More pain sites over time = greater risk of work disability

It struck me today, as I spent a little time with two people who have been returned to Pain Management Centre for a review of their progress, that something we don’t do very well is help people distinguish between an acute or new problem and what might be a flare-up of the old chronic problem. And by ‘we’ I mean all health providers.

Ok, so that the problem is there is not really so surprising – after all, helping clinicians work out that chronic pain doesn’t respond to acute pain management is quite a change of focus (from short-term cure to long-term management), but I guess I hadn’t really thought through how to help people deal with new pain problems as they arise.

Let me illustrate what I mean. Gary (not his real name, and other details are also disguised to protect privacy) has returned to work after nearly five years since his injury. The original injury was a crush injury to his foot and he was left with a complex regional pain syndrome. For at least the first three years he believed, because he was told by surgeons, that surgery would ‘fix’ the problem – and it was a case of him simply waiting for the surgeons to decide what the best surgical option would be. Unfortunately, his foot pain didn’t respond to surgery and he’s ended up with an arthrodesed ankle and chronic pain. The pain is not resolving – but he is feeling quite confident about how to manage it after completing a pain management programme and with some individual input to help with his mood and return to work planning.

Unfortunately, he’s hurt his knee now. He came off a ladder and landed awkwardly on his knee about five months ago. Initially his GP suggested that he simply wait for it to settle, but Gary had learned from his foot problem that it’s better to get on with moving it – and he didn’t want to risk his return to work planning. So he got a knee brace, had some physiotherapy, and carried on. After about two months, he saw a surgeon who said his knee didn’t need surgery right now although it was a little ‘sloppy’ in the ligaments, so Gary should keep on with his exercises, be ‘careful’ and wait for a while before considering a surgical review.

Now the point of this is that Gary didn’t know whether his knee pain was something he should worry about, or whether it was something he should treat as he does his foot pain – using pain management strategies. I’m picking that he found it hard to know whether he was going to do further damage by using his knee normally (ie what are the risks from using a ‘sloppy’ knee), given that he knows that his foot pain is no longer related to damage.

It seems likely that if someone has a central sensitisation problem, for example, they develop a CRPS, the chance of their nervous system responding similarly to another trauma is quite high. A similar case might be someone who has fibromyalgia, with widespread body pain, and a sensitive nervous system – a person in this situation may also be quite likely to take a long time for post-traumatic aches and pains to settle down.

BUT I don’t think I routinely mention this to people I’ve worked with.

What might the implications be for someone who has a chronic pain problem, and then develops a new, acute pain? Well, given the difficulty we find with treatment providers switching from acute management to chronic management, I think the same old problems are likely to rise. Lots of investigations to work out why the pain isn’t settling as it ‘should’ (and as it would if there wasn’t an underlying central nervous system sensitivity), and lots of passive treatments to reduce the pain – but if the pain isn’t directly related to the acute tissue disruption, then it’s unlikely to respond to these treatments – and I’m sure yet more investigations and treatments are tried.

Let’s take a step back and look at whether there are differences between acute management and chronic management.

  1. In acute management, for the majority of problems (and I’m racking my brain to think of one actually) we ask people to start doing things normally as soon as possible – pain doesn’t have to be completely gone before we encourage people to get moving.  In chronic pain management, we ask people to do things despite pain.
  2. In acute management, we encourage a ‘start low and go slow’ approach to increasing activity.  We do the same in chronic pain management.
  3. In chronic pain management, we recognise the pain is a stressor, and that there is a relationship between having pain and physiological arousal.  In acute pain, the same phenomenon occurs.

So is the main difference is in determining the end goal of treatment? – in acute pain management, we are relatively certain that pain will eventually subside.  In chronic pain management, we are relatively sure that pain will persist.    So we are really looking in both cases at encouraging a focus on function – but in acute pain, the ‘end point’ is often reaching when the pain reduces.

I wonder whether we need to focus on using the same cognitive behavioural approach to self managing many acute problems that we use for chronic pain. And maybe we should consider whether we need to advise people who have chronic pain of their susceptibility to pain in other parts of their body and manage that pain accordingly.  It might just save an awful lot of money on treatments for ‘acute on chronic’ low back pain (just what is that, really?), or for ‘acute back pain’ when the low back pain has never really gone away…

I included this study from Norway, because I think it illustrates something that we observe very often.  I call it ‘recycling’, but other people call it ‘frequent fliers’ – people who have pain in more than one part of their body are more likely, at least in this study, to eventually move onto Disability payments, and stop work.

I don’t think this is simply the effect of a person having trouble coping with the additional burden of pain – I think it’s much more about a systems problem.  If the participants in this study engage with the health system each time they develop a new pain site, the chance of their encountering another provider who follows an acute pain management model (with all that can entail when problems fail to resolve) is pretty high. And with each new encounter with a health provider challenging their own belief in their ability to self manage, these people have a real struggle to remain confident that they can do things despite their various pain.

For this week I’m going to focus on follow-up and effective use of the health care system – care to join me on this journey?  If you do, you can subscribe using the RSS feed link above, or you can just bookmark this page and come back.  I do write most days during the week, and I do love comments.  If you don’t want people to read your comments, you can send them to me via the ‘About’ page which gets sent directly to my email, otherwise they’ll appear on here for others to respond to.  I’m looking forward to hearing from you!

Kamaleri, Y., Natvig, B., Ihlebaek, C., & Bruusgaard, D. (2009). Does the number of musculoskeletal pain sites predict work disability? A 14-year prospective study European Journal of Pain, 13 (4), 426-430 DOI: 10.1016/j.ejpain.2008.05.009

Returning to work is a complex business

There have been many studies looking at factors that can be used to predict whether a person will return to work after developing pain. Many, quite naturally, look at factors relevant to acute and subacute pain problems, aiming to reduce the number of people eventually progressing to longterm disability. Some people will slip through these interventions – for many reasons – and the news for returning to work is not good for those who do have extended periods of time away from the workforce.

The factors that might precipitate stopping work in the acute or subacute stages may not be the same as those involved in maintaining longterm disability. For example, it’s well known now that pain-related fear and avoidance can influence people’s initial disability (see Prkachin, Schultz,& Hughes, 2007), but studies looking at whether interventions to reduce avoidance behaviour through psychosocial methods haven’t been entirely positive (e.g.Frost, Haahr,& Andersen, 2007).

Marois and Durand describe a descriptive correlational study of over 200 people with work disability who participated in the Canadian ‘Previcap’ work rehabilitation programme.

This programme is a roughly 12 week interdisciplinary programme based on the ‘Sherbrooke’ model (go here for a nice powerpoint by Patrick Loisel on this programme).  The programme has three components –

  1. Work disability diagnostic interview, which is intended to ‘rule out a serious medical diagnosis and to formulate a diagnosis based on one or more factors explaining long term work disability of musculoskeletal origin.’
  2. Preparation for Therapeutic Return to Work – clinic-based interdisciplinary rehabilitation
  3. Therapeutic Return to Work – graded exposure to a real work environment

Participants in this study had been enrolled in these programmes and included in this study if they had persistent musculoskeletal pain, an existing employment relationship (i.e. had a job to return to), and had been completely off work for a minimum of 12 weeks.

Data was collected twice during the participants progress through the Previcap Programme – once at the initial assessment, and again at completion of the programme.  I’m not going to go through the method or measures, suffice to say that 83 different factors were measured, and the authors state that ‘these variables … include most of the factors identified in the literature as being associated with long-term work disability during the sub-acute phase’.  Several additional factors were added by a committee of clinicians.

Work status was measured at the end of the programme in terms of ‘back at work’ full time or part-time, or ‘able to go back to work’ but had no job available or had non-musculoskeletal problem reasons for not returning.  The final group were ‘unable to return to work’ related to their musculoskeletal problem.

I don’t want to go into any detail with regard to the analysis undertaken – suffice to say that it involved a lot of logistic regression both multivariate and univariate!  The full details are described in the article itself.  What is interesting are the characteristics of the people in the programme, and the findings themselves.  What is even more interesting are the implications.

Cutting to the chase: the participants were around 40 years old, had an average time off work of 31 weeks, particpated in the Previcap Programme for about 15 weeks or so, and mainly, returned to work – more women than men did so, however.

The factors that ended up predicting return to work were different for men and for women, and three different models of return to work were developed.  Out of the original 65 factors measured, only 17 were retained – and these were mainly work related and psychosocial.

So, what were they?

The key ones from this study for the ‘general’ model were:

  • diagnostic labelling
  • fear of aggravating symptoms
  • no light duties
  • awkward postures needed at work
  • static work postures needed
  • longer time on the Previcap Programme

For the men’s model:

  • diagnostic labelling
  • absence of musculoskeletal history requiring time away from work
  • longer time away from work
  • no light duties
  • longer time on the Previcap Programme

For the women’s model:

  • higher psychological distress
  • fear of aggravating symptoms
  • presence of recent personal events
  • presence of work equipment that is unsuitable

Of lower odds ratio, a common factor for all models was the person’s perception that treatment had failed.

These models were able to predict between 84 – 96% of those who returned to work, but were less successful at identifying those who didn’t do so (37 – 48%).

So, where does that leave us?

Now first of all, some interesting things to ponder.

At least in New Zealand, people who still have an employment relationship are more likely to return to paid employment than those who don’t. Three months isn’t a long time in the rehabilitation game, but it is to an employer who needs to have someone on deck to keep the wheels of industry turning.  In another roughly three months, (six months total time away from work) some estimates suggest that the chances of returning to work are around 50% (see Waddell, 2004 for example), while by 12 months, the chances have reduced to around 10% or less.  So my best guess is these people were slightly different from those in New Zealand – after roughly 30 weeks off work, I’m not sure that as many NZers would still have jobs to return to.

Another point to consider is the way ‘able to return to work’ is measured. I can readily understand those who do return to their original job (either in suitably selected or reduced hours), but when someone is judged ‘able’ to return to work in the absence of actually testing it in the real workplace, I’m suspicious.  Read here for a great discussion of ‘designated guessers‘ by Dr Jennifer Christian.

There are several factors that seem to need to line up for someone to return to work IMHO: they need to believe at some level that they can be successful, they need to believe they won’t harm themselves – and that they have what it takes to cope.  There also need to be suitable work duties and employer support, and the support from a health provider (preferably someone familiar with the workplace).

The factors that were associated with unsuccessful attempts to return to work were quite interesting. I’m not at all surprised by the finding that men with a shorter period of time in employment at that place of work were less likely to re-engage.  For women, attempting to return to work but failing (notably because of increased pain), and ‘wanting’ to return to work were both associated with poorer outcome.

The authors suggest that ‘wanting’ to return to work might be influenced by social desirability in women – I’d suggest there could be a lot of reasons for women to say they want to return to work, but not be able to, including the influence of others (who benefits when a woman doesn’t return to work?) and logistic problems around re-engaging in the work role alongside other occupational demands for women (transport to and from work, integration of grocery shopping, childcare, household management and so on).

Another interesting finding is the relationship between health services factors and return to work – the person’s perception that health care has failed (maybe a mismatch between expectations and results?), and, in men at least, duration of a work rehabilitation programme.  Perhaps this means more time to address the obstacles that are identified by the person, maybe it’s partly the mediating role that health providers can play to liaise between the person and the employer (acting as a buffer to set limits perhaps).

More on return to work and similar things tomorrow – sorry for the length of this post, but returning to work is a complex business!

If you’ve enjoyed this post, and want to continue reading – subscribe using the RSS feed link above, or you can bookmark and return at your leisure.  I post most days during the week, and love comments and discussion.

Marois, E., & Durand, M. (2009). Does participation in interdisciplinary work rehabilitation programme influence return to work obstacles and predictive factors? Disability & Rehabilitation, 31 (12), 994-1007 DOI: 10.1080/09638280802428374
Frost, P., Haahr, J. P., & Andersen, J. H.(2007). Reduction of Pain-Related Disability in Working Populations: A Randomized Intervention Study of the Effects of an Educational Booklet Addressing Psychosocial Risk Factors and Screening Workplaces for Physical Health Hazards. Spine 32(18),1949-54.
Prkachin, K. M., Schultz, I. Z., & Hughes, E. (2007). Pain Behavior and the Development of Pain-related Disability: The Importance of Guarding. Clinical Journal of Pain Vol 23(3) Mar-Apr 2007, 270-277.

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

Fantastic resource

Blatant advertising today! I’m blown away by the content available in RTW Matters.  I occasionally get to write a column for them, so I’ll own up to that right now, but despite my bias – this list of topics is exactly what I’d like everyone in pain management to read (and these ones are free! – there is a subscriber service with more content too)

Take a look at these topics:

Facilitators and Barriers to Return to Work: A Literature Review (Australia – Institute for Primary Care)

On Giving Advice to People Who Are Coping with Disability / Impairment at Home or Work
(US – Webility)

Are People with Disability at Risk at Work – A Review of the Evidence (Australia – Safety and Compensation Council)

But wait – there’s more!

Tools for healthier lives (US – Mayo Clinic)

Glossary of jargon words often used in medicine (UK – Bandolier)

The winter fitness survival guide (Australia – ABC)

Do I need to go on?
I haven’t even started to list the resources for health providers…

Seriously, if we work in the area of chronic pain, we need to know about anything and everything that will help our clients/patients return to work. Working is normal, healthy, and an important part of our lives. Without working, people’s health suffers. Two references to read and ponder if you’re not convinced that working is healthy…(thanks to Dr JA for his links to these two references)

Bamia, C., Trichopoulou, A., Trichopoulos D., (2008). Age at retirement and mortality in a general population sample: the Greek EPIC study. American Journal of Epidemiology, 167, 561-569.

Tsai, SP., Wendt JK., Donnelly, RP., de Jong, G., Ahmed, FS. (2005). Age at retirement and long term survival of an industrial population: prospective cohort study. BMJ doi:10.1136/bmj.38586.448704.E0.

A couple of other links for RTW info:
rtw knowledge
Institute for work and health

Where pain management meets vocational rehabilitation

I had a conversation with a case manager yesterday.  The pain management team had asked for the inclusion of several sessions with me to look at coping with pain at work, along with some anxiety management and some exercise extension for a chap who has been off work for about two years with chronic low back pain.  The case manager seemed mystified as to why I might need to work with this man, saying ‘but we’ve already got a vocational plan in place’.

I asked about the plan they had – it involved developing a good working CV/resume, obtaining a work trial, supervising that work trial, helping him develop effective interview skills, and getting him used to the routine of working again.  A good plan for returning to work.

Let me backtrack for a moment to take you through our reasoning for asking for input from me.

This man has been extremely deactivated – worried about harming himself if he moved.  He’d been depressed.  When he had a flare-up of pain he’d stopped everything he was doing.  He was very distressed about the changes in his functional abilities because he’d previously been a very fit and you could almost say ‘go-getting’ man, and for two years he’d been so scared of moving that he’d hardly left the home.  It had taken a long time for him to begin to gain confidence to move from his home environment to community settings.

He’d had some good pain management and had started to develop and use active coping skills – but in his home only.  He had some very strong beliefs about what a man ‘should’ and ‘should not’ do, and more than that, he had very strong beliefs about what an employer would tolerate.  This lead him to push himself very hard to be ‘normal’ and not accommodate his functional limitations – and you’ll know the consequences of that! Yes, he’d have a flare-up and become deactivated, despondent and distressed.

Over time he had begun to use his coping skills reasonably consistently within his home environment.  As he put it, ‘At home I know I’m the only one who is going to get worried if I leave something until later’.  But when someone came to visit who might judge him, he’d do everything he could to ‘get it all done’ – the coping strategies completely forgotten.  When we discussed going back to work with his pain – his comment was that he knew he would revert to this pattern, so his confidence to be at work – and remain there – was very low, even though working was important to him.

In fact, you could say that working was so important to him that it elicited his internal ‘shoulds’ and ‘should nots’ so he was bound to avoid using active coping skills because it was so important that he do everything to meet the expectations of his employer.  A high risk situation if ever there was one!

There was clearly a gap between his use of active coping skills at home, and his ability to manage his pain in a work situation.

Now while I value my colleagues immensely, and wouldn’t work without them, we each have an area of expertise. 

My psychology colleagues are brilliant at working with thoughts, beliefs, and introducing concepts of pain management – and yes, developing behavioural change plans. 

My physiotherapy and occupational therapy colleagues are great at helping people develop and use skills to increase activity level and engage in coping skills. 

BUT my area of expertise is the workplace – knowing about the factors that influence behaviour at work, the social and interpersonal situations, the unwritten ‘rules’ of work, the specific demands that are different about the workplace from home or social settings.

When the case manager I spoke to said ‘but why can’t the psychologist help him get confident to do pain management at work’ she had a point – that’s definitely something they can do to a certain extent.  But given the amount of time clinical psychologists get during training to learn about specific workplace and return to work factors (especially those specific to returning to work with chronic pain), that’s a little unfair (especially given the rest of the work our psychologist had to do with this man anyway!).

Knowing about pain management coping skills is one thing.  Knowing which skill to apply when, and how within the context of a workplace is a completely different thing.  It’s complex.  It’s about being cognitively flexible.  It’s about problem-solving on the fly. It’s about feeling OK about having different ways of doing things from before the pain started, and from the way other people do things. It’s about being assertive and telling people about functional limits – admitting vulnerability.  This is not easy to do when you’re a man who has prided yourself in being ‘strong’.

Simply telling someone to ‘get on with it’ and use the skills they know about in a workplace can sometimes work.  But for some people, and especially those who have very strong beliefs about how things ‘should’ be done, and those who have other vulnerabilities such as low mood, anxiety, pain-related anxiety and avoidance, or an extended period of time away from work, there is more required.

Vocational providers, by and large, are great at helping people look for work, identifying their skills, linking functional abilities to the tasks demanded in a workplace. 

But there are some things that are not always handled well – does the provider have a good grasp of chronic pain management? Do they use consistent models, do they support the strategies that the pain management provider has helped a person develop?  Do they recognise that people with pain have different vulnerabilities – some tend to over-do, as in this man’s case, while some under-do?  And how do they respond to this?  What is the scientific basis for the programme they develop for the person?

There is a dire need to develop really strong links between pain management and vocational management in New Zealand.  The workplace represents one of the contexts that people with pain identify as ‘high risk’ situations – or a situation where they are least likely to use their newly developed coping strategies.  This means additional and specialised help can be needed.  It means skills need to be robust, and professionals helping the person return to work need to be consistent in their approach.

I can’t tell you whether I’ll be able to work with this man.  What I will do is support the team to address some of the contextual issues that are common in the workplace.  And hopefully encourage providers to read more about the process people go through to return to work, so that the right support is given to the right person at the right time.

RTW Matters!

My copy of the weekly update from RTW Matters has arrived with some great new articles for people working in the field of helping others return to work.
If you haven’t been there before, head on over to take a look at the free stuff, then if you’re excited by it, think about subscribing. It’s well worth it with some of the most prominent researchers and workers in the field contributing from their experience.
Some of the articles this week:

  1. Comparing Australian and New Zealand rates and duration of durable and non-durable RTW over time
  2. Early intervention and good communication: everyone’s responsibilities. The top points from the Dr William Shaw interview.
  3. oh, and yes there’s one from me! New Zealand’s Bronnie Thompson looks at the next steps back to work – looking broadly at the path forward.

Why should we look at return to work for people with chronic pain?
Well, lots of reasons actually, but some of the most consistent findings are that people who return to work are healthier than those who don’t. In fact, being off work increases the risk of ill health (Waddell & Burton, 2006).

The link between work disability and receiving compensation means that those who continue to be off work are often still engaged in a health care system such as insurance or ACC (in NZ) that means the person has to maintain ‘disablement’ or illness behaviour to retain compensation – this means repeated assessments, programmes and justification to both health providers and the compensation provider that the person is still unfit. This isn’t conducive to people living a full and healthy life. (Hadler, 2006)

Is return to work a legitimate part of pain management? Well, apart from the need to specifically address it as an outcome for general health reasons, many people give poor pain management as their reason for not returning to work. There is no doubt that for some people, functional limitations do prevent their return to specific tasks permanently. For many, however, it’s the sense of self efficacy, or confidence to reliably manage their pain and function at work that limits their actual return.

While authors like Gordon Waddell, Kim Burton & Nick Kendall (Vocational Rehabilitation: What works, for whom, and when? 2008) suggest that ‘Vocational rehabilitation [is] defined as whatever helps someone with a health problem to stay at, return to and remain in work: it is an idea and an approach as much as an intervention or a service’, and needs to start immediately, they also state that ‘the evidence in this review shows that effective vocational rehabilitation depends on work-focused healthcare and accommodating workplaces. Both are necessary: they are inter-dependent and must be coordinated.’

I’d suggest that separating vocational management efforts from health care and especially pain management (as has happened over the past few years in New Zealand) is not effective. Both elements need to be integrated, so that the two efforts support each other.  If that means pain management needs to learn about how people experience the workplace and help them develop effective coping skills that can be used at work, then so be it! Similarly, if vocational providers need to learn about effective chronic pain management so they can provide a consistent message that hurt does not equal harm and pain should not be a guide – then so be it.

Comprehensive, intensive pain management is cost effective


There are many treatments for chronic low back pain.  One paper recently reviewed the range of treatments as if they were available on a supermarket shelf – they made the point that ‘When a new treatment approach is being considered in fields as cardiology, infectious diseases, acute trauma, or neurology, there is a general expectation that adequate research will support its effectiveness, safety, and cost effectiveness before it is endorsed as a viable treatment option. With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence. (Hageman & Dagenais, 2008)(my emphasis).

Multidisciplinary pain management has been accused of being complex, expensive and seemingly slower to produce results – and often purchasers of health care would much prefer to buy ‘quick fix’ solutions, or single discipline approaches in the belief that it will provide just as much benefit as a more expensive multidisciplinary programme.  After all, the more quickly you get someone back to work, the more quickly a case can be closed – or is it?

This study by a group of researchers in Sweden has found that even after seven years, an intensive multidisciplinary pain management programme with a cognitive behavioural approach to self management, reactivation and return to work was more effective than a lower intensity manual therapy (physiotherapy) programme. There were some other bells and whistles to the intensive programme, which also included post-programme follow-up such as workplace intervention, training and support; and the manual therapy approach also included work-related intervention within the workplace, but did not include the cognitive therapy elements. (more…)

Vocational Rehabilitation – working well!

I just ran across this paper written by Sainsbury Centre and the College of Occupational Therapists in the UK, about vocational rehabilitation in mental health. Great free paper, with some ideas that are really helpful and, yes, practical.
Cited in this paper is a reference by Waddell, Burton & Kendall (2008) reviewing vocational rehabilitation. Waddell, G., Burton, K. & Kendall, N. (2008) Vocational Rehabilitation – what works, for whom and when? London: TSO. Given my knowledge of the authors – definitely one worth seeking out! I’ll review it myself on here sometime soon.

Returning to work – occupational therapists can help!

It’s not often that a really practical tool is published that works both as a guide to ‘what to do’ and as a marketing strategy for a profession. Today I want to introduce you to this guide to returning injured workers to work, developed by the Institute for Work and Health and two Canadian (Ontario to be precise) occupational therapy organisations.

The Institute for Work and Health is an independent, not-for-profit organization whose mission is to conduct and share research with workers, labour, employers, clinicians and policy-makers to promote, protect and improve the health of working people. The Institute operates with the support of the Ontario Workplace Safety & Insurance Board (WSIB). In addition to this core funding, the Institute receives grants from funding agencies such as the Canadian Institutes of Health Research, the US National Institutes of Health and the Social Sciences and Humanities Research Council of Cana (more…)

Making the most of a referral for pain management

This is a post for people who may refer someone for pain management, or someone who is personally being referred. When I talk about pain management, I’m meaning a multidisciplinary or interdisciplinary pain management programme where participants learn about their pain, develop strategies to cope with life despite their pain, and get involved in reactivation.

The contents of a cognitive behavioural pain management programme (eg INPUT, ADAPT, vary considerably – it’s essential that the approach includes these concepts:

  • That clients can learn to accept the chronicity of their pain.
  • That clients can change their relationship to their pain in a way that allows them to broaden their sense of identity/self beyond the pain to that of “a well person with pain”.
  • That clients can learn or re-explore skills to deal more effectively with their pain, e.g., relaxation training, activity-rest cycling, graded exercise, attention management. (Morley, Biggs & Shapiro) (more…)