Following an injury or health problem return to work is an important part of rehabilitation. In many cases we follow a standard course; identify the restrictions, look for the duties that match, and put the two together to develop a return to work plan. Whilst that works in many cases, following the routine channel can stop us, and the people we care, from using the opportunity to look at the ‘big picture’. 

The path to return to work is not exactly well-mapped. Although have our usual routes, they don’t fit everyone all the time. I was mulling over this when planning the ‘next steps’ for several people I’ve been working with recently. 

I thought about Geoff. He’d stopped work at the end of last year, and had been taking the last three months to learn to manage his pain. He sustained an above-knee amputation about 3 years ago, and returned to work very quickly after the initial accident. He was a senior manager of a team of sales and merchandising staff, and used to working to a high level. Twelve months ago for no apparent reason, he developed an intermittent but very intense neuropathic pain affecting his amputated leg, which exacerbated his existing phantom pain. He’d managed to continue with his job until mid-year when he started to, as he put it, ‘run out of puff’.   He continued to put in long hours at work, but said later that he was being less and less effective as he fought against the intermittent burning, stabbing pain down his leg.

Now he’s learning to manage his pain by ‘going with’ his pain, no longer fighting against it, but breathing through it. He’s gaining confidence in using a range of skills including mirrorbox therapy and developing good sleep patterns. He’s at the point of starting to think about what he wants to do for work.

He had a discussion with his employer last week, and decided he didn’t want to return to his previous job, although it had been held open for him. Instead, he thought that at his age (he’s in his mid-50’s), he might think about developing a better balance in his life. He’s had a range of jobs over the years, many of them manual work, but he’s usually moved from ‘hands-on’ work to managing a team. The problem with managing a team, he said, was that it is really high-demand, and he felt it wasn’t helping him manage either his stress levels, or his pain.

So, what is his next best step? His goals are to spend some time exploring what is important to him while at the same time integrate his pain management coping into his life. He knows work is important to him, but not as important as it had been when he was younger. He was very confident he could manage most of the previous jobs he’d been in, but not if he needed to work the long hours he’d always done. 

Geoff has set a two-month plan together, during which time he has clear goals for maintaining his daily routine which currently includes exercise, deep relaxation, social activities, household activities and reviewing the jobs he’s done in the past. He intends to start actively job seeking towards the end of the two months, and considers job seeking to be his ‘work’ until he obtains employment.

Mark has a different story. He’s been self-employed as an electrician for almost all his adult life. When he crushed his hand, his surgeon said he would have to change jobs, because the hand function he could achieve would be limited. Mark developed persistent pain in his hand, and he learned quickly to avoid using his hand because he dropped things, and it throbbed after being loaded. He became very despondent when he was told, after 4 months, that his pain wasn’t going to resolve quickly, and his mood plummeted when his business began to fail because he couldn’t fulfil jobs he’d had lined up. And he couldn’t get more work because he wasn’t confident he could do it. When he first saw the team he was depressed, fearful of using his hand, and hadn’t been working since his accident.

Mark was initially recommended for intensive pain management over a three week programme. His confidence to cope independently with his pain was low, and his mood continued to be variable. He had doubts about his ability to work as an electrician but didn’t really know what else to do and he was definite he didn’t want to be anyone’s employee. Despite this, his hand function improved and he became quite confident that he wasn’t harming his hand when he used it, despite the pain.

Together, the team and Mark discussed his options. We thought he would benefit from some ongoing but less intensive contact with the team. He was so concerned about returning to work, that the team agreed it would be good to start him on a vocational rehabilitation pathway. Part of that was to clarify whether in fact he could manage his old job.

Mark’s ‘next best step’ was to start a two month work trial with hands-off monitoring by the interdisciplinary team. Mark hasn’t quite completed his trial, but he is already working most days. While he comments that he is a bit slow, he’s very confident that he can manage the tasks, although admits to using modifications to help him manage his limited wrist mobility. His pain continues but he has said that he’s able to tolerate this because he’s busy.

Two people with totally different paths to take on their journey to returning to work. While both men are remarkable in their belief that work is important to them, both had to work through a process of deciding whether they could remain in their old job or needed to consider alternatives. The ‘next best step’ for each of them was different. 

As a health professional, my job was to advise them of their options and the consequences of any decisions (as far as I could see), and then to help them work through a process of resolving their ambivalence. Not every ‘next best step’ ends as well as these two cases, but until I have a crystal ball I can’t identify what the outcome will be. But what I can do is help set up a system that allows the person to make an informed decision. Helping them understand they do have options and choices is an important part of my work. 

Bronwyn Thompson originally trained as an occupational therapist. She has worked in pain management for 18 years, with a main focus on pain management at work.  Her work has ranged from interdisciplinary pain management programmes, private practice, case management both for private organizations, and ACC, primary prevention and secondary prevention, and since 2002, teaching postgraduate papers in pain and pain management at Otago University, and Otago Polytechnic.