If there is one aspect of chronic pain management that has received more attention than returning to work, I don’t know it! In 1995 when I started working at my current workplace, work was almost a dirty word. I was accused at one time of being a ‘Siberian workcamp’ Commandante because some people thought it was cruel to ‘force’ people with chronic pain into the workplace. Thankfully this attitude has changed over the years, and most people recognise that working when you have chronic pain, while difficult, is achievable and good for health. At the same time, returning to work with pain has never been especially easy and there are numerous issues to work through.
Today is the first day I will discuss the practical aspects of returning to work with the current group of people participating in the three week pain management programme. We’ve already discussed what work is (something to organise your day, social role, productive activity, source of income and self esteem, identity, social contact – that list goes on!), and each participant has looked at how important returning to work or being at work is, and how confident each individual is to achieve that goal. Each person has looked at the ‘stages of change’ cycle (Prochaska and diClemente) and identified where he or she sits on that model.
The findings in this group are pretty typical of most groups that I’ve worked with. Most people indicate that work, however they conceive it, is pretty high in importance. At the same time, most people also indicate that their confidence to achieve their goals in work is lower than the importance – and some cannot even rate their confidence above 0/10. Many of the participants indicate that they’re ambivalent about returning to work – probably in the ‘contemplation’ or ‘preparation’ stage in the stages of change model.
What are the issues?
Amongst the issues, one is prime: the ability to attend work consistently, to be reliable as an employee. This is a real challenge for many of the participants in this programme, and I don’t see that they are very different from most people with long-standing chronic pain. Until being in the programme, these patients have often relied on pain intensity as their guide to activity level – and this has often lead to a saw-tooth pattern of ‘boom and bust’, or a gradual reduction in activity level to the point where they are quite deactivated.
Another critical issue is the difficulty talking about their pain and any functional limitations – or even the ‘work-arounds’ that people have developed to manage their pain – with employers. The belief is that if chronic pain is mentioned, ‘no employer will have me’.
And yet another issue is the difficulty translating generic pain management strategies into the workplace. Things like activity management (aka ‘pacing’) or regular stretch breaks or relaxation are not thought to be acceptable in a workplace, and communicating about the value of doing these things is, as I’ve mentioned above, incredibly difficult.
This is an area of pain management that I think has been omitted. In the rush to ‘get people fit enough’ to return to work, or to ensure they have ‘pain management’ often delivered in a clinic setting, I think the core problem has been either ignored or glossed over. And the core problem IMHO is that people with chronic pain need to feel confident that they will succeed if they attempt to return to work.
To feel confident, people need to have their individual concerns addressed, and to develop strategies to help them work through the challenges of applying pain management in the work environment. Because, like it or not, the work environment is different from a clinic, the home, or even within a family. We ignore this at our peril.
I am not an advocate of dividing the delivery of pain management and vocational management. The two need to go hand-in-hand. So often return to work is seen as separated from healthcare. It’s not – it’s as integral to people’s wellbeing as being able to use the toilet or have a bath, to be able to walk to the shops, to manage the household tasks, or to budget and do the grocery shopping. At the same time as we consider functional movements, we also must consider work activities.
This paper by Cost-Black, Loisel, Anema and Pransky elaborates on the current state of play with respect to helping people return to work. I’ll be discussing more of this tomorrow – and the day after! But, I do believe that this paper omits a crucial aspect of returning to work, and that is the issue of self efficacy for returning to work and managing pain. The ‘how’ of returning to work is more than accessing selected duties, or becoming fit enough, or even coordinating the process with all the various providers involved in the process. It is all of these things, but if we fail to help the people we are trying to assist to feel more confident, it is unlikely to work.
And we face enormous challenges in this work – economy, conflicting advice from various providers, a sense of urgency to ‘move quickly’ by insurers (often too soon and ill-coordinated), clumsy administrative systems, lengthy time off work (in this group of people one person has had 30 years away from the paid workforce), and loads of anxiety and fear of failing.
I don’t see the problem of return to work as one of motivation on the part of the individual – motivation is often about how important an activity is, and how confident the person is that he or she can do it. At least in the people that I see, it’s the latter that creates the resistance to move on. Working can be SO important that to fail would be devastating, so people just don’t attempt it. This is maybe what we need to focus on.
Costa-Black, K., Loisel, P., Anema, J., & Pransky, G. (2010). Back pain and work Best Practice & Research Clinical Rheumatology, 24 (2), 227-240 DOI: 10.1016/j.berh.2009.11.007