1. Managing Complex Injuries
Dr Keith Adam, occupational physician
Navigating the Mine Field Conference
16 September 2008
The Rehabilitation Model, with some specific discussion about stress
presentation for GPs about the relevance of the rehabilitation model, and potential problems and pitfalls in workplace based rehabilitation. Some specific discussion about stress. Keith Adam
The pitfalls
Concept of Rehabilitation
Simple cases
Clear diagnosis
Responds appropriately to treatment.
Rehabilitation program can facilitate timely return to work, minimise time lost
Complex cases
Protracted
A number of factors in play
Not improving as expected.
Pitfalls
Medical model fails – medical vs rehabilitation model
Tar baby – benefit of doubt
Patient advocate
Reinforcement – Illness behaviour
Talking x-rays
Stress

2. 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

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

4. “Complex cases” Greater than 3 weeks The diagnosis is not clear
Disability greater than expected
Additional factors influencing outcome

5. 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
Three significant shortcomings
does not concern itself with the consequences of the illness or injury
the practitioner takes responsibility for the treatment and outcome. the patient must share the responsibility for their own recovery with the doctor. I often see patients who have handed over control - Adam’s sig.
requires a diagnosis. When a diagnosis is not obvious, there may be progression through further and more invasive investigations endeavouring to find the diagnosis, while the consequences of the injury or illness may be neglected. The continuing investigations may serve to reinforce the patient’s belief in his/her disability.

6. The first consultation
Consults doctor
Rest
Certificate
Review in 1-2 weeks

7. The Medical Model History  Examination  Investigations  Diagnosis 
Treatment 
Cure!!

8. 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?
Three significant shortcomings
does not concern itself with the consequences of the illness or injury
the practitioner takes responsibility for the treatment and outcome. the patient must share the responsibility for their own recovery with the doctor. I often see patients who have handed over control - Adam’s sig.
requires a diagnosis. When a diagnosis is not obvious, there may be progression through further and more invasive investigations endeavouring to find the diagnosis, while the consequences of the injury or illness may be neglected. The continuing investigations may serve to reinforce the patient’s belief in his/her disability.

9. 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

10. X Rays MRI Findings < 60yrs > 60yrs Herniated disc 22% 36%
Bulging disc 54% 79%
Degenerative disease 46% 93%
Journal of Bone and Joint Surgery 1990
From Ric Deyo’s presentation
Bode? Journal of Bone and Joint Surgery 1990: 12 A, 403

11. 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,

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

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

14. Disease v Illness Disease The result of pathology Illness
A social construct
Confers certain rights/benefits
Altered expectations

15. 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.

16. 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;

17. 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!

18. The Tactic then Evolves
The condition becomes medicalized
Personality difficulties + Troubled life situation
= Unacceptable Disability
Unacceptable Disability + Accident/Illness
= Acceptable Disability
(Hirschfeld and Behan)
To mix in a military metaphor, they cave captured the medical (moral) high ground. Frontal assault with further medical opinions will be met with contrary opinions = stalemate

19. What reinforces the Sick Role?
Secondary gains
Well meaning doctors
Adversarial process – lawyers, claims managers

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

21. Secondary gains Getting Getting out of Getting back at hurting
controlling

22. 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)

23. Stalemate An advocate for his/her patient
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

24. Effects of Legal Involvement
Surgical outcomes at 1yr follow up
With No
attorney attorney
Great improvement 9% 68%
Much better 9% 64%
Lovelace Clinic, New Mexico
? How much of the

25. The Tar Baby Syndrome
Defined first by Joel Chandler Harris in “Uncle Remus’ Tales of the Old Plantation 1881”
Redefined by Ober K.P : Uncle Remus and the Cascade effect in clinical medicine: Brer Rabbit kicks the Tar Baby. Am J Med 1987; 82:

26. The Solutions

27. Risk for poor RTW: Bio-psycho-social perspective
Biological
Serious pathology
Co-morbidity
Personal and environmental
Factors (Psychosocial)
Yellow
flags
Unhelpful beliefs about pain/injury
Unhelpful (eg. avoidant) coping strategies (eg. resting)
Emotional distress
Passive role in recovery
Overly solicitous carers
Blue
Perceived low social support at wk; Perceived unpleasant work
Low job satisfaction
Perception of excessive demands
Environmental (systemic)
(Mayou, Main, Auty, 2004)
Black
Legislative criteria for compensation
Nature of workplace (eg. heavy work)
Threats to financial security
Red flags

28. 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

29. 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

30. 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?

31. Systematic review of Workplace-based RTW interventions. (Franche et al
Systematic review of Workplace-based RTW interventions (Franche et al. JOR, 2005)
Workplace intervention strategies Strength of Evidence
(less time lost)
Early contact with the worker by
the workplace Moderate
Work accommodation offer Strong
Contact between healthcare provider Strong
and the workplace
RTW coordination Moderate
Super-numerary replacements Insufficient

32. Early use of OMPQ at Concord Hospital, NSW
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)

33. 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
$4,878
Medium
$6,240
High
$17,178

34. 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”

35. RESULTS: Comparison between Control and Intervention Cohorts
CONTROL GROUP
INTERVENT
GROUP
INTERVENT GROUP
RISK CATEGORY %
$ 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%

36. 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

37. Buchbinder et al, BMJ, 2003

38. 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

39. “Stress”

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

41. 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

42. 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

43. Pain Traps - 2 Oh no, What does that (pain) mean?
Focus on pain, and what it may mean
Michelle Kearns

44. Pain Traps - 3 You broke me; you fix me! Feels robbed Feels entitled
Blame and anger are all consuming
Michelle Kearns

45. 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

46. Pain Traps - 5 I’ll never be able to enjoy life again! Catastrophe!
Michelle Kearns

48. Rehabilitation
The single most important factor in determining the success of rehabilitation is early intervention

49. Pogo’s Law

50. The Rehabilitation Model
A problem-oriented and function related approach to management
Seeks to restore the individual to the highest possible level of
physical
economic
social
psychological, and
vocational self sufficiency

51. The worker’s concerns Will I get better? How/when will I be paid?
Will I have a job to go back to?
What do they think of me?

52. The Tar Baby Syndrome
The recursive clinical pattern in which medical intervention leads to disaster;
disaster is then reinterpreted as indication for escalating medical intervention.

53. Stalemate The manager? The worker? The doctor? The insurer?
Who is managing?
The manager?
The worker?
The doctor?
The insurer?

54. Stalemate
The manager?
In the face of illness, and in the absence of any specific information/guidance, managers cannot/ do not manage
Managers (involuntarily, reluctantly) confer the rights and benefits of illness

55. Stalemate
The worker?
The patient’s livelihood and self-respect may be heavily invested in an illness which to his doctor is a clinical oddity
Might be ‘enjoying’ the secondary gains of illness
It is not whether you have symptoms but how you cope with them that constitutes Health.

56. Rehabilitation First consultation
“If the first medical attendant assesses the patient thoroughly, gives an indication of probable progress, orders investigations and referral in a logical and co-ordinated sequence,[and explains this to the patient], there is a strong likelihood of recovery”
Colm Moore

57. Rehabilitation First consultation
“If however the worker is attended by someone who does not trouble to make a [demonstrably] thorough assessment, or who is vague or pessimistic about the outcome, or who does not co-ordinate treatment and investigations . the likelihood is that the injured worker will be absent from work for a prolonged period.”
Colm Moore

58. Rehabilitation Value of early return to work
positive reinforcement of recovery
self esteem
minimise time, opportunity for secondary gains
Importance of link to workplace, to be able to provide appropriate duties

59. Chronic Incapacity The Hidden Costs
chronic pain and suffering
lifetime reduced earning capacity
family and marriage strain / break-up
loss of control of life

60. The Role of the Doctor in Primary Care
Identify and encourage the patient’s capacity to work, rather than focussing on disability
Understand the incentives and disincentives for return to work in the W.C. system
Effectively and responsibly fulfil the medico-legal requirements
The importance of the first consultation

61. The Role of the Doctor in Primary Care
The doctor patient interaction is based on mutual trust and an expectation of honesty
The only information available to the doctor is that provided by the injured worker
Information
You should understand that at the outset that doctors have some limitations placed on the information presented to them. The doctor patient-relationship is based on mutual trust and an expectation of honesty. When you visit the doctor, you expect that your account of your symptoms will be believed, and in turn the doctor will expect to be able to believe you. That is not to say that doctors are all náive, nor are they unaware that patients sometimes have another agenda which may colour their presentation of the “facts”. This may be occurring at a conscious or unconscious level. However, the basic medical consultation would be impossible if the doctor was not able to commence the consultation by believing what they are told. EXPAND
In addition. when an injured worker first consults the doctor, the only information which that doctor has about the injury and the workplace is that provided by the patient. I can recall one example where a worker was absent from work for an extended period with a back injury. The treating doctor was reluctant to permit the worker to return to work until he was fully recovered, because the worker explained that his job was to lift car bodies. He did not go on to explain that he did this with the assistance of an overhead crane! The doctor had managed the patient reasonably, given the information that she had.
Patient advocate

62. Rehabilitation The Role of the Doctor in Primary Care
The doctors tools
prescription pad
book of certificates
referral

63. Rehabilitation Certification
Describe limitations as precisely as possible
Specify time limits

64. Krause's Law:
The Treatment becomes itself the Illness of which it purports to be the cure.

65. 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

66. 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

67. 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
Example -

68. Rehabilitation Team Injured worker Supervisor/Manager
Internal Rehabilitation Coordinator
Treating Practitioner
Rehabilitation Provider
Workers’ Compensation Board QLD

69. Stages of rehabilitation
“Treatment with a purpose”
Add a therapist
The team
The centre
1. “Treatment plus”
Treatment with a plan /goal
Awareness of the other factors.
2. Add a therapist
3. The team
Need for communication, co-ordination
? team meetings
The centre
Need for all facilities concentrated in one place

70. A Change of Tactic Medical advice which informs management decisions
Working collaboratively
Commence a process which will deliver a result

71. 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

72. The “medical cloak”

73. How might these lead to disability?
REDUCED
ACTIVITY
PHYSICAL
DETERIORATION
(eg. muscle wasting,
joint stiffness)
UNHELPFUL
BELIEFS &
THOUGHTS
EXCESSIVE
SUFFERING
CHRONIC
PAIN
FEELINGS OF
DEPRESSION,
HELPLESSNESS,
IRRITABILITY
REPEATED
TREATMENT
FAILURES
LONG-TERM
USE OF ANALGESIC,
SEDATIVE DRUGS
SIDE EFFECTS
(eg. stomach problems
lethargy, constipation)
LOSS OF JOB, FINANCIAL
DIFFICULTIES, FAMILY
STRESS
M K Nicholas PhD
Pain Management & Research Centre
Royal North Shore Hospital
St Leonards NSW 2065
AUSTRALIA

74. 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

75. 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)
Time off No time off
Took painkillers (%)*
Rested or avoided activity (%)*
Stayed in bed more than usual (%)*
Sought care (%)*

76. 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)

77. Evidence has accumulated on psychological and social/environmental risk factors for disability
Strength of Strength Evidence 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]

78. All injuries and treatments occur in a context

79. 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

80. Challenges Key: Don’t wait until symptoms cease before RTW
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)

81. 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?

82. 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)

83. 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

84. 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

85. Intervening in psychosocial aspects before chronicity sets in (controlled studies from 2000)
Study
Intervention & Outcomes (bold)
Comment
Van den Hout et al. 2003
Graded activities (behavioural principles) + problem-solving training > Graded activities + education
(on longer-term work status)
Åsenlöf et al.., 2005
Individually-tailored cbt + exercises > exercises (on disability, pain fear of movement)
Linton & Andersson, 2000
6 x 2-hr grp sessions with Clin. Psychologist + Rehab > Information + Rehab (on lost time from work)
Marhold et al., 2001
Same treatment as above > for sub-acute lbp than chronic lbp. (RTW outcome)
Linton et al., 2005
CBT grp = CBT + exercise grp >> minimal tmt grp (examination, reassurance, advice on activities).
(lost time)
Verbeek et al., 2002
Many similarities in content of control grp and treatment grp. No difference between grps on disability & RTW outcome (both improved).
Low distress in both groups
Jelema et al., 2005
Psychosocial intervention = standard care (both by GP only) (on disability)
Low level of psychosocial risk factors at baseline
Hlobil et al., 2005
Graded activity grp > usual care. (GPs consistency with program encouraged): Earlier RTW
Hay et al., 2005
CBT (pain management) and manual therapy (+ home exercise) achieved similar results (disability)
Average distress low initially so difficult to show much change.
Sullivan et al., 2006
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.
Loisel et al., 2002
All interventions achieved gains, but comprehensive ‘Sherbrooke’ model (combined occupational and clinical interventions) had fewer days on benefits. (RTW)
Gatchel, et al
‘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).
Kant et al
Physician intervention that targeted identified specific individual concerns + problem-focused counselling when needed) > standard care (on RTW outcomes)
Damush et al., 2003
Brief group program, with telephone follow-up, aimed at increased function, health status > usual care

86. 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

87. When pain has become chronic?
Is it too late?

88. 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

89. Getting workers with chronic pain back to work. Haldorsen et al
Getting workers with chronic pain back to work? Haldorsen et al. (2002): More intensive CBT pain management >> ‘light’ pain management with more disabled cases

90. 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

91. Obstacles
In UK: A guideline-based psychosocial intervention for the early management of musculoskeletal disorders was effectively undermined by organizational obstacles, such as policies and procedures (Black flags) (McCluskey et al., 2006)
In NSW: In 2005/6, WorkCoverNSW introduced OMPQ as a key tool in case identification which would guide more work-related activity interventions
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

92. 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

93. Treatments alone unlikely to be enough (Franche et al. 2005)
Workplace intervention strategies Strength of Evidence
(less) Work loss
Early contact with the worker by
the workplace Moderate
Work accommodation offer Strong
Contact between healthcare provider Strong
and the workplace
RTW coordination Moderate
Super-numerary replacements Insufficient
Bottom Line: Workplace needs to be actively involved for best RTW results

94. General Practitioners’ behaviour
Derived from responses to a case study with sub-acute LBP presented by Buchbinder et al.
Response
Vic vs NSW*
No tests ordered
More likely not to order tests
Prescription of bed rest
Less likely to support bed rest
Advice on exercise
More likely to support exercise
Advice on work modification
More likely to advise change

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