Supporting Return to

Work for People

Living with Pain

Applications of the principles of interdisciplinary treatment

Pain BC ConferenceOctober 20, 2012

Presenters

� Dr. Erik Baasch, Medical Doctor

� Dr. Matt Graham, Psychologist

� Cat Douglas, Occupational Therapist

� Leigh Fortuna, Physiotherapist

Objectives

� Review acute and chronic pain and return to work approaches with each population

� Challenge clinical decision making around when to recommend a patient in pain stop working

� Discuss factors to consider when a patient in pain is returning to work

Outline

� Introductions

� Case example

� Differences in acute and chronic pain and return to work

� The physician’s role in return to work

� How to develop and implement a gradual return to work plan for someone with pain

� Importance of patient’s belief system in return to work

� Case example

� Panel for questions/discussion

Case Example

� Case #1 discussion (10 minutes)

�Discuss at your tables

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Acute vs. Chronic Pain

when should someone return to work with pain?

� Definition of Pain from IASP:

� An unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such damage.

� Definition from Lorimer Moesley1:

� Pain as a BRAIN OUTPUT

� Neither definition clearly differentiates acute vs.

chronic

Acute Pain

� Generally accepted as pain

due to damage in body tissue.

� Even with acute pain,

pain is an OUTPUT

Chronic Pain

� Generally accepted as pain that persists longer than expected healing time.

� Often becomes

less about the

tissue and more

about a maladaptive

OUTPUT from the

brain.1,2

Image from Explain Pain5

Which is more “Chronic”?

� 57 year old male with:

a) Severe knee osteoarthritis waiting for a knee replacement, continuing to work and golf

b) A lumbar strain 1 month ago at work, DDD, not sleeping, not working, financial stress, mood changes

What would be different about treatment and RTW approach with each situation?

Importance of Return to Work

� The longer a patient is away from work due to injury/pain, the less likely they will return.10

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Keys to supporting RTW with pain

� Know the prognosis

� Understand concept of “pain vs. damage” or “hurt vs. harm”

� Know patient’s functional abilities

� Know job duties� Ensure all parties are clear about what patient is

being asked to do

� Understand pacing and use of active coping skills

The role of the physician in the

process of return to work for a

person in pain.

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Writing the Sick Note

� Reasons for this

�Compassion

�Medical

�Patient Driven

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Terminology used

� Restrictions

� Limitations

� Tolerance

Some Thoughts about Return to

Work

� Return to work as the goal of treatment

� Return to work as part of the treatment

The Importance of Work and

Approaches for Building

Understanding and Confidence for

the Process

Guiding the Process

� Return to work:�Recovery expectations

�Transitional Psychology� Cognitive, affective, identity

adjustment – perceived threats

�Building self-efficacy

�Psychology without action

does not workFree image courtesy of FreeDigitalPhotos.net

Return to Work – why is this so

important?

� Unemployment means:� Higher cardiovascular disease� Higher suicide

� Higher stroke

� Higher sleep disturbance� Higher traffic fatalities

� Higher anxiety� Higher depression

� Higher alcoholism� Higher healthcare use9

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Expectations

� Acute versus chronic�Prevent stance of waiting for “someone (i.e.

medical professional) to do something”

�Warning signs:� Fear/catastrophizing

� Low self-efficacy

� Depressive symptoms

� Workplace factors

� Adversarial RTW process

Preparation

� Pain vs. Damage, Hurt vs. Harm

� Normalizing loss, grief and adjustment

� Kinesophobia

� Pain is physical and psychological = normalizing the complexity

� Return to work as part of healing

� Understanding the process of

other stakeholders

Preparation into Action

� Integration and practice

� Pacing and flare up management

� Reconnection with the workplace11

� Systematic review by France et al. identifies the importance of that connection to the workplace for reducing work disability

� Problem solving and coping

� Facilitating responsibility for the process (ownership)

Action (Return to Work)

� Creating the GRTW (Graduated Return to Work)

� Why a GRTW is a good idea

� Family Physician role/involvement

� Expectations post GRTW

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Creating the GRTW – how and

why?

� How?

�Patient reported job demands

�Confirming job demands via a job site visit

(with patient if available)

�Confirming meaningful modified/lighter duties

�Functional program = starting point for GRTW

�Modifications if needed

Why do a GRTW?

� Reconnection with the workplace

� Gradual progression of hours

and duties

� Rehabilitation time as well as work hours

� Practice of active management skills when at work

� Development of self-efficacy

� Idea of durable abilities (helps claims process too)

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Family Physician Involvement

� Keep family physician aware of plan

� Medical notes

�Changing the GRTW

�Stopping the GRTW

What to expect post GRTW

� As with any change in activity (i.e. starting rehabilitation or a GRTW) the patient is going to struggle with increased pain/symptoms and life balance

� Encouragement to continue is key

Conclusion

� Return to work with pain is more effective with coordinated treatment relationships viewing the problem through a biopsychosocial lens.

� Expect setbacks, continually reinforce patient capabilities and ongoing communication is key.

Case Review/Panel Discussion

� Review Case 1

� Discuss Case 2

� Questions

References

1. Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

2. Neil Pearson (2012, January 23). Acute versus Chronic Pain: Understanding the difference and choosing appropriate treatment. Retrieved from:www.orionhealth.ca.

3. Rossignol, M., Arsenault, B., Dionne, C., Poitras, S., Tousignant, M., Truchon, M., Allard, P., Cote, M., Neveu, A. (2007). Clinic on Low Back Pain in Interdisciplinary Practice (CLIP) guidelines. Montreal: Direction de sante publique, agence de la sante et des services sociale de Montreal. Retrieved from: http://www.bibliotheque.assnat.qc.ca/01/mono/2007/02/926313.pdf

4. Dunstan, D.A. (2009). Are sickness certificates doing our patients harm?. Australian Family Physician, 38 (1/2), 61 - 63.

5. Butler, D. & Moseley, G.L. (2003). Explain Pain. Adelaide: NOI Group Publications.

6. Illes, R. A., Davidson, M., & Taylor, N. F. (2008). Psychosocial predictors of failure to Return to work in non-chronic non-specific low back pain: A systematic review. Occupational Environmental Medicine, 65, 507-517.

References

7. Stewart, A. M., Polak, E., Young, R., & Schulz, I. Z. (2012). Injured workers construction of expectations of return to work with sub-acute back pain: The role of perceived uncertainty. Journal of Occupational Rehabilitation, 22, 1-14.

8. Thorn, B. E (2004). Cognitive therapy for chronic pain: A step-by-step guide. The Guilford Press: London.

9. Jin, Shah and Svoboda (1995) The impact of unemployment on health.

10. Crook, J., & Modolfsky, H. (1994). The probability of recovery and return to work from work disability as a function of time. Quality of Life Research, 3 (Supplement 1), S97 - S109.

11. Franche, R.L., Cullen, K., Clarke, J., Irvin, E., Sinclair, S., Frank, J. and The Institute for Work & Health (IWH) Workplace-Based RTW Intervention Literature Review Research Team (2005). Workplace-Based Return-to-Work Interventions: A Systematic Review of the Quantitative Literature. Journal of Occupational Rehabilitation, 15 (4), 607-631.