Psychosocial barriers can render injured workers emotionally paralyzed and unable to return to functionality. But a short-term behavioral intervention developed in Canada and now being used in the U.S. can help get chronic pain sufferers back to work.
"It's geared to the behaviors that get in the way of recovery, the avoidance behaviors," said Dr. Marianne Cloeren, medical director of Managed Care Advisors Inc. "It also includes a goal-setting approach by using incremental goals."
MCA is among the first U.S. companies using the Progressive Goal Attainment Program, a short-term behavioral intervention that can be delivered telephonically by trained health care professionals who are not therapists. Created at the Centre for Research on Pain, Disability and Social Integration at Canada's McGill University, PGAP® is the first disability prevention program designed to target psychosocial risk factors for disability. MCA's workers' comp nurse case managers have been trained to identify these risk factors and use PGAP in injured workers at risk.
Disability mind-set. "The majority of people who are disabled long term have these risk factors, although some people are severely injured but continue to work, such as Christopher Reeve," Cloeren said. "So it's got to be more than the injury; it's a mind-set."
Some of the risk factors identified as creating a disability mind-set are:
- Fear of reinjury.
- Perceived injustice -- feeling as if the person is being treated unfairly.
- Tendency to catastrophize -- anticipating worst-case scenarios.
Unlike traditional therapy which helps the patient understand reasons for his behavior, both PGAP and cognitive behavioral therapy provided by licensed therapists are designed to quickly get the injured person back into productive life.
"PGAP involves a maximum of 10 sessions," Cloeren said. "Every week the patient is asked to reach a little higher, move a little more, and set her own goals based on things she is missing in her life since the injury; physical activity is part of it."
The patient keeps track of her progress and reviews it weekly with the PGAP provider. The intervention is targeted to the psychosocial risk factors.
PGAP may not do the trick for everyone. Some patients, especially those whose pain has become chronic, may need the help of licensed mental health care providers trained in short-term CBT for pain.
Even though several research studies have shown that CBT reduced the risk for long-term leave of injured workers by threefold to ninefold and significantly reduced physician and physical therapy visits, the technique has not been used much in the workers' comp system, possibly because the system required a psychiatric diagnosis in order for the therapist to bill for the care, and many insurers did not want to assume additional mental health diagnoses as part of the claim. However, the system has changed.
As Cloeren explains, the American Medical Association recently added Health and Behavioral Intervention CPT codes that permit treatment of the psychosocial factors that are getting in the way of recovery from the medical condition. No longer is a psychiatric diagnosis required for authorization and fee schedule reimbursement.
The key to the success of behavioral interventions is to do them early. Experts say evaluation of the psychosocial drivers of chronic pain should be done two to six weeks after an injury to identify and intervene with patients at risk of developing chronic pain.
"A lot of the therapists that understand this kind of disability prevention approach to pain are not in the workers' comp system," Cloeren said. "Therapists need to understand this model and understand workers' comp and how they can get paid to do it, and insurers need to understand why they need these therapists and how to find them."
Read more at the WorkersComp Forum homepage.
November 29, 2010
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