Return to work and chronic pain


ResearchBlogging.org
Again this post is a bit of a reflective one, but also refers to the literature a wee bit too…

I’ve posted before about the importance of support in the workplace for people returning to work…and of the value of work to people living with chronic pain.

How about some of the wider issues that may influence work disability.
First of all, I think it’s important to consider whether pain is getting the blame, when actually a lot of other things are influencing the work disability. Let me be a bit pedantic here for a moment: disability is limitation in ability to perform normal activities; while pain is an unpleasant sensory experience. It’s entirely possible to have pain, even persistent pain, and even pain that is quite intense, and have no disability. It’s also highly possible that pain intensity can be quite low, while disability or limitation in ability to perform normal activities, is quite high. This is why focusing purely on reducing reported pain intensity just doesn’t see the whole picture (or touch the whole problem).

Factors such as fear of harm, kinesiophobia (fear of movement), punishing responses from other people, low mood, high anxiety about managing activities to the standard the person normally expects from him or herself will influence disability.

In return to work situations, factors such as having an unsupportive work environment, having very poor expectations of success, feeling constantly critiqued or monitored, not enjoying the job anyway, along with heavy physical demands and working alone or in shift work – these will all make returning to work difficult.

Papers such as this one written by Covington (2007) published in Neurologic Clinics do try to provide a biopsychosocial model of pain, so that medical practitioners are exposed to the idea that ‘at some point interminable searching for peripheral pathology that can explain the patient’s status becomes futile and possibly even harmful’, and asks them to consider that although ‘these ideas fly in the face of a health care system that is predicated on eliminating symptoms by identifying and correcting underlying tissue
pathology … they are well supported by experimental findings and the results of treatment.’

Covington goes on to review sources of pain, psychosocial issues, environmental factors (with specific attention to psychosocial factors at work), and notes that ‘progression to chronic pain was more dependent on demographic, psychosocial, and occupational factors than on medical pathology’.

Finally in this section, and very importantly, he reviews the influence of what he calls ‘the system’. This refers to many factors, but Covington pays particular attention to the thought that ‘Workers’ compensation systems may be especially toxic, with long delays in diagnosis and treatment, during which time workers must continually prove how sick they are to obtain care they believe they need.
Physicians and attorneys for each side may take polarized and improbable positions. The result is that patients receiving and applying for workers’ compensation benefits seem to fare worse with virtually all interventions than those not so encumbered.’

The situation in New Zealand is quite different from that referred to by Covington, in that the majority of claims made do not take long to establish cover, and there is no requirement to find ‘fault’ or attribute blame or responsibility to any party.
However, systemic delays in receiving treatment, the ongoing provision of income replacement (especially over prolonged periods, and where it pays more than other benefits such as sickness benefits), and poor or ineffective case management still occurs in our relatively enlightened system.

He continues with a comprehensive review of psychological factors as well as psychiatric disorders – a very useful review that is concise and up-to-date.

When he turns his attention to treatment, his turn of phrase is really quite excellent! He states ‘we must challenge the value of, for example, a month of good relief for a condition that lasts many years. And we must ask whether the answer varies depending on whether we are the payer, the clinician, or the parent of the person suffering.’ When considering the outcomes of treatment, he ponders the question of what should be measured. ‘The obvious answer, that pain reduction is the primary outcome variable, may be wrong. For example, a treatment that enabled a person isolated in bed with a pain level of 7 on a scale of 10 to begin playing golf with the same pain level would clearly be beneficial, perhaps more so than one that only improved the level of pain in bed.’

Covington also reviews a large range of treatments appropriate for back pain. Disappointingly, however, he makes minimal mention of the role of the workplace, or working as a key element in treatment. Given the attention he pays to the various factors known to be involved in the development and maintenance of disability associated with pain, and more critically, the value that individuals place on returning to work, it’s disappointing that so little is covered in his review.

So, I thought I’d put in a couple of thoughts that might make sense to you:
1. All return to work programmes need to be individualised
2. Return to work needs to start early on in rehabilitation, and be considered an essential part of it
3. The key people involved in a return to work programme must communicate well – and throughout the entire return to work period
4. Expectations need to be clear, and reviewed on a regular basis, an in an open forum where all key people are available
5. Functional updates need to be provided at regular review points, so that expectations for the level at which the employee needs to be working are clear
6. Communication needs to be not just spoken, but in written form too, so that they can be available for review throughout the period
7. ‘Performance’ issues need to be deferred until the return to work programme has been completed.
8. Questions of ‘motivation’ and ‘attitude’, and of functional ability need to be answered via medical or health care team reports. The programme needs to adjust according to functional ability, rather than any other factor influence changes in hours or duties. Functional ability can only be assessed by the health care team, and is not part of manager’s role.
9. It’s really important that the individual returning to work has the opportunity to have normal holidays, and to continue to balance outside of paid work responsibilities with paid work responsibilities. This means the person managing the return to work programme should be able to assess the demands overall, rather than just the workplace demands.
10. Progress, any progress, needs to be celebrated to ensure the person returning to work feels like his or her efforts are being recognised and appreciated.

There, that’s my tuppenceworth.

If you’ve been enjoying these posts, want to continue to read them, and don’t want to miss another exciting instalment – don’t forget to use the RSS feed above, or bookmark this page and come on back. Comments are always welcome, and I respond to each one!

COVINGTON, E. (2007). Chronic Pain Management in Spine Disorders. Neurologic Clinics, 25(2), 539-566. DOI: 10.1016/j.ncl.2007.01.009

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