Early Intervention to Prevent the Development of Chronic Musculoskeletal Pain Disorders and Disability

Outcome measure

HR-I (n = 22)

HR-NI (n = 48)

LR (n = 54)

p Value

% Return-to-work at follow-up

91 %

69 %

87 %

0.027

Average # healthcare visits regardless of reason

25.6

28.8

12.4

0.004

Average # healthcare visits related to LBP

17.0

27.3

9.3

0.004

Average # of disability days due to back pain

38.2

102.4

20.8

0.001

Average of self-rated most “intense pain” at 12-month follow-up (0–100 scale)

46.4

67.3

44.8

0.001

Average of self-rated pain over last 3 months (0–100 scale)

26.8

43.1

25.7

0.001

% Currently taking narcotic analgesics

27.3 %

43.8 %

18.5 %

0.020

% Currently taking psychotropic medication

4.5 %

16.7 %

1.9 %

0.019

Calculating cost-comparisons between groups yielded quite impressive results. Using unit cost multipliers obtained from the Bureau of Labor Statistics for compensation costs due to disability days (2002), from the Medical Fees in the United States 2002 (Practice Management Information Corporation [PMIC], 2002) for healthcare costs, and the Drug Topics Red Book 2002 (2002) for medication costs, we were able to calculate the average costs per patient associated with healthcare visits related to LBP, narcotic analgesic and psychotropic medications, and work disability days/lost wages. Table 21.2 lists these costs associated with the HR-I and HR-NI groups. As can be seen, the average overall costs per patient over the 1-year follow-up period (even taking into account the $3,885/patient cost of the early intervention for the HR-I group) were significantly higher for the HR-NI group. The differences were statistically significant. Thus, these results, obviously, have major implications in terms of decreasing emotional distress and producing socioeconomic cost-savings for this prevalent LBP and disability problem.

Table 21.2

Cost-comparison results (average cost per patient/year) (from Gatchel et al., 2003)

Cost variable	HR-I (n = 22)	HR-NI (n = 48)
Healthcare visits related to LBP	$1,670	$2,677
Narcotic analgesic medication	$70	$160
Psychotropic medication	$24	$55
Work disability days/lost wages	$7,072	$18,951
Early intervention program	$3,885	NA
Totals	$12,721	$21,843

Obstacles to Return to Work

Another interesting finding from this above investigation was that even in the early intervention group, problems were encountered by some patients returning to work. Preliminary evaluations indicated that workplace factors presented significant obstacles for some patients to immediately return to work when ready. This result supports a significant body of literature highlighting workplace issues as a potential obstacle in the return-to-work process (e.g. Hagen, Svensen, & Eriksen, 2005; Schultz, Crook, & Winter, 2005; Shaw et al., 2010). Adding a financial angle, early interventions including a workplace component likely have a financial benefit (Carroll, Rick, Pilgrim, Cameron, & Hillage, 2010).

For these preliminary evaluations, two patient assessments were administered via structured telephone interviews: the Linton Obstacles to Return-to-Work Questionnaire (ORQ; (Marhold, Linton, & Melin, 2002) and the Liberty Mutual Disability Risk Questionnaire (Shaw, Pransky, Fitzgerald, Patterson, & Winters, 2002). The results of this pilot study indicated that many of the early intervention patients reported a willingness to return to work earlier if they had not encountered some significant workplace obstacles to return to work. For example, from the Liberty Mutual Disability Risk Questionnaire, a patient who did not return to work immediately after he or she was ready, but instead was delayed and initiated vocational retraining, reported to be not satisfied. Relative to those who did promptly return, she reported the impactful workplace variables were as follows: the employer’s lack of attempts to communicate with her after the injury, the perception that her boss blamed her for the injury, and the absence of job accommodations to support recovery despite her physician ordering some work changes. Interestingly this patient reported complete job satisfaction before her injury on the “Work Satisfaction” scale of the ORQ, contrasting to her post-injury, lowered satisfaction. Even though these pilot, retrospective evaluations were not collected for all patients, such results provided additional important preliminary data suggesting the need to modify potential obstacles for return-to-work return to (1) maximize the early intervention program for “high-risk” patients and, subsequently, (2) further prevent the development of chronic disability. Such data aligns with study results from Marhold et al. (2002) further suggesting the importance of patients’ perceptions of workplace variables representative of potentially formidable obstacles to expeditious work return.

Not surprisingly, these preliminary results became a major evaluation focus in our third study in this series of NIH-supported investigations. Here, we systematically evaluated potential return-to-work obstacles within the context of our already developed and successful biopsychosocial assessment-treatment protocol (based on the past two reviewed studies) for “high-risk” ALBP patients. This revised protocol represented a three-component, biopsychosocial model of early intervention:

The identification of “high-risk” status using the developed empirically supported statistical algorithm

The administration of our empirically supported, successful, early intervention program for these “high-risk” patients

The introduction of a back-to-work transition component in order to directly modify potential work force obstacles that may prevent an expeditious return to work

The inclusion of the latter work-transition component was hypothesized to the “final puzzle piece” in this biopsychosocial model of early intervention, maximizing early work return and the prevention of chronicity in “high-risk” ALBP patients.

In this study by Whitfill et al. (2010), “high-risk” ALBP patients were randomly assigned to one of four groups: early intervention alone (EI), early intervention plus work transition (EI/WT), work transition alone (WT), or standard care (SC). The work-transition component, consisting of up to six individual sessions, provided guidance in the transition back to work and helped address current work conditions that might aggravate the injury. Modifications related to schedules, tasks, and ergonomics are examples of areas that might benefit from adjustment. Results of this study again clearly demonstrated the effectiveness of the EI program. However, the WT component did not significantly add anything to these positive outcomes. This lack of effect could be due to patients viewing WT as a “complicating” factor in the return-to-work process with concerns around the potentially negative impact of their “suggestions” to their employers. Thus, the success of the EI supports the position that additional work-specific interventions may be unnecessary, due to the added costs and compliance issues, in an acute population. They may be better suited for a more chronic population. This is consistent by current research indicating that workplace interventions are indicated for the subacute population (e.g. Anema et al., 2007; Loisel et al., 2001; Schultz, Crook, & Winter, 2005). Additionally, Frank et al. (2000) argues that the subacute stage, when compared to the acute stage, is more amenable to treatment to reduce subsequent disability.

Finally, Rogerson, Gatchel, and Bierner (2010) conducted a cost utility analysis of this early intervention program, versus standard treatment, for the high-risk ALBP patients. Results revealed that the early intervention group again reported fewer healthcare visits and missed workdays, relative to the standard treatment group. Moreover, the early intervention was more effective and less costly from a societal perspective, as well as being the preferred option in over 85 % of the cases. Such findings support the utilization of an early intervention program, both in its cost effectiveness and in patient satisfaction. This concurs with the research conducted by Palmer et al. (2012) who advocates the use of expensive interventions only with “rigorous cost benefit evaluation planned from the outset” (p. 230).

Other LBP Early Intervention Programs

It should be noted that other similar clinical research programs have demonstrated efficacy. This is not surprising; Schultz, Crook, and Winter (2005) has noted that in their review of early intervention literature, one of the key elements include multidisciplinary, multimodal programs.

For example, Loisel and Durand (2005) provided a detailed account of the Sherbrooke Model. This well-researched multidisciplinary approach involves both the worker and the workplace using a progressive and graded schedule. They have noted that

The interventions included in this model of management had as a principle aim the early identification of workers at risk of prolonged disability (four weeks of absence from regular work). A work rehabilitation process, graded to match the improvement of the worker’s capacities with a progressive augmentation of work demands, was utilized. Additionally, a simultaneous ergonomic intervention was undertaken to permanently reduce excessive work demand. (pp. 480–481)

The efficacy of this model was evaluated by a randomized control trial, which compared it with usual care, as well as with other traditional rehabilitation approaches. Results of this study clearly demonstrated that the Sherbrooke Model approach was significantly more efficacious at returning workers to their regular jobs faster, reducing the duration of absence from work, and self-report measures of pain and disability were reported as further reduced when compared to usual care treatment or partial interventions (Loisel & Durand, 2005). Finally, on a financial note, this model was reported to be more cost-beneficial for the Quebec workers compensation board and to have saved benefit days when compared with partial interventions or usual care (Loisel et al., 2002).

Another example of a successful, multidisciplinary early intervention program with demonstrated efficacy for preventing prolonged disability is within the vocational and rehabilitation medicine realm (Nastasia, Tcaciuc, & Coutu, 2011). Here, Taylor, Simpson, Gow, and McNaughton (2001) developed a 6-week program that utilizes an interdisciplinary rehabilitation team and a cognitive-behavioral model for a population of individuals with disabling musculoskeletal pain (in particular LBP). Cognitive-behavioral therapy has been indicated as a best practice in early intervention treatment (Schultz, Crook, & Winter, 2005). The program’s focus includes teaching adaptive beliefs and attitudes (including addressing fear avoidance beliefs), development of personal control, and self-management skills; vocational rehabilitation, psychological pain management, and reconditioning strategies are also major focuses. Results demonstrated a significant impact on returning clients to work; three-quarters of the cohort had a successful outcome (Taylor et al., 2001).

An important subset of the LBP population is injured workers; for workers under 45, LBP forms the leading disability cause and for all workers this issue is considered to be reoccurring (Koes, van Tulder, & Thomas, 2006). Surprisingly, this group is underrepresented in intervention research with focus primarily on workers generally, not on “at-risk” workers (Loisel et al., 1997). However, addressing this gap, Schultz, Crook, Berkowitz, Milner, and Lewis (2008) designed a study involving integrated clinical, occupation, and case management intervention “at-risk” workers in the subacute injury phase in the workers’ compensation system. A conventional worker’s compensation case management approach was controlled for and compared to an integrated, multidisciplinary, and multimodal early intervention. In this latter intervention, key approaches included a multisystem and multi-method approach (providing a coordinated effort between the worker and the treatment team, barrier reduction, and encouragement), a support network of service and education for workers, and resource coordination. Workers identified as those at risk for disability (high to moderate risk) using the Disability Risk Questionnaire, which was developed and validated in an earlier study (Schultz, Crook, Berkowitz, Milner, & Meloche, 2005), were provided with one-to-one motivational interviewing session and follow-up with the occupational health nurse employed by the workers’ compensation system (WorkSafeBC, Canada), case planning and coordination by a case, workplace visit to address barriers to return to work, as well as a telephone communication between a workers’ compensation physician and a family physician. Results showed that this early intervention approach was effective with respect to time loss reduction (87 days for the intervention group versus 120 days for the control group). In addition, statistically significant differences were recorded at 6 months post-intervention for workers at the highest risk of protracted disability. As studies on other medical conditions show, the effect of early intervention might not be observed immediately, but rather becomes more prominent in longer-term outcome studies. Moreover, interestingly, the study results showed that this intervention was unnecessary and redundant for injured workers who were not identified as “at high risk,” including workers at moderate and low risk. Thus, early intervention should not be applied indiscriminately.

In a subsequent randomized control study, this early intervention (EI) approach was applied in two intervention groups: the first experimental group, which offered protocol-driven “fixed” EI with high-risk injured workers, and the second group, whereby the same intervention component was not protocol driven, but rather offered in a “flexible” and clinically customized individualized manner by the members of the workers’ compensation team. The “flexible” approach to early intervention led to superior results as compared to fixed, protocol-driven intervention (Schultz et al., 2009).

In a randomized trial comparing a multidisciplinary to a brief intervention with patients in the workers compensation environment with LBP, Stapelfeldt et al. (2011) examined the effectiveness of treatment for patient subgroups. This follows previous research that argued that specific subgroups of patients should be offered specific treatment (e.g., Shaw, Linton, & Pransky, 2006; Steenstra et al., 2009). In this study, the multidisciplinary intervention involved patients on sick leave from 3 to 16 weeks participating in a primarily occupationally and socially focused treatment. Results reported that the multidisciplinary intervention was more effective with worker populations with low job satisfaction, feeling at risk of losing their jobs, and experiencing no influence on work planning (when compared to groups of high job satisfaction, no perceived risk at losing their job, and having an influence over their work plan). Findings were confirmed with an additional subset of patients.

Finally, addressing general risk factors contributing to disability, Sullivan and colleagues developed the now popular program, the Progressive Goal Attainment Program (PGAP), for individuals with pain conditions. A cognitive-behavioral focus, this 10-week course is focused on developing a structured activity program within a strong therapeutic relationship, establishing goals, addressing return-to-work obstacles, and facilitating a return to work. It integrates psychosocial and behavioral interventions to achieve optimal rehabilitation outcomes in LBP patients (Sullivan, 2012; Sullivan et al., 2005). Researchers have demonstrated PGAP to be effective in addressing psychological barriers, including reducing fear of movement, perceived injustice, and catastrophic thinking for patients with LBP. They were able to identify potential risk factors and then tailor the rehabilitation program accordingly. The researchers studied “at-risk” injured workers with LBP in the acute and subacute stages with PGAP. In addition to the above named psychological changes, results showed a success rate of 60 % (i.e., 45 % return to work and 15 % readiness to return to work) (Sullivan & Adams, 2012; Sullivan & Stanish, 2003). These results revealed that a psychologically focused program might play a meaningful role in early intervention in order to prevent the development of chronic pain and disability and in the return-to-work process.

On a final note, Wickizer et al. (2011) conducted a population-based intervention study examining the role of financial incentives to providers all focused on reducing disability time from work for individuals in the workers compensation environment. Incentives were geared to develop enhanced health information technology, improve adherence to best practices, and provide organizational support. Results showed that the individuals with LBP, the reduction of days from work, was 29.5 % (P = 0.003) when compared to a non-equivalent comparison group. For all compensation claims, including those involving TMJMD and LBP, medical costs were reduced by $510USD (P < 0.01) per claim and had a reduction of disability days of 19.7 % (P = 0.005).

Temporomandibular Joint and Muscle Disorder (TMJMD)

Similar to our work on LBP, the authors of this chapter developed a parallel line of research on TMJMD. Temporomandibular joint (TMJ) pain is part of the larger diagnostic category called TMJMDs. The majority of cases of TMJMD involve either disc displacements, muscle disorders, internal derangements or degenerative changes of the TMJ, or combined muscle-joint disorders. The American Academy of Orofacial Pain (2004) estimates that 75 % of the US population experiences symptoms of TMJMD during their lifetime and that 5–10 % require professional treatment. Although the prevalence of TMJMD varies widely among studies, researchers surveying the prevalence literature estimated that in any given year, 10 % of women and 6 % of men have TMJMD-related pain, which translates to some 20 million adults (Drangsholt & LeResche, 1999). These researchers also estimated that within a 6–12-month period, more than 5.3 million US residents would seek treatment for TMJMD; a conservative estimate for only direct treatment costs is $2 billion. Although studies measuring indirect costs are presently lacking, researchers have found that 28 % of TMJMD patients report disability and limitations, in addition to unemployment (Von Korff, Ormel, Keefe, & Dworkin, 1992). National Institute of Dental and Craniofacial Research (2008) report that total estimated temporomandibular disorders (TMD) costs exceed $4 billion annually.

Indeed, with healthcare costs an issue for many patients and healthcare providers, researchers have found that some biobehavioral treatments offer a significant medical cost-offset effect (e.g. Chiles, Lambert, & Hatch, 1999). Annual managed care treatment costs for orofacial pain individually can range from $12,000 to $20,000 (Brotman, 1997). Von Korff, Lin, Fenton, and Saunders (2007) observed 372 TMJMD patients over a 3-year period and found that this pain population made more doctor visits than controls. Thus, in addition to the dental and psychosocial benefits in preventing patients from progressing from acute to chronic TMJMD, a great cost benefit is also identified. Additionally, traditional TMJMD treatment is considered more physical and reactive in nature and known to be unresponsive for this pain population. Predominately, treatment has been invasive and includes TMJ surgery, occlusional adjustments, and a wide array of pharmocotherapeutic approaches. Other nonsurgical treatments, such as interocclusal appliances, physical therapy, and nocturnal alarms, also have been used. Unfortunately, research clearly establishes that as the duration of pain increases, patients become more refractory to intervention (Gatchel, 2002).

Clearly, TMJMD is a common, complex, and costly disorder. High costs in addition to the treatment non-responsiveness have resulted in a trend toward more conservative treatment. Stohler and Zarb (1999), in their seminal article on this issue, made a plea for a “low-tech, high-prudence therapeutic approach (p. 258).” In response to this plea, a number of effective behavioral medicine approaches have been developed to better assess and treat TMJMD disorders. However, as Dworkin (1995) began to highlight, a more comprehensive biopsychosocial approach was needed to address both the physical and psychosocial factors involved in TMJMDs. Nearly two decades later, this assertion is affirmed by Palla (2011); further, he notes that the majority of treatment outcomes research conducted continue to address only physical and not psychosocial issues. On a hopeful note, Orlando, Manfredini, Salvetti, and Bosco (2007) performed an exhaustive search on current psychosocial treatments and recommended its inclusion in the management of TMD. Additionally, the International RDC-TMD Consortium (2012) announced that more expansive diagnostic criteria for TMD, expected to include nonphysical factors, would be available late 2012.

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