A small but significant number of musculoskeletal patients presenting for examination are suffering from a serious medical condition or illness. To filter out these patients quickly the concept of Red Flags has been developed to increase the reliability of the history taking and examination, thereby reducing the likelihood of something being missed. The large increase in costs and disability which has accompanied the rise in low back pain absence from work has thrown the spotlight on developing tools to identity and counteract negative influences for recovery after low back pain.
Yellow flags are psychosocial risk factors for work loss and disability after episodes of low back pain, although the principles could apply well to any musculoskeletal condition. Whilst red flags should lead to appropriate medical investigation and intervention, yellow flags should lead to the appropriate behavioural and cognitive intervention. The presence of a yellow flag should lead to a decision whether a more detailed assessment is needed and if so the identification of a specific intervention should be the goal. Without the application of an appropriate therapy the identification of yellow flags has no point.
Reductions in functional ability, coping with the pain and compromise in the ability to do paid work are the three major consequences of a history of low back pain episodes. A small but significant group of back pain sufferers develop chronic pain problems and preventative measures do not seem to be very effective. Painkillers control symptoms but have no effect on the course of the pain but the best initial strategy seems to be to control the levels of the acute pain as high levels of persistent pain in the early parts of the episode increases the chances of it developing into a chronic syndrome.
The Belief that Pain and Activity are Harmful: In the initial injury responsible for the episode of low back pain some damage is likely to have occurred. However, this settles quickly and the road to recovery involves confronting the pain to some extent and continuing with normal activities. A graded return to exercise, not backing off if the pain increases to some degree, is the way to return to normality. If the patient believes that the pain and physical activity are harmful they will avoid activity and will not follow the road towards recovery, choosing to rest in response to the pain.
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.
Depression and Withdrawal from Social Contact: A pain problem can change the way a person thinks, leading to low mood, negative thinking and a withdrawal from social activities. Due to their altered thinking patterns, attitudes, beliefs and motivation, patients may choose poor coping techniques such as avoidance, overdoing, alcohol and drug intake. In severe cases they may suffer agoraphobia and panic attacks.
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.
Good recovery from back pain can be interrupted by many factors such as having had back pain before, taking a lot of sick leave, being unhappy at work and with poor work satisfaction, undertaking heavy work in poor hours and having a family which is either over-protective or uncaring.
Other complications to a good recovery from low back pain include having episodes of back pain previously, taking much sick time, having problems and low level of satisfaction at work, working unsociable hours and in heavy work and having an unsupportive or over solicitous family. - 14130
Yellow flags are psychosocial risk factors for work loss and disability after episodes of low back pain, although the principles could apply well to any musculoskeletal condition. Whilst red flags should lead to appropriate medical investigation and intervention, yellow flags should lead to the appropriate behavioural and cognitive intervention. The presence of a yellow flag should lead to a decision whether a more detailed assessment is needed and if so the identification of a specific intervention should be the goal. Without the application of an appropriate therapy the identification of yellow flags has no point.
Reductions in functional ability, coping with the pain and compromise in the ability to do paid work are the three major consequences of a history of low back pain episodes. A small but significant group of back pain sufferers develop chronic pain problems and preventative measures do not seem to be very effective. Painkillers control symptoms but have no effect on the course of the pain but the best initial strategy seems to be to control the levels of the acute pain as high levels of persistent pain in the early parts of the episode increases the chances of it developing into a chronic syndrome.
The Belief that Pain and Activity are Harmful: In the initial injury responsible for the episode of low back pain some damage is likely to have occurred. However, this settles quickly and the road to recovery involves confronting the pain to some extent and continuing with normal activities. A graded return to exercise, not backing off if the pain increases to some degree, is the way to return to normality. If the patient believes that the pain and physical activity are harmful they will avoid activity and will not follow the road towards recovery, choosing to rest in response to the pain.
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.
Depression and Withdrawal from Social Contact: A pain problem can change the way a person thinks, leading to low mood, negative thinking and a withdrawal from social activities. Due to their altered thinking patterns, attitudes, beliefs and motivation, patients may choose poor coping techniques such as avoidance, overdoing, alcohol and drug intake. In severe cases they may suffer agoraphobia and panic attacks.
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.
Good recovery from back pain can be interrupted by many factors such as having had back pain before, taking a lot of sick leave, being unhappy at work and with poor work satisfaction, undertaking heavy work in poor hours and having a family which is either over-protective or uncaring.
Other complications to a good recovery from low back pain include having episodes of back pain previously, taking much sick time, having problems and low level of satisfaction at work, working unsociable hours and in heavy work and having an unsupportive or over solicitous family. - 14130
About the Author:
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. 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 Liverpool or elsewhere in the UK.
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