There are many people who have completed a pain management programme, know how to do things like breathing, working to quota (pacing), relaxation strategies, distraction and exercise – but when they are asked about returning to work say ‘I can do these things at home, but not at work’.
I have many books on pain management – self-paced learning books, books on cognitive therapy for pain management, academic texts on pain management methods and concepts. What I don’t yet have is a book dedicated to ‘how to apply pain management in the workplace’.
Why should it be different? Well I think for one thing, it’s about the demand characteristics at work alongside the power differential many of the people I work with experience. At home it’s entirely possible to decide ‘I can leave that for a while and come back to it’ – this is often called pacing, although I’m not sure that it really is. While it works at home, where many things can be carried out in ‘chunks’, it’s a very different situation in, for example, a production line, or a plumbing business, or a lawyers office. Deadlines rules in each of these situations – and the individual has little control over what needs to be done, and more importantly, when it can be done.
The power differential at work is really evident for semi-skilled or unskilled workers where they are employed to get a job done, done quickly under the supervision or direction of a skilled worker. For many people this has been their whole working life, and despite years of experience, in the workplace they are required to work as directed. This work is characterised by ‘high demand, low control’ – and it’s common. The demands are to work fast, don’t argue – and many employees feel they have no choices and no power. Their opinion doesn’t count – or they agree that ‘get the job done’ is just the way it’s done at work.
If an individual has only developed pain management strategies that focus on avoiding or controlling pain (eg relaxation and pacing), and the ability to tolerate variations in pain intensity hasn’t fully been developed, it makes sense that it’s going to be difficult to cope with situations where activities need to be maintained despite pain fluctuations.
What are the implications of this? Is there a need for ‘targeted’ pain management to specifically address pain management at work?
I think so – and I think part of why it hasn’t been recognised and developed is that many clinicians are fearful of provoking a flare-up in their clients, perhaps afraid of ‘pushing’ their clients, and/or are themselves unconvinced that it’s possible for people to cope with increases in pain.
Another part of the problem? To date, pain management has been fairly generic – one size fits all. In fact, it’s only been recently that we have become aware that people experiencing chronic pain are not a homogenous ‘chronic pain group’ – they have quite distinct subtypes, even though refining what those subtypes are is yet to be complete!
If we have a complex model of pain, which the biopsychosocial model is, we are likely to have quite complex hypotheses about the factors maintaining disability. This means we need to have tailored approaches to pain management to suit the individual’s needs.
Here are some suggestions for developing pain management for work:
Suggesting to someone, even inadvertently, that they can ‘push through’ the pain won’t work – after all, they have probably been told this before, tried it, had a flare-up, and learned that it’s not pleasant. Even if they are using a ‘boom and bust’ pattern, they are usually fully aware that this isn’t the most effective way of managing.
What might work? Identifying what is going through their mind when they start to experience increased pain, and establishing a way to work through that thought. This might mean problem solving, reality testing, using the ‘good’ and ‘not so good’ decisional balance, and perhaps even developing a graded hierarchy of activities so the person can develop confidence that the world won’t end because their pain has increased.
Not allowing the person to experience a flare-up during therapy, not expressing confidence in their ability to cope, not being specific about the skills they have used. Measuring ‘success’ in terms of pain intensity or avoiding a flare-up sends the message to the person that the primary aim of therapy is to avoid pain, and that a flare-up means they have failed.
What might work more effectively? Working through pain fluctuations using coping strategies – not, as I’ve mentioned above, telling the person to ‘work through’ the pain! Find out what’s going through the person’s mind, help them see that although it’s an unpleasant experience, it can be tolerated even when it increases from baseline. Success needs to be measured in terms of two things:
- Did they use the skills they’ve been developing?
- Did they manage to get the task they were working on done?
Flare-ups are inevitable: minimsing flare-ups is not necessarily a helpful goal. Developing confidence in the skills they are learning, learning to use them consistently – now that is a helpful goal.
Developing only passive coping skills (yes, I think relaxation and pacing can, at times, be passive coping!). These skills are easily recognised and named (therefore often recalled), they can reduce pain intensity and physiological arousal (so reduce distress) – but in many cases, especially the longer forms of relaxation like Jacobsen/progressive relaxation, can’t be carried out readily in a workplace. Where do you think a builder is going to find to lie down and spend half an hour relaxing?! More importantly, they can’t readily be used while the person is carrying out activities. Yes, even pacing means altering the time spent on an activity, which in many workplaces just can’t happen (think of a meatworks production line, a paintbrush assembling factory, a bakery in full swing).
What might help? Developing other skills such as mindfulness, positive coping statements, body scans and ‘take 5s’, differential relaxation, and so on. Helping people think about, and practice, applying their skills during activity – even during exercise sessions, while doing the grocery shopping, when driving. This requires specific problem solving to help the person bring the skills to mind, and begin to integrate into their everyday activities. It doesn’t seem to be enough to simply mention that the skills can be applied in these situations, being specific about when and how to use them seems to be important (as well as monitoring and reinforcing their use before the person is discharged).
Divorcing vocational rehabilitation and pain management from each other will not work. It especially will not work if a person hasn’t developed robust skills that can and are applied consistently. And it won’t work if vocational rehabilitation is carried out before pain management skills are addressed.
Although they are distinct phases for reducing disability, pain management strategies need to be supported in the challenging context of the workplace. Practitioners who help an individual during the return to work phase need to be familiar with the factors that are prevalent in a workplace – attitudes, beliefs, controls and so on – and be prepared to be respectful of the individual’s concerns then help them address the concerns. IMHO this is a specialist role, you really need to be someone who has been to workplaces, knows the literature on occupational/workplace culture, and is thoroughly versed in cognitive behavioural pain management (not simply vocational therapy, not simply pain management).
Generalising pain management skills into the ‘real’ world involves a whole raft of skills that I am not sure have been thoroughly researched or analysed – yet. Certain professions have an advantage in this, and yes, I think occupational therapists are well-suited to the task – IF and only IF they have developed skills in cognitive behavioural pain management. A challenge to consider huh?