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How To Identify the Variables of Chronic Pain To Achieve Holistic Return to Work

Researchers estimate that there are currently at least 75 million Americans who experience some form of debilitating pain; and with the aging of the baby boomers, that number is expected to grow significantly. I have been a disability specialist for the last 20 years. During that time, I have had the opportunity to serve individuals who, because of the direct and indirect affects of a medical condition, were unable to perform their work, and among them were individuals with a chronic pain diagnosis.

Although the service provisions were similar to other disabilities, there were differences that required a different case management approach. In the effort to better understand chronic pain, I looked to the experts for advice and recommendations. What I found was that, although there was some disagreement among the authorities as to what chronic pain was, there was a general agreement that it:

+ Is pain that lasts longer than the typical healing time.

+ Is complex and difficult to measure or define.

+ Has unique physiological and psychological responses.

+ Varies greatly from individual to individual.

Those areas of agreement — particularly the final two — provide a helpful framework when dealing with chronic pain cases. I keep in mind the concept, “The whole is greater than the sum of its parts.” The “whole” represents the individual, and the “parts” are the factors unique to that individual’s work limitations and chronic pain. Identifying all of the “parts” is no easy task in itself, but failure to address the needs and issues of the individual can result in missing key issues. This will lead to insufficient planning, compromising an otherwise comprehensive rehabilitation plan. The end result is a waste of time, resources and effort, not to mention the cost of an individual’s potential. A holistic approach is not an effortless process. It can be time- and labor-intensive, and may take more than one try, but will yield a more successful outcome.

By the time an individual is referred to me for vocational rehabilitation, a diagnosis has been made, functional limitations have been determined, and job accommodations have been recommended. Among the people I see with a chronic pain diagnosis, many carry an additional diagnosis, most often related to musculoskeletal and neuromuscular disorders. Symptoms of fatigue and general weakness often affect their ability to function on a daily basis. In addition to, or because of a chronic pain diagnosis, there is also a high incidence rate of psychological disorders.

As noted in the incidence statistics put forth by the Handbook of Disability Studies, nearly 60 percent of people with chronic pain also report symptoms of depression and anxiety. In the effort to manage physical or psychological symptoms, there have been, and may continue to be, therapeutic intervention. These can range from the more conventional methods of medication, physical therapy and surgery, to alternative treatments such as hypnotherapy, acupuncture, herbal therapies and yoga. Along with treatment for physical symptoms, psychological treatment may be co-occurring in the effort to learn more effective coping skills or to treat the psychological symptoms.

Although medical recommendations regarding work restrictions and job accommodations serve as a good place to start in the creation of a rehabilitation plan, I find that the most useful information comes from the individual and their perceptions around their return to work. Although these questions are not medically based and not a typical function of the rehabilitation planning, I have found them to be paramount to gaining insight and information that may otherwise have been lost. This is where the rubber hits the road when it comes to developing an effective return-to-work plan, as this information often provides insight and the opportunity to problem solve.

It is not uncommon for a client to have non-disability-related reasons that impede the return to work. Losing disability benefits or returning to a job they do not like are just two examples. Do not assume that these factors are not important because they are not related to the medical condition. You will find that if these factors are present, and if they are not addressed, the best efforts at vocational rehabilitation can be derailed. I have been humbled when the rehabilitation plan did not go well, and later learned that I was making assumptions and recommendations about the needs of my client without knowing all of the facts.

Recently, I was in the process of coordinating an employee’s return to work. For all practical purposes, the employee was ready and able to return to his job. It was not until the end of our meeting that I detected a look on his face that told me that the plan was not quite finished. I took the risk of asking more probing questions about his views on going back to work. In this situation, the employee said he was concerned about how he was going to be able to get to work, as his car had become unreliable during the time he was on his medical leave. Since this was not a “work restriction” spelled out by his medical provider, neither one of us thought that this issue was relevant to our discussion.

Nonetheless, it posed as big of an obstacle in his return to work as his lifting limit. With this additional information, we brainstormed other options and planned for the provision of alternative transportation. I quickly learned that by inviting individuals to discuss their needs in returning to work, you may gain helpful information and insights that help eliminate or prevent return-to-work barriers.

Eliminating Fear, Moving Forward

Another factor external to the medical condition that is more subtle and harder to detect revolves around the fear of returning to work.  Apprehensions about ability to perform the job and the perception of co-workers and supervisors are common. Although these non-medical factors pose additional challenges, it is not our place to judge their merits, and it is certainly not the time to terminate the rehabilitation plan, pack up and go home. Instead, they represent additional factors that need to be addressed and planned for.

People are very complex, as are the systems that they must deal with. Although there is a tendency to believe that people are out to abuse the system, that is not the norm; most people want to get back to work. If we, as professionals, start with that premise, our ability to be successful is greatly increased. If judgment can be withheld, with a focus on the best outcome for all involved, and a more holistic approach utilized, much can be accomplished.

In beginning a plan for a return to work, keep in mind the accommodation needs that are often associated with chronic pain, such as difficulty with concentration, fatigue, reduced strength and fluctuating symptoms. Examples of accommodations include work tasks that are routine and predictable, limits on timelines and other time pressures, and the ability to work at one’s own pace. It is typical of people in pain that their symptoms will vary in severity depending on the other stress factors operating at that moment.

Some flexibility in the work plan to accommodate for this is advisable. Before the accommodations are implemented, there should be a clear understanding of what is expected from the employer, as well as from the employee. Once an agreement is reached with regard to the provision of accommodation and the expectations around the work standards, it should be enforced.

Despite the Best Efforts

Even with planning that takes into consideration all the variables, and despite our best planning and efforts, there will be times when an individual simply cannot return to the job. Most often, this is because the employer is unable to accommodate the work restrictions. Because of the nature of their work restrictions, people with chronic pain may often require work environments and routines that are uncharacteristic of how work is usually performed. When this occurs, I find that it is useful to view this as a fork in the road, not the end of the road. This is where it gets fun: instead of fitting the person to the job, you can become creative and start to explore options that will fit the job to the person. With this in mind, explore vocational options that would better allow for their needs, such as self-employment or retraining in an occupation that would financially sustain them on a more flexible or part-time work schedule.

Because this can be a long process, a return to work may be delayed. In these instances, short- and long-term disability insurance (if available) may be used. Typically, short-term disability pays a percentage of a person’s salary when a person becomes unable to work due to illness or injury. The duration of the benefits can range anywhere between 13 and 52 weeks, depending on the policy. If it is determined that disability will extend beyond the limits of the short-term disability policy, long-term disability benefits and/or Social Security disability benefits can be pursued.

Although disability benefits can be useful, one should take care to not see this as the end goal, unless absolutely necessary. There are many pitfalls associated with pursuing disability status for the client that one should be aware of. In the process of assisting clients in obtaining disability benefits, they have described the application process as confusing, frustrating and, at times, demoralizing. From the onset of the claim, they and their doctors are put in a position of having to prove they are unable to work, which can become a repetitive administrative chore, and can solidify a disability mindset.

The claim process can be confusing and frustrating, which often results in an income that may be far less than what they were earning. In addition to these drawbacks, being out of a job can be mind-numbing and lacking in stimulation, and the loss of work relationships creates a feeling of being out of the loop. Disability benefits are helpful when used as a way to bridge the financial gap, while going through the vocational rehabilitation process, or, in other words, are used as a means to an end.

I have found that people do better when they are empowered to live life to the best of their ability. As professionals, we can best facilitate this by keeping an open mind, a willingness to listen and to serve as a support in what can be a difficult journey. The people we assist depend on us for direction and guidance, which can only be useful if we first take the time to discover and understand the unique characteristics that make people tick — the “whole” and not just the “parts.” Once we have that understanding, we can have confidence in the development and provision of services that will result in a successful outcome.