Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

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Clinical measurement, crosssectional.


Pain-associated psychological distress adversely influences outcomes for patients with musculoskeletal pain. However, assessment of pain-associated psychological distress (ie, yellow flags) is not routinely performed in orthopaedic physical therapy practice. A standardized yellow flag assessment tool will better inform treatment decision making related to psychologically informed practice.


To describe the development of a concise, multidimensional yellow flag assessment tool for application in orthopaedic physical therapy clinical practice.


A 136-item yellow flag item bank was developed from validated psychological questionnaires across domains related to pain vulnerability (negative mood, fear avoidance) and resilience (positive affect/coping). Patients seeking physical therapy with neck, back, knee, or shoulder pain completed the item bank. Iterative statistical analyses determined minimal item sets meeting thresholds for identifying elevated vulnerability or low resilience (ie, upper or lower quartile, as indicated). Further item reduction yielded a concise yellow flag assessment tool to assess 11 psychological constructs measuring pain-associated psychological distress. Correlations between the assessment tool and individual psychological questionnaires were measured and compared between anatomical regions. Concurrent validity was assessed by determining variance explained in pain and disability scores by the assessment tool.


Subjects with elevated vulnerability and decreased resilience were identified with a high degree of accuracy (minimum of 85%) using a 17-item tool. Correlations were moderate to high between the 17-item tool and individual psychological questionnaires, with no significant differences in correlations between different anatomical regions. Shorter 10- and 7-item versions of the assessment tool allow clinicians the flexibility to assess for yellow flags quickly with acceptable trade-offs in accuracy (81% and 75%, respectively). All versions of the tool explained significant additional variance in pain and disability scores (range, 19.3%-36.7%) after accounting for demographics, historical variables, and anatomical region of pain.


Concise assessment of yellow flags is feasible in outpatient physical therapy settings. This multidimensional tool advances assessment of pain-associated psychological distress through the addition of positive affect/coping constructs and estimation of full questionnaire scores. Further study is warranted to determine how this tool complements established risk-assessment tools by providing the option for efficient treatment monitoring. J Orthop Sports Phys Ther 2016;46(5):327-345. Epub 21 Mar 2016. doi:10.2519/jospt.2016.6487

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