Yellow Flags and Exercise Treatment: - PowerPoint Presentation

Slide1

Yellow Flags and Exercise Treatment:

Predictor or Result of Poor Outcome?

Ron Donelson, MD, MS

SelfCare First, LLCSlide2

Red Flags

Red flagsIndicators

of

underlying insidious pathology: spine fracture, tumor, infx

Main & Burton, 2000; Nicholas, et al, 2011

Orange flags

Psychiatric sxs and disorders: Axis I and II disorders

Blue FlagsBeliefs about workplace (lack of support from supervisors, co-workers); belief that return will cause injury

Black FlagsFamily and system factors (insurance claim conflicts, overly solicitous family or health care provider)

 Others

Yellow flags

(Kendall 1997)Unhelpful beliefs about pain/emotional responses/pain behavior & coping



Yellow FlagsSlide3

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.Slide4

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?Slide5

WARNING: Diagnosing low back pain means sorting through many false-

positives or misleading findingsUnreliable exam findings: asymmetries, tenderness

Referred

tenderness: SIJ,

myofascial trigger points,

pyriformis, trochanteric bursitis

Imaging: HNPs and DDD in symptomaticsQ#2: Which findings are relevant

? False-positives? Slide6

Q#3: Why are

YFs sorelevant with LBP?Why aren’t they also prominent

with abdominal, chest, shoulder, hip or knee

pain?

Or

even spinal fractures,

HNPs and sciatica? Slide7

Would making a

patho-mechanical diagnosis (DP?) early make a difference?Would making a diagnosis

early make a difference?

Q#4: Are

YFs

only relevant when

the underlying diagnosis is uncertain?Slide8

Q#5: Do

YFs cause pain to persist or does persisting pain cause YFs to develop?

OR BOTH?Slide9

Do they ever co-exist?

If so, which prevails? Dir. pref. and centralization are found in most LBP patients and predict an excellent prognosis for recovery.Consider:

In contrast,

YFs

are considered to be possible obstacles to recovery.Slide10

Centralization and Fear-Avoidance Beliefs

Centralizers have lower involvement of psychological factors.The presence of yellow flags (elevated fear-avoidance beliefs) was associated with non-centralization.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. Slide11

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 fear-avoidance beliefs and centralization phenomenon. Arch Phys Med Rehab. 2009Slide12

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 223 acute back and neck pain centralizers with a DP

:Slide13

In

71 patients with a dir. pref.:Both

Beck Depression Inventory and

Interference

W

ith W

ork and Leisure A

ctivity 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 2004Slide14

All studies of LBP outcome predictors need to include baseline determination of the presence or absence of both:

Yellow FlagsDirectional PreferenceSlide15

On the other hand…..

with directional preference so common and so strongly predictive of good outcomes with appropriate directional treatment….How important is baselineYellow Flag determination?Yellow flags may only have relevance if MDT evaluation and treatment fail….

Along with imaging, injections, and surgeries

.Slide16

As high quality MDT becomes the

front-line of care for painful cervicaland lumbar disorders….yellow flags, imaging, medications, injections, and surgeries need only be considerations for a small percentage of patients. Slide17

17

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.FEVER

> 60% of health care budget

 14%.Slide18

Prevalence of dir. pref. & centralization:

Donelson (Spine 1990) 84-89 %Sufka (JOSPT, 1998) 60-83 %Werneke (Spine, 1999) 77 %

Karas (Phys. Ther. 1997) 73 %

Donelson (Spine 1991, ISSLS 1991) 58 %

Delitto (Phys. Ther. 1993) 61 %

Erhard (Phys. Ther. 1995) 55 %Kopp (CORR, 1986) 52 %

Long (Spine, 1995) 43 %Donelson (Spine ,1997) 49 %Laslett (Spine Jrnl, 2005) 32 %

Acute

Chronic

How common is dir. pref.: a reducible derangement?

Acute, Chronic

Axial pain, SciaticaDegenerative discPseudo-claudicationSpondysSlide19

Chronic: 50% reducible

Acute: 70-89% reducible derangements

Many became irreducible chronics

Misdiagnosed

Ineffective, costly, avoidable care

LOST window of opportunity

Undiscovered

while

acute and

subacute

.

Ineffective, costly, avoidable care

Misdiagnosed

QTF: “inaccurate dxs which are then further confounded with each succeeding step in care”

Missed window of opportunity

Yellow Flags

Yellow flags, MRIs, medications, injections, surgeriesSlide20

After TESIs, MDT exam repeated

69 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. 2014.16%

16%22%

46%Centralizers

38% Non-Centralizers

underwent TESIs

.Yellow Flags?Slide21

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. Slide22

Recurrences often progressively worsen and last longer….

Until recovery finally stops……and pain becomes constant and chronic?Are worsening recurrences acommon a pathway to chronicity

? Slide23

Ques: If dir. pref. is found in 70-90% of

acute LBP, predicts excellentoutcomes and prevents recurrences using directional exercises, what is the biggest obstacle to recovery?Answer: Depriving patients ofa good MDT assessment. A far more significant obstacle

than the presence of yellow flags?Slide24

Chronic: 50% reducible

Acute: 70-89% reducible derangements

Chronic: 30%(?) now

irreducible

All preventable!

Accurate mechanical diagnosis when acute or subacuteSlide25

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%.Slide26

To minimize the effects of

Yellow Flags, LBP clinical

g

uidelines 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 disappearas obstacles to recovery with Dir. Pref.? Slide27

Red Flags

 Yellow Flags   

Red

flags

Indicators

of underlying insidious pathology: spine fracture, tumor, infx

Main & Burton, 2000; Nicholas, et al, 2011

Yellow flags (Kendall 1997)Unhelpful beliefs about pain /emotional responses / pain behavior & copingOrange flags

Psychiatric sxs and disorders: Axis I and II disordersBlue FlagsBeliefs about

workplace (lack of support from supervisors, co-workers; belief that return will cause injuryBlack Flags

Family and system factors (insurance claim conflicts), overly solicitous family or health care provider

Green FlagDirectional preference / centralizationSlide28