Identifying and managing modifiable risk factors for chronic pain and disability

Over the past two decades disability due to musculoskeletal problems has been increasing in almost epidemic proportions, with 10% to 20% of those with work-related musculoskeletal injuries progressing toward chronic pain and disability. 

Once symptoms become chronic, methods for managing pain, whether pharmacological or psychological, have only a modest impact on suffering and function. Musculoskeletal injury can contribute to increasing distress and disability associated with discontinuation of life role activities, progressive decline toward a sedentary lifestyle, and social isolation.

If we can identify those at risk before the problems become chronic, we may be able to prevent—or significantly reduce—suffering.

In 2012 WorkSafeBC will start screening injured workers to determine if they have significant, modi­fiable psychosocial risk factors for chronic pain and disability. If one or more risk factors are identified and validated, WorkSafeBC will employ mitigation strategies to help workers recover and return to work in a safe, timely, and durable fashion.

Risk factors
While severity of pain associated with a musculoskeletal condition might be presumed to be the primary basis of work disability, surprisingly, patient-reported pain severity accounts for only 10% of the variance in occupational disability. Research has shown that psychosocial factors may be more important determinants of risk for chronicity than medical factors associated with the injury.

Catastrophic thinking, fear of movement, disability beliefs, and perceptions of injustice are psychosocial risk factors that are particularly likely to lead to a trajectory of persistent pain, emotional distress, and prolong­ed occupational disability.

Effective management of modifiable psychosocial risks
WorkSafeBC strategies to assist in­jured workers with significant psycho­social risk factors include:
Cognitive behavioral therapy (CBT)—A validated strategy to assist workers to resume activity and return to work.

Progressive Goal Attainment Program (PGAP)—The first intervention program specifically designed to target psychosocial risk factors for chronic pain and disability. Injured workers meet with a PGAP-trained clinician once a week until the worker is ready to return to the workplace, for a maximum of 10 weeks. 

The PGAP clinician uses a variety of activity-based techniques shown to yield significant reductions in psychosocial risk factors and promote return to work. Clinical trials have shown that PGAP can be effective in decreasing pain-related disability in a variety of populations, including those with subacute musculoskeletal pain, chronic pain, comorbid pain and depression, or fibromyalgia. 

PGAP clinicians are currently being trained in BC, and by the end of 2012, there will be a network of more than 100 of them across the province. A telephone-based version of PGAP will be available in communities where there is no trained clinician. For more information on PGAP, visit www.pdp-pgap.com or e-mail info@pdp-pgap.com.

Control Over Pain Effects (COPE) Program—This program, similar to the PGAP in terms of focus on activity resumption and return to work, is offered by psychologists with training in disability management. A DSM-IV diagnosis is not required (in fact, such a diagnosis may complicate treatment).

The injured worker is counseled weekly for up to 10 weeks. The focus is on mitigating the psychosocial impediments and having a goal of return to work. A network of COPE-trained psychologists is also being developed across the province.

For more information on the Work­SafeBC psychosocial risk management programs, please contact your patient’s case manager or a medical advisor in your nearest WorkSafeBC office.
—Michael Sullivan, PhD
Departments of Psychology, Medicine and Neurology
Canada Research Chair in Behavioural Health
McGill University
—Peter Rothfels, MD
Chief Medical Officer and Director, Clinical Services, WorkSafeBC

Bibliography
Sullivan MJL, Adams H. Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain. Physiother Canada 2010;62:181-189.

Sullivan MJL, Adams H, Rhodenizer T, et al. A psychosocial risk factor targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy 2006;86:8-18.

Adams H, Ellis T, Stanish WD, et al. Psychosocial factors related to return to work following rehabilitation of whiplash injuries. J Occupation Rehabil 2007;17,305-315.

This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.