Managing Complex Injuries

 Dr Keith Adam, occupational physician  Navigating the Mine Field Conference  16 September 2008

Workers’ Compensation System

 The system works well enough for simple cases – who will probably recover and return to work despite our best efforts!

 The system fails for “complex cases”  Little correlation with the apparent severity of initial injury  Relatively small in number; large proportion of costs

Simple cases

 Usually < 3 weeks  Clear diagnosis  Recovery as anticipated  Rehabilitation program can facilitate timely return to work, minimise time lost

“Complex cases”

 Greater than 3 weeks  The diagnosis is not clear  Disability greater than expected  Additional factors influencing outcome

What goes wrong?

 Rarely predicted by severity of initial injury  Usually additional non-medical factors  The workers’ compensation process can reinforce disability  Evidence suggests that some such cases are “predestined”  Let us walk through the minefield of a typical case, to discover the barriers to effective rehabilitation

The first consultation

 Consults doctor  Rest  Certificate  Review in 1-2 weeks

The Medical Model

History  Examination  Investigations  Diagnosis  Treatment  Cure!!

The Medical Model

 Emphasis on correction of pathology  The patient not required to play an active part  Stops short of the consequences of injury - loss of function not considered  It is the consequences which intrude on life  What happens when there is no diagnosis?

X Rays

 “talking x-rays”  may tend to reinforce belief in incapacity  an abnormality may become a self fulfilling prophesy  labelling may lead to disability

X Rays

MRI Findings Herniated disc Bulging disc Degenerative disease < 60yrs 22% 54% 46% > 60yrs 36% 79% 93% Journal of Bone and Joint Surgery 1990

INVESTIGATIVE RECURSIONS

 Kendrick et al.: Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001; 322:400 421 patients with low back pain. 50% had X-rays. 50% had no X-ray. 6 month follow up,

Those who had had No X-ray reported  Little pain  Normal function  Low satisfaction with medical process  Low satisfaction with doctor

Those who had had X-ray reported  Significantly more pain  Significantly worse function  High satisfaction with medical process  High satisfaction with doctor.

Disease v Illness

Disease

 The result of pathology

Illness

 A social construct  Confers certain rights/benefits  Altered expectations

Illness

 Not a biological, but a human event, shaped by culture, environment and life stresses, which frequently but not necessarily includes Disease. (Barondess)  Illness is Complex Adaptive Human Action involving both patient and others, and occurs in a universe of emotions, beliefs, behaviours and social forces.

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The Sick Role

 may confer desirable secondary gains.  It absolves from fault and failure, especially when  it is culturally acceptable;  it may resolve personal and social problems;

 Societies do not accept emotional disorder or difficulty coping with life as acceptable entry into the sick role to the same extent they accept Disease or Physical injury.

 i.e., We provide First to Budget Class tickets to the Sick Role –  and we all want an upgrade!

The Tactic then Evolves

The condition becomes medicalized  Personality difficulties + Troubled life situation = Unacceptable Disability  Unacceptable Disability + Accident/Illness = Acceptable Disability (Hirschfeld and Behan)

What reinforces the Sick Role?

 Secondary gains  Well meaning doctors  Adversarial process – lawyers, claims managers

Secondary Gains

 “the recognition of secondary gains is exceedingly important as they commonly maintain all kinds of illness and disability”  Warwick Williams

Secondary gains

 Getting  Getting out of  Getting back at   hurting controlling

Medical reinforcement

 Looping  The Process whereby Medical Classification influences Patient Behaviour  which in turn further modifies Medical Classification and so on….

(Ian Hacking: Mad Travellers 1999)

Stalemate

 The doctor?



An advocate for his/her patient



Often, the only information about the workplace is that provided by the patient/worker

 

Starts by giving the worker the benefit of the doubt May (unwittingly) reinforce the sick role

Effects of Legal Involvement

Surgical outcomes at 1yr follow up With attorney Great improvement Much better 9% 9% No attorney 68% 64%

The Solutions

Risk for poor RTW: Bio-psycho-social perspective

Biological Personal and environmental Factors (Psychosocial) Environmental (systemic)

(Mayou, Main, Auty, 2004)

Red flags Yellow flags Blue flags Black flags

• • Serious pathology Co-morbidity •Unhelpful beliefs about pain/injury •Unhelpful (eg. avoidant) coping strategies (eg. resting) •Emotional distress •Passive role in recovery •Overly solicitous carers •Perceived low social support at wk; Perceived unpleasant work •Low job satisfaction •Perception of excessive demands •Legislative criteria for compensation •Nature of workplace (eg. heavy work) •Threats to financial security

Yellow Flags

 find factors that may be influenced positively to facilitate the recovery and prevent /reduce the long-term disability and work loss of the injured worker  the frequent unintentional barriers and the less common intentional barriers to improvement. Kendal, N. et al (1997). Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk factors for Long Term Disability and Work Loss ACC, NZ

Yellow Flags

 Prior pain in the same body region (strongest indicator)  Job dissatisfaction (with fellow workers/ employer)  Belief that pain is harmful or disabling  Chronic depression  Low socio-economic status or manual worker  Current disability income

Yellow Flags

 Afraid of more pain with activity or work  Smoking  Low activity level  High pain or illness behaviour  Passive attitude to rehabilitation  Back to work in next 3-6 months  Ligation involved with the claim?

Systematic review of Workplace-based RTW interventions

(Franche et al. JOR, 2005) Workplace intervention strategies

 Early contact with the worker by the workplace 

Work accommodation offer



Contact between healthcare provider and the workplace

 RTW coordination  Super-numerary replacements

Strength of Evidence (less time lost)

Moderate

Strong Strong

Moderate Insufficient

Early use of OMPQ at Concord Hospital, NSW

Pearce, McGarity, Nicholas, Linton, Peat, 2008)

Two year study with hospital employees making injury claims  Modified OMPQ: 13 item scale  OMPQ given when claim submitted (ie. generally within 48 hrs of injury) Phase 1: usual care, OMPQ data not examined until RTW  Three groups identified – high, medium, low scorers  High scorers reporting more pain, more distress, expectations of delayed RTW Phase 2: Additional interventions offered to high score (high risk) group  Costs obtained from insurer (for each case in both phases)

Preliminary cost findings with Concord OMPQ study

Costs, from insurer, when claims closed (~ 1 yr).

OMPQ scores

(at time of claim)

Ave. cost of claims

(at closure) Low Medium High $4,878 $6,240 $17,178

Intervention (phase 2 of Concord study)

High Risk (scores >85)

    Independent Rehabilitation Provider within 2 weeks Clinical Psychological assessment and treatment within 2 – 3 weeks.

Independent Medical Assessment within 1 month Independent Physiotherapy Assessment after 6 weeks.

 File review by Rehabilitation Medical Specialist if not returned to work within 4 weeks

Medium risk (70 – 84)

 “Usual care + clinical psychologist”

Low risk (<69)

 “Usual care”

RESULTS: Comparison between Control and Intervention Cohorts

CONTROL GROUP INTERVENT GROUP CONTROL GROUP INTERVENT GROUP RISK CATEGORY % % $ COST $ COST

LOW 47 51 4,878 4,898 MEDIUM 31 29 6,240 6,752

HIGH 22 19 17,178 12,847 Difference $ 4331 or 25%

Changing beliefs about pain: A community intervention

 Population-based, state-wide public health intervention to alter beliefs about back pain and its medical management.

 N = 4730 interviewed 2.5 yrs apart; 2556 GPs interviewed 2 yrs apart. 1 state (Victoria) = intervention, another state (NSW) = control Buchbinder et al. Spine 2001;26:2535–2542

Buchbinder et al, BMJ, 2003

The way forward

 We have developed a model for regular review of protracted claims  Checklist  Not one problem but a range of different possible problems requiring different solutions  Complex claims require sophisticated analysis, aggressive management  Particular advantage of self insurers

“Stress”

Stress Claims

 Multifactorial  Judgemental  Conflict present from the start  “Medicalization” of a problem  More vulnerable to secondary gains  Invariable delay in decision making

Management of Stress Claims

 Early intervention even more important  Provision of assistance prior to acceptance of claim “without prejudice”  Accept distress  Try to avoid/exacerbate conflict

Pain Traps - 1

There has got to be something or someone who can fix me!

 Focus on pain, and what it may mean  Handing over control  Doctor shopping Michelle Kearns

Pain Traps - 2

Oh no, What does that (pain) mean?

 Focus on pain, and what it may mean Michelle Kearns

Pain Traps - 3

You broke me; you fix me!

 Feels robbed  Feels entitled  Blame and anger are all consuming Michelle Kearns

Pain Traps - 4

People will think I am a bludger!

 High expectations (of self), inflexible  Weak; a failure  Overdo it – peaks and troughs Michelle Kearns

Pain Traps - 5

I’ll never be able to enjoy life again!

 Catastrophe!

Michelle Kearns

Pogo’s Law

Workplace based rehabilitation

What is different about the workplace?

 The industrial environment  Work is not optional  The games people play(at work)  Motives and agendas

Why Rehabilitate ?

Successful rehabilitation produces win / win  For management  cost saving    retention of skills, knowledge the process will help resolve uncertainty For injured workers    return to normal physical and social function in optimal time minimize losses self esteem

Principles of a return to work program

 What is the desired outcome  Is it achievable?

 How long can you accommodate restricted duties?

 Define the length of any program  What are the required performance criteria  during a program  at its completion

Why do workers present with illness?

 Because they are sick  As a means of communication  Because they want the benefits of the sick role – an excuse for poor performance 

You cannot ignore a medical certificate

The “medical cloak”

How might these lead to disability?

REDUCED ACTIVITY CHRONIC PAIN

UNHELPFUL BELIEF

S

& THOUGHTS REPEATED TREATMENT FAILURES LONG-TERM USE OF ANALGESIC , SEDATIVE DRUGS LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS PHYSICAL DETERIORATION (eg. muscle wasting, joint stiffness) FEELINGS OF DEPRESSION, HELPLESSNESS, IRRITABILITY SIDE EFFECTS (eg. stomach problems lethargy, constipation)

EXCESSIVE SUFFERING

© M K Nicholas PhD Pain Management & Research Centre Royal North Shore Hospital St Leonards NSW 2065 AUSTRALIA

One reason many not disabled: active self management

 Psychological distress and self-management style are strongly related to pain-related disability (Blyth et al., Pain, 2005: survey of people with chronic pain in Northern Sydney).  Active coping strategies (attempting to maintain normal activities/exercise despite pain)  Passive coping strategies (reliance on others, devices, drugs to fix pain first) – a pain-focused approach

Canadian study: difference between those who took time off from work for LBP

  Gross et al. Spine 2006;31:2142–2145 Telephone survey in 2 states (n = 2,700) Took painkillers (%)* Rested or avoided activity (%)* Stayed in bed more than usual (%)* Sought care (%)* 70.5 77.2 49.6

Time off No time off

39.9

44.8

7.8

78.6 32.3

A recent prospective study

 Caragee et al. (2005): In LBP patients with both structural and psychosocial risk factors:  Serious disability was best predicted by baseline psychosocial variables.

 Structural variables on both MRI and discography at baseline had no association with disability or future medical care. (Caragee et al.The Spine Journal 5 (2005) 24–35)

Evidence has accumulated on psychological and social/environmental risk factors for disability

Evidence Strength of Strength of Predictor

____________________________________________________________________

Personality Anxiety Stressful life-events Poor perceptions of general health * * * *** * * * ** Psychological distress Depression *** *** *** ** Fear avoidance ** ** Maladaptive coping (Catastrophising) *** ** Pain behaviour *** **  Strong Moderate Weak *** ** _____________________________________________________________ (Waddell et al (2003) [Now at least 5 other systematic reviews with broadly similar findings]

All injuries and treatments occur in a context

Implications

 Successful adjustment to living with chronic pain requires injured worker to take an active & informed role  Workplace (employer) can play a key role in promoting sustained RTW  Healthcare providers can also help if they are linked to workplace

Challenges

1) to prevent injury-related pain from becoming disabling 2) to find ways of maximising and sustaining the functional capacity of those who do return to the workforce

Key: Don’t wait until symptoms cease before RTW

(Carter J & Birrell L, Occupational health guidelines for the management of low back pain at work. Faculty Occ. Med, London, 2000)

How might we meet these challenges?

   What if we could identify those at risk of becoming more disabled and delayed RTW?

Before they got into trouble?

And what if we intervened to prevent the problems developing?

Yellow Flags

 1997: the concept of Yellow Flags was born (Kendall et al. and ACC in NZ)  Aim: to identify those injured people at high risk of developing chronic disability  Expectation: would lead to interventions aimed at preventing secondary disability in these people.  2007: Major review at Keele University in the UK (monograph on this being prepared)

Concept of Yellow flags

 Psychological AND Environmental barriers to RTW in injured workers  Associated with increased risks for prolonged disability and chronic pain (if left unchanged)  Significantly, may respond to targeted interventions

Yellow flags have included:

        Excessive resting/activity avoidance; Persisting worry about the basis of persisting pain; Fear of pain and its possible implications; Emotional distress; Overly supportive or hostile interactions with home/workplace; Dissatisfaction with workplace; Ongoing pursuit of symptom relief versus resumption of activities; Expectation of delayed RTW

Intervening in psychosocial aspects before chronicity sets in (controlled studies from 2000) Intervention & Outcomes (bold) Comment Study

Van den Hout et al. 2003 Å senl ö f et al.., 2005 Linton & Andersson, 2000 Graded activities (behavioural principles) + problem-solving training > Graded activities + education

(on longer-term work status

) Individually-tailored cbt + exercises > exercises (

on disability, pain fear of movement

) 6 x 2-hr grp sessions with Clin. Psychologist + Rehab > Information + Rehab (

on lost time from work

) Marhold et al., 2001 Linton et al., 2005 Verbeek et al., 2002 Jelema et al., 2005 Hlobil et al., 2005 Hay et al., 2005 Sullivan et al., 2006 Loisel et al., 2002 Gatchel, et al . 2003 Kant et al. 2008 Damush et al., 2003 Same treatment as above > for sub-acute lbp than chronic lbp. (

RTW outcome

) CBT grp = CBT + exercise grp >> minimal tmt grp (examination, reassurance, advice on activities).

(lost time)

Many similarities in content of control grp and treatment grp. No difference between grps on

disability & RTW outcome

(both improved). Psychosocial intervention = standard care (both by GP only) (

on disability

)

Low distress in both groups Low level of psychosocial risk factors at baseline

Graded activity grp > usual care. (GPs consistency with program encouraged):

Earlier RTW

CBT (pain management) and manual therapy (+ home exercise) achieved similar results (

disability

) Psychosocial risk factors reduced in both groups (Physio + CBT vs Physio only), but catastrophizing reduced more in combined group. Combined group had

better RTW

4-wks after end of treatment. All interventions achieved gains, but comprehensive ‘ Sherbrooke ’ model (combined occupational and clinical interventions) had fewer days on benefits. (

RTW

) ‘high risk’ acute patients in functional restoration group (CBT approach) >a treatment-as-usual group. (on indices of

disability; work, healthcare utilization, medication use and self-reported pain).

Physician intervention that targeted identified specific individual concerns + problem-focused counselling when needed) > standard care (on

RTW outcomes

) Brief group program, with telephone follow-up, aimed at

increased function, health status

> usual care

Average distress low initially so difficult to show much change.

Implications

 When psychosocial risk/prognostic factors low, usual care is sufficient ( Usual care seems effective in “uncomplicated cases of LBP” – Jallema et al. Pain 2006)  When psychosocial risk/prognostic factors high, interventions targeting these aspects often more effective than usual care

When pain has become chronic?

 Is it too late?

Pain management plan for chronic pain may need to be adjusted for severity/complexity of case

 ‘Dose-response’ relationship for CBT pain management programs and chronic pain 

Basic message: More distressed/disabled cases need more intensive treatment

 Evidence: Guzman et al., BMJ 2002: systematic review Williams et al. Pain 1999: RCT Marhold and Linton, Pain 2001: RCT Haldorsen et al., Pain 2002: RCT

Getting workers with chronic pain back to work?

Haldorsen et al. (2002): More intensive CBT pain management >> ‘light’ pain management with more disabled cases

Possible consequences if we ignore yellow flags?

   Claim is likely to take longer to close and to cost more (more lost time and treatment costs) Disability is likely to be greater Worse if treatments focus only on physical symptoms

Obstacles

In UK: A guideline-based psychosocial intervention for the early management of musculoskeletal disorders was effectively undermined by organizational obstacles, al., 2006) such as policies and procedures (Black flags) (McCluskey et In NSW: In 2005/6, WorkCoverNSW introduced OMPQ as a key tool in case work-related activity interventions identification which would guide more Despite 2 years of consultation with stakeholders, many opposed to use of OMPQ and activity-based approach that centred on identified risk factors: “Only applies to low back pain” “Not validated in NSW” “Too prescriptive/narrow” “Not comprehensive enough…” Result?

Program stalled. Recently revised and we’ll see what happens this time

Implications?

  We can’t assume that good ideas and evidence will suffice.

Need to address problem at multiple levels and engage as many stakeholders as possible

Treatments alone unlikely to be enough

et al. 2005) (Franche Workplace intervention strategies Strength of Evidence (less) Work loss

    Early contact with the worker by the workplace

Work accommodation offer Contact between healthcare provider and the workplace

RTW coordination  Super-numerary replacements Moderate

Strong

Moderate

Strong

Insufficient

Bottom Line: Workplace needs to be actively involved for RTW results best

General Practitioners’ behaviour

 Derived from responses to a case study with sub-acute LBP presented by Buchbinder et al.

Response

No tests ordered Prescription of bed rest Advice on exercise Advice on work modification Vic vs NSW* More likely not to order tests Less likely to support bed rest More likely to support exercise More likely to advise change

Findings

 In Victoria: Decline in claims for back pain, rates of days off, and costs of medical management  In NSW: No change