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Yellow Flags and Secondary Prevention. Michael E. Geisser, Ph.D. University of Michigan. Annual costs of low back disability in the United States have been estimated to be approximately $50 billion

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Yellow flags and secondary prevention l.jpg

Yellow Flags and Secondary Prevention

Michael E. Geisser, Ph.D.

University of Michigan


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Annual costs of low back disability in the United States have been estimated to be approximately $50 billion

Back pain is the second leading cause of work absenteeism and leads to greatest productivity loss of any disease

Single case of work-related back pain exceeds $8000

Estimated that 70-80% of the costs for work-related low back claims are accounted for by 5-10% of patients who develop chronic low back pain (CLBP; pain lasting 3 or more months)

Significance-The Costs of Back Pain


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Time out of work is a significant predictor of long-term outcome

Return-to-work within the first six months is predictive of good long-term outcomes

Likelihood of returning to work after being out a year or more is small

Key to recovery is treatment within the first 6-12 months

Functional Recovery After an Acute Musculoskeletal Injury



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Types of prevention outcome

Primary – target a population at large

Secondary – target at-risk population

Tertiary – target diseased population to reduce disease progression, morbidity/mortality, costs

Prevention of Chronic Pain


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Buchbinder et al. (2001) conducted media campaign in Australia (state of Victoria) encouraging persons with back pain to stay active and exercise (based on the Back Book)

Conducted phone surveys and sent physicians two scenarios regarding the treatment of low back pain

Compared responses to persons/physicians in an adjacent state (New South Wales)

Primary Prevention


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Excerpt from information booklet Australia (state of Victoria) encouraging persons with back pain to stay active and exercise (based on the The Back Book *

It's your back

Backache is not a serious disease and it should not cripple you unless you let it. We have tried to show you the best way to deal with it. The important thing now is for you to get on with your life. How your backache affects you depends on how you react to the pain and what you do about it yourself.

There is no instant answer. You will have your ups and downs for a while—that is normal. But look at it this way

There are two types of sufferer

One who avoids activity, and one who copes

* The avoider gets frightened by the pain and worries about the future

* The avoider is afraid that hurting always means further damage—it doesn't

* The avoider rests a lot and waits for the pain to get better

* The coper knows that the pain will get better and does not fear the future

* The coper carries on as normally as possible

* The coper deals with the pain by being positive, staying active, or staying at work

Back Book (Burton et al., 1999)


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Measures obtained from 4730 individuals and 2556 general practitioners

Decrease in fear-avoidance beliefs in Victoria over time, but not in New South Wales

Significant improvement in back pain management among physicians in Victoria (decrease in ordering tests, prescribing bed rest)

15% decrease in absolute number of back claims, reduction of 20% of costs for a back claim

Buchbinder et al., 2001 (Continued)


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Health Scotland-Working Backs Scotland practitioners

Public education campaign initiated in October of 2002.

Consists of ads, seminars, and website information (http://www.workingbacksscotland.com)

Preliminary data suggests 60% penetration and a 20% shift in public beliefs about back pain

Primary Prevention


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Costly practitioners

Targets many in the population who may not have acute pain (although lifetime prevalence of disabling back pain is 80%)

Difficulties with Primary Prevention


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95% of persons with acute back pain improve within 12 weeks practitioners

However, research suggests that a number of factors prospectively predict the development of chronic pain among persons with acute pain

These factors are often termed “yellow flags”

For musculoskeletal pain conditions such as back pain, most of these factors are psychosocial

Is Secondary Prevention of Pain Feasible?


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Catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury.

What Are the Risk Factors for Chronic Pain?


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Bigos et al. (1992) examined 3020 employees of Boeing fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of fault over injury.

279 persons filed a back injury claim

The only physical variable that was associated with filing a back claim was a history of prior medical treatment for back pain

Work satisfaction and scores on scale 3 of the MMPI were the best predictors of filing a claim

Risk Factors for Filing Back Claim


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Burton et al. (1995) examined factors associated with the development of chronic back pain in a primary care setting

252 subjects with acute back pain were assessed again at 1 year

Pain catastrophizing alone accounted for 47% of the variance in the development of chronic low back pain

Psychological distress and prior history of back pain were also significantly related to the development of chronic pain

Risk Factors for Chronic Pain


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Klenerman et al. studied 300 acute low back pain patients. development of chronic back pain in a primary care setting

A measure of fear-avoidance of pain alone correctly classified 66% of subjects who developed chronic low back pain at 12 months.

A combination of physiological and psychological data correctly classified 88% of patients.

Risk Factors for Chronic Pain


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Model of Chronic Pain Disability development of chronic back pain in a primary care setting(Vlaeyen et al., 1995)


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Factors are multiple, may vary across persons development of chronic back pain in a primary care setting

While we know the factors related to chronicity, what “score” or cut-off should be used in a clinical assessment?

Schemes used to classify subjects may be sample dependent, unstable

While relationships exist, can risk factors be used prospectively to predict chronicity with a high degree of accuracy?

Potential Difficulties with Risk Assessment


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Main et al. (1995) recommend evaluating: development of chronic back pain in a primary care setting

General level of distress

Beliefs and fears about pain and rehabilitation

Pain coping strategies

Fear of physical activity

Socioeconomic implications of continued incapacity

Perception of safety

Job satisfaction

Risk Assessment – Clinical Evaluation


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Hazard et al. (1996) utilized an 11-item questionnaire to predict chronicity

Items assess current pain intensity, blame for pain problem, prediction of ability to work in the future, physical demands of job

Utilizing a cut-off score of .48, the measure had .94 sensitivity and .84 specificity

Findings have not been replicated

Risk Assessment


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Hallner and Hasenbring (2004) developed a computer-based statistical model that utilizes yellow flags to determine chronicity in persons with low back pain

Yellow flags used were psychological distress and the use of certain pain coping strategies

Overall accuracy of model was 83.1%, with 73% sensitivity and 97% specificity

Risk Assessment


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Linton and Boersma (2003) published data on the statistical model that utilizes yellow flags to determine chronicity in persons with low back painÖrebro Screening Questionnaire

Twenty-five item questionnaire assesses factors such as work demands, pain intensity, distress, fear-avoidance beliefs, sleep disturbance

A cut-off of 90 had 89% sensitivity (65% specificity) for predicting work absenteeism, and 74% sensitivity (79% specificity) for functional recovery

Subsequent study found overall accuracy for predicting return to work to be between 88%-96% (Dunstan et al, in press) for low back and other types of musculoskeletal pain

Risk Assessment


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How Can the Risk be Reduced (Secondary Prevention)? statistical model that utilizes yellow flags to determine chronicity in persons with low back pain


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Indahl et al (1995) assigned subjects with back injuries who were off work greater than 8 weeks to conventional treatment (n = 5 12) or light normal activity (n = 463)

200 days after the intervention, 60% in the control group were still on sick leave, compared to 30% in the intervention group

Low back pain treated as a benign, self-limiting condition recommended to light mobilization gives superior results as compared to conventional medical treatment

Secondary Prevention


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George et al. (2003) examined effectiveness of fear-avoidance based physical therapy among subjects with acute back pain (< 8 weeks)

Intervention based on education (Back Book) and graded exercise

Subjects with elevated fear-avoidance beliefs at baseline had greater improvements with intervention as opposed to standard care

Secondary Prevention


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Sullivan and Standish (2003) tested a cognitive-behavioral intervention for injured workers at risk for developing chronic back pain

Subjects had to be off work for 6 weeks and have at least one yellow flag

10-week intervention designed to increase subject involvement in goal directed activity and decrease psychological barriers to activity

104 subjects completed treatment

45% returned to work, and 15% were ready to return to work (contacted employer) following treatment

Study not randomized or controlled

Secondary Prevention


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Educate patient about the nature of pain (e.g., hurt versus harm)

Light, normal activity is OK

Avoid unnecessary investigation

Pay attention to the psychological aspects of symptom presentation (affect, beliefs)

Advise patients on preventing recurrence (e.g., lifting sensible loads)

Consider referral for multidisciplinary evaluation if patient exhibits yellow flags or doesn’t improve

Early intervention is important

Summary of Secondary Prevention Strategies


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How you interact with the acute pain patient can significantly impact outcomes and adjustment to pain

The interaction helps to shape patient beliefs about their pain, which in significantly impacts their experience of pain

The Importance of the Provider


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Physician education regarding the etiology of pain is related to increased patient satisfaction (Deyo & Diehl, 1986; Cherkin & MacCormick, 1989).

Lacroix et al. (1990) found that accuracy of patients understanding of the basis of their pain significantly predicted return to work while injury severity, “nonorganic” signs, and MMPI scores were unrelated.

Educate the Patient About Their Pain!


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Geisser & Roth (1997) examined agreement between physician and patient beliefs about the cause of their pain.

Controlling for pain duration and intensity, patients whose diagnostic impression agreed with the physician were less distressed, less disabled, and had fewer maladaptive pain beliefs and coping strategies compared to patients who were unsure about their diagnosis or who disagreed with the physician.

Pain Beliefs and the Experience of Pain


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Underlying mechanisms may not be known or obvious and patient beliefs about the cause of their pain.

Musculoskeletal diagnoses are subjective and sometimes unreliable

May simply be enough to dispel significant pathology

Difficulties “Diagnosing” Causes of Pain


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