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Dynamic Chiropractic – November 30, 2002, Vol. 20, Issue 25

What to Do about "Yellow Flags"

By Craig Liebenson, DC
On May 1-3, 2003, the World Federation of Chiropractic's 7th Biennial Congress will host a preeminent European leader in musculoskeletal medicine, Professor Stephen Linton. He is an expert in psychosocial aspects of back and neck pain patients, and has pioneered the identification of risk factors of chronicity and preemptive reactivation treatments with a cognitive-behavioral emphasis. This article will summarize the impact of psychosocial factors on prediction of patient prognosis, and how patients with such factors can be appropriately managed.

Epidemiologic Data Shows LBP Is More Chronic than Previously Believed
  • Did you know that 12 months after initial consultation for LBP the majority of patients have not recovered?
  • Even though patients have stopped seeking care, this does not mean they are asymptomatic or fully functional.
  • It is better to advise patients that LBP tends to recur, rather than build up expectations that it can be "fixed" or cured. Reassurance about the safety of reactivation and warnings about the dangers of deconditioning are recommended.

Source: Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ 1998;316:1356-1359.

What Are "Yellow Flags?"

"Yellow flags" are risk factors associated with chronic pain or disability.1-6,9,20,21 They are subjective and have a significant psychosocial predominance. Examples include negative coping strategies, poor self-efficacy beliefs, fear-avoidance behavior, and distress. Whereas "red flags" require urgent attention, further testing and possibly specialist referral, "yellow flags" only require a shift in the focus of care. Psychological screening via history taking has low sensitivity and predictive value for identifying distressed patients, thus formal screening of some sort, such as with a questionnaire, is recommended.7

According to Pinchus, et al.,8 the risk of developing long-term LBP, related activity limitations (disability), and work loss arises from four main sources that interact with each other: the individual; treatment provider; compensation or health care system; and workplace or home environment.

Nonpsychological patient factors predictive of a slow recovery include duration of disability, heavy job demands, past history of frequent recurrences, and sciatica.1,2,6,8,12,13 What treatment provider factors suggest a slower recovery? Thorough physical and functional examination not performed; report of findings not given; emphasis on medication and passive care; emphasis on pathology, disease, injury and the importance of "high-tech" testing; promotion that hurt equals harm; and the recommendation of bed rest, instead of promotion of activity modification and gradual exercise.14

Reis, et al., evaluated both the patients' and clinicians' perceptions of worry; coping; limitations; expectations of pain relief; and pain interference.15 When evaluated individually, both patients' and clinicians' perceptions were found to predict outcome at two, four, eight and 12 months.

What to Do about "Yellow Flags"

A patient with a high "yellow flags" score is either experiencing abnormal illness behavior or is at risk for it. Diagnosis should be oriented toward avoiding "labeling" the patient with an injured back (i.e., ruptured disc) or degenerative condition, since coincidental structural pathology is so common.16 Treatment should reduce dependency on medication and other passive forms of treatment (including manipulation) and encourage the development of self-treatment skills. Surgical success rates in otherwise properly selected individuals are much lower in the presence of "yellow flags." In certain cases, specialist referral for behavioral medicine counseling regarding affective and cognitive issues is required. It is important to realize that "yellow flags" are not patients' fault, but they suggest that management strategies need to be altered to maximize the likelihood of recovery.

Ciccione and Just10 showed that in susceptible individuals, there is discordance between pain expectancies and pain intensity with activity. However, these are unknown to the patients. To decrease fear-avoidance behavior, patients should be gradually and incrementally exposed to perceived painful activities. The clinician should guide and teach patients that their expectations are not accurate. In particular, reducing anxiety and pain expectations associated with the specific movements that the patient is most afraid of should become the goal of care.11 As part of this process, operant-conditioning therapy involves "graded exposures" to a progressively greater duration, intensity and frequency of exercise. This is often referred to as "exercise administered and progressed by quota."17-19


image - Copyright – Stock Photo / Register Mark


Patient education should focus on the fact that normal activities can be resumed (such as walking, swimming, biking) safely while informing the patient about simple activity modifications to reduce biomechanical strain (i.e., hip hinge, cats, abdominal bracing). Patients should be advised to stay as active as possible; to gradually increase their physical activities; that it is safe to do so as long as the pain is not peripheralizing; and that hurt does not necessarily equal harm, but is just a sign they are mobilizing stiff areas.

Indahl's Long-Term Follow-Up Work Shows that Reassurance and Reactivation Are Key to Recovery!

  • Being too careful was emphasized as the worst form of self-treatment.
  • Patients were instructed to take regular, brisk walks.
  • Remaining in one rest position, lying, sitting or standing, was discouraged.
  • Light stretching was recommended for acute "flare-ups" rather than rest.
  • Patients were informed that anticipation of pain can increase muscle tension and perpetuate the pain.

Source: Indahl A, Haldorsen EH, Holm S, Reikeras O, Hursin H. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 1998;23:2625-2630.

Such behavorial approaches utilize an educational discussion about recovery goals and the means to reach them. This can encompass McKenzie's centralization principles, stabilization's "neutral" postural awareness concepts, and an appreciation that hurt does not necessarily equal harm. A problem-solving approach can be utilized by teaching patients how to take an active role, reduce modifiable risk factors, and avoid impulsively seeking mainly symptomatic relief (Shaw, et al., 2001).


  1. Hazard RG, Haugh LD, Reid S, Preble JB, MacDonald L. Early prediction of chronic disability after occupational low back injury. Spine 1996;21:945-951.
  2. Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients' own criteria. Spine 1996;21:2900-2907.
  3. Linton SJ, Hallden BH. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain 1998:14;1-7.
  4. Linton SJ, Hallden K. Risk factors and the natural course of acute and recurrent musculoskeletal pain: Developing a screening instrument. Proceedings of the 8th World Congress on Pain, Progress in Pain Research and Management, Vol 8, ed. Jensen TS, Turner JA, Wiesenfeld-Hallin Z, IASP Press, Seattle, 1997.
  5. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long-term disabilty and work loss. Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee 1997. Wellington, NZ. Available from
  6. Burton AK, Tillotson K, Main C, Hollis M. Psychosocial predictors of outcome in acute and sub-acute low back trouble. Spine 1995;20:722-8.
  7. Grevitt M, Pande K, O'dowd J, Webb J. Do first impressions count? A comparison of subjective and psychologic assessment of spinal patients. Eur Spine J 1998;7:218-223.
  8. Pincus T, Burton A, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109-120.
  9. Fransen M, Woodward M, Norton R, Coggan C, Dawe M, Sheridan N. Risk factors associated with the transition from acute to chronic occupational back pain. Spine 2002;27:92-98.
  10. Ciccione DS, Just N. Pain expectancy and work disability in patients with acute and chronic pain: A test of the fear avoidance hypothesis. Journal of Pain 2001;2:181-194.
  11. Van den Hout JHC, Vlaeyen JWS, Houben RMA, Soeters APM, Peters ML. The effects of failure feedback and pain-related fear on pain report, pain tolerance, and pain avoidance in chronic low back pain patients. Pain 2001;92:247-257.
  12. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000;25:1148-1156.
  13. Liebenson CS, Yeomans SG. Yellow flags: Early identification of risk factors of chronicity in acute patients. J Rehabil Outcomes Meas 2000;4(2):31-40.
  14. Linton SJ. The socioeconomic impact of chronic back pain: is anyone benefiting? Editorial. Pain 1998;75:163-168.
  15. Reis S, Hermoni D, Borkan J, et al. The RAMBAM-Israeli Sentinel Practice Network. The LBP Patient Perception Scale. A new predictor of chronicity and other episode outcomes among primary care patients. (In preparation).
  16. Bogduk N. What's in a name? The labeling of back pain. Medical Journal of Australia 2000;173:400-1.
  17. Fordyce WE. Lansky D, Calshyn DA, Shelton JL, Stolov WC, Rock DL. Pain measurement and pain behavior. Pain 1984;18:53-69.
  18. Frost H, Klaber Moffett JA, Moser JS, Faribank JCT. Randomized controlled trial for evaluation of fitness programme for patients with chronic low back pain. British Medical Journal 1995;310:151-154.
  19. Lindstrom A, Ohlund C, Eek C, et al. Activation of subacute low back patients. Physical Therapy 1992;4:279-293.
  20. Linton SJ, Buer N, Vlaeyen J, & Hellsing AL. Are fear-avoidance beliefs related to a new episode of back pain? A prospective study. Psychology and Health 2000;14:1051-1059.
  21. Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MIV, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. BMJ 1999;318:1662-7.

Craig Liebenson,DC
Los Angeles, California

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