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More recently, a distinction has been drawn between psychological risk factors that might be considered essentially “normal,” but unhelpful, psychological reactions to musculoskeletal symptoms (eg, the belief that pain necessarily implies damage) and clearly “abnormal” psychological or psychiatric factors or disorders (eg, posttraumatic stress disorder, major depression) suggestive of diagnosable psychopathology<ref name="Main2">Main CJ, Phillips CJ, Watson PJ. Secondary prevention in health-care and occupational settings in musculoskeletal conditions focusing on low back pain. In: Schultz IZ, Gatchel RJ, eds. Handbook of Complex Occupational Disability Claims: Early Risk Identification, Intervention and Prevention. New York, NY: Kluwer Academic/Plenum; 2005:387–404.</ref><ref name="Main3">Main CJ, Sullivan MJ, Watson PJ. Risk identification and screening. In: Main CJ, Sullivan MJ, Watson PJ, eds. Pain Management: Practical Applications of the Biopsychosocial Perspective in Clinical and Occupational Settings. Edinburgh, Scotland: Churchill Livingstone Elsevier; 2008:97–134.</ref>. It has been suggested that the normal but unhelpful psychological reactions should be described as yellow flags, and those meeting criteria for psychopathology should be termed “'''orange flags'''.”<ref name="Main2" /><ref name="Main3" /> The primary significance of this distinction is to differentiate yellow flag factors, which might be amenable to change by suitably trained health care providers such as general medical practitioners and physical therapists, from orange flag factors that probably require specialist mental health referral.
More recently, a distinction has been drawn between psychological risk factors that might be considered essentially “normal,” but unhelpful, psychological reactions to musculoskeletal symptoms (eg, the belief that pain necessarily implies damage) and clearly “abnormal” psychological or psychiatric factors or disorders (eg, posttraumatic stress disorder, major depression) suggestive of diagnosable psychopathology<ref name="Main2">Main CJ, Phillips CJ, Watson PJ. Secondary prevention in health-care and occupational settings in musculoskeletal conditions focusing on low back pain. In: Schultz IZ, Gatchel RJ, eds. Handbook of Complex Occupational Disability Claims: Early Risk Identification, Intervention and Prevention. New York, NY: Kluwer Academic/Plenum; 2005:387–404.</ref><ref name="Main3">Main CJ, Sullivan MJ, Watson PJ. Risk identification and screening. In: Main CJ, Sullivan MJ, Watson PJ, eds. Pain Management: Practical Applications of the Biopsychosocial Perspective in Clinical and Occupational Settings. Edinburgh, Scotland: Churchill Livingstone Elsevier; 2008:97–134.</ref>. It has been suggested that the normal but unhelpful psychological reactions should be described as yellow flags, and those meeting criteria for psychopathology should be termed “'''orange flags'''.”<ref name="Main2" /><ref name="Main3" /> The primary significance of this distinction is to differentiate yellow flag factors, which might be amenable to change by suitably trained health care providers such as general medical practitioners and physical therapists, from orange flag factors that probably require specialist mental health referral.
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Below is a table with some examples of a flag colour, the nature of the flag and examples of clinical signs to look for on assessment<ref> Leerar,P. Boissonnault,W. Domholdt,E. Roddey,T. Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain.J Man Manip Ther. 2007; 15(1): 42–49.</ref><span style="line-height: 1.5em;">:</span>
{| width="100%" border="1" align="center" cellpadding="1" cellspacing="1"
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| Red
| Red
| Signs of serious pathology
| Signs of serious pathology
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| Cauda equina syndrome, fracture, tumour
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| Cauda equina syndrome, fracture, tumour
, unremitting night pain, sudden weight loss of 10pounds over 3 months, Bladder & Bowel incontinence
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| Orange
| Orange
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| Unhelpful beliefs about pain: indication of injury as uncontrollable or likely to worsen.<br>Expectations of poor treatment outcome, delayed return to work.
| Unhelpful beliefs about pain: indication of injury as uncontrollable or likely to worsen.<br>Expectations of poor treatment outcome, delayed return to work.
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|-
-
| Yellow
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| Yellow
| Emotional Responses
| Emotional Responses
| Distress not meeting criteria for diagnosis of mental disorder.<br>Worry, fears, anxiety.<br>
| Distress not meeting criteria for diagnosis of mental disorder.<br>Worry, fears, anxiety.<br>
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|-
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| Yellow
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| Yellow
| Pain behaviour (including pain and coping strategies)
| Pain behaviour (including pain and coping strategies)
| Avoidance of activities due to expectations of pain and possible reinjury.<br>Over-reliance on passive treatments.
| Avoidance of activities due to expectations of pain and possible reinjury.<br>Over-reliance on passive treatments.
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=== Cognitive behavioural approach ===
=== Cognitive behavioural approach ===
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[[Cognitive Behavioural Therapy]] (CBT) is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner <ref name="Beck 1995">Beck, J., 1995. Cognitive Therapy: Basics and Beyond. Guildford Press: New York</ref> <ref name="NHS Choices 2012">NHS Choices, 2012. Cognitive behavioural therapy. [online] Available at:
&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;
http://www.nhs.uk/conditions/cognitive-behavioural-therapy/Pages/Introduction.aspx [Accessed 8th Jan 2014]</ref>.
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[[Cognitive Behavioural Therapy]] (CBT) is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner <ref name="Beck 1995">Beck, J., 1995. Cognitive Therapy: Basics and Beyond. Guildford Press: New York</ref> <ref name="NHS Choices 2012">NHS Choices, 2012. Cognitive behavioural therapy. [online] Available at:http://www.nhs.uk/conditions/cognitive-behavioural-therapy/Pages/Introduction.aspx [Accessed 8th Jan 2014]</ref>.
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It is not just psychologists or psychiatric nurses who specialise in CBT as some ESP physiotherapists, mainly in a MSK setting, have been trained in this specialist area so it is worth investigating who you could refer a patient to.
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It is not just psychologists or psychiatric nurses who specialise in CBT as some ESP physiotherapists, mainly in a MSK setting, have been trained in this specialist area so it is worth investigating who you could refer a patient to.
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