Due to the tremendous costs associated with chronic disability, secondary prevention strategies targeted to high risk acute/subacute patients are the most economically valuable management options. This questionnaire is a tool for identification of the high risk patients.1 It is recommended to be used on the first contact day, but it can be used even after one month if recovery goals have not been met. Administration and scoring are taught in the LACC rehabilitation courses by Dr. Steven Youmans.2 Software programs are also available for capturing many of these risk factors automatically.3
The recent New Zealand low-back pain guidelines are accompanied by an excellent guide to capturing yellow flags by taking history and questionnaires.4 This is available from their excellent website. LACC has also begun offering a distance learning educational module on biopsychosocial approaches to spinal disorders, which includes much of this information.5
Standard Form
Primary complaint -- please circle: Low back/leg OR Neck/arm
Name ___________________________
Date ______________
BD _________ SC _________
- Is this the first time you have had this pain/complaint? Yes/No (If Yes, skip to #4)
- How many previous episodes required treatment? ______ 4 or more ______
- Have you been hospitalized or had surgery for the same or similar complaint before? Y/N
- Please indicate your usual level of pain during the past week: No pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible pain
- of your pain/complaint? Y/N
- How long ago did your current episode begin?
__ Less than two weeks ago
__ 2 weeks to <3 months ago
__ Three months to <6 months ago
__ 6 months ago - Do you smoke a pack or more of tobacco a day? Y/N
- How would you rate your general health? Fair ___ Poor ___
- How many times have you been married? __ Two __ Three or more __ Divorced
- How physically demanding is your job? (Include housework if not employed outside the home)
Not at all demanding 0 1 2 3 4 5 6 7 8 9 10 Very demanding - How anxious (e.g., tense, uptight, irritable, fearful, difficulty in concentrating/relaxing) have you been feeling during the past week?
Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely anxious - How much have you been able to control (i.e., reduce/help) your pain/complaint on your own during the past week?
Well controlled 0 1 2 3 4 5 6 7 8 9 10 Can't control at all - Please indicate how depressed (e.g., down in the dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopefulness) have you been feeling in the past week?
Not depressed at all 0 1 2 3 4 5 6 7 8 9 10 Extremely depressed - Does pain, numbness, tingling or weakness extend into your leg (from the low back) or arm (from the neck)?
None of the time 0 1 2 3 4 5 6 All of the time - During the last week, how often have you taken medication (such as aspirin, Motrin, Tylenol or prescription medication) for your pain complaint?
__ 3 or more times a day __ couple of day __Once a week - If you had to spend the rest of your life with your condition as it is right now, how would you feel about it?
__ Delighted (satisfied and dissatisfied) __ Mostly dissatisfied
References
- Liebenson CS, Yeomans S. Early identification of risk factors of chronicity. In: Yeomans S. Clinical Application of Outcomes Assessment. Appleton & Lange, sched. publication 1999.
- Yeomans S. Outcomes assessment. LACC first 100-hour rehabilitation course, LACC postgraduate division, (562) 902-3379.
- Synergy Solutions. (800) 950-8133 or (218) 326-0437.
- Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee. Wellington, New Zealand. Available at http://www.nhc.govt.nz.
- Biopsychosocial distance learning module. LACC first 100-hour rehabilitation course, LACC postgraduate division, (562) 902-3379.
Click here for previous articles by Craig Liebenson, DC.