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

2. 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.

3. 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?

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

5. 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.

6. Cost of Disability

7. Disability Impacts Life Roles

8. 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

9. The Illness/Wellness Continuum

10. The Illness/Wellness Continuum

11. Wellness or Disability?

12. Wellness or Disability?

13. Pain As the Primary Obstacle?

14. Pain/Symptoms only partially explain disability

15. We Treat Symptoms

16. 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.

17. Biopsychosocial Model

18. Biopsychomotor Model of Pain

19. BPS Interventions: Obstacles to RTW

20. Iceberg model of Health and Disease

21. Catastrophic Thinking

22. 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

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. Perceived Disability

30. 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”.

31. Perceived Disability

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

33. 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

34. Perceived Injustice

35. 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.

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

37. 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.

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

39. Interventions

40. 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