Discussion

Pain takes a significant toll on individuals, on families, and on society. In part that damage is mediated by the loss of occupation, and the unwelcome distortion of roles, of financial capability, and of purpose. We judged that the effects of work on pain, and equally of pain on work, are becoming invisible. There is too little serious academic study on what are major drivers of modern society and well-being. This book draws together leaders in their field to teach us how we can re-conceptualize our response to the current challenges in the field of pain and work. Our final chapter comprises a conceptual and analytical map of the forces of change in work, occupation, and pain management. We use this to suggest directions for research and policy and how we can innovate, as we find better solutions for managing one of the most significant health burdens of our age.

The psychology of pain-related disability: Implications for intervention

Research over the past two decades a pointed to a number of pain-related psychological variables and mental health conditions that impede recovery following musculoskeletal injury. This chapter briefly reviews evidence suggesting that pain-related psychological variables such as recovery expectancies, self-efficacy, pain catastrophizing, perceived injustice, and fear-avoidance beliefs, depression, and post-traumatic stress disorder (PTSD) play a significant role as determinants of work-disability in individuals with musculoskeletal conditions. Although significant advances have been made with respect to the identification of psychological variables that contribute to prolonged work disability, what has lagged is the development of risk-targeted interventions to promote occupational reintegration. Although numerous clinical trials have shown statistically significant changes in pain-related psychological risk factors, the clinical significance of observed changes has been questioned. The development and evaluation of risk targeted interventions aimed at promoting occupational reintegration in work-disabled individuals will need to be a priority for future research in this area.

Pain, employment, and policy

As we have seen, the invisibility of pain can make it very difficult for those living with it to get recognition, support, and treatment. This is not just a challenge in workplace or clinical settings, however. Chronic and work-limiting pain in the working age population can also find itself in a policy blind spot, falling between often competing policy ‘silos’ for attention, resources and—perhaps most crucially—joined up and coordinated action. In this chapter we look at the policy landscape within which those living and working with pain are often having to vie for these resources. We will look at some of the policy ‘levers’ and incentives which might be used to improve both clinical and work outcomes for those living with pain, and we will look at some international examples of initiatives which offer some hope that practical solutions can be found.

The impact of chronic pain on school functioning in young people

School plays a central role in young people’s lives, offering a developmental environment that fosters crucial academic, emotional, cognitive, and social milestones. This chapter presents a critical discussion of how a young person’s school functioning can be negatively affected by chronic pain. We highlight how the impact of chronic pain, and associated psychosocial factors, goes beyond school absenteeism to influence school engagement, executive functioning skills, and social skills development. Furthermore, the challenges teachers face to provide an inclusive school environment for young people with chronic pain will be discussed in depth. The chapter ends with suggestions of how to overcome the barriers to implementing a comprehensive approach towards school functioning within both research and clinical practice, including reviewing standardized tools to assess school impairment and offering guidance for biopsychosocially informed approaches to foster adaptive school functioning in young people with chronic pain.

Introduction

This chapter sets out how the book achieves its aim of providing an authoritative, thought-provoking analysis of the relationship between all forms of occupation (school, employment, later life production) and pain. We begin with a brief introduction to why this aim is important, and show what a consideration of work and pain can offer. We introduce our life-span approach and scope of the book, covering Foundations (what is work, what is pain, how do they link), Investigations (into the interactions between pain and family life, learning, emerging adulthood, the occupational health workforce, and later life), and Interventions (from psychological, workplace, and policy-making perspectives). We signpost readers to our Discussion in which we bring together the book’s findings in a conceptual and analytical map of the forces of change in work, occupation, and pain management to suggest future ways of thinking about policy, practice, and research agendas.

Lives lived longer: Chronic pain, subjective well-being, and occupation

We are living longer. Later life for many will be characterized by learning to live with pain, and how to live well despite pain. Theories of adjustment are reviewed with a focus on the dual process model of coping, which puts all attempts at coping with adversity within in a developmental and ageing framework. Examples of how one comes to negotiate what is possible, desirable, achievable, and allowable in later life occupation are explored. Finally, a consideration of this new age is discussed with its implications for identity and for social change.

Chronic pain across the life span

Pain can be thought about at individual, social, and global levels and discursively defined in different ontological and epistemological ways. There is presently no absolute agreement about how to define it. However, there are movements to bridge the sufferer–observer, subjective–objective gap, and to think about pain from a functional perspective as opposed to conceptualizing it simply as an experience. Key conceptualizations of pain focus on its embodied nature and its extant function in protecting the organism from threat. Many epidemiological studies and systematic reviews define pain via International Association for the Study of Pain and International Classification of Diseases criteria, and show the extent of the global pain burden. Pain has many negative consequences across the life span, including a distinct impact on people’s working lives. How pain is conceptualized has important implications for clinical, research, and policy agendas. The embodied view of pain as an action against uncertainty means that if we are to reduce pain intrusion and interference (including whilst we work, or more broadly occupy ourselves) we must attend more deeply to how people manage threats to identity and coherence. We need clearer agendas to seek better pain-relieving resolutions than we achieve today.

Managing pain-related limitations in the workplace: The role of the employer

The main focus of this chapter is on pain-related work limitations (PWL), and in particular on the role of the employer and the challenges of implementing change in an occupational environment often focused sharply on profit and the avoidance of litigation. It will be argued that full and appropriate engagement in a healthy and motivated workforce is in everyone’s interests, although changes in the types of work, in working conditions, and in increasingly diverse work practices, represent real challenges in the design of interventions and their implementation in practice. In this chapter we begin with a description and attempted quantification of the burden of PWL. We then offer a review of the major organizational processes, the influence of management structures and prognostic factors before considering workplace interventions, and the influence of health/social policy. We conclude with a series of recommendations for an integrated approach to the management of PWL.

Workers with occupational pain

Occupational pain is pain caused by occupational activities. Most pain that is labelled occupational originates in the musculoskeletal system, for instance occupational back pain and upper limb pain. The additional diagnosis ‘occupational’ is important for treatment, prevention, and compensation. Workplace interventions such as ergonomic improvements can resolve pain or prevent pain in workers. However, studies of prevention of back pain and prevention of upper limb pain do not show major effects. Changes in working life such as the advent of computers have led to an increase in occupational pain. Preventive ergonomic improvements probably have effectively reduced these increases since then. Better evaluation of ergonomic intervention as part of treatment is needed. For prevention, studies with large numbers of participants are needed. Regulation should be more flexible and be adaptive to progress in science.

Emerging adulthood: Millennials, work, and pain

Millennials, born from 1980 onwards, may differ in important ways from previous generations. Differences have been explored in personality and occupational psychology, but largely ignored in medical and clinical psychology. Chronic pain, which peaks in incidence during puberty, can have negative effects on adolescents socially, emotionally, and physically. If unresolved, it may persist into adulthood, limiting opportunities. This brings challenges in understanding what it means to have chronic pain as a millennial and how this impacts on expectations and actions. In this chapter, we explore what we know from research on the millennial generation, including how millennials engage with work and with health care, and how an understanding of millennial generational features can help us determine how young people cope with pain. Finally, we consider what it means to be a millennial health-care provider, all within a generational framework.