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LWCC Provider Partnership Conference. Charles R. Herring, DC, DABCC, FICC Academy of Industrial Injury Management, President 4701 Bluebonnet Blvd., Suite B Baton Rouge, Louisiana 70809. The Biopsychosocial Patient, Functional Improvement Applying the Louisiana Medical Treatment Guidelines

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LWCC Provider Partnership Conference

Charles R. Herring, DC, DABCC, FICC

Academy of Industrial Injury Management, President

4701 Bluebonnet Blvd., Suite B

Baton Rouge, Louisiana 70809

The Biopsychosocial Patient, Functional Improvement

Applying the Louisiana Medical Treatment Guidelines

The Roosevelt New Orleans

October 14-15, 2011

Academy of Industrial Injury Management


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The major cost drivers are:

Pain Management & Surgery

Medical Treatment Guidelines encourage Conservative Care

Routine Care and Cost of Louisiana WC Claims

Academy of Industrial Injury Management


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Acute Inflammatory Response: (Stage I)

Repair Phase: (Stage 2)

Remodeling Phase: (Stage 3)

RESPONSE STAGES

Academy of Industrial Injury Management


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Modalities are permitted in the acute care phase following injury to initial response to injury (edema, pain, and spasm).

Strongly supports adding active care at the earliest phase of recovery (with careful administration to avoid additional soft tissue trauma).

Passive Care Vs. Active CareGuidelines

Academy of Industrial Injury Management


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Physicians are comfortable with the (bio)medical model

“Physicians are trained to perform within a medical model; to the extent that determinations of disability are primarily psychosocial, not medical, our training and orientation are poorly suited to address effectively return to work.”

- J Rainville; The physician as disability advisor for patients with musculoskeletal complaints. Spine 2005; 30 (22): 2579-2584

Academy of Industrial Injury Management


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Psychosocial Issues

…have been found to be more predictive of treatment outcomes than physical capacity.

Academy of Industrial Injury Management


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Must Recognize Factors thatPredict Delayed Recovery

  • Routine care is provided using the “Biomedical Model”

  • Injury management care requires “Psychosocial Model

  • Early recognitionof factors that delay recovery is essentialto injury management

Academy of Industrial Injury Management


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  • The “Biopsychosocial Model”of back pain and disability emphasizes the interaction between multiple factors.

Academy of Industrial Injury Management


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Early Recognition

… so what are the indicators.

…of patients more likely to have delayed return to work is imperative

Academy of Industrial Injury Management


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Risk FactorsPredict Delayed Recovery

Availability of modified duty

Physician awareness of the availability of modified duty

Injured worker’s expectation of RTW

Physician’s expectation of RTW

Injured worker seeking a physician experienced in treating work-injured patients

Academy of Industrial Injury Management


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Risk FactorsPredict Delayed Recovery

> 30 days before onset of treatment

Treatment without early mobilization

Imaging

Initial pain intensity

Psychological distress

Fear of re-injury

Patient’s perception of health change

as a result of the injury

Response of worker’s employer

Academy of Industrial Injury Management


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Demographic FactorsPredict Delayed Recovery

Older age

More severe injury

Greater pain and dysfunction

Occupation was not associated significantly

with chronic disability

Demanding work

Job accommodation associated with shorter

duration of disability

Workers who blame work factors for their pain

(as opposed to blaming self or other factors)

Poor co-worker relations

Academy of Industrial Injury Management


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Biomedical FactorsPredict Delayed Recovery

Lower socioeconomic status

Greater number of co-morbid conditions

Obesity

Worse self-reported health prior to injury

Radiating pain below knee

Multiple pain sites

Worse baseline self-reported physical functioning

Use of opiate or sedative/hypnotic drugs >4 weeks

Greater number of sick leave days in year prior to injury

Little treatment targeting reactivation & RTW

Academy of Industrial Injury Management


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Work-related FactorsPredict Delayed Recovery

Smaller size employer

Loss of job within two months of claim

No offer of modified or light duty

Lack of communication between doctor

and employer regarding RTW

Greater physical demands at work

Biomechanical factors at work

Lower job satisfaction

Little confidence regarding RTW

Academy of Industrial Injury Management


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Administrative/Legal FactorsPredict Delayed Recovery

Greater time from claim receipt to acceptance

Employer protest of claim validity

Retention of an attorney

Academy of Industrial Injury Management


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Psychosocial FactorsPredict Delayed Recovery

Worse baseline mental status

Alcohol abuse

Greater fear-avoidance (perception that return to work might cause symptom worsening or re-injury), & greater pain-related catastrophizing (excessive focus on pain, magnification of the threat associated with pain, and feeling helpless to control pain)

Academy of Industrial Injury Management


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Biopsychosocial Model(Early to Treat Differently)

Academy of Industrial Injury Management


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Initial Evaluation

History should include job tasks

QVAS

Pain drawing

Orthopedic and Neurological tests

Functional movement tests

Waddell’s signs

Oswestry

Biopsychosocial Indicators

Academy of Industrial Injury Management


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Screening(Three questions)A screening questionnaire to predict no return to work within 3 months for low back pain claimants, Eur Spine J. (2008) 17:380-385

Question 1: Score

Where did you have pain last week?

Back or above knee only 0

Below Knee also 2

Academy of Industrial Injury Management


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Screening(Three questions)

Question 2: Score

In your estimation, what are the chances

that you will NOT be able to resume

work in six months?

(circle one number) (8 or more = 4)

0 1 2 3 4 5 6 7 8 9 10

No chance Very large chance

(7 or less = 0)

Academy of Industrial Injury Management


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Screening(Three questions)

Question 3: Score

How much has your pain interfered

with your ability to plan activities?

(circle one number)

0 1 2 3 4 5 6 7 8 9 10

No interference Very large interference

(8 or more = 4)

(7 or less = 0)

Academy of Industrial Injury Management


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Screening(Three questions)

Score of four or more indicates high risk of:

not RTW within 3 months.

This screening tool (based on these three items) correctly classified:

73.7% of the non-resumers, and

78.4% of the resumers

Academy of Industrial Injury Management


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Yellow Flags

  • Look for Yellow Flags during consultation

  • Probe for Yellow Flags during each visit

  • Listen to what patient says e.g.:

    • I don’t think I will ever RTW

    • My boss didn’t even call to see how I am

    • I wish I could find another job

Academy of Industrial Injury Management


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Yellow Flags

Based on all the things you do to cope or deal with your pain on an average day, how much are you able to decrease the pain?

If you take into consideration your work routines, management, salary, promotion possibilities and co-workers, how satisfied are you with your job?

Academy of Industrial Injury Management


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Yellow Flags

Physical activity makes my pain worse.

An increase in pain is an indication that I should stop what I am doing until the pain decreases.

I should not do my normal work with my present pain.

I can do light work for an hour.

Academy of Industrial Injury Management


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Yellow Flags

I can walk for an hour.

I can do ordinary household chores.

I can go shopping.

I can sleep at night.

Academy of Industrial Injury Management


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Unfavorable Pain Drawing


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Pain Drawing Interpretation

Poor anatomical localization

Total leg or arm pain

Circumferential thigh pain

Bilateral anterior tibia area pain

Circumferential foot pain

Bilateral foot pain

Unlikely to report all four types of pain (burning, stabbing, pins & needles & numbness) all together

Academy of Industrial Injury Management


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Pain Drawing InterpretationCont’d

Pain drawing outside the outline of the body

Adding explanatory notes

Circling painful areas

Drawing lines to demarcate painful areas

Use of arrows

Tendency toward total body pain

Academy of Industrial Injury Management


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Clinical Focus

Help patient understand that the injury is not severe…if that is the case.

Encourage patient to be active.

Ask patient about job description & requirements.

Contact employer:

1. Goal – early RTW 3. Ask employer to contact IW

2. Need job description 4. What light duty is available

Academy of Industrial Injury Management


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Clinical Focus

Focus on job requirements “Physical Demands”

1. Lifting

2. Squatting

3. Standing

4. Walking

5. Sitting

6. Working overhead, etc.

Academy of Industrial Injury Management


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Clinical Focus

Ask yourself…Is the patient catastrophizing?

Is the pain limiting movements/ADLs

Encourage patient to be active

Begin the process of preventing de-conditioning

Begin active care – to help patient develop confidence in ability to perform job tasks

Set realistic goals/expectations regarding RTW

Academy of Industrial Injury Management


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Clinical Focus

Talk to CR, employer, other doctors, therapist, nurse case manager, vocational rehab specialist and in particular spouse about RTW, understanding condition and seeking their help to re-assure patient.

Immediately begin assessment to identify movement and activities that increase pain and required movements of job.

Think in terms of “work conditioning”.

Academy of Industrial Injury Management


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Clinical Focus

Immediately have patient actively perform movement at ranges that do not significantly increase pain, to build confidence – “Desensitize Fear Avoidance Behavior”

Immediately begin stretching, active ROM & walking (multiple times a day)

Ask spouse to assist, but do not do everything for the patient. Don’t be an “Enabler”

Academy of Industrial Injury Management


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Clinical Focus

Pain Drawing

Q-VAS

Oswestry Low Back Pain Questionnaire

Examine thoroughly

Accurate Diagnosis

Aggressively treat to decrease pain & improve function

Refer for co-management when appropriate

Conservative care first

Academy of Industrial Injury Management


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Clinical Focus

Test isometric lifting from the floor

Repeat specific job tasks in the office

Use QCE “Quick Capacity Evaluation”

Work tolerance Screening

Step test for aerobic demand

Academy of Industrial Injury Management


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Clinical Focus

Assess ability to RTW on the first visit - attitude

Describe condition, treatment plan, ADLs exercises, job specific activities, & RTW motivation

Follow-up visits continue to assess job tasks, step aerobic test, home exercises, QVAS, and watch for signs of catastrophizing, FABQ & Depression

Academy of Industrial Injury Management


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Clinical Focus

At two weeks re-evaluate:

1. Repeat positive orthopedic & neurological tests

2. Assess ADLs with Oswestry Low Back Disability Questionnaire

3. Measure Injured workers’ current capacity

4. Compare to “Physical Demands” of the job

5. If not improving – use FABQ, Zung for depression

Academy of Industrial Injury Management


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Clinical Focus

  • At two weeks re-evaluate:

  • FABQ score: Work subscale > 29

    (Physical Activity scale not predictive)

  • Zung Score: At Risk – 17-33

    (Distressed/Depressed = > 33)

  • Oswestry: Clinically Significant improvement

    Change > 30%

Academy of Industrial Injury Management



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Motivation: Definition

M = (Value of task) X (Probability of Success)

Cost of the Effort

M = Motivation

Academy of Industrial Injury Management


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How do you answer the question?

“Can Joe Work

…Despite His Back Pain?”

Academy of Industrial Injury Management


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3 Major Considerations:Terms to Understand

  • Risk

  • Capacity

  • Tolerance

    When completing a Return to Work form, what do these terms really mean?

Academy of Industrial Injury Management


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Definitions

  • Risk: basis for physician imposed

    “work restrictions”.

    What the patient should NOT do,

    based on risk assessment of injury to self or others.

    • MAY NOT drive a commercial vehicle with epilepsy.

Academy of Industrial Injury Management


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Definitions

  • Capacity: basis for physician described

    “work limitations”

    What the patient is NOT able to do.

    • CANNOT flex or abduct right arm at the shoulder more than 80º, thus cannot reach overhead controls.

Academy of Industrial Injury Management


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Definitions

  • Tolerance: basis for patient decisionas to whether or not the rewards of work are worth the “cost”of the symptom.

    • What the patient can do, but dislikes doing, or will not do, because of symptoms.

    • No place to describe this on most return to work forms.

    • Unique to each patient. (Subjective)

      (Not predictable by objective findings)

Academy of Industrial Injury Management


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Capacity:…is Measurable?

Academy of Industrial Injury Management


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Injured Worker Capacity

Work Tolerance Screening: is a determination of an individual's tolerance for performing a specific job based on a job activity or task and may be used when a full Functional Capacity Evaluation is not indicated.

Academy of Industrial Injury Management


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Job Task Requirements

Review Job Task form - employer

Review Job Task form - injured worker

Discuss differences with – injured worker

If need discuss with – employer

Make certain you know the requirements before examining the injured worker

Academy of Industrial Injury Management


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Injured Worker Capacity

Perform routine physical examination

Include usual orthopedic & neurological tests

Perform functional tests that replicate job tasks

Make a notation of capacity deficits

If there are no deficits – Full Duty

Academy of Industrial Injury Management


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Injured Worker Capacity

If there are deficits:

1) Is transitional/modified duty available?

2) If not, call employer to discuss

3) If yes, RTW with limitations

4) Encourage being active

5) Set expectation of RTW and/or full duty

Academy of Industrial Injury Management


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Considerations in Return to Work Decisions: Capacity

Strength, Endurance

Measurable, but Rarely Measured, fairly scientific

Assumes training to maximum ability has occurred Example: competitive athlete, or worker fully trained & acclimated to job

Usually measure “current ability”,Not Capacity

Academy of Industrial Injury Management


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Re-evaluate CapacityTwo Weeks

Should include:

1) Physical testing

2) Functional testing – job task focus

3) Psychological Screening with failure to improve

Academy of Industrial Injury Management


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Re-evaluate CapacityTwo Weeks

Psychological Screening should include:

1) Zung Depression Questionnaire

2) Fear-Avoidance Beliefs Questionnaire

3) Somatic Perception Questionnaire

4) Q-VAS

5) Oswestry Low Back Pain Questionnaire

Academy of Industrial Injury Management


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Re-evaluate CapacityTwo Weeks

Make frequent assessments to monitor improvement

Watch for non compliance

Watch for lack of full effort

Listen for indicators of lack of desire to RTW

Watch for biopsychosocial issues

Elevate to Full Duty as quickly as possible

Academy of Industrial Injury Management


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Re-evaluate CapacityTwo Weeks

Failure to meet or exceed functional goals:

1) Need to discuss with injured worker

2) Need to set up discussion with employer

3) Consider Disability Management team

4) Consider Psychological Testing

5) Consider Multi-model Care

Academy of Industrial Injury Management


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