economic factors, the so-called blue flags of pain, together with emotional and affective disorders, have a significant impact on the outcome of the pain syndrome and largely determine the chronification of pain, with a regression in the quality of life of patients with back pain.

Function-based tests to determine the return-to-activity state inpatients with non-specific low back pain

Most people with back pain suffer from non-specific low back pain, for which no specific reasons can be found. Two out of three have recurrent pain episodes. To reduce the likelihood of recurrence and long-lasting pain, functional tests are increasingly used to determine the current functional status. This literature study evaluates evidence of functional tests in patients with non-specific low back pain and their validity related to the return-to-activity (RTA) status. The objective of this analysis is to give recommendations for specific activities and to assess the risk of chronification and recurrent pain. PubMed-based literature search. Narrative review focusing on data from the past ten years. A total of twelve studies were included in the analysis. Overall, 33 different tests were identified for which positive statements regarding reliability, validity and relevance for the assessment of the RTA status in non-specific back pain could be made. The tests identified may be able to provide useful information when assessing the RTA status and to recognise yellow and blue flags in patients with non-specific low back pain. The ability to walk, the behaviour when lifting and carrying objects, motor control, muscle strength and mobility play a particular role. The determination of the RTA status in patients with non-specific low back pain should be patient-specific and based on biopsychosocial aspects rather than relying exclusively on movement-related tests. Exact statements regarding the point in time when patients can resume everyday activities and work without an increased risk of recurrence or chronicity do not seem possible with functional tests alone. The major influence of psychological and social factors on disease development, course and prognosis are limiting factors. Movement and strain-related tests can still be used to evaluate activities related to everyday life, to design therapy programs and to give patients confidence.

SURVEI SARANA PRASARANA KARETEKA DI DOJO KODIM 1004 KOTABARU

The aims of the research is to know about the condition infrastructure of facilities on sport of karate in Dojo kodim 1004 Kotabaru. The method of this research is used of descriptive kualitatif or survey and technique of collecting data used of the interview, observation, questionaire and documentation. Thechnique take of sampel is that purposive of sampling, and take of sample with the ceritain of purpose. This thing show with have training building with one number that located on kodim 1004 Kotabaru or 100% that include in good category, karate clothes facilities good category, hand protector in good category, shind guard in good category, chest protector in good category.The jury referee uniforms include: white shirt, gray pants, red tie, black rubber shoes without soles in good category, scoring board in good category, score board in good category, red belt and blue in good category, red and blue flags for judges in good category, whistle for referee in good category, mattress in good category, Samsak in good category. Completeness of facilities and infrastructure at the Dojo Kodim 1004 Kotabaru is quite complete.
 
 Keywords: Karate Facilities and Infrastructure, at the Dojo Kodim 1004 Kotabaru

Are blue flags a good indicator of the quality of sea water on beaches? An empirical analysis of the Western Mediterranean basin

Beach tourism in an important industry in many countries, and in the Mediterranean it supposes an extra pressure on the seawater quality. Concern about this aspect led the European Union to issue a first directive on the quality of bathing water in 1976 and modify it in 2006. This regulation establishes a mandatory control, in all European Union (EU) countries, of the proliferation of bacteria (specifically Intestinal enterococci and Escherichia coli) that can cause serious harm to public health. Meanwhile, the Blue Flag program born in 1987 as an award granted by the Foundation for Environmental Education, to which all municipalities that so wish can voluntarily participate, aimed to publicly value beaches. This award adds to the beaches that receive it a commitment to superior water quality, among other requirements, to that required by the European Union which attracts tourists. The aim of this paper is to obtain empirical evidence of beaches awarded with a Blue Flag (BF) have cleaner waters than those ones that have not in the three main tourist destinations in the Mediterranean that represents circa 5000 coastal monitoring points: Spain, France and Italy. The results point out that the BF areas have significantly cleaner waters than the monitoring points that are not in these areas.

Translation, adaptation, validity and reliability of the Dutch version of the ‘blue flags’ questionnaire

Purpose To translate and culturally adapt the Swedish version of the ‘Blue flags’ questionnaire into Dutch and to examine the validity and reliability aspects of the Dutch version. Methods The ‘Blue flags’ questionnaire was translated and culturally adapted to the Dutch situation. A total of 58 participants filled in the first questionnaire at baseline and 51 participants filled in the second questionnaire sent two weeks later. The data of the participants who filled in the first questionnaire was used to determine internal consistency, structural validity and concurrent validity. The data of the participants who filled in both questionnaires was used to determine test-retest reliability. Results The internal consistency was good with a Cronbach’s alpha of 0.83. The structural validity was satisfactory with a Kaiser–Meyer–Olkin (KMO) test of 0.75 and a significance of p < .001 for the Bartlett’s test. Four factors were extracted using principal component analysis (PCA) with varimax rotation with an explained total variance of 70.8%. Spearman’s rho for concurrent validity was 0.68 (p < .001). The intraclass correlation coefficient (ICC) for test-retest was 0.80 (p < .001) for the total score. Conclusions The Dutch version of the ‘Blue flags’ questionnaire showed good internal consistency, satisfactory structural validity, strong concurrent validity (with mixed item representation results) and strong reliability.

Schmerzprävention in der Grundversorgung

Based on health insurance data, approximately 37.4million patients (46%) in Germany are diagnosed with "pain". The prevalence of patients with debilitating chronic pain is around 7.3%. From the health care perspective, and given the high socioeconomic relevance of chronic pain, effective preventive measures represent useful therapeutic approaches. In the context of pain medicine, primary prevention aims to avoid acute pain. Secondary prevention is targeted at preventing acute pain from turning into chronic pain. Tertiary prevention comprises measures to diminish pain-associated disability and impairment to everyday life. Finally, quaternary prevention focuses on avoiding medically non-indicated or unhelpful medical interventions. In addition to general approaches of pain prevention, such as detecting and treating of chronification factors (yellow, black and blue flags), the present article also describes educational and disease-specific approaches in musculoskeletal and neuropathic pain syndromes as well as headaches.

On biodiversity and conservation of the Iris hexagona complex (Phaeiris, Iridaceae)

AbstractTaxonomic revisions using newly available molecular data can have profound consequences for identifying areas of high endemism and, therefore, high conservation priority. A good example of the connection between taxonomy, biodiversity ecology, and conservation issues is genus Phaeiris (Iris subsect. Hexagonae), an endemic taxon of the southeastern United States and in particular P. hexagona (I. hexagona) (Blue Flag), perhaps the best‐known species of this genus. Some authors recently provided evidence for the need to revise the taxonomy of the Blue Flag, which has usually been considered to consist of a single species, P. hexagona. Using molecular and bioclimatic analyses of Blue Flags from Florida and Louisiana, collected at their loci classici, we challenge the notion that P. hexagona is a single species, referring to the almost forgotten taxonomic context of Phaeiris as established by John K. Small and Edward J. Alexander nearly 90 yr ago. Our vision of the P. hexagona complex reinforces the current treatment of Southern Coastal Plain as a biodiversity hotspot. Our results also argue for the complex nature of endemism on the Florida Peninsula, and elsewhere on the Southern Coastal Plain, including a new interpretation of the well‐studied Louisiana irises. We also propose that the valleys of Florida rivers and lakes are likely to harbor additional hidden biodiversity. Accurate taxonomy proved to be a heuristic tool to characterize better the actual level of biodiversity within Southern Coastal Plain as well as to describe the different areas endemism. The newly re‐documented taxonomic diversity in broadly defined P. hexagona should also be considered in future conservation efforts.

Assessing environmental pollution levels in marinas

Despite the growing interest in recreational boating and the increasing number of marinas along the world's coastlines, environmental knowledge of these ecosystems is still very scarce. Detailed data of pollutants in marinas are necessary to provide a global approach of environmental risks in the context of international management strategies. In the present study, a set of 64 variables (30 in seawater and 34 in sediments) were measured to compare marinas from the Southern Iberian Peninsula (SIP). Uni and multivariate analyses showed significant differences among marinas, evidencing the importance of management on a local scale. The most relevant variables determining these differences were turbidity and the biocide Irgarol 1051 in seawater, and granulometry, hydrocarbons and faecal coliforms in sediment. The use of normalization techniques with Al or Fe, and the suitability of different methodologies to measure Total Organic Matter in marinas were also discussed. Additionally, we perform a comprehensive literature review of worldwide marina stressors and develop a simple and straightforward method for assessing environmental quality. The method was tested using SIP marinas and was based on the comparison of 15 selected sediment stressors with background values, concentrations of worldwide sediment quality guidelines (SQGs), and reference conditions/security thresholds established by the programme of coastal waters in port areas (ROM 5.1). A global score was assigned using a new proposed index, Marinas Environmental Pollution Index (MEPI), ranging from 0 to 150 points according to the environmental quality (<90: bad, 90–120: moderate, >120: good). MEPI of marinas from SIP ranged from 60 to 110 points indicating bad or moderate levels of pollution. Environmental quality is one of the decisive factors for awarding eco-labels or eco-certifications, such as Blue Flags in marinas. Therefore, pollution baseline information and environmental tools are mandatory for correct assignation of these awards and necessary for assessing the efficiency of management actions.

Measuring the role of Blue Flags in attracting sustainable ‘sun-and-sand’ tourism

ABSTRACT Eco-labels such as Blue Flags can be effective for enhancing both sustainability and tourism. Given the ongoing political debate on the effectiveness of Blue Flags for promoting tourism, we analyze the impact of the number of Blue Flag beaches on tourist arrivals (international and domestic, respectively) for Spanish coastal provinces. Panel data techniques are used to evaluate Blue Flags econometrically for the longest and most recent time period in the literature (2000–2019). Findings suggest that Blue Flags are effective at promoting international tourism but not domestic tourism. Different patterns for international and domestic tourists mean that differentiated policies should be applied.

Sustainable beach management and promotion of the local tourist industry: Can blue flags be a good driver of this balance?

The aim of this paper is to analyse to what extent the recognition of sustainable management of coastal resources may act as a driver of local economic growth. To this end, the importance of Blue Flag certification in promoting the development of a local tourism sector is analysed. Using a natural experiment based on some localities increasing the number of their certified bathing areas through recognition of sustainable management, whereas other localities reduce them, we analyse the impact of that recognition on the evolution of the local tourism sector in Comunitat Valenciana (CV) in Spain. CV is the Spanish region with the largest number of beaches with this award, and tourism linked to beaches and marine activities represents a large share of its economy. The results confirm that in this case, Blue Flag recognition has a positive impact on the economic development of the tourism sector in those municipalities that have opted for more sustainable tourism, whereas municipalities that have not introduced any sustainable ecolabel schemes have had lesser development of tourism.

Using ’White Flags’ to categorize socio-cultural aspects in chronic pain

Abstract Issue Persistent chronic pain is a major medical and health economic problem. To assess the individual pain situation, the classification of various factors (flags) has been established. Description of the problem Structural biomechanical factors are classified as “red flags”. Psychological or behavioral factors are summarized as “yellow flags”, psychiatric and mental illness as “orange flags”. Both last flags are important for planning adequate therapies or rehabilitation, as well as for decisions to prognoses and tailored reintegration programs. An extension of the flag model was achieved by naming personal factors at workplace as “blue flags”, and “black flags”, if there is a restriction for returning to work. All these groups do not consider other important reasons for unsuccessful rehabilitation or failed reintegration. Results In these cases, often described as ’therapy-refractory’, clients often exhibit a special subjective understanding of illness that reacts neither to psychological interventions nor to behavioral therapies. These include individual beliefs based, for example, on cultural socialization, religious education, or spiritual experiences. Since such individual mental illnesses are culturally ideologically or religiously justified, they should be classified in a separate group called ’white flags’. Lessons The advantages of categorizing sociocultural aspects separately from other flag classifications are avoidance of unnecessary therapies, including surgery,prevention of iatrogenisation,prevention of legal disputes. It is important to realize that only health restrictions for insurance benefits can be taken into account and that individual socio-cultural circumstances or health convictions are not evaluated. Main messages: A classification of ’white flags’ could contribute to a better classification of pain which are not accessible to various therapies and reduce reservations and misunderstandings by intercultural communication approaches. Key messages For medical professions it is important to recognize, that only health inabilities are taken into account for insurance compensation and not individual socio-cultural circumstances or health beliefs. In Future classifying ’white flags’ could help to properly assess persistent pain conditions.

“Battlefields” of blue flags and seahorses: Acts of “fencing” and “de-fencing” place in a gold mining controversy

The objective of the present study was to investigate how meanings of place were constructed to shape contrasting positions in a gold mining conflict in Greece, and the implications of these dynamics for place-attachment. A social divide has gradually deepened in the area, separating employees of the mining company, on the one side, from residents involved in agriculture, forestry, fishing, and tourism, on the other. Local people engaged in the conflict were interviewed and interview data were analysed in the frame of discursive positioning of respondents, in order to follow how place-based referents were voiced. Acts of positioning might be approached as acts of “fencing”, namely acts of designating specific areas and assigning specific significations or place-based projects to them. These acts were followed by counter-acts of “de-fencing”, namely, acts of challenging significations attempted by the opposing side. Implications of the study for future research are discussed.

Long Day's Journey Into Night

Long Day's Journey Into Night

Seaside tourism and eco-labels: The economic impact of Blue Flags

In a period of rising competition and environmental concern, tourism destinations increasingly use signals that certify and communicate the quality provided in order to gain a competitive advantage over competitors. Given their aim of providing synthetized information on destinations, certifications particularly affect foreign tourists who suffer more from asymmetric information. This study considers the Blue Flag, one of the most popular eco-labels aiming at promoting seaside tourist destinations. The relationship between label achievement and inbound tourist flows is explored. Panel data techniques and highly geographical disaggregated data covering a rather long time span (2000–12) are used to compare the attractiveness of certified and non-certified Italian provinces. The empirical evidence suggests that current certification positively affects future foreign tourist decisions to visit the destination. Moreover, while the presence of at least one signal is effective in attracting tourists, no significant difference emerges among destinations with different signal intensity.

Little Green Peas: A Big Book of Colors by Keith Baker (review)

Reviewed by: Little Green Peas: A Big Book of Colors by Keith Baker Hope Morrison Baker, Keith Little Green Peas: A Big Book of Colors; written and illus. by Keith Baker. Beach Lane/Simon, 2014 34p Trade ed. ISBN 978-1-4424-7660-8 $17.99 E-book ed. ISBN 978-1-4424-7661-5 $10.99 R 3-5 yrs The peas (from 1-2-3 Peas, BCCB 10/12) are back, and this this time they’re celebrating the world of color. Each color is introduced in huge block letters (“BLUE”) followed by a few specific examples, in rhymed verse, of things that are that color (“Blue boats, blue seas, blue flags, and …”), followed by a spread of the green peas amid a landscape dominated by that color (little green peas cavort on a sandbar in a blue ocean next to a blue ocean liner). As in the previous titles, the story stands second to the delight of poring over the highly detailed digitally rendered illustrations of the personified peas, who are doing everything from sunbathing and unicycling to hula-hooping and downhill skiing. Cool white backdrops effectively set off the juicy palette, making this a true visual feast for the eyes. While there’s not much story here, viewers will nonetheless love the opportunity to borrow this one after storytime for a closer look. Copyright © 2014 The Board of Trustees of the University of Illinois

Reflections on the assessment and management of Yellow and Blue Flags in LBP patients

Invited commentary on: ‘Physiotherapists’ assessment and management of psychosocial factors (Yellow and Blue Flags) in individuals with back pain’, Gray H and Howe T.The subject of Gray and Howe’s ...

Physiotherapists’ assessment and management of psychosocial factors (Yellow and Blue Flags) in individuals with back pain

Background: Personal and work-related psychosocial factors play an important role in persisting symptoms and delaying return to work in individuals with back pain. Therefore, it is essential that physiotherapists have the motivation and skills to assess and manage psychosocial factors as part of back pain management.Objectives: To systematically review and summarize the literature on physiotherapists’ perceptions of and skills in assessing and managing psychosocial factors (Yellow and Blue Flags) in individuals with back pain.Methods: Searches were conducted of the: Ovid versions of MEDLINE, PsycINFO and EMBASE; EBSCO CINAHL; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials (Clinical Trials); and Physiotherapy Evidence Database (PEDro) from inception until end October 2011.Results: There were 384 hits of which 17 papers describing 15 studies met the inclusion criteria; these were: two randomized controlled trials; two observational studies; six survey based studies; two qualitative studies; and three using Delphi consensus development. Studies found that although physiotherapists theoretically support a biospychosocial management approach to back pain, in practice few are doing so adequately, even following training in cognitive behavioral principles. Physiotherapists expressed reluctance to engage in the management of work-related psychosocial factors (Blue Flags), perceiving that tackling work issues was outside their professional role.Conclusions: Despite evidence of the barriers to doing so, we put out a call to action that physiotherapists embrace the importance of integrating psychosocial factors in their everyday professional practice. In particular, gaining confidence in tackling Blue Flags is critical to establish physiotherapists as essential players in combating the growing public health concern of worklessness.

Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research

In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, termed "psychologically informed practice," is offered as a "middle way" between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the "flags" framework, with psychologically informed practice requiring routine and specific consideration of "yellow flags" and "blue flags" (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification-but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential "black flags"). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that are associated with outcome of treatment.

Challenges to Remaining at Work with Common Health Problems: What Helps and What Influence Do Organisational Policies Have?

Common health problems have a significant impact on work productivity (presenteeism), and sickness absence. The aim of this study was to examine the attitudes and beliefs of employees in the public sector about common health problems and work using the Flags system as a conceptual framework to identify problems and potential solutions. 63 employees took part in 14 focus groups in two public sector organisations. Discussions were audio-recorded, transcribed, and analysed thematically using NVivo. The study confirmed the importance of heath-focused clinical factors (Yellow flags), perceptions of work (Blue flags), and more objective characteristics of work and organisational policies (Black flags), which emerged as major themes. The social and moral norms surrounding sickness absence and presenteeism were frequently discussed, including the impact of absence on colleagues, guilt, legitimising illness, and trust. There were interactions between the different Flags, often mediated by managers via their relationships with employees and their role in implementing organisational policy. The Flags system was useful as a conceptual framework in this context for identifying a number of obstacles to working with health problems, many of which were potentially modifiable on worker, workplace, or wider systems levels.