Pain in the back and work: Guidance for employers, patients and doctors on helping people with back pain return to work
October 2010

1. Assessment of the key, psychosocial barriers to successful rehabilitation
    
2. Development of an action plan to provide comprehensive treatment to address these barriers
    
3. A coordinated approach involving of healthcare workers, employers and patients to prevent work loss
    
4. A recognition that a return to full engagement in society, including work, is beneficial to health of those with chronic pain

Pain is a common experience, everyone has experienced it at sometime in their lives; it is usually self limiting and improves. For some pain will persist and most of us will experience chronic pain (lasting longer than 12 weeks) in our lifetime.

Pain is complex, significant damage may or may not result in pain, and moderate to severe pain can exist in the absence of significant damage or pathology.

We now understand that pain is an interpretation of incoming stimuli some of which are associated with damage and some which are benign but interpreted in terms of threat and injury.

Furthermore ethno-cultural differences exist in pain threshold in experimental studies, and in pain intensity and distribution in the clinical setting. Many people who have chronic pain do not become severely disabled by it, disability due to chronic pain is better explained by psychosocial rather than clinical factors.

The failure to adequately manage chronic pain has been called a modern healthcare disaster. The cost to the public purse of musculoskeletal pain is greater than any other condition.

The cost of low back pain alone in 1998 in the UK was estimated at £12.3 billion, the majority of these costs, around 80%, were not associated with healthcare but due to lost work production and associated wage replacement benefits.

These figures demonstrate the importance of maintaining people with chronic pain in useful employment. The role of healthcare practitioners in sanctioning work absence has been investigated and this has demonstrated that the health service is currently ill equipped to manage work loss in people with chronic pain and may in itself contribute to the high societal costs.

Studies on the long-term unemployed have demonstrated that they can be successfully returned to work and this formed a base for the Pathways to Work initiative by the UK Government. Attention has now turned to helping people who experience pain in the workplace and an evidence based review informs how the psychosocial factors which lead to work absence should be managed through a coordinated approach involving patients, employers, health providers and funders. This evidence based approach will be made available free to all interested parties soon after this inaugural lecture.

All pain is not the same. There are gender differences in chronic pain. Treating both physical and mental symptoms is best.

Women experience chronic pain longer, more intensely and more often than men, according to a psychologist who works with both men and women dealing with diseases and conditions that leave them suffering.

"Chronic pain affects a higher proportion of women than men around the world," said Jennifer Kelly, PhD, of the Atlanta Center for Behavioral Medicine. "We need to encourage women to take a more active role in their treatment and reduce the stigma and embarrassment of this problem."

Pain is considered chronic when it lasts six months or longer and most medical treatment options have been exhausted.

Chronic pain conditions that are more prevalent in women than in men include fibromyalgia, irritable bowel syndrome, rheumatoid arthritis and migraines.

Women are also more likely than men to experience multiple painful conditions simultaneously, which can lead to greater psychological distress and greater likelihood of disability, according to the report.

Hormones may be to blame for these differences, said Kelly, who added that estrogen clearly plays a role in conditions such as migraines. Rates of other painful conditions increase for girls as they pass through puberty whereas rates for adolescent boys are stable or rise less steeply.

"Pain perception does vary according to the menstrual cycle phases in women with chronic pain," said Kelly. "For example, temporomandibular [jaw] pain, or TMJ, is highest in the pre-menstrual period and during menses."

As for treating pain, studies have shown men and women experience different side effects of analgesic medications. There have also been studies into whether men respond better to opioid medications, but the findings are ambiguous at best, she said. However, research has shown that there are numerous factors involved in response to pain medications. "Genetic and hormonal differences may be the main reason for any differences, but it's becoming increasingly clear that social and psychological factors are also important," said Kelly.

In her practice, Kelly treats the social and psychological factors in dealing with patients with chronic pain. She has made many observations of how women handle pain differently than men.

"Women tend to focus on the emotional aspects of pain," she said. "Men tend to focus on the physical sensations they experience. Women who concentrate on the emotional aspects of their pain may actually experience more pain as a result, possibly because the emotions associated with pain are negative."

Kelly offered these tips for better treatment of patients with chronic pain, especially women:

1. Encourage patients to take an active role in their treatment and in caring for themselves, such as eating well and getting exercise
    
2.  Provide psychological support
    
3. Explore cognitive coping strategies
    
4.  Offer relaxation and biofeedback training

Depressed patients may also benefit from psychotropic medications, she said, but antidepressants should not serve as a replacement for psychological intervention.

She advocated for cognitive coping strategies that work on changing the thoughts associated with the pain. "If women can see the pain as something that can be managed and something that they can work with, then they can make more positive modifications in their life and become more functional," she said.
 

Bibliography - Sources

1. University of Leicester
2. American Psychological Association
3. Atlanta Center for Behavioral Medicine