Screening for yellow flags in orthopaedic physical therapy: a clinical framework

Key Points

1. To address biological, psychological, and social aspects, it can be efficient to use screening forms for consistency.
2. Clinics and clinicians should choose forms that are validated such as the OSPRO-YF and have them available in the languages spoken in their population.
3. Consistency of application is key for clinical practice regarding the use of outcome measures and screening forms.

BACKGROUND & OBJECTIVE

Pain and the treatment of pain make up the bulk of physical therapy cases. Neurological distress and disease, the long-term effects of chronic disease, and the emerging challenge of Long Covid all share the need of addressing a biopsychosocial framework in order to individualize interventions.

To address biological, psychological, and social distress, it is efficient to use screening forms for consistency. The authors of this clinical commentary suggested the use of consistent screening for yellow flags in order to identify areas of need at the beginning of care. There are multiple options; this paper used the Optimal Screening for Prediction of Referral and Outcome Yellow Flag tool (OSPRO-YF) as the example (1).

There is consensus in the International Association for the Study of Pain (IASP) in their interdisciplinary education criteria of the importance of psychological distress as well as physical function (2). Multiple clinical practice guidelines also recommend standard screening of yellow flags as well as referral to other professionals as needed for proper management.

Despite these recommendations there is not yet a consistent use of screening for yellow flags in physical therapy (3). The authors of this commentary provided a clear framework that is adaptable to move the conversation about screening for yellow flags, to discussions on how to use the information to guide clinical practice.

Multiple clinical practice guidelines also recommend standard screening of yellow flags as well as referral to other professionals as needed for proper management.

Screening for yellow flags is appropriate for all patients in physical therapy regardless of their diagnosis.

CLINICAL FRAMEWORK

A three-step framework is proposed to create clinical consistency:

Step 1: Establish a standard screening process

• Chose a screening tool among the available validated tools
• Identify which patients to screen (all or a select group)
• Establish frequency of screening

Step 2: Shared decision-making

• Collaborative treatment planning (patient and therapist)
• Appropriate referral to other providers, including emergency care if indicated based on the screening results and risks

Step 3: Treatment monitoring

• Monitor changes as treatment progresses to determine treatment response
• Adapt treatment focus as needed based on screening

LIMITATIONS

The recommendations in this paper and other similar papers regarding standardizing screening for psychosocial factors are intuitively sensible and still not supported by strong evidence as to which form to use. There is also no evidence that using such screening increases the outcome quality of therapy or shortens the duration of therapy.

CLINICAL IMPLICATIONS

Consistency of application is key for clinical practice regarding the use of outcome measures and screening forms. Screening for yellow flags is appropriate for all patients in physical therapy regardless of their diagnosis. By screening all patients at the first visit, the therapists and clinics avoid the error of assuming who might be having problems.

This paper refers to psychologically informed physical therapy as separate from standard physical therapy (as shown in Figure 1). It would be best for consistency if instead, all physical therapy be psychologically informed!

This would simplify Figure 1 to three pathways for decision making and include self-management, encouragement, and advice to remain active to all patients regardless of diagnosis, while also being mindful of the individual psychosocial strengths and areas in need of extra support.

How clinicians can implement this in clinical practice:

• Clinics and clinicians should choose forms that are validated such as the OSPRO-YF and have them available in the languages spoken in their population.

• Give the form to all patients on the first encounter.

• Review the form during the evaluation and use the information to guide recommendations at that first encounter and at each subsequent visit.

• On discharge or follow up visits, have the patients fill out the screening form again to assess progress made during therapy and aid the clinicians in refining their skills in addressing maladaptive thoughts, beliefs, and expectations.

+STUDY REFERENCE

Stearns Z, Carvalho M, Beneciuk J and Lentz T (2021) Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework. Journal of Orthopaedic & Sports Physical Therapy, 51(9), 459-469.

SUPPORTING REFERENCE

1. Lentz, T., Beneciuk, J., Bialosky, J., Zeppieri, G., Dai, Y., Wu, S. and George, S., 2016. Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort. Journal of Orthopaedic & Sports Physical Therapy, 46(5), pp.327-343.
2. IASP Interprofessional Pain Curriculum Outline | International Association for the Study of Pain (IASP). [online] International Association for the Study of Pain (IASP). Available at:<www.iasp-pain.org/education/curricula/iasp-interprofessional-pain-curriculum-outline/> [Accessed 17 October 2021].
3. Östhols, S., Boström, C. and Rasmussen-Barr, E., 2018. Clinical assessment and patient-reported outcome measures in low-back pain – a survey among primary health care physiotherapists. Disability and Rehabilitation, 41(20), pp.2459-2467.