Yellow flags in back pain
The most important and widely used model for the examination of the spine is the Bio-Psycho-Social model. This aims to encompass all elements of a patient's problem. The aim of the psychosocial assessment is to find those patients who are likely to develop chronicity. The factors which highlight the patient's risk of chronicity can be identified using the 'yellow flags' system:
- Attitudes - towards the current problem. Does the patient feel that with appropriate help and self management they will return to normal activities?
- Beliefs - The most common misguided belief is that the patient feels they have something serious causing their problem-usually cancer. 'Faulty' beliefs can lead to catastrophisation.
- Compensation - Is the patient awaiting payment for an accident/ injury at work/ RTA?
- Diagnosis - or more importantly Iatrogenesis. Inappropriate communication can lead to patients misunderstanding what is meant, the most common examples being 'your disc has popped out' or 'your spine is crumbling'.
- Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxietous states are at a high risk of developing chronic pain.
- Family - There tends to be two problems with families, either over bearing or under supportive.
- Work - The worse the relationship, the more likely they are to develop chronic LBP.
A more formal tool used to assess psychosocial issues is the STarT back screening tool. This enables the identification of those LBP patients at risk of developing chronicity thus allowing the implementation of appropriate treatment.
The early treatment of patients at risk of developing chronic pain has been found to be effective at preventing long-term disability and chronicity.
Click here to access an electronic version of the STarTback tool. For paper based versions, please see the MSK referral form.
Linton S.J Understanding Pain For Better Clinical Practice 2005 Elsevier; Edinburgh
Linton SJ, Andersson T 2000 Can Chronic Disability Be Prevented? A Randomized Trial of a Cognitive-Behavior Intervention and Two Forms of Information for Patients With Spinal Pain
Spine 25(21) 2825-2831
Hill JC, Dunn KM, Main CJ, Hay EM Subgrouping low back pain: A comparison of the STarT Back Tool with the Orebro Musculoskeletal Pain Screening Questionnaire Eur J Pain (2009) In press
Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM 2008 A Primary Care Back Pain Screening Tool:Identifying Patient Subgroups for Initial Treatment Arthritis & Rheumatism Vol. 59, No. 5, May 15, 2008, pp 632-641
Moore JE, Von Korff M, Cherkin D, Saunders K, Lorig K. 2000 A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting
Pain, 88(2) pp.145-153