Why return to work when still in significant levels of pain?

This concept is a controversial topic depending on whom it concerns in the occupational rehabilitation space; their attitudes, motivations, and beliefs towards pain and activity; and has on my own admission been a view which has changed dramactically in the latter half of my physiotherapy career.

When I first graduated and commenced private practice I tended to err on what now seemed to be the “overtly cautious side”, and recommended rest and avoidance of aggravating activities when patients initially presented with significant levels of pain.

When dealing under compensable frameworks, often patients would report that their case manager was stressing the importance of early return to work – which they were struggling to understand the apparent need for given their levels of symptoms. On face value it seemed to the patient that the insurer simply wanted them back at work so they could close their workcover case.

Most frequently I noticed Treating Doctors would predominately certify a significant period of bed rest and acute treament before consideration for return to normal activities including work. Given same, it was difficult to agree with Insurers and contradict primary care by suggesting that if you are in significant levels of pain, you should be staying in your normal routine regardless of how you feel.

However, as time went on though (in line with current evidence) it became clear that the longer pain behaviour lingered, the more impact it tended to have on each patient’s physical, emotional and social considerations. Not being able to do daily normal activity created frustration, anxiety, and depressive symptoms in my patients, and I could see significant impact on them both individually and on their family and social dynamics.

It became obvious that maintaining activity levels, and returning to normal routines as quickly as possible was essential. Moreover, consistency in message amongst stakeholders was key to ensure each patient understood “why” and “when” it was important to start getting back into normal routine – so reasonable and achievable RTW goals could be set and agreed upon by all parties, and progressed as each patient recovered. The age old adage “move it or lose it” had significant relevance – as long as each patient efforts to upgrade their activity post injury was initially sensible and meaningful. Helping patients to develop skills which allow them to understand pain, validate it, pace their activity and upgrade capacity was also vital.

These days, I encourage my team of providers to stress keeping patients at work in any capacity post a work-related injury, regardless of their pain experience. I have also linked with a number of treating specialists to create triage clinics which allow rapid-access to assessment and open communication amongst stakeholders. This has ensured that waiting periods for initial appointments is a factor that can be managed thereby helping to minimise the amount of time away from work and normal routines. The reasons for this I will attest to research quoted from the Australasian Faculty of Occupational and Environmental Medicine (AFOEM) and the Royal Australasian College of Physicians’ position statement, ‘Realising the health benefits of work‘.

The paper highlights that being off work for long periods of time can significantly reduce the likelihood of a worker ever returning to work and can have a negative effect on the worker and their family. The paper indicates work plays an important role in any rehabilitation process because ‘doing’ promotes recovery.

If a person is off work for:

– 20 days, the chance of ever getting back to work is 70 per cent.

– 45 days, the chance of ever getting back to work is 50 per cent.

– 70 days, the chance of ever getting back to work is 35 per cent.

So in essence, I am happy to own the fact that my initial approach to managing people with significant pain from work-related injury was wrong, and as such I encourage all health providers to get on board and open communication channels with both the patient, and their case manager/employers to achieve a durable and meaningful RTW as soon as reasonably possible.