Biopsychosocial Management of Disability Elaine A. Tonel DO, MS Center of Occupational and Environmental Medicine, UCI

W.P. 60 y/o male Ironworker with a longstanding history of chronic back pain due to a lifting injury. He is recovering from a second back surgery. He is dependent on long-acting and short acting narcotics, anxiolytics-Xanax, ativan. About a $2000 is spent a month on medications. He is homebound and has not worked for several years since the injury or participates in any recreational activities.

Questions Can patients at risk for disability and delayed recovery be identified early? Are there risk factors that predict disability? Are there interventions or treatments that yield better outcomes for these patients?

Disability Associated with Pain-Related Conditions Musculoskeletal conditions are the most expensive non-malignant health problems affecting the working age population.

Disability Associated with Mental Health Conditions Within 5 years, depression (and stress-related conditions) will rank as the second leading cause of disability in industrialized countries.

Cost of Disability

Disability Impacts Life Roles

Disability as a “behavior” Reduced activity in daily living Engage in fewer social, occupational, and recreational activities Job loss Dependence on narcotics, anxiolytics, alcohol, recreation drugs Mental illness High medical utilization Family Conflict

The Illness/Wellness Continuum

The Illness/Wellness Continuum

Wellness or Disability?

Wellness or Disability?

Pain As the Primary Obstacle?

Pain/Symptoms only partially explain disability

We Treat Symptoms

Symptom-Focused Interventions Symptom-focused interventions do not necessarily yield reductions in disability. Research is accumulating that symptom- focused interventions are not sufficient to achieve return to work. In some cases symptom-focused interventions have actually been shown to increase as opposed to decrease disability.

Biopsychosocial Model

Biopsychomotor Model of Pain

BPS Interventions: Obstacles to RTW

Iceberg model of Health and Disease

Catastrophic Thinking

Catastrophic Thinking Excessive negative orientation towards one’s symptoms and health status Focus excessively on symptoms Tendency to exaggerate the threat value of symptoms Helplessness-belief that one is powerless to control or decrease one’s suffering Poor recovery after surgery, higher levels of pain, higher levels of anxiety, more severe depression, likely to be referred to specialists

Implications for Clinical Management Communication goals may be more important determinants of disability than pain itself. The interpersonal style of high catastrophizers will interfere with the development of a strong working relationship with the provider. Difficult to connect with Disclosure techniques important component that targets catastrophic thinking.

Clinical Management Disclosure Technique-opened ended questions, empathetic reflection, prompting Let them communicate their “illness/injury story” Avoid giving advice-unsolicited advice or suggestions will be perceived as criticism Education Attention-demanding activity participation to assist patients in disengaging from catastrophic rumination.

Symptom Exacerbation Fears Fear is a common response to distressing physical symptoms. Fear is common response to distressing psychological symptoms. Fear promotes avoidance. Fear promotes escape. Fear amplifies experience of pain. Fear leads to avoidance of physical activity of reduced social involvement-disability.

Consequences of Pain-related Fear Longer periods of disability Premature termination of physical therapy Less benefit from physical therapy Lower success of return to work trials.

Implications for Clinical Management Techniques for treating phobias might assist in the treatment of disability. Exposure techniques can also be and important tool for reducing disability associated with fear. Exposure techniques: movement/ exercise, activity interventions, volunteer work, modified RTW programs.

Conditions of Successful Exposure Probability of negative anticipated consequences must be minimized. Do it until it hurts strategy will increase fear of pain and lead to increased activity avoidance. Patient’s sense of control must be maximized. Predict exacerbations.

Perceived Disability

Perceived Disability Patient’s appraisal of level of disability Beliefs are central determinants of behavior and roadmaps of behavior. Family background may be a source Health professionals play a role Strong beliefs impair the ability to think in terms of degrees. Automatic reply to a challenging activity is “ I can’t”.

Perceived Disability

Consequences of Disability Beliefs Longer periods of work disability Difficult to engage in rehabilitation Reduced motivation for rehabilitation Negative expectancies for outcomes.

Rehabilitation as a Belief Change Intervention Disability beliefs cannot be challenged directly. Patients become strongly anchored in their beliefs when they sense someone is attempting to change their beliefs. Identify life roles that have discontinued due to pain and illness. Life roles are basis of one’s identity. Assist patients in resuming life role-relevant activities-more pertinent and relevant Goal setting, increasing life role activities- create reality that is incompatible with beliefs

Perceived Injustice

Perceived Injustice Exaggerated sense of loss and blame on someone else. Most resistant to change than any other pain- related psychosocial factor. Targets-driver, doctor, employer, insurer Goals-proving injustice to others, revenge motives Anger and depression is a vehicle for higher level of pain experiences. Invalidation increases motivation to provide proof of injustice.

Consequences of Perceived Injustice Longer periods of work disability Expressions of anger or hostility Working Alliance challenges Non-compliance

Validation Issues Recognize the patient’s losses and suffering Use language that is consistent “emotionally” with the patient’s communication. Don’t focus on the positive when they are trying to communicate suffering. Don’t disagree with their perception of suffering and severity of disability. Don’t use “yes” “but” language Validate the emotional experience not the sense of injustice.

How to provide early intervention 3 Problem Clusters Functional Concerns WorkPlace Concerns Emotional Concerns

Interventions

What happened to W. P.? Authorized a psychological assessment High catastrophizer, increased levels of depression and anxiety Identified that had a history of alcohol abuse, childhood physical abuse Treated with cognitive behavioral therapy Stopped narcotics, and anxiolytics. Psychiatrist started SSRI. Had sex with wife after 5 years, started to travel, and spend time with his grandchildren