Addressing workplace and psychosocial concerns of patients at high risk of disability during the acu

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Addressing workplace and psychosocial concerns
of patients at high risk of disability during the
acute phase of low back pain
Liberty Mutual Research Institute for Safety

• William Shaw, Ph.D.

Impairment without Disability Duluth, MN Oct
9-10, 2008
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Presentation Agenda

• Prognostic factors in LBP disability
• Early disability prevention
• Supervisor support
• Provider communication
• RTW Coordinator
• Question/answer

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Acute Low Back Pain

• Social and economic losses are enormous
• 80 lifetime prevalence
• Clinical presentation age 20-55 years
• Lumbosacral region, buttocks, and thighs
• Pain is mechanical in nature
• varies with physical activity
• varies with time
• Patient otherwise well

Waddell, 2004
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Clinical management guidelines for acute low
back pain

• Rule out serious disease (red flags)
• Reassurance
• Simple symptom relief (NSAIDs)
• Avoid labeling, over-pathologizing or unnecessary
  diagnostics
• Continue ordinary activities as normally as
  possible (bed rest lt 2 days)
• Early return to work
• Intensive re-activation and rehabilitation if
  pain persists beyond 4-6 weeks

Waddell, 2004
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Distribution of WC claims and costs for LBP by
duration of work absence
10 claims 83 costs
months
Hashemi et al., 1997, J Occup Environ Med,
39(10), 937-945.
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Medical treatment-based classification and
clinical decision rules

• Fritz et al., 2006
• Immobilization
• Lumbar mobilization
• Sacro-iliac mobilization
• Extension syndrome
• Flexion syndrome
• Lateral shift
• Traction

Only moderate inter-rater reliability and weak
predictive validity
Fritz et al., 2006, SPINE, 31, 77-82
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Classification by spinal MRI results
Poor specificity

• Asymptomatic subjects
• Finding Percent
• Herniated disk 22-60
• Bulging disk 20-81
• Degenerative disk 46-91
• Stenosis 1-21
• Annular tear 14-56

Deyo 2002, Arch Int Med, 162, 1444-1447
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Prognostic factors Workplace

• Heavy physical demands
• Ability to modify work
• Workplace social support
• Job stress
• Job satisfaction
• Expectations for RTW
• Fear of re-injury

How should these factors be integrated in
routine medical history-taking and advice?
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Prognostic factors Psychosocial

• Belief that pain and activity are harmful
• Sickness behaviors (like extended rest)
• Low or negative moods, social withdrawal
• History of back pain, time-off, other claims
• Overprotective family or lack of support

How should these factors be integrated in
routine medical history-taking and advice?
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Absence from workPsychological and workplace
well-being

• Discomfort
• Financial woes
• Job insecurity
• Family stress
• Pain beliefs
• No workplace contact
• Workplace stigma
• No active treatment

Week 1 2 3 4 5 6 7
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Concerns about returning to work
Shaw Huang, Disabil Rehabil 27(21) 1269-1281.
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Back Disability Risk Questionnaire18 items (Shaw
et al., 2005 Spine)
(18 items)

• Supervisor response
• Mood and stress
• Pain severity ratings
• Health and wellness
• Expectations for recovery
• Physical demands of work
• Modified work options

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Work status at one month
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Pain vs. functional limitation (1 mo.)
(N 568)
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Overlap of clinical outcomes (3 months after
pain onset)
N 163 unresolved cases (of 519 total)
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BDRQ Results (1)

• BDRQ item
• 56.3 Work absence before consulting MD
• 37.6 Employer has no modified duty
• 36.6 Worried activity will increase pain
• 34.5 Pain getting worse
• 31.4 Unsure able to RTW lt 4 weeks
• 29.7 Depressed good bit of time
• 28.7 Past LBP with lost work time

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BDRQ Results (2)

• BDRQ item
• 28.1 lt1 year job tenure
• 26.6 Pain rating 8
• 18.3 Job satisfaction lt 6 out of 10
• 17.3 Negative supervisor response
• 14.1 Stressed all or most of time
• 2.3 Prior back surgery

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Results Significant BDRQ predictors

• BDRQ item OR 95 CI
• Fall injury 2.82 (1.40 5.68)
• Work absence 2.17 (1.35 3.51)
• lt1 year job tenure 2.04 (1.05 4.00)
• Prior back surgery 4.69 (1.18 18.61)
• Re-injury worries 1.95 (1.08 3.52)
• Unsure of RTW 2.33 (1.19 4.55)
• Feeling stressed 2.80 (1.32 5.93)

logistic regression analysis, simultaneous
variable entry, p lt .05
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Classification accuracy (BDRQ)
Overall classification accuracy 75.0
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Clinician Questionnaire (post visit)11 items
(11 items)

• Prior medical eval for LBP?
• Rating of functional impairment
• Non-organic signs?
• Localized or diffuse pain?
• Radicular pain?
• Leg pain below knee?
• Any evidence of depression?
• Modified duty available?
• Expected days until FD RTW?
• Risk of chronicity?
• Significant comorbidities?

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(No Transcript)
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Workplace Intervention?
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Systematic reviewWorkplace-based RTW
interventions

• 7 databases, 1990-2003
• Musculoskeletal and pain-related disorders
• 4,124 papers 10 studies
• Intervention strategies
• Early contact with employee
• Offer of accommodation
• Contact with health care provider
• Ergonomic worksite visit
• Presence of RTW coordinator
• Supernumerary replacements

Review of 10 studies, Franche et al., J Occup
Rehabil 2005 15607-631.
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Review of 10 studies, Franche et al., J Occup
Rehabil 2005 15607-631.
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7 principles for successful RTW
March, 2007

• Demonstrated commitment to health and safety.
• Routine offer of modified work/ job
  accommodation.
• RTW without disadvantaging co-workers.
• Supervisors trained and included in RTW planning.
• Early and considerate contact with injured
  worker.
• Designated person to coordinate RTW.
• Communicate with providers (with worker consent).

www.iwh.on.ca/assets/pdf/rtw_7_principles_rev.pdf
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Onset of musculoskeletal symptoms
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Supervisor role in responding to injuries (worker
perspective)
Percent of employees mentioning role
Shaw, Robertson et al., J Occup Rehabil
200313129-142.
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Supervisor role in WC injuries (supervisor
perspective)

• Perceived role
• Complete injury report (90)
• Assess validity of claim (65)
• Protect company (53)
• Communicate with worker (41)
• Include worker in process (30)
• Significant challenges
• Encouraging early reporting
• Documentation without blame
• Unhelpful physician restrictions
• Co-worker support
• Job performance issues

McLellan, Pransky et al., J Occup Rehabil
20011133-41.
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Training workshop - 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

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Controlled trial in the food processing industry

• 24 supervisors (800 workers)
• Randomized to training or control group
• Two 2-hour workshops
• Outcome claims costs

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Workers comp claim costs
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Results Long-term gains
Post-intervention
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The potential role of provider communication in
preventing back disability?
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The myth of job matching
Job description and industry type
Clinical observations and objective measurements
Systematic return-to-work recommendations
X Providers have workplace details X Job
restrictions easily applied X Worker input not
necessary
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Retrospective studies of provider communication
and LBP

• Greater patient satisfaction (Shaw et al., 2005)
• Took problem seriously
• Explained condition clearly
• Tried to understand my job
• Advised to prevent re-injury
• Fewer lost work days (Dasinger et al., 2001)
• Tried to understand my job
• Advised about helpful workplace changes
• Discussed my behavior that might influence
  recovery
• Discussed my readiness for RTW

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Patient-provider communicationCoding of verbal
exchanges

• Socioemotional exchange (examples)
• Shows concern or worry
• Shows agreement or understanding
• Laughs, tells jokes
• Shows criticism
• Shows disapproval
• Task-focused exchange (examples)
• Paraphrase/ check for understanding
• Asks for opinion
• Gives information
• Asks open-ended question
• Asks closed-ended question

Content areas 1. Medical condition 2.
Therapeutic regimen 3. Lifestyle 4. Psychosocial
Roter et al., Patient Educ Counsel 2002, 46,
243-251.
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Prognostic categories

• 48 low risk (0-1 yellow flags)
• 37 medium risk (2-3 yellow flags)
• 15 high risk (4-9 yellow flags)

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Results Communication patterns

• Visit duration
• 3.2 31.0 minutes, M 15.4 (SD 7.0)
• Communication utterances
• Provider Mean 256.7 (SD 99.0)
• Patient Mean 154.3 (SD 70.7)
• 32 provider questions open-ended
• Patients asked median of 2 questions

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Graph Provider communication



p lt .05
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Graph Patient communication

p lt .05
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The potential role of return-to-work
coordinators in preventing back disability?
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Why RTW coordinators?

• Mistrust
• Miscommunication
• Inadequate job modifications
• Non-medical factors in work disability
• Rates of re-injury or recurrence

Williams Westmorland, 2002
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Variability in the RTW coordinator role
Extent of worker involvement
Focus on ergonomic factors?
Level of medical training?
Need for systematic intervention protocol?
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LMRIS research study of RTW coordinator skills
competencies

• Systematic literature review of research studies
  evaluating RTW coordination
• 46 articles (19 studies)
• 12 interviews with key researchers
• RTW coordinator background training
• Intervention elements
• Most effective elements of RTW coordination
• 10 practitioner focus groups
• Occupational therapists, nurse case managers,
  disability managers, physical therapists,
  ergonomists, physicians

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Defining RTW Coordination

• ...any efforts by a designated individual to
  facilitate early workplace reintegration of a
  worker following a sickness absence through
  face-to-face, on-site communication with workers,
  supervisors, and other stakeholders to plan
  appropriate work modifications and timelines.

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Frequent RTW coordinator activities

• Meeting on-site with worker, supervisor, others.
• Developing plans for work modifications.
• Facilitating agreement on accommodations.
• Providing the worker on-site training
  instruction.
• Conducting a brief ergonomic assessment.
• Assessing prioritizing barriers to RTW.
• Discussing accommodation requests with
  supervisor.
• Responding to individual concerns of workers.

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Consensus competency areas
9 domains, 44 competencies identified by over
75 of the focus groups
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RTW Coordination

• Knowledge areas
• ergonomics
• medicine
• benefits and laws
• Knowledge vs. Experience
• 10 previous knowledge
• 10 acquired knowledge
• 80 mentorship experience
• Communication gt Training background
• Few differences between professions

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Differences in RTW coordination

• Nurses place a higher emphasis on medical
  training (credibility).
• Vocational rehabilitation professionals place a
  higher emphasis on worksite evaluation.
• Regional differences
• US quick response, knowing policies
• CA being client-centered
• Insurance benefit system
• WC rapport-building and conflict resolution
• STD disabling effects of medical conditions

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Conclusions

• Screening can identify patients at highest risk
  of persistent disability.
• Early intervention for high-risk patients should
  integrate
• Supervisor support cooperation
• Provider communication and advice
• Designated RTW coordinator
• Other possibilities?
• Psychological counseling
• Physiotherapy/ activity exposure

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