LWCC Provider Partnership Conference

1. 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

2. 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

3. Acute Inflammatory Response: (Stage I) Repair Phase: (Stage 2) Remodeling Phase: (Stage 3) RESPONSE STAGES Academy of Industrial Injury Management

4. 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

5. 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

6. Psychosocial Issues …have been found to be more predictive of treatment outcomes than physical capacity. Academy of Industrial Injury Management

7. 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

8. The “Biopsychosocial Model”of back pain and disability emphasizes the interaction between multiple factors. Academy of Industrial Injury Management

9. Early Recognition … so what are the indicators. …of patients more likely to have delayed return to work is imperative Academy of Industrial Injury Management

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Biopsychosocial Model(Early to Treat Differently) Academy of Industrial Injury Management

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Unfavorable Pain Drawing

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Some Jobs Are NOT Fun

43. Motivation: Definition M = (Value of task) X (Probability of Success) Cost of the Effort M = Motivation Academy of Industrial Injury Management

44. How do you answer the question? “Can Joe Work …Despite His Back Pain?” Academy of Industrial Injury Management

45. 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

46. 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

47. 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

48. 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

49. Capacity:…is Measurable? Academy of Industrial Injury Management

50. 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