Yellow Flags and Secondary Prevention

Michael E. Geisser, Ph.D.

University of Michigan

Significance-The Costs of Back Pain

• Annual costs of low back disability in the United States have been estimated to be approximately $50 billion

• Back pain is the second leading cause of work absenteeism and leads to greatest productivity loss of any disease

• Single case of work-related back pain exceeds $8000• Estimated that 70-80% of the costs for work-related low

back claims are accounted for by 5-10% of patients who develop chronic low back pain (CLBP; pain lasting 3 or more months)

Functional Recovery After an Acute Musculoskeletal Injury

• Time out of work is a significant predictor of long-term outcome

• Return-to-work within the first six months is predictive of good long-term outcomes

• Likelihood of returning to work after being out a year or more is small

• Key to recovery is treatment within the first 6-12 months

Prevention of Chronic Pain

Prevention of Chronic Pain

• Types of prevention

– Primary – target a population at large

– Secondary – target at-risk population

– Tertiary – target diseased population to reduce disease progression, morbidity/mortality, costs

Primary Prevention

• Buchbinder et al. (2001) conducted media campaign in Australia (state of Victoria) encouraging persons with back pain to stay active and exercise (based on the Back Book)

• Conducted phone surveys and sent physicians two scenarios regarding the treatment of low back pain

• Compared responses to persons/physicians in an adjacent state (New South Wales)

Back Book (Burton et al., 1999)

• Excerpt from information booklet The Back Book * • It's your back • Backache is not a serious disease and it should not cripple you unless you let it. We

have tried to show you the best way to deal with it. The important thing now is for you to get on with your life. How your backache affects you depends on how you react to the pain and what you do about it yourself.

• There is no instant answer. You will have your ups and downs for a while—that is normal. But look at it this way

• There are two types of sufferer • One who avoids activity, and one who copes• * The avoider gets frightened by the pain and worries about the future• * The avoider is afraid that hurting always means further damage—it doesn't• * The avoider rests a lot and waits for the pain to get better• * The coper knows that the pain will get better and does not fear the future• * The coper carries on as normally as possible• * The coper deals with the pain by being positive, staying active, or staying at work

Buchbinder et al., 2001 (Continued)

• Measures obtained from 4730 individuals and 2556 general practitioners

• Decrease in fear-avoidance beliefs in Victoria over time, but not in New South Wales

• Significant improvement in back pain management among physicians in Victoria (decrease in ordering tests, prescribing bed rest)

• 15% decrease in absolute number of back claims, reduction of 20% of costs for a back claim

Primary Prevention

• Health Scotland-Working Backs Scotland

• Public education campaign initiated in October of 2002.

• Consists of ads, seminars, and website information (http://www.workingbacksscotland.com)

• Preliminary data suggests 60% penetration and a 20% shift in public beliefs about back pain

Difficulties with Primary Prevention

• Costly

• Targets many in the population who may not have acute pain (although lifetime prevalence of disabling back pain is 80%)

Is Secondary Prevention of Pain Feasible?

• 95% of persons with acute back pain improve within 12 weeks

• However, research suggests that a number of factors prospectively predict the development of chronic pain among persons with acute pain

• These factors are often termed “yellow flags”

• For musculoskeletal pain conditions such as back pain, most of these factors are psychosocial

What Are the Risk Factors for Chronic Pain?

• Catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury.

Risk Factors for Filing Back Claim

• Bigos et al. (1992) examined 3020 employees of Boeing

• 279 persons filed a back injury claim

• The only physical variable that was associated with filing a back claim was a history of prior medical treatment for back pain

• Work satisfaction and scores on scale 3 of the MMPI were the best predictors of filing a claim

Risk Factors for Chronic Pain

• Burton et al. (1995) examined factors associated with the development of chronic back pain in a primary care setting

• 252 subjects with acute back pain were assessed again at 1 year

• Pain catastrophizing alone accounted for 47% of the variance in the development of chronic low back pain

• Psychological distress and prior history of back pain were also significantly related to the development of chronic pain

Risk Factors for Chronic Pain

• Klenerman et al. studied 300 acute low back pain patients.

• A measure of fear-avoidance of pain alone correctly classified 66% of subjects who developed chronic low back pain at 12 months.

• A combination of physiological and psychological data correctly classified 88% of patients.

Model of Chronic Pain Disability(Vlaeyen et al., 1995)

Catastrophizing

Fear of Movement/ReinjuryDisabilityDisuse

Depression

Pain

Avoidance

Catastrophizing

Fear of Movement/ReinjuryDisabilityDisuse

Depression

Pain

Avoidance

Potential Difficulties with Risk Assessment

• Factors are multiple, may vary across persons• While we know the factors related to chronicity,

what “score” or cut-off should be used in a clinical assessment?

• Schemes used to classify subjects may be sample dependent, unstable

• While relationships exist, can risk factors be used prospectively to predict chronicity with a high degree of accuracy?

Risk Assessment – Clinical Evaluation

• Main et al. (1995) recommend evaluating:– General level of distress– Beliefs and fears about pain and rehabilitation– Pain coping strategies– Fear of physical activity– Socioeconomic implications of continued

incapacity– Perception of safety– Job satisfaction

Risk Assessment

• Hazard et al. (1996) utilized an 11-item questionnaire to predict chronicity

• Items assess current pain intensity, blame for pain problem, prediction of ability to work in the future, physical demands of job

• Utilizing a cut-off score of .48, the measure had .94 sensitivity and .84 specificity

• Findings have not been replicated

Risk Assessment

• Hallner and Hasenbring (2004) developed a computer-based statistical model that utilizes yellow flags to determine chronicity in persons with low back pain

• Yellow flags used were psychological distress and the use of certain pain coping strategies

• Overall accuracy of model was 83.1%, with 73% sensitivity and 97% specificity

Risk Assessment

• Linton and Boersma (2003) published data on the Örebro Screening Questionnaire

• Twenty-five item questionnaire assesses factors such as work demands, pain intensity, distress, fear-avoidance beliefs, sleep disturbance

• A cut-off of 90 had 89% sensitivity (65% specificity) for predicting work absenteeism, and 74% sensitivity (79% specificity) for functional recovery

• Subsequent study found overall accuracy for predicting return to work to be between 88%-96% (Dunstan et al, in press) for low back and other types of musculoskeletal pain

How Can the Risk be Reduced (Secondary Prevention)?

Secondary Prevention

• Indahl et al (1995) assigned subjects with back injuries who were off work greater than 8 weeks to conventional treatment (n = 5 12) or light normal activity (n = 463)

• 200 days after the intervention, 60% in the control group were still on sick leave, compared to 30% in the intervention group

• Low back pain treated as a benign, self-limiting condition recommended to light mobilization gives superior results as compared to conventional medical treatment

Secondary Prevention

• George et al. (2003) examined effectiveness of fear-avoidance based physical therapy among subjects with acute back pain (< 8 weeks)

• Intervention based on education (Back Book) and graded exercise

• Subjects with elevated fear-avoidance beliefs at baseline had greater improvements with intervention as opposed to standard care

Secondary Prevention

• Sullivan and Standish (2003) tested a cognitive-behavioral intervention for injured workers at risk for developing chronic back pain

• Subjects had to be off work for 6 weeks and have at least one yellow flag

• 10-week intervention designed to increase subject involvement in goal directed activity and decrease psychological barriers to activity

• 104 subjects completed treatment• 45% returned to work, and 15% were ready to return to work

(contacted employer) following treatment• Study not randomized or controlled

Summary of Secondary Prevention Strategies

• Educate patient about the nature of pain (e.g., hurt versus harm)

• Light, normal activity is OK• Avoid unnecessary investigation• Pay attention to the psychological aspects of symptom

presentation (affect, beliefs)• Advise patients on preventing recurrence (e.g., lifting

sensible loads)• Consider referral for multidisciplinary evaluation if

patient exhibits yellow flags or doesn’t improve• Early intervention is important

The Importance of the Provider

• How you interact with the acute pain patient can significantly impact outcomes and adjustment to pain

• The interaction helps to shape patient beliefs about their pain, which in significantly impacts their experience of pain

Educate the Patient About Their Pain!

• Physician education regarding the etiology of pain is related to increased patient satisfaction (Deyo & Diehl, 1986; Cherkin & MacCormick, 1989).

• Lacroix et al. (1990) found that accuracy of patients understanding of the basis of their pain significantly predicted return to work while injury severity, “nonorganic” signs, and MMPI scores were unrelated.

Pain Beliefs and the Experience of Pain

• Geisser & Roth (1997) examined agreement between physician and patient beliefs about the cause of their pain.

• Controlling for pain duration and intensity, patients whose diagnostic impression agreed with the physician were less distressed, less disabled, and had fewer maladaptive pain beliefs and coping strategies compared to patients who were unsure about their diagnosis or who disagreed with the physician.

Difficulties “Diagnosing” Causes of Pain

• Underlying mechanisms may not be known or obvious

• Musculoskeletal diagnoses are subjective and sometimes unreliable

• May simply be enough to dispel significant pathology