Psycho-Social
Psycho-social barriers are characteristics that can naturally occur as a result of injury and have the potential to influence the natural recovery process. They were originally blanket termed as 'clinical yellow flags' which was clear and concise however as our understanding regarding these barriers has increased so has the number of flags. In fact we now seem to have so many flags that we are going to run out of colours!! To make life easier, unless specific issues are being discussed, we will continue to refer to the blanket term yellow flags in this explanation.
It is important to appreciate at this stage that yellow flags should not be confused with the other important group of red flags. These are signs or symptoms indicating serious underlying pathological problems that need to be investigated further as a matter of urgency. These are always bio-medical in origin.
The following diagram illustrates nicely the different flags and what defines that colour. Please note that since this was formulated an orange flag has also been added. Yellow, blue and black flags should be considered born of normal psychological processes whereas orange flags indicate actual psychiatric disorders. These are obviously beyond the management of non-specialists so are not always listed in common context.
It is important to appreciate at this stage that yellow flags should not be confused with the other important group of red flags. These are signs or symptoms indicating serious underlying pathological problems that need to be investigated further as a matter of urgency. These are always bio-medical in origin.
The following diagram illustrates nicely the different flags and what defines that colour. Please note that since this was formulated an orange flag has also been added. Yellow, blue and black flags should be considered born of normal psychological processes whereas orange flags indicate actual psychiatric disorders. These are obviously beyond the management of non-specialists so are not always listed in common context.
After injury we all tend to exhibit some pyscho-social characteristics and this is part of being human, reflecting the environment we live in. They only become barriers to recovery when they deviate your normal recovery process from its normal path. We gave some examples on the previous page regarding psycho-social barriers and if you refer back to them, placing them with the appropriate flag group within the diagram, it gives you a practical understanding of the system. We do know however that some changes tend to have a far higher impact on recovery than others with the worst offenders being:
1) Catastrophrophising (this is where you only concentrate on the worst possible outcomes)
2) Fear Avoidance (this is where you don't do something becasue of the fear it may be detrimental e.g. be painful, rather than it actually being so)
3) Maladapted Coping strategies (these are the changes made to your normal activities, lifestyles, habits etc to enable you to continue, but actually have a negative effect on your overall recovery rate)
4) Anxiety/Distress
5) Stress
6) High Workload
2) Fear Avoidance (this is where you don't do something becasue of the fear it may be detrimental e.g. be painful, rather than it actually being so)
3) Maladapted Coping strategies (these are the changes made to your normal activities, lifestyles, habits etc to enable you to continue, but actually have a negative effect on your overall recovery rate)
4) Anxiety/Distress
5) Stress
6) High Workload
When do they occur? The very nature of psycho-social barriers means that they evolve with time although the rate at which they do so is ultimately defined by you as an individual. The general consensus, backed up by primary investigations concluded that they were present only in chronic pain presentations which is defined as the same continuous pain for a duration greater than 3 months. This is a great point at which to point out some obvious floors when basing medical conclusions on research alone. No matter how good the investigation, the results can only reflect the method of the study. In this case one cannot argue that psycho-social barriers were present in the chronic presentation, but that is only because this was the primary group at which the studies were aimed! Interpretation of data is at times more important that the data itself.
More recently however research has been targeted with a specific aim of identifying when psycho-social factors become adverse rather than when they are obviously present. It would make perfect sense to most of us that addressing the issues at their 'birth' will be easier than doing so when they have had time to evolve and perpetuate across many levels. These have shown that some people are negatively affected as early as in the acute phase. This is considered to be the first 3 month following the injury. For many practitioners this was seen as quite a shock and has led to the need for more vigilance and screening to be undertaken at a much earlier stage. New Zealand tends to lead the world in this type of screening with national guidelines stipulating its direct inclusion if progress at 2-4 weeks in not deemed normal. Currently, there are no hard and fast rule within the UK regarding this topic in relation to initial contact with advice simply encouraging us to 'take psycho-social factors in to account'. The are recommendations however, published within the NICE guidelines, that recommend referral to a Functional Restoration programme if primary forms of rehabilitation fail to resolve the issue. Due to the funding available however it can be very hard for clients to access this reliably.
How are they screened/measured? The only validated means, that is clinically proven to be reliable, is by specific questionnaire. These tend to be long winded however and in a normal outpatient environment are, for most unrealistic, unless in a specialised setting or unit such as a pain clinic. Instead, practitioners will tend to use verbalised cues to pick up on any factors they feel may begin to impact upon your recovery rate and level. The success of this is process is reliant upon the individual clinician and their willingness to identify, act upon and ultimately accept these characteristics. Unfortunately there is evidence to suggest that many of the 'average' practitioners may not identify them!
More recently however research has been targeted with a specific aim of identifying when psycho-social factors become adverse rather than when they are obviously present. It would make perfect sense to most of us that addressing the issues at their 'birth' will be easier than doing so when they have had time to evolve and perpetuate across many levels. These have shown that some people are negatively affected as early as in the acute phase. This is considered to be the first 3 month following the injury. For many practitioners this was seen as quite a shock and has led to the need for more vigilance and screening to be undertaken at a much earlier stage. New Zealand tends to lead the world in this type of screening with national guidelines stipulating its direct inclusion if progress at 2-4 weeks in not deemed normal. Currently, there are no hard and fast rule within the UK regarding this topic in relation to initial contact with advice simply encouraging us to 'take psycho-social factors in to account'. The are recommendations however, published within the NICE guidelines, that recommend referral to a Functional Restoration programme if primary forms of rehabilitation fail to resolve the issue. Due to the funding available however it can be very hard for clients to access this reliably.
How are they screened/measured? The only validated means, that is clinically proven to be reliable, is by specific questionnaire. These tend to be long winded however and in a normal outpatient environment are, for most unrealistic, unless in a specialised setting or unit such as a pain clinic. Instead, practitioners will tend to use verbalised cues to pick up on any factors they feel may begin to impact upon your recovery rate and level. The success of this is process is reliant upon the individual clinician and their willingness to identify, act upon and ultimately accept these characteristics. Unfortunately there is evidence to suggest that many of the 'average' practitioners may not identify them!
