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.
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 dbruga@lifeteamhealth.com or visit www.lifeteamhealth.com.
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.References:
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.
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