OPTIMISING OPTIMISING ASSESSMENT OF ASSESSMENT OF

REHABILITATION NEEDSREHABILITATION NEEDS

Virginia PascallVirginia Pascall

Consultant Occupational Consultant Occupational PhysicianPhysician

Your rehab. mental flow Your rehab. mental flow chartchart

Can the employee Can the employee

– work at all?work at all?– increase his/her hours at work?increase his/her hours at work?– increase the range of duties or tasks increase the range of duties or tasks

they are given?they are given?– resume normal work/hours at work?resume normal work/hours at work?

What are your questions?What are your questions?

What is wrong with the employee What is wrong with the employee (diagnosis)?(diagnosis)?

Different or more treatment?Different or more treatment? Is it the work that is slowing their Is it the work that is slowing their

recovery?recovery? Is it the travel to work?Is it the travel to work? Can I change anything about the Can I change anything about the

work?work?

The underlying questionsThe underlying questions

Anything about this employee’s Anything about this employee’s complaints that are due to their:complaints that are due to their:

– Underlying constitutional endogenous Underlying constitutional endogenous degenerative or pre-injury condition(s)?degenerative or pre-injury condition(s)?

– Their personality (including other Their personality (including other agendas)?agendas)?

The Treating DoctorThe Treating DoctorHis mental flow chartHis mental flow chart

My patient is injuredMy patient is injured I prescribe treatmentI prescribe treatment I write WC certificateI write WC certificate

YOU do whatever is on certificate YOU do whatever is on certificate

The Next VisitThe Next Visit

I see my patient againI see my patient again I listen to my patientI listen to my patient I give new treatment or same I give new treatment or same

treatmenttreatment I write new WC certificateI write new WC certificate

YOU do what is on certificate.YOU do what is on certificate.

The ethos of medical The ethos of medical practicepractice

Do no harmDo no harm Make people betterMake people better

If I can’t make them better, I feel I should If I can’t make them better, I feel I should try harder and at times, I can hand over try harder and at times, I can hand over the management to my patient because the management to my patient because they often are happy to receive what they they often are happy to receive what they want, even if not recovered.want, even if not recovered.

AT SOME STAGEAT SOME STAGE

My patient tells me that they are My patient tells me that they are betterbetter

I write final certificateI write final certificate

OROR

My patient keeps telling me they are My patient keeps telling me they are no betterno better

I don’t know what to do, so I do I don’t know what to do, so I do nothing but write another WC nothing but write another WC certificate and REFER to A SPECIALISTcertificate and REFER to A SPECIALIST

My role has now become much more My role has now become much more passive ….passive ….

TURN IT AROUNDTURN IT AROUND

The best thing for recovery is for the The best thing for recovery is for the patient to resume as NORMAL a life patient to resume as NORMAL a life as possible – including working life.as possible – including working life.

You do not need to be pain free to You do not need to be pain free to achieve that. achieve that.

THE OBJECTIVE IS NOT FREEDOM THE OBJECTIVE IS NOT FREEDOM FROM PAINFROM PAIN

IT IS TO LEAD A NORMAL LIFEIT IS TO LEAD A NORMAL LIFE

PAIN CANNOT BE CENTRE STAGE FOR PAIN CANNOT BE CENTRE STAGE FOR NORMAL LIFE – NORMAL LIFE –

PAIN cannot be the determining factor PAIN cannot be the determining factor in what a person will or will not do …..in what a person will or will not do …..

The sooner you can shift the emphasis The sooner you can shift the emphasis in the employee’s mind and in the in the employee’s mind and in the treating doctor’s mind from pain treating doctor’s mind from pain intolerance to capability the sooner intolerance to capability the sooner you will have your employee working you will have your employee working effectivelyeffectively

The ‘One’ MessageThe ‘One’ Message

Keep talking about capabilityKeep talking about capability Praise achievementPraise achievement Look for small steps not big goalsLook for small steps not big goals Show confidence in the employee’s Show confidence in the employee’s

ability to overcome pain avoidanceability to overcome pain avoidance

Walk this talk with Walk this talk with

The employeeThe employee The supervisorThe supervisor Especially the doctorEspecially the doctor The rehabilitation provider (who The rehabilitation provider (who

should be doing it anyway but can should be doing it anyway but can become bogged down in the become bogged down in the emotions of a visit to the doctor emotions of a visit to the doctor situation)situation)

The Doctor’s PerspectiveThe Doctor’s Perspective

Always believes his patientAlways believes his patient Underlying fear that he might miss Underlying fear that he might miss

some crucial medical conditionsome crucial medical condition Does not want to disenfranchise his Does not want to disenfranchise his

patientpatient

Doctors don’t want conflict Doctors don’t want conflict

If you cannot persuade the doctor to If you cannot persuade the doctor to increase hours/tasks/reduce restrictionsincrease hours/tasks/reduce restrictions

ASKASK

When might it occur?When might it occur?

How could it occur?How could it occur?

What needs to be done to make it What needs to be done to make it happen?happen?

The treating doctor and The treating doctor and BARRIERSBARRIERS

The treating doctor may be the barrierThe treating doctor may be the barrier

Many do not have up to date Many do not have up to date knowledge of medical conditions and knowledge of medical conditions and base their diagnosis, causation and base their diagnosis, causation and treatment on old fashioned and often treatment on old fashioned and often failed strategies.failed strategies.

The employee may be very The employee may be very faithful/trusting of their treating doctorfaithful/trusting of their treating doctor

Suggest a ‘second opinion’ – but Suggest a ‘second opinion’ – but watch out for the nexus between an watch out for the nexus between an old fashioned GP and an old old fashioned GP and an old fashioned specialistfashioned specialist

You will need to persuade regarding You will need to persuade regarding a specialist with the skills you wanta specialist with the skills you want

The patient/employee who is The patient/employee who is accustomed to the restricted hours accustomed to the restricted hours and tasksand tasks

The treating doctor may be oblivious The treating doctor may be oblivious to the underlying agenda to the underlying agenda – BRING IT OUT INTO THE OPEN IN FRONT BRING IT OUT INTO THE OPEN IN FRONT

OF THEIR DOCTOR – CHALLENGE THE OF THEIR DOCTOR – CHALLENGE THE EMPLOYEE TO REJECT THIS SUPPOSITIONEMPLOYEE TO REJECT THIS SUPPOSITION

The employee who likes the day off The employee who likes the day off each week to each week to

– Sleep inSleep in– Have their treatmentHave their treatment– See doctorsSee doctors– RECOVERRECOVER

It may be the treating doctor’s belief It may be the treating doctor’s belief that their patient is so exhausted that their patient is so exhausted with working whilst in pain that they with working whilst in pain that they need ‘a day off to recover’.need ‘a day off to recover’.

THEY’RE MISSING THE POINT!THEY’RE MISSING THE POINT!

WE ALL WOULD LIKE A DAY OFF WE ALL WOULD LIKE A DAY OFF WORK (at full pay or even less than WORK (at full pay or even less than full pay) TO RECOVER FROM full pay) TO RECOVER FROM WORKING A COUPLE OF DAYS …. WORKING A COUPLE OF DAYS ….

WE ARE ALL TIRED AND WE OFTEN WE ARE ALL TIRED AND WE OFTEN ARE ACHINGARE ACHING

Couple of StepsCouple of Steps

Reinforce the aim is to return to Reinforce the aim is to return to normal lifenormal life

Propose the idea that if so tired after Propose the idea that if so tired after two days, that is not good in itselftwo days, that is not good in itself

Propose that shorter hours per day Propose that shorter hours per day should prevent such a level of should prevent such a level of fatigue/painfatigue/pain

Come up with a combination of hours Come up with a combination of hours for 5 days a week, but the TOTAL for 5 days a week, but the TOTAL hours is the same as employee has hours is the same as employee has been managingbeen managing

Doctors find the logic hard to reject Doctors find the logic hard to reject and will usually give it a tryand will usually give it a try

Don’t forgetDon’t forget

LOTS OF PRAISELOTS OF PRAISE MAKE THEM FEEL IMPORTANTMAKE THEM FEEL IMPORTANT

–BUT MOST OF ALL, MAKE BUT MOST OF ALL, MAKE THEM FEEL CAPABLETHEM FEEL CAPABLE

Questions for the Independent Questions for the Independent SpecialistSpecialist

DiagnosisDiagnosis

– Got to know what the working diagnosis Got to know what the working diagnosis is for the specialist, because all the is for the specialist, because all the opinions and recommendations must be opinions and recommendations must be logical in relation to this .....logical in relation to this .....

1.1. DiagnosisDiagnosis

Why is the employee experiencing the Why is the employee experiencing the symptoms?symptoms?

Is there more than one condition (incl. the Is there more than one condition (incl. the underlying etc etc)?underlying etc etc)?

What is the relationship between the What is the relationship between the condition and the employee’s work?condition and the employee’s work?

Why are the symptoms recurring/not getting Why are the symptoms recurring/not getting better?better?

2.2. Ability to workAbility to work

– Can the employee do normal work/hours Can the employee do normal work/hours now or in the future – what is the now or in the future – what is the expectation for recovery?expectation for recovery?

– What is their current capability if not What is their current capability if not normal hours/work?normal hours/work?

– Anything about current tasks, Anything about current tasks, equipment that is impeding recovery?equipment that is impeding recovery?

– Can anything be changed re. tasks, Can anything be changed re. tasks, equipment?equipment?

3.3. Psychological IssuesPsychological Issues

– Is there a discrepancy between what the Is there a discrepancy between what the employee complains about and the employee complains about and the medical condition/injury they have?medical condition/injury they have?

Every medical condition and injury has a Every medical condition and injury has a known set of symptoms and signs. Anything known set of symptoms and signs. Anything outside this should raise a flag of one outside this should raise a flag of one colourcolour or or anotheranother..

Ask about Ask about

–Symptom MagnificationSymptom Magnification–Pain BehavioursPain Behaviours

THESE ARE NOT THE SAME AS THESE ARE NOT THE SAME AS SAYING THE PERSON IS SAYING THE PERSON IS MALINGERING OR CREATING A MALINGERING OR CREATING A FACTITIOUS CONDITIONFACTITIOUS CONDITION

They are usually genuineThey are usually genuine They are often fearful/anxiousThey are often fearful/anxious They often believe that pain means They often believe that pain means

damage or injury or generally ‘Don’t do!’damage or injury or generally ‘Don’t do!’ They are often not aware that they are They are often not aware that they are

acting or thinking in a acting or thinking in a negative/abnormal/counter-productive negative/abnormal/counter-productive wayway

They often believe they are doing the right They often believe they are doing the right thing to recover – and some do not like to thing to recover – and some do not like to be challenged on this.be challenged on this.

PAIN BEHAVIOURPAIN BEHAVIOUR

Apparent that the person is in painApparent that the person is in pain Verbal and nonverbal – serve to Verbal and nonverbal – serve to

communicate the fact that there is communicate the fact that there is painpain

If you are getting the message that If you are getting the message that the person is in pain, most likely they the person is in pain, most likely they are manifesting pain behavioursare manifesting pain behaviours

– Moaning, grimacing, crying, body Moaning, grimacing, crying, body postures, facial expressions, shifting postures, facial expressions, shifting posture, limping, not using a limbposture, limping, not using a limb

– But also, history of medication each But also, history of medication each time in pain, ceasing activity to pursue a time in pain, ceasing activity to pursue a pain-related activity, not accepting pain-related activity, not accepting medical advice – 2medical advice – 2ndnd opinion, & 3 opinion, & 3rdrd, more , more teststests

SYMPTOM MAGNIFICATIONSYMPTOM MAGNIFICATION Vague, inconsistent historyVague, inconsistent history Inappropriate health care utilisationInappropriate health care utilisation Symptom complex inconsistent with conditionSymptom complex inconsistent with condition Functional limitations inconsistent with conditionFunctional limitations inconsistent with condition Disability more than indicated by conditionDisability more than indicated by condition Abnormal pain inventoriesAbnormal pain inventories Reported pain level inconsistent with Reported pain level inconsistent with

observationsobservations Reported functional limitations inconsistent with Reported functional limitations inconsistent with

observationsobservations Pain behaviour demonstratedPain behaviour demonstrated Non-physiologic findings on examinationNon-physiologic findings on examination

C Brigham, ACOEM, Advanced Topics, 1996C Brigham, ACOEM, Advanced Topics, 1996

ASKASK

For any outstanding pain behaviour For any outstanding pain behaviour or complaint or complaint

– ASK the DOCTOR ASK the DOCTOR --

–Why Is It Present?Why Is It Present?–What Can Be Done What Can Be Done –When Will It Stop?When Will It Stop?