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Screening of Psychosocial Risk Factors (Yellow Flags) for Chronic Back Pain and Disability 

Screening of Psychosocial Risk Factors (Yellow Flags) for Chronic Back Pain and Disability
Screening of Psychosocial Risk Factors (Yellow Flags) for Chronic Back Pain and Disability

Chris J. Main

, Nicholas A.S. Kendall

, and Monika I. Hasenbring

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date: 16 May 2022

There is a wide range of pain conditions in which there is evidence of significant dysfunction but little or no evidence of disease or nerve damage. The impact of non-specific pain conditions on suffering is considerable, as is the cost in terms of healthcare provision and work compromise. When a clearly identifiable ‘pain generator’ is not apparent, as is often the case, then promise of a complete cure seems improbable. What then can be done? Two major strategies have emerged:

Prevention of chronic pain becoming unnecessarily disabling.

Prevention of the development of chronic pain/disability in patients with acute/subacute pain.

Health and safety legislation has improved the safety of the workplace but population surveys and consultation rates still indicate a high prevalence of back pain in the community. Differences in methodology have made it difficult to compare directly the results from different studies, e.g. differing criteria for the identification of ‘new episodes’ lead to different estimates. Waddell (2004) in a further analysis of the data from the South Manchester population study (Thomas et al. 1999), found that 38% had had back pain in the previous year and of those who had been pain-free, 19% reported new episodes in the following year. Furthermore, of the 32% of those who had had intermittent or less disabling pain in the previous year, almost half would have further episodes during the following year and of the 6% with longstanding or seriously disabling back pain, one-third would improve to some extent. There is thus a significant minority of people experiencing pain who go on to develop persistent pain, and may develop long-lasting disability, in terms of reduced participation in usual activity and work, and the concomitant psychological impact on their mood, self-confidence, and personal identity (Pincus and Morley 2001). The goal of completely preventing the onset of all musculoskeletal pain is simply not achievable and attempts to clinically alleviate pain, or reduce its severity are often less effective than hoped. However, reducing the impact of pain by preventing it becoming unnecessary disabling and enhancing the back sufferer's quality of life, do appear to be worthwhile endeavours.

There is some evidence for the effectiveness of intervention strategies for people with chronic musculoskeletal pain problems, and the potential for secondary prevention, has now been recognized for more than a decade (Linton and Anderson 2000). In fact clear guidelines have been developed for the management of acute non-specific low back pain (LBP; Box 11.1).

Although psychosocial factors seem to be stronger predictors of outcome than biomedical/biomechanical factors (Burton et al. 1999; Crombez et al. 1999), and several randomized controlled trials (RCTs) in early intervention (Hay et al. 2005; Jellema et al. 2005) have demonstrated the feasibility of early intervention tackling these risk factors, there is not clear evidence of superiority of clinical outcomes for biopsychosocial approaches over usual care, either because they don't work or because of methodological limitations in the design of the research. Van der Windt et al. (2008) have identified a number of methodological limitations such as insufficient statistical power or adoption of a ‘one size fits all approach’ to the intervention, the relative lack of therapeutic power in the treatments offered, or the inability to match the right treatment to the right patient at the right time (see for more detail Chapter 27). A possible solution in terms of an approach combining screening and targeting approach is described and discussed later in this chapter.

Estimation of risk is at the core of screening but the literature contains a number of overlapping and similar terms such as ‘risk factors’, ‘predictive factors’, and ‘prognostic factors’ that at times are used interchangeably. As a precursor to considering the nature and efficacy of risk factor identification and screening for improved outcome, we offer our understanding of these terms.

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