Preventing delayed recovery by

adopting a biopsychosocial approach

IFDM 2018

October 15, 2018

Vancouver, BC

Marcos Iglesias MD, MMM, FAAFP, FACOEM

OBJECTIVES

01. Review the importance of addressing

disability from a biopsychosocial

perspective

02. Describe a flag system to identify medical,

psychosocial, psychiatric, work and

system barriers to functional recovery

03. Learn the tools that are available to

minimize delayed recovery

Expected recovery Delayed recovery

DELAYED

RECOVERY

IWs WHO RTW –

BY QUARTERS

AFTER DOI

z

Washington State Department of Labor and

Industries conducted a study of all the state’s

compensable claims from 2011 to 2012 and

tracked them for two years post-injury, finding that

the probability of returning to work after one year

was 32% if not returned in the previous quarter,

and after two years fell to just 4.9%. [WDLI, 2013]

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8

IAIABC Disability Management and Return to Work Committee, 2016

NEEDLESS DISABILITY

of lost work days attributed to medical conditions

in the United States involved time off from work

that was not really required by the condition itself.

to 60% 80%

Jurisic M, et al. The Personal Physician’s Role in Helping

Patients with Medical Conditions Stay at Work or Return to Work. JOEM. 2017

WORKLESSNESS

2-3 X | 2-3 X | 6 X | 120%

WARNING

Not working may be harmful to your health

Biochemistry

Anatomy

Physiology

Pathology

Diagnostics

Therapeutics

Pharmacology

BIOMEDICAL MODEL

The body as a machine

The good physician treats the

disease; the great physician treats

the patient who has the disease.

Sir William Osler

Function Psycho Social

Bio

BIOPSYCHOSOCIAL APPROACH

Risk factors for disability are the

same regardless of the nature of the

condition

FLAG SYSTEM

Age

Gender

Comorbid conditions

Obesity

Diabetes

COPD

Smoking Opioids

Red flags

BIOLOGICAL RISK FACTORS

Compensation

Administrative delays

Iatrogenesis

Black Flags

NOMOIATROGENESIS

SYSTEM RISK FACTORS

Job Dissatisfaction

Unsupportive work environment

Work overload and pressure

Blue Flags

Workplace climate

Belief that work may cause injury

CONTEXTUAL OBSTACLES

Blue Flags

Heavy manual job

Long commute distance

CONTEXTUAL OBSTACLES

Fear Catastrophic thinking

Recovery expectation

Perceived injustice

Maladaptive coping

Absence of positive adaptive behaviors

Yellow Flags

PSYCHOSOCIAL BARRIERS

Yellow Flags

Low social support

Dysfunctional family situation

ACE

PSYCHOSOCIAL BARRIERS

Progression to chronic low back pain was more

closely dependent on demographic, psychosocial and

occupational factors than on medical characteristics.

Valat et al, 1997

Psychosocial risk factors play a

dominant role in developing chronic

low back pain disability.

Spine, 1995

PSYCHOSOCIAL BARRIER

PSYCHOLOGICAL SYMPTOM

PSYCHIATRIC DISORDER

Depression

MDD

Anxiety

Anxiety disorders

Poor coping

Adjustment disorder

Unpleasant experience

Traumatic experience

PTSD

Maladaptive behavior

Personality

disorder

Absence of positive adaptive behaviors

Job avoidance

Orange Flags

PSYCHIATRIC ILLNESS

DATA

TEXT

SCREENING TOOLS

FORMAL ASSESSMENT

GUT FEEL

SCREENING TOOLS: GENERAL

Orebro

STarT

Back Disability Risk Questionnaire (Shaw)

Acute Low Back Pain Screening Questionnaire

SCREENING TOOLS: SPECIFIC FACTORS

Pain catastrophizing

Perceived injustice

Fear avoidance

PCS

IEQ

TSK, FABQ

SCREENING TOOLS: SPECIFIC FACTORS Depression

Anxiety

Alcohol and substance abuse

PHQ-9; PHQ-2; BDI

GAD-7; Beck Anxiety Inventory

CAGE; AUDIT

Interventions

Rapid return to work

Activity

Motivational interviewing

Health/RTW coaches

Cognitive behavioral therapy

THANKS!