Medical Screening: Yellow Flags

What is a Yellow Flag?

MSK disorder with underlying medical or psychological issue that may need co-management or referral for optimal rehabilitation outcomes

Examples of Physical Comorbidities Associated with LBP

Arthritic conditions: OA, RA

Endocrine conditions: thyroid

CV conditions: HTN, hyperlipidemia, angina pectoris, atherosclerosis

GI conditions: constipation

Metabolic conditions: diabetes

Neuropathies: MSK conditions, irreducible disc lesion, congenital spine pathologies

Pulmonary conditions: asthma, coughing, COPD

What tool is commonly used for assessment of physical comorbidities?

Charlson Comorbidity Index is most common and widely used

What psychological comorbidities are associated with LBP?

anxiety and depression

What tools screen anxiety and depression?

HADS

PHQ-9

PHQ-2 --> score of 3 or higher needs further evaluation

Types of flags and their domains

yellow - psychological

blue - perceptions of work

black - system/contextual

orange - psychiatric symptoms

transparent - positive/protective factors

Examples of yellow flags

catastrophizing

fear-avoidance

depression

anxiety

passive coping

Examples of blue flags

job dissatisfaction

perceived workplace demands

Examples of black flags

compensation

legislation

employer/insurer barriers

Examples of orange flags

clinically significant psychiatric disorders requiring referral - PTSD, major depression

Examples of transparent flags

resilience

self-efficacy

optimism

social support

ALL EXAMPLES OF PROTECTIVE PROGNOSTIC FACTORS

Why do PTs focus on yellow flags primarily?

they are intrinsic factors we can modify and they are more predictive of poor treatment outcomes

How does pain affect our psychological processes: attention, cognition, emotions/emotion regulation, overt behavior?

attention: pain demands our attention, more attention to pain more it hurts

cognition: how we think about our pain may influence it

emotions and emotion regulation: pain often generates negative feelings which may influence pain as well as fuel attention, cognition, overt behaviors

overt behaviors: what we do to cope with our pain influences our perception

Possible effects of emotions/emotion regulation on pain and disability

fear - increase avoidance behavior and disability

anxiety and depression - increase pain disability

distress - fuels negative cognition and pain disability

positive emotions - decrease pain

Possible effects of overt behavior on pain and disability

avoidance - increase disability

overactivity - provoke pain

pain behaviors (observable actions, facial expressions, etc.) communicate pain

Outcome measures for fear of movement

FABQ

Tampa Scale of Kinesiophobia

Outcome measures for pain catastrophizing

Pain Catastrophizing Scale (PCS)

Outcome measures for pain interference, depression, and anxiety

PROMIS

What is the OSPRO-YF outcome measure?

multidimensional clinical tool used as an alternative to administering all tools independently

What is the STarT Back screening tool? What is it used for?

9 item screen (NOT OUTCOME MEASURE) to predict progression of chronic status - puts patient in low, moderate, high likelihood/risk to develop into chronic status; used primarily for shared decision-making and communication tool rather than rigid triage gate

What is the fear-avoidance model?

painful injury may result in catastrophizing and fear --> avoidance of certain movements

this behavior --> more avoidance, dysfunction, depression, and pain

What psychological processes are featured in the fear-avoidance model?

cognitive interpretation featuring catastrophizing

emotions: fear, worry, and depression

attention: fear keys attention on internal stimuli (hypervigilance)

behavior: avoidance of movement

What is the mechanism involved in the fear-avoidance model?

activity avoidance --> physical degeneration and social isolation

What are examples of treatment intervention strategies in the fear-avoidance model?

promote physical and social activation