The gap between pain management – and returning to work


One of the most satisfying experiences I have in my job is seeing someone who has been off work for ages finally return to work.  It’s like seeing the person open up and bloom again. 

I often see people who have been off work for several years – most of them don’t have jobs to return to, and most of them have experienced a couple of attempts to return to work that have, for some reason or another, failed.  Often pain is given the blame for this, and the remedy is thought to be ‘develop pain management skills’ – and I guess in part that’s true.  But not completely.

There is a difference between using pain management skills at home, where for the most part, activities can be picked up and put down as needed, and at work where other demands are present.  There’s an element of discretion about when and how things are done at home.  People can, if they want to, take it a bit quietly on days when their pain is worse, and fit things in more readily on days when they’re feeling better.  Not so at work!  At work we have to do things to fit into an external timetable – deadlines exist! There are jobs we have to do that are not so forgiving – we have to do them in a certain way, or at a certain time whether we’re feeling great or not.

And therein lies the one of the reasons I think there is a gap between pain management and returning to work.  There’s a whole lot more riding on being able to keep going at work.

Let’s take a case like Allan.  Allan has been off work for three years now.  Before his accident he’d been working for two years as a night supervisor in a food production factory, and before that he’d been the primary caregiver for his wee girl who is now 8 years old.  And before that he’d been a professional athlete.

When he hurt his back he thought it would resolve quickly – but after a series of unsuccessful nerve blocks attempting to ‘find and obliterate the cause’ of his pain, and after two multidisciplinary physical rehabilitation programmes, he finally had to accept that his back pain wasn’t going to just go away.

He lost his job after he tried to return to work for about six weeks on a graduated return to work programme.  Allan had an occupational therapist visit his work place and was advised that he could do X, Y and Z tasks – but this wasn’t practical given the nature of the work, not even as a supernumerary.  Like many employers, his employer didn’t have any ‘selected duties’, and needed to employ someone else to cover Allan’s shift, and eventually told Allan that he couldn’t come back to work until he could manage certain tasks.  Allan’s employer terminated his employment after both of them decided that he wasn’t going to make it back in the next two or three months.

Allan was finally referred for pain management, and attended a three week interdisciplinary pain management programme.  He struggled with many of the concepts, particularly activity regulation (pacing was his least favourite word!), and he experienced panic when trying to use relaxation techniques.  He had been using a walking stick, and although he tried to stop using it during the programme, shortly afterwards he fell, and the stick became an ongoing fixture.  Allan was trying very hard to learn how to do things differently – but needed another twelve week programme of pain management using a cognitive behavioural approach before he could consistently maintain even his normal home activities.

Work was out of the question initially.  Allan’s confidence was shot – he knew he could do ‘some’ pain management, but much of what he did involved minimising fluctuations in pain, and when he did have an increase in pain he’d either push himself very hard to ‘get the job done’, or he’d use medications or rest to get through the tough patch.

Let’s make one thing clear, Allan really wanted to go back to work.  He told me he felt worthless, not a ‘real man’ because he wasn’t providing for his family and he felt trapped in his own home.  His confidence though, was at rock bottom.

The specific issues he saw as obstacles to going back to work were:

  1. Managing his pain without resorting to prn medication
  2. Coping with the side effects of his medication
  3. Confidence to tell an employer that he would be reliable
  4. Confidence he could be reliable and work consistently
  5. Confidence to be assertive and let others know what he could and could not do
  6. Worry that he would increase his pain and the other important aspects of his life would be under strain
  7. Feeling out of touch with the technology and specific skills in the workplace
  8. Not knowing how to present himself positively in a job interview – how would he answer those tricky questions about the time he’s had off work and about his health?
  9. Knowing his own functional abilities – he knew what he couldn’t do, but not what he could rely on doing consistently
  10. Identifying specific job options now that he couldn’t work the way he used to

You can see that the gap is not just about job seeking skills, although that’s certainly a part of it, but it’s also about how to use his skills to be reliable at work – to experience pain but persist and be consistent with his output.

How confusing it would be for Allan to be seen by a vocational provider who had a limited knowledge of chronic pain management.  How scary would it be for Allan to start to return to work after having failed in the past.  How demeaning to feel inadequate about his own skills and lack confidence to ask for help not only with every day work technology, but also with his pain (after all, that’s what lead to his loss of job early on).

The literature on returning to work after illness or injury is clear.  It’s not simply about coping with pain, it’s not simply about coping with disability, it’s not just about finding work, it’s not just about the person with the pain problem.  Vocational management is anything that helps a person remain at work or return to work – and it includes all of us on the team, including the employer.

For the most extensive review on vocational management that has been published recently, go to here for the executive summary of the report into vocational rehabilitation ‘What works for Whom’ by Waddell, Burton & Kendall (2008). 

Go here for a great set of downloadable documents about work and health (Working for Health, UK government)

And of course, RTW Matters  (Australasian) and ACC (New Zealand) Return to Work search page

10 comments

  1. Allan seems like he is in a tough place. With scenario’s like this I’m often reminded of the rather depressing statistics on likelihood of returning to work after so long away from the workplace.

    As part of a pain management team working with lots of people who have been away from work for prolonged periods how realistic is it to expect an outcome that involves return to regular paid employment?

    I appreciate this appears a somewhat pessimistic outlook, but I know that as a clinician (‘the expert’) I’m quite uncertain at onset as to what is realistic for an individual. i like to try and give my patients an idea of what a ‘good outcome’ would be from investing time and energy into Pain Management, but feel I’m only confident to talk around pre-vocational goals.

    What gives you an idea of there likely vocational / functional potential?

    1. The main predictor is always ‘Do you think you will return to work?’ – if the answer is ‘yes’ then they probably will – no matter what kind of work they want to go back to! If they don’t think they will, I think identifying specific obstacles (as identified by the individual) and using CBT and problem solving strategies will do more than any physical fitness training programme.

      Of course helping people remain at work in the first place is the best option – but many people stop working for different reasons – perhaps their GP has inadvertently suggested that some time away from work would be good, maybe the employer can’t hold the job open any more because of financial or productivity reasons, maybe the family suggest that work is increasing the person’s pain etc etc.

      We can’t address all of these reasons in a one-stop-shop approach (eg PGAP, ‘remain at work’) because the factors influencing work disability are many – and at the moment we don’t have a systematic theory base or assessment process for work disability.

      It’s assumed that work disability arises directly from pain, injury, impairment, functional loss – but in fact it’s as likely to be the individual’s attitude, their colleague’s attitudes, self efficacy, socio-economic stressors, transport and so on. A thorough assessment of obstacles to returning to work should identify these, then a range of interventions apply to get around them.
      IMHO of course!

  2. Thanks for this – your first paragraph in particular brings a wry smile to my face. As a physiotherapist I believe I understand the role of CBT and the multifactorial presentation of someone absent of work. And I agree that a physical fitness programme (particularly in isolation) isn’t going to address many (or any) of the identified barriers.

    So…..

    As a clinician interested primarily in a patients movement what can I measure, observe, study, influence in order to establish if what I am doing is making a difference? I know this moves away from the original blog (and please feel free to therefore ignore!) but it’s something I struggle with most weeks. I know you are not one for defining the physio’s ‘role’, or anyone elses in an IDT, but ultimately there are certain strengths to our profession that we need to stay close to in order to give the patient the best input – eg I can use CBT and discuss patients beliefs around their pain, but perhaps not as effectively as a psychologist.

    If I am not trying to help the person get fitter, stronger, bendier etc (and certainly there doesn’t appear to be much evidence to support this approach in isolation) then wouldn’t a psychologist with a behavioural approach do this better? Or am I just a cheap alternative?!

    1. Now you caught me grinning with that comment! I think if you’ve ever trained a dog or kid you’ll know that the best time to give them feedback and check in with what’s really going on in said individual’s head, you’ll know that the best time to do it is when the person is engaged in the act of DOING it! So I think PT and OT are placed well to provide that feedback that people need in the midst of activity…it’s when people are engaged in activities that they do the thinking, so the automatic thoughts are really accessible and able to be challenged.
      Not to mention that if behaviour doesn’t change then all the talking (or other input like medications or pain relief) in the world is not worth doing.
      So, in a nutshell – PT’s are accepted for their role in helping people DO things. OT’s similarly. So they have ‘face validity’ for working with people as they engage in activities they may have avoided or overdone. At the same time, OT and PT has a definite role in eliciting and responding to unhelpful thinking patterns and carrying out ‘behavioural experiments’ to test the reality of the beliefs that people develop.
      In situ. Not in a clinic!
      What do you think?!

  3. I think it’s an exciting area to work in, and far more fun than a lot of other clinical areas I’ve worked in, but I still can’t put my finger on what exactly it is that I’m doing!

    I know what a good outcome looks like, and I definitely see the huge overlaps between different professions, but i still cant measure the changes I am (or am not) making.

    Evidence now challenges the notion of ‘deactivation’ as a given with a fear avoidant patient at least in a generic ‘wholebody’ sense, and i would agree with that anecdotally. i want to be able to PROVE that I am making a difference (for my own sanity, as much as that of any quality plan) and feel that is very difficult to do within a IDT model and BPSframework.

    Reading that back over, perhaps I’m just not a team player, but I don’t think that’s true, i just want to make sure I’m giving best value to my team, and as a clinician (and especially a physio) I want to put an objective mark against what I am doing.

    I wonder if this is more philosophy than anything else – and in which case I am definitely out of my depth!

    1. Lots of points here Mary!
      – ‘what you’re doing’ is probably somewhat indefinable. That possibly reflects the models that you and I were educated in professionally – after all, we were taught it’s about what WE do that counts. In this business, however, it’s what the person does that makes the difference rather than anything specific that we may do. Simply being in the right place at the right time can be enough!
      – in terms of your own contribution and whether it’s making a difference, again I think it’s about the synergy between the whole team and the person rather than the specific of what each individual offers. I wonder if we looked at it in terms of a process of change rather than a distinct episode of care we might get a better view of how things occur. That also probably means that we may not be able to differentiate the element that any single team participant makes, but without them all the whole wouldn’t occur. Does that make sense?!
      – Deactivation certainly occurs, but deconditioning (ie low cardiovascular fitness) probably doesn’t. Deactivation to me is about reduced engagement in the activities that matter to the person. And I do think it occurs in different ways with different people – some will have an overall low level of participation, while others will have a saw-toothed pattern of high and low levels of engagement (boom and bust) – what may matter more is consistency of engagement.
      – to demonstrate that you’re making a difference may mean looking at different outputs and outcomes from what we’re used to measuring. I’m not sure we routinely measure quality of life, or engagement in preferred activities etc I feel best if I know that the person and I have developed a mutual understanding of what is happening now for them to be in the place they’re in, and what they want to achieve in life – and the ‘next best step’ forward for them.
      – the objective mark might be individualised goals for each patient/person – who in the team actually ‘does the work’ may be indefinable. Is it the medication, the explanation, the goal setting, the encouragement, the progression or something else that someone in the team has contributed?

      Can you put your hand on your heart and say you’ve done what has an evidence base, that you’ve worked collaboratively with the team and the person, and the person has taken their own ‘next best step’ – and if you can, then you’ve done a quality job!
      **stepping off soapbox right now and huddling in a corner!!**

      1. Thanks for that. No soap box seen (or no more than usual!) and yes it does make sense!
        I’m grateful for your thoughts and perspective, and bite my tongue with the ‘yes, buts’ that spring up. Your more recent blogs address some of those.

        I just know that deep down I need to have a score out of ten to make me happy!

  4. Not at all – I find your blogs a great resource, and they frequently make me stop to think about why and how I am practising. Always constructive (apart from the funnies!).

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