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Assessment of Yellow Flags

In medical examination the concept of Red Flags has been developed to ensure the identification of symptoms and signs with potentially worrying medical findings on assessing a patient. This ensures a systematic questioning and examination of the patient to reduce the likelihood of missing medically important issues. With the great increase in low back incidence and the expense and disability there has been an emphasis on finding out the risk factors for poor outcome after an episode. Many types of coloured flag systems have been developed to measure and take action against a defined negative outcome.

The identification of yellow flags involves pinpointing the psychosocial risk factors for disability and work loss in back pain, with the principles applicable to other pain conditions. Red flags are meant to engage the necessary medical diagnosis and intervention whilst yellow flags necessitate the application of planned cognitive and behavioural intervention. If yellow flags are detected then further assessment may be necessary so that the appropriate therapeutic intervention can be planned. There is no point in spending the time and effort in identifying yellow flags without identifying the necessary interventions.

Low back problems have significant consequences which are pain itself, the loss of functional activity and a reduction or loss of the ability to work. When we have acute back pain, the probability of it becoming chronic is small but significant and our ability to intervene to change the course of the episode may be limited. Pain medications have little effect on whether we develop chronic pain but controlling the initial acute pain as well as possible may be a useful thing to do. Excessive and long-lasting pain may increase the likelihood of developing chronic pain.

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.

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.

Pursuing Poor Treatment Techniques: Patients' outcome can be significantly affected by the approach of the physiotherapist and an enabling approach to improve function should be engaged. Passive therapies applied to the patient by a therapist should be avoided along with the idea that their back pain problem can be fixed. Active therapies to engage the patient in their own functional rehabilitation should be chosen, with an explanation of the symptoms and the strategy for returning towards normal function, including remaining in work.

Legal Claims and Compensation: Spinal pain conditions are often the result of injuries or work related problems. This can lead to legal claims for compensation which can drag on for years and involve repeated consultations with different specialists. Some people find it very hard to move forward while the process is going on and get stuck in their situation, others fear being filmed if they do anything active and withdraw from normal activities.

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.


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