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Appendix 
The appendix is included to save you time. It begins with a letter to increase understanding about work recommendations that can be provided to both the patient and whoever is involved in limitations at work (employer, insurance company and personnel).  The next page is the actual limitation recommendations made for the patient who insists that continuing with normal activity is impossible.  The third page will markedly reduce work made for you by insurance systems.  You can reassure them that you do not decide whether a patient can or cannot work but provide limitations.  When confronted with job analysis or activity assessment for your blessing or condemnation, the form letter along with the last limitations on the Work Recommendation form allows your position to be crystal clear.  I usually make out such recommendations only in the presence of the patient to avoid misunderstanding and open the door for dealing with showing my concern for the patient's dilemma (see Slow Recovery Approach - Validation and Reflection). 
 
Patient Activity Handouts are also included along with Patient Discussion Handouts for your use.  All can be reproduced as long as proper citation is included.  Please do not change without permission. 
 
Activity Handouts 
General Endurance Patient Handout 
Specific Back Muscle Conditioning Handout 
Upper Back Reconditioning 
NON-TREATMENT SYMPTOM CONTROL 
   Legs Reconditioning  
   Arms and Abdominal Reconditioning  
   Work Limitation sheet 
Clinician letter about Limitations at work  
Understanding Work Limitations 
Approach to Care and Documentation 
 
Musculoskeletal Information Resources 
 Cochrane Collaboration & Non-Back links  
  
Patient Discussion Handouts 
Handout 1:  Back problems - Yes or No?  First visit 
Handout 2:  Seeking dangerous reasons for slow recovery . . .   Before special studies 
Handout 3:  Overcoming your back problem  Activity Begets Comfortable tolerance 
Handout 4:  When activity and time is not helping  Considering Work Options 
 
Explanation of Handouts 
  Four discussion handouts for patients are provided.  They are sufficiently specific to address a full range of patient concerns.  The patient's focus tends to change during treatment.  Early concerns may focus on comfort, or fear of potentially dangerous causes of low back symptoms. Later, questions about special studies, procedures, and diagnoses may arise.  The few patients having trouble overcoming their activity limitations may have to consider the relative benefits either of conditioning more vigorously or of changing their activity goals.  These handouts are not intended to stand alone for all patients.  Rather, they are designed to foster the clinician's discussions with patients about important issues, as needed. 
 -   The first discussion handout is intended to prepare the patient for treatment recommendations. It can be provided to all patients if no serious condition is detected ( Handout 1:  Back problems - Yes or No? probably at the first visit). 
 -   The second discussion handout, which is only useful for the 10 percent of patients who are slowest to recover, helps patients understand about the use of special studies to seek dangerous reasons for symptoms and the potential for diagnostic confusion. Handout 2:  Seeking dangerous reasons for slow recovery . . . 
 -   The third discussion handout is for the same 10 percent of patients after dealing with further diagnostic considerations and perhaps surgery. It helps the patient understand the change in focus from merely caring for symptoms and avoiding debilitation to building comfortable activity tolerance through safe conditioning exercise. Handout 3:  Overcoming your back problem 
 -   The last discussion handout is only for those patients who, for whatever reasons, are experiencing difficulties in overcoming their activity limitations. It allows the clinician to help the patient develop an understanding of available options. If the patient is failing to overcome his or her limitations and seeks no other alternatives, the clinician has an avenue to further address potential nonphysical pressures (e.g., psychological and socioeconomic) that can complicate overcoming a reduced activity tolerance due to low back symptoms. Handout 4:  When activity and time is not helping 
 
 
 
 
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