Socio-economic reintegration of chronic pain patients: outcome parameter for pain therapy? June 4, 2016 Dr. Marie Van Remoortere

Transcription

1 Socio-economic reintegration of chronic pain patients: outcome parameter for pain therapy? June 4, 2016 Dr. Marie Van Remoortere

2 Multidisciplinary Pain Centre ZNA Middelheim Hoge beuken

3 ZNA multidisciplinary pain team Psychologist : Maureen Malone Physiotherapist: Saskia Claes Social worker: Hendrik Devriendt Occupational therapist: Astrid Hoens Pain nurse: Tanja De Bruyn Pain consultants: Dr. Goossens Dr. Opsomer Dr. Turlot Dr. Van Remoortere

4 SUMMARY I. Rationale II. Literature vocational reintegration III. Model proposal for vocational reintegration of the pain patiënt IV. Implementation V. Closing remark

5 I. Rationale 1. Case series 2. Mental impact of long-term work disability on the patient 3. Economical impact of long-term work disability on the society

6 1. Case series Often young patients with a long-term work disability lower income, social isolation, poor self image: downwards spiral Uncertainty about disability benefits Focus on what can I still do rather than what can t I do anymore Conflicting recommendations from occupational health physician/medical advisers/treating physician

7 ????? Who determines work disability? Who determines the remainder capability? Who prescribes work disability? Better working with pain than being at home with pain? Is there a job for every patient? Medical adviser: develop a plan for progressive vocational reintegration, provide information, support patient in this process instead of screening for fraude? Creation of a reintegration plan with intensive social/emotional/occupational/practical support?

8 ???? Responsability of employer? Are the disability benefits too high? Role of occupational health physician? Do we need a return to work manager?

9 2. Mental impact of long-term work disability on the patient Work has a central role to social reintegration and personal achievement (Shepherd, 1989) Work is one of the most important factors in creating identity and purpose in life (De botton, 2008) Long-term work disability leads to lower psychological and physical well-being (McKee-Ryan et al. 2005) Long-term work disability is linked to early death, higher incidence of suicide and higher risk of developing mental and general health problems (WHO 2000)

10 If you think work is stressful, try poverty, unemployment and social isolation (Marrone and Golowka, 1999)

11 Is work good for your health and well being? Waddel and Burton, 2006 work is therapeutic helps to promote recovery and rehabilitation leads to better health outcomes minimises the harmful physical, mental and social effects of long-term sickness absence reduces the risk of long-term incapacity promotes full participation in society, independence and human rights reduces poverty improves quality of life and well-being.

12 3. Economical impact of long-term work disability on the society In Belgium unemployment around 8% Benefit from RVA unemployment by chronic disease Benefit from RIZIV grey zone

13 3-10% of patients with aspecific low back pain develop permanent work disability (Melloh et al. 2009) Prevalence of chronic pain: 19% (Breivik et al, 2006) 19% chronic pain patients in Europe are unable to work (Langley et al. 2011, Reid et al. 2011)

14 long-term disabled in Belgium 5% each year, in 2014 and % mental (34,83%) musculosceletal (28,75%) cardiovascular (6,67%) RIZIV 2013 In 2015: nearly 5 billion euros in health benefits

15 Indirect costs (absence and early retirement): 59% Out of hospital treatment: 21% In hospital treatment: 14% Analgetics: < 1% (Gustavvson et al, 2012)

16 Passive support >>> active support in Belgium: 1 euro vs 0,17 euro Workforce participation of chronic ill patients 47% (vs 57% mean Europe) (EU-Silc 2010) Return on investment of active support: 12/1 (Dr. J. Breuer, German Social accident insurance)

17 II. Literature vocational reintegration

18 Spice-model Colledge A. A model for the prevention of iatrogenic disease associated with work-related low back pain. J Occup Rehabil Dec;3(4):

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20 SPICE: Simplicity

21 SPICE: Proximity

22 SPICE: Immediacy

23 SPICE: Centrality

24 SPICE: Expectancy

25 The development of chronic pain and disability depends more on individual and work related pscyhosocial factors than on physical or clinical symptoms (Boersma et al, 2005, Linton et al, 2003, Linton et al. 2002, Vandenkerkhof et al. 2011, Melloh et al. 2009, Pincus et al. 2002) Permanent disabling symptoms can be prevented by early identification and treatment of psychosocial factors (Jellema et al, 2005)

26 Indirect costs can significantly be decreased by a multidisciplinary pain rehabilitation program (Thomson et al. 2002, Eriksen et al. 2004) Early return to work with rest symptoms decreases the risk of relapse and absenteeism during the following years (Du bois et al. 2008, Bigos et al. 1991)

27 Return to work as a treatment objective for patients with chronic pain? Sullivan and Hyman, 2014 Reduction in emotional and physical distress which does not translate into improved return to work outcomes is costly for society and decreases the autonomy of the indivual No return to work wrong idea about return to work Therapy should not only focus on patients functional rehabilitation but primarily on the belief change and the wrong perception about chronic pain and work

28 Du Bois et al. 2012

29 Epidemiology, outcome and costs of surgery for lumbar disc herniation M. Du Bois, 2004 Median duration of work incapacity before surgery: 6 months Work incapacity 1 Y after : - Discectomy: 20% - PLIF + discectomy: 55,4% Duration of work disability before surgery! factor for outcome

30 Risk factors for no-return to work Radicular pain Expectancy of the patient Score ODI Score fear-avoidance beliefs questionnaire Blue collar workers Low back pain > 12 week before work incapacity Female Older age! Duration of work disability duration of healing Du Bois et al en 2009

31 Possibility for prevention policy? Instrument to detect high risk patients Early and intensive treatment : win-win for society and patient

32 Yellow flags Psychological risk factors Normal but non constructive emotional response to pain E.g.: pain = damage, fear, low belief in recovery and evolution of the complaint, avoidance behavior, bad expectation

33 Blue flags Belief that the workplace is stressfull, not supportive and too demanding -> psychologist, physiotherapist, occupational worker

34 Orange flags Abnormal psychological factors Psychiatric disorders E.g.: posttraumatic stress syndrome, personality disorders, depression = psychopathology -> psychiatrist

35 Black flags Context/properties of the workplace More objective parameters Type of work Type of social security system for industrial accidents -> occupational health physician, medical adviser

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37 Scoring of 21 items: Physical functioning Fear avoidance Pain perception Psychological factors (coping/depression/distress) Work related factors

38 Stratification: Low risk < 90 Intermediate risk: High risk > 105 Predictive value: Assessment by the GP > SARNSP (Jellema et al 2007) Assessment by orthopedic surgeon << SARNSP (Grevitt et al. 1998) SARNSP guide for anamnesis

39 A screening questionnaire to predict no return to work within 3 months for low back claimants M. Du Bois, 2008

40 Questionnaire: creating an individual risk profile based on high values of specific items (Sattelmayer et al. 2012) Better to overinclude (Grotle et al. 1976, Linton et al. 2002) Targeted intervention on psychosocial risk factors: better results (Nicholas et al. 2011) -> multimodal rehabilitation versus monomodal therapy

41 Treatment focus on pain reduction with return to work as a central objective

42 In conlusion: Treat pain to the lowest/acceptable level Reassuring the patient after excluding red flags Motivate towards early, gradual return to work Screen early for risk factors (yellow flags) Treat high risk patients intensively and multidisciplinarily Early contact with the employer Create a schedule with fixed time points

43 Interaction and communication GP: captain of the ship? Multidisciplinary team (consultant, psychologist, social worker, physiotherapist, occupational therapist, ) Employer Medical adviser Employement sector Who will be the coordinator?

44 III. Model proposal for vocational reintegration of the pain patiënt Van Remoortere, NTTP, 2016

45 1. Questions to the GP Prescription of work disability (WD): always by the same GP Strict follow up by the GP of a patient with WD, including early screening of yellow flags Active reassuring of the patient after excluding red flags Motivating towards early return to work

46 2. Fast lane in MPC for (sub)acute complaints Patient is referred by GP or specialist Specific complaint of acute pain (< 6 months) Focus on maintaining job position adaptation - rehabiliation

47 3. Societal participation as a central objective of pain therapy Self-motivation of the patient Early screening of risk factors Discussed from the start Tool to evaluate the vocational capacity and performance

48 4. Who is who? Medical adviser, GP, occupational health physician E-health

49 5. Building a local network within the work sector GTB VDAB GOB Coaching of the patient by the jobcoach in the patients habitat

50 6. Integration of care and work Occupational therapist, physiotherapist or social worker of the MPC are the link between the work sector and the care sector 1 team member follows the training of disability case manager at RIZIV Support the patient with the admission at GTB/VDAB

51 7. Return to work meeting Monthly at the MPC Follow up of patients in a regular way GP may attend this meeting

52 8. Contact with the medical adviser From the moment the patient indicates to be ready for professional reintegration Contact between the MPC and the GP / medical adviser By phone/letter/ E-health? Gradual professional reintegration convention for professional rehabilitation Before admission at GTB/VDAB

53 9. Other requierements Raising awareness of GP s and specialists about the impact of work disability on the mental and physical health condition of our patients The role of the occupational health physician needs further attention

54 IV. Implementation Therapeutic arm: MPC Preventive arm: - Peri-operative phase - Peri-procedural phase - Development of a clinical path - Optimisation of registration system

55 IV. Closing remark Socio-economical reintegration as an outcome parameter for pain therapy

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