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Secondary Research on Job Satisfaction

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Secondary Research on Job Satisfaction Powered By Docstoc
					Yellow Flags and Secondary
        Prevention

    Michael E. Geisser, Ph.D.
     University of Michigan
 Significance-The Costs of Back Pain

• Annual costs of low back disability in the United States
  have been estimated to be approximately $50 billion
• Back pain is the second leading cause of work
  absenteeism and leads to greatest productivity loss of
  any disease
• Single case of work-related back pain exceeds $8000
• Estimated that 70-80% of the costs for work-related low
  back claims are accounted for by 5-10% of patients who
  develop chronic low back pain (CLBP; pain lasting 3 or
  more months)
 Functional Recovery After an Acute
       Musculoskeletal Injury
• Time out of work is a significant predictor
  of long-term outcome
• Return-to-work within the first six months
  is predictive of good long-term outcomes
• Likelihood of returning to work after being
  out a year or more is small
• Key to recovery is treatment within the first
  6-12 months
Prevention of Chronic Pain
    Prevention of Chronic Pain

• Types of prevention
  – Primary – target a population at large
  – Secondary – target at-risk population
  – Tertiary – target diseased population to
    reduce disease progression,
    morbidity/mortality, costs
           Primary Prevention
• Buchbinder et al. (2001) conducted media
  campaign in Australia (state of Victoria)
  encouraging persons with back pain to stay active
  and exercise (based on the Back Book)
• Conducted phone surveys and sent physicians
  two scenarios regarding the treatment of low
  back pain
• Compared responses to persons/physicians in an
  adjacent state (New South Wales)
    Back Book (Burton et al., 1999)
•   Excerpt from information booklet The Back Book *
•   It's your back
•   Backache is not a serious disease and it should not cripple you unless you let it. We
    have tried to show you the best way to deal with it. The important thing now is for you
    to get on with your life. How your backache affects you depends on how you react to
    the pain and what you do about it yourself.
•   There is no instant answer. You will have your ups and downs for a while—that is
    normal. But look at it this way
•   There are two types of sufferer
•   One who avoids activity, and one who copes
•   * The avoider gets frightened by the pain and worries about the future
•   * The avoider is afraid that hurting always means further damage—it doesn't
•   * The avoider rests a lot and waits for the pain to get better
•   * The coper knows that the pain will get better and does not fear the future
•   * The coper carries on as normally as possible
•   * The coper deals with the pain by being positive, staying active, or staying at work
 Buchbinder et al., 2001 (Continued)

• Measures obtained from 4730 individuals and
  2556 general practitioners
• Decrease in fear-avoidance beliefs in Victoria
  over time, but not in New South Wales
• Significant improvement in back pain
  management among physicians in Victoria
  (decrease in ordering tests, prescribing bed rest)
• 15% decrease in absolute number of back claims,
  reduction of 20% of costs for a back claim
           Primary Prevention
• Health Scotland-Working Backs Scotland
• Public education campaign initiated in October of
  2002.
• Consists of ads, seminars, and website
  information
  (http://www.workingbacksscotland.com)
• Preliminary data suggests 60% penetration and a
  20% shift in public beliefs about back pain
 Difficulties with Primary Prevention

• Costly
• Targets many in the population who may
  not have acute pain (although lifetime
  prevalence of disabling back pain is 80%)
   Is Secondary Prevention of Pain
             Feasible?
• 95% of persons with acute back pain improve
  within 12 weeks
• However, research suggests that a number of
  factors prospectively predict the development of
  chronic pain among persons with acute pain
• These factors are often termed ―yellow flags‖
• For musculoskeletal pain conditions such as back
  pain, most of these factors are psychosocial
            What Are the Risk Factors for
                  Chronic Pain?
•   Catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis,
    perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement,
    perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of
    fault over injury, entitlement, catastrophizing, fear of movement, perception of disability, fear of reinjury,
    knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement,
    catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis,
    perceived control over pain, perception of fault over injury, entitlement, catastrophizing, fear of movement,
    perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of
    fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury,
    knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement ,
    catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis,
    perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement,
    perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of
    fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury,
    knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement ,
    catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis,
    perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement,
    perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of
    fault over injury, entitlement , catastrophizing, fear of movement, perception of disability, fear of reinjury,
    knowledge of pain diagnosis, perceived control over pain, perception of fault over injury, entitlement ,
    catastrophizing, fear of movement, perception of disability, fear of reinjury, knowledge of pain diagnosis,
    perceived control over pain, perception of fault over injury, entitlement , catastrophizing, fear of movement,
    perception of disability, fear of reinjury, knowledge of pain diagnosis, perceived control over pain, perception of
    fault over injury.
 Risk Factors for Filing Back Claim

• Bigos et al. (1992) examined 3020 employees of
  Boeing
• 279 persons filed a back injury claim
• The only physical variable that was associated
  with filing a back claim was a history of prior
  medical treatment for back pain
• Work satisfaction and scores on scale 3 of the
  MMPI were the best predictors of filing a claim
   Risk Factors for Chronic Pain
• Burton et al. (1995) examined factors associated with
  the development of chronic back pain in a primary care
  setting
• 252 subjects with acute back pain were assessed again at
  1 year
• Pain catastrophizing alone accounted for 47% of the
  variance in the development of chronic low back pain
• Psychological distress and prior history of back pain
  were also significantly related to the development of
  chronic pain
   Risk Factors for Chronic Pain
• Klenerman et al. studied 300 acute low back pain
  patients.
• A measure of fear-avoidance of pain alone
  correctly classified 66% of subjects who
  developed chronic low back pain at 12 months.
• A combination of physiological and
  psychological data correctly classified 88% of
  patients.
Model of Chronic Pain Disability
     (Vlaeyen et al., 1995)

               Pain               Catastrophizing




       Disability
        Disuse              Fear of Movement/Reinjury
      Depression



                      Avoidance
     Potential Difficulties with Risk
               Assessment
• Factors are multiple, may vary across persons
• While we know the factors related to chronicity,
  what ―score‖ or cut-off should be used in a
  clinical assessment?
• Schemes used to classify subjects may be sample
  dependent, unstable
• While relationships exist, can risk factors be used
  prospectively to predict chronicity with a high
  degree of accuracy?
       Risk Assessment – Clinical
              Evaluation
• Main et al. (1995) recommend evaluating:
  – General level of distress
  – Beliefs and fears about pain and rehabilitation
  – Pain coping strategies
  – Fear of physical activity
  – Socioeconomic implications of continued
    incapacity
  – Perception of safety
  – Job satisfaction
              Risk Assessment
• Hazard et al. (1996) utilized an 11-item
  questionnaire to predict chronicity
• Items assess current pain intensity, blame for
  pain problem, prediction of ability to work in the
  future, physical demands of job
• Utilizing a cut-off score of .48, the measure had
  .94 sensitivity and .84 specificity
• Findings have not been replicated
             Risk Assessment
• Hallner and Hasenbring (2004) developed a
  computer-based statistical model that utilizes
  yellow flags to determine chronicity in persons
  with low back pain
• Yellow flags used were psychological distress
  and the use of certain pain coping strategies
• Overall accuracy of model was 83.1%, with 73%
  sensitivity and 97% specificity
               Risk Assessment
• Linton and Boersma (2003) published data on the
  Örebro Screening Questionnaire
• Twenty-five item questionnaire assesses factors such as
  work demands, pain intensity, distress, fear-avoidance
  beliefs, sleep disturbance
• A cut-off of 90 had 89% sensitivity (65% specificity) for
  predicting work absenteeism, and 74% sensitivity (79%
  specificity) for functional recovery
• Subsequent study found overall accuracy for predicting
  return to work to be between 88%-96% (Dunstan et al,
  in press) for low back and other types of
  musculoskeletal pain
How Can the Risk be Reduced
  (Secondary Prevention)?
           Secondary Prevention
• Indahl et al (1995) assigned subjects with back injuries
  who were off work greater than 8 weeks to conventional
  treatment (n = 5 12) or light normal activity (n = 463)
• 200 days after the intervention, 60% in the control group
  were still on sick leave, compared to 30% in the
  intervention group
• Low back pain treated as a benign, self-limiting
  condition recommended to light mobilization gives
  superior results as compared to conventional medical
  treatment
         Secondary Prevention
• George et al. (2003) examined effectiveness of
  fear-avoidance based physical therapy among
  subjects with acute back pain (< 8 weeks)
• Intervention based on education (Back Book) and
  graded exercise
• Subjects with elevated fear-avoidance beliefs at
  baseline had greater improvements with
  intervention as opposed to standard care
            Secondary Prevention
• Sullivan and Standish (2003) tested a cognitive-behavioral
  intervention for injured workers at risk for developing chronic
  back pain
• Subjects had to be off work for 6 weeks and have at least one
  yellow flag
• 10-week intervention designed to increase subject involvement in
  goal directed activity and decrease psychological barriers to
  activity
• 104 subjects completed treatment
• 45% returned to work, and 15% were ready to return to work
  (contacted employer) following treatment
• Study not randomized or controlled
  Summary of Secondary Prevention
            Strategies
• Educate patient about the nature of pain (e.g., hurt
  versus harm)
• Light, normal activity is OK
• Avoid unnecessary investigation
• Pay attention to the psychological aspects of symptom
  presentation (affect, beliefs)
• Advise patients on preventing recurrence (e.g., lifting
  sensible loads)
• Consider referral for multidisciplinary evaluation if
  patient exhibits yellow flags or doesn’t improve
• Early intervention is important
  The Importance of the Provider

• How you interact with the acute pain patient
  can significantly impact outcomes and
  adjustment to pain
• The interaction helps to shape patient
  beliefs about their pain, which in
  significantly impacts their experience of
  pain
    Educate the Patient About Their
                 Pain!
• Physician education regarding the etiology of
  pain is related to increased patient satisfaction
  (Deyo & Diehl, 1986; Cherkin & MacCormick,
  1989).
• Lacroix et al. (1990) found that accuracy of
  patients understanding of the basis of their pain
  significantly predicted return to work while
  injury severity, ―nonorganic‖ signs, and MMPI
  scores were unrelated.
  Pain Beliefs and the Experience of
                 Pain
• Geisser & Roth (1997) examined agreement
  between physician and patient beliefs about the
  cause of their pain.
• Controlling for pain duration and intensity,
  patients whose diagnostic impression agreed with
  the physician were less distressed, less disabled,
  and had fewer maladaptive pain beliefs and
  coping strategies compared to patients who were
  unsure about their diagnosis or who disagreed
  with the physician.
 Difficulties “Diagnosing” Causes of
                 Pain
• Underlying mechanisms may not be known
  or obvious
• Musculoskeletal diagnoses are subjective
  and sometimes unreliable
• May simply be enough to dispel significant
  pathology

				
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