Spo$ng and Managing Delayed Recovery in Injured Workers

Disclosure Informa5on Western Occupa5onal Health Conference 2011 I have the following financial rela5onships to disclose: I have nothing to disclose - and- I will not discuss off label use and/or inves5ga5onal use in my presenta5on Spo$ng and Managing Delayed Recovery in Injured Workers Ravi Prasad, PhD Assistant Director, Division of Pain Management Stanford University School of Medicine rprasad@stanford.edu Delayed Recovery: Key Features Failure to respond to ini5al treatment interven5ons Disability out of propor5on with degree of impairment Increased likelihood to develop chronic disability 1

Implica5ons: Pa5ent Decreased overall func5oning Increased work, social absenteeism Increased u5liza5on of healthcare system Increased emo5onal distress Increased family stress Loss of income, financial strain Implica5ons: Provider Provider frustra5on Medica5on escala5on Repeated use of interven5ons with no demonstrated efficacy for pa5ent Increased likelihood of treatment denials from carrier Implica5ons: Society IOM Report (2011) Chronic pain affects 116 million American adults More than those affected by heart disease, cancer, and diabetes combined Es5mated annual cost of $635 billion in medical treatment and lost produc5vity 2

Delayed Recovery Pathway Delayed Recovery Pathway Family Friends Work School Sports Leisure Self-care Music Vacations Hobbies Dining Entertainment Socializing Cooking Cleaning Errands Delayed Recovery Pathway Family Friends Work School Sports Leisure Self-care Music Vacations Injury Hobbies Dining Entertainment Socializing Cooking Cleaning Errands 3

Delayed Recovery Pathway Decreased activity levels Increased Family Physical Friends Work School emotional deconditioning distress Sports Leisure Self-care Music Injury Vacations Hobbies Dining Interpersonal Sleep problems disturbances Entertainment Socializing Increased number of Cooking Cleaning Errands doctor office visits Delayed Recovery Pathway Family Friends Work School Sports Leisure Self-care Music Vacations Hobbies Dining Entertainment Socializing Cooking Cleaning Errands Injury Who is at Risk? Adverse Childhood Experience (ACE) Study CDC/Kaiser Permanente collabora5on Co- PIs: Robert Anda, MD, Vincent Felib, MD Examining rela5onship between ACEs and health/ behavioral outcomes later in life Data gathered from 17K individuals between 1995-97 4

Who is at Risk? Adverse Childhood Experiences Physical/emo5onal neglect Recurrent emo5onal abuse Recurrent physical abuse Sexual abuse (contact) Household substance abuse Incarcera5on of household member Chronic mental illness Mother treated violently One or no parents Who is at Risk? Higher ACE scores increase risk for developing Medical/psychiatric disease CD/SA issues Health- related QOL issues Partner violence Sexual ac5vity Suicidality Who is at Risk? Implica5ons of ACE Development of Axis II Disorder/Traits: Diatheses- stress model (Weisberg, 2000) Presence of an underlying Personality Disorder related to higher levels of self- reported distress and pain (Elliot, Jackson, Layfield, & Kendall 1996) High risk individuals tend to have higher pain ra5ngs 5

Who is at Risk? Other ACE- associated psychological risk factors (Pulliam, Gatchel, & Gardea, 2001; Vlaeyen & Linton 2000; Crombez, Vlaeyen, Heuts, & Lysens 1998) Higher prevalence of Axis I disorders Low posi5ve temperament (enjoyment of life, undertaking projects with enthusiasm, etc.) Avoidant/passive coping style: wishful thinking, escape behaviors Pain- related fear/fear- avoidance Maladap5ve cogni5ons (Nega5ve appraisal of internal and external s5muli, catastrophiza5on) Displacement Who is at Risk? Subconscious process Medical diagnosis is a safer/more acceptable representa5on of internalized emo5onal distress Treatments subsequently serve to treat the underlying pathology Who is at Risk? Non- psychiatric risk factors: Job dissa5sfac5on Prolonged work absence Pending li5ga5on 6

Iden5fying Delayed Recovery Clinical judgment Pros: Minimal 5me involvement, no addi5onal resources necessary Cons: Difficult to jus5fy treatment recommenda5ons without addi5onal corrobora5ng data Iden5fying Delayed Recovery Basic Psychological Assessment Tools Examples Pain Catastrophizing Scale (PCS) Fear Avoidance Beliefs Ques5onnaire (FABQ) Pros: Easy to administer and score, provides a star5ng point for pa5ent educa5on Cons: Only iden5fies a cogni5ve tendency, not a screen for Axis I pathology, not as predic5ve of delayed recovery as other measures PCS Sample I worry all the 5me about whether the pain will end Not at All To a Slight Degree To a Moderate Degree To a Great Degree All the Time 0 1 2 3 4 I feel I can t go on 0 1 2 3 4 It s terrible and I think it s never going to get any beoer 0 1 2 3 4 7

FABQ Sample My pain was caused by physical ac5vity Completely Disagree Unsure Completely Agree 0 1 2 3 4 5 6 Physical ac5vity makes my pain worse 0 1 2 3 4 5 6 Physical ac5vity might harm my back 0 1 2 3 4 5 6 Iden5fying Delayed Recovery Diagnos5c Assessment Tools Example: Structured Clinical Interview for DSM- IV (SCID) Pros: Assist with iden5fying the presence of psychiatric disorders known to be associated with disability and func5onal impairment Cons: Time consuming, not as predic5ve of delayed recovery as other measures, not self- administered (SCID) Iden5fying Delayed Recovery Gatchel Algorithm (Gatchel, Pola5n, Mayer, 1995) Pros: Predicted with 90.7% accuracy ACLB pa5ents that would go on to develop chronic disability problems Cons: Time intensive requires administra5on of mul5ple assessment devices 8

Iden5fying Delayed Recovery Orebro Muskuloskeletal Pain Screening Ques5onnaire Pros: Brief (25- items rated 0-10), self- administered, decent reliability & validity, 80+ % accuracy of iden5fying individuals who may go on to have extended sick leave secondary to func5onal problems Cons: Lower level of accuracy in iden5fying individuals who may go on to have extended sick leave due to pain Orebro Sample Other Variables to Explore Cultural factors Are cultural variables playing a role in use of injury as a socially accepted reason for disability? Other culture specific issues Family influences Are solicitous behaviors from well- meaning family members crea5ng subconscious secondary gain? Are other family stressors crea5ng subconscious secondary gain? 9

Other Variables to Explore Work environment Is a stressful work environment of lack of workplace sa5sfac5on crea5ng subconscious secondary gain? Can RTW be accomplished through sebng up a modified transi5on plan with IW & employer? Presence of untreated medical condi5ons Fractures, cancer, other organic pathologies Early Interven5on Par5cipa5on in a structured program comprised of cogni5ve behavioral treatment and physical therapy training General Goals: Develop healthier, adap5ve coping habits Shit locus of control Decrease fear- avoidance behaviors Increase overall func5oning Return to work Different structures Early Interven5on Average program dura5on: 6-9 weeks Weekly sessions combine PT and psychology treatment (~ 3 hours), or CBT alone Emphasis on self- management versus passive strategies 10

Common Curriculum Components: CBT Overview of pain (hurt vs. harm) Introduc5on to self- management strategies (e.g., relaxa5on training, pacing) Pacing of Ac5vi5es Typical ac5vity paoern of chronic pain pa5ents: Pacing of Ac5vi5es Goal Ac5vity Paoern: 11

Common Curriculum Components: CBT Iden5fying environmental stressors (work & home) Development of stress management techniques (e.g., cogni5ve restructuring, communica5on skills training, etc.) Cogni5ve Restructuring Cogni5ve behavioral theories posit that our thoughts guide our behavior Thought processes are oten rooted in our core percep5on of ourselves and our roles in this world Usually shaped by early experiences Much of our maladap5ve behaviors are rooted in nega5ve thought paoerns Pa5ents with depression typically have a nega5ve view of self, world, and future Cogni5ve Restructuring Situation Interpretation Outcome Joe Wake with pain -Nothing I can do -Life is terrible -Nothing will get done -Irritable -Depressed -Anxious -Isolate -Frustration -Increased physiological arousal 12

Cogni5ve Restructuring Previous Thoughts There is nothing I can do to control this Life is terrible Nothing will get done today Modify Thoughts Are these statements helpful? Are these statements accurate? Cogni5ve Restructuring Previous Thoughts There is nothing I can do to control this Life is terrible Nothing will get done today Modified Thoughts I can prac5ce self- management skills Life may feel terrible now, but I know this flare will end I don t know what the rest of the day will be like but I will make the most of it by pacing Cogni5ve Restructuring Situation Interpretation Outcome Joe Wake with pain -I can practice selfmanagement skills -Life may feel terrible now, but I know this flare will end -I don t know what the rest of the day will be like but I will make the most of it through pacing -Hopeful -Increased motivation -Less anxious -Engaged -Goal-oriented -Decreased physiological arousal 13

Common Curriculum Components: CBT Flare con5ngency planning Maintaining gains Common Curriculum Components: PT Replica5on of work ac5vi5es (graded exposure as needed) Individualized exercise plans Behaviorally address fear avoidance behaviors Empirically Validated Treatment: Self- Management Educa5on Lambeek, Van Mechelen, Knol, Loisel, Anema (2010) Buchner, Zahlten- Hinguranage, Schiltenwolf, Neubauer (2006) Linton & Ryberg (2001) Flor, Fydrich, Turk (1992) 14

Empirically Validated Treatment: Early Interven5on Risk for developing long- term sick absence significantly reduced (Linton & Andersson, 2000) Sustained increases in ac5vity, QOL (Linton & Nordin, 2006) Less loss produc5vity costs (Linton & Nordin, 2006) Empirically Validated Treatment: Early Interven5on Lower rates of healthcare u5liza5on, medica5on use, and self- report pain variables (Gatchel, Pola5n, Noe, Gardea, Pulliam, & Thompson, 2003) Greater cost savings associated with early interven5on ($12,721) vs no interven5on group ($21,843). Cost variables included healthcare visits, medica5on, lost wages, early interven5on program cost x1 year (Gatchel, Pola5n, Noe, Gardea, Pulliam, & Thompson, 2003) Timing is Cri5cal! Marhold, Linton, Melin (2000) Randomized control trial (n=72): Compared outcomes from a 12- session CBT RTW program in individuals who had a history of LT sick leave (> 12 mo) versus ST sick leave (2-6 mo), & a control group Treatment was more effec5ve than control in the ST leave group but not for the LT leave group 15

Addressing Delayed Recovery with Limited Resource Availability Employ use of a biopsychosocial formula5on of the pa5ent s predicament versus focusing solely on a biomedical model Engage in mul5disciplinary treatment whenever possible, even if an EIP is not available Remain confident, posi5ve, and reassuring (Thomas & McAdams, 2004) Addressing Delayed Recovery with Limited Resource Availability Provide pa5ent educa5on on course of pain Dedicate a fixed por5on of the appointment to counseling Set weekly appointments to track func5oning Provide overview of pain course Normalize tendency to develop fear of movement and address fear- avoidance behavior Addressing Delayed Recovery with Limited Resource Availability Emphasize focus on func5on versus pain elimina5on: Set func5onal goals (resump5on of normal ac5vi5es, RTW) and use ac5vity tracking sheets (Hawthorne Effect) Monday Tuesday Wednesday Thursday 5:00 Gym Pool Ex Gym Pool Ex 6:00 Dinner Prep Dinner Clean Dinner Prep Dinner Clean 7:00 Walk dog Kids HW Walk dog Kids HW 8:00 PC work Car project Pay bills Read book 16

Addressing Delayed Recovery with Limited Resource Availability Minimize repeated invasive procedures & medica5on dose escala5on in the absence of func5onal improvement Summary Delayed recovery has significant implica5ons for pa5ents, providers, and society Remain cognizant of risk factors associated with delayed recovery Use assessment tools and/or local providers (e.g., psychologist, PT) to assist with iden5fica5on of high risk pa5ents Enroll in Early Interven5on program as soon as delayed recovery iden5fied Dedicate a fixed por5on of the session to pa5ent educa5on & reassurance Focus on func5oning vs. symptoms References Buchner M, Zahlten- Hinguranage A, Schiltenwolf M, Neubauer E. (2006). Therapy outcome ater mul5disciplinary treatment for chronic neck and chronic low back pain: a prospec5ve clinical study in 365 pa5ents. Scandinavian Journal of Rheumatology35, 363-367. Commioee on Advancing Pain Research, Care, and Educa5on: Ins5tute of Medicine. Relieving Pain in America: A Blueprint for Transforming Preven5on, Care, Educa5on, and Research. 2011. Crombez G, Vlaeyen JWS, Heuts PHTG, Lysens R. (1999). Pain- related fear is more disabling than pain itself: evidence on the role of pain- related fear in chronic back pain disability. Pain 80, 329-339. Elliot TR, Jackson WT, Layfield M, & Kendall D. (1996). Personality disorders and response to outpa5ent treatment of chronic pain. Journal of Clinical Psychology in Medical Se@ngs 3(3), 219-234. Flor H, Fydrich T, Turk DC. (1992). Efficacy of mul5disciplinary pain treatment centers: a meta- analy5c review. Pain, 49(2) 221-230. 17

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