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Evidence Informed Approach to

Early Identification and

Intervention in Occupational

Disability

Izabela Z. Schultz

Ph.D., R.Psych., ABPP, ABVE

Professor, University of British Columbia

Occupational and Environmental Medicine Association of Canada

Whistler, BC, September, 2016

Predicting Occupational Disability

and RTW Outcomes

• What predicts occupational outcomes

and what does not?

• Research has been accumulating…

• How clinicians can use science of

prediction in increasingly evidence-

based medicolegal debate and RTW interventions?

1. Length and outcomes of

hospitalization?

2. Level of care?

3. Service needs?

4. Work performance?

5. Receipt of benefits?

6. Social integration? (Peterson, 2005)

Does Diagnosis Predict Outcomes?

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1. More impairment - more disability

2. Psychological factors are more important than workplace, job-related and other environmental and contextual factors

3. Secondary gains are more important than secondary losses in disability prediction

4. We know predictive (ecological) validity of most clinical measures of impairment

Problems with Translating Clinical

Impairment into Work DisabilityTRUE OR FALSE?

5. We can rely on published standards or guidelines for

mental/psychological functional capacity evaluation

6. Clinicians routinely measure work functions and functional limitations of injured workers

7. There is a clear commonly accepted operational definition of occupational disability:

Problems with Translating Psychological Impairment into Work Disability (cont’d)

loss of earnings? return to pre-injury

employment? employer?

disability duration? work with modifications

or accommodations?

employability, competitive

edge, any job?

repeated pattern of work

absences? productivity?

What Causes the Quagmire?

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Causes of the Quagmire

1. Multiple conceptual models of disability

2. Multiple legal and statutory definitions of disability

3. Limited advances in transdisciplinary research

4. Silos of “individual” versus “system-oriented” health sciences and specialties

5. Researchers and disability stakeholders have vested interest in their preferred disability outcomes

Causes of the Quagmire (cont’d)

6. Politicization and polarization of the field:

does moral outrage fuel science or bias?

7. Clinicians forced into black and white legal paradigms

8. Fragmented empirical base for predictions

9. Task complexity: standardized versus judgement-based approaches

Science of Occupational Disability

Prediction?

• Impairment does not equal disability…

• Relationships between impairment and disability is multifactorial and dynamic

• Psychosocial predictors of disability

lead the way

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Impairment & Occupational Disability

Relationships

Schultz, I. Z. (2003) in I. Z. Schultz & D. O. Brady (Eds.) Psychological Injuries at Trial, American Bar Association

Workplace

factors:demands,

control & support including work

accommodations

Coping

resources and motivation

Impairment

Past experience in coping with

adversity

Sociodemographic

factors

Current

stressors

HeHealth

Personality and cognitive

status

Secondary gains and

losses

Social support

Job

satisfaction

Occupational

disability

How do Clinicians Assess

Work Capacity?

1. Usually one time behavioural sample only

2. Reliance on self-report

3. Reliance on tests of unknown predictive (“ecological”) validity

4. Limited collateral information

5. Not using specific tests to measure work-relevant mental and physical function

Problems with Clinical Assessments

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6. Work records rarely sought and/or reviewed; limited understanding of work functions and workplace

7. Timidity in describing vocational impact or over-generalizations

8. Baseline rates of different conditions and symptoms: clinicians may overpathologize and focus excessively on dysfunction - ignoring coping, context and intact domains

Problems with Clinical Assessments

Predictive Factors

WORKER FACTORS:

• Demographic, psychosocial, health/medical

• Modifiable-nonmodifiable

WORKPLACE FACTORS:

• Support, demands, autonomy, fairness

• Modifiable-nonmodifiable

• OTHER SYSTEMIC FACTORS

Evidence-Based Prediction

• Can be applied in occupational disability

cases to improve clinician’s prognostic accuracy

• Identify modifiable predictors

• Target modifiable predictors in clinical

and occupational interventions

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Are We Turning into Actuaries?

• Clinical judgement and actuarial judgement are on a continuum

• Actuarial predictions tend to be more

accurate than clinical predictions

• Actuarial means research supported

• Clinicians are experts in selecting predictors

for research

• The more research data we have on a given

condition the better our actuarial prediction

What Does Research Say?

• Back pain disability by far leads the way

in research on predictors;

• There were 3,500 studies in 2003 and

then I stopped counting…

• Systematic reviews and systematic

reviews of systematic reviews emerged

PREDICTING DISABILITY

MUSCULOSKELETAL PAIN

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WORKER RELATED FACTORS:

NONMODIFIABLE

1. DEMOGRAPHICS

• Older age (White et al., 2015)

• Gender (female) (e.g. Crook et al., 2002; Hendricks et al., 2005; Brede et al., 2012)

• Job tenure (Crook et al., 2002)

2.PSYCHOSOCIAL FACTORS

• Lack of work experience and education (White et al.,

2015)• Negative family feedback regarding illness (Kuijer et al.,

2006); family strain (Cote & Coutu, 2010)

• Comorbidity; antisocial personality (Brede et al., 2012)

• Employer’s and insurance company’s

response/perceptions of support (Schultz et al., 2002;

2005)

WORKER RELATED FACTORS:

NONMODIFIABLE

3. HEALTH FACTORS• Overweight (Steenstra, 2005)

• Poor general health (Steenstra, 2005)

• Comorbid injuries (White et al., 2015)

• History of low back pain (Truchon & Fillion, 2000)

• Widespread pain (Grotle et al., 2010)

• History of sick leave (White et al., 2015)

• Opiate dependence (Brede et al., 2012)

WORKER FACTORS:

MODIFIABLE

1. Clinical predictors:

• Lack of early intervention (Kuijer et al., 2006)

• Chronicity

• Sleep disturbance (Hendriks et al., 2005)

• Anxiety and depression?

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WORKER FACTORS:

MODIFIABLE

2.Personality, beliefs & coping:• Expectations of recovery (Gross & Battie, 2010; Iles

et al., 2008; Kuijer et al., 2006; Schultz et al., 2004)

• Negative health and disability perceptions (Wagner et al., 2014)

• Fear avoidance and fear of pain/distress (Iles et al., 2008; Wideman & Sullivan, 2011)

• Catastrophizing (Fedoroff et al., 2014;Sullivan et al., 2012; Sullivan & Stanish, 2003)

• Perception of injustice (Sullivan et al., 2009)

• Pain and guarding (Schultz et al., 2002)

WORKER FACTORS:

MODIFIABLE

3. Other vulnerability factors: • Life stressors; worrying about life and health (Iles et

al., 2008)

• Burnout and work stress (Wagner et al., 2014)

• Low work-related activity at baseline

• Motivation: sense of involvement and desire to remain employed (Wagner et al., 2014)

WORKPLACE FACTORS:

MODIFIABLE

• Job satisfaction (Iles et al., 2008; Truchon & Fillion, 2000; White et al., 2013)

• Perceived support (White et al., 2013)

• Job accommodation (Crook et al., 2002)

• Workplace characteristics (White et al., 2013)

• Perception of fairness (Davey et al., 2009, Hepp et al., 2011)

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Work Disability Predictors in Musculoskeletal Pain Disorders: AN INTEGRATIVE APPROACH

Research Syntheses: White, Wagner, Schultz et al. (2013); Wagner, White, Schultz et al. ( 2013)

PREDICTING DISABILITY IN

DEPRESSION

WORKER FACTORS:

NONMODIFIABLE

1. SOCIODEMOGRAPHIC FACTORS• Single parent

• Lack of social support

• Lower education (Lerner et al, 2004)

• Married workers: presenteeism; unmarried workers: absenteeism (Duijts et al., 2007; Cocker et al., 2011)

• Older age (Dewa et al., 2002; Lagerveld et al., 2010; Wang, 2007)

• Non-Caucasian patients tend to drop out of treatment (Lagerveld et al., 2010)

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WORKER FACTORS:

NONMODIFIABLE

2. Health• Poor general physical health (Lerner, 2010)

• Presence of comorbid medical condition: cancer, pain, diabetes, asthma, hypertension (Ervasti et al., 2015)

• Previous sick leave (Lagerveld at al., 2010)

• Substance use (Wagner et al., 2014)

WORKER FACTORS:

NONMODIFIABLE

3. Psychosocial factors:• Life stressors and threats of violence (Duijts et al.,

2007)

• Social support (Duijts et al., 2007)

WORKER FACTORS:

MODIFIABLE

1. MENTAL HEALTH PREDICTORS

• Severity of depression (Lagerveld et al., 2010; Lerner et al., 2010; Karpansalo, 2005) and comorbidity (Ervasti et al., 2015; Hees et al., 2012)

• Atypical or Psychotic Symptoms (Gnam 2005)

• Length of illness (Lagerveld et al., 2010)

• Sense of hopelessness (Kruijshaar et al., 2003)

• Timely treatment (Schoenbaum et al., 2002)

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WORKER FACTORS:

MODIFIABLE

2. PERSONALITY AND COPING• Conscientiousness (Verboom et al., 2011; Hees at

al., 2012)

• Openness (Verboom et al., 2011)

• Extraversion (de Vries et al., 2015)

• Neuroticism (de Vries et al., 2015; Hees et al., 2012)

• Pessimism, external locus of control and passive withdrawal (de Vries et al., 2015; Lagerveld et al., 2010)

WORKPLACE FACTORS:

NONMODIFIABLE

• High psychological demands

• High physical demands

• Low control

• Low decision latitude

• Low flexibility

• Unsupportive supervisory factors: ambiguities, lack of communication

• (Duijts et al, 2007; Lagerveld et al., 2010; Lerner et al., 2010; Michie & Williams, 2003; White et al., 2013 & 2015)

WORKPLACE FACTORS:

MODIFIABLE

• Imbalance between effort and reward at work (Duijts et al., 2007)

• High work stress (Verboom et al., 2011)

• Job satisfaction ( Dujits et al., 2007)

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Cross-Diagnostic Predictors of

RTW in Accidental Injuries

• RTW is best predicted by patient’s own appraisals of injury severity and ability to cope with accidental injury – systematic review across conditions (Hepp et al., 2011)

• Readiness to return to work

• Limitations of research data:

• is your client represented in the research model?

• studies limited to specific sample and context; generalizability problems

• lack of research on comorbid conditions

• limited research on diverse populations

Use of Predictors in Determination of

Disability Outcomes1. Establish presence or absence of factors that have

moderate to strong evidentiary support as predictors of work disability

2. Review published predictive models of disability and RTW

3. Determine factors predictive of disability in a given clinical scenario that are based on research and published clinical observations

4. Determine case-specific individual and systemic barriers and facilitators of RTW

Strong Moderate Limited

Low social support Non full-time work ↑ Absenteeism

tolerance

Low job satisfaction Poor quality leadership ↑ Time to treatment

Low supervisory support Low job control Reorganizational stress

Low worker control Low fairness

↑ Psychological

demands

Low managerial involvement

↑ Job strain

↑ physical demands

Modifiable Workplace Factors

Predictive of Work Disability: Evidence

White , Wagner , Schultz, . et al. (2013)

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Nonmodifiable RTW Predictors:

Evidence

• Lower occupational status

• Existence of a worker’s compensation claim

• Older age

• Poor personal functioning

• Increased psychological symptoms

• Increased clinical/complicating factors

• Decreased physical functioning

• Overweight status

• Increased emotional distress

• Non-married status

• Female gender (in cases of rheumatoid arthritis & LBP)

• Presence of respiratory conditionsWhite , Wagner , Schultz, . et al. (2013)

Inferences: Determination of Work

Capacity / Disability

• Consider worker’s diagnosis, personal characteristics, coping resources and clinical prognosis

• Integrate work function-related evidence from multiple sources

• Recognize demands, support and control factors in the workplace

• Establish positive and negative predictive factors and balance them out (include modifiable and nonmodifiable individual and system factors)

• Apply recognized work function/disability evaluation/rating system; be aware of relevance, applicability and limitations of such systems

Inferences: Determination of Work

Capacity / Disability (cont’d)

• Determine readiness to return to work (if individual is employable) and risk for work disability

• Determine current or anticipated work capacity-related strengths and limitations in the following areas: daily activities, concentration, persistence and pace, social function, and adaptability to stress

• Consider functional change: pre- versus post-injury status

• Estimate the overall severity and complexity of work

disability

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Toolbox for Work Disability

Prediction

• Custom made from existing research and case characteristics

• Musculoskeletal disorders: Research supported:

• For example: Orebro Musculoskeletal Pain Questionnaire

(OMPQ) used to predict long term disability and failure to RTW due to personal and environmental factors, with a higher score

equal to higher risk:

• ≤105 = low risk; 105-130 = moderate risk; ≥130 = high risk

(Linton, Nicholas et al., 2011)

• Caution: Existing instruments are designed for screening and

not diagnosis

Inferences: Determination of Work

Capacity / Disability (cont’d)

Determine under what conditions the individual can/cannot work,

giving consideration to:

• degree of structure and predictability

• amount of work supervision required

• amount of supervisory or coworker support

• task demands such as: hours of work, accuracy, speed, complexity, multitasking, volume, ambiguity, conflict, social

interaction, language and literacy

• decision latitude and skill discretion

• job accommodations: e.g., flexibility, rest breaks

• optimistic, pessimistic and realistic employment scenarios

How About RTW?

Common Myths to Challenge

1. “This is not my job” attitude among clinicians.

2. Someone else will do it: VRC or OT.

3. Work is not therapy.

4. Wait with RTW until clinical condition remits.

5. RTW to start only after complete discharge from therapy.

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From Assessment to RTW

1. Understand functional strengths and limitations and their anticipated course

2. Establish readiness and risk for disability; with positive and negative predictive factors for RTW/disability

3. Determine which individual and workplace/system factors are modifiable

4. Design integrative clinical and occupational intervention targeting modifiable factors.

5. Determine work accommodations that match functional limitations and other appropriate and timely interventions

Best Research Informed Practices in

Early RTW: Musculoskeletal Disorders

1. A multidisciplinary biopsychosocial rehabilitation program with

workplace visits or comprehensive occupational intervention

2. Intervention matched to risk level

3. Interaction and cooperation among multiple RTW stakeholders

4. Work accommodation: e.g., light duties

5. Worker active participation in accommodations: trust & control

6. Encouragement to return to normal activities including work activities as soon as possible.

Best Research Informed Practices in

Early RTW: Musculoskeletal Disorders

7. Graded physical activity. Women may benefit from a

combination approach with cognitive-behavioural therapy.

8. A cognitive-behavioral approach that addresses depression, stress, fears of re-injury and pain, catastrophizing and

uncertainty. Past pain history and current pain intensity need to

be reviewed.

8. Brief, five minute clinician initiated telephone calls once every two weeks with emphasis on active listening, offering

supportive and encouraging comments and monitored Web-

based programs. (Schultz et al, 2013)

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RTW in Anxiety and Depression

• Integrate CBT principles within RTW program; CBT with graded activity showed better results than as stand-alone intervention (e.g. Blonk et al. 2006).

• Participatory interventions involving worker, with mutually agreed upon goals and problem-solving with employee on accommodations, such as: job description modification, flexible scheduling, environmental changes, job sharing, assistive devices, coworkers as mentors, and behavioral interventions, such as regular meetings (Schultz et al.,

2011).

RTW in Anxiety and Depression (cont’d)

• Conceptualize accommodations along the realms of cognitive, interpersonal, motivational, and symptom exacerbations (Conyers & Ahrens, 2003).

• With more severe anxiety and mood disorders, consideration should be given to using more intensive, combined approaches. Typical CBT interventions are more effective with milder disorders; thus, more optimization is required for more severe clinical scenarios. Consider extending the treatment time (Schultz, Chlebak & Law, 2015)

META-CONCLUSIONS

1. TO BE CREDIBLE ASSESSMENT MUST REST ON CURRENT RESEARCH

EVIDENCE AND BEST PRACTICES

2. INTEGRATE CLINICAL AND RESEARCH DETERMINANTS OF DISABILITY TO MAKE BEST PREDICTIONS FOR YOUR

CASE

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META-CONCLUSIONS (CONT’D)

3. TRANSLATE MULTIVARIATE OUTCOME PREDICTION METHODOLOGY INTO

CLINICAL CASE APPLICATION

4. INTEGRATE INDIVIDUAL AND SYSTEMIC FACTORS: VENTURE BEYOND FAMILIAR RESEARCH TERRITORY

META-CONCLUSIONS (CONT’D)

5. WHAT IS MODIFIABLE AND WHAT IS NOT: DESIGN INTEGRATED CLINICAL AND OCCUPATIONAL INTERVENTION TARGETING MODIFIABLE RISK FACTORS

6. DRAW FROM KNOWLEDGE OF STRENGTHS, RESOURCES AND PERFORMANCE

7. GO BEYOND PATHOLOGY AND DEFICIT FRAMEWORK TOWARDS DYNAMIC PERSON-ENVIRONMENT INTERACTION

8. TRANDISCIPLINARITY IS THE FUTURE

Anticipated Research

& Clinical Advances

1. Methodological improvements in RTW prediction of disability research allowing development of probability of RTW/disability risk indices for different diagnostic groups

2. Meta-analytic studies; systematic analyses of systematic reviews

3. Early intervention linked to early risk factors: disability prevention

4. Inclusion of systemic and person-system interaction factors in research and practice

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Anticipated Research &

Clinical Advances (cont’d)

5. Systematic research on validity, reliability and fairness of disability determination methods; no method introduced without evidence of satisfactory measurement properties in high stakes assessments

6. Research on integration of actuarial and clinical approaches – leading to clinical guidelines and best practices

7. Research advances in causation of “biopsychosocial” disorders

Anticipated Research &

Clinical Advances (cont’d)

8. Development of transdisciplinary research paradigms and research; including multi-system and system-person interactions;

9. Growth in empirical base for the biopsychosocial model leading to more clear articulation of the tenets and relationships;

10. Qualitative studies into the decision making and judgements of disability evaluators;

11. More clinical advances in systematic applications of debiasing techniques;

Anticipated Research &

Clinical Advances (cont’d)

12. Better research on the integration of the “clinical” with the “occupational”;

13. Systematic inclusion of coping, motivational and cognition (beliefs, expectations and perceptions) in disability evaluations;

14. Research on cross-diagnostic functional manifestations of disorders.

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Please contact:

izabela.schultz @cortexcentre.com 604-221-4199

CORTEX Centre for Advanced Assessment affiliated with the University of British Columbia

Vancouver Canada

Thank you