1. Chronic pain and return to work
A Case Study
Andrea James
AFOEM June 2018

2. Work related shoulder injury
45 y.o male operator at a cement manufacturing and distribution plant
Work related right shoulder injury after forcibly turning a valve
Diagnosis: bursitis and impingement
W/Claim accepted promptly, company self insured, RTW coordinator appointed
Treating GP certified worker as fit for modified duties, full time hours, day shift only
Patient reported high levels of constant pain, lots of time off work
6/12 conservative treatment including two steroid injections, physiotherapy, NSAIDs, occasional opioids
No improvement and referred to a surgeon.
Surgery at 8/12 after injury
Yellow flags – pain avoidant behaviours, prior Hx of slow recovery due to chronic pain after a muscular back strain, worker’s beliefs about work/exercise aggravating condition
Red Flags – nil
Blue Flags – relationship with LM not great, disgruntled about recent changes at the worksite

3. Return to work post surgery
4/12 post operatively certified as fit to return to a graded RTW (12 hours/week) light duties in a control room gatehouse
Over next 6/12 chronic pain and sleep disturbance
GP treating pain with increasing doses of oxycontin and endone
No increase in work capacity
OP appointed by employer. OP liaison with GP - led to referral to a pain management specialist
Yellow flags – ongoing pain avoidance behaviours, worker resistant to increasing hours, ?due to new family responsibilities, length of commute to and from work, symptoms of depression becoming apparent
Red Flags – nil However, should chronic pain and opioid use be regarded as a red flag?
Blue Flags – colleague attitudes to worker’s incapacity and length of time for recovery

4. Pain Management Program
Treatment: multi disciplinary approach - tailored for this patient
- pain specialist, physiotherapist and psychologist,
Medications at various times: Fentanyl patches, tapentadol SR (Palexia) oxycodone/naloxone (Targin), gabapentin, endone for break through pain, celoxicib, duloxetine (Cymbalta)
OP engagement with worker to address occupational factors and psychosocial factors, liaison with all parties
Pain specialist addressed medications/pain education
Psychologist and physio addressed pain behaviors/responses to pain/sleep
GP involvement maintained (mainly COCs)
Yellow flags –pain avoidance behaviours addressed by psychologist, worker resistant to increasing hours, other psychosocial factors addressed by OP in conjunction with manager
Red Flags – nil
Blue Flags – addressed by manager and RTW coordinator

5. Return To Work
Over the next 6/12 gradual increase in work capacity commencing with a graded increase in hours and then additional duties
RTW full duties
Key issues:
Early identification of chronic pain
Pain control - medications, addressing pain behaviors and responses to pain
Coworker and LM responses to a worker with chronic pain
Mental health comorbidity and pain impact on sleep
Insidious development of psychosocial factors
Availability of suitable meaningful duties