Psychosocial Risk Factors for Extended Disability
Highlight from the 2nd Annual Spine 10 x 25 Spine Summit
Why do some people recover from an acute musculoskeletal injury, while others transition out of the acute injury phase in the opposite direction—toward chronic disability? During the 2nd Annual Spine 10 x 25 Spine Summit, Kyle Babick, PhD, a clinical psychologist specializing in the assessment and treatment of psychological issues in injury and disability, tackled this complex issue. In his experience in treating patients with pain and physical injuries, it “isn’t just their tissue, it’s how they think, what they believe, and how they behave.”
Dr. Babick pointed out that in the US, a “biomedical model” is traditionally used to treat musculoskeletal injuries. A biomedical model assumes that every painful musculoskeletal injury has a specific traumatic cause, and that the cause can be identified and eradicated, returning the patient to their baseline health. In Dr. Babick’s view, this model is flawed when applied to musculoskeletal pain. Clear traumatic causes are rare, total symptom elimination is often not possible, and the biomedical approach ignores other influences on behavior.
Dr. Babick contrasted the biomedical model to a biopsychosocial model of illness and injury, which research shows better accounts for the full range of factors influencing patient outcomes after physical injury. “Disabling pain and off-work status is primarily a psychosocial issue, not so much based on the actual physical pathology,” he stated.
The biopsychosocial model recognizes the dynamic interaction of multiple factors that affect the presentation of a medical condition and its treatment. Those factors are biological (tissue changes), psychological (beliefs, attitude) and social (culture, family, work, legal). The interaction of all these factors shapes how patients seek treatment, how they respond to treatment, the length of time disabled, and when they return to work.
Dr. Babick noted that a patient who ends up chronically disabled, and out of work after a musculoskeletal injury has reached that destination via a pathway of complex, interacting variables. “Our biomedical approach, which addresses only the physical aspect of disability, is inherently limited in changing health behaviors and positively resolving musculoskeletal injury,” he said.
The significant economic impact of injured workers, in both medical costs and lost time from work, has driven research and also the implementation of new approaches to physical injury worldwide. Dr. Babick described the New Zealand Acute Low Back Pain Guideline, adopted by that country in 1997. This guideline describes a systematic approach to back injury that has been successful in quickly identifying and targeting psychosocial indicators that make a patient high risk for chronic, pain-delayed recovery, and disability. Patients who don’t progress as expected during the first 2-4 weeks post-injury are immediately screened, using objective assessment tools, for psychosocial “yellow flags.” Those who score as high risk for delayed recovery are quickly transitioned into multi-disciplinary treatment, which includes behavioral health interventions. This initiative and other similar programs in Australia and Sweden have resulted in reduced medical utilization, reduced healthcare and disability costs, and reduced time lost from work.
Disability Risk Factors
From the research into psychosocial causes of disability some clear risk factors have emerged, Dr. Babick noted. Fear avoidance, or the avoidance of movement or activity based on the belief that it will cause harm or damage, is an important risk factor for extended disability. Additionally, patients who score high on negative emotions—depression, anxiety, anger—tend to have less favorable outcomes. These and other psychological risk factors that complicate injury recovery respond well to cognitive-behavioral techniques, according to Dr. Babick.
Dr. Babick emphasized the importance of moving toward a more integrated, multidisciplinary approach to treating musculoskeletal injury. To reduce overall costs and get injured patients back to work and actively engaged in their lives, he recommended following in the footsteps of successful programs that emphasize early assessment and early intervention in high-risk patients. He also highlighted short-term cognitive-behavioral techniques as evidence-based therapies that can change the thoughts, beliefs and behaviors that negatively impact patient outcomes.
Challenges to Change
Dr. Babick acknowledged that challenges remain in changing the way healthcare practitioners think about and treat musculoskeletal pain and disability in our healthcare delivery system. “These interventions can significantly reduce lost time and overall costs of claims,” he concluded, “but are still not a standard practice.”