A question a day 30092018 (W1D7)

Q1 Yellow flags are psychological, social and environmental risk factors for prolonged disability, long
term chronicity, affecting recovery and failure to return to work as a consequence of
musculoskeletal symptoms.

Q2. Refusing to be managed properly (belief that passive treatment such as rest is more helpful than
active participation in treatment)

Q3. Red flags are signs and symptoms that might indicate possible serious pathology and which
require careful assessment and reassessment, and possible urgent intervention

Q4.

Age ≥ 50 years / less than 20 years old Commented [nlk1]: Any other age group at risk?
No improvement after 4 weeks of treatment Commented [JKEH2R1]: less than 18 years old
Unexplained weight loss
Pain worse at night / unrelieved by rest
Previous history of cancer
 Progressive neurological deficits
Bladder or bowel dysfunction
Prolonged use of corticosteroids or
immunosuppression
Intravenous drug use Commented [nlk3]: Abuse?
Recent bacterial infection (eg UTI)
Significant trauma
Systemic symptoms (Fever, night sweats, loss of
appetite)
Anemia Commented [nlk4]: Why?
Vertebral tenderness Suspect multiple myeloma
Limited spinal range of motion anemia results from bone malignancy metastases to the
bone marrow, resulting in reduced RBC production. Low
Saddle anesthesia back pain caused by underlying Crohn's, will have anemia
Loss of anal spinchter tone too.
Elevated ESR, CRP

Q5. Age of 71, frequent use of corticosteroids, and tenderness to palpation

If patient has these yellow flags, what is the most appropriate next step

Communicate! Some patients don't like to be labeled "sick" so the attitude in approaching must be
friendly and different. Instead of recommending investigations immediately, take time to explore
their belief, on their pain and back condition, the emotional assessment of the patient is critical to a
successful clinical outcome. One of the major pillar of diagnosis apart from functional, is
EMOTIONAL. Need to understand the "why" of refusal :)

Then re-enforce positive expectations haha, some patients just need some convincing and
reassuring.

Instead of promoting passive treatment, since pain is still manageable, begin to decrease and de-
emphasize passive treatments, set achievable health goals like neck exercises. Patients are more
compliant to the idea sometimes if they are actively pursuing self-care. Then give instructions like
haha “Must get an appointment if realizing frequent pain upon neck movement exercises”

If all else fails, can consider bringing in the behavioural therapists, let them help address
psychological risk factors and problems that we can't

No straightforward approach in this kind of patient

Need to assess why the patient refused to be tested and assess for any signs of depression or if
patient insists to rest at home, ask the patient to return if his symptoms havent improved.

TUNA FISH? Red flags of low back pain:

T: Trauma

U: Unexplained weight loss

N: Neurological symptoms
A: Age>50

F: Fever

I: Intravenous drug user

S: Steroid use

H: History of cancer