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Risk Factors of LBP
Risk Factors of LBP
K
endall and colleagues1 coined included a clinical interview and a is to differentiate yellow flag factors,
the term “yellow flags” to psychosocial screening questionnaire. which might be amenable to change
encompass psychological risk This approach assumed that individ- by suitably trained health care pro-
factors and social and environmental uals at risk for poor outcomes could viders such as general medical prac-
risk factors for prolonged disability be identified on the basis of either titioners and physical therapists,
and failure to return to work as a con- a small cluster of highly salient fac- from orange flag factors that proba-
sequence of musculoskeletal symp- tors or the cumulative combination bly require specialist mental health
toms. The concept of yellow flags of several factors. Because many of referral. A brief summary of the dif-
sparked much attention and debate these factors are potentially modifi- ferent flags is presented in Table 1.
and was adopted in some guidelines able, the monograph also contained
on the early management of work- additional advice on how to incor- Given these developments in the
use of flags in identifying patients at Emotional responses Distress not meeting criteria for diagnosis
Although the search was not Pain[MeSH:NoExp] OR Abdominal Pain[MeSH] OR Arthralgia[MeSH] OR Back Pain[MeSH]
OR Chest Pain[MeSH:NoExp] OR Facial Pain[MeSH:NoExp] OR Headache[MeSH] OR Neck
intended to be exhaustive and Pain[MeSH] OR Neuralgia[MeSH] OR Pain, Intractable[MeSH] OR Pain, Referred[MeSH]
methodological assessments were OR Shoulder Pain[MeSH] OR Pain Threshold[MeSH] OR Pelvic Pain[MeSH:NoExp]
not conducted, the studies were Neck/Shoulder Pain[tiab] OR Low Back Pain[tiab] OR Back Pain[tiab] OR Whiplash[tiab] OR Back
selected on the basis that they met Disorders[tiab] OR Musculoskeletal Pain[tiab] OR Fibromyalgia[tiab] OR Pelvic Pain[tiab]
the criteria of being published in OR Shoulder Pain[tiab] OR Low Back Disability[tiab]
peer-reviewed journals and were 2. Combination of search words for psychological factors
RCTs; used people with mostly back Psychological Risk Factor*[tiab] OR Yellow Flags[tiab]
pain that had persisted or caused Risk Factors[MeSH]
clear disability (eg, work time lost) Behavioral Symptoms[MeSH] OR Mental Disorders[MeSH] OR Psychology[MeSH]
for mostly less than 6 months (ie, OR Psychology[Subheading]
generally within the acute and sub- 3. Combination of 1 and 2⫽1,241 citations
acute range); and reported on func-
tional outcomes, especially return to Figure.
work or reduced disability. It should Search strategy.
previously published normative data episodes of significant pain and dis- sistent relationship was found
on psychological factors in pati- ability. These findings challenge the between psychological factors and
ents with chronic pain at different concept of chronicity as a continu- the onset of pain, as well as the tran-
pain sites, and no difference was ous development and reliance on the sition from acute to chronic pain
found across pain sites for these number of weeks since onset (eg, problems. These factors included
variables.12 In addition, only studies using 4 or 12 weeks as a point for stress, distress, and anxiety, as well
that included interventions directed determining risk). The recurrent as measures of depressed mood. Lin-
at psychological risk factors (eg, nature of the pain may make time ton16 found that certain beliefs,
unhelpful beliefs, activity avoid- judgments unreliable because the including fear-avoidance beliefs and
ance, mood disturbance, fears of point of onset is difficult to deter- catastrophic thoughts, were strongly
pain or reinjury) were included. The mine and because there is consider- associated with the development of
tion and more social isolation, outcomes. Those who catastrophize question is whether our knowledge
heavier work, and receiving higher frequently, are depressed, have about psychological risk factors can
compensation.24 Thus, it is impor- intense pain, and hold high fear- be applied to individual cases in the
tant to understand yellow flags in avoidance beliefs are more likely to clinic. In recognition of this con-
context and to appreciate that they develop persistent pain problems. cern, most guidelines recommend a
do not operate in isolation from These variables may be considered 2-phase process, with questionnaires
other factors. within a moderator or mediator being supplemented by a clinical
perspective. interview.31 Despite these cautions,
Three recent reviews provide in- there is reasonably consistent evi-
sight into the most current investi- Moderators (or treatment effect dence supporting the idea of yellow
gations where more-sophisticated modifiers) are baseline characteris- flags as risk factors for adverse
including more cases that turn out to risk, and high-risk groups. In an initial vention studies.40 The results to date
be negative (false-positive). Thus, it follow-up study of patients receiving are reviewed next.
has been argued that although such a primary care to determine predictive
measure needs to have high sensitiv- ability, it was shown that 17% of the The Case for Linking Risk
ity, it could have low specificity.33,34 low-risk group, 53% of the medium- Identification With Interventions
risk group, and 78% of the high-risk The idea of allocating patients to
Most guidelines on the application group had disability at the 6-month treatment on the basis of their ini-
of risk assessment in early musculo- follow-up.38 These examples indi- tial presenting characteristics is
skeletal pain recommend using a cate there are instruments avail- long-standing.41,42 However, to date,
combination of interviews, impres- able that can help clinicians to iden- relatively few studies have shown
sions formed during examination, tify yellow flags and assess risk at attempts to link interventions to psy-
functional or return-to-work out- psychological risk factors. Instead, behavioral principles, was provided
comes than those that were more patients were selected if they were by physical therapists or general
symptom-based and did not target seeking help for back pain of less medical practitioners. In other cases,
psychological risk factors (often than 6 months’ duration. In addition, a psychologist (sometimes called a
called “usual care”). In contrast, 6 the groups treated in these studies behavior therapist or psychothera-
studies50 –56 did not find targeting generally had low levels of psycho- pist) provided the psychological
psychological risk factors for inter- logical risk factors in the first place, intervention, usually working along-
vention was differentially effective which means there was little room side members of other disciplines.
on functional outcomes relative to for improvement on these dimen-
the alternative (mostly usual care) sions. Only one placebo-controlled It might be relevant that in the 7
treatments. intervention61 was found, but as the studies in which psychological inter-
tance of treatment content and fidel- Concordant with this observation, in as a comparison group,70 it was
ity. In some studies, psychological one of the few RCTs to test the role found that an integrated occupa-
interventions amounted to little of risk factors for disability in tional, clinical, case management
more than education about pain and patients with chronic pain,67 it was intervention that was individually tai-
injury, attempted reassurance that all found that matching patients iden- lored, cognitive-behavioral methods
was well, and encouragement to tified by these risk factors to level achieved better return-to-work out-
return to normal activities, including of intervention was important in comes at 6 months posttreatment,
work.65,66 In some studies, these achieving better and more economic but only in those workers who were
interventions appeared quite similar return-to-work outcomes. In that assessed as at high risk for long-term
to those provided to the comparison study, those individuals identified disability. At 3 months posttreatment
group,50,51 which could have diluted as at high risk benefited more from in those workers assessed as being
status, is ineffective and likely to be the development of persistent pain patients are not selected for yellow
uneconomical. disability has generated a plethora of flags and psychological interventions
research articles. As this database are provided indiscriminately, the out-
When this evidence is considered grows, various psychological factors comes tend to be disappointing.
alongside a recent article on blue have consistently been linked with
flags72 that described the benefits to poor prognosis. A point of conten- The available evidence provides a
be gained from linkages between tion is not whether yellow flags have consistent picture that yellow flags
interventions and the workplace, an impact, but rather which vari- are prominent in the development
there does seem to be an increas- ables are the central ones. Theoreti- of disability due to musculoskeletal
ingly compelling case for early inter- cal models have been helpful in guid- pain. Tomorrow’s challenge is to
ventions targeting yellow flags spe- ing this research, but none fully build upon this base to provide
Table 2.
Yellow Flags as Prognostic Factors for Persistent Pain and Pain-Associated Disabilitya
Linton,16 2000 Critical review of 37 prospective 29 studies pertained to prior This review also looked at the Emotional, behavioral, and
investigations (11 prior to to onset of pain to risk factors in relation to cognitive variables are
onset of back or neck pain, subacute pain the setting and time point related to the transition
18 of patients with acute or Psychological variables were and found good generality from acute to chronic pain
subacute pain, 8 of patients related to pain onset, Support
with chronic pain); 29 studies particularly to the
included here (not chronic transition from acute pain
pain) to subacute or chronic
pain
Emotional variables (eg,
Crook et al,18 2002 Systematic search and Psychological distress, self- A rigorous review, with clear Found distress, dysfunction,
methodological evaluation perceived dysfunction, and criteria for inclusion and of and pain to be risk factors
Included 19 prospective studies pain were risk factors for the factors Support
of people within 6 mo of future sick absenteeism
injury
Pincus et al,19 2002 Systematic review of 25 Moderate effect (depression Selected studies based on Distress (moderate effect)
prospective articles on or distress) and small effect prospective design and and somatization
patients with acute or (somatization) on future acute or subacute pain, (small effect)
subacute pain pain and disability estimates size of the effect Partial support
problems
Bair et al,22 2003 Narrative review of 10 clinical Depression was found to be A very exhaustive review Depression is a very
trials examining the related to the onset of focusing on depression important, but often
relationship between back pain, higher levels of and pain overlooked, aspect
depression and back pain pain intensity reports, Support
more dysfunction, poorer
treatment outcome, and
chronicity
(Continued)
Table 2.
Continued
Sullivan et al,21 2005 Selective review of 8 studies Pain-related fears, self- A selective review of worker- Worker-related psychological
with psychological variables perceived health, pain related psychosocial risk variables increase risk for
catastrophizing, poor factors for work disability future work disability
problem-solving skills, and Selection of studies may lead Support
expectations concerning to bias in conclusions
recovery were found to be Emphasizes the need to
related to future work integrate workplace risk
disability factors
Steenstra et al,24 Systematic review of 7 studies Self-perceived function Included only 7 studies Function, pain, and
2005 with psychological variables (ES⫽2.4), pain intensity Strict inclusion criteria of only depression found to have
Leeuw et al,25 2007 Narrative, critical review of Fear-avoidance beliefs, Extended review that places There is mounting evidence
studies of relevance to the catastrophizing, avoidance studies in relation to the to support the main
“fear-avoidance” model behavior, and pain fear-avoidance model features of the fear-
intensity were found to be Discusses dysfunction as avoidance model
important for future pain, avoidance behavior Support
disability, and performance
Mallen et al,26 2007 Systematic review of 45 studies 11 factors at baseline found An exhaustive review, with 11 factors, including yellow
of prognostic factors in to be associated with poor special relevance for flags, may be generic
primary care outcome: pain severity, primary care services prognostic indicators
pain duration, multiple Support
pain sites, previous pain,
anxiety or depression,
distress, coping strategies,
social support, age,
dysfunction, and
movement restriction
Melloh et al,27 2009 Systematic review of screening Work status best predicted Review focuses on actual Psychological and
instruments published by fear-avoidance beliefs screening instruments and occupational variables are
between 1970 and 2007 about work and perceived thus is a relevant test of good predictors and
predicting work status, chance of being able to the yellow flags’ utility to should be included in
function, and pain work; occupational factors predict early identification
Extracted variables from studies also important screening
to determine what predicts Functional limitations best Depression and function
outcome predicted by sleep and fear predict all 3 outcomes,
13 studies included avoidance whereas fear, sleep, and
Pain best predicted by expectations about
intensity, duration, and outcome were more
coping specific
Depression and function Support
are predictive of all 3
outcomes
a
LBP⫽low back pain, SLR⫽straight leg raise, ES⫽effect size.
Table 3.
Early Intervention Randomized Controlled Studies (2000 –2008) in Patients Seeking Help for Musculoskeletal (Mainly Spinal) Paina
Linton and 243 patients with subacute Six 2-hr group CBT 2 levels of information All groups improved Sample of patients with
Andersson,43 LBP (mainly) (still sessions with on back care, on pain, disability, mixed pain durations,
2000 working but missing psychologist physical therapy and mood, with but all working and
days); self-perceived risk significantly less lost missing days due
of developing chronic work time over to pain. Results
problem (RCT) 12 mo. consistent with role of
skills in managing work
despite pain vs
information alone. Pain
Hagen et al,65 457 patients sick-listed 8 At spine clinic, 1 session Usual care by GP At 12-mo follow-up, Results similar to those of
2000 to 12 wk for LBP (RCT) with advice on 68.4% in previous studies of this
good prognosis and intervention group vs type, but raise the
importance of 56.4% in control question of whether
remaining active to group had full RTW. more-extensive
avoid development of intervention might have
muscle dysfunction. achieved better results
Walking encouraged, for those not RTW at
advice on exercising 12-mo follow-up.
at home. Advice on Consistent with yellow
how to manage the flag hypothesis.
back pain and how to
resume normal
activities.
Verbeek et al,56 Patients with LBP on sick Occupational physician Reference group: At 3- and 12-mo Many similarities in
2002 leave for at least 10 d (based on guidelines, no review with follow-ups, no content of control and
(RCT) biopsychosocial occupational difference between treatment groups. Low
assessment, physician in first groups on work time distress in both groups.
intervention in 3 mo, but lost and health Not really testing
identified RTW treatment as outcomes (both yellow flag hypothesis.
obstacles, usual by GP, improved), but
encouragement to physical therapist, recurrences more
remain active); other or specialist. frequent in
treatments via GP or Workplace intervention group.
physical therapist on supervisor given
case basis. Workplace same management
supervisor also advice as
advised on intervention group.
management.
Loisel et al,44 104 workers absent from Comprehensive 3 groups (clinical At 6.4-yr follow-up, Including workplace
2002 work ⬎4 wk due to Sherbrooke model intervention, all interventions in intervention (in
work-related LBP (combined usual care, and achieved gains, but addition to clinical
(mean⫽38–43 days occupational and occupational intervention group input) seems important
across 4 groups) (RCT) clinical interventions) intervention) had fewer days on for retention at work,
benefits and more consistent with other
cost beneficial. findings and
importance of blue
flags. Also addressed
problems at individual
level regarding RTW.
Consistent with yellow
flag hypothesis.
van den Hout 84 employees, recently on Graded activities with Graded activities ⫹ Intervention was Mixed group of patients
et al,45 2003 sick leave due to behavioral principles education associated with with acute and chronic
nonspecific LBP; mean ⫹ problem-solving better long-term pain, but all had been
sick leave⫽8 wk, but training work status. working despite pain
mean pain duration of until mean of 8 wk
current episode⫽1.5 y before treatment.
(RCT) Consistent with yellow
flag hypothesis.
(Continued)
Table 3.
Continued
Damush et al,58 211 patients with acute Brief (3-session) group Usual care At 12 mo, intervention Brief intervention may have
2003 LBP (⬍90 d); excluded program, with group significantly been enhanced by lack of
any receiving disability telephone follow-up, better on the Roland- patients involved in
insurance payments aimed at increased Morris Disability disability insurance, but
or in the process of function, health status Questionnaire, results consistent with
applying for back pain mental functioning, yellow flag hypothesis.
disability (RCT) self-efficacy to
manage acute LBP,
time spent in
Karjalainen et 164 workers with subacute 2 interventions: (1) brief Usual health care by At 2-yr follow-up, no Usual health care may be
al,59 2004 LBP of ⬎4 wk and “back school” (2.5– GP (ie, did not differences between different from others of
⬍3 mo duration (mean 3 hr) (exercise, advice, attend special groups on pain, same name, especially in
days on sick leave in discussion about pain, occupational health disability, and Netherlands, but both
previous 3 mo⫽14.7– encouragement for center in contrast quality-of-life intervention groups were
15.8) (RCT) RTW, being active to other 2 groups) measures. Costs of given very brief treatment,
despite pain, body ⫹ leaflet of LBP treatment lower which may explain why
mechanics; conducted information about in both intervention there were no differences in
by occupational LBP groups vs usual care disability and quality-of-life
physician and group; days absent measures. More-extensive
physical therapist) from work fewer in interventions might have
and (2) same as above, both intervention been more effective.
plus worksite visit and groups vs usual care Information insufficient for
advice by physical group. retention at work. Although
therapist patients not selected for
high psychosocial risk
factors, results broadly
consistent with yellow flag
hypothesis.
(Continued)
Table 3.
Continued
Schiltenwolf 64 patients with a first- BT group: received same MT group: received Both groups improved The addition of behavioral
et al,47 2006 time sick leave of 3– functional restoration same functional posttreatment, but at therapy for dealing with
12 wk due to LBP (RCT) program as the control restoration program 6 mo, the BT group stress and problems
group, but included a of individual improved on multiple generally seems to have
behavioral therapy physical therapy, parameters relative to added significantly to
component (problem group therapy in the MT group, which the exercise/activity
solving, stress water, workout, deteriorated. At 2 y, no program. Results
management, and back school with sick leave by 59% in BT consistent with yellow
partner involvement, stretching and group vs 10% in MT flag hypothesis.
Hay et al,52 402 patients seen by their Brief individualized pain Brief (median⫽4 Both groups improved; Average baseline
2005 GP for LBP of ⬍12 wk management program sessions) standard similar outcomes on catastrophizing and
duration (RCT) (median⫽3 sessions) by physical therapy Roland-Morris Disability depression low in both
physical therapists (basic including manual Questionnaire at 3 and groups, which may
cognitive behavioral techniques 12 mo; no significant mean that CBT unlikely
techniques over a course differences for pain, to confer advantage
of 2 d with follow-up time off work, or over standard care. Not
study days and psychological really testing the yellow
mentoring) measures. flag hypothesis.
(Continued)
Table 3.
Continued
Anema et al,57 196 workers sick-listed 2 to Workplace intervention: (1) Graded activity: Time to RTW significantly Different results for
2007 6 wk due to nonspecific workplace assess- biweekly 1-hour less for workplace graded activity in this
LBP (RCT) ment, work modifi- exercise sessions intervention. Graded study relative to others
cations, and case based on operant- activity had negative may be related to
management conditioning effect on RTW and nature and extent of
involving all principles functional status. this intervention here,
stakeholders. Those (2) Usual care Combined intervention which may not have
still sick-listed at 8 wk had no effect. addressed yellow flags.
randomly assigned to Compare with Staal
Pengel et al,61 259 patients with subacute Factorial design study, Placebo/attention All groups improved over As patients not selected
2007 LBP treated in physical with advice control, with treatment period and for presence of
therapy clinics. All (education, goal discussion and all maintained gains at psychosocial risk factors
patients recruited setting, activity interest from 1-y follow-up. The and the levels of these
⬍12 wk since onset, but upgrading, physical therapist combined advice and factors were generally
not selected on basis of reinforcement for (no advice), plus exercise treatment low, this study
psychosocial risk factors. attempts) compared sessions of detuned was slightly more provided only limited
with exercises and a short-wave and effective than either support for the yellow
combination of ultrasound intervention individually flag hypothesis.
advice and exercise treatments. Patients and the placebo/
asked not to have attention control on
other back measures of pain and
treatments during functional activities at
6-wk treatment 1-y follow-up.
phase of study.
George et al,51 108 patients attending 3 All 3 groups received Standard physical All 3 groups improved; As in the 2003 study
2008 physical therapy clinics; same standard therapy (TBC no differences at 4-wk George et al,50 patients
patients divided into 3 physical therapy protocols), as and 6-mo follow-ups not selected on basis
treatment conditions; described by George described by on disability, pain, pain of psychosocial risk
across conditions, mean et al.50 In addition, George et al.50 catastrophizing, and factors, and inter-
number of weeks of 1 group was given physical impairment. ventions in TBC had
present episode of graded activity, and Fear-avoidance beliefs many elements in
LBP⫽5.8–9.8, 50%–69% 1 group was given reduced in TBC and common with graded
had prior history of LBP, graded exposure graded exposure activity and graded
and 70%–74% (performance of groups, relative to exposure, so the
employed (RCT) feared activities under graded activity group, additional elements
supervision). only at 6 mo. may not have been
No benefit to TBC by different enough.
adding graded activity
or graded exposure.
a
CT⫽clinical trial, RCT⫽randomized controlled trial, CBT⫽cognitive-behavioral treatment, RTW⫽return to work, GP⫽general practitioner, TBC⫽treatment-
based classification protocols, BT⫽behavior therapy, MT⫽biomedical therapy.
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