Managing Complex Injuries

Dr Keith Adam, occupational physicianNavigating the Mine Field Conference16 September 2008

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

Simple cases

Usually < 3 weeksClear diagnosisRecovery as anticipatedRehabilitation program can facilitate timely return to

work, minimise time lost

“Complex cases”

Greater than 3 weeksThe diagnosis is not clearDisability greater than expectedAdditional factors influencing outcome

What goes wrong?

Rarely predicted by severity of initial injuryUsually 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 rehabilitation

The first consultation

Consults doctorRestCertificateReview in 1-2 weeks

The Medical Model

History Examination

Investigations Diagnosis

Treatment Cure!!

The Medical Model

Emphasis on correction of pathologyThe patient not required to play an active partStops 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?

X Rays

“talking x-rays”may tend to reinforce belief in incapacityan 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

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 painNormal functionLow satisfaction with medical processLow satisfaction with doctor

Those who had had X-ray reported

Significantly more painSignificantly worse functionHigh satisfaction with medical processHigh satisfaction with doctor.

Disease v Illness

DiseaseThe result of pathologyIllnessA social constructConfers certain rights/benefitsAltered 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 medicalizedPersonality difficulties + Troubled life situation

= Unacceptable Disability Unacceptable Disability + Accident/Illness

= Acceptable Disability

(Hirschfeld and Behan)

What reinforces the Sick Role?

Secondary gainsWell meaning doctorsAdversarial 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

GettingGetting out ofGetting 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

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 upWith No

attorney attorney

Great improvement 9% 68%

Much better 9% 64%

The Solutions

Risk for poor RTW: Bio-psycho-social perspective

Biological • Serious pathology• Co-morbidity

Personal and environmentalFactors (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 flags

•Perceived low social support at wk; Perceived unpleasant work•Low job satisfaction•Perception of excessive demands

Environmental (systemic)

(Mayou, Main, Auty, 2004)

Black flags

•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 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

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

Yellow Flags

Afraid of more pain with activity or workSmokingLow activity level High pain or illness behaviourPassive attitude to rehabilitationBack to work in next 3-6 monthsLigation involved with the claim?

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 Strongand the workplace

RTW coordination Moderate

Super-numerary replacements Insufficient

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

OMPQ scores (at time of claim)

Ave. cost of claims (at closure)

Low $4,878

Medium $6,240

High $17,178

Costs, from insurer, when claims closed (~ 1 yr).

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 weeksMedium risk (70 – 84) “Usual care + clinical psychologist”Low risk (<69) “Usual care”

RESULTS: Comparison between Control and Intervention Cohorts

CONTROL GROUP

INTERVENTGROUP

CONTROL GROUP

INTERVENT GROUP

RISK CATEGORY

% % $ COST $ COST

LOW 47 51 4,878 4,898

MEDIUM 31 29 6,240 6,752

HIGH 22 19 17,178 12,847Difference

$ 4331 or 25%

Changing beliefs about pain: A community interventionPopulation-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

ChecklistNot one problem but a range of different possible

problems requiring different solutionsComplex claims require sophisticated analysis,

aggressive managementParticular advantage of self insurers

“Stress”

Stress Claims

MultifactorialJudgementalConflict present from the start “Medicalization” of a problemMore vulnerable to secondary gains Invariable delay in decision making

Management of Stress Claims

Early intervention even more importantProvision of assistance prior to acceptance of claim

“without prejudice”Accept distressTry 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 meanHanding over controlDoctor 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 robbedFeels entitledBlame and anger are all consuming

Michelle Kearns

Pain Traps - 4

People will think I am a bludger!High expectations (of self), inflexibleWeak; a failureOverdo it – peaks and troughs

Michelle Kearns

Pain Traps - 5

I’ll never be able to enjoy life again!

Catastrophe!

Michelle Kearns

Pogo’s Law

Workplace based rehabilitation

What is different about the workplace?The industrial environmentWork is not optionalThe 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

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 performance

You cannot ignore a medical certificate

The “medical cloak”

REDUCEDACTIVITY

UNHELPFULBELIEFS &THOUGHTS

REPEATEDTREATMENTFAILURES

LONG-TERMUSE OF ANALGESIC,SEDATIVE DRUGS

LOSS OF JOB, FINANCIALDIFFICULTIES, FAMILYSTRESS

CHRONICPAIN

PHYSICALDETERIORATION(eg. muscle wasting, joint stiffness)

FEELINGS OF DEPRESSION,HELPLESSNESS,IRRITABILITY

SIDE EFFECTS(eg. stomach problems lethargy, constipation)

© M K Nicholas PhDPain Management & Research CentreRoyal North Shore HospitalSt Leonards NSW 2065AUSTRALIA

EXCESSIVESUFFERING

How might these lead to disability?

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 39.9Rested or avoided activity (%)* 77.2 44.8Stayed in bed more than usual (%)* 49.6 7.8Sought 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

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 reviewWilliams et al. Pain 1999: RCTMarhold and Linton, Pain 2001: RCTHaldorsen et al., Pain 2002: RCT

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 Strongand 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