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Research Reports |
MJL Sullivan, PhD, is Professor, Department of Psychology, University of Montreal, CP 6128 Succ. Centre Ville, Montreal, Quebec, Canada H3C 3J7
H Adams, RWS, is Program Coordinator, Department of Psychology, University of Montreal
T Rhodenizer, OT, is Occupational Therapist, University Centre for Research on Pain and Disability, Halifax, Nova Scotia, Canada
WD Stanish, MD, is Professor, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
(michael.jl.sullivan{at}umontreal.ca). Address all correspondence to Dr Sullivan
Submitted October 26, 2004;
Accepted August 1, 2005
 | Abstract |
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Subjects and Methods. A sample of 60 subjects enrolled in a functional restoration physical therapy intervention were used as a historical cohort comparison group. Subjects who received the functional restoration physical therapy intervention were compared with a sample of 70 subjects who received PGAP in addition to physical therapy.
Results. Participation in PGAP plus physical therapy resulted in a higher return-to-work rate (75%) than participation in physical therapy alone (50%). Differences between treatment conditions were most pronounced for the subgroup of subjects who had the largest number of psychosocial risk factors. Discussion and Conclusion. The findings suggest that a psychosocial risk reduction intervention can be an effective means of improving function and facilitating return to work in people who are at risk for prolonged pain-related disability. [Sullivan MJL, Adams H, Rhodenizer T, Stanish WD. A psychosocial risk factor–targeted intervention for the prevention of chronic pain and disability following whiplash injury.
Key Words: Pain-related disability • Psychosocial risk factors • Whiplash
| Introduction |
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Over the past decade, considerable research has addressed the importance of psychosocial factors as determinants of pain and disability associated with whiplash injuries.8–11 Research findings suggest that affective variables, such as depression and anxiety,8 or cognitive variables, such as pain catastrophizing,9 are associated with heightened pain and disability in people who have sustained whiplash injuries. Recent reviews12–14 indicate that psychosocial factors are significant risk factors for the development of prolonged pain and disability associated with a variety of pain-related conditions. Findings such as these have highlighted the need to develop intervention programs that specifically target the psychosocial variables that contribute to pain and disability.15–18
The Progressive Goal Attainment Program (PGAP) is a risk factor–targeted intervention program designed to be administered by rehabilitation professionals, such as physical therapists, occupational therapists, or occupational health nurses. The PGAP is a 10-week standardized psychosocial intervention program that aims to increase daily involvement in goal-directed activity and minimize psychosocial barriers to rehabilitation progress following musculoskeletal injury. The PGAP differs from most secondary prevention programs because of its primary focus on the reduction of psychosocial barriers to rehabilitation progress. The ultimate goal of the PGAP is to facilitate return to work.
The psychosocial risk factors targeted by the PGAP include pain catastrophizing,19 fear of movement or reinjury,17 and perceived disability.20 The term "catastrophizing" is used to describe a particular response to pain symptoms that includes elements of rumination (ie, excessive focus on pain sensations), magnification (ie, exaggerating the threat value of pain sensations), and helplessness (ie, perceiving oneself as unable to cope with pain symptoms).19 Fear of pain refers to a negative emotional reaction associated with pain that elicits a high degree of escape and avoidance behavior.17 The term "perceived disability" refers to people’s beliefs about the degree to which their condition interferes with their ability to participate in activities of daily living.20 These variables have been shown to contribute to pain-related disability beyond the variance accounted for by medical status variables or pain itself.16
The purpose of this study was to assess the effectiveness of the PGAP in facilitating return to work for a sample of people who had sustained whiplash injuries in motor vehicle accidents. The treatment program was delivered by community-based rehabilitation professionals who had attended a 2-day training workshop. Return-to-work outcomes associated with participation in the PGAP were compared with outcomes for a sample of subjects who were matched with regard to diagnosis and psychosocial risk profile and who participated in a functional restoration physical therapy program. The comparison subjects were drawn from the same clinics as the participants in the PGAP but were recruited prior to the training of clinic staff in PGAP procedures. We predicted that participation in the PGAP would be associated with superior return-to-work outcomes than participation in the functional restoration program, particularly for subjects with more pronounced psychosocial risk profiles. We also predicted that participation in the PGAP would be associated with greater reductions in psychosocial risk factors than participation in the functional restoration program. Finally, the relationship between treatment-related changes in psychosocial risk factors and return-to-work outcomes was explored.
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Demographic, injury, and occupational characteristics of the sample are provided in Table 1. There were no group differences in age (t128=0.88, not significant [NS]), sex distribution (
21=0.75, NS), or duration of pain-related disability (t128=0.93, NS). There were no group differences in the physical demands associated with preinjury employment (22=0.63, NS).
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The PGAP clinicians for the present study were 6 physical therapists and 4 occupational therapists. The mean number of years of clinical experience for the physical therapists was 3.3, with a range of 2 to 6 years. The mean number of years of experience for the occupational therapists was 4.0, with a range of 2 to 8 years. Although there was no minimum number of years of experience required to enroll in the PGAP training workshop, some degree of experience likely is required to appreciate the nature of psychosocial challenges that may be encountered during rehabilitation.
All 6 physical therapists who treated clients in the physical therapy alone group also treated clients in the PGAP+physical therapy group. However, for a particular client in the PGAP+physical therapy group, a physical therapist could provide the functional restoration intervention or the PGAP, but not both. The 4 occupational therapists who treated clients in the PGAP+physical therapy group were employed in the same clinics that provided the functional restoration intervention but were involved only in the return-to-work component of the treatment of clients in the physical therapy alone group.
The PGAP is provided as a program complementary to traditional approaches to the management of musculoskeletal injury. Through the addition of the PGAP to existing medical and physical therapy interventions, the objective is to create virtual multidisciplinary teams at the community-based level. Subjects are considered candidates for the PGAP if they score within the risk range (ie, above the 50th percentile) on at least 1 of the psychosocial measures targeted by the program. Normative tables for the risk factors assessed in the PGAP are available at the PGAP Web site (www.pdp-pgap.com). All subjects in the PGAP+physical therapy group also were participating in a functional restoration physical therapy program.
Return-to-work outcomes for the PGAP+physical therapy group were compared with those for the historical cohort comparison group. The comparison group consisted of subjects who had participated in a functional restoration physical therapy program prior to clinic staff receiving training in the PGAP protocol. The functional restoration program consisted of 3 weekly visits of 2.5 hours. The functional restoration program was characterized by a sports medicine approach consisting primarily of joint manipulation, active-range-of-motion exercises, and strengthening exercises, progressively increasing in intensity. For the purposes of this study, subjects were considered part of the comparison group only if they met the same inclusion criteria as those in the PGAP+physical therapy group (ie, diagnosis of whiplash injuries, with at least 1 initial score on the psychosocial risk factor measures above the 50th percentile).
For both treatment groups, treatment was discontinued once a subject had returned to work. That is, the interventions were designed to run for a maximum of 10 weeks but could be terminated once return to work was achieved. Therefore, subjects who discontinued treatment prior to 10 weeks and returned to work were not considered treatment dropouts. For the purposes of this study, only subjects who discontinued treatment prior to 10 weeks and did not return to work were considered dropouts. On the basis of these criteria, only 1 subject in the physical therapy alone group dropped out of treatment. The data for this subject were retained for analyses with the last observation on dependent measures carried forward.
Measures
Catastrophizing
The Pain Catastrophizing Scale (PCS)23 was used to assess catastrophic thinking in relation to pain. On this scale, respondents are asked to rate the frequency with which they experience 13 different thoughts and feelings related to pain. The PCS has been shown to have high internal consistency (coefficient alpha=.87)23 and to be associated with heightened pain, self-reported disability, and employment status.19 The 50th percentile cutoff score for participant selection was 20.
Fear of movement or reinjury
The Tampa Scale for Kinesophobia (TSK)24 was used to assess fear of movement or reinjury. The TSK is a 17-item questionnaire that has been shown to have adequate to high internal consistency (coefficient alpha=.77)21 and to be associated with measures of behavioral avoidance and self-reported disability.25 The 50th percentile cutoff score for participant selection was 39.
Perceived disability
The Pain Disability Index (PDI)26 was used to assess the degree to which respondents perceived themselves to be disabled in 7 different areas of daily living (home, social, recreational, occupational, sexual, self-care, and life support). The PDI has been shown to yield data that are reliable and is significantly correlated with objective measures of disability.22,27 The 50th percentile cutoff score for participant selection was 37.
Pain severity
The Pain Rating Index of the McGill Pain Questionnaire28 was used to assess current pain severity. The Pain Rating Index is a weighted sum of all pain adjectives endorsed and is considered to be a reliable and valid measure of an individual’s pain experience.29
Primary Outcome Variable
Return-to-work status was assessed by telephone interview 4 weeks following termination of the treatment program. Clients were asked the following questions: (1) Have you returned to full-time work? (2) If not, have you returned to part-time work? If so, how many hours per week? and (3) Have you returned to the same employment you had prior to your injury? The interviewer was an office assistant who was unaware of treatment condition and the hypotheses of the study. For the purposes of the present study, clients were classified as having returned to work if they had returned to full-time preinjury employment or alternate employment. All other clients were classified as not having returned to work.
Data Analysis
Chi-square analysis was used to assess treatment-related differences in return-to-work rates. Follow-up analyses addressed potential demographic, injury, and occupational influences on return to work. Multivariate analysis of covariance was used to examine treatment-related differences in changes in psychosocial risk factors between treatment initiation and treatment completion. Follow-up univariate analyses of covariance were used to evaluate treatment effects separately for pain catastrophizing, fear of movement or reinjury, and perceived disability.
Logistic regression was applied in hierarchical analyses to determine predictors of return to work. The significance of improvement in model fit with the addition of variables in the hierarchical analyses was obtained from chi-square comparisons, and the unique contribution of each variable was evaluated on the basis of the significance of the corresponding odds ratio (OR). The 95% confidence interval (CI) for each OR also was computed, and model fit for groups of variables was assessed with the value of –2 times the log likelihood. The Nagelkerke R2, which ranges between 0 and 1, provided an index of the proportion of variability that was explained by the predictor variables in each analysis. Percentages of correct classification were determined for the probability threshold value of .5.
| Results |
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21=9.2, P<.01). Subjects who returned to work did not differ significantly in age (t128=0.38, NS) or years of education (t128= –0.29, NS) from those who did not return to work. Subjects who returned to work had been absent from work for a significantly shorter duration of time (
=23.6 weeks, SD=12.4 weeks) than subjects who did not return to work (=42.0 weeks, SD=20.1 weeks) (t128=6.4, P<.01). The probability of returning to work did not vary as a function of sex (21=0.10, NS) or physical demands of occupation (22=1.82, NS). Return-to-work outcomes were compared between treatment groups as a function of initial psychosocial risk profiles. For these analyses, risk factor profile was defined in terms of the specific risk factor measures on which subjects scored above the 50th percentile. Return-to-work outcomes were compared between treatment groups for subjects who scored above the 50th percentile on measures of pain catastrophizing, fear of movement or reinjury, perceived disability, or all risk factor measures. Categories were not mutually exclusive; therefore, the sum of participants in each risk factor category exceeds the total sample size.
The Figure
shows the differences in return-to-work rates for the 2 treatment groups as a function of different psychosocial risk profiles. For subjects who scored above the 50th percentile on measures of pain catastrophizing, fear of movement or reinjury, or perceived disability, participation in PGAP contributed to a 54% to 62% increase in the probability of returning to work. The most marked difference between the 2 groups was in the subgroup of subjects who scored above the 50th percentile on all psychosocial risk factors; for these subjects, the addition of PGAP was associated with a 128% increase in the probability of returning to work. Differences between treatment groups were significant at P<.05 for all comparisons.
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=.58, F2,127=44.8, P<.001), a significant time x scale interaction (Wilks =.69, F6,123=8.9, P<.001), and a significant group x scale interaction (Wilks =.92, F3,126=3.4, P<.05). Follow-up analyses revealed significant reductions in all risk factor measures, although the magnitudes of the reductions varied as a function of the specific risk factors. For both groups combined, pain catastrophizing showed the most marked reduction (33%), followed by perceived disability (24%), fear of movement or reinjury (10%), and pain severity (4%). Analyses of covariance were used to examine group differences in the magnitudes of treatment-related reductions in the various psychosocial risk factor scores. Dependent variables in these analyses were scores on psychosocial risk factor measures for changes between treatment initiation and treatment completion. In order to control for initial values, pretreatment scores were used as covariates. Adjusted means are presented in Table 3. Analyses of mean differences revealed that significant group differences emerged only for pain catastrophizing, for which the PGAP+ physical therapy group showed greated reductions than the physical therapy alone group (F1,127=5.0, P<.05).
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23=35.2, P<.001). Change in the score for pain severity was entered in the second block of the analysis and contributed significantly to the prediction of return to work (21=9.2, P<.01). Changes in scores for pain catastrophizing, fear of movement or reinjury, and perceived disability were entered in the last block of the analysis. As shown in Table 4, changes in risk factor scores contributed significantly to the prediction of return to work, beyond the variance accounted for by age, sex, duration of work absence, and change in pain severity (23=21.1, P<.001).
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| Discussion |
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Participation in the physical therapy alone group was associated with a 50% return-to-work rate. Return-to-work rates of this magnitude would be in the range of expected outcomes at 6 months after injury for a sample of subjects participating in a rehabilitation intervention.4,6–8 Participation in the PGAP+physical therapy group was associated with a 75% return-to-work rate. When examined in relation to subjects scoring in the risk range (50th percentile) on specific risk factor measures, participation in the PGAP+physical therapy group was found to be associated with a 54% to 62% increase in the probability of returning to work. The most marked benefit of participation in the PGAP+physical therapy group was for the subgroup of subjects who scored in the risk range on all 3 psychosocial risk factor measures. For these subjects, participation in the PGAP+physical therapy group was associated with a 57% return-to-work rate, compared with 25% for the physical therapy alone group. These data suggest that people who have severe psychosocial risk profiles are particularly resistant to treatment and that the probability of return to work can be significantly augmented by the addition of a psychosocial risk factor–targeted intervention.
For the various risk factors targeted, the results suggest that PGAP affected primarily the levels of catastrophic thinking. Numerous investigations16,34–36 have highlighted the important role of pain catastrophizing as a determinant of pain and disability and have emphasized the need to specifically target catastrophic thinking to achieve a positive rehabilitation outcome. People with high scores on measures of pain catastrophizing report more intense pain, display more pain behavior, consume more pain medication, and remain off work for longer periods of time following musculoskeletal injury.9,13,19 Several components of PGAP were designed to effect reductions in pain catastrophizing. These components include education and reassurance, collaborative activity planning, activity prescription, thought monitoring, reappraisal, and cognitive restructuring. These program components may have contributed to the more pronounced reductions in catastrophic thinking observed in the PGAP+physical therapy group than in the physical therapy alone group.
Both treatment conditions were associated with moderate decreases in perceived disability. It is possible that levels of perceived disability decrease when clients observe themselves achieving goals that they had previously considered beyond their reach. In PGAP, this objective is achieved through incremental increases in activity demands and feedback to clients about the gains that have been made in treatment. These same features may be present in functional rehabilitation approaches in physical therapy, in which clients are encouraged to progressively increase their physical abilities and endurance. As clients become aware of the gains that they have made, their beliefs in their levels of disability may be challenged.
Graded activity involvement, progressive goal setting, and task decomposition strategies were intended as the primary tools to effect reductions in fear of movement or reinjury. Despite program techniques aimed at reducing fear of movement or reinjury, only a modest reduction was obtained in the PGAP+physical therapy group; this reduction was not significantly different from the reduction observed in the physical therapy alone group. It is possible that a more focused approach to fear reduction is required to decrease levels of fear of movement or reinjury, perhaps one involving direct exposure to feared activities.30,33
Reductions in pain severity were not anticipated as a function of participation in PGAP. The intervention tools of PGAP are aimed at increasing activity involvement and reducing disability, not decreasing pain. Indeed, initial increases in activity involvement are more likely to be associated with increases as opposed to decreases in pain. It is noteworthy that in both treatment conditions, return-to-work outcomes were achieved despite only modest decreases in levels of pain. Pain reduction may not be an essential component of successful rehabilitation.15
It is interesting that although PGAP was designed specifically to target psychosocial risk factors for prolonged disability, superior reductions in psychosocial risk factors were obtained only for pain catastrophizing. That is, the functional restoration physical therapy program yielded comparable decreases in perceived disability and fear of movement or reinjury. These results suggest that traditional physical therapy interventions are able to yield significant reductions in psychosocial risk factors. Changes in psychosocial risk factors through physical therapy may emerge secondary to improvements in physical function or may be the direct result of interpersonal processes that exist in the physical therapist-client relationship. More research is needed to systematically address which psychosocial risk factors are reduced through traditional physical therapy interventions and which are not. Such research may provide useful insights into how physical therapy interventions may be modified to augment their impact on psychosocial risk factors.
Psychosocial interventions for pain and disability traditionally have been administered by mental health professionals.16 Although the services of mental health professionals are indispensable in the management of complex problems of disability, such services tend to be solicited only once chronicity has been established. Referral agents are often reluctant to refer clients for psychological services in the early stages of recovery from injury. The stigma associated with mental health services has had a negative impact on the inclusion of psychological services in secondary prevention programs. The preliminary findings from PGAP suggest that it is possible to train rehabilitation professionals in the skills necessary to effectively manage psychosocial barriers to rehabilitation progress. It is important to note that the psychosocial risk factors targeted by PGAP are not mental health disorders and as such do not require intervention by mental health professionals. When there is evidence of clinically significant psychosocial risk factors, such as depression or anxiety, intervention by mental health professionals likely will be required.
The risk factors targeted by the PGAP, namely, pain catastrophizing, fear of movement or reinjury, and perceived disability, represent but a subset of psychosocial variables shown to contribute to prolonged pain-related disability.13,14,37 These variables were chosen as targets of the PGAP on the basis of the availability of sound measurement instruments and their amenability to change through intervention. Several important psychosocial risk factors, such as age, sex, education, and job satisfaction, cannot be modified readily within the context of rehabilitation intervention. The distinction between modifiable and nonmodifiable risk factors is paramount to the development of effective screening and intervention programs aimed at facilitating recovery following debilitating injury.
The development of the PGAP proceeded from the view that successful disability prevention would entail the reestablishment of a structured activity schedule and the reduction of psychological barriers to activity.38 The development of the PGAP also proceeded from the view that a viable secondary prevention program would need to embrace a population health philosophy, allowing for timely access to service by the entire population of people who require the service.39,40 To achieve this end, a community-based model of service delivery was adopted. The use of community-based resources for service delivery, particularly in rural regions, maximizes the accessibility of service and minimizes the inconvenience to the client participating in treatment.39 To date, several hundred front-line rehabilitation professionals have been trained to be PGAP providers, thus ensuring the availability of the service in many regions of Canada and the United States.
A community-based approach to secondary prevention has a higher probability of being sustainable within the budgetary constraints of health care systems and third-party payers. Although multidisciplinary treatment centers have been discussed as the treatment of choice for people with persistent pain disability, these centers are typically situated in large cities, not readily accessible to people living in outlying or rural regions. Furthermore, the cost associated with treatment in multidisciplinary centers is often beyond the means of many third-party payers. Through the establishment of "virtual" multidisciplinary teams at the community-based level, the PGAP holds the promise of making available the essential ingredients of multidisciplinary treatment to people who otherwise would not have access to such services.
One limitation of this study is that a method of objectively assessing adherence to the treatment protocol was not included. Training clinicians to deliver a structured intervention does not ensure that the intervention will be delivered with complete fidelity by all clinicians providing the service. The PGAP training workshops do not include examination for the purposes of certification; therefore, there is no assurance that all clinicians emerge from training with the same level of skill. A number of strategies were used to maximize fidelity to the treatment protocol. First, the PGAP Treatment Manual* provides a detailed description of all intervention strategies used in the program, as well as guidelines for the sequence of their implementation. Second, all clients viewed the PGAP Information Video, which describes the goals and procedures of the intervention program. The videotape also is used as a vehicle for providing important medical and rehabilitation information that is difficult to communicate effectively within the time constraints of typical physician visits. The videotape format is more engaging than text-based information and ensures that the same medical and rehabilitation information is provided to all clients. Finally, clients were provided with a copy of the PGAP Client Workbook. The daily recording format of the Client Workbook is sufficiently structured to maintain consistency in treatment direction but sufficiently open to accommodate various paces of treatment progression. Although the PGAP Client Workbook was not intended as a self-help book, it contains detailed information on the basics of activity planning, structured scheduling, and strategies for overcoming barriers to activity involvement. The PGAP Client Workbook also provides the client with a summary of the central themes of the treatment sessions.
Some degree of caution must be brought to bear in the interpretation of the present findings. Clients were not randomly assigned to treatment conditions; therefore, differences between groups cannot be unambiguously attributed to participation in the PGAP. Although a randomized clinical trial is the ideal design for ascertaining treatment effect, legal and policy constraints presented obstacles to the use of such a design. All clients in the present study were receiving indemnity benefits and were involved in litigation. Difficulties in securing legal consent for participation in an experimental treatment study led to the adoption of the sequential group approach used in the present study. The choice of return to work as the primary outcome variable also presents interpretive difficulties, as does the absence of an objective ascertainment of return-to-work status. People may or may not return to work as a function of factors that may be completely unrelated to functional ability. The absence of follow-up also precludes any conclusions about work retention and the maintenance of treatment gains.
It is also important to emphasize that psychosocial factors are but one domain of barriers to successful reintegration into the workplace. It is becoming clearer that successful interventions for achieving sustainable return to work following injury must address workplace factors as well as risk factors that exist within an individual.41 Factors such as the availability of modified work can play a significant role in maximizing the success of return-to-work interventions.41 In the present study, return to work was a primary objective of treatment, whether clients were in the physical therapy group or the PGAP+physical therapy group. However, detailed information on the availability of modified work options was not available; therefore, such options could not be compared between treatment groups. The combined effects of interventions targeting psychosocial risk factors and workplace barriers remain a topic for future research.
Finally, clients in the PGAP+physical therapy group received 10 hours of intervention beyond what those in the physical therapy alone group received. Therefore, the possibility that the superior treatment outcomes associated with participation in the PGAP may have been attributable to the increased number of intervention hours cannot be ruled out. Confidence in the conclusions drawn about the potential advantages of the PGAP must await replication within a randomized clinical trial.
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| Footnotes |
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The research was approved by the Research Ethics Review Committee of the University of Montreal.
This work was funded by the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council of Canada (funding awarded to Dr Sullivan), and the Sports Medicine Institute of Nova Scotia.
Portions of this research were presented at the Annual Meeting of the Canadian Association of Occupational Therapy; June 26, 2004; Prince Edward Island, Canada.
* PGAP treatment materials can be ordered through the PGAP Web site (www.pdp-pgap.com). 
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