Transcript Yellow flags - Rackcdn.com

Ron Donelson, MD, MS
SelfCare First, LLC
Red Flags  Yellow Flags  Others
Red flags
Yellow flags Indicators of
Black Flags
Family and system
(Kendall 1997)
underlying
Beliefs about factors (insurance
Unhelpful
insidious
workplace (lack of claim conflicts,
beliefs about pathology:
spine support from
overly solicitous
Orange flags
pain/emotional fracture,
tumor,
Psychiatric
sxs supervisors, co- family or health
responses/pain and infx
disorders:workers); belief that care provider)
behavior &
Axis I and II return will cause
coping
disorders
injury
Blue Flags
Main & Burton, 2000; Nicholas, et al, 2011
Yellow Flags
Psychological and social factors that
increase the likelihood of long-term
disability and work loss in persons
with low back pain.
But not always.
Yellow flags: “Obstacles to Recovery”
More questions than answers..
Some YFs are indeed obstacles to recovery
that need attention.
But some aren’t. They’re false-positives.
Q#1: How do we know which are which?
WARNING: Diagnosing low back pain
means sorting through many false-positives
or misleading findings
Unreliable exam findings: asymmetries, tenderness
Referred tenderness: SIJ, myofascial trigger points,
pyriformis, trochanteric bursitis
Imaging: HNPs and DDD in symptomatics
Q#2: Which findings are relevant? False-positives?
Q#3: Why are YFs so
relevant with LBP?
Why aren’t they also prominent with
abdominal, chest, shoulder, hip or knee pain?
Or even spinal fractures, HNPs and sciatica?
Q#4: Are YFs only relevant when
the underlying diagnosis is uncertain?
Would making a diagnosis
early make a difference?
Would making a patho-mechanical
diagnosis (DP?) early make a difference?
Q#5: Do YFs cause pain
to persist or does
persisting pain cause YFs
to develop?
OR BOTH?
Consider:
Dir. pref. and centralization are found in
most LBP patients and predict an
excellent prognosis for recovery.
In contrast, YFs are considered to
be possible obstacles to recovery.
Do they ever co-exist?
If so, which prevails?
Centralization and Fear-Avoidance Beliefs
Centralizers have lower involvement of
psychological factors.
The presence of yellow flags (elevated fearavoidance beliefs) was associated with noncentralization.
Christiansen D, et al. Pain responses in rpted end-range spinal mvts and psycho’l
factors in sick-listed pts with LBP: is there an association? J Rehabil Med. 2009.
Centralization and Fear-Avoidance
Fear-avoidance was equally present in centralizers
and non-centralizers.
Even with high fear, centralization still predicted a
good outcome in the majority. So in centralizers,
addressing fear-avoidance beliefs is unnecessary.
If centralization is not present, but high levels of fear
are, formal cognitive behavioral techniques should be
used to address these beliefs.
Werneke M, Hart D, George S. Clinical outcomes for patients classified by fearavoidance beliefs and centralization phenomenon. Arch Phys Med Rehab. 2009
In 223 acute back and neck pain centralizers
with a DP:
Yellow flags were common:
non-organic physical signs, overt pain behaviors,
depressive symptoms, somatization, fear-avoidance
beliefs, and perceived disability.
When treated with directional exercises, the outcomes at
one year were so positive, the yellow flags were
non-predictors of outcome.
Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for
chronic low back pain and disability. Spine 2001
In 71 patients with a dir. pref.:
Both Beck Depression Inventory and Interference With
Work and Leisure Activity significantly improved after just
two weeks of matching directional exercises only.
It is futile to conduct prognostic studies
without including baseline centralization/DP
determination.
Long A, Donelson R, Fung T. Does it matter which exercise? A randomized
controlled trial of exercise for low back pain. Spine 2004
All studies of LBP outcome predictors
need to include baseline determination of
the presence or absence of both:
Yellow Flags
Directional Preference
On the other hand…..
with directional preference so common and
so strongly predictive of good outcomes with
appropriate directional treatment….
How important is baseline
Yellow Flag determination?
Yellow flags may only have relevance if
MDT evaluation and treatment fail….
Along with imaging, injections, and surgeries.
As high quality MDT becomes the
front-line of care for painful cervical
and lumbar disorders….
yellow flags, imaging, medications, injections,
and surgeries need only be considerations for a
small percentage of patients.
FEVER
a non-specific symptom that once was
attributed to non-physical issues:
immorality, lack of faith, etc.
But innovative diagnostic technologies:
microscope  microbes  infection, and
sensitivities to antibiotics.
> 60% of health care budget  14%.
17
How common is dir. pref.: a reducible derangement?
Prevalence of dir. pref. & centralization:
Donelson (Spine 1990)
84-89 %
Sufka
(JOSPT, 1998)
60-83 %
Acute, Chronic
Werneke (Spine, 1999)
77 %
Sciatica
Karas Axial
(Phys.pain,
Ther. 1997)
73 %
Donelson Degenerative
(Spine 1991, ISSLS
1991)
58 %
disc
Delitto Pseudo-claudication
(Phys. Ther. 1993)
61 %
Erhard
(Phys. Ther. 1995)
55 %
Spondys
Kopp
(CORR, 1986)
52 %
Long
(Spine, 1995)
43 %
Donelson (Spine ,1997)
49 %
Laslett
(Spine Jrnl, 2005)
32 %
Acute
Chronic
Misdiagnosed
Acute: 70QTF: “inaccurate dxs
89%
Missed
window
of
which are then further
reducible
opportunity
confounded
with each
succeeding step in care” derangements
Ineffective, costly,
avoidable care
Yellow
Chronic:
flags, MRIs,
Yellow
50%
medications,
Flags
reducible
injections,
Undiscovered while surgeries
acute and subacute.
Misdiagnosed
LOST window of
opportunity
Ineffective, costly,
avoidable care
Many
became
irreducible
chronics
69 non-centralizers underwent TESIs.
After TESIs, MDT exam repeated
35
46%
30
Yellow Flags?
25
22%
20
15
Total Relief
N-C No Surg
N-C+Surgery
Centralizers
16%
16%
Total Relief
N-C No Surg
10
5
0
N-C+Surgery
Centralizers
38% Non-Centralizers
van Helvoirt H, et. al. Transforaminal epidural steroid injections followed by Mechanical
Diagnosis and Therapy to prevent surgery for lumbar disc herniation. Pain Medicine. 2014.
Recurrences: Benign or Worsening?
Survey of 589 respondents with LBP:
• 73% had prior episodes; 54% had 10 or more
and 19% had more than 50 episodes.
• 61% had recent episodes worse than prior ones;
21% were worse in all 5 surveyed domains.
Conclusion: Recurrences often worsen
over time.
Donelson R, McIntosh G, Hamilton H. Is it time to rethink the typical course
of low back pain? Physical Medicine & Rehabilitation Journal. 2012.
Recurrences often progressively
worsen and last longer….
Until recovery finally stops……and
pain becomes constant and chronic?
Are worsening recurrences a
common a pathway to chronicity?
Ques: If dir. pref. is found in 70-90% of
acute LBP, predicts excellent
outcomes and prevents recurrences using
directional exercises, what is the biggest
obstacle to recovery?
Answer: Depriving patients of
a good MDT assessment.
A far more significant obstacle
than the presence of yellow flags?
Accurate
Acute: 70mechanical
89%
reducible
diagnosis when
All preventable! derangements acute or subacute
Chronic:
50%
reducible
Chronic:
30%(?)
now
irreducible
So are YFs the biggest obstacle to
recovery from LBP and neck pain?
Not if their influence disappears
in the presence of a dir. pref.
If 70-89% of acute LBP have a
dir. pref., then YFs are only
relevant in the other 11-30%.
To minimize the effects of Yellow Flags,
LBP clinical guidelines recommend
reassurance of likely recover…..
based on the positive natural history.
What could possibly be more reassuring than
showing a patient that their pain is reversible and
that they can eliminate it themselves?
Is that why Yellow Flags disappear
as obstacles to recovery with Dir. Pref.?
Red Flags  Yellow Flags   
Black Flags
Red flags
Family and system
factors (insurance
Yellow flags Indicators of
Blue Flags
(Kendall 1997)
claim conflicts),
underlying
Beliefs about
Unhelpful
overly solicitous
insidious
workplace
(lack
of
Directional
beliefs about pathology:
family or health
spine support from
Orange flags
pain /emotional fracture,preference
care provider
/
tumor,
Psychiatric
sxs supervisors,
coresponses / pain
and infx
disorders:
centralization
workers; belief that
behavior &
Axis I and II return will cause
coping
disorders
injury
Green Flag
Main & Burton, 2000; Nicholas, et al, 2011