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Yellow Flag screening in lumbar disorders

Yellow Flags (PDF 106KB) are psychosocial factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain.

Kendall et al. (1997) developed guidelines for assessing ‘yellow flags’ in acute low back pain, outlining factors that should be assessed particularly when progress is slower than expected. The presence of such factors is a prompt for further detailed assessment and early intervention. ‘Red flags’ and ‘yellow flags’ are not mutually exclusive and intervention may be required to address both clinical and psychosocial risk factors.

Poor outcome predictors

There is good agreement that the following factors are important and consistently predict poor recovery outcomes:

  • The presence of beliefs that back pain is harmful or potentially severely disabling.
  • Fear-avoidance behaviour (avoiding a movement or activity due to misplaced anticipation of pain) and reduced activity levels.
  • Tendency to low mood and withdrawal from social interaction.
  • An expectation that passive treatments rather than active participation will help.

Questions to ask your patient

Below are some questions to assist you in identifying potential psychosocial barriers to recovery. These questions are to be phrased in your own words.

  • Have you had time off work in the past with back pain?
  • What do you understand is the cause of your back pain?
  • What are you expecting will help you?
  • How is your employer responding to your back pain?
  • Your co-workers?  Your family?
  • What are you doing to cope with back pain?
  • Do you think that you will return to work? When?

Suggestions for early behavioural management of low back pain.

The Keele STarT Back Screening Tool

The Keele STarT Back Screening Tool is a brief, validated tool (Hill et al 2008), designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making.

The instrument is being used by a range of clinicians to systematically identify patients ‘at risk' of persistent symptoms.

The 9-item tool is designed to classify patients into one of three subgroups for targeted primary care management:

  • low risk
  • medium risk (physical indicators)
  • high risk (physical and psychosocial indicators) 

Psychology and Counselling Services

For patients who are identified at high risk of persistent symptoms referral to psychology and counselling services should be considered. A list of local services are available in the Psychology and counselling services information sheet (PDF 164KB).

Further information regarding assessing psychosocial yellow flags in acute low back pain as well as details of the acute low back pain screening questionnaire is available on the New Zealand Guidelines Group website.

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