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

Although the service provisions for chronic pain 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. I found 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; and
   
• 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 of, “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. Missing key issues will lead to insufficient planning, and compromises 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 labour-intensive, and may take more than one try, but will yield a more successful outcome.

By the time an individual is referred to a disability specialist for vocational rehabilitation, a diagnosis has been made, functional limitations have been determined, and job accommodations have been recommended. Among the people seen 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 per cent of people with chronic pain also report symptoms of depression and anxiety.  In the effort to manage physical or psychological symptoms, there has 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 occur 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 their 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.

Let's take the example of one employee's return to work process that I coordinated; we'll call him "Joe." For all practical purposes, Joe 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. Joe responded that 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, Joe and I 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.