Addressing Question One: What are the outcomes of Low Back Pain and how do they relate?

1. Boston International Forum X Primary Care Research on Low Back Pain Addressing Question One: What are the outcomes of Low Back Pain and how do they relate? Mansel Aylward Director, The Centre for Psychosocial and Disability Research, Cardiff University AylwardM@cardiff.ac.uk www.cf.ac.uk/psych/unum/index.html Harvard School of Public Health: Monday, June 15 2009

2. Fundamental Precepts: • Main determinants of health and illness depend more upon lifestyle, socio-cultural environment and psychological (personal) factors than they do on biological status and conventional healthcare.1 • Work: most effective means to improve well-being of individuals, their families and their communities.2 • LBP: rigorously tackling an individual’s obstacles to a life in work. 1. Marmot M. Status Syndrome, Bloomsbury, London: 2004 2. Waddell G, Burton K. Is work good for your health and well-being? TSO, London: 2006

3. Making the distinction: definitions and usage • Disease: objective, medically diagnosed, pathology • Impairment: significant, demonstrable, deviation or loss of structure or function • Illness: subjective feeling of being unwell (internal) • Sickness: social status accorded to the ill person by society (external)

4. Unbundling: definitions and usage • Disability: limitations of activities and restriction of participation • Incapacity: inability to work or reduced functioning and performance at work associated with sickness or disability.1 • Unbundling: different elements of the human predicament that underlie incapacity: • No linear causal chain • not interchangeable 1. Waddell G, Aylward M. The scientific and Conceptual Basis of Incapacity Benefits. TSO, London: 2005

5. Symptoms: • Symptoms: subjective bodily or mental sensations that reach awareness and are generally “bothersome” or “of concern” to the person. • Clinical representation/manifestation of disease • associated with normal or unaccustomed activities of daily living • unassociated with any identifiable disease 1,2 • ubiquitous and omnipresent 3,4 • limited correlation with illness, disability and (in) capacity for work 5,6 • Ursin H: 1997 • Deyo RA et al : 1998 • Eriksen H et al: 1998 • Buck R et al: 2009 5. Waddell,G: 2004 6. Waddel G, Aylward M : 2005

6. Cardiff Health Experiences Survey (CHES): Face-to-Face Interviews [N=1000] GB population: Main Complaint Open Question: Inventory: LBP 8.9% 14.6% Musculoskeletal 4.6% 7.0% Mental Health 7.5% 25.6% Cardio-respiratory 3.6% 5.9% Headache 2.9% 9.3% G/I 2.4% 4.0% Without any complaint 70.1% 33.6% ______________________________________________________________________________________________________________________________________________________________________ At least one complaint 20.6% 66.4% 2 or more complaints 8.4% 26.3% Severity of main complaint greater for open question than inventory

7. Cardiff Research: Negative Influences on Return to Work: • Personal / psychological: • Catastrophising (even minor degrees) • False beliefs • Pervasive thoughts about personal illness • “Stress” as a causal factor (esp. at work) • Low self-efficacy • Lack of self-esteem/ confidence • Minimal health literacy

8. Cardiff Research: Negative Influences on Return to Work: • Occupational and Social: • Job dissatisfaction • Limited attendance incentives • (esp. work colleagues) • Line Manager • Socio-economic status • Economic: Availability of alternative sources of income/support

9. Ranking of Obstacles to Work by Principal Category: • Rank(%) • Psychological / Cognitive: 38 % • Occupational: 32 % • Social: 11 % • Economic: 9 % • Symptom severity 7 % • (esp: pain, fatigue) • Impaired function 3 % • _____ • 100 %

10. Positive Influences on RTW: • Moral obligations • Respect for Employer • Strong health literacy • High score on subjective “happiness” • Well managed chronic condition • Resilience and coping

11. The limited Correlation between illness, disability and (in) capacity for work1 Illness Working Disability Economically Inactive 1. Waddell G, Aylward M : 2005

12. Recipients of key working age benefits (UK): Source: DWP and ONS

13. Number of claimants Waddell, Aylward & Sawney, 2002

14. The changing proportion of Incapacity Benefit claimants by diagnosis 1995 2008 National Statistics: www.dssni.gov.uk/incapacity_benefits)

15. IB Recipients - Diagnoses Incapacity-related benefit recipients by diagnosis group, November 2003

16. UK Incapacity Benefit • ‘Severe Medical Conditions’ <25% • ‘Common Health Problems’ - Mental health problems 44% - Musculoskeletal conditions 25% - Cardio-respiratory conditions 10%

17. Common health problems Less severe mental health, musculoskeletal and cardio-respiratory conditions Limited objective evidence of disease Largely subjective complaints Often associated psychosocial issues

18. Common health problems • Common features • High prevalence in working age population • Largely subjective - little or no disease or impairment • Multifactorial causation – work usually only one contributory factor • Most episodes settle rapidly – though often persistent or recurrent • Most people remain at work or return to work quite quickly • Essentially whole people, with what should be manageable health conditions • Long –term incapacity is not inevitable

19. Common Health Problems: disability and incapacity • High prevalence in general population • Most acute episodes settle quickly: most people remain at work or return to work. • There is no permanent impairment • Only about 1% go on to long-term incapacity Thus: • Essentially people with manageable health problems given the right support, opportunities & encouragement • Chronicity and long-term incapacity are not inevitable

20. SOCIAL PSYCHO- BIO- Why do some people not recover as expected? • Bio-psycho-social factors may aggravate and perpetuate disability • They may also act as obstacles to recovery &barriers to return to work

21. The Radical Shift in UK Policies (late 1990s): • Focus: Overcoming obstacles to (return to) work. • Arresting: Flow of short-term incapacity becoming chronic • Intervention packages and • support to help move IB recipients into the labour market • Embracing: A bio-psycho-social paradigm

22. The 1998-1999 Reforms1-3 Work for those who can: security for those who cannot • Structures and Processes: • Optimal early intervention/management • Encourage work retention • Emphasise abilities not functional restrictions/limitations • Support behaviour change, re-education/skilling and • rehabilitation (RTW) • HM Government (1998) New ambitions for our country.Cm3805.HMSO: London • HM Government (1998) A new contract for welfare: principles into practice. CM4101. HMSO: London • HM Government (1999) Welfare Reform and Pensions Act-1999.

23. Pathways to Work: Helping people into employment (2002).1 A significant step to realise a vision. • Better framework of support and more focused interventions • Improved, tangible financial incentives • Condition Management-jointly with local NHS providers • A fundamental philosophical shift in services provided for sick and disabled people. A social rather than a health care intervention 1. DWP (2002) Pathways to work: helping people into employment. Department for Work and Pensions CM5690. HMSO: London.

24. UK Government “Pathways to Work” Initiative • Return to Work Payment £40-120 per week • Mandatory Work Focused Interviews (Case Managers) • New Condition-Management Programmes: (focus: m/s, Mental Health; Cardiorespiratory) - helping people to understand and manage their condition - using CBT and related interventions

25. Principles of Condition Management: • Voluntary option routed through the Personal Advisor • Cognitive/educational interventions common to all conditions • Evidence based • Tailored to individual needs – biopsychosocial approach • Case-managed • Goals “owned”; not imposed.

26. Condition Management: The Pathway to Success • Modulate expectations, exploit values and build confidence • Recognise and address the social contexts of health, disadvantage and economic inactivity • Promote emotional/physical well-being • Encourage behaviour change • Living with fatigue/pain

27. PTW: Evaluation Methodology:1 Condition Management • Condition Management Programmes delivered according to local demographics and needs • Focus on 3 main causes of incapacity: Musculoskeletal • Mental health • Cardio-respiratory • Innovative “non-treatment” interventions. 1. Ford F, Plowright C. Realistic Evaluation of the Impact and Outcomes of the condition Management Programme, UCLAN: 2009

28. PTW: Evaluation Methodology:1 Condition Management • A “spirit of experimentation” • process pilots: what delivery works best in what circumstances? • impact pilots: assessment/measurement against control groups • pragmatic approach 1. Ford F, Plowright C. Realistic Evaluation of the Impact and Outcomes of the condition Management Programme, UCLAN: 2009

29. Realistic Evaluation Theory1 • Modelling contextual, quantitative and qualitative data • What works, for whom, in what context? • Establish: causal relationship between programme and outcome • Confirmation: impact of the intervention • Explanatory components model: • context (C) mechanism (M) ; outcome (O) 1. Pawson R, Tilley N. Realistic Evaluation. Sage, London: 1997

30. Mixed Methods for Community Interventions1: • Multiple forms of data collection and analysis: • deductive and inductive thinking • qualitative and quantitative methods • Data Transformation Model: • independent analysis of all data • pooling and triangulated convergence for data comparison • Embedded qualitative, independent (“blind”) study • subsequent triangulation, limiting error and bias 1. Creswell J, Plano Clark V. Designing and conducting mixed methods research. Sage, London:2006

31. Range Analysis Results: • M:F:Total: • Participants1683 1748 3431 • (49%) (51%) • CMP duration: Mean: 16 weeks (range:4-32wks) • Median: 16 weeks (in 6 of 7 pilots) • 13 weeks (in 3 of these)

32. Core Components: Activity/lifestyle modules (fitness and well-being) Symptom management (eg: pain, fatigue, anxiety, depression etc) Coping (eg: goals, positive thinking, assertiveness) Return to work (sequential; throughout)

33. Condition Management Programmes: Principal Findings • Undue and mistimed emphasis on RTW had negative effects on engagement and outcomes • Most common benefits: increased confidence and ability to cope • Evidence that improvements occurred despite unaltered or deteriorating health condition

34. Condition Management Programmes: Principal Findings • Rather than aiming for control of a health condition, successful outcomes dependent on learning process towards self-management and independence • New roles for health professionals: support and guidance rather than therapy

35. CMP Findings relevant to LBP: • Reconciling health and work integral to successful outcomes • Optimal timing of RTW element among core components critically important • Statistically significant improvements in HADS anxiety (p<0.001) and depression (p<0.001) • not related to underlying health condition • not dependent on age or gender • associated with successful work outcomes

36. CMP Findings relevant to LBP: • Significant improvements in confidence and coping, independent of changes in health status, associated with successful work outcomes • 20% RTW by end of CMP • 66% (in work, work ready or moving towards work) • 45% in work at 6 months after CMP

37. Pathways to work: the pilots (Oct, 2003 & April, 2004) • Condition Management Programmes: • Very favourable reception by participants, personal advisers and CMP practitioners • Doubling of claimants entering work • Higher than expected take-up rates • Exceeds threshold for cost-effectiveness • Perceived to have lasting effects

38. PATHWAYS TO WORK: PILOTS (2003-2004) • 6-800 new job entries each month in existing Pathways areas • Take-up around 5 times that expected from previous RTW interventions • Welfare Reform :extending provision across country by 2010 :reducing by 1 million the number on Incapacity Benefits :employment rate = 80% working age population

39. Pathways to Work – So Far • Puts the United Kingdom at the forefront in actively engaging with the client group. • Very few,1 if any,2 social security interventions in the world have ever achieved such take-up rates, labour market outcomes and enthusiasm. • Strong potential to reverse the long history of failed international efforts to address successfully long-term incapacity3. • Corden A, Thornton P (2002) Employment programmes for disabled people. Lessons for research evaluations. DWP In-House Report 90, Department for Work and Pensions: London • Aylward M,Sawney P (2007) Support and rehabilitation (restoring fitness for work). In fitness for Work (Edo: Palmer, Cox and Brown), 4th Edition. Oxford University Press: Oxford.

40. Work as an Outcome: • Organisational Factors: • dominant work focus • strong partnerships with providers • RTW component throughout programme

41. Work as an Outcome: • Programme Factors: • Improvement in anxiety and depression (controlling for initial anxiety and depression scores) • Improved confidence and coping

42. Work as an Outcome: • Changes effected by CMP participation: • 38% increased confidence • 27% improved management of health condition • 21% increased activity • 15% increased motivation/moving on

43. LBP Outcomes (Symptoms):

44. LBP Outcomes (Symptoms):

45. Functional Status Outcomes: • Dependent on inclusion of work – focus throughout

46. Functional Status Outcomes:

47. CONCLUSIONS: • The outcome of work in LBP is largely independent from other outcomes • Work outcome is highly dependent on critical elements of the support and management package and the context in which it is delivered:

48. CONCLUSIONS: Organisational: dominant and enduring work, focus, strong partnership with (and among) providers Programme: focus on anxiety and depression, confidence building and coping, symptom management and insight

49. The Scientific and Conceptual Basis of Incapacity Benefits Gordon Waddell and Mansel Aylward

50. The Power of Belief Peter Halligan and Mansel Aylward