Presentation on theme: "Managing Complex Injuries"— Presentation transcript:
1 Managing Complex Injuries Dr Keith Adam, occupational physicianNavigating the Mine Field Conference16 September 2008The Rehabilitation Model, with some specific discussion about stresspresentation for GPs about the relevance of the rehabilitation model, and potential problems and pitfalls in workplace based rehabilitation. Some specific discussion about stress. Keith AdamThe pitfallsConcept of RehabilitationSimple casesClear diagnosisResponds appropriately to treatment.Rehabilitation program can facilitate timely return to work, minimise time lostComplex casesProtractedA number of factors in playNot improving as expected.PitfallsMedical model fails – medical vs rehabilitation modelTar baby – benefit of doubtPatient advocateReinforcement – Illness behaviourTalking x-raysStress
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 injuryRelatively small in number; large proportion of costs
3 Simple cases Usually < 3 weeks Clear diagnosis Recovery as anticipatedRehabilitation 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 expectedAdditional factors influencing outcome
5 What goes wrong? Rarely predicted by severity of initial injury Usually additional non-medical factorsThe workers’ compensation process can reinforce disabilityEvidence suggests that some such cases are “predestined”Let us walk through the minefield of a typical case, to discover the barriers to effective rehabilitationThree significant shortcomingsdoes not concern itself with the consequences of the illness or injurythe 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 doctorRestCertificateReview 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 partStops short of the consequences of injury - loss of function not consideredIt is the consequences which intrude on lifeWhat happens when there is no diagnosis?Three significant shortcomingsdoes not concern itself with the consequences of the illness or injurythe 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 prophesylabelling 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 1990From Ric Deyo’s presentationBode? 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; 322:400421 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 painNormal functionLow satisfaction with medical processLow satisfaction with doctor
13 Those who had had X-ray reported Significantly more painSignificantly worse functionHigh satisfaction with medical processHigh satisfaction with doctor.
14 Disease v Illness Disease The result of pathology Illness A social constructConfers certain rights/benefitsAltered expectations
15 IllnessNot 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 whenit 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 medicalizedPersonality difficulties + Troubled life situation= Unacceptable DisabilityUnacceptable 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 gainsWell meaning doctorsAdversarial 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 LoopingThe Process whereby Medical Classification influences Patient Behaviourwhich 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 patientOften, the only information about the workplace is that provided by the patient/workerStarts by giving the worker the benefit of the doubtMay (unwittingly) reinforce the sick role
24 Effects of Legal Involvement Surgical outcomes at 1yr follow upWith Noattorney attorneyGreat improvement 9% 68%Much better 9% 64%Lovelace Clinic, New Mexico? How much of the
25 The Tar Baby SyndromeDefined 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:
27 Risk for poor RTW: Bio-psycho-social perspective BiologicalSerious pathologyCo-morbidityPersonal and environmentalFactors (Psychosocial)YellowflagsUnhelpful beliefs about pain/injuryUnhelpful (eg. avoidant) coping strategies (eg. resting)Emotional distressPassive role in recoveryOverly solicitous carersBluePerceived low social support at wk; Perceived unpleasant workLow job satisfactionPerception of excessive demandsEnvironmental (systemic)(Mayou, Main, Auty, 2004)BlackLegislative criteria for compensationNature of workplace (eg. heavy work)Threats to financial securityRed flags
28 Yellow Flagsfind factors that may be influenced positively to facilitate the recovery and prevent /reduce the long-term disability and work loss of the injured workerthe 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 disablingChronic depressionLow socio-economic status or manual workerCurrent disability income
30 Yellow Flags Afraid of more pain with activity or work Smoking Low activity levelHigh pain or illness behaviourPassive attitude to rehabilitationBack to work in next 3-6 monthsLigation 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 bythe workplace ModerateWork accommodation offer StrongContact between healthcare provider Strongand the workplaceRTW coordination ModerateSuper-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 claimsModified OMPQ: 13 item scaleOMPQ given when claim submitted (ie. generally within 48 hrs of injury)Phase 1: usual care, OMPQ data not examined until RTWThree groups identified – high, medium, low scorersHigh scorers reporting more pain, more distress, expectations of delayed RTWPhase 2: Additional interventions offered to high score (high risk) groupCosts 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$4,878Medium$6,240High$17,178
34 Intervention (phase 2 of Concord study) High Risk (scores >85)Independent Rehabilitation Provider within 2 weeksClinical Psychological assessment and treatment within 2 – 3 weeks.Independent Medical Assessment within 1 monthIndependent Physiotherapy Assessment after 6 weeks.File review by Rehabilitation Medical Specialist if not returned to work within 4 weeksMedium risk (70 – 84)“Usual care + clinical psychologist”Low risk (<69)“Usual care”
35 RESULTS: Comparison between Control and Intervention Cohorts CONTROL GROUPINTERVENTGROUPINTERVENT GROUPRISK CATEGORY%$ COSTLOW47514,8784,898MEDIUM31296,2406,752HIGH221917,17812,847Difference$ 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) = controlBuchbinder et al. Spine 2001;26:2535–2542
38 The way forwardWe have developed a model for regular review of protracted claimsChecklistNot one problem but a range of different possible problems requiring different solutionsComplex claims require sophisticated analysis, aggressive managementParticular advantage of self insurers
50 The Rehabilitation Model A problem-oriented and function related approach to managementSeeks to restore the individual to the highest possible level ofphysicaleconomicsocialpsychological, andvocational 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 SyndromeThe 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 StalemateThe manager?In the face of illness, and in the absence of any specific information/guidance, managers cannot/ do not manageManagers (involuntarily, reluctantly) confer the rights and benefits of illness
55 StalemateThe worker?The patient’s livelihood and self-respect may be heavily invested in an illness which to his doctor is a clinical oddityMight be ‘enjoying’ the secondary gains of illnessIt 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 recoveryself esteemminimise time, opportunity for secondary gainsImportance of link to workplace, to be able to provide appropriate duties
59 Chronic Incapacity The Hidden Costs chronic pain and sufferinglifetime reduced earning capacityfamily and marriage strain / break-uploss 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 disabilityUnderstand the incentives and disincentives for return to work in the W.C. systemEffectively and responsibly fulfil the medico-legal requirementsThe 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 honestyThe only information available to the doctor is that provided by the injured workerInformationYou 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. EXPANDIn 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 toolsprescription padbook of certificatesreferral
63 Rehabilitation Certification Describe limitations as precisely as possibleSpecify 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 environmentWork is not optionalThe games people play(at work)Motives and agendas
66 Why Rehabilitate ? Successful rehabilitation produces win / win For managementcost savingretention of skills, knowledgethe process will help resolve uncertaintyFor injured workersreturn to normal physical and social function in optimal timeminimize lossesself esteem
67 Principles of a return to work program What is the desired outcomeIs it achievable?How long can you accommodate restricted duties?Define the length of any programWhat are the required performance criteriaduring a programat its completionExample -
69 Stages of rehabilitation “Treatment with a purpose”Add a therapistThe teamThe centre1. “Treatment plus”Treatment with a plan /goalAwareness of the other factors.2. Add a therapist3. The teamNeed for communication, co-ordination? team meetingsThe centreNeed for all facilities concentrated in one place
70 A Change of Tactic Medical advice which informs management decisions Working collaborativelyCommence a process which will deliver a result
71 Why do workers present with illness? Because they are sickAs a means of communicationBecause they want the benefits of the sick role – an excuse for poor performanceYou cannot ignore a medical certificate
73 How might these lead to disability? REDUCEDACTIVITYPHYSICALDETERIORATION(eg. muscle wasting,joint stiffness)UNHELPFULBELIEFS &THOUGHTSEXCESSIVESUFFERINGCHRONICPAINFEELINGS OFDEPRESSION,HELPLESSNESS,IRRITABILITYREPEATEDTREATMENTFAILURESLONG-TERMUSE OF ANALGESIC,SEDATIVE DRUGSSIDE EFFECTS(eg. stomach problemslethargy, constipation)LOSS OF JOB, FINANCIALDIFFICULTIES, FAMILYSTRESSM K Nicholas PhDPain Management & Research CentreRoyal North Shore HospitalSt Leonards NSW 2065AUSTRALIA
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;31:2142–2145Telephone survey in 2 states (n = 2,700)Time off No time offTook 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** ModerateWeak (Waddell et al (2003)[Now at least 5 other systematic reviews with broadly similar findings]
79 ImplicationsSuccessful adjustment to living with chronic pain requires injured worker to take an active & informed roleWorkplace (employer) can play a key role in promoting sustained RTWHealthcare 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 disabling2) to find ways of maximising and sustaining the functional capacity of those who do return to the workforceKey: 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 Flags1997: 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 disabilityExpectation: 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 workersAssociated 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) StudyIntervention & Outcomes (bold)CommentVan den Hout et al. 2003Graded activities (behavioural principles) + problem-solving training > Graded activities + education(on longer-term work status)Åsenlöf et al.., 2005Individually-tailored cbt + exercises > exercises (on disability, pain fear of movement)Linton & Andersson, 20006 x 2-hr grp sessions with Clin. Psychologist + Rehab > Information + Rehab (on lost time from work)Marhold et al., 2001Same treatment as above > for sub-acute lbp than chronic lbp. (RTW outcome)Linton et al., 2005CBT grp = CBT + exercise grp >> minimal tmt grp (examination, reassurance, advice on activities).(lost time)Verbeek et al., 2002Many similarities in content of control grp and treatment grp. No difference between grps on disability & RTW outcome (both improved).Low distress in both groupsJelema et al., 2005Psychosocial intervention = standard care (both by GP only) (on disability)Low level of psychosocial risk factors at baselineHlobil et al., 2005Graded activity grp > usual care. (GPs consistency with program encouraged): Earlier RTWHay et al., 2005CBT (pain management) and manual therapy (+ home exercise) achieved similar results (disability)Average distress low initially so difficult to show much change.Sullivan et al., 2006Psychosocial 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., 2002All 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 alPhysician intervention that targeted identified specific individual concerns + problem-focused counselling when needed) > standard care (on RTW outcomes)Damush et al., 2003Brief group program, with telephone follow-up, aimed at increased function, health status > usual care
86 ImplicationsWhen 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
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 painBasic message: More distressed/disabled cases need more intensive treatmentEvidence:Guzman et al., BMJ 2002: systematic reviewWilliams et al. Pain 1999: RCTMarhold and Linton, Pain 2001: RCTHaldorsen 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 greaterWorse if treatments focus only on physical symptoms
91 ObstaclesIn 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 interventionsDespite 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 lossEarly contact with the worker bythe workplace ModerateWork accommodation offer StrongContact between healthcare provider Strongand the workplaceRTW coordination ModerateSuper-numerary replacements InsufficientBottom 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.ResponseVic vs NSW*No tests orderedMore likely not to order testsPrescription of bed restLess likely to support bed restAdvice on exerciseMore likely to support exerciseAdvice on work modificationMore likely to advise change
95 FindingsIn Victoria: Decline in claims for back pain, rates of days off, and costs of medical managementIn NSW: No change