Transcript www.firefitsteeringgroup.co.uk

Return to Work Rehabilitation
Clare Evans
Fit Mind, Fit Body, Fit Fire Service?
22nd June 2005
RehabWorks Ltd
Fitness for Work and Life
Aims of the talk
• To explain bio-psycho-social model of rehabilitation
• How rehabilitation works in the workplace
– National response and current evidence based guidelines
– Hierarchy of risk control:
• Primary prevention
• Secondary treatment
• Tertiary intervention (rehabilitation)
• Benefits through a case study
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Main Messages
Bio-psycho-social Rehabilitation:
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•
•
•
•
Is a generic problem solving process
Evidence based
Not physiotherapy
Biological
Not psychotherapy
Not rest
Psychological
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What is Rehabilitation?
• New WHO model of disability/illness
Emphasises sickness is not due to one factor
• Pathology
• Impairment -> (limitation in) activity
• Disability -> (restriction on) participation
• An educational, problem-solving process that focuses
on activity limitations and aims to optimise social
participation
• A move from the impairment to functional focus
• Improve individuals capability to function normally and
RTW
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The cost of work related injury
• 14.4 million work days lost (2001)
• Burden to state benefits – 90% of 3,500 new benefit
awards per week are work-related injuries
• Cost to Society in UK of work-related illness is £10bn
(1995)
• Cost of musculoskeletal alone £5.5bn (2000)
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A Chronic Problem
6 months 50% chance of rtw
12 months 30% chance of rtw
24 months 10% chance of rtw
Once on IB for 6 – 12 months 90% remain
on for at least 5 years
Long term absence accounts for 80% of the
cost
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The cost of work related injury
• Burden to families – 500 people leave employment
every week (never to return)
• Many result in long term incapacity to work and
personal injury claims
• Significant impact on the social functioning and quality
of life
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Why do people become chronic?
•
•
•
•
Yellow, Blue and Black Flags
Medical management
Deconditioning Cycle
Activity, Participation
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Yellow Flags
•Pain intensity / functional disability
•Poor perceptions of general health
•Psychological distress
•Depression
•Fear avoidance
•Catastrophising
•Pain behaviour
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Blue Flags
•Job (dis)satisfaction
•Duration of sickness absence / incapacity
•Occupational status
(still employed / not)
•Expectations about
return to work
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Black Flags
• Specific job characteristics
– Demand/control
– Time pressure
– Management style
• Rehabiltation and Retention
policies
– Facilitation of RTW &
optimal function
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What is the country doing about it?
•
Department for Work and Pensions (DWP)
•
Securing Health Together (2001) – long term occupational health
strategy
•
Regulators – Health and Safety Executive (HSE)
•
Evidence based guidelines for RTW Rehabilitation
–
–
–
CSAG 1994
RCGP 1996
FOM 2000
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Evidence Based Guidelines:
Application in OH Setting
• Primary Intervention
• Secondary intervention / Acute
• Tertiary intervention / Chronic
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Evidence Based Guidelines:
Application in OH Setting
• Primary Intervention
– Risk assessment and ergonomics programme
– Targeted training
• Secondary intervention / Acute
• Tertiary intervention / Chronic
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Evidence Based Guidelines:
Application in OH Setting
• Primary Intervention
– Risk assessment and ergonomics programme
– Targeted training
• Secondary intervention / Acute
– Case management and advice
– OH Physiotherapy – (+ outcome measurement)
– Effective in first 6-weeks of absence
• Tertiary intervention / Chronic
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Evidence Based Guidelines:
Application in OH Setting
• Primary Intervention
– Risk assessment and ergonomics programme
– Targeted training
• Secondary Intervention / Acute
– Case management by OHA and advice
– OH physiotherapy – (+ outcome measurement)
– Effective in first 6-8 weeks of absence
• Tertiary Intervention / Chronic
– Bio-psycho-social functional restoration for chronic disease
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Bio-psycho-social Rehabilitation:
a problem-solving process
• Assessment
– identification and analysis of problems and barriers to RTW
• Goal setting
• Interventions should be:
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–
–
–
–
–
–
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Active and exercise based
In Group's
Educational and use a CBT approach
Work related and include work conditioning and hardening
Able to suggest and make ergonomic interventions
Encouraging lifestyle changes
Allow graduated RTW programmes
Spread over-time
• Re-assessment (monitoring)
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Assessment
• Physical (Against work/life demands)
– Strength, flexibility, mobility, functional strength, aerobic
fitness, posture
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•Psychological
–Stress,
–Depression,
–Anxiety,
–Catastrophising
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•Psycho-social
–Beliefs
–Fear-avoidance
–Social support
–Pain management
–Litigation
–Compensation
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•Work factors
–Relationships
–Support
–Control
–Beliefs
–History
–Restricted duties
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Typical problems
•
Poor posture
•
Loss of flexibility
•
Weak trunk musculature
•
Poor aerobic fitness
•
Poor work posture/technique
•
Loss of confidence and low in mood
•
Fear of movement, activity and work
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Measuring the Requirement
Lifting /
Activity
Sedentary
Sedentarylight
Light
Lightmedium
Medium
Mediumheavy
Heavy
Occasional
1-33% of
day
5kg
7kg
9kg
16kg
23kg
34kg
45kg
Frequent
34 -66%
negligible
3.5kg
4.5kg
7kg
11kg
16kg
23kg
Constant
67 -100%
nil
nil
negligible
2.5kg
5kg
7kg
9kg
Activity
sit
sit/stand
stand/
walk
stand/
walk
stand/
walk
stand/
walk
Stand/w
alk
Source: U.S. Department of Labor
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SMART Goal Setting
• Behaviours are actions primarily directed towards
function
• Goals are directed aims based on thoughts and
behaviours
– Own hopes, family wishes, consequences of (non)achievement etc
• Therefore necessary to establish:
– Patient goals (achievable chunks)
– Rehabilitation goals
(correlate to patient goals)
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Negative effect of Bio-Medical model
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•
•
•
•
•
•
Beliefs there is broken part that can be fixed
Ongoing expensive investigations (False Positives)
Patient passivity, reduced motivation
Patient role instead of worker role
Ineffective therapies
Low level of activity
Increasing levels of distress
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Group Therapy
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Medical exercise therapy
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Work Conditioning
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Education
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Sport
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Work Interventions
• Rehab not light duties
• Vehicle assessments
• Workplace assessments
• Job evaluations and
modifications
• Equipment evaluations
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Research Results: Utility Company
85 employees entered programme
All failed Physio and absent for longer than 8-12
weeks




83 completed.
81 returned to work on full duties
2 returned to work on restricted duties.
2 dropped out and did not return to work.
• 58 were followed up at 12 months.
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Pain levels
Pain Scale
No. Patients
30
25
FCE
20
End
12m
15
10
5
0
0
0.5
1
2
3
4
5
6
7
8
9
10
Borg Scale
Pain reduced during the programme from an average of 4
on a 0 – 10+ scale to 1.5
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Oswestry Disability Index
Oswestry Disability Index
No. Patients
30
FCE
25
End
20
12m
15
10
5
0
0-9
10-19
20-29
30-39
Oswestry Score
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40-49
50-59
ODI Perceived
disability scores
decreased
immediately post
programme from an
average of 34% to
an average of 14%
(t=10.244, p<.000)
and the difference
between pre
programme scores
and scores twelve
months later
remained significant
(t=7.130, p<.000).
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Acute Pain Screening Questionnaire
Acute Pain Screening Questionnaire
No. Patients
16
14
FCE
12
End
10
12m
8
6
4
2
0
<40
41-60
61-80
81-100
101-120
>120
APSQ score
General Psychological status (APSQ) improved pre &
post programme (t=8.113, p<.000) and at twelve
months (t=5.332, p<.000).
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Perceived Work Capability ( EPIC)
No. Patients
EPIC Spinal Sort
50
45
40
35
30
25
20
15
10
5
0
FCE
End
12m
<100
101-120
121-140
141-160
161-180
181-200
EPIC score
Perceived work capability improved immediately post
programme, (t=-6.909, p<.000) and the difference
between pre programme scores and twelve months later
was still significant (t=-6.476, p<.000).
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Safe Dynamic Lifting Capability
Isometric leg lift (kgs)
No. Patients
18
16
FCE
14
End
12
12m
Lifting capability also
improves by
30%(F=34.185,
p<.000)
10
8
6
4
2
0
<40
41-60
61-80
81-100
101-120
>120
Strength (Kg)
Safe lifting capability (kgs)
No. Patients
40
35
FCE
30
End
25
12m
20
15
10
5
0
<10
11-20
21-30
31-40
>40
Weight (Kg)
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Results indicate that
• The approach is having an immediate impact on
psychological status, perceived disability and
perceived capability
• The effect remains for a twelve month period.
• Repeated measures analysis on various strength
and physical capability indicates that these results
improve also
• Return of more than 80% to full time work
• Saving of £180K and cost of £60K
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Main messages
• Organisations must:
– Have robust health & safety procedures
– Provide occupational health to workforce
– Rehabilitate employees to work through evidence-based
interventions
• Early treatment intervention
• Tertiary Rehabilitation
• Vocational rehabilitation must
– Involve all parties towards an agreed goal
– Be a team activity crossing all boundaries
• Rehabilitation
– is a way of thinking
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Case history – Kevin age 39
• Married and has 2 boys ages 9 and 7
• Job – utilities worker 30% driving 70% walking,
stooping, bending to clean/ sweep/ dig channels.
Climbs ladders and lifts manhole covers up to 40kg
• Liked walking, football, swimming
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The back problem
•
•
•
•
1st injury 1995 - lifting at work -1 week off
2nd injury 1996 - at home – 2 weeks off work
3rd injury 1998 - hurt back at work no time off
4th injury 2000 - 6 weeks off work and reporting
pain and niggles all the time
• 5th injury 2002 - 9 months off
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Case Study Kevin 39
200
180
160
140
120
100
80
60
40
20
0
days absent
1995
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1996
1997
1998
1999
2000
2001
2002
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Treatment to date
• Osteopathy – helped relieve symptoms at first
• Physiotherapy – gave exercises but they hurt so
patient stopped – no real benefit
• Referred back to GP for 2nd opinion
• Waited 6 months for MRI scan
• Mild disc bulge and wear and tear changes –
surgery not indicated
• 2 Epidurals and 3 facet joint blocks
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The effect
• Gave up sport in 1996 on advice of GP
• Now can’t work
– Can’t sit for very long
– Can’t bend or lift
•
•
•
•
Can’t play football with boys or walk the dog
Wife fed up
Financial problems likely to occur at 12 months
No help to date from the Company
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The effect (cont)
• Consultant says nothing can be done – has to live
with it
• Feels very angry
• Likely to make a claim
• Sees only way out is to get ill health early retirement
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What should companies do?
• Early intervention
– Screen for red flags
– Must not medicalise the problem
– Use Occupational Health Professionals
• Keep control
Only 3% of all people with back pain have a serious
problem and require a consultant input or MRI scan
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OH Management system
• Medical management
– OHA if in acute pain or symptoms last longer than 7 days
– Timely reviews if no RTW
• Physio / Rehab - Competent Practitioners
– Liaison with company – work restrictions
• Graduated RTW
– Goals to increase activity week by week
– Time limited
– Personal risk assessment
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What happened to Kevin?
• Referred to the OHA and OHP
• Recommended functional restoration programme
in line with evidence based guidelines from faculty
of occupational medicine
• 10 week programme alongside graduated return to
work at RehabWorks (cost £2500)
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Questionnaires
140
120
100
80
60
40
20
0
ODI
RehabWorks
APSQ
TSK
FABQ
PAIN
Zung
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Kevin’s Outcome
•
•
•
•
•
•
•
•
•
Pain reduced ( 7 to 2)
He can walk, bend, dig, sweep channels
He can sit for an hour
He can lift 45kg (was 25kg) with excellent technique
He is back at work on normal duties
Understands how to manage his problem
Play football with kids
Exercises 3 times a week to prevent recurrence
Says he is 200% better!
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And if we hadn’t done anything?
• Ongoing sickness – 17 months £25,200
• Ill health retirement?
• Claim against the organisation for Accident at work?
• Further medical interventions?
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Take home message
•In a work context it may be helpful to consider
Pain in the context of more general symptom
management.
•Chronic cases need to be assessed and treated
in a holistic way using a Bio-Psycho-Social
approach.
•Need more research and access into biopsycho-social rehabilitation programmes
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Thank you for listening
and
Any questions?
Contact: [email protected]
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