Disability Prevention Robert J. Barth, Ph.D.

1. Disability Prevention Robert J. Barth, Ph.D. Largely based on programs that were originally prepared for: American Medical Association American Academy of Orthopaedic Surgeons American College of Occupational and Environmental Medicine

2. Robert J. Barth, Ph.D. Parkridge Hospital Plaza Two 2339 McCallie Ave. Chattanooga, TN 37404 423/624-2000 RJBarth@BarthNeuroScience.org

3. Disability Prevention Key References Population Based Efforts • Buchbinder R. Self-management education en masse: effectiveness of the Back Pain: Don't Take It Lying Down mass media campaign. Med J Aust. 2008 Nov 17;189(10 Suppl):S29-32. • Buchbinder R, et al. Understanding the characteristics of effective mass media campaigns for back pain and methodological challenges in evaluating their effects. Spine (Phila Pa 1976). 2008 Jan 1;33(1):74-80.

4. Key References AMA Guides to the Evaluation of Work Ability and Return to Work

5. Key References Caruso G, Barth RJ, et al. CORNERSTONES OF DISABILITY PREVENTION AND MANAGEMENT. In: ACOEM Occupational Medicine Practice Guidelines, 2011. NOTE: 128 pages, 534 references

6. Disability Prevention Population Based Efforts For Back Pain, this has already been attempted in… • Australia • Scotland • Norway • Canada

7. Disability Prevention Population Based Efforts Some references: • Buchbinder R. Self-management education en masse: effectiveness of the Back Pain: Don't Take It Lying Down mass media campaign. Med J Aust. 2008 Nov 17;189(10 Suppl):S29-32. • Buchbinder R, et al. Understanding the characteristics of effective mass media campaigns for back pain and methodological challenges in evaluating their effects. Spine (Phila Pa 1976). 2008 Jan 1;33(1):74-80.

8. Disability Prevention Population Based Efforts The Australian effort Primary Medium: Television Advertisements

9. The Australian effort Other Interventions • Radio Ads • Print Ads • Posters • Seminars • Workplace visits • Publicity articles • The Back Book • Doctors provided with guidelines

10. Disability Prevention Population Based Efforts The Australian effort Ten million Australian dollars from 1997-1999. This week, equivalent to USA $7.6M

11. Disability Prevention Population Based Efforts The Australian effort Messages: “Back pain is not a serious problem”

12. Disability Prevention Population Based Efforts The Australian effort Messages: • “Continue usual activities” • “don’t rest for prolonged periods”

13. Disability Prevention Population Based Efforts The Australian effort Messages: • “continue exercising” • “remain at work if possible”

14. Disability Prevention Population Based Efforts The Australian effort Messages: “positive attitudes are important and it is up to you”

15. Disability Prevention Population Based Efforts The Australian effort Messages: • Imaging is not useful • “surgery may not be the answer”

16. Disability Prevention Population Based Efforts The Australian effort Messages: “keep employees at work”

17. Disability Prevention Population Based Efforts The Australian effort Evaluation: Population-based telephone surveys before, during, and after the campaign (New South Wales as the control group)

18. Disability Prevention Population Based Efforts The Australian effort Evaluation: Before-after postal surveys of general practitioners

19. Disability Prevention Population Based Efforts The Australian effort Evaluation: Analysis of workers compensation claims

20. Disability Prevention Population Based Efforts The Australian effort Outcomes: Significant, sustained change in population attitudes and reported behavior

21. Disability Prevention Population Based Efforts The Australian effort Outcomes: Significant reduction in workers compensation claims for back pain

22. Disability Prevention Population Based Efforts The Australian effort Outcomes: Significant reduction in days away from work for back pain

23. Disability Prevention Population Based Efforts The Australian effort Outcomes: Significant reduction in workers compensation costs for back pain claims

24. Disability Prevention Population Based Efforts Scotland, Norway, Canada • Far less investment • Far less extensive efforts • Far less impressive results

25. AMA Guides to the Evaluation of Work Ability and Return to Work

26. AMA Guides to Work Ability The USA is experiencing a disability epidemic that does not make sense from occupational or health science perspectives.

27. AMA Guides to Work Ability A disability epidemic that does not make sense • Work is progressively becoming less physically demanding, less dangerous, etc. • Health care is progressively improving • But…the rate of claimed disability is increasingat a rate that is faster than the rate population growth

28. AMA Guides to Work Ability Clinicians have contributed to the disability epidemic, by… • Endorsing disability claims simply because the patient asked them to do so (no expertise introduced by the clinician) • Taking patients out of work, or introducing work restrictions that are based on pain or other subjective complaints

29. AMA Guides to Work Ability Vocational work is good for health, and should be a central part of the treatmentplan

30. AMA Guides to Work Ability Work is good for health • “Simply stated: it is usually in the patient’s best interest to remain in the workforce”. • “As patient advocates, physicians therefore should strongly urge patients to return to work or to stay at work and should decline to certify disability unless it is obvious.”

31. AMA Guides to Work Ability Inappropriate for clinicians to address disability “In the final analysis, return-to-work decisions are always those of the patient and his or her employer.”

32. AMA Guides to Work Ability Chapter 11: Working with Common SpineProblems “…for common diagnoses such as lumbar disk herniations and low back pain…”

33. AMA Guides to Work Ability lumbar disk herniations and low back pain • Most patients with these problems are capable of remaining at work. • Current work ability may increase with recreational activity, formal work conditioning therapy, and/or with return to work with gradually increasing work assignments. • “There is no science to support the need for activity restrictions in patients with lumbar disk herniations or low back pain, and limitations may in fact impede the patient’s return to work and foster disability unnecessarily.”

34. Key Reference Caruso G, Barth RJ, et al. CORNERSTONES OF DISABILITY PREVENTION AND MANAGEMENT. In: ACOEM Occupational Medicine Practice Guidelines, 2011. NOTE: 128 pages, 534 references

35. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Key Points that arose within committee discussions Most of the world does not understand the following (we must educate them): • There is little relationship between objectively verifiable health problems and disability. • Disability is primarily driven by social and psychological issues, rather than by general medical issues. • Disability can be prevented in spite of most health problems, by addressing the social and psychological determinants of disability.

36. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Recommendations: Communicate the health benefits of work, and the health-compromising effects of being away from work, to all parties.

37. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Recommendations: Avoid Iatrogenesis

38. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “medicalization of nonmedical issues” such as… Back pain (primarily predicted by job dissatisfaction, rather than by anything medical) Refer to it as “common back pain” rather than “sprain”, “strain”, “back injury”, “pulled muscle”, “threw back out”, “disc bulge”, “DDD”, etc.

39. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “Aggressive, extensive, or prolonged medical treatment of benign conditions such as non-specific low back pain because it increases the risk of iatrogenic and advocagenic impairment and work disability.”

40. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis Avoid “a focus on pain relief instead of functional restoration”

41. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis • (Avoid) Bed rest and prolonged inactivity. • (Avoid) Early or prolonged use of narcotic analgesics.

42. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “Withdrawing patients from work or writing strict work restrictions and limitations based on patient preference, fear, or pain alone without a sound or objective medical or functional basis.”

43. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “Implying that work disability is medically necessary when it is actually due to discretionary decisions or other non-medical factors.”

44. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “Inappropriate specialist and rehabilitation referral practices… • premature referral for diagnostic imaging, specialist evaluation or extensive rehabilitation in the absence of red flags or failure of simple initial evidence-based care; and • delayed referral despite the patient’s failure to recover as expected based on normative disability duration data.”

45. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “c. Beyond the acute or immediate post-operative setting, treatments whose only therapeutic endpoint is the relief of pain rather than restoration of function.”

46. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Avoid Iatrogenesis (Avoid) “d. Prolonged or extensive passive treatments…especially if the intervention is not focused on or progressively effective in restoring the ability to perform a specific function necessary at work or home.”

47. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Moving Beyond Iatrogenesis

48. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Recommendation: Investigate for psychological factors that might predict and explain otherwise unexplainable disability: E.g. pre-existing psychopathology, historical or current substance abuse, etc. What is the #1 health finding for chronic disabled back pain patients in workers comp? Personality Disorders Dersh J, et al. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine. 2006 May 1;31(10):1156-62.

49. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT Recommendations: • Investigate for psychological factors that might predict and explain otherwise unexplainable disability: • Recommend psychological evaluation and treatment (on the condition that they will expedite functional recovery) • particularly short-term, evidence-based and non-dependency producing techniques such as cognitive behavioral therapy…

50. ACOEM’s DISABILITY PREVENTION AND MANAGEMENT “CBT has strong scientific support for preventing and reversing unnecessary disability.” • “A review of 205 studies of patients with low back pain, most of them high-quality RCTs, found overall, that CBT and other psychological interventions were more effective than standard biomedical treatments, including surgery, for decreasing pain intensity, pain-related disability, and depression and for improving health-related quality of life.” • “A 2006 study showed positive effects of a short (6 hour) CBT intervention in low back pain patients, including lower risk for long-term disability leave for back pain (odds ratio 2.6) and any illness (odds ratio 2.9).”