1. Recognizing Failed Low Back Treatment: Role of the Field Nurse Case Manager Presenter:Marlene Vergillo, RN, CCM Manager of Medical and Disability Services Manager of Medical and Disability Services Liberty Mutual Insurance Group December 2, 2005

2. Learning Objectives Establish the role of Field Nurse Case Manager (NCM) in the Treatment of Chronic Low Back Pain Identify “Red Flags” of Failed Low Back Treatment Discuss Effective Management Strategies

4. Return to Work (RTW) Statistics If someone is out of work for 6 months Only a 50% chance of achieving RTW If someone is out of work for 1 year Only a 25% chance of achieving RTW If someone is out of work for 2 years Virtually no chance of achieving RTW Source: Bureau of Labor Statistics

5. WC Claims Data Suggests For individual out of work 1 month after onset of low back pain: –52% will remain out of work at least 6 months –62% will remain out of work at least 1 year Source: Hashemi, Webster, Clancy et al., Length of disability and cost of workers’ compensation low back claims., Journal Occupational Environ Med 1997; 39: 937-45.

6. Low Back Pain (LBP) Historical Data 80% of Americans experience LBP 80-90% of attacks resolve within 6 weeks 5% resolves by end of 12 wks 5% becomes chronic LBP is 2nd only to the common cold as cause of lost work time 3 rd most common reason for surgery Source: Wheeler, Stubbart, Schneck et. al, Pathophysiology of CBP, eMedicine

7. Occupational Low Back Pain (OLBP) Statistics 10% of workers with OLBP have a chronic course of pain & disability that lasts >3 mos 80% of all medical & indemnity costs are attributable to OLBP Most common reason for disability among persons under 45 years of age Most costly of the top 10 most common causes of occupational injury Source: Shaw, Pransky, Fitzgerald, Early Prognosis for Low Back Disability: Intervention Strategies for HCP

8. Case Management Process AssessmentPlanningImplementationCoordinationMonitoringEvaluation Source: Commission for Case Manager Certification

9. Nurse Case Management Role Work with all parties to promote recovery and return to work. Ensure access to quality medical care after the injury Provide physician with job demands, injured worker’s mental state & employer/employee relationship Ensure RTW job is commensurate with functional ability of injured worker and job responsibilities

10. Initial Nurse Case Manager Evaluation Purpose of the initial evaluation: To make an accurate assessment of the prognosis Determine estimated return to work date Develop Case Management Strategy Evaluation includes gathering information from the injured worker, employer and healthcare provider.

11. Red Flags- Physical Factors Pain unrelieved by rest History of Cancer Fever or immunosuppressed status Intravenous drug abuse Pain that worsens when supine or at night Bowel or bladder dysfunction Unable to ambulate or care for self Source: Wheeler, Stubbart, Schneck et. al, Pathophysiology of Chronic Back Pain, eMedicine

12. Red Flags- Prognostic Factors Out of work, disabled, or seeking disability Presence of other chronic pain condition Psychological features Narcotic or psychoactive drug requests Repeated failed surgical or medical TX Nonorganic signs and symptoms Source: Wheeler, Stubbart, Schneck et. al, Pathophysiology of Chronic Back Pain, eMedicine 2004

13. Red Flags- Social Factors Family or spousal dynamics Job dissatisfaction and/or conflict Perception of norm, i.e. family history Financial security Legal representation Limited education or vocational potential Environmental stressors Source: Wheeler, Stubbart, Schneck et. al, Pathophysiology of Chronic Back Pain, eMedicine 2004

14. Nurse Case Manager Assessment Includes:Severity Appropriateness of treatment Duration of disability Rehabilitation opportunities Source: Mullahy, Catherine, The Case Manager’s Handbook, 1998

15. Rehabilitation Potential ExperienceMotivationTalentAdaptability Prior skills Past history Reasonable Expectations Source: Brodwin, Fernando, et. al, Medical, Psychosocial and Vocational Aspects of Disability, 2002

16. Nurse Case Manager Plan of Action Provide ongoing encouragement and support to all parties Communicate information and status to all parties Understand consequences of disability to all parties Match functional capabilities to alternate job opportunities

17. Definition of Pain “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective.” Source: International Association for the Study of Pain (IASP) 1986

18. Acute vs. Chronic Pain AcuteChronic SimpleComplex Self-limiting Persistent- lasts 3-6+ months Easy to manage Influenced by psychological factors Time alone heals Debilitating RTW common RTW frequently impaired

19. Medical Evaluation Several conditions can lead to CLBP: –Recurrent disc herniations –Degenerative disc disease –Degenerative osteoarthritis –Spinal Stenosis –Spondylolisthesis –Arachnoiditis Source: Brodwin, Fernando, et. al, Medical, Psychosocial and Vocational Aspects of Disability, 2002

20. Psychological Assessment 1. Orientation and neuro-cognitive status 2. Depression & potential for suicide 3. Anxiety and PTSD 4. Substance Abuse 5. Pain Behaviors 6. Status of litigation 7. Beliefs about pain 8. Consequences of pain reduction 9. Expectations of treatment

21. Biopsychosocial Evaluation Used to identify: Sources of feedback within the family, social and work Attitudes that become psychological modulators of pain Cognition and perceptions that interact with affective, behavioral, & environmental factors Source: Brodwin, Fernando, et. al, Medical, Psychosocial and Vocational Aspects of Disability, 2002

22. Cycle of Pain & Influences Pain-Stress & Cognitive Distortions Anxiety Depression Guilt Anger Family Problems Trauma Subs Abuse Medlcal Proced Phys Decondition Medical Uncertainty Job Dissatisfaction Financial Problems Financial Incentives

23. Vocational Factors Early intervention Employer interest and involvement Understanding of chronic pain Reasonable accommodations Successful pain mgt treatment program Source: Brodwin, Fernando, et. al, Medical, Psychosocial and Vocational Aspects of Disability, 2002

24. Failed Back Treatment Obstacles Healthcare providers and insurer/payer often assume pain is purely objective Primary physicians do not have experience treating chronic Low Back Pain No guiding agency providing credibility to Pain Management Programs Substance abuse Pre-morbid psychological disorders Patient non-compliance in treatment program

25. NCM Role in Failed Low Back Treatment Serves as an effective liaison Gathers information from all parties and completes an in depth assessment Communicates “Red Flags” to treating physician Recognizes early the subtleties of chronic pain Works with physician to adjust treatment plan Facilitates communication from the pain management program to the outside providers, family, and insurer/payer. Assures that the many facets of the pain management program are on track.

26. NCM Fulfill A Role Not Provided Elsewhere in the Healthcare System Becomes the eyes and ears for others Serves as a resource for parties involved Observes & communicates early “Red Flags” of Failed Low Back Pain Maintains workplace relationship between employer & injured worker to maintain injured worker’s self-efficacy Assists family to deal with practical matters Source: Mullahy, Catherine, The Case Manager’s Handbook, 1998

27. “The mind has great influence over the body and maladies often have their origin there” Moliere 1622-1673