The Power OF PGAP: Solving The Access Problem for Delayed Recovery Rehabilitation Services in the U.S.


by Darrell Bruga

Bio-psychosocial is a buzz term these days.  If you attend any major workers’ compensation or disability conferences, you are likely to hear a session or two on whole-person approaches to rehabilitation.  Over the past several years, a significant body of research which focuses on the psychosocial risk factors and delayed recovery has become more widely known.  That is because new strategies are emerging to tackle the work-disability problem which research shows can be attributed to psychosocial risk factors.
Research over the past two decades conducted by Michael Sullivan, PhD and colleagues at the University Centre for Research on Pain and Disability, McGill University reveal that psychosocial variables can present significant obstacles to recovery following musculoskeletal injury.1 Modifiable risk factors such as fear-avoidance beliefs, catastrophic thinking, perceived disability, and perceived injustice have been identified as contributing to poor rehabilitation outcomes in individuals who have sustained musculoskeletal injuries.2–4There has been increasing interest in the development of intervention approaches that would permit early detection and treatment of psychosocial risk factors for poor recovery from musculoskeletal injury.2,5,6  Individuals with an elevated psychosocial risk profile seem to benefit less from traditional approaches to medical management, are less responsive to physical therapy interventions, and are less likely to return to work.
Dr. Sullivan’s research led to the development of an intervention program that specifically targets these modifiable psychosocial risk factors.  The concept was that if psychosocial barriers could be effectively targeted in an intervention program, then it might be possible to reduce or even prevent chronic suffering and disability following injury. The Progressive Goal Attainment Program (PGAP™) is an outgrowth of Dr. Sullivan’s published research and is considered the first disability prevention program specifically designed to target psychosocial risk factors for disability. It is an evidence-based rehabilitation program for reducing disability associated with pain, depression, and other chronic health conditions. Publish peer-reviewed research on PGAP™ has demonstrated how PGAP™ improves return to work outcomes as well as reduces treatment and pain medication.2,7,8,9
Despite its proven efficacy and wide use throughout the international workers’ compensation community, PGAP™ is considered cutting edge and not yet widely known in the U.S. work comp market.  For over a decade, PGAP™ has been successfully delivered in Canada’s workers’ compensation and disability system, which is similar to the US system. More recently, PGAP™ became part of a National Strategy in New Zealand where hundreds of providers have been trained and the Accident Compensation Corporation (ACC) approves the service.
Here in the U.S., PGAP™ was selected in 2006 to be a part of a $40 million dollar trial within the Social Security Administration to determine if PGAP™ and other services can help get SSDI recipients off of disability and re-integrated  to the workplace.  PGAP™ is the only proven early and chronic intervention work disability program that has been delivered on such a wide scale.
Beyond the scientific robustness of PGAP™ the program and delivery model are also attractive because PGAP addresses the need for increased access to evidenced-based biopsychosocial (BPS) rehabilitation services.  We have known that limited access has been a barrier to receiving evidence-based biopsychosocial (BPS) rehabilitation in the U.S.  This was highlighted in a recent issue of Back Letter, “Barriers to the Effective Prevention of Chronic Disabling Low Back Pain.”10 In this issue, there was discussion that the U.S. healthcare and insurance systems are not organized optimally to provide timely, reimbursable care for individuals with risk factors for chronic disabling low back pain.
We know that 10%-20% of individuals with work-related musculoskeletal injuries will progress toward chronic pain and disability.  We also know that this relatively small subgroup consumes most of the medical and financial resources.  Yet, we know that there is a void of targeted disability treatment services for these types of occupational related disabling health conditions. The article goes on to suggest that, “although cognitive behavioral therapy is an effective approach for several ‘yellow flags’, back pain-oriented cognitive behavioral therapy is not widely available in U.S. healthcare systems.  Nor are effective multidisciplinary rehabilitation programs for individuals with low back pain. (See Chou and Shekelle, 2010.)
PGAP’s community-based delivery model is significant because it can be delivered within the immediate geographic reach of the injured worker’s place of residence.  Furthermore, PGAP is delivered by a continuum of rehabilitation professionals including OTs, PTs, vocational counselors and psychologists.  This allows for increased access to PGAP™ through a wide variety of specially trained providers. This model has been shown to be effective in both face-to-face and telephonic interactions when a PGAP™ provider is not available.
PGAP™ has the ability to meet the demand of these populations and LifeTEAM™ Health was developed to deliver PGAP™ and other delayed recovery services to the U.S. market. Through its unique specialty outcome provider network, LifeTEAM™ Health delivers a powerful tool to payors, TPAs, employers and medical management companies with focus on the prevention and reduction of delayed recovery and needless work disability.  Because LifeTEAM™ Health is able to deliver services in large and small communities throughout theU.S., PGAP is a cost-effective option in comparison to higher cost programs which more commonly serve larger urban areas. Today, LifeTEAM™ Health’s outcome-based provider network reaches across 8 states.  By the end of 2012, LifeTEAM’s PGAP network will cross 12-15 states. This is the largest – and most focused – known U.S. network of its kind.
For inquiries about LifeTEAM™ and PGAP™ please send emails to Dr. Bruga at or visit  
Darrell Bruga is founder and CEO of LifeTEAM Health, a network focused on delayed recovery rehabilitation. He has worked as a clinical service innovator and change agent with a focus on affecting positive solutions for work disability.   Prior to LifeTEAM, he was co-founder of the SpineOne Program, an interdisciplinary functional restoration program.  He also served as the Chief Clinical Officer for SpineOne from 2005 to 2010.  He has always had a strong interest in outcome-driven rehabilitation methods.
1. Sullivan MJL. Emerging trends in secondary prevention of pain- related disability. Clin J Pain. 2003;19:77–9.
2. Sullivan M, Feuerstein M, Gatchel RJ, Linton SJ, Pransky G. Integrating psychological and behavioral interventions to achieve optimal rehabilitation outcomes. J Occup Rehabil. 2005;15:475–89.
3. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30:77–94. doi:10.1007/ s10865-006-9085-0
4. Lotters F, Franche RL, Hogg-Johnson S, Burdorf A, Pole JD. The prognostic value of depressive symptoms, fear-avoidance, and self- efficacy for duration of lost-time benefits in workers with musculos- keletal disorders. Occup Environ Med. 2006;63:794–801. doi:10.1136/ oem.2005.020420
5. Boersma K, Linton S. Screening to identify patients at risk: profiles for psychosocial risk factors for early intervention. Clin J Pain. 2005;21:38–43.
6. Linton SJ. New avenues for the prevention of chronic musculoskele- tal pain and disability.Amsterdam: Elsevier; 2002. doi:10.1016/ S0899-3467(07)60096-2
7.  Sullivan, M.J.L., Adams, H. Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain. Physiother Can. 2010; 62:180 – 189.
8.  Sullivan, M., Adams, H., Rhodenizer, T., & Stanish, W. (2006). A psychosocial risk factor targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy, 86, 8–18.
9.  Sullivan, M., Ward, L., Tripp, D., French, D., Adams, H., & Stanish, W. (2005) Secondary prevention of work disability: Community-based psychosocial intervention for musculoskeletal disorders. Journal of Occupational Rehabilitation, 15, 377–392.
10. The BackLetter. Vol. 25, No. 8, August 2010.

The Cost of War: Vets are Essentially Injured Workers Who Served Our Country

We have a problem folks.  Evidence-based resources and services that are sorely needed for injured workers are similar to the resources and services needed for disabled Vets. Let’s get going to help our warriors!


LifeTEAM Health – “New Crop of Innovators”

LifeTEAM® in the Media
LifeTEAM® was mentioned recently as an innovator in the industry by Joe Paduda “…there is a new crop of innovators beginning to emerge LifeTEAM Health is also narrowly focused; They do “disability prevention” based on identifying and addressing psychosocial risk factors  – perhaps THE key factor in long-term, seemingly-intractable disability.  With providers around the country, they can and do bring a much-needed service to an industry that has yet to fully appreciate the importance of psychosocial issues.”
LifeTEAM Health is the first to market in the U.S. with an innovative strategy to greatly reduce comp and disability costs and improve return to work rates. LifeTEAM’s utilization of PGAP® helps insurers, TPAs, networks, employers, etc change the way they spend their dollars.

“Meanwhile payers and vendors appear increasing aware that the injured work actually will respond favorably when their confusions, anxieties and wavering expectations for recovery are addressed intelligently……I can’t help thinking that the emergence of behaviorally – oriented interventions modeled after cognitive behavioral therapy, or the Toronto-based PGAP program, is a reflection of a greater awareness that a lot of injured workers want to address their anxieties and confusions, particularly in venues that do not over-medicalize their concerns.” -Peter Rousmaniere Work Comp Analysis Group 2014

Currently resources are mainly devoted to symptom reduction while ignoring the psychosocial factors that can and do often delay recovery. LifeTEAM changes this focus to a behavior model – specifically the modifiable psychosocial factors that prevent a worker from returning to a more normal life. By changing the way we view disability in the industrial/occupational space – LifeTEAM can effectively change the game. Over 30,000 cases have participated in PGAP® over the last 10 years in U.S. and Canada-all PGAP® cases. PGAP® ROI- For every dollar spent on PGAP®, $38 dollars are saved- a 1:38 ratio. PGAP® outcomes demonstrate a 50% reduction in medication and treatment spend.

Please feel free to contact LifeTEAM Health for more information.

LifeTEAM Invitation – PGAP™ Workshop 2014 Boston

LifeTEAM Invitation – PGAP Workshop 2014 – Mark Your Calendar!


We are pleased to invite rehabilitation counselors, OTs, PTs, Voc Rehab, RNs, and other health care providers to participate with LifeTEAM Health. This is an exciting opportunity to learn how to address psychosocial risk factors from leading expert, Michael Sullivan PhD. Dr. Sullivan’s program, The Progressive Goal Attainment Program (PGAP™) is currently one of the most empirically supported interventions for targeting psychosocial risk factors for work disability. It is also an opportunity to participate with a leading edge community of rehabilitation professionals, LifeTEAM Health. LifeTEAM and PGAP are utilized for clients in workers compensation, disability (STD/LTD), and it is currently being piloted with the VA. It is utilized with clients who are disabled from health conditions such as pain, mental health issues, and other chronic occupational and non-occupational disabling conditions.

We know today that 10-20% of claims are in need of services beyond traditional clinical approaches to address the barriers to recovery. We also know that 10-20% of these delayed recovery cases drive 80% of the costs seen in most claims. Needless work disability, sometimes referred to as delayed recovery, has reached near epidemic proportions over the last 30 years. More recently, research over the last 10 years has taught us that psychosocial factors (non medical factors) are one of the major contributors that drive costs seen in both workers compensation and disability claims. Unfortunately, proven interventions have been scare to address this population. LifeTEAM was developed to target psychosocial risk factors through specialized evidence-based rehabilitation programs utilizing our national network of consultants. PGAP is an evidence-based program and has demonstrated improved RTW and health outcomes. PGAP is being utilized in 10 countries worldwide with over 30,000 people going through the program.

We are holding the workshop at the Sheraton Boston Hotel.  The dates are March 7-8. More details regarding room rates, course fees, CEUs, and how to register will be announced soon.

LifeTEAM is proud to work with major employers and national insurers. These institutions have utilized PGAP as a better spend and as a major tool to reduce costs, increase return to work, and improve the lives of many people.

Please feel free to contact us at any time for more information.

Interesting Article on Spinal Fusions

From the Washington Post

Spinal fusions serve as case study for debate over when certain surgeries are necessary

By some measures, Federico C. Vinas was a star surgeon. He performed three or four surgeries on a typical weekday at the Daytona Beach, Fla., hospital that employed him, and a review showed him to be nearly five times as busy as other neurosurgeons. The hospital paid him hundreds of thousands in incentive pay. In all, he earned as much as $1.9 million a year.

Yet given his productivity, some hospital auditors wondered: Was all of the surgery really necessary?

To answer that question, the hospital in early 2010 paid for an independent review of cases in which Vinas and two other neurosurgeons had performed a common procedure known as a spinal fusion. The review was conducted by board-certified neurosurgeons working for AllMed, a company accredited to audit health-care businesses.

Of 10 spinal fusions by Vinas that were selected, nine were deemed not medically necessary, according to a summary of the report.

Vinas is still working at Halifax Health, and a hospital spokesman said that, after the AllMed report, the hospital conducted an internal review that validated his surgeries. Another review conducted this year in response to litigation also validated them, the spokesman said. The hospital would not answer further questions or release details of those reviews.

Vinas “has never and will never perform an unnecessary surgical procedure on any patient,” his attorney, Robert H. Pritchard, said in a statement.

More than 465,000 spinal fusions were performed in the United States in 2011, according to government data, and some experts say that a portion of them — perhaps as many as half — were performed without good reason.

The rate of spinal fusion surgery has risen sixfold in the United States over the past 20 years, according to federal figures, and the expensive procedure, which involves the joining of two or more vertebrae, has become even more common than hip replacement.

It can be difficult, in individual cases, to get doctors to agree about when the procedure is warranted.

But at a broader level, the rapid rise of spinal fusions in the United States, especially for diagnoses that generally don’t require the procedure, has raised questions from experts about whether, amid medical uncertainty, the financial rewards are spurring the boom.

Advancements in diagnostic and surgical technology may explain some of the increase in surgery. And patients may have become more demanding.

But a Washington Post analysis of 125,000 patient records also shows that roughly half the tremendous rise in spinal fusions in Florida has been on patients with diagnoses that experts and professional societies say should not routinely be treated with spinal fusion.

Questions are raised

Normally, information that might shed light on the ways that economics shape medical decisions by doctors and hospitals doesn’t become public. But a wide-ranging lawsuit at Halifax Health offers an unusual glimpse into these issues.

In 2009, a former compliance official at the hospital filed a whistleblower lawsuit alleging illegal financial incentives for doctors. The court filings make available an array of documents — e-mails, testimony, audits. These and other sources allow a fuller depiction of the financial rewards and relationships that depended on treatment decisions. They also show how hospital administrators responded when suspicions arose that a doctor, who was generating millions in profits, may have been performing unnecessary surgery.

Focus on the Symptoms or Focus on the Risk Factors?

Why the Focus on Risk Factors
Approximately 10%-20% of individuals with work-related injuries will progress toward chronic pain and disability. Once symptoms of pain and disability become chronic, available methods of managing pain, whether pharmacological or psychological, have only modest impact on suffering and function. Musculoskeletal injury can contribute to a trajectory of increasing distress and disability associated with discontinuation of life role activities, progressive decline toward a sedentary lifestyle, and social isolation. If individuals at risk for prolonged pain and disability following musculoskeletal injury can be identified before the problem becomes chronic, individuals’ suffering might be prevented or reduced to a significant degree.

What are the Risk Factors for Chronic Pain and Disability
Intuitively, we might presume that the severity of pain associated with a musculoskeletal condition is the primary basis of work-disability. Surprisingly, pain severity has been shown to account for only 10% of the variance in occupational disability following occupational disability. Contrary to the expectations of many clinicians, research has shown that psychosocial factors might be more important determinants of the risk for chronicity than medical factors associated with the injury.

A number of psychosocial risk factors have been shown heighten the risk of chronic pain and disability. These include catastrophic thinking (negative thinking), fear of movement, disability beliefs, and perceptions of injustice are particularly likely to follow a trajectory of persistent pain, emotional distress and prolonged occupational disability.

These “Risk Factors” do not constitute a “psychological diagnosis” but rather they are factors often seen with delayed recovery claims (claims beyond 3 months) that have an impact on recovery from injury or illness. Addressing these risk factors reduces delayed recovery and reduces costs.

What Are Some Options?

PGAP® has a strong behavioral focus (not an educational approach)…
If we recognize that disability is a behavior, then overcoming disability requires a behavioral approach. Efforts to educate an individual out of disability can be quite challenging and met with increased resistance to change. If we also recognize that disability is a discontinuation of life roles such as social, familial, and occupational roles, then an intervention designed to re-engage individuals into those life roles will best challenge the disability.

PGAP® is unique…
As individuals’ become disabled due to an injury or debilitating illness, they abandon their involvement in many important activities of their lives including work. Many of these activities previously made up various life roles that defined the person’s sense of identity and self-worth. Some of these activities are abandoned because of significant functional limitations. However, some of the activities are abandoned due to psychosocial factors such as fears, loss of confidence and a pessimistic outlook on their lives. By engaging individuals through progressive activity planning and scheduling while targeting the psychosocial factors that are contributing to disability, PGAP® can assist individuals resume participation in activities that once gave their life
a sense of meaning and purpose. Resumption of occupational activities is a central objective of PGAP®. Therefore PGAP® can best be described as a ‘Life Role Re-integration’ program.

Progressive Goal Attainment Program (PGAP®) is considered the first disability prevention program specifically designed to target psychosocial risk factors for occupational and nonoccupational disability. The primary goals of PGAP® are to reduce barriers to rehabilitation progress, promote re-integration into life-role activities, improve quality of life, and facilitate return-to-work if appropriate. PGAP® is delivered with the LifeTEAM™ Physio Program to achieve optimal outcomes with workers compensation cases.

PGAP® delivers:
-Targeted identification of psychosocial risk factors
-Structured activity scheduling and graded-activity involvement
-Goal-setting and problem-solving
-Motivational enhancement strategies

Leading national disability guidelines recently approved PGAP

Progressive goal attainment program (PGAP™) is recommended as an option where there is access to trained providers. PGAP is a standardized community-based intervention delivered by OTs or PTs who have been trained by the PGAP program. The primary goal of PGAP is to reduce psychosocial barriers to return-to-work. PGAP has produced positive results for individuals suffering from musculoskeletal conditions, depression, and cancer. This study showed that participation in PGAP increased the probability of return to work following whiplash injury by more than 50%. (Sullivan2, 2006)  Findings suggest that PGAP can be a cost-effective means of improving function and facilitating return to work in individuals at risk for prolonged disability. (Sullivan, 2010) (Adams, 2007)
Criteria for the Progressive goal attainment program (PGAP™):
– Lack of improvement with early active physical therapy
– Off work at least 5 weeks, but less than 5 months of continuous time lost
– Surgery not planned or likely
– No evidence of drug or alcohol problem
– Not currently in work hardening

– Maximum of 10 weeks treatment with one hour sessions on a weekly basis (L&I, 2013)

For more information contact LifeTEAM.

LifeTEAM’s Announces National Opioid Addiction Program

LifeTEAM Introduction

LifeTEAM’s rehabilitation professionals are delivering evidence-based solutions for reducing psychosocial, medical, and return to work obstacles. By adopting high touch best evidence programs we are achieving improved health and financial outcomes.

LifeTEAM™ is leading the way and has brought together the biopsychosocial rehabilitation continuum. LifeTEAM™ consultants are available throughout the U.S. as a resource to deal with difficult cases. Our face-to-face intervention services include:

–       Progressive Goal Attainment Program (PGAP®)

–       Supervised Withdrawal of Opioids Program (SWOP©)

The LifeTEAM™ SWOP© -(Supervised Withdrawal of Opioids Program) has been made available to positively impact the growing opioid dependency problem in the U.S. A successful intervention for opioid withdrawal of a chronic pain patient requires integrated medical management of medication and disability behaviors arising from pain and opioid dependency as well as management of the clinical pathology foundation of the pain.  The LifeTEAM™ network provides addiction specialists and health psychologists to undertake the evaluation and management of these complex patients requiring medically supervised withdrawal of opioids.  The LifeTEAM™ specialists work closely with the treating provider(s) and the case manager to ensure continuity of care. The services are provided in the claimant’s home community, reducing the need for inpatient care.

LifeTEAM™ SWOP© is a comprehensive interdisciplinary opioid tapering outpatient rehabilitation program for workers’ compensation clients. The team includes an addictions case manager, addictions specialist and health and behavior psychologist, and PGAP® Plus Physio specialists.

Twelve Week Treatment Protocol

Treatment Initiation Stage

-Peer Review and Peer to Peer Call with Prescribing Physician

-Treating Physician Order for Tapering

-Assessment by Addictionologist and Psychologist

-Treatment Plan / Recommendations

-Non–Opioid Pain Management Plan

-Medication Management Plan

-Biopsychosocial Pain Management Plan by Health Psychologist

Tapering Stage (4 weeks)

-Psychological sessions to prepare patient for tapering and non-opioid pain management

-Addictionologist tapering

-Addictions counseling and behavioral pain management

Maintenance Stage (8 weeks)

-Addictions counseling and behavioral pain management

-PGAP® Plus Physio initiated to reduce psychosocial barriers, promote reactivation to life and work roles

-Addictionologist maintenance and medication management

-Relapse planning

-Discharge and relapse prevention planning

LifeTEAM™ has physicians throughout the U.S. who are qualified as Addiction Specialists under The Drug Addiction Treatment Act of 2000.  Requirements include a current State medical license, a valid DEA registration number, specialty or subspecialty certification in addiction from the American Board of Medical Specialties, American Society of Addiction Medicine, American Osteopathic Association or State certification as an Addiction specialist.

LifeTEAM PGAP®, Physio, SWOP© and Workabilities consultants are available throughout the U.S.

Contact LifeTEAM at