Trent Occupational Medicine Symposium 2008 Fitnotes or Sick Notes: Evolving Occupational Health Prac - PowerPoint PPT Presentation

Loading...

PPT – Trent Occupational Medicine Symposium 2008 Fitnotes or Sick Notes: Evolving Occupational Health Prac PowerPoint presentation | free to view - id: 9a8ff-NmY3N



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Trent Occupational Medicine Symposium 2008 Fitnotes or Sick Notes: Evolving Occupational Health Prac

Description:

Arthritis Research Campaign National Primary Care Centre. Trent Occupational ... Key supervisor competencies for achieving safe & sustainable RTW (Shaw 2008) ... – PowerPoint PPT presentation

Number of Views:75
Avg rating:3.0/5.0
Slides: 71
Provided by: igri
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Trent Occupational Medicine Symposium 2008 Fitnotes or Sick Notes: Evolving Occupational Health Prac


1
Trent Occupational Medicine Symposium (2008)
Fit-notes or Sick Notes Evolving Occupational
Health Practice
  • Flying the Flag prognostic Pointers
  • Chris J. Main Ph.D.
  • arc National Primary Care Centre
  • Keele University, U.K.
  • Thurs 9th October 2008
  • E.M.C.C. University of Nottingham

2
OUTLINE OF PRESENTATION
  • 1 Models of pain and disability
  • 2 Nature and development of chronic disability
  • 3 Risk factors for chronic pain/disability
  • 4 The Flags initiative
  • 5 Recommendations
  • (a) Clinical Yellow Flags
  • (b) Occupational Blue Flags
  • 6 Flags in Practice
  • (a) Supervisors and Case manager
  • (b) Need for a systems approach (lessons from
    WiW)
  • 7 Concluding observations and reflections

3
1 Models of pain and disability
4
PAIN PERCEPTIONThe mind and the body
spino-thalamic tract
Rene Descartes
5
Descending inhibition or excitation
6
IMPLICATIONS FOR UNDERSTANDING THE EXPERIENCE OF
PAIN
  • There are individual differences in the rate and
    pattern of recruitment of parts of the brain
    following nociception
  • These may be reflected in differences in pain
    experience and may explain differences in pain
    tolerance
  • The experience of pain is further influenced by
    pain memories
  • The nervous system is not hard-wired as
    previously thought but responds to new sensory
    input
  • Pain has to be understood in its psychological as
    well as its biological context

7
UNDERSTANDING THE MEANING OF PAIN
  • Instinctive responses are progressively shaped
    by social processes
  • As we mature we learn about the meaning and
    significance of pain. We observe how others react
    to situations and gradually we become become more
    skilled and effective in managing pain
  • Social learning begins with the neonate
  • Communications about pain trigger responses,
    within families, at work and during consultations
  • Pain also has to be understood in a social as
    well as a biological context

8
TAKE HOME MESSAGE
  • The Brain is active not passive

9
MODERN DISEASE MODEL Concept of Cellular
Pathology Virchow
pathomorphology symptoms and signs diagnosis trea
tment pathology expect symptoms to resolve
10
(No Transcript)
11
THE BEHAVIOURAL LEGACY
  • Dept. of Rehab Medicine University of Washington
    - late 1960s
  • Fordyce W.E. et. Al
  • Operant conditioning in the treatment of chronic
    pain
  • (Arch Phys Med Rehabil 1973 54 399-408)
  • Behavioral methods in chronic pain illness

12
KEY MESSAGES
  • All pain behaviour occurs in a social context
  • Symptomatic presentations may be highly
    idiosyncratic
  • A patients reaction to the persistence of pain
    may range from the expression of mild concern, to
    evidence of significant distress
  • Their pain behaviour may range from display of
    guarded movements to full-blown chronic pain
    syndromes
  • Pain-associated work compromise (or work
    disability) can be complex
  • At present our interventions are geared almost
    entirely to medical or biomechanical
    interventions
  • No wonder they have limited success!

13
TAKE HOME MESSAGE
  • Biopsychosocial problems need biopsychosocial
    solutions

14
2 Nature and development of chronic pain and
disability
15
From models to mechanismsSome common types of
explanations for the persistence of pain
  • Biomedical explanations for the persistence of
    pain
  • Inflammatory or degenerative disease
  • Neoplastic disease
  • Neuropathic pain (nerve-damage secondary to
    disease or trauma)
  • Biomechanical
  • Misalignments and derangements of the
    musculoskeletal system secondary to disease or
    trauma
  • Disuse
  • Psychological
  • Psychologically-mediated responses to pain
  • Attentional mechanisms
  • Attributions of intent e.g.malingering
  • Social
  • Physical demands of work/participation

16
What do we know about the transition to
chronicity?
  • Epidemiological studies have identified a number
    of demographic, clinical and psychosocial risk
    factors for chronicity.
  • Not all are modifiable
  • In considering interventions we need to pay
    particular attention to modifiable factors
  • Psychological factors are particularly good bets
  • Interest in psychological factors is not new!

17
CHRONIC LBP
Chronic Pain Chronic LBP Fibromyalgia Neuropathic
pain
Acute Pain nociceptive pain
18
KEY TYPES OF PSYCHOLOGICAL FACTORS
  • IMPORTANT TO DISTINGUISH
  • Beliefs
  • Emotional Responses/Reactions
  • Pain Behaviour
  • BUT
  • They patients do not clearly distinguish them or
    understand their interactions
  • They may become a style of life

19
Cognitive-behavioral model
Vlaeyen et al., Pain, 1995
INJURY/STRAIN
DISUSE DISABILITY DEPRESSION
RECOVERY
EXPOSURE
PAIN EXPERIENCE
FEAR OF MOVEMENT (RE)INJURY, PAIN
LOW FEAR
20
TAKE HOME MESSAGE
  • In musculoskeletal disorders,
  • Psychological factors have a powerful influence
    on outcome

21
3 Risk factors for chronic pain disability
22
RISK FACTORS
  • Risks of what?
  • The importance of outcome
  • Pain persistance
  • Persistence/worsening of pain-associated
    limitations
  • Sustained Return to work

23
RISK FACTORS
  • What risk factors are important?
  • Epidemiological studies have found a range of
    demographic, clinical and psychological factors
    all of which have an association with chronicity
  • Psychological factors have particularly strong
    associations with outcome (Linton, 2000 Truchon
    and Fillon,2000)
  • Even after control for demographic, clinical and
    physical factors (Burton et al.,1995 Wessels et
    al.,2007)

24
DOES THIS MEAN THAT BIOLOGICAL FACTORS ARE
IRRELEVANT?
  • Certainly not
  • We know that the brain is neuroplastic rather
    than hard-wired
  • Experimental clinical studies using imagery such
    as fMRI are now showing us the bits of the brain
    that light up in responses to a pain stimulus
  • Our pain perceptions are underpinned by pain
    memories and social learning, all of which can be
    understood potentially in terms of biological
    processes as well as psychology
  • However, in terms of access to interventions, we
    have the opportunity to address
  • Beliefs
  • Emotional Responses/Reactions
  • Pain Behaviour

25
RISK FACTORS Conclusions
  • The importance of Context
  • Setting, outcomes, timing and nature of
    interventions (Waddell, Burton Main,2003)
  • Not all risks factors are modifiable
  • Key challenge
  • Identification of Modifiable risk factors
  • Targeting interventions
  • Overcoming obstacles
  • Turning potential obstacles into opportunities
    for intervention
  • Need for an over-arching framework
  • These observations apply to occupational as well
    as clinical interventions

26
TAKE HOME MESSAGES
  • Mechanisms of chronicity are not the same as the
    mechanisms of injury
  • Chronic incapacity is not the same as a series of
    acute episodes

27
4 The Flags initiative
28
PSYCHOSOCIAL RISK FACTORSYellow Flags(Kendall,
Linton and Main,1997)
  • Beliefs, behaviours and emotional responses
    identifying those likely to develop long-term
    problems
  • Contained both health and occupational elements
  • Flags include
  • screening
  • assessment guidelines and
  • recommendations for early management

29
Yellow Flags Why were they developed?
  • In the early/mid 90,s, in New Zealand,the costs
    of musculoskeletal problems, and LBP in
    particular were becoming a major problem
  • Patients had a legal entitlement to as much
    treatment as requested following a (self-defined)
    musculoskeletal accident
  • Physiotherapists and chiropractors in particular
    offering massive number of treatment sessions
  • One patient given gt500 treatments
  • Chronic low back pain was bankrupting the New
    Zealand Accident and Compensation Corporation
    (ACC)

30
Key Questions
  • Why were so many cases becoming chronic, so
    disabled, and not returning to work?
  • Was their any way of preventing this situation?
  • Nick Kendall, a SL at the University of Otago
    (and pain psychologist) was asked to help the ACC
    to investigate the problem
  • He ask Steven Linton (Sweden) and myself (UK) to
    help
  • This led to the birth of the Flags which had an
    unusual gestation

31
(No Transcript)
32
(No Transcript)
33
Maruia Thermal Springs
34
Thermal mineral water plus several bottles of
fine New Zealand wine
Interesting chemical reaction
35
(No Transcript)
36
(No Transcript)
37
Psychosocial
  • Psychosocial refers to the interaction between
    the person and their social environment, and the
    influences on their behaviour

38
EXAMPLES OF YELLOW FLAGS(Kendall et al.,1997
Main et al,2008))
  • Unhelpful/mistaken beliefs about pain and injury
  • Hurt and harm
  • High levels of distress
  • Symptom concern
  • Depressive symptoms
  • Pessimism and catastrophising
  • Maladaptive coping strategies
  • Poor pacing
  • Excessive/inappropriate medication use
  • Unrealistic expectancies
  • Low confidence (lack of self-efficacy)

39
BLUE BLACK FLAGS (Main Burton, 2000)
Prof. Kim Burton
  • Blue Flags perceptions of work and working
    conditions
  • After injury may become significant obstacles to
    recovery
  • Often not addressed specifically in clinical
    treatment or rehabilitation
  • Black Flags Objective working characteristics
    conditions also seemed to be important

40
(No Transcript)
41
YELLOW FLAGS nature and identification(Nicholas
et al, Submitted)
  • There is good evidence that Yellow flags are
    predictive of subsequent persisting pain and
    associated disability in injured workers.
  • Equally, there is good evidence that some
    self-report scales can assist in identifying the
    presence of these Yellow flags (Hockings et al.,
    2008).
  • Flags are potentially modifiable risk factors
  • However, how these risk factors operate in
    practice is not well-established.
  • There is some evidence that the more risk factors
    present the greater the likelihood of a poor
    outcome.
  • Initial Yellow flag identification, whether by
    questionnaire or more individualized screening,
    should be understood as the first part of a
    two-stage process linking a broad-brush
    epidemiological approach with individualized
    management.

42
BLUE BLACK FLAGS (Main Burton, 2000)
Prof. Kim Burton
  • Focus on perceptions of work and working
    conditions
  • After injury may become significant obstacles to
    recovery
  • Often not addressed specifically in clinical
    treatment or rehabilitation
  • Objective working characteristics conditions
    also seemed to be important
  • Over the last 10 years we have tried to define
    them in a number of ways

43
DISTINCTION BETWEEN Blue and Black Flags
  • The original distinction in 2000 was between
  • Blue Flags as subjective work perceptions and
  • Black Flags as objective work characteristics or
    working conditions
  • However The Flags think tank recommended a
    further distinction to be made further between
    external policy factors and actual
    characteristics of organisations referred to as
    Organisational Black flags and System Black
    flags
  • We have ended up therefore with three distinct
    types of occupational flags
  • 1 Blue flags perceptions about work
  • 2 Organisational Black Flags characteristics of
    work and the work settings
  • 3 System Black flags which include government
    policy affecting conditions of employment,
    statutary entitlements to benefits etc
    negotiated by statutary bodies e.g. WorkCover

44
BLUE FLAG Conclusions Recommendations(Shaw et
al.,Submitted) 1
  • Systematic literature reviews have been somewhat
    inconsistent with regard to the specific
    occupational factors affecting back disability.
  • Reviewers have been critical of the
    methodological rigor of prognostic studies and
    the lack of concordance among occupational
    factors studied.
  • Reviews have indicated support for the effects of
    heavy physical demands, ability to modify work,
    workplace social support, job stress, job
    satisfaction, expectations for return-to-work,
    and fear of re-injury.
  • Patient screening methods should assess not only
    the physical and psychosocial work environment,
    but also personal perceptions of work.

45
BLUE FLAG RECOMMENDATIONS(Shaw et
al.,Submitted) 2
  • Following a systematic review, the utility of
    seven different screening methods in identifying
    27 workplace factors is examined.
  • These factors are clustered into Four domains
  • Physical demands of work
  • Psychological demands of work
  • Social/managerial factors
  • Workplace beliefs
  • Thus patient screening methods should assess not
    only physical and psychological workload
    characteristics, but also perceived support and
    other workplace beliefs shown to affect work
    absence duration.
  • Depending on the specific factor a worker-centred
    intervention, a workplace-centred change or a
    combination may be required

46
BLUE FLAG RECOMMENDATIONS(Shaw et
al.,Submitted) 3
  • A review of the predominant workplace-focused
    interventions led to the suggestion that a
    screening method should help providers choose
    between four types of workplace-focused
    intervention
  • physical conditioning to job demands,
  • counseling and education,
  • job accommodation
  • workplace communication.
  • Workplace factors should be assessed as early as
    possible after pain onset

47
7a Examples of addressing Flags(from W.S.Shaw
with permission)
48
Concerns about returning to work Shaw Huang,
Disabil Rehabil 27(21) 1269-1281.
49
Key supervisor competencies for achieving safe
sustainable RTW(Shaw 2008)
  • Understand recurrent nature of work-related MSK
    pain.
  • Provide more effective and supportive
    communication with workers.
  • Design more effective (ergonomic)
    job accommodations.
  • Build a more collaborative, less
    adversarial relationship with
    injured workers.

50
Key messages
  • Listen to worker concerns
  • privately, confidentially
  • Support and reassurance
  • We want you back
  • Maintain contact during work absence
  • List job tasks and limitations
  • Collaborative problem-solving
  • Suggest temporary work modifications

51
7b Flags in practice(The Wellbeing-in Work
project)
52
The Well-being in Work Project (WiW)
  • The project
  • Multi-disciplinary collaboration between Keele,
    Swansea and Cardiff Universities
  • Based in Merthyr Tydfil, South Wales, UK, where
    there are high levels of socio-economic
    deprivation
  • Carried out via a partnership with local
    government, employers health service to promote
    a joined-up approach
  • Funded by the Welsh Assembly Government Wales
    Centre for Health

53
The WiW Project
  • Key research questions
  • How do health and well-being impact on work (and
    vice versa)?
  • What factors moderate the relationship between
    health and work?
  • Can psychosocial interventions reduce the impact
    of health on work?
  • Staged programme of research
  • Stage 1 profiling the socio-economic context
  • Stage 2 primary research in local organisations
  • Stage 3 developing and evaluating interventions

54
Key findings of the WiW survey
  • High prevalence of physical mental health
    problems in the workforce
  • Both Yellow and Blue Flags are related to
    sickness absence and work performance many of
    these factors are potentially modifiable
  • Using absence as a marker for the impact of
    health underestimates the effect of health on
    work
  • A bio-psychosocial approach is crucial to
    understanding wellbeing in the workplace

55
What happens at work when youre unwell? A
qualitative approach
  • 101 participants (66 female) with an age range
    of 18-60 took part in this study
  • 14 Focus groups (63 participants)
  • Interviews with 18 individuals with
    musculoskeletal pain
  • Interviews with 20 managers

56
Black Flags OrganisationalPossible interventions
  • Consult employees about changes in policies and
    provide timely information on changes
  • Ensure all staff have access to policy documents
  • Train managers to implement policies effectively
  • Develop structured training in communication
    skills for managers, including training in giving
    feedback and conducting appraisals

57
Joined-up thinking..
Benefit system
Health care system
Employment legislation
Organisational policies
58
However we need to remember an important lessons
  • In many jurisdictions there are major obstacles
    to collaborative efforts and integrating policies
    across departments and budgets.
  • In trying to develop a clearer and more focused
    strategy for health-associated work compromise in
    the U.K., we need to align policy not only in
    three major government departments but also at
    Cabinet level
  • Currently our government is an a state of near
    meltdown.
  • We know what we need

59
Joined Up Thinking
WORK PENSIONS
  • HEALTH

TREASURY
we all need to be singing from the same hymn
sheet!
60
Do we need to be wary of BROWN Flags?
61
Unfortunately Im not sure who he is getting
advice from
62
(No Transcript)
63
Possible implications
  • Do we need to consider a sharper focus for our
    Objectives
  • Aspirations are only a starting point
  • Only of any value if they can be operationalised
  • Declaring a policy is not same as implementing it
  • We need to pay specific and focused attention on
    policy implementation strategy

64
Further strategic considerations
  • Are partnership projects possible
  • Can we get better data and use it wisely
  • Develop screening/targeting protocols
  • How, where and with whom do we develop training
    into flag identification and management?
  • N.B. We cant and mustnt assume competencies
  • Should we consider specific implementation
    strategies for different groups
  • Big employers
  • S.M.Es

65
Would it be helpful to reconsider our overall
research and developmental strategy?
  • 1 Re-examining the role of the Employer
  • 2 Investigation of the psychosocial climate at
    work
  • 3 investigate new linkages between healthcare and
    occupational intervention

66
Finally two major Black flags
  • Changing Workplace Culture towards health,
    performance and absence
  • Changing the public perception of DWP and
    vocational initiatiatives
  • Develop ways Changing systems
  • Need for change incentives
  • Ways of joining up
  • Worker and union Buy-in
  • Need for iterative systems to prevent
    entrenchment

67
Occupational Health Black Flags
  • Getting careful data
  • Problem of Outsourcing
  • Devising mixed methods approaches
  • Tyrannies of risk management
  • Re-examining Roles of Human Resources and
    Occupational Health
  • Conflict between attendance management and
    sickness management
  • Addressing Workplace Culture
  • Social Climate
  • Attitudes to Sickness
  • Systems for minimising impact of symptoms
  • Decreasing presenteeism
  • Enhancing wellness
  • Facilitating RTW
  • Liaison with Primary Care

68
WHERE DO WE GO FROM HERE?
  • Lets be optimistic
  • I managed to interview a couple of Occupational
    Health doctors about the challenges in persuading
    employers to adopt a more worker-centred approach
  • How difficult was it?

69
(No Transcript)
70
Thanks for listening
  • cjmain_at_gmail.com
About PowerShow.com