New Zealand Guidelines Group - New Zealand Guidelines Completed: Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work loss
New Zealand Guidelines Group
New Zealand Guidelines Group - New Zealand Guideline - Completed

Guideline Title:
Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain:
Risk Factors for Long-Term Disability and Work Loss

Risk Factors for Long-Term Disability and Work Loss

This guide is to be used in conjunction with the New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long-term disability and work loss, and an outline of methods to assess these. Identification of those At Risk should lead to appropriate early management targeted towards the prevention of chronic pain and disability.

What This Guide Aims to Do

This guide complements the New Zealand Acute Low Back Pain Guide and is intended for use in conjunction with it. This guide describes ‘Yellow Flags’; psychosocial factors that are likely to increase the risk of an individual with acute low back pain developing prolonged pain and disability causing work loss, and associated loss of quality of life. It aims to:

  • provide a method of screening for psychosocial factors
  • provide a systematic approach to assessing psychosocial factors
  • suggest strategies for better management of those with acute low back pain who have ‘Yellow Flags’ indicating increased risks of chronicity.

This guide is not intended to be a rigid prescription and will permit flexibility and choice, allowing the exercise of good clinical judgement according to the particular circumstances of the patient. The management suggestions outlined in this document are based on the best available evidence to date.

What are Psychosocial Yellow Flags?

‘Yellow Flags’ are factors that increase the risk of developing, or perpetuating long-term disability and work loss associated with low back pain.

Psychosocial ‘Yellow Flags’ are similar to the ‘Red Flags’ in the New Zealand Acute Low Back Pain Guide. Psychosocial factors are explained in more detail in Appendix 1.

Yellow and Red Flags can be thought of in this way:

  • Yellow Flags = psychosocial risk factors
  • Red Flags = physical risk factors
Identification of risk factors should lead to appropriate intervention. Red Flags should lead to appropriate medical intervention; Yellow Flags to appropriate cognitive and behavioural management.

The significance of a particular factor is relative. Immediate notice should be taken if an important Red Flag is present, and consideration given to an appropriate response. The same is true for the Yellow Flags.

Assessing the presence of Yellow Flags should produce two key outcomes:
  • a decision as to whether more detailed assessment is needed
  • identification of any salient factors that can become the subject of specific intervention, thus saving time and helping to concentrate the use of resources

Red and Yellow Flags are not exclusive - an individual patient may require intervention in both areas concurrently.

Why is there a Need for Psychosocial Yellow Flags for Back Pain Problems?

Low back pain problems, especially when they are long-term or chronic, are common in our society and produce extensive human suffering. New Zealand has experienced a steady rise in the number of people who leave the work force with back pain. It is of concern that there is an increased proportion who do not recover normal function and activity for longer and longer periods.

The research literature on risk factors for long-term work disability is inconsistent or lacking for many chronic painful conditions, except low back pain, which has received a great deal of attention and empirical research over the last 5 years. Most of the known risk factors are psychosocial, which implies the possibility of appropriate intervention, especially where specific individuals are recognised as being At Risk.

Who is At Risk?
An individual may be considered At Risk if they have a clinical presentation that includes one or more very strong indicators of risk, or several less important factors that might be cumulative.

Definitions of primary, secondary and tertiary prevention
It has been concluded that efforts at every stage can be made towards prevention of long-term disability associated with low back pain, including work loss.

Primary prevention:
elimination or minimisation of risks to health or well-being. It is an attempt to determine factors that cause disabling low back disability and then create programmes to prevent these situations from ever occurring.
Secondary prevention:
alleviation of the symptoms of ill health or injury, minimising residual disability and eliminating, or at least minimising, factors that may cause recurrence. It is an attempt to maximise recovery once the condition has occurred and then prevent its recurrence. Secondary prevention emphasises the prevention of excess pain behaviour, the sick role, inactivity syndromes, re-injury, recurrences, complications, psychosocial sequelae, long-term disability and work loss.
Tertiary prevention:
rehabilitation of those with disabilities to as full function as possible and modification of the workplace to accommodate any residual disability. It is applied after the patient has become disabled. The goal is to return to function and patient acceptance of residual impairment(s); this may in some instances require work site modification.
Figure 1

The focus of this guide is on secondary prevention

Secondary prevention aims to prevent:
  • excess pain behaviour, sick role, inactivity syndromes
  • re-injury, recurrences
  • complications, psychosocial sequelae, long-term disability, work loss


Before proceeding to assess Yellow Flags, treatment providers need to carefully differentiate between the presentations of acute, recurrent and chronic back pain, since the risk factors for developing long-term problems may differ even though there is considerable overlap.

Acute low back problems:
activity intolerance due to lower back or back and leg symptoms lasting less than 3 months.
Recurrent low back problems:
episodes of acute low back problems lasting less than 3 months but recurring after a period of time without low back symptoms sufficient to restrict activity or function.
Chronic low back problems:
activity intolerance due to lower back or back and leg symptoms lasting more than 3 months.

Goals of Assessing Psychosocial Yellow Flags

The three main consequences of back problems are:

  • pain
  • disability, limitation in function including activities of daily living
  • reduced productive activity, including work loss

Attempts to prevent the development of chronic pain through physiological or pharmacological interventions in the acute phase have been relatively ineffective. Research to date can be summarised by stating that inadequate control of acute (nociceptive) pain may increase the risk of chronic pain.

Preventing loss of function, reduced activity, distress and low mood is an important, yet distinct goal. These factors are critical to a person’s quality of life and general well-being. It has been repeatedly demonstrated that these factors can be modified in patients with chronic back pain. It is therefore strongly suggested that treatment providers must prevent any tendency for significant withdrawal from activity being established in any acute episode.

Work loss
The probability of successfully returning to work in the early stages of an acute episode depends on the quality of management, as described in this guide. If the episode goes on longer the probability of returning to work reduces. The likelihood of return to any work is even smaller if the person loses their employment, and has to re-enter the job market.

Long-term disability and work loss are associated with profound suffering and negative effects on patients, their families and society. Once established they are difficult to undo. Current evidence indicates that to be effective, preventive strategies must be initiated at a much earlier stage than was previously thought. Enabling people to keep active in order to maintain work skills and relationships is an important outcome.

Most of the known risk factors for long-term disability, inactivity and work loss are psychosocial. Therefore, the key goal is to identify Yellow Flags that increase the risk of these problems developing. Health professionals can subsequently target effective early management to prevent onset of these problems.

Please note that it is important to avoid pejorative labelling of patients with Yellow Flags (see Appendix 2) as this will have a negative impact on management. Their use is intended to encourage treatment providers to prevent the onset of long-term problems in At Risk patients by interventions appropriate to the underlying cause.

How to Judge if a Person is at Risk

A person may be At Risk if:

  • there is a cluster of a few very salient factors
  • there is a group of several less important factors that combine cumulatively
There is good agreement that the following factors are important and consistently predict poor outcomes:
  • presence of a belief that back pain is harmful or potentially severely disabling
  • fear-avoidance behaviour (avoiding a movement or activity due to misplaced anticipation of pain) and reduced activity levels
  • tendency to low mood and withdrawal from social interaction
  • an expectation that passive treatments rather than active participation will help
Suggested questions (to be phrased in treatment provider’s own words):
  • Have you had time off work in the past with back pain?
  • What do you understand is the cause of your back pain?
  • What are you expecting will help you?
  • How is your employer responding to your back pain? Your co-workers? Your family?
  • What are you doing to cope with back pain?
  • Do you think that you will return to work? When?

How to Assess Psychosocial Yellow Flags

A detailed discussion of methods to identify Yellow Flags is given in Appendix 3.

  • If large numbers need to be screened quickly there is little choice but to use a questionnaire. Problems may arise with managing the potentially large number of At Risk people identified. It is necessary to minimise the number of false positives (those the screening test identifies who are not actually At Risk).
  • If the goal is the most accurate identification of Yellow Flags prior to intervention, clinical assessment is preferred. Suitably skilled clinicians with adequate time must be available.
  • The two-stage approach shown in Figure 2 is recommended if the numbers are large and skilled assessment staff are in short supply. The questionnaire can be used to screen for those needing further assessment. In this instance, the number of false negatives (those who have risk factors, but are missed by the screening test) must be minimised.
  • To use the screening questionnaire.
  • To conduct a clinical assessment for Acute Back Pain, see Table 1.
Clinical assessment of Yellow Flags involves judgements about the relative importance of factors for the individual. Table 2 lists factors under the headings of Attitudes and Beliefs about Back Pain, Behaviours, Compensation Issues, Diagnosis and Treatment, Emotions, Family and Work.

These headings have been used for convenience in an attempt to make the job easier. They are presented in alphabetical order since it is not possible to rank their importance. However, within each category the factors are listed with the most important at the top.

Please note, clinical assessment may be supplemented with the questionnaire method (ie the Acute Low Back Pain Screening Questionnaire in Table 1) if that has not already been done. In addition, treatment providers familiar with the administration and interpretation of other pain-specific psychometric measures and assessment tools (such as the Pain Drawing, the Multidimensional Pain Inventory, etc) may choose to employ them. Become familiar with the potential disadvantages of each method to minimise any potential adverse effects.

The list of factors provided here is not exhaustive and for a particular individual the order of importance may vary. A word of caution: some factors may appear to be mutually exclusive, but are not in fact. For example, partners can alternate from being socially punitive (ignoring the problem or expressing frustration about it) to being over-protective in a well intentioned way (and inadvertently encouraging extended rest and withdrawal from activity, or excessive treatment seeking). In other words, both factors may be pertinent.

Fig2: Deciding how to assess Psychosocial Yellow Flags

Click here to print the algorithm and quick reference guide for off-line use!

Clinical Assessment of Psychosocial Yellow Flags

These headings (Attitudes and Beliefs about Back Pain, Behaviours, Compensation Issues, Diagnosis and Treatment, Emotions, Family and Work) have been used for convenience in an attempt to make the job easier. They are presented in alphabetical order since it is not possible to neatly rank their importance. However, within each category the factors are listed with the most important at the top of the list.

Table 1:   clinical assessment of Psychosocial Yellow Flags

    Attitudes and Beliefs about Back Pain
  • 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
  • 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
  • Passive attitude to rehabilitation

  • Use of extended rest, disproportionate ‘downtime’
  • 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
  • Report of extremely high intensity of pain, eg, above 10, on a 0 to 10 Visual Analogue Scale
  • Excessive reliance on use of aids or appliances
  • 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
  • Smoking

    Compensation Issues
  • Lack of financial incentive to return to work
  • Delay in accessing income support and treatment cost, disputes over eligibility
  • 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 12 weeks)
  • History of previous back pain, with a previous claim(s) and time off work
  • Previous experience of ineffective case management (eg absence of interest, perception of being treated punitively) Diagnosis and Treatment
  • Health professional sanctioning disability, not providing interventions that will improve function
  • Experience of conflicting diagnoses or explanations for back 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
  • Number of times visited health professional in last year (excluding the present episode of back pain)
  • Expectation of a ‘techno-fix’, eg, requests to treat as if body were a machine
  • Lack of satisfaction with previous treatment for back pain
  • Advice to withdraw from job

  • Fear of increased pain with activity or work
  • 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 disinterested in social activity
  • Feeling useless and not needed

  • 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
  • Lack of support person to talk to about problems

  • History of manual work, notably from the following occupational groups:
    • fishing, forestry and farming workers;
      construction, including carpenters and builders;
      truck drivers;
  • 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
  • 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’
  • Minimal availability of selected duties and graduated return to work pathways, with unsatisfactory implementation of these
  • Negative experience of workplace management of back pain (eg absence of a reporting system, discouragement to report, punitive response from supervisors and managers)
  • Absence of interest from employer

Remember the key question to bear in mind while conducting these clinical assessments is ‘What can be done to help this person experience less distress and disability?’

What can be done to help somebody who is At Risk?
These suggestions are not intended to be prescriptions, or encouragement to ignore individual needs. They are intended to assist in the prevention of long-term disability and work loss.

Suggested steps to better early behavioural management of low back pain problems

  1. Provide a positive expectation that the individual will return to work and normal activity. Organise for a regular expression of interest from the employer. If the problem persists beyond 2 to 4 weeks, provide a ‘reality based’ warning of what is going to be the likely outcome (eg loss of job, having to start from square one, the need to begin reactivation from a point of reduced fitness, etc).

  2. Be directive in scheduling regular reviews of progress. When conducting these reviews shift the focus from the symptom (pain) to function (level of activity). Instead of asking ‘how much do you hurt?’, ask ‘what have you been doing?’. Maintain an interest in improvements, no matter how small. If another health professional is involved in treatment or management, specify a date for a progress report at the time of referral. Delays will be disabling.

  3. Keep the individual active and at work if at all possible, even for a small part of the day. This will help to maintain work habits and work relationships. Consider reasonable requests for selected duties and modifications to the work place. After 4 to 6 weeks, if there has been little improvement, review vocational options, job satisfaction, any barriers to return to work, including psychosocial distress. Once barriers to return to work have been identified, these need to be targeted and managed appropriately. Job dissatisfaction and distress cannot be treated with a physical modality.

  4. Acknowledge difficulties with activities of daily living, but avoid making the assumption that these indicate all activity or any work must be avoided.

  5. Help to maintain positive cooperation between the individual, an employer, the compensation system, and health professionals. Encourage collaboration wherever possible. Inadvertent support for a collusion between ‘them’ and ‘us’ can be damaging to progress.

  6. Make a concerted effort to communicate that having more time off work will reduce the likelihood of a successful return to work. In fact, longer periods off work result in reduced probability of ever returning to work. At the 6 week point consider suggesting vocational redirection, job changes, the use of ‘knight’s move’ approaches to return to work (same employer, different job).

  7. Be alert for the presence of individual beliefs that he/she should stay off work until treatment has provided a ‘total cure’; watch out for expectations of simple ‘techno-fixes’.

  8. Promote self-management and self-responsibility. Encourage the development of self-efficacy to return to work. Be aware that developing self-efficacy will depend on incentives and feedback from treatment providers and others. If recovery only requires development of a skill such as adopting a new posture, then it is not likely to be affected by incentives and feedback. However, if recovery requires the need to overcome an aversive stimulus such as fear of movement (kinesiophobia) then it will be readily affected by incentives and feedback.

  9. Be prepared to ask for a second opinion, provided it does not result in a long and disabling delay. Use this option especially if it may help clarify that further diagnostic work up is unnecessary. Be prepared to say ‘I don’t know’ rather than provide elaborate explanations based on speculation.

  10. Avoid confusing the report of symptoms with the presence of emotional distress. Distressed people seek more help, and have been shown to be more likely to receive ongoing medical intervention. Exclusive focus on symptom control is not likely to be successful if emotional distress is not dealt with.

  11. Avoid suggesting (even inadvertently) that the person from a regular job may be able to work at home, or in their own business because it will be under their own control. This message, in effect, is to allow pain to become the reinforcer for activity - producing a deactivation syndrome with all the negative consequences. Self employment nearly always involves more hard work.

  12. Encourage people to recognise, from the earliest point, that pain can be controlled and managed so that a normal, active or working life can be maintained. Provide encouragement for all ‘well’ behaviours - including alternative ways of performing tasks, and focusing on transferable skills.

  13. If barriers to return to work are identified and the problem is too complex to manage, referral to a multidisciplinary team as described in the New Zealand Acute Low Back Pain Guide is recommended.

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What are the Consequences of Missing Psychosocial Yellow Flags?

Under-identifying At Risk patients may result in inadvertently reinforcing factors that are disabling. Failure to note that specific patients strongly believe that movement will be harmful may result in them experiencing the negative effects of extended inactivity. These include withdrawal from social, vocational and recreational activities.

Cognitive and behavioural factors can produce important physiological consequences, the most common of which is muscle wasting.

Since the number of earlier treatments and length of the problem can themselves become risk factors, most people should be identified the second time they seek care. Consistently missing the presence of Yellow Flags can be harmful and usually contributes to the development of chronicity.

  • There may be significant adverse consequences if these factors are overlooked.

What are the Consequences of Over-identifying Psychosocial Yellow Flags?

Over-identification has the potential to waste some resources. However, this is readily outweighed by the large benefit from helping to prevent even one person developing a long-term chronic back problem.

Some treatment providers may wonder if identifying psychosocial risk factors, and subsequently applying suitable cognitive and behavioural management can produce adverse effects. Certainly if the presence of psychosocial risk factors is misinterpreted to mean that the problem should be translated from a physical to a psychological one, there is a danger of the patient losing confidence in themselves and their treatment provider(s).

  • There are unlikely to be adverse consequences from the over-identification of Yellow Flags.

The presence of risk factors should alert the treatment provider to the possibility of long-term problems and the need to prevent their development. Specialised psychological referrals should only be required for those with psychopathology (such as depression, anxiety, substance abuse, etc), or for those who fail to respond to appropriate management.

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