Yellow flags are an important aid to our management of acute low back pain, as Dr Charles Sears explains


The new version of the RCGP Guidelines on the Management of Acute Low Back Pain1 highlights the importance of yellow flags (beliefs or behaviours on the part of the patient which may predict poor outcomes). The previous guidelines stressed the need to carry out psychosocial assessment, and the yellow flags merely flesh this out.

The main message of the new guidelines is unchanged from the original: keep the patient mobile and at work if at all possible.

The yellow flags are given in abbreviated form in the RCGP Guidelines, and in full in the New Zealand Back Pain Guidelines.2 These have been developed by a multinational group of experts. Their work is evidence based and formed part of the first RCGP Guidelines, but gives more detail on the importance of psycho-social assessment in predicting the outcome of acute back pain in an individual, and on the methods one might use to make this assessment.

Back pain is very common, but most often resolves spontaneously. GPs cannot afford to offer treatment at an early stage, however effective it may be, when the majority of patients will be better in a few days anyway. On the other hand, we know that once chronicity sets in, treatment is less likely to be effective.

The big question is how to predict,at an early stage, which patients are likely to develop chronic back pain and, more importantly, associated disability.

Many of the physical factors that might be expected to have predictive value in this context are not helpful, but the psychosocial factors, referred to as 'yellow flags', have been shown to be good predictors of poor outcome.

The New Zealand Guidelines are detailed and include a questionnaire that can be used as an assessment tool. On a day-to-day basis, this is probably too cumbersome for anyone but a person with a special interest, but the main features to watch for, which are cited in the RCGP Guidelines, are as follows:

  • Presence of a belief that back pain is harmful or potentially severely disabling
  • Fear-avoidance behaviour (avoiding a movement or activity because of misplaced anticipation of pain) and reduced activity levels
  • Tendency to low mood and withdrawal from social interaction
  • Expectation that passive treatment rather than active participation will help.

The New Zealand Guidelines suggest simple questions that can help to draw out these features in even the briefest of consultations. Even if we do not use the full questionnaire in our daily practice, the guidelines draw our attention to an important aspect of the back pain consultation.

We are encouraged to be positive in outlook, to focus on improvement in function, however small, at reviews, and to keep our patients active and at work when possible.

The New Zealand Guidelines website2 is well worth visiting for more detail. Some may even wish to use the questionnaire.

There is also a very helpful textbook by Professor Gordon Waddell,3 which covers all aspects of the management of back pain, detailing the evidence 'nd covering all the recent guidelines. The yellow flags are discussed in full.

Regardless of where we learn about them, yellow flags are an important aid to our management of patients with low back pain.

  • The one-page version of Clinical Guidelines for the Management of Acute Low Back Pain (first revision) is available from Paula-Jayne McDowell at the RCGP. The full evidence base for the guidelines is available from the same source, price £11 (£10 for members).


  1. Clinical Guidelines for the Management of Acute Low Back Pain (first revision). London: RCGP, 1999.
  3. Waddell G. The Back Pain Revolution. London: Churchill Livingstone, 1998.


Guidelines in Practice, October 1999, Volume 2
© 1999 MGP Ltd
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