Yellow Flags

The incidence of serious underlying illnesses or conditions occurring with musculoskeletal conditions such as neck pain or low back pain is low. However, it is vital to screen out these patients so they get appropriate medical diagnosis and treatment. Red Flag questions have been developed to identify these patients and ensure that during the examination and the taking the history these considerations are not omitted. The huge rise in disability and costs from low back pain work absence has pinpointed the necessity of identifying the risk factors and formulating treatment strategies.

Psychosocial risks for long term disability and inability to work after a low back pain episode are what yellow flags identify and their principles can likely be applied to other pain syndromes. Referral for immediate medical consultation and treatment is the goal of identifying red flags, while engaging further assessment and the necessary treatment intervention is the goal of identifying yellow flags. The effort and time expended in identifying the yellow flag risk factors is wasted if there is no accompanying plan for behavioural and cognitive interventions.

The consequences of an acute episode of low back pain are important and include a diminution or loss of working activity, a loss of normal function and the suffering of the pain itself. There is a small risk of acute low back pain becoming chronic and therapeutic effectiveness at preventing chronicity may be restricted. Analgesics are not effective in preventing chronic pain but a promising approach is to attempt to control the high levels of the initial pain. Having a high level of pain in the back pain episode may make chronic pain more likely.

Believing the Pain and Activity are Damaging: A tissue injury is likely when the initial low back pain occurs but after a short period it becomes less important and rehabilitation should commence. If the patient interprets their pain as reflecting ongoing injury in the back they might choose to avoid performing normal actions and rest in response to the pain because they are fearful. However, the better strategy is to challenge the pain when it occurs by continuing with the chosen activity and as the graded approach continues the pain should subside.

The Adoption of a Sick Role: People vary hugely in how they respond to pain, sickness or injury, from ignoring it and carrying on the stopping all activity completely. Choosing to rest as a therapy for the pain is a poor choice and such a choice of a sick role is a risk factor for developing disability.

Low Mood and Social Withdrawal: The stress of a pain problem can induce low mood or depression. This can have a significant effect on a patients thinking, beliefs, attitudes and actions, tending to chose resting and poor coping strategies. A patient may also withdraw from normal social contacts, avoid going out and in some cases suffer panic attacks and become agoraphobic.

Treatment not fitting Best Practice: The physiotherapist can do a lot to change the patient's status both for good and ill. They should avoid settling for the disability and should choose active therapies aimed at improving function rather than passive therapies applied to the patient by the therapist. Physiotherapists should not criticise others' diagnoses but try and clear up any confusion about this matter and the expectation of a technological fix should be minimised. Physiotherapists have the responsibility to engage the therapies with the best evidence and to encourage patients to remain in employment.

Compensation and Legal Issues: It is common for legal claims to be instituted after spinal injuries or work related back injuries. Compensation claims can take a very long time to be settled as the process can take years as the patient consults various medical specialists. Patients may get stuck in a rut, unable to move on until all the legal proceedings are settled or fear performing any activity in public in case they are filmed by the other side.

Other difficulties which can complicate the recovery from low back pain include a previous history of low back pain, having a lot of time off, difficulties at work, poor satisfaction at work, heavy work and poor hours and an overprotective or unsupportive family.

Jonathan Blood Smyth is a Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for Physiotherapists in Bournemouth.