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Dynamic Chiropractic – June 29, 1998, Vol. 16, Issue 14

Yellow Flags: Early Identification of Risk Factors of Chronicity in Acute Patients

By Craig Liebenson, DC
Recovery Rate for LBP

It is commonly stated that most disabled workers return to work within one month.1 Reid et al. concluded that there is a 95 percent return to work within 6-12 weeks.2 These statistics have led to the mistaken belief that most acute back pain patients recover quickly and therefore require minimal treatment.

Recovery depends on outcomes besides just return to work. For instance, persistent symptoms or activity intolerances have both been demonstrated to remain present in a substantial number of patients even one year after the onset of an acute low back pain episode. Data from Cherkin et al. (219 patients presenting to a primary care clinic) showed that only 46 percent were symptom-free after seven weeks, and 29 percent had poor outcomes after one year.3 Van Korff found 15-20 percent show moderate to severe activity limitations one year after the initial back pain episode has resolved.4

The Effectiveness of Different Treatment Interventions on the Recovery Rate

Economic evaluations show that an increase in secondary prevention treatment costs would result in decreased health care costs due to surgery and disability. Goosens and Evers reviewed 23 studies that conducted an economic analysis.5 They concluded that, "... post-incidence management programs appear to produce cost savings due to reduced absenteeism (p. 15)."

The real question is, at what time does the intervention take place? Is it at one week, seven weeks, three months, or later? Do we wait for behavioral aspects of chronicity to be fully formed, or can we predict who will become chronic and take a more aggressive preventive approach? Early ID of those "destined for chronic disability" would allow stratification of patients into two groups: one requiring less intensive care; the other, more intensive care.

The acute low-back pain guidelines by the AHCPR suggest diagnostic triage, reassurance, activity modification advice and pain relief modalities (medication, manipulation) be utilized for management of the acute pain patient.6

A recent evidence-based consensus document from New Zealand suggests at the earliest time both red flags of serious disease and yellow flags of chronicity should be looked for.7

Yellow Flags The following is a list of yellow flag risk factors of a prolonged recovery that have been prospectively identified.

  • history of numerous episodes;8,9

  • duration of symptoms before the first visit of greater than one week;10

  • duration of symptoms;10,11

  • severe pain intensity (>70% on a VAS);8,9

  • anxiety (e.g., tense, uptight, irritable, fearful, difficulty in concentrating/relaxing);

  • locus of control (e.g., ability to control (i.e., reduce/help) your pain);12

  • depression (e.g., down in the dumps, pessimistic, feelings of hopelessness);3

  • catastrophizing;1,2

  • job dissatisfaction;3

  • sciatica;3,9,12

  • anticipation of trouble sitting or standing at work six weeks into the future;8

  • activity intolerances.8

A simple-to-administer questionnaire screens for these yellow flags.7,13 In the next issue, I will discuss the questionnaire. How to implement this in your practice is taught in the LACC postgraduate rehabilitation program by Dr. Steven Yeomans.14 Software programs are also available to help identify such risk factors automatically.15

Once yellow flags have been identified, treatment strategies incorporating reassurance, activity modification advice, remobilization and reactivation, and behavioral modification have shown to be the most successful. Recent studies have shown that simple advice to continue or resume normal activities is therapeutic for acute low-back pain.

A meta-analysis review conducted by experts working with RAND indicated that spinal manipulation is most effective between the second and fourth weeks, imparting a 30 percent improvement in rate of recovery over traditional treatments.16 The results are short-term, but it increases patient satisfaction and can be utilized to reduce yellow flags such as anxiety and severe acute pain and facilitate reactivation.17

Many argue that it is best to wait until the subacute stage to treat since many patients will have resolved spontaneously.18 Chiropractic treatment with manipulation of patients with pain over seven weeks has demonstrated that it is more effective than traditional treatments. Lindstrom demonstrated that rehabilitation given to those off work for six weeks was more effective than a traditional treatment group.19

Rehabilitation programs focusing on low-tech but specific exercise programs have been shown to be effective for chronic groups. There is evidence to suggest that more challenging patients should be treated with a multidimensional approach, incorporating behavioral components. Treatment of the chronic, disabled patient with multidisciplinary functional restoration has demonstrated its cost-effectiveness.


  1. Spitzer WO, et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders. Spine 1995;20:8S, 1S-73S.
  2. Reid S, Haugh LD, Hazard RG, Tripathi M. Occupational low back pain: recovery curves and factors associated with disability. J Occup Rehab 1997;7:1-14.
  3. 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.
  4. Von Korff M, Saunders K. The course of back pain in primary care. Spine 1996;21:2833-2839.
  5. Goosens MEJB, Evers SMAA. Economic evaluation of back pain interventions. J Occup Rehab 1997;7:15-32.
  6. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994.
  7. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee. Wellington, New Zealand. Available at
  8. 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.
  9. Frank JW, Kerr MS, Brooker AS, DeMaio SE, Maetzel A, et al. Disability resulting from occupational low back pain, part 2: what do we now about secondary prevention? Spine 1996;21:2918-2929.
  10. van den Hoogen HJM, Koes BW, Deville W, van Eijk JTM, Bouter LM. The prognosis of low back pain in general practice. Spine 1997;22:1515-1521.
  11. Von Korff M, Deyo RA, Cherkin D, Barlow W. Back pain in primary care: outcomes at one year. Spine 1993;18:855-62.
  12. Burton AK, Tillotson K, Main C, Hollis M. Psychosocial predictors of outcome in acute and subacute low back trouble. Spine 1995;20:722-8.
  13. Liebenson CS, Yeomans S. Early identification of risk factors of chronicity. In: Yeomans S. Clinical Application of Outcomes Assessment. Appleton & Lange, sched. publication 1999.
  14. Yeomans S. Outcomes assessment. LACC first 100-hour rehabilitation course. LACC postgraduate division, (562) 902-3379.
  15. Synergy Solutions, (800) 950-8133 or (218) 326-0437.
  16. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low-back pain. Ann Intern Med 1992;117:590-8.
  17. Cherkin DC, MacCornack. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989;51:355.
  18. Triano J, McGregor M, et al. Manipulative therapy vs. education programs in chronic low back pain. Spine 1995;20:948-954.
  19. Lindstrom A, Ohlund C, Eck C, et al. Activation of subacute low back patients. Physical Therapy 1992;4:279-293.

Craig Liebenson, DC
Los Angeles, California

Click here for previous articles by Craig Liebenson, DC.

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