Best Practices


work-hardening

Expediting the Return to Work Process Using Work Conditioning/Hardening

Creativity, problem-solving, and assessment help forge the foundation for a work conditioning/hardening program.

 

 The American Physical Therapy Association (APTA) defines work conditioning or hardening as a “work related, intensive, goal-oriented treatment program specifically designed to restore an individual’s systemic, neuromusculoskeletal and cardiopulmonary functions. The objective of the work conditioning program is to restore the injured employee’s physical capacity and function for return to work.”1  Other therapists, case managers, and adjusters sometimes want to know how a work conditioning/hardening program is implemented. Their previous experience with work conditioning may have involved placing the injured worker on a bike or treadmill and having the patient perform supervised strengthening exercises. The idea that a work conditioning/hardening program is merely a conditioning and strengthening program must be dispelled. The overall objective of work conditioning is to restore the physical capacity and function of the worker to work fully and safely.

Who Is a Candidate for Work Conditioning/Hardening Program?

When determining whether an individual is a candidate for work conditioning, a variety of factors must be considered, including the physical demand of the job and successful completion of an acute physical/occupational therapy program. Injured workers with medium to heavy job demands are more appropriate candidates than those with sedentary job demands because their jobs are more physically strenuous. The worker also must be ready to begin job-specific, progressive endurance and conditioning exercises along with education about body mechanics and work safety guidelines. In addition, candidates for a work conditioning/hardening program should need minimal to no manual treatment, with modalities used “as needed.” The worker also must have demonstrated continued progression throughout the acute therapy sessions and have the motivation to return to work.

Outcomes That Compare Functional and Passive Programs

“Rehabilitation interventions that emphasize a functional Return to Work philosophy may facilitate a faster recovery and prevent injured workers from becoming unemployed. A review of the current literature suggests a direct relationship between workers’ demographic and disability-related characteristics and early referral to rehabilitation including a successful RTW program.”2  

Time Frame for a Work Conditioning Program

According to the Official Disability Guidelines (ODG), a worker must be “moving in a positive direction” to justify further treatment. Work conditioning program sessions are usually 90 to 120 minutes in duration. Per ODG, the number of visits is injury-specific, and they state the length of the program should be up to 4 weeks with an additional 2 weeks available depending on severity and other comorbidity factors, such as obesity, chronicity, and medical history. For the additional weeks, preauthorization may be required. These additional visits must be justified by diagnosis (eg, hand injuries), documentation of good participation and positive progress, and necessity to reach a vocational goal. Criteria admission for work hardening standards allows “for progressive reactivation and participation for a minimum 4 hours per day for 3 to 5 days a week. An exception may be made for hand injuries and other specialized diagnoses to begin at 2 to 3 hours per day.”3 Upon discharging a worker from a work conditioning program, goals have usually been met or there is a recommendation for return to work (RTW) on a trial basis. In addition, the therapist may work with an employer to suggest accommodations to allow the worker to return to work.

ODG, FCA/FCE, and Work Conditioning: How They Work Together

Across the nation, state workers’ compensation agencies are adopting evidence-based medicine and guidelines to manage and control costs. Advantages of ODG Guidelines are that they are evidence-based, comprehensive, and injury-specific. Establishing a baseline of the physical capacity of the worker by performing a full or mini functional capacity evaluation/assessment (FCE/FCA) prior to beginning the work conditioning/work hardening program is vital to having a successful program. This establishes goals that are objective and are specifically tailored to the gap between the physical abilities of the worker and the physical demands of the job. By utilizing the ODG Guidelines, therapists remain on track with nationally recognized treatment recommendations for work-related conditions. “Both job-specific and comprehensive FCE/FCA’s can be valuable tools in clinical decision-making for the injured worker; however, FCE/FCA is an extremely complex and multi-faceted process. An FCA is not recommended if the sole purpose is to determine a worker’s effort level or compliance.”4 An FCE/FCA ordered to identify a malingerer dilutes the value of finding the worker’s true safe maximum, which is the genuine purpose of performing an FCE/FCA.

Determining an individual’s baseline on a pre-work conditioning program FCE/FCA identifies any musculoskeletal deficits compared to the physical demands of the job. It will give evidence of a valid mismatch between the capacity of the worker and specific job requirements/demands that have not been met. Therefore, the FCA will show where there is room for progression and improvement.

Example of a Construction Worker/Sheet Rocker and Grocery Stocker:

When assessing a candidate for work conditioning, a therapist’s evaluation not only is dependent upon the initial interview with the worker but also involves creating a picture of the worker’s day. For example, a therapist will ask not only how much a worker lifts, but also what type of PPE (personal protective equipment) is worn and whether work is performed in extreme weather. This information is needed to set, and agree to, specific RTW goals and to develop a team relationship. A job description should be requested when implementing therapeutic activities to strengthen job-specific muscles and reduce risk factors by tailoring the program accordingly. The exciting opportunity for therapists is thinking outside the box and creating an environment similar to the worker’s job environment. The workers are recruiting and strengthening the same muscles they use at work as well as learning new postural behaviors that will carry over to permanent behavior modifications. A specific example with a construction worker is using ladder climbing, pushing/pulling a wheelbarrow, and hammering or drilling with active corrective coaching by the therapist to cue for use of good body mechanics and safety education. When coaching a grocery store stocker in proper lifting technique, the therapist may implement repetitive lifting at various levels including lower shelves, shelves between waist and shoulder, or those overhead. Through discussion with the worker, the therapist will understand the lightest and heaviest items that are stocked to create a more realistic goal-setting program. For example, for a grocery store stocker, the therapist may consider using props in the clinic that mimic actual tasks, such as dog food, cases of soda, cereal boxes, and other products.

Taking Work Conditioning On-site to the Employer

Getting an opportunity to work on-site with an employer further expands the work conditioning program where it matters most, at the employee’s workstation. When sufficient progress has been made in the clinic, transitioning back to work allows the worker to perform the job, identify areas of challenge or trouble, and continue to improve strength and function. This may be participating in a work conditioning program for part of a day and performing job duties at work the rest of the day, or having the worker perform components of the job they successfully match and alternate work the rest of the day. In either situation, it is imperative to have good communication with the employee, employer, supervisor, physician, and therapist.  Understanding where weakness, decreased function, and struggle exist allows the conditioning program to be focused and advanced for the safest and quickest full RTW possible.

How Are Work Hardening/Conditioning Program Workers’ Compensation Patients Coded? 

Per the guidelines on the APTA website, CPT defines 97545 as “work hardening/conditioning; initial 2 hours.” 97546 cannot be utilized alone without 97545. If only one hour of care is provided, then it could be argued that you are not at the level of a work hardening/conditioning program. In that case, codes 97110 or 97530 might be appropriate. If less than 2 hours of care is provided, then you are not at the level of a work hardening/conditioning program and codes 97110 or 97530 might be appropriate. 97545 does not require direct one-on-one contact; however, CPT assumes that each person will have an “individualized” program to meet their needs. Some fee schedules may require the use of local codes for work hardening and/or work conditioning. Check state fee schedule and payment rules to determine whether they use 97545/97546 or local codes. Direct questions about referrals and related regulations to the state workers’ compensation commission.5

Being Creative with the Physical/Occupational Therapy Professions

We have a great opportunity to specialize in industrial rehab by implementing work conditioning/work hardening programs. It is ideal to have therapists develop expertise with true on-site experience, and the value of having therapists work on-site and in the clinic goes beyond normal training provided during a doctorate level curriculum. A therapist who works on-site will have experience from observation, analysis, and exposure to many job tasks. They will better appreciate the demands, equipment, and environment of the workplace as well as the value of accommodating workers in the return to work process. This is what creates a champion work conditioning/work hardening program. RM

 

Gina Sandoval, PT, DPT, CEASII, is the owner of Spine Solutions Inc—worksite strategies and physical therapy in Santa Fe, NM. Her mission is to return the injured worker back into the workforce sooner and safely. She is also an expert with DSI Work Solutions Inc and provides injury prevention consulting services nationwide. For more information, contact RehabEditor@nullallied360.com. 

Curt DeWeese, PT, is COO of DSI Work Solutions Inc in Bowling Green, Ky, and president of Work Injury Solutions & PT, PC in Webster, NY. He is a national consultant for workplace injury prevention and management and teaches the DSI Job Function Matching programs. For more information, contact RehabEditor@nullallied360.com.

References

1. www.apta.org. Accessed May 12, 2014.

2. Tate DG. Workers’disability and return to work. Am J Phys Med Rehabil. 1992;71(2):92-6.

3. Department of Labor and Industries. Work Hardening Program Standards. Available at: http://www.lni.wa.gov/ClaimsIns/Files/Return to Work/WhStds.pdf

4. www.odg-wc.com. Accessed April 29, 2014.

5. www.apta.org website. Accessed May 12, 2014.