The Progressive Goal Attainment Program (PGAP) An evidence-based treatment program targeting psychosocial barriers to recovery and rehabilitation for clients suffering from debilitating health or mental health conditions. The PGAP® is the most researched standardized intervention for reducing disability associated with a wide range of debilitating health and mental health conditions. The PGAP is an empirically supported intervention that has been shown to reduce disability and contribute to successful return-to-work in individuals with back pain, whiplash, fibromyalgia, cancer, depression, and PTSD. The primary goal of the PGAP is to reduce psychosocial barriers to rehabilitation progress. This goal is achieved through the use of evidence-based techniques specifically designed to target psychosocial risk factors. The PGAP includes: -Cognitive Behavioural techniques such as thought monitoring and reappraisal -Behavioural techniques such as graded exposure, goal setting -Relational techniques such as disclosure and validation The PGAP would be considered a CBT intervention, with a primary focus on behaviour change. One of the advantages of the PGAP is that it can be offered by clinicians from a variety of rehabilitation disciplines, such as occupational therapy, physical therapy, kinesiology, vocational rehabilitation, nursing, social work and psychology. Traditionally, CBT interventions have been provided primarily by clinicians with a background in mental health. The wider range of disciplines able to provide the PGAP greatly increases the accessibility of the program. The standardization of the PGAP is an additional strength. The PGAP is standardized such that all PGAP providers follow a specific set of intervention guidelines designed to have the greatest impact on reducing the client’s psychosocial risk profile. In the PGAP, CBT techniques have been adapted such that ‘disability reduction’ is the central objective of treatment as opposed to symptom management. Finally, the evidence base speaks clearly in favour of the PGAP, particularly as it pertains to return-to-work outcomes. In all clinical trials of the PGAP, return to work has been the primary outcome variable. “PGAP” is a registered trademark of PDP Program Inc. | ® Registered trademark of PDP Program Inc. | ™ Trademark PDP Program Inc. | © COPYRIGHT 2015 PDP Program Inc. University Centre for Research on Pain and Disability 5595 Fenwick Street, Suite 314 Halifax, Nova Scotia, Canada B3H 4M2 Tel: (902) 471 7864, Fax: (902) 421 1292 www.pgapworks.com E-mail: info@PGAPworks.com “ PGAP is a standardized ten (10)-week intervention program whose goal is to maximize the rate of progress in rehabilitation and reduce the probability of the development of chronicity. PGAP is a suitable intervention for individuals with pain-related limitations who are in need of an active mobilization intervention and for whom psycho-social issues such as fear of re-injury or pessimistic outlook are considered to be important contributors to disability. PGAP focuses on disability reduction as opposed to pain reduction. WHEN TO REFER: From 6 weeks post injury onward. Remember that an important factor in successful rehabilitation outcomes is early intervention. CAN PARTICIPATION IN PGAP OCCUR AT THE SAME TIME AS OTHER TREATMENTS ARE OCCURRING? Yes; in fact, PGAP will increase the successful treatment outcomes. DOES PGAP ASSIST CLIENTS IN RETURNING TO WORK? Yes; PGAP’S return to work outcomes are 65-75%. PGAP is suitable for clients who are suffering from a persistent pain condition, and for whom pain symptoms and psychosocial factors are significant barriers to rehabilitation progress. PGAP has produced positive results for individuals suffering from chronic musculoskeletal conditions, whiplash, fibromyalgia, osteoarthritis and rheumatoid arthritis. 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. Sullivan et al. Physical Therapy volume 86 number 1, January 2006 Each year, hundreds of thousands of people become disabled due to injury or illness. Whether addressed in relation to personal, social or health care costs, chronic disability remains one of the most expensive health problems facing modern society. PGAP® was designed to prevent or reduce the severity of disability that can arise following injury or illness. The primary goals of PGAP are to reduce psychosocial barriers to rehabilitation progress, promote re-integration into life-role activities, increase quality of life, and facilitate return-to-work. These goals are achieved through targeted treatment of psychosocial risk factors, structured activity scheduling, graded-activity involvement, goal-setting, problem-solving, and motivational enhancement. The treatment objectives of the PGAP® proceed from the view that return to work is the highest level of independence that can be offered to someone with a debilitating health or mental health condition. The PGAP® is currently the most researched risk-targeted intervention designed to reduce disability associated with a wide range of debilitating health and mental health conditions. The PGAP® is considered to be one of the most cost effective approaches for reducing disability and fostering return to work in individuals who suffer from a wide range of debilitating health and mental health conditions. The PGAP® has been shown to be effective in facilitating return to work in individuals who have sustained musculoskeletal injuries, individuals with chronic low back pain and fibromyalgia, as well as individual with debilitating mental health conditions such as depression and post-traumatic stress disorder. Referral Susan is a 40 year old woman who was referred to occupational therapy for the PGAP program. Susan had been diagnosed with a chronic incurable and untreatable kidney disease. Other medical issues included tachycardia and her heart skipping a beat. The cardiologist who she saw recommended that she take time away from work because of the stress associated with her job as a Program Planner for the Ministry of the Attorney General. Susan had been off work for 15 months in order to address her disease process. The rehab therapist had documented that Susan was showing signs of depression, cognitive issues related to memory, attention and concentration and becomes easily frustrated when discussing her future plans. The rehab therapist referred Susan for Occupational Therapy in order to address goal setting, reduce depressive symptoms, increase her tolerance for performing her ADL tasks and to address her cognitive issues through use of the daily log. OT steps: If required, clarifying the referral and the referral goals with the referring rehabilitation therapist. Assessment with Susan-intake assessment and include goal planning. Completion of the questionnaires in order to address pain (McGill Pain Questionnaire), fear-fatigue (FFQ-Chr), assess level of perceived disability (GPDI), assess depressive symptom severity (PHQ9), assess persons thoughts with regards to activity (TSK), and assess the thoughts and feelings that the person has related to pain (PCS). Provide feedback to the referral source by way of an initial assessment report. If the entire program has been approved, the client is contacted and provided with the date for the subsequent appointment. If not, than the therapist waits to hear from the referral source prior to scheduling the client. Once approved, the client is provided with a work book which has a log book in it as well as work sheets. The focus of therapy is based upon the client’s performance and their participation with completing the daily schedule sheets. Discussion regarding facilitation of short and long term goals is completed. Activation through the implementation of a daily walking program is also discussed and the client is assisted to brain storm strategies that will allow her to achieve her goals. Discontinued activities are also addressed and energy conservation strategies are provided in order to ensure that a set-back does not occur. Mid-treatment (5th session)- The client is provided with the questionnaires to complete again and the results are compared to the initial results. The results are also analyzed and provided to the referral source by way of a report. Issues identified by the questionnaires that are still outstanding will be addressed as well as return to work. Strategies, return to work plan and accommodations maybe addressed at this stage as well. Discharge (10th session)-the questionnaires are repeated again prior to discharge. At this point, issues should ideally be resolved and a firm return to work plan should be in place. The questionnaires are again repeated and compared to the initial results. A discharge report is completed and sent to the referring party. If there continues to be outstanding issues that mildly interfere with the return to work plan, the Occupational Therapist may recommend additional Occupational Therapy sessions in order to address those issues identified. In Susan’s case, she was provided with instruction on how to use the log book. She found that the log book was too difficult for her as that would be her third appointment book. She was currently using one for her medical appointments and another one to keep track of her family’s activities. It was recommended that she merge all of those books into one and use her smart phone’s agenda as the primary one as she always had her phone. This worked very well and she was happy with this recommendation. Susan also had a lot of appointments. She was encouraged to evaluate the appointments that she was attending and determine whether they were required at this time. She was able to cut back on most of them freeing up her time and not making herself so stressed. With that Susan was also advised to be proactive when booking her appointments. She was advised to look at her schedule and determine whether the time given was convenient for her based on the other things that she had to do. She was encouraged to ask for alternate times for her appointments instead of rushing around arriving late and feeling out of control. This helped to decrease her irritability and provided her with that sense of control over her medical issues. As soon as the use only the on The first step is to identify the life-role activities that have been discontinued due to pain or illness symptoms. Proceeding from a list of pre-injury or pre-illness life-role activities, the pgap provider will assist the client in developing activity goals. The focus on life-role activities is critical to the success of the pgap. Life role activities are the basis of an individual’s identity. The discontinuation of life-role activities impacts negatively on an individual’s identity. The discontinuation of life role activities impacts negatively on an individuals sense of self and augments the probability that the individual with develop or exacerbate symptoms of mental health problems like depression or anxiety. Role relevant activities will always be more successful as they are more likely to be perceived by the client as meaningful or pertinent to his or her own life. Goal setting will be an important component of techniques used to alter the individuals disability beliefs. SMART goals. Goals setting will also progressively increase the client’s participation in life role activities, ultimately creating a reality that is incompatible with disability beliefs. Disability beliefs are never challenged directly. Indirect strategies will be used in the pgap. Efforts to change beliefs directly in order to influence behaviour are typically unsuccessful. The goal is not to eradicate the individual’s disability. Rather the objective is to modify an individual’s appraisal of his or her abilities, such that the individual who believed he or she could not overcome the challenges associated with his or her condition, now believes that he or she is able to overcome those challenges.
