Identify risk factors for chronicity

Guidelines for primary care management of acute back pain highlight the identification of risk factors for chronicity. A useful approach has been developed in New Zealand. It aims to involve all interested parties—patient, the patient's family, healthcare professionals, and, importantly, the patient's employer. Four groups of risk factors or "flags" for chronicity are accompanied by recommended assessment strategies, which include the use of screening questionnaires, a set of structured interview prompts, and a guide to behavioural management. The focus is on key psychological factors or "yellow flags" that favour chronicity:

• The belief that back pain is due to progressive pathology

• The belief that back pain is harmful or severely disabling

• The belief that avoidance of activity will help recovery

• A tendency to low mood and withdrawal from social interaction

• The expectation that passive treatments rather than active self management will help.

The assessment of "red flags" will identify the small number of patients who need referral for an urgent surgical opinion. Similarly, patients with declared suicidal intent require immediate psychiatric referral. These two groups of patients need to be managed separately.

For the vast majority of patients, however, the identification of contributory psychological and social factors should be seen as an investigation of the normal range of reactions to pain rather than the seeking of psychopathology. Questions in the form of interview prompts have been designed to elicit potential psychosocial barriers to recovery in the "yellow flags" system. They can be used at the time of initial presentation by the general practitioner.

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