Physiotherapy Management of Chronic Low Back Pain Patients with Yellow Flags: A Systematic Review

CLBP is the leading cause of years lived with disability worldwide and patients with yellow flags have the worst outcomes and contribute significantly to the societal cost. Clinicians are aware of the importance of yellow flags but feel undertrained to deal with them. Furthermore there is a lack of clarity for clinicians looking at how to specifically manage these patients from guidelines and an incredibly varied set of approaches available to clinicians. The objective of this review was to review the effectiveness of the physiotherapy interventions for chronic low back pain patients with yellow flags that have been studied. Three approaches were used for retrieving literature. Searches were conducted initially using the terms “physiotherapy”, “chronic low back pain”, psychosocial and “management or treatment”, using the databases PubMed, Embase, PEDro and CINHAL from January 1987 up to February 2017. In addition content experts were consulted to ensure no additional papers were missed and citation tracking was implemented. 39 studies were identified with 20 meeting the selection criteria. Interestingly the term yellow flags is not used in the treatment literature and instead specific psychosocial terms are used. This review tentatively suggests specific exercise and passive interventions are more beneficial for reducing measures of pain, whilst psychological input and general exercise appears more targeted towards psychosocial measures. as hernia nucleus, infection, inflammatory disease, osteoporosis, rheumatoid arthritis, fracture or tumour [8]. There is no effective cure for non-specific low back pain (NSCLBP) and this represents the 90% of the LBP population that cannot be classified as specific LBP [9]. Most guidelines are based on the assumption that symptoms resolve spontaneously and that return to work equals recovery [6,10]. However, when pain is assessed it appears patients may be returning to work despite their pain [11], and whilst spontaneous recovery occurs in approximately a third of patients after 3 months, 71% still have pain after 1 year [12]. CLBP patients with psychosocial, psychological and social, risk factors are known to have poorer outcomes and increased management costs [13,14]. The term “yellow flags” was originally used to describe psychosocial risk factors that predict disability in LBP patients [15]. These risk factors are predictors of return to work and disability in CLBP patients [16]. The risk factors can be identified using a questionnaire or a clinical diagnosis [17]. Questions cover beliefs that are associated with delayed return to work and disability. These include fears about pain, injury, recovery and being despondent or anxious. It is suggested that having a few strongly held negative beliefs or several weaker ones could be used to identify at risk patients [14]. These beliefs increase a patient’s perception of threat and modern neuroscience suggests that pain is the conscious interpretation that tissue is in danger [18]. These beliefs can be viewed as “thought viruses” [19]. Yellow flags are now included in most LBP guidelines although there is wide variation in suggestions in how to manage these patients [8]. All guidelines consider the Introduction Low back pain (LBP) is usually defined as pain localised below the costal margin (ribs) and above the inferior gluteal folds (buttock crease). It is the leading cause of years lived with disability worldwide and is becoming increasingly prevalent [1-5]. Chronic low back pain (CLBP) is variously defined as lasting longer than 7-12 weeks, to 3 months [6,7]. LBP is typically classified as “specific” or “non-specific”. Specific LBP refers to symptoms caused by specific pathophysiologic causes, such ISSN: 2572-3243 DOI: 10.23937/2572-3243.1510060 Macphail. J Musculoskelet Disord Treat 2018, 4:060 • Page 2 of 11 • chosocial”. In addition content experts were consulted to ensure no additional papers were missed and citation tracking was implemented. Foreign language papers that were identified using the English terms were included. Refworks was used to store and remove duplicates from the searches. Selection of Studies The researcher initially screened the title and abstract of the identified studies. The full text was then analysed. Studies were selected on the basis of the following selection criteria; 1. Primary experimental design study of human participants with chronic (> 12 weeks) or recurrent (repeated episodes over 12 months) low back pain. 2. Participants must have yellow flags or measured psychosocial status commensurate with yellow flags. 3. Studies must cover the management of patients. Studies were excluded if; 1. The intervention group did not have yellow flags or measurable psychosocial factors. 2. Looked at post surgical patients. 3. Mixed groups of sub-acute and chronic patients. 4. Mixed groups of neck and CLBP patients. 5. The intervention was purely psychological (CBT) and outside the scope of traditional physiotherapy practice.