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Assessing Psycho-social Barriers to Rehabilitation in Injured Workers with Chronic Musculoskeletal Pain: Development and Item Properties of the Yellow Flag Questionnaire (YFQ)

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Abstract

Purpose To develop a multidimensional scale to asses psychosocial beliefs—the Yellow Flag Questionnaire (YFQ)—aimed at guiding interventions for workers with chronic musculoskeletal (MSK) pain. Methods Phase 1 consisted of item selection based on literature search, item development and expert consensus rounds. In phase 2, items were reduced with calculating a quality-score per item, using structure equation modeling and confirmatory factor analysis on data from 666 workers. In phase 3, Cronbach’s α, and Pearson correlations coefficients were computed to compare YFQ with disability, anxiety, depression and self-efficacy and the YFQ score based on data from 253 injured workers. Regressions of YFQ total score on disability, anxiety, depression and self-efficacy were calculated. Results After phase 1, the YFQ included 116 items and 15 domains. Further reductions of items in phase 2 by applying the item quality criteria reduced the total to 48 items. Phase factor analysis with structural equation modeling confirmed 32 items in seven domains: activity, work, emotions, harm & blame, diagnosis beliefs, co-morbidity and control. Cronbach α was 0.91 for the total score, between 0.49 and 0.81 for the 7 distinct scores of each domain, respectively. Correlations between YFQ total score ranged with disability, anxiety, depression and self-efficacy was .58, .66, .73, −.51, respectively. After controlling for age and gender the YFQ total score explained between R2 27% and R2 53% variance of disability, anxiety, depression and self-efficacy. Conclusions The YFQ, a multidimensional screening scale is recommended for use to assess psychosocial beliefs of workers with chronic MSK pain. Further evaluation of the measurement properties such as the test–retest reliability, responsiveness and prognostic validity is warranted.

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Acknowledgements

The authors thank the patients and clinicians of the Department of Work Rehabilitation in the Rehabilitation Clinic in Bellikon for the help in the development of the Yellow Flag Questionnaire. Furthermore, the authors thank Stefan Kälin for his help in item analysis.

Funding

Part of the study was funded by the Swiss Accident Insurance Fund, SUVA (Schweizerische Unfallversicherungsanstalt).

Author information

Authors and Affiliations

  1. Department of Work and Organisational Psychology, Institute of Psychology, University of Bern, Fabrikstrasse 8, 3012, Bern, Switzerland

    Cornelia Rolli Salathé, Livio Claudio Terribilini & Achim Elfering

  2. Department of Work Rehabilitation, Rehaklinik Bellikon, SUVA Care, Bellikon, Switzerland

    Maurizio Alen Trippolini & Michael Oliveri

  3. National Centre of Competence in Research, Affective Sciences, University of Geneva, CISA, Geneva, Switzerland

    Achim Elfering

Authors
  1. Cornelia Rolli Salathé
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  3. Livio Claudio Terribilini
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  4. Michael Oliveri
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  5. Achim Elfering
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Contributions

Maurizio Trippolini and Michael Oliveri were project leaders, conceived the design of the study, provided funding, and data collection. Livio Terribilini performed data analysis and wrote the first draft of the manuscript. Cornelia Rolli Salathé and Achim Elfering structured the ideas, offered statistical support, performed psychometric analyses, and wrote the manuscript. All authors were involved in data interpretation, revised the manuscript, and gave final approval of the manuscript.

Corresponding author

Correspondence to Cornelia Rolli Salathé.

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Conflict of interest

All authors declare that they have no financial or non-financial competing of interests related to this study.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Patients were only included in the study if they had consented to the use of their data for research purposes. The ethical committee of Aargau canton, Switzerland approved the study.

Appendix 1

Appendix 1

The Yellow Flag Questionnaire (YFQ)

Instructions: Please read each statement and indicate how much you agree. Please choose only one answer per question.

□ Strongly Agree.

□ Somewhat Agree.

□ Unsure.

□ Somewhat Disagree.

□ Strongly Disagree.

Activity

F1. I can do physical activities even if these (might) make my pain worse [r].

F8. I should rest and not do physical activities when I am in pain.

F13. I should lay down for a longer period of time when I am in pain.

F18. Regular exercise decreases the amount of pain experience [r].

F26. If I get the chance to do something I enjoy, I do it even if it causes pain [r].

F33. Although I might experience more pain, I would be better off if I were physically active [r].

F39. I will stop any activity as soon as I sense pain coming on.

Work

F35. I do not think that I will ever be able to go back to work.

F47. Doctors and insurers must understand that I am entitled to claim for compensation for my pain.

F58. Only if my pain is gone I will be able to work.

F104. I believe that further adapted work on light duties would worsen my health.

Emotions

F50. I constantly need to clench my teeth in order to perform at my best.

F56. Due to my pain I have withdrawn from social interactions with family or friends.

F60. I did not lose my sense of humour despite of my pain [r].

F68. I do enjoy things in life despite of my pain.

F69. I feel tenser than before.

F73. I feel useless.

Harm and Blame

F2. Whenever I feel increasing pain, I am afraid of an additional injury.

F7. I am afraid that I might harm myself if I exercise.

F10. Knowing whom to blame for my injury is of great importance to me.

F22. I am suffering due to somebody else’s negligence treating my problem.

Diagnostic Beliefs

F31. Further inquiries such as imaging would contribute to find the right treatment.

F54. I expect doctors to solve my pain-problem.

Co-morbidity

F66. Due to my pain, my sleep is severely disturbed.

F67. I often feel downhearted and depressed.

Control

F9. I can influence my pain in a positive manner without taking medications [r].

F15. Pain dominates my life.

F25. I am afraid that my pain will eventually get worse.

F27. I cannot possibly control nor intervene in my pain conditions.

F28. My pain does not bother me whenever I am distracted [r].

F37. When pain exacerbates, I call my physician or visit the emergency room.

F40. As soon as feel pain, I start worrying when it will stop again.

Notes: F-codes refer to the numbering in the original sample of 116 questionnaire items; [r] indicates a reverse-scored item.

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Salathé, C.R., Trippolini, M.A., Terribilini, L.C. et al. Assessing Psycho-social Barriers to Rehabilitation in Injured Workers with Chronic Musculoskeletal Pain: Development and Item Properties of the Yellow Flag Questionnaire (YFQ). J Occup Rehabil 28, 365–376 (2018). https://doi.org/10.1007/s10926-017-9728-8

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