Once HR acknowledges the pain is real, cost-saving return-to-work strategies can be deployed
Returning injured employees with chronic pain to meaningful work is one of the most difficult tasks an HR professional will ever face.
The challenge is, after incurring some type of injury, an employee can suffer severe pain, despite the fact that doctors can’t determine why the pain continues. By all accounts, the worker should be recovering. Knowing this, the worker may often feel guilty but remain unable to do the tasks expected.
It is a tricky situation. To handle it effectively, HR professionals must have some understanding of chronic pain disorder and be aware of the usual traps that sometimes complicate return-to-work initiatives.
First and foremost, it is important for HR to understand the worker is not faking. The pain is real, and the worker can’t be persuaded otherwise.
Just as one can experience a seizure and brain tests will reveal nothing, likewise people can feel pain and doctors will not be able to find abnormalities in any of the tests.
What’s more, HR must ensure the worker that nobody thinks he’s faking and that the organization appreciates the pain is real. Not doing so creates more guilt for the worker and puts him on the defensive, making it difficult to have constructive discussions about returning to work.
Pain system changes can change injury
The usual healing time for soft tissue injuries ranges from a few days for a mild wrist sprain to four months for a herniated disc.
But after the usual healing times, the worker may continue to experience pain. In the medical literature, the length of time that defines chronic pain is six months. In my experience as an occupational physician, if the worker is experiencing pain severely for three months or more, then it is time to begin treatment for chronic pain. Chances of success improve with earlier treatment.
It is also important to understand that medical research shows that the body’s pain system may change over time. With prolonged pain, the pain is no longer a message from damaged tissue but rather a mistaken message from healed tissue. The nervous system has changed by developing new connections that deliver a constant message even with normal movement. This change in the body necessitates a lifestyle change that is often very difficult to achieve.
The individual might have to learn to pace his work by completing it in multiple sittings rather than all at once. This can prove frustrating and may decrease a person’s self worth and self-image, as he may feel like less of a person following the injury.
Chronic pain versus chronic pain disorder
Experiencing chronic pain is quite different from suffering from chronic pain disorder (CPD). People with chronic pain, or prolonged pain, cope and arrange their work and their lives to accommodate the pain. They rest and exercise to allow their days to continue. They may have to live differently but, usually, they return to work and to their normal lives within a reasonable period of time.
However, CPD is quite different. It is a behaviour that occurs for unknown reasons as the tissue is healing from the injury. Injured workers change their behaviour to cope with the pain in an unhealthy manner. Injured workers with CPD focus on their pain so much that it becomes their single most important thought.
They are afraid of moving the previously injured body part out of concern that movement will increase their injury. This, despite pleas from their physiotherapists, chiropractors and kinesiologists to do so.
Often, the injured worker will seize on ill-chosen words from these frustrated therapists such as, “That is a really terrible strain,” or “You likely will never be the same.”
The injured worker will use pain relievers to excess and, when asked, will often say the pain is still present despite the high dose of narcotic.
In truth, the pain described by a CPD sufferer usually continues and worsens following the injury. An individual with CPD will unknowingly contract the muscles surrounding the injury to avoid the pain. These muscles then become sore and stiff so that the individual feels like the condition is worsening.
Acknowledge pain is real
HR professionals involved with return-to-work efforts must understand that while it is safe for the injured worker to work and move, the rehabilitation process can only truly begin once everyone involved acknowledges the pain the employee is suffering.
Then, the worker must learn how to manage the pain with relaxation, pacing and exercise.
Cognitive behavioural therapy has been proven to provide an educational component to help the worker accept therapy and to understand the change that has occurred in the nervous system. This is a method used by counsellors to get at the false beliefs — the thoughts that lead to the unhealthy behaviour. The injured worker has a benign chronic condition that must be understood and dealt with.
This therapy is taught in multi-disciplinary pain clinics. Although it is time consuming, labour intensive and costly, it is cost-effective when compared to the costs of conventional treatment and continued time off.
Psychological counselling or physical therapy alone does not work. It is only when a CPD sufferer simultaneously integrates both the cognitive behavioural approach and the physical therapy that successful return to work may occur. The optimal method of therapy seems to occur when it is provided both in the clinic and at the job site.
Personality types shape strategies
Some personality types are often susceptible to CPD and different personality types call for different strategies for therapy.
Dependent individuals take little responsibility for their therapy and feel that they should be healed and made better. Later, they will overdo their physical work. Hearing that it is safe to move, they might clean out the entire garage when they have not done any physical work for a year. Naturally, this would worsen the pain. The therapy team must be aware of this person’s tendency to overdo it and make sure he understands the importance of pacing.
Another personality type prone to CPD is the histrionic individual. This person sees the relatively minor injury as a catastrophe and refuses to understand the physiology of pain.
Lastly, the narcissistic personality type may also be susceptible to CPD. These individuals believe that no one understands what they are experiencing and that they cannot find anyone to understand how important their dilemma really is.
Often, this personality will say that the therapist cannot understand as it is not the therapist’s body and that the therapist has never experienced this problem. Again, to ease rehabilitation, it is important to explain to the worker these are abnormal thought patterns.
All of the above approaches are exacerbated by compulsive or aggressive traits. These traits hinder therapy as they create unpleasant interactions with the therapists, with the worker exhibiting uncontrolled anger or the driven perception that there must be something terribly wrong and everyone is missing it.
Teamwork for return to work
To successfully reintegrate a worker with chronic pain, two distinct teams have to work together. At the workplace the HR professional must work within a reintegration team to develop a return-to-work plan that makes sense to all involved. This team would include the injured worker, the therapist, the occupational health nurse, the union and often a representative of the workers’ compensation board.
At the rehabilitation facility, the clinical team is usually comprised of the worker, the therapist from the workplace team, a cognitive behavioural therapist, a biofeedback therapist and a psychologist or physician. It’s the latter who communicates with the worker’s treating health professionals.
The HR professional must not only understand the condition but also be ready to help the worker learn that the diagnosis has changed from a soft tissue injury to a chronic pain disorder.
Lastly, HR must be ready to create a respectful framework wherein workers, their advocates, their supervisors and the therapists can work together to succeed at achieving successful reintegration to the workplace.
Howard Hamer is the medical director of the functional restoration program at the University Health Network’s Rehabilitation Solutions Department, Toronto Western Hospital Division. He can be contacted a (416) 603-5800, ext. 5105 or [email protected].
The challenge is, after incurring some type of injury, an employee can suffer severe pain, despite the fact that doctors can’t determine why the pain continues. By all accounts, the worker should be recovering. Knowing this, the worker may often feel guilty but remain unable to do the tasks expected.
It is a tricky situation. To handle it effectively, HR professionals must have some understanding of chronic pain disorder and be aware of the usual traps that sometimes complicate return-to-work initiatives.
First and foremost, it is important for HR to understand the worker is not faking. The pain is real, and the worker can’t be persuaded otherwise.
Just as one can experience a seizure and brain tests will reveal nothing, likewise people can feel pain and doctors will not be able to find abnormalities in any of the tests.
What’s more, HR must ensure the worker that nobody thinks he’s faking and that the organization appreciates the pain is real. Not doing so creates more guilt for the worker and puts him on the defensive, making it difficult to have constructive discussions about returning to work.
Pain system changes can change injury
The usual healing time for soft tissue injuries ranges from a few days for a mild wrist sprain to four months for a herniated disc.
But after the usual healing times, the worker may continue to experience pain. In the medical literature, the length of time that defines chronic pain is six months. In my experience as an occupational physician, if the worker is experiencing pain severely for three months or more, then it is time to begin treatment for chronic pain. Chances of success improve with earlier treatment.
It is also important to understand that medical research shows that the body’s pain system may change over time. With prolonged pain, the pain is no longer a message from damaged tissue but rather a mistaken message from healed tissue. The nervous system has changed by developing new connections that deliver a constant message even with normal movement. This change in the body necessitates a lifestyle change that is often very difficult to achieve.
The individual might have to learn to pace his work by completing it in multiple sittings rather than all at once. This can prove frustrating and may decrease a person’s self worth and self-image, as he may feel like less of a person following the injury.
Chronic pain versus chronic pain disorder
Experiencing chronic pain is quite different from suffering from chronic pain disorder (CPD). People with chronic pain, or prolonged pain, cope and arrange their work and their lives to accommodate the pain. They rest and exercise to allow their days to continue. They may have to live differently but, usually, they return to work and to their normal lives within a reasonable period of time.
However, CPD is quite different. It is a behaviour that occurs for unknown reasons as the tissue is healing from the injury. Injured workers change their behaviour to cope with the pain in an unhealthy manner. Injured workers with CPD focus on their pain so much that it becomes their single most important thought.
They are afraid of moving the previously injured body part out of concern that movement will increase their injury. This, despite pleas from their physiotherapists, chiropractors and kinesiologists to do so.
Often, the injured worker will seize on ill-chosen words from these frustrated therapists such as, “That is a really terrible strain,” or “You likely will never be the same.”
The injured worker will use pain relievers to excess and, when asked, will often say the pain is still present despite the high dose of narcotic.
In truth, the pain described by a CPD sufferer usually continues and worsens following the injury. An individual with CPD will unknowingly contract the muscles surrounding the injury to avoid the pain. These muscles then become sore and stiff so that the individual feels like the condition is worsening.
Acknowledge pain is real
HR professionals involved with return-to-work efforts must understand that while it is safe for the injured worker to work and move, the rehabilitation process can only truly begin once everyone involved acknowledges the pain the employee is suffering.
Then, the worker must learn how to manage the pain with relaxation, pacing and exercise.
Cognitive behavioural therapy has been proven to provide an educational component to help the worker accept therapy and to understand the change that has occurred in the nervous system. This is a method used by counsellors to get at the false beliefs — the thoughts that lead to the unhealthy behaviour. The injured worker has a benign chronic condition that must be understood and dealt with.
This therapy is taught in multi-disciplinary pain clinics. Although it is time consuming, labour intensive and costly, it is cost-effective when compared to the costs of conventional treatment and continued time off.
Psychological counselling or physical therapy alone does not work. It is only when a CPD sufferer simultaneously integrates both the cognitive behavioural approach and the physical therapy that successful return to work may occur. The optimal method of therapy seems to occur when it is provided both in the clinic and at the job site.
Personality types shape strategies
Some personality types are often susceptible to CPD and different personality types call for different strategies for therapy.
Dependent individuals take little responsibility for their therapy and feel that they should be healed and made better. Later, they will overdo their physical work. Hearing that it is safe to move, they might clean out the entire garage when they have not done any physical work for a year. Naturally, this would worsen the pain. The therapy team must be aware of this person’s tendency to overdo it and make sure he understands the importance of pacing.
Another personality type prone to CPD is the histrionic individual. This person sees the relatively minor injury as a catastrophe and refuses to understand the physiology of pain.
Lastly, the narcissistic personality type may also be susceptible to CPD. These individuals believe that no one understands what they are experiencing and that they cannot find anyone to understand how important their dilemma really is.
Often, this personality will say that the therapist cannot understand as it is not the therapist’s body and that the therapist has never experienced this problem. Again, to ease rehabilitation, it is important to explain to the worker these are abnormal thought patterns.
All of the above approaches are exacerbated by compulsive or aggressive traits. These traits hinder therapy as they create unpleasant interactions with the therapists, with the worker exhibiting uncontrolled anger or the driven perception that there must be something terribly wrong and everyone is missing it.
Teamwork for return to work
To successfully reintegrate a worker with chronic pain, two distinct teams have to work together. At the workplace the HR professional must work within a reintegration team to develop a return-to-work plan that makes sense to all involved. This team would include the injured worker, the therapist, the occupational health nurse, the union and often a representative of the workers’ compensation board.
At the rehabilitation facility, the clinical team is usually comprised of the worker, the therapist from the workplace team, a cognitive behavioural therapist, a biofeedback therapist and a psychologist or physician. It’s the latter who communicates with the worker’s treating health professionals.
The HR professional must not only understand the condition but also be ready to help the worker learn that the diagnosis has changed from a soft tissue injury to a chronic pain disorder.
Lastly, HR must be ready to create a respectful framework wherein workers, their advocates, their supervisors and the therapists can work together to succeed at achieving successful reintegration to the workplace.
Howard Hamer is the medical director of the functional restoration program at the University Health Network’s Rehabilitation Solutions Department, Toronto Western Hospital Division. He can be contacted a (416) 603-5800, ext. 5105 or [email protected].
