The incidence of serious underlying illnesses or conditions occurring with musculoskeletal conditions such as neck pain or low back pain is low. However, it is vital to screen out these patients so they get appropriate medical diagnosis and treatment. Red Flag questions have been developed to identify these patients and ensure that during the examination and the taking the history these considerations are not omitted. The huge rise in disability and costs from low back pain work absence has pinpointed the necessity of identifying the risk factors and formulating treatment strategies.
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.
Sickness Behaviours: When confronted with pain and loss of ability some people adopt a disabled or sick role, choosing to rest for extended periods of time after an injury rather than attempting to go back towards normal. This increases the likelihood of the development of 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.
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