When assessing patients who report pain, it is important to identify all risk factors so that appropriate referrals to specialists can be made. Risk factors can be divided into two groups Red flags and Yellow flags
Red Flags are the physical risk factors associated with pain and should lead to further medical intervention, even when tests come back normal.
Yellow flags are the psycho-social risk factors that may be barriers to recovery. They should lead to appropriate cognitive and/or behavioural interventions.
Features of Cauda Equina Syndrome*
Severe worsening of pain, especially at night or when lying down
History of cancer
Use of intravenous drugs or steroids
Patients over the age of 50 years
The recommended approach in the presence of Red Flags is:
All patients with symptoms or signs of Cauda Equina Syndrome should be referred urgently to hospital for orthopaedic or neurosurgical assessment.
Patients with Red Flags should be investigated appropriately and referred to a specialist if indicated by clinical findings and test results.
Investigations in the first 4-6 weeks of an acute low back pain episode do not provide clinical benefit, unless there are Red Flags.
A full blood count and ESR should usually be performed only if there are Red Flags. Other tests may be indicated depending on the clinical situation.
Radiological investigations (X-rays and CT scans) carry the risk of potential harm from radiation related effects and should be avoided if not required for diagnosis or management.
Remember Red Flag pathology may lie outside the lumbar region and may not be detected by radiology.
MRI scans are not indicated for non-specific acute low back pain.
Many people without symptoms show abnormalities on X-rays and MRIs**. The chances of finding coincidental disc prolapse increase with age. It is important to correlate MRI findings with age and clinical signs before advising surgery.
Attitudes and belief that all pain and activity are harmful
Belief that pain is harmful or disabling resulting in fear-avoidance behaviour, eg, the development of guarding and fear of movement
Belief that all pain must be abolished before attempting to return to work or normal activity
Fear of increased pain with activity or work
Expectation of increased pain with activity or work, lack of ability to predict capability
Catastrophising, thinking the worst, misinterpreting bodily symptoms
Belief that pain is uncontrollable
A passive attitude to rehabilitation (expectation of being a passive recipient)
The presence of 'sickness behaviours'
Use of extended rest
Report of extremely high intensity of pain, eg, above 10, on a 0-10 Visual Analogue Scale
Excessive reliance on use of aids or appliances
Number of times visited health professional in last year (excluding the present episode of back pain)
Low or negative moods
Depression (especially long-term low mood), loss of sense of enjoyment
More irritable than usual
Anxiety about and heightened awareness of body sensations (includes sympathetic nervous system arousal)
Feeling under stress and unable to maintain sense of control
Presence of social anxiety or disinterest in social activity
Feeling useless and not needed
Sleep quality reduced since onset of back pain
High intake of alcohol or other substances (possibly as self-medication), with an increase since onset of back pain
Reduced activity level with significant withdrawal from activities of daily living
Irregular participation or poor compliance with physical exercise, tendency for activities to be in a ‘boom-bust’ cycle
Avoidance of normal activity and progressive substitution of lifestyle away from productive activity
Engagement in treatment that does not fit best practice
Health professional sanctioning disability, not providing interventions that will improve function
Experience of conflicting diagnoses or explanations for pain, resulting in confusion
Diagnostic language leading to catastrophising and fear (eg, fear of ending up in a wheelchair)
Dramatisation of back pain by health professional producing dependency on treatments, and continuation of passive treatment
Lack of satisfaction with previous treatment for pain
Problems with claims and/or compensation
Lack of financial incentive to return to work
Delay in accessing income support and treatment cost, disputes over eligibility
Advice to withdraw from job
Minimal availability of selected duties and graduated return to work pathways, with unsatisfactory implementation of these
A History of claim/s due to other injuries or pain problems
History of extended time off work due to injury or other pain problem (eg more than 12weeks)
Previous experience of ineffective case management (eg, absence of interest, perception of being treated punitively)
Problems at work or poor job satisfaction
History of manual work, notably from the following occupational groups:
Fishing, forestry and farming workers
Construction, including carpenters and builders
Work history, including patterns of frequent job changes, experiencing stress at work, job dissatisfaction, poor relationships with peers or supervisors, lack of vocational direction
Belief that work is harmful; that it will do damage or be dangerous
Unsupportive or unhappy current work environment
Low educational background, low socioeconomic status
Negative experience of workplace management of injury (eg, absence of a reporting system, discouragement to report, punitive response from supervisors and managers)
Absence of interest from employer
Heavy work, unsociable hours
Job involves significant bio-mechanical demands, such as lifting, manual handling heavy items, extended sitting, extended standing, driving, vibration, maintenance of constrained or sustained postures, inflexible work schedule preventing appropriate breaks
Job involves shift work or working unsociable hours
An overprotective family OR obvious lack of familial or social support
Over-protective partner/spouse, emphasising fear of harm or encouraging catastrophising (usually well-intentioned)
Solicitous behaviour from spouse (eg, taking over tasks)
Socially punitive responses from spouse (eg, ignoring, expressing frustration)
Extent to which family members support any attempt to return to work