Ways to ask about sensitive topics

I teach postgraduate courses in pain and pain management.  Many of my students are experienced general practitioners who often ask me “how do I talk to people with pain about psychosocial issues without them thinking I’m telling them their pain is ‘all in the head’?” It can be a pretty sensitive topic for the person with unexplained pain that doesn’t go away because to somehow suggest (a) they’re not coping with their situation or (b) they have some psychological problem can seem uncaring or even that the person’s pain is ‘imaginary’.

The psychosocial ‘yellow flags’ are widely known, but even after a decade or more of exposure to what the ‘yellow flags’ are, there is much confusion and misconception.  Today’s post will hopefully help to clarify things a little.

In 1997, the Acute Low Back Pain Guidelines were published in New Zealand.  As a companion to this publication, the ‘Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain’ was also produced by my then colleague Dr Nicholas Kendall, along with Steve Linton and Chris Main.  It was a very new concept and a little bit revolutionary – for the first time not only were physical risk factors and medical management of acute low back pain detailed, but risk factors for long-term disability and work-loss were included and considered to be of equal importance.

Red flags are risk factors in acute low back pain that indicate the need for urgent medical investigation and management in order to prevent serious harm – things like caudae equinae and tumours and so on need to be identified as soon as possible so that effective management can be instituted.  Yellow flags are described as ‘the analogue’ to these physical risk factors, and are equally likely to lead to long-term disability and ‘serious harm’ from back pain. They are the psychosocial factors (note: not psychological) that need to be identified and managed as early as possible so that people can have the best chance for recovery.

The distinction between psychosocial factors and psychological factors is very clear: psychosocial includes the social in the original publication, it is described as ‘the interaction between the person and their social environment, and the influences on their behaviour’. (frequent readers of this blog – do you see a theme happening here?!)  This includes family members, friends, people at work, employers, the compensation system and health professionals.  It also includes cultural and community and socioeconomic factors.  All these things can affect how a person views his or her pain, and how they respond behaviourally.

There are seven ‘headings’ or groups of psychosocial factors to explore: Attitudes and beliefs, Behaviours, Compensation issues, Diagnostic/Iatrongenic factors, Emotions, Family and Friends, and Work factors.  (Observant people will note that these translate into the mnemonic ‘ABCDEFand W’)  People can have problems recovering from acute pain because of the presence of a few very striking factors, or multiple, less important factors.  In any event, if psychosocial factors that are known to be associated with the risk of long-term disability are present, they need to be assessed and managed effectively and promptly. And by everyone in the health care team from case manager, GP, practice nurse, physiotherapist, occupational therapist – yes, everyone!And not necessarily by clinical psychologists although they may be helpful with more seriously affected people.

So, how do you raise the questions?

The Yellow flags document (click on the link to go to KendallBurton’s page full of great documents, and including the YF doc from 1997) has some great suggestions about how to phrase the questions:

• Have you had time off work in the past with back pain?
• What do you understand is the cause of your back pain?
• What are you expecting will help you?
• How is your employer responding to your back pain? Your co-workers? Your family?
• What are you doing to cope with back pain?
• Do you think that you will return to work? When?

Here are some more, grouped under the headings.  I’d weave them into your normal history-taking – they are absolutely as relevant as any physical examination.

Attitudes and beliefs

‘Some people think pain like yours is always a sign of damage or harm – what do you think?’
‘What do you think is causing your pain? What do you think should happen to help you recover?’
‘What do you think about starting to do normal activities even while your pain is present?’


‘To help me understand how this pain is affecting you, could you take me through a typical day?’
‘Are there movements or activities that you are worried about doing, or even steer clear of?’
‘How is your sleep at the moment?’

Compensation issues

‘Is there anything going on with your medical/accident claim right now?’
‘How is the process of making a claim affecting you at the moment?’
‘How is your relationship with your case manager?’

Diagnostic/Iatrogenic issues

‘What is your theory on the cause of your pain?’
‘What have other health providers said about your pain?’
‘What kind of advice have you had from the health people you’ve seen?’


‘Can you tell me how you’ve been feeling about your situation?’
‘How has your pain affected your spirits?’
‘Can your mood take a dip? Does it make you feel wound up?’

Family and Friends

‘What lets other people know you’re having a bad day?’
‘How do your family and friends feel about you starting to do everyday activities?’
‘What have your friends and family suggested you do about your pain?’
‘What do your friends and family do or say when they know you’re having a bad day?’

Work issues

‘How have your employers and workmates been about your pain?’
‘Can you take me through a typical work day?’
‘How has your employer been about taking you back at work?’
‘What has your contact with your work been like?’

(Acknowledgement to Dr David Craig, Clinical Psychologist, Greater Glasgow Back Pain Service)

To find some really good suggestions about how to best support a person with acute low back pain – head to the link above, and within the Yellow Flags document is a great section on strategies that ANYONE can suggest or integrate into their clinical practice.

Psychosocial risk factors shouldn’t just be identified – although that’s a first step. They also need to be managed and managed promptly. After reading a medical report yesterday in which a well-known musculoskeletal doctor clearly identified the presence of ‘fear avoidance’ but did not make a single suggestion about this being managed (instead, lots of suggestions about more diagnostics and ‘physical rehabilitation’) – I think I need to post about ‘what to do when you’ve found yellow flags’ tomorrow!


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