Rehabilitation in Workers Compensation

By Dr Coralie Wales, Pain Educator, Rehabilitation Counsellor and President Chronic Pain Australia

One of our members who was very distressed in her job felt that the Workers Comp people were not listening to her. With a little bit of encouragement, this lady started to set some goals and took control of the situation. She set a return to work date and started an activity program at home including some clever movements that simulated some of her work activities, at a very low level indeed. She did two lots of these movements at first (each for 5 minutes at a time) and gradually built these up over the weeks she was off work to a level that was practical and useful in the workplace. She then adopted an assertive approach in which she took control of her own situation (not aggressively, but respectful of her own and others' needs) to negotiate the work duties she felt confident she could achieve. It was successful, the workplace was happy, Workers Compensation was happy, and so was the client. This lady went back to work according to her plan and is managing her pain beautifully. She even set a goal to give up cigarettes, and she has achieved that too!

Some of our members will be experiencing pain whilst trying to maintain or return to work. Their pain may have occurred as a result of an injury at work, or a car accident or misadventure on the way to or from work. As it is associated with work, a Workers Compensation system exists in all states of Australia, to protect workers rights, and to ensure that their income continues if they are having difficulties maintaining or returning to work. Many of our members in pain tell us about the challenges they face when participating in Workers Compensation schemes. Chronic pain (persistent pain is another term used to describe long term pain) is very poorly understood in Workers Comp systems. This is because the tradition for such claims is that there must be a medical diagnosis for the claim to be seen as "legitimate". This is fine if the persistent pain is due to an injury that hasn't healed, or a traumatic injury like a crush or fracture that is really bad, gets infected or some other nasty scenario. But the reality is that minor injuries that are classified as "strains and sprains" can heal but leave ongoing pain. In fact, in NSW alone minor injury claims which resulted in permanent impairment cost a staggering $109 million (WorkCover NSW 2008). It is these cases that provide doctors with a real challenge, as they are expected to note a diagnosis and traditionally "Persistent Pain" is not considered to be a diagnosis.

Another problem is that in cases of persistent pain due to a minor injury, some health professionals can give the impression that the pain "is in their heads", "they should just get on with it" and other such unhelpful comments or insinuations. We actually know that there are nervous system changes that occur the longer that pain continues, which then start to contribute to the pain experience. And guess what, chronic stress, which occurs when a claim becomes the subject of an argument, makes pain much worse.

However, if you are in such a situation, it is important to know what you can do to facilitate your own healing process. Firstly, you may be referred to a "rehabilitation provider" who is given the task of managing your rehabilitation needs. This person will be a health professional, qualified at University, perhaps an Occupational Therapist, a Physiotherapist or a Rehabilitation Counsellor or a Psychologist. Their role is not to provide treatment as such, their role is to assess your needs and then recommend to the insurer what treatment you need to recover from your pain. The way these systems work, you are supposed to have access to a rehabilitation provider quite early, but unfortunately, if there has been a minor injury (so called), i.e. if you haven't had a fracture or dislocation or something like that, you may not be offered that referral to a provider.

Very importantly, you may be referred for an exercise program. Not all exercise programs are the same! Before commencing any exercise program it is best to discuss what exercise is appropriate for your condition with your health professional e.g. GP or a trusted physiotherapist.

Australian health authorities recommend that everyone, regardless of whether or not they have persistent pain, should aim to do at least 30 minutes of moderate intensity physical activity everyday. This doesn't mean however that you would necessarily start on 30 minutes. If you have been out of action even for one or two months, you will have to start small and build up! Many people start on levels of 5 minutes or less, then gradually build up over time. Examples of moderate exercise activity could include a walk or cycling or hydrotherapy (exercise in warm water usually under supervision). Click here to go to Exercising with pain.

Unfortunately, some exercise providers you may be referred to in Workers Compensation systems do not understand this principle. It is important that you do! If you are referred to a gymnasium, for example, it is important that you feel confident that the person who is supervising the program is an expert in chronic pain, and has explained the physiology of the SENSITISED CENTRAL NERVOUS SYSTEM. Ask them about it. Not all providers understand this important phenomenon and it is critical that the person selected to supervise you does. Go to ‘Explaining the Nervous System" to find out more.

Some people with persistent pain may fear exercise because it has caused them pain in the past or because they fear that they may be causing further injury. With reassurance and support from your doctor and a healthcare professional (e.g. physiotherapist) you can develop an individual exercise program that is more suitable for you. As you build strength, your pain can decrease. GO SLOW, you are more likely to succeed if you do. Going hard often leads to flaring up, then having to take time off then trying again too hard, flaring up, and so on. What a vicious cycle.

It is so important not to overdo your activities (pace yourself), especially on the days you feel ‘good' as this may make the pain worse the following day. If you do experience a flare up after exercise it might mean that you have increased too quickly or there may be a particular exercise that isn't right for you just yet.

There are well-informed exercise providers around Australia. Identifying them is the important part. There are physiotherapists help teach their clients set meaningful goals and then share some of the strategies necessary to gradually build up over time so that they can successfully and sustainably get back to their goals. It is best to get this kind of help earlier rather than later. Look for a physio who has a philosophy that each person is an individual, and that the client is the expert in their own pain, so there is a respectful relationship set up where the client becomes the decision maker about what exercises are right and what are not and the health professionals become resource people, teaching the client tricks and strategies to help then achieve THEIR goals. Ensure that your physiotherapist is trained to understand the Sensitive Central Nervous system. (Very important!). There are organisations these days who understand the nervous system and chronic pain. Ask questions of your health professionals to find out whether they are right for you. Click here to find out more about how to choose your health care team.