TABLE 2
Warning signs and risk factors for chronification of low back pain
Extravertebral causes
of low back pain Somatic warning signs
(‘red” flags’) Psychosocial risk
factors for
chronification
(‘yellow” flags’) Workplace/employee
perceptions about work
and health (‘blue flags’)
Processes affecting
neighbouring organs:
• Abdominal/visceral
processes
• Vascular changes
• Gynaecological
causes
• Urological causes
• Neurologic diseases
• Mental and
psychosomatic
disorders • Fracture/osteoporosis
• Infection
• Radiculopathy/ • Depressive mood/ Concerns about whether
employee is able to meet
demands of the job
Low job satisfaction
Little or poor support at
work
A perception that the job
is very stressful
An accommodating
approach in the
workplace to providing
altered duties or modified
work options to facilitate
a return to work
Poor communication
between employer and
employee
neuropathy
• Tumours/metastases
• Axial spondylarthritis
Adapted from reference 23
majority of patients will present with somatic low
back pain of musculoskeletal origin – low back
symptoms are non-specific for most patients,
meaning that the pain is localised to the back/
buttocks and is due to a presumed musculo-
ligamentous process. – ruling out these ‘red-flag’
conditions is paramount (Table 2).
More specific radiological and neurophysiological
tests can be applied to determine the presence of
a nerve lesion or compression, but they do not
always provide conclusive results and/or might lack
specificity. Abnormalities in X-rays and magnetic
resonance imaging (MRI) and the occurrence of
non-specific low back pain do not seem to be
strongly associated. Therefore, self-assessment
screening tools such as painDETECT aim to identify
potential patients with neuropathic back pain and
can be tremendously helpful in clinical practice,
because they can be easily applied and interpreted
by non-specialists. 2,11 The use of these tools,
especially in combination with pain drawings, which
are often more sensitive than conventional imaging
techniques such as MRI, can assist in the delineation
and recording of a patient’s pain category. The
painDETECT questionnaire helps in the
identification of spatial patterns of pain radiation,
thus contributing to the determination of the
underlying type of pain and, with this, to treatment
optimisation based on this assumption (Figure 1). 12
It is essential to determine during the
examination whether the pain is musculoskeletal
(paradigm of ‘look, move, feel’) or an indicator to
search for non-musculoskeletal causes and red flag
conditions.Musculoskeletal patients need plenty of
reassurance (and not a multitude of diagnostic tests
such as radiography/CT/MRI), which can be provided
during a careful examination without excessive
effort. This approach has the potential to be of great
therapeutic benefit in its own right, and staying
active speeds up recovery and reduces chronic
disability. Therefore, when ordering an imaging
study, it is important to keep in mind the limitations
of the technique and to consider how the
information obtained will actually influence the
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distress
• Pain-related conditions
• Passive pain behaviour
• Pain-related cognitions
• Tendency to
somatisation