Question
QUESTION: Dr. Ellis,

My doctor has recently told my employer that my injury appears to be a permanent injury!  

what does this mean?

ANSWER: Hello Mark,

I've taken some time to consider your question, and am now able to provide you with a response. Please be aware that this is my opinion only, and that I am only offering advice. You may feel that my answer is incorrect, or does not help much... and if so, I apologize in advance for this. However, you are free to act on my advice as you choose. I would also suggest that if you are still unsure about anything, after reading through my response, you seek a "second opinion".

I understand that you have experienced a back injury, and that you are in a situation now where your Doctor has informed your employer that the injury appears to be permanent. I have gained this information from your question, so assume that it is correct.

From the information you have provided, I can also deduce the following:
1. That you are employed by someone (e.g. a Company or Organization acting as your employer), as opposed to being self-employed.
2. That you have sustained a back injury that appears to have lasting effects.
3. That you have been receiving care and/or treatment from your Doctor for this injury.
4. That your employer has contacted your Doctor for information about the nature and/or effects of your injury (i.e. how it may impact upon your work situation).
5. That your Doctor has contacted your employer to say that your back injury is possibly permanent.
6. That YOU are concerned as to what all of this means.

I am going to attempt to provide a response to your question that is broken into stages. I hope that this will prove to be the most helpful solution, because I will be able to cover different aspects of your question. I will try to look at the following:
1. Why your Doctor has been in contact with your employer to say that your injury appears to be permanent.
2. How this may impact upon you at work, and what rights you may have.
3. What steps your employer may be required to take to assist you to effectively return to work (including what your Doctor can do to help).

Here goes...

1. PERMANENT INJURY - DOCTOR INFORMS EMPLOYER:
   Under current legislation, employers have what is known as a "duty of care" to their   
  employees. This means that should an employee find him/herself in a crisis (usually
  injury/sickness related, or else due to serious family problems e.g. bereavement) the
  employer is expected to be of assistance and to provide support. Where illness or
  injury is concerned, employers are obliged (where reasonably possible) to make
  accommodations so that the employee may retain their job.
   A Doctor will therefore inform an employer in cases where an injury has been sustained.
  There are various reasons for this, which have to do with the employer's obligation to
  provide support and assistance to help the employee safely back to work. If, as in your
  case, a potentially permanent injury has been sustained; it is important for the employer
  to be able to understand the possible impact of this upon your ability to do your job.
  Your Doctor may provide information to assist in this process. Your employer is then
  required to consider whether you can safely return to your original duties, or whether
  some adjustments might need to be made to take account of your injury and its effects.
  This could mean that you return to the same role, but undertake it in a different way (to
  accommodate the effects of your injury). It could mean that your employer negotiates a
  graded return to full duties (returning on reduced hours and slowly working up to full).
  It could mean returning, but to a different role (one that is easier for you to do, taking
  account of your injury).
   If your Doctor is conscientious and caring, he/she will wish to assist you in returning
  safely to work - and remaining there. Thus, your Doctor should liaise with your employer
  on your behalf, informing your employer about the nature and effects of your injury; and of
  any treatment. The information provided should be of a nature that assists your employer
  to support you in returning safely to work. It may include information about how
  long you are expected to stay off work. It may include information about what
  treatment you are having, and when (especially if you must attend medical
  appointments that necessitate more time off work). Clearly, your Doctor should be discussing   
  this with YOU as you go along.

2. YOUR RIGHTS WITH REGARD TO RETURNING TO WORK AFTER YOUR INJURY:
   As I have stated above, an employer has a duty to assist an individual in returning safely
  to work following an injury such as yours. This means that YOU have certain rights. These
  are intended to protect your job security to a certain degree. Clearly, an employer cannot
  simply "sack" or dismiss you for having been injured - this would be a VERY unwise thing to
  do. Remember that it is LEGISLATION which obliges your employer to assist you to RETURN TO
  WORK. The employer must make serious efforts to assist you back to work, and this must be
  undertaken in a thoughtful, sympathetic, supportive and conscientious manner. The employer
  MUST consider ALL the available options (i.e. return to original role/return to amended but
  original role/return gradually/return to completely different role... etc.). They must
  demonstrate (if asked) that they are making every effort to assist you to come back to work.
   Given that you are entitled to a certain degree of protection, you are also entitled to
  participate fully in negotiating a return to work with your employer. This means that you
  have a right to attend meetings to discuss your return. It also means that you have a right
  to know what information your Doctor has provided your employer with, and to ask to see it
  (ideally, a good Doctor will let his/her patient see any report that he/she intends to send
  to an employer before it is sent - this is to try to avoid inaccuracy).
   However, it is prudent to remember that your rights are not inexhaustible. Employers are
  NOT obliged to "bend over backwards" to accommodate. You should be willing to participate
  fully in negotiations, and prepared to accept your limitations. Any accommodation your
  employer makes should be one that enables you to participate fully in work, and YOU must
  be willing and prepared to participate as fully as you can. What this basically means is
  that an employer cannot be forced to make an accommodation that would prove excessively
  impractical or unproductive. You should still be able to perform the duties of any job you
  are given to do.      

3. STEPS AN EMPLOYER SHOULD TAKE TO ASSIST IN RETURN TO WORK:
   The employer, as I have stated above, requires information about the nature and effects of
  your injury so as to be able to effectively assess potential effects upon your ability to
  return safely to work. Employers are required to make every reasonable effort, short of
  undue hardship, to find an accommodation for an employee with a disability.
   The employer must investigate whether you can return to your existing job, as it is, or
  whether you might return to it if it were to be "modified". The employer must also
  investigate whether another position/role in the workplace might now be more suitable for
  you. This will involve gathering evidence from you, and also from your Doctor, that explains
  your injury and its effects, and looks at what you will be able to do within the workplace
  without exacerbating your injury, or suffering ill-effects.
   It is prudent and conscientious for YOU to be fully involved in this process. Not only does
  this demonstrate that you are willing and eager to return to work; it also ensures that
  you are fully able to contribute to any discussions about a return, and are kept up to date.
    Your employer should consider the ways in which you could be assisted to do your job (if
  you need such help). These could include technologies (e.g. a voice operated computer for a
  blind person, or a special ergonomic chair for a painful back). It could mean simply staging
  a graded return to full duties, if this will help ease you back into work. It could involve
  agreeing that you may take time off work, without risk of punishment, to attend necessary
  medical appointments. It might mean looking at ways in which you can help yourself, such as
  sitting down to do something that once you did standing; or taking more regular breaks. It
  might mean negotiating to allow you to wear a back brace at work, or use a "Tens machine",
  or perhaps have a cushion on your chair to ease your back pain. These (and more) are all
  things that it is prudent to raise, and to discuss as options. (You and your employer may
  well come up with other solutions - it is there for you and your employer to negotiate).
   If changes are needed to your role, or if you need assistance (e.g. an ergonomic chair),
  your employer should also be prepared to conduct assessments to look at the overall impact
  of such things on the whole working environment (to ensure they are practical and
  sustainable solutions). Again, your Doctor may be required to provide information to
  assist in this process.

I do hope that my response is of some assistance to you. I have tried to cover as much information as I possibly can (without being too long-winded). I am sorry that there is so much to read, but I really did wish to be as informative as I could. I know from personal experience that returning to work after an injury or major illness can be a stressful and worrying time. I do hope that the information I have given you makes it somewhat easier.

I would also SERIOUSLY ADVISE that you READ THE FOLLOWING article that I found on the Internet. It is VERY INFORMATIVE, and, I think, covers many aspects relating to your circumstances. You can find the article at:
www.blindcanadians.ca/publications/cbm/8/accommodating-disabilities-canadian-workplace


Oh, and by the way... If by any chance you SUSTAINED YOUR INJURY WHILST AT WORK, then it is VERY IMPORTANT that you discuss this matter with your Doctor. Clearly, there will be LEGAL IMPLICATIONS, but it will be up to you as to whether you wish to make any sort of claim. I would advise that IF THIS IS THE CASE, you seek the support and services of a SOLICITOR.

I hope that I may have been of some assistance. Wishing you all the very best, and a safe return to work.
Regards,
Elaine Ellis.


---------- FOLLOW-UP ----------

QUESTION: Elaine,

Thanks for the insight!

Here is my problem in a nut shell.

I injured my back and was told by several work doctors that I sprained my back with multiple injuries and that I had a rib pop out!

When I re-injured my back I was sent to another doctors office that works for the company and they told me the exact same thing.  I found this to be a little odd and decided to go to my own doctor at Kaiser and was given x-rays.  They told me I fractured my rib at the T6 level about a few milimeters away from my spine.  The problem started when the pain never went away!  

I was then sent to an orthopedic doctor and was given an MRI of my thorasic and lumbar spine.

On my Thorasic spine they only showed that I had mild disc digeneration at the T7 level and my lumbar I had minimal bone spurs on my L2, L3, L4 as well as small bulging disc:

L2-L3 1mm bulging disc
L3-L4 1mm bulging disc
L4-L5 1mm bulging disc
L5-S1 2mm bulging disc

The workmans comp doctor told me to take Tylenol and Advil and placed me back on full duty.  

and to add to this I have some really bad pain that has not gone away for the last 2 1/2 years now.  When I begin to try and lift something heavy or if I try to do anything physical it hurts me really bad to the point where I literally have to stop what I am doing!

My job is working with the utility company climbing utility poles and the work is extremely demanding.  My problem is...how am I supposed to do my job safely if I have to stop what I am doing and without my back hurting so bad I literally want to cry!  I understand that pain is subjective, but there has to be some kind of test that can be done in order to prove my problems.

I was also sent over to do some Range of Motion and lost ROM on my neck, right shoulder and spine.

I really need help!

Answer
Hi Mark,

Thanks for the follow-up. I've read through what you say, and first of all, allow me to express my deep sympathy. It sounds like you have gone through a really unpleasant and unfortunate time. Life often seems to be somewhat like this - problems come in the multiples, and little seems to run smoothly.

Anyway, I am glad that at least you had the common sense to seek a second opinion following the further injury to your back. I hope that this means that you are on the right track now, with regard to diagnosis and treatment/management of your medical condition.

I can very much understand what you say about the nature of your job, and the impact that your injuries, and associated pain, have had. It must indeed be very difficult for you to manage such work, given that the very nature of your job requires a lot of physical exertion, and a high degree of agility. I appreciate that you may well experience an unpleasant amount of pain.

It sounds to me (and this is just my opinion) that you began with the fracture to your rib, causing pain. This may initially have been a manageable pain in the long term, but for the fact that it turned out you also had some degeneration in the condition of your thoracic vertebrae. Pain from the injured rib would, indeed, have been only normal - and as the rib healed, it would have been expected that the pain decreased proportionally.

In your case, I would suspect that many (if not all) of your current pain issues are related to the underlying degenerative problem that was discovered. I accept that you understand the degeneration to be mild in nature. You write that it is "mild disc degeneration" as well as "minimal spurs" and "small bulging discs"... You do NOT tell me when this investigation took place (i.e. the date)... OR whether there is any likelihood that further degeneration may have occurred since.

Again, I can only give my opinion (so you may wish to seek professional advice - i.e. check it out via your Doctor)... However, I would hypothesize that, because you are undertaking a physically demanding job - one in which you are expected to climb utility poles, and also to bend/stretch often, and lift weighty objects - this will have some impact on the problems you experience with your back. Where there is damage to discs and/or vertebrae, it cannot be expected that this will improve significantly, if a person continues to place demands upon their physical ability.

Look at it like this... Any individual who experiences injury to a particular area is both sensitive in that area, and wary of doing further damage. Whilst the initial damage heals, they may suffer pain, and limited range of movement. They will naturally wish to protect that bodily area.

In your case, you suffered an initial rib fracture, which is probably now fully healed. However, further investigations also revealed stress/damage to your spine, which appears to be more permanent in nature (I think this is why your Doctor told you that your condition is permanent). Unfortunately, you do a job that places physical demands on your body, and may well therefore exacerbate any pain caused by your spinal condition.

Here, I can only make some recommendations, as it is up to you in the long run to make a decision as to what you believe to be the best course of action. However, I am trying to think in a common sense way, and wish to offer you as many alternatives to think about as I can. That way, you are able to fully think things through, and weight up all the "Pros and Cons":

1. Seek further advice and assistance from your Doctor. There are various reasons for this. First of all, if it is correct that the damage is permanent, you will benefit from knowing the likely prognosis (i.e. long term effects and outcomes). It would be prudent to ask about different types of treatment/management and their likely impact. You need to check out what it is that your Doctor thinks can be done; what may benefit you. You also need to know of any potential problems or side-effects. Ask to talk openly and thoroughly (book longer {double?} appointments if necessary) so that you can discuss all that you feel needs to be discussed with your Doctor. If you feel it may benefit you, write down the things that you wish to ask your Doctor, or talk about. Try to find out what options you have; whether they be medication, surgery, physiotherapy, chiropractor. You need, with the help and guidance of your Doctor, to put a plan of treatment and possible recovery in place.  

2. Make sure you know exactly what it is that you are suffering from, and ensure that your Doctor keeps you up-to-date. Ask that your Doctor help you by liaising with your employer - keeping your employer informed as to your diagnosis, symptoms and treatment. The better your Doctor can work effectively alongside your employer, the more likely it is that you will be able to remain safely at work. You need to be able to explore various options with the help of both your Doctor and employer. These include looking at such matters as whether you might benefit from time off work to recuperate more fully. Whether you might benefit from reduced hours, or reduced duties. Whether any adjustments can be made so that your job can be done without badly affecting your back. Whether you might benefit from transferring to a job with different duties, to safeguard your back. Such conversations as these need to take place in an atmosphere that is open, honest and supportive. As I said, your employer has a duty of care towards you, and the desired outcome is that you remain productive and in some form of work.

3. Discuss frankly with your Doctor your present situation (i.e. the pain and impact on work). This should give your Doctor some idea of the effect of your back problems upon your employment. Again, the Doctor should be there to assist you, on the understanding that you do wish to continue working, and stay productive in a job. You need to be able to ask your Doctor frankly about the type of tests that are available; both to diagnose and evaluate the progress of your spinal degeneration (if it continues to deteriorate), as well as to look at the impact of your back problems at work. You would be correct in understanding that such tests are a necessary past of evaluating your ability to continue in your present job, given your back injury. Tests should also be able to demonstrate what you are capable of doing, and thus inform discussions about the nature of work, or adjustments to work, suitable for you.

4. Try thinking of ways in which you might help yourself. This may be ways of doing your job tasks slightly differently, so as to have less impact on your spine. For example, think about how you lift objects. Could you change this to have less impact? Could you use equipment to aid you? Think about when you take your painkillers, how often and how many. Are there more effective ways to manage pain? Are there more effective painkillers? Could you take your tablets at different times of day, or in such a way as to make their impact more long-lasting, or more targeted? Things like this are what you need to discuss with your Doctor and employer.

5. Try to access information about other job roles within the utility company. Look at these, and compare them with your role. Are there jobs that you could do more easily, and that would not affect your back as much? Are there any vacancies? If you moved to a different role, would you get training? What might be the impact, for example in terms of hours, location or pay? If you need to discuss such matters as this along the way, you might be able to seek advice from your employer's H.R. (Personnel) department. They are best placed to know about roles and recruitment.

6. Try to access information about "alternative" or "complementary" therapies. Some people find Acupuncture to be helpful for pain. Others try massage, Yoga, Pilates, and so forth. I accept that such therapies as these are not necessary medical, or scientific, and that for said reasons some people do not view them as valid. However, always remember that WHAT WORKS FOR YOU, WORKS FOR YOU... simple as that. If you feel that such therapies might be for you, then why not check them out. Always involve your Doctor, and let them know what you are considering. Your Doctor may be able to tell you if there are any "Pros & Cons" to a particular therapy. You will also want to know if it has any interaction with treatment recommended by your Doctor (of course, negative interactions are to be avoided!).

7. Finally, if you have any support services available to you, try to get them on board. Workplace Unions can help you to negotiate discussions with your employer. Support groups for people with back problems may mean you meet people in similar situations as you, share experiences, and discover new insights into treatment and managing your illness. Ask about for information on such services near you.

8. Make sure you have support from family and friends. If you feel you can talk easily and openly, do so. It is always good to have loved ones "on board", and by keeping them informed, you try as best you can to avoid any nasty surprises (i.e. they know where you are at, so cannot pressure you to do more than you are able). They will more easily understand your pain, worries and moods, and this may enable them to assist you more effectively. Besides, you never know if they may be the very people to come up with a treatment suggestion, or recovery hint, that really helps, and works for you. Everyone has valid life experience!

I truly hope that you have not felt daunted, or bombarded, by the amount of information I have tried to provide. It may be sensible to read through this response in stages, and more than once, to help make sense of the best options for you. In the meantime, be persistent, and keep an open mind. Maintain dialogue with people who are important, and who can assist. Stay strong. Illness and injury can be worrying and frustrating. It takes patience and determination to stay on the right track.

All the very best,
Elaine Ellis.