CLBP is the leading cause of 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 establish the effectiveness of physiotherapy interventions for chronic low back pain patients with yellow flags. 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 specific psychosocial terms are used. This review suggests specific exercise and passive interventions are more beneficial for reducing measures of pain, whilst psychological input and general exercise are more targeted towards psychosocial measures.
Given the significant nature of the problem of chronic low back pain it is surprising only 20 studies met the inclusion criteria. These studies show a consistent pattern that a variety of interventions are able to decrease psychosocial symptoms, improve function and decrease perceived pain. Disappointingly none of the research on the popular Maitland and McKenzie approaches met the inclusion criteria. Of the studies included the reporting of how interventions were carried out is often not sufficient to allow reproducibility or use in practice, with limited details on sets, repetitions, tempo and progressive overload of exercises across all studies.
Of all the studies those using the CFT approach had the most positive effects as measured by disability and pain. The other particularly effective approach was the walking programme of Hurley and colleagues (2015) which had the same effect as their exercise group and usual physiotherapy interventions for pain, disability and psychosocial measures but the walking programme had greater adherence and lower costs. This fits with some of the emerging research in whiplash pain which suggests a low cost telephone based intervention was equal to a more expensive and time intensive motor control intervention (Michaelef et al. 2014).
A general theme emerging across the studies was the benefits to pain of more specific exercise programmes and the benefits to psychosocial factors through general exercise and psychological input. The admittedly very limited selection of two studies (Weiner et al. 2003, 2008) suggests that whilst passive interventions could positively affect pain, the addition of general conditioning was required to reduce fear avoidance. Similarly, Vincent et al. (2014) found that the lumbar extensor strengthening was sufficient to increase physical function but the total body programme was required to improve perceived disability and psychosocial measures. Supporting this Geisser et al. (2015) found specific exercise and manual therapy reduce pain whilst their general exercise group had reduced disability.
Improvements in fear avoidance beliefs are often associated with improved function (Crombez et al. 1999) nonetheless in these studies it appears that active treatment such as walking or whole body exercise is required to improve psychosocial measures. There were only two education-based studies but the positive results suggest pain acceptance and neurophysiology education in combination should be useful. The results from intensive functional restoration and CBT programmes suggests these kind of multidisciplinary programmes are effective across all measures, with Pfingsten and Hilderbrandt (2001) noting the importance of work hardening in promoting return to work.
The classification based approaches such as Macedo et al. (2014) suggest that there could be future developments allowing clinicians to classify which patients respond best to general exercise and to more general exercise based approaches. In particular patients classified as dysfunctional on the multidimensional pain inventory have been shown to respond best to combined psychosocial and physical input (Riipen et al. 2015).
Considering that CLBP is the leading cause of disability worldwide and those with yellow flags are known to suffer the worst and contribute most to societal cost it is surprising how few studies met the selection criteria. This review has shown that whilst the term yellow flags are used in the assessment literature and guidelines, the term psychosocial and the factors that make it up are used in the treatment literature. The studies selected highlight that passive, active; more comprehensive and simple education interventions can all positively impact the pain experience of this patient group. While passive interventions can improve pain, more whole body active approaches such as whole body weight training or walking may be necessary to positively impact the psychosocial aspects. Comprehensive CBT and functional restorations are effective but the inclusion of work hardening may significantly aid in return to work. Pain education approaches involving pain neurophysiology education and pain acceptance were both effective compared with more traditional back school and pain avoidance approaches respectively. A combination of these may be useful clinically. The CFT approach was the most effective in terms of disability and self reported pain. This review suggests specific exercise and passive interventions are more beneficial for reducing measures of pain, whilst psychological input and general exercise are more targeted towards psychosocial measures.
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