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

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 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.

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? 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.

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 < 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

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.

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) 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

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 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

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

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; 82:1009-1013.

The Solutions

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

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 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

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)

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

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 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%

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

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

Pogo’s Law

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

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?

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.

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

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

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.

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

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

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

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

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

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

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

Rehabilitation Certification Describe limitations as precisely as possible Specify time limits

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

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 Example -

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

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

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

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 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

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) Time off No time off Took painkillers (%)* 70.5 39.9 Rested or avoided activity (%)* 77.2 44.8 Stayed in bed more than usual (%)* 49.6 7.8 Sought care (%)* 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 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]

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 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)

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) 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 . 2003 ‘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. 2008 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

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 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, 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

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 (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

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

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