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Identifying personal and environmental risk factors with FACTORWEB

FACTORWEB is an acronym that outlines known risk factors for long term disability associated with soft tissue injury. These personal and environmental factors are also referred to as psychosocial risk factors or 'yellow flags'.

FACTORWEB is customised for New South Wales (NSW) based on the NZACC Clinical assessment of psychological yellow flags checklist.1

Workers are at risk if they have one or more strong risk factors, or an accumulation of several less important risk factors. Each heading is equally important as a category of risk. Within each heading the risk factors are arranged in order of importance. The strongest risk factor is at the top.

F = Family

  1. Overly protective partner who emphasises fear of harm or encourages the perception of injury as a catastrophe (usually well-intentioned).
  2. Overly solicitous behaviour from partner (may inadvertently reinforce disability by taking over tasks and doing too much for the injured worker).
  3. Partner overly involved in claim and injury management. For example, calling insurer and treatment providers (this needs to be assessed in light of cultural, ethnic, religious or linguistic background).
  4. Hostile or socially punitive responses from partner. For example, ignoring, belittling or expressing anger.
  5. Lack of family support for recovery at/return to work.
  6. Lack of support person to talk to.

A = Attitudes and beliefs

  1. Belief that pain is harmful or indicates ongoing physical damage (resulting in fear of anything that leads to more pain and avoidance of activities expected to be painful).
  2. Belief that the injury must be diagnosed and treated first.
  3. Belief that one is unable to function in pain and pain relief must occur before attempting to return to normal activity including work.
  4. Expectation of increased pain with activity or work, lack of ability to predict personal capacity.
  5. The perception of the injury as a catastrophe, thinking the worst, misinterpreting bodily symptoms, assigning all problems to the injury.
  6. Belief that pain is uncontrollable.
  7. Passive, symptom-focused attitude to rehabilitation and return to work.

C = Compensation issues

  1. Lack of financial incentive to return to work.
  2. Delayed payment of weekly and/or medical compensation benefits.
  3. Negative experience when notifying employer of injury. For example, being discouraged from reporting, disbelief of stated circumstances of injury or employer requests the insurer dispute liability for the claim.
  4. Unresolved disputed over causation, liability or return to work requiring recourse to an external decision maker.
  5. Lack of early assessment of barriers to recovery at/return to work by insurer/employer.
  6. Inappropriate insurer case management strategies to address barriers to return to work. For example, a generic plan covering a range of general contingencies, non-referral for indicated services, inactivity or "wait and see" approach in the presence of yellow flags.
  7. Perception of uncaring or ineffective case management. For example, the case manager does not return calls promptly, disagrees that treatment is reasonably necessary, or does not approve further sessions in a timely manner with minimal explanation.
  8. History of extended time off work with payment by compensation.
  9. Worker engages a representative (legal, family or union) to negotiate matters with insurer or employer in circumstances that would not ordinarily require representation.

T = Treatment and diagnosis

  1. Health professional sanctioning disability. For example, not supporting recovery at work, not providing interventions that will improve function.
  2. Nominated treating doctor fails to respond to communication by insurer/providers.
  3. Conflicting diagnoses or explanations for pain.
  4. Diagnostic language leading to the perception of the injury as a catastrophe and fear. For example, the fear of ending up in a wheelchair.
  5. Dramatisation of pain of musculoskeletal origin by health professional producing dependency on treatments.
  6. Continuation of symptom-focused treatment by provider in the absence of improvement in functional outcomes. For example, continued treatment resulting in no upgrade of functional and/or work capacity.
  7. Number of visits to health professional(s) in last year excluding the present injury (more visits may increase risk of continuing disability).
  8. Expectation of a mechanical or technical "fix".
  9. Advice to withdraw from work.

O = Older/other occurrences of injury

  1. Previous injury with extended time off work.
  2. Previous compensable injury.
  3. History of previous pain.
  4. Persistent pain problem. For example pain is continuing for more than 12 weeks.
  5. Older worker.

R = Return to work

  1. Failure to return to work by 52 weeks predicts permanent unemployment in most workers.
  2. Negative attitude to the worker's return to work by employer/treatment provider.
  3. Employer does not have required return to work systems in place. For example, no return to work program, untrained or inexperienced return to work coordinator.
  4. Negative experience of employer's management of injury and return to work processes including absence of contact, lack of open communication or interest in worker by employer.
  5. Unavailability of suitable work to support recovery at work.
  6. Disputed return to work status. For example, nominated treating doctor disagrees with injury management consultant (independent doctor) and/or workplace rehabilitation provider that the worker could recover at work.
  7. Adequate workplace assessment information not available before developing the recovery at work plan.

W = Work

  1. History of manual work - notable NSW occupations include builders, carpenters, labourers, truck drivers and nurses.
  2. Work history includes job dissatisfaction, pattern of frequent job changes, or poor vocational direction.
  3. Belief that work is harmful, that it will do damage or be dangerous.
  4. Unsupportive or unhappy current environment, stress at work, poor relationship with peers or supervisors, subject to disciplinary action.
  5. Low educational background, low socio-economic status.
  6. Job involves significant bio-mechanical demands. For example lifting, manual handling of heavy items, prolonged sitting/standing/driving, vibration, maintenance of constrained or sustained posture, inflexible work schedule preventing appropriate breaks.
  7. Job involves shift work or hours that are unsociable/not family friendly.
  8. Casual work, labour hire.

E = Emotions

  1. Fear of increased pain from activity or work.
  2. Depression (especially long term low mood), loss of sense of enjoyment.
  3. Increased irritability.
  4. Anxiety and heightened awareness of body sensations (includes sympathetic nervous system arousal).
  5. Feeling under stress and unable to maintain sense of control.
  6. Presence of social anxiety or disinterest in social activity.
  7. Feeling useless and not needed.

B = Behaviours

  1. Use of extended rest, disproportionate "downtime".
  2. Reduced activity level with significant withdrawal from activities of daily living, particularly work.
  3. Irregular participation or poor compliance with physical exercise or activity.
  4. Tendency for activities to be in a "boom-bust" or "do too much-pay for it later" cycle.
  5. Avoidance of normal activity and progressive substitution of a lifestyle away from work/productive activities.
  6. Has not returned to work within the usual time frame for injury type. For example, outside normal clinical guidelines.
  7. Report of intense pain - above 10 on a 0 to 10 scale.
  8. Excessive reliance on aids or appliances.
  9. Sleep quality reduced since onset of pain.
  10. High intake of alcohol or other substances, possibly as self-medication, with an increase since onset of pain.
  11. Smoking.

1 Kendall NAS, Linton SF, Main CJ. Guide to assessing psycho-social yellow flags in acute low back pain: Risk factors for long-term disability and work loss. Accident Compensation Corporation and the New Zealand Guidelines Group: Wellington 2004.