ResolutionsRTK

Biopsychosocial Perspectives

Erin Pilgrim, Occupational Therapist
Principal Consultant
Restore

Erin Pilgrim is an Occupational Therapist who recently joined our occupational rehabilitation team, Restore. She has returned to Australia fresh from a position as an OT in the London and East England branch of Atos Healthcare, one of the largest rehabilitation providers worldwide. While working in the UK, and studying at an Australian University, Erin worked with Atos to implement the Australian "yellow flags" test. Though standard practice to Australian practitioners, Erin remembers being amazed at how such a complex change in approach – from biomedical to biopsychosocial – could be practically effected by such a simple measure.

In the spirit of our 'relocation ezine',
we thought it would be timely to publish an article she wrote at the time of this change, to serve as a reminder of the importance of testing and challenging the assumptions that dominate any system of practice.

Compensable Work Disability Management
A Literature Review of Biopsychosocial Perspectives
Erin Pilgrim | Occupational Therapist

FACTS

The total cost of work related injuries continue to rise.
70% to 80% of the total cost of all workplace injury (claims) is incurred by approximately 10% of injured workers who, although not diagnostically different to work-resumers, become long-term work disabled.
Reducing the numbers and costs associated with the 'chronic pain/long-term sickness absence' group is a major goal of authorities and the present challenges for health professionals working in the Occupational Rehabilitation arena.

Research into the factors that mediate and maintain work disability has led to the conclusion that clinical reasoning and practices need to a shift away from a focus on physical factors alone, towards those informed by a more comprehensive theoretical framework (BSRM, 2000).

Compensable Work Disability management by D. Dunstan and T. Covic reviews and discusses critical factors in the development, maintenance and management of work disability, and outlines the essential components of multidisciplinary biopsychosocial rehabilitation.

Two Key Models

1) The Biomedical Model: proposes that an illness is caused by some identifiable physical pathology and that symptoms of illness are directly attributable and proportional to that underlying pathology (Waddell, 1992).

Any psychological symptoms that may arise are considered to be a secondary effect that will remit after the pathology is remedied.

This model, while effective in application to diseases produced by a specific pathogen (e.g. Spinal tumour), it is insufficient to explain other conditions that lack clear physical pathology, such as chronic non—specific lower back pain (Bernard & Krupat, 1994).

2) The Biopsychosocial (BPS) Model: Assumes illness, pain and disability to be the products of the interaction between psychological + physical variables, which together are set against a background of social and environmental influences.

When applied to work related injuries, this model accommodates for the clinical observation that injured workers diagnosed with similar physical pathology, can and do report differences in pain intensity and level of work disability. This implies that variability in disability when physical injury factors are equal can be due to the effects of psychological and/or social-environ factors.

In order to maximise the likelihood of recovery and to control the costs associated with sickness absence, a biopsychosocially-based, evidenc-linked, clinicial guideline for diagnostic triage and management of soft-tissue injuries, back injuries, neck injuries has been rolled out across Australia.

Evidence shows that adherence to standardised diagnostic and treatment protocols can reduce both time lost from work by up to 40% and total injury costs by up to 60% (Wiesel, Boden & Feffer, 1994). Unfortunately, there has been low application of evidence-linked guidelines. Records of Australian, German, Dutch, Israeli, Swedish and American injured workers all reveal that in injury management remains in accordance with the biomedical model. Furthermore, the longer a person is off work, the more somatically focused treatment and investigations they receive and despite 'evidence of psychological disturbance' this is rarely addressed. Such practice is blamed for producing long-term work disability and its associated costs.

Why continue using the biomedical model?

In the majority of cases it is believed to be the result of a perceived need to 'do something' when an injured worker's complaints of pain continue beyond the period in which the condition was expected to resolve.

So what is chronic Pain?

Chronic pain is not ongoing acute pain (Waddell, 2004).

While it has an initial physical cause, the connection with injury is progressively lost; with time it becomes either disproportionate to the original physical problems or has not clear pathophysiological basis. Chronic pain develops as the result of an interaction between physiological and psychological factors. Through repeated pairing of pain with certain movements, activities, emotions, etc, neutral stimuli can acquire the capacity to produce pain long after the noxious input for damage has ceased.

Chronic pain is maintained through multiple reinforces:

Attention and Empathy
Passive physical treatment
Investigations
Activity avoidance
Release of responsibilities; and
Payment of wage/sickness benefits.

Treatments that provide symptomatic relief for acute pain are inappropriate for chronic pain as they are ineffective in extinguishing such pain or reducing pain-related to work disability.

Furthermore, because of their role in the development and maintenance of chronic pain and disability, acute pain treatments are considered potentially harmful in the chronic phase.

Biopsychosocially based, evidence-linked guideline recommendations

1) Acute injury phase:

Early return to progressively upgrading, goal focused and suitable (modified) duties.
Facilitating communication between all parties ('social-occupational') (Carter & Birrell, 2000)
The avoidance of diagnostic imaging (X-rays, MRI) of non-serious conditions (Alliance, 2002).

2) Subacute stage

A medical review to confirm the absence of serious physical pathology ('Red Flags'). If none are found the next step is to screen for the presence of 'Yellow Flags' (psychosocial factors known to increase the risk of long-term disability).
If no serious physical or psychosocial risk factors are identified then adopt acute phase strategies
If problems are identified rehabilitation should entail:
An exercise component, including graded participation in work activities and ADL's (Assessment of Daily Living); and Cognitive Behavioural Therapy strategies to modify maladaptive beliefs, emotions and behaviours.

3) Chronic Phase (beyond 12 weeks post-injury)

In this phase, the main causes of ongoing disability are psychological and social-occupational factors (Turk);
Workers are to receive intensive CBT to address the expected impairments in physical, social, familial and occupational functioning; and
Specialist multidisciplinary biopsychosocial rehabilitation.

How can 'we' deliver the biopsychosocial interventions within the existing environment?

The first and most vital step is to recognise the need to assess, and if necessary address, psychological and social-occupational-environmental issues, as well as physical factors, in the rehabilitation of all physically injured workers.

During the initial interview injured workers can be screened (by the Rehab Consultant) for the presence of psychosocial risk factors for long-term disability using a tool such as the Orebro Musculoskeletal Pain Questionnaire (OMPQ) (Linton & Halden, 1998; Dustan, Covic, Tyson & Lennie, 2005).

If the total score is in the high risk range (>130), then this risk can be communicated and a referral for psychological intervention (CBT for pain and disability management) can be recommended.

The Cognitive Behavioural Therapist can be advised of the critical physical demands of suitable duties (identified by a workplace assessment) and a collaborative goal, with graded steps for active treatment, can be established.

Communication between all parties can be facilitated, workplace issues addressed and the provision of workplace duties arranged.

Limitations

Injured/sick clients are typically seen in the subacute and chronic phases.
This article addresses sickness absence workers only.
Unable to directly recommend /refer for CBT or directly recommend exercise and activity programmes, however this can be achieved by phone call/email to Agent.
Many stakeholders trained in the biomedical model continue to favour somatic treatments and are yet to be educated in the need for biopsychosocial intervention.