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Page 1: Psychosocial Yellow Flags for acute low back pain: ‘Yellow Flags’ as an analogue to ‘Red Flags’

European Journal of Pain (1998) 2: 87-89

Bulletin Board

Psychosocial Yellow Flags for acute low back pain: ‘Yellow Flags’ as an analogue to ‘Red Flags’

Low back pain problems, especially when they are long term or chronic, produce extensive human suffering. Interest has recently focused on the possibility of improving early management of acute low back pain (ALBP) to prevent the development of long-term problems. As the pre- vention of chronic pain per se through physio- logical or pharmacological interventions in the acute phase have been relatively ineffective to date, the associated disability and loss of quality of life has been considered as the component of the problem which may best be prevented. The concept of psychosocial Yellow Flags has been proposed as a method of elucidating risk factors for long-term disability to health professionals.

A collaborative project was undertaken in New Zealand during 1996 by the National Health Committee and Accident Rehabilitation Com- pensation Insurance Corporation to develop evi- dence-based guidelines for the assessment and treatment of ALBP (less than 3 months). A concurrent project was initiated to provide advice on the potential role of psychosocial factors in the development of long-term problems, and to develop a set of guidelines that could be used by primary care health professionals. This was undertaken due to: (a) the widespread recognition that psychosocial factors are important in LBP disability; and (b) the acknowledgement by pro- fessional groups involved that they often have difficulty assessing psychosocial factors, and lack confidence to deal with them effectively.

Following a literature review, a discussion document was circulated to all relevant pro- fessional organizations, and a subsequent draft was presented and submitted for comment at a limited public hearing. The resulting guideline promotes the concept of psychosocial Yellow Flags as an analogue to Red Flags. Yellow Flags

1090~3801/98/010087 +03 $12.00/O

are risk factors for long-term disability and work loss. The resulting 22 page document contains three laminated inserts that can be used by clini- cians in their everyday practice during inter- actions with patients., A brief screening questionnaire to detect ‘at risk’ individuals is provided.

It must be emphasized that the principal goal of this project from the outset was to integrate, not separate, the assessment and management of psychosocial and behavioural issues with other aspects of primary care for ALBP. The key goals were to provide primary care treatment providers involved in low back care with: (a) a systematic approach to identifying and quantifying the risk of psychosocial factors contributing to long-term disability; and (b) suggestions for improved early behavioural management of ALBP patients that may prevent the development of long-term prob- lems.

The Yellow Flags approach was based on three important assumptions: (a) injuries and im- pairments are rarely due primarily to psy- chological causes; (b) the report of injuries and pain is usually mediated by a complicated inter- action of medical, work-related beliefs and be- haviours, and psychosocial factors; and (c) the disability (loss of functions, withdrawal from activity and work loss) secondary to impairment and the subjective experience of pain is commo~lfy influenced by psychosocial factors.

A number of practical conclusions were con- sidered important for primary care treatment providers: l What should be assessed varies with the timing

of the assessment (from the point of onset). At the time of presentation, the most important consideration is the presence of Red Flags, although the presence of Yellow Flags can be

0 1998 European Federation of Chapters of the International Association for the Study of Pain

Page 2: Psychosocial Yellow Flags for acute low back pain: ‘Yellow Flags’ as an analogue to ‘Red Flags’

88 BULLETIN BOARD

noted. However, as time goes by, the potential for psychosocial Yellow Flags to be salient increases.

l Impairment, disability and pain need to be considered as related, but independent. This is especially relevant when outlining targets for prevention, since each may result in goals that are unique. The primary prevention of impairment remains an elusive goal, as does the secondary prevention of chronic pain. However, there are several indications that the secondary prevention of disability is a realistic goal.

l Our clinical work force currently does an in- adequate job of identifying recurrent and chronic problems. And, when clinicians do identify long-term or chronic problems they invariably feel they have little to offer. Neither of these conclusions is pejorative. Rather, they reflect the curriculum and training provided in professional courses in the past. Widespread enthusiasm for updated knowledge about pain problems has been evident amongst health professionals.

l The repeated application to long-term (chronic) problems, of treatments or inter- ventions that are designed for short-term (acute) problems is often disabling in itself, and results in lower levels of activity and functioning through increased patient pas- sivity.

l We should recognize that in the same way that not every patient has Red Flags, we cannot assume they all have psychosocial Yellow Flags. However, care needs to be taken to ensure that psychosocial factors are not missed, since the results of this may be more detrimental than over-identification. The sig- nificance of a particular factor is relative. Im- mediate notice should be taken if an important Red Flag is present, and consideration given to an appropriate response. The same is true for the Yellow Flags.

l Red and Yellow Flags are not exclusive-an individual patient may require intervention in both areas concurrently.

l The presence of Yellow Flags should cause consideration to be given to the behavioural aspects of management, tailored to the in- dividual. Put another way, the identification

of risk factors should lead to appropriate inter- vention. Red Flags should lead to appropriate medical intervention; Yellow Flags to ap- propriate cognitive and behavioural man- agement.

The number of potential psychosocial factors that might contribute to the development of long- term disability is large. For this reason a brief 24-item screening questionnaire was provided to quantify the probability of the individual with low back pain being at risk of long-term disability and time off work. It is recommended that this screening questionnaire be used as just that, a screening tool, and not as an end result. It should alert the clinician to the possibility of psycho- social barriers to recovery, or improvement in function. These factors still need to be properly explored within the clinical setting. In the spirit of trying to encapsulate the important psychosocial issues in a simple mnemonic-ABCDEFW-the following headings were used to outline the fac- tors that were considered to be important: At- titudes and Beliefs about Back Pain, Behaviours, Compensation Issues, Diagnosis and Treatment, Emotions, Family and Work.

It was concluded that the following factors may be the most important and consistently predict poor outcomes: (a) the presence of a belief that back pain is harmful or potentially severely disabling; (b) fear-avoidance behaviour (avoiding a movement or activity due to misplaced anti- cipation of pain) and reduced activity levels; (c) tendency to low mood and withdrawal from social interaction; and (d) an expectation that passive treatments rather than active parti- cipation will help. Some simple questions were suggested to elicit this information, which can be easily phrased in a clinician’s own words:

l Have you had time off work in the past with back pain?

l What do you understand is the cause of your back pain?

l What are you expecting will help you? l How is your employer responding to your

back pain? Your co-workers? Your family? l What are you doing to cope with back pain? l Do you think that you will return to work?

When?

European Journal of Pain (1998), 2

Page 3: Psychosocial Yellow Flags for acute low back pain: ‘Yellow Flags’ as an analogue to ‘Red Flags’

BULLETIN BOARD 89

In summary, it may be said that assessing the presence of psychosocial Yellow Flags should produce two key outcomes. The first is a decision as to whether more detailed assessment is needed, and the second is the identification of any salient factors that can become the subject of specific intervention, thus saving time and helping to concentrate the use of health-care resources. It must be emphasized that the presence of psycho- social Yellow Flags in no way indicates the like- lihood of malingering. Rather, they should be interpreted as individual, employment and system factors that may interact with the pathway to full recovery. It is to be hoped that primary care treatment providers will explore the benefits of

this approach within their regular clinical prac- tice, and that this is done in a manner that results in improved quality of life for those with low back pain problems.

N.A.S. KENDALL, S.J. LINTON AND C. MAIN hebro, Sweden

REFERENCE

Kendall NAS, Linton SJ, Main C. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability and Work Loss. Accident Rehabilitation & Compensation Insurance Cor- poration of New Zealand and the National Health Com- mittee, Wellington, New Zealand, 1997.

European Journal of Pain (1998), 2