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Preventing delayed recovery by
adopting a biopsychosocial approach
IFDM 2018
October 15, 2018
Vancouver, BC
Marcos Iglesias MD, MMM, FAAFP, FACOEM
OBJECTIVES
01. Review the importance of addressing
disability from a biopsychosocial
perspective
02. Describe a flag system to identify medical,
psychosocial, psychiatric, work and
system barriers to functional recovery
03. Learn the tools that are available to
minimize delayed recovery
Expected recovery Delayed recovery
DELAYED
RECOVERY
IWs WHO RTW –
BY QUARTERS
AFTER DOI
z
Washington State Department of Labor and
Industries conducted a study of all the state’s
compensable claims from 2011 to 2012 and
tracked them for two years post-injury, finding that
the probability of returning to work after one year
was 32% if not returned in the previous quarter,
and after two years fell to just 4.9%. [WDLI, 2013]
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8
IAIABC Disability Management and Return to Work Committee, 2016
NEEDLESS DISABILITY
of lost work days attributed to medical conditions
in the United States involved time off from work
that was not really required by the condition itself.
to 60% 80%
Jurisic M, et al. The Personal Physician’s Role in Helping
Patients with Medical Conditions Stay at Work or Return to Work. JOEM. 2017
WORKLESSNESS
2-3 X | 2-3 X | 6 X | 120%
WARNING
Not working may be harmful to your health
Biochemistry
Anatomy
Physiology
Pathology
Diagnostics
Therapeutics
Pharmacology
BIOMEDICAL MODEL
The body as a machine
The good physician treats the
disease; the great physician treats
the patient who has the disease.
Sir William Osler
Function Psycho Social
Bio
BIOPSYCHOSOCIAL APPROACH
Risk factors for disability are the
same regardless of the nature of the
condition
FLAG SYSTEM
Age
Gender
Comorbid conditions
Obesity
Diabetes
COPD
Smoking Opioids
Red flags
BIOLOGICAL RISK FACTORS
Compensation
Administrative delays
Iatrogenesis
Black Flags
NOMOIATROGENESIS
SYSTEM RISK FACTORS
Job Dissatisfaction
Unsupportive work environment
Work overload and pressure
Blue Flags
Workplace climate
Belief that work may cause injury
CONTEXTUAL OBSTACLES
Blue Flags
Heavy manual job
Long commute distance
CONTEXTUAL OBSTACLES
Fear Catastrophic thinking
Recovery expectation
Perceived injustice
Maladaptive coping
Absence of positive adaptive behaviors
Yellow Flags
PSYCHOSOCIAL BARRIERS
Yellow Flags
Low social support
Dysfunctional family situation
ACE
PSYCHOSOCIAL BARRIERS
Progression to chronic low back pain was more
closely dependent on demographic, psychosocial and
occupational factors than on medical characteristics.
Valat et al, 1997
Psychosocial risk factors play a
dominant role in developing chronic
low back pain disability.
Spine, 1995
PSYCHOSOCIAL BARRIER
PSYCHOLOGICAL SYMPTOM
PSYCHIATRIC DISORDER
Depression
MDD
Anxiety
Anxiety disorders
Poor coping
Adjustment disorder
Unpleasant experience
Traumatic experience
PTSD
Maladaptive behavior
Personality
disorder
Absence of positive adaptive behaviors
Job avoidance
Orange Flags
PSYCHIATRIC ILLNESS
DATA
TEXT
SCREENING TOOLS
FORMAL ASSESSMENT
GUT FEEL
SCREENING TOOLS: GENERAL
Orebro
STarT
Back Disability Risk Questionnaire (Shaw)
Acute Low Back Pain Screening Questionnaire
SCREENING TOOLS: SPECIFIC FACTORS
Pain catastrophizing
Perceived injustice
Fear avoidance
PCS
IEQ
TSK, FABQ
SCREENING TOOLS: SPECIFIC FACTORS Depression
Anxiety
Alcohol and substance abuse
PHQ-9; PHQ-2; BDI
GAD-7; Beck Anxiety Inventory
CAGE; AUDIT
Interventions
Rapid return to work
Activity
Motivational interviewing
Health/RTW coaches
Cognitive behavioral therapy
THANKS!