By Jeanne Griffin
Returning to work following an injury has changed considerably over the past decade. From “must be at 100%” to “light duty,” the wide range of options for workers can pose challenges for the health care provider who needs to offer appropriate recommendations. Solutions must be as unique as each injury case and job. Work Fitness Testing The main objective of the physical capacities evaluation is to assess the worker’s current physical capacity compared to the critical physical demands of the preinjury job. The evaluation report includes recommendations as to how rehabilitation problems, if present, can be remedied. Often the worker demonstrates the ability to perform at the required level of function and a full return to work is recommended; therefore, further rehabilitation services are not required. The evaluation process can help remove the guesswork for the physician who must establish work restrictions or full release. It also provides an objective assessment of the worker’s consistency of effort during testing and motivation to return to work. During the evaluation, the required job demands are explored through an interview with the worker. The information collected is then correlated to existing resources of comparable jobs. Cooperation from the employer is necessary to verify the job demands to be tested. In addition, the employer is asked about the current availability and nature of any modified work. If the response is negative regarding modified work, an educational opportunity exists to provide the employer with information about how modified work can actually be a cost-containment strategy. Making the physician aware of the availability, or lack of, modified work can also assist in moving a case forward. The evaluation process should be adaptable to unique circumstances. For example, extreme job tasks (eg, utility pole climbing) may need to be assessed at the conclusion of the physical capacities evaluation at the employer’s training grounds. This assumes the worker was able to demonstrate all of the other critical demands of the job including ladder climbing with safe balancing. If the employer is involved in the process by providing specific job equipment, such as fire fighting gear, the test result is enhanced. While a variety of modes of testing exist, a worthwhile result ultimately depends on the skills, knowledge, experience, objectivity, and creativity of the evaluator. Modified Work The benefits of releasing an injured worker to modified work as soon as possible have been extolled for more than a decade. There is little dispute about the impact of early return to work on worker self-esteem, worker-employer relations, and cost containment. However, many workers experience multiple failed work returns as a result of exposure to the same stressors that were involved in the preinjury work (eg, repeated bending, awkward posturing, forceful motions). It becomes a more complicated issue than simply “No lifting over 10 pounds.” It is also common to see inappropriate work assignments, such as a construction worker doing office filing. Employers sometimes have to assume the rehabilitation role when providing work within certain restrictions. It is not surprising that the result is an overcautious approach that may lead to physical deconditioning of the worker. Furthermore, the worker may assimilate to the new job assignment and become unmotivated to return to the preinjury job. Why would the construction worker want to leave the air-conditioned office to return to the heat and physical demands of his preinjury job? The lack of a specific rehabilitation plan places the employer at a disadvantage and questions arise about how to get the worker off modified duty. Clinicians can improve these situations by providing recommendations that detail the worker’s capabilities in practical and functional terms. Employers understand “can push/pull 100 pounds on a 4-wheeled cart” or “can sweep with a pushbroom on a frequent basis.” However, “avoid use of the right upper extremity” or “no bending” are phrases that are confusing and not very useful. Therefore, the evaluator needs to be as specific as possible with the recommendations. Employer confusion can increase the risk of worker reinjury. The clinician can make a follow-up visit to the workplace, if the employer needs further assistance with appropriate task assignment. Work Hardening Revisited A major advantage that a rehabilitation facility-based work hardening program provides is a controlled environment for safe progression of a worker’s physical capacity. After assessment by means of a physical capacities evaluation, rehabilitation goals and timeframes are established. These goals routinely involve exercise prescription for advancement to the level of function required of the job, injury prevention training, and pain management techniques. This program allows for professional monitoring of real and simulated work tasks. Depending on the type and mechanism of injury, workers often have concerns about returning to the job without a transitional functional phase after therapy. Rehabilitation providers sometimes drop the ball on this all-too-important phase that takes the worker from passive hot packs and ultrasound to climbing, shoveling, or using a jackhammer. Rehabilitation facility-based work hardening should be considered for the worker who has been off the job for an extended period of time, who requires considerable functional strengthening, or who requires a work adjustment period. Facility-based work hardening can be more costly than modified work if applied as a singular long-term approach. However, a brief period of work hardening that assesses worker compliance with a rehabilitation plan can help avoid disruptions and failed return(s) to work. Another benefit is the ability to provide one-on-one comprehensive injury prevention training with demonstrated follow-through of learned techniques. This is more advantageous when initiated in a clinical setting. If attempted in the workplace, coworker distraction and production rates can impede the problem-solving and learning process. Also, it is vital to build a professional rapport with the worker before going to the work-site. Who wants to listen to someone they don’t know telling them how to do their job? Facility-based work hardening programs can be a valuable adjunct for individuals with specific needs that would best be served in a controlled environment. On-Site Work Hardening Providing work hardening at the job site is a service that continues to evolve. While larger corporations may dedicate entire departments to providing medical and rehabilitation services, smaller companies may need guidance with implementing on-site work hardening. How does on-site work hardening work? The clinician travels to the employee’s job site to supervise the performance of job tasks and the progression of worker responsibilities. This can provide a natural transition from facility-based work hardening and allows professional monitoring of real work tasks. Typically, the worker is released by the physician to modified duty. A second release by the physician allows the worker to perform tasks that are increasingly more difficult while the clinician is present to supervise. After the clinician leaves for the day, the worker returns to performing tasks within the original restrictions. The goal is to provide support for the worker until the preinjury job demands are demonstrated. Of additional benefit is the opportunity to document the employer’s, as well as the worker’s, compliance with restricted duty work. Providing on-site work hardening requires considerable communication with the worker, employer, physician, and/or case manager to obtain the necessary prescriptions, authorization for funding, and scheduling of site visits. Once arranged, there are other considerations for the clinician: proper attire (eg, hard hat, ear plugs, steel-toed boots), hours of supervision (can involve second or third shift hours), travel expenses, and confidentiality issues for the worker. Having an accurate awareness of the work and the job requirements is essential to communicate with the worker’s supervisor(s). On-site services may involve mediation between the worker and the supervisor regarding the goals and expectations of service. The clinician should unobtrusively provide the services without disruption to production or work flow. Hopefully, after a few visits, the clinician will blend into the workplace. Unless the time frame of service is clear at the onset, the worker can become dependent on having company at work and may feel abandoned once the on-site service ends. It is also possible the worker will feel increased confidence in being able to perform the job tasks without supervision and ask for the on-site work hardening to be concluded. In either case, a fairly aggressive decrease of supervision is suggested for worker independence and cost containment. It is not surprising that costs can mount, considering the service involves reimbursement of the clinician’s time, with hours per visit and visits per week varying. Ideally, on-site work hardening is a short-term service that concludes with a recommendation to the physician for release to full duty work when capability is demonstrated by the worker. If the worker does not progress under supervision in a timely manner, modified work can be continued. However, it is advised to incorporate a time frame to reassess the modified work, either by a return work-site visit or through another physical capacities evaluation. Combination Rehab Combining different services during rehabilitation provides the worker with the most efficient plan for addressing existing rehabilitation problems. For example, combining part-time modified duty with rehabilitation facility-based work hardening not only keeps the worker connected to the workplace, but allows for a safe environment to increase those tasks that are more physically demanding. This combined approach works best if both the worksite and the rehabilitation facility are reasonably close to each other. Otherwise, attending work and rehabilitation on alternate days is suggested. Another consideration, though not a responsibility for the clinician, is the worker’s wage reimbursement during the hours of rehabilitation. Some employers expect the rehabilitation time to occur in addition to the worker’s regular work schedule, which can result in overtime hours. The case manager may be able to provide assistance with this issue. Another benefit of combining services is the opportunity to receive feedback from the worker about how modified work is being tolerated. Task adjustments can be made, if needed, on-site and in work hardening to facilitate the best result. Usually the worker will attend a half-day of modified work and then attend work hardening for a half-day. As with on-site work hardening, a clearly defined progression of increased time spent at work and decreased time in rehabilitation is suggested for worker independence. Conceivably, a worker could attend facility-based work hardening full-time, advancing to a combination of half-day modified work and half-day facility-based work hardening, then followed by modified work and on-site work hardening, and, finally, a return to regular duty work. These services require close communications with the physician and employer to upgrade modified work as the worker’s physical abilities improve. Ergonomic Intervention The goal of ergonomic intervention for the injured worker is to attempt to fit the work to the person and decrease those physical stresses that may contribute to reinjury. This process can occur at any phase of return to work, but tends to be more beneficial after the worker has received injury prevention training. By then, the worker has a basic understanding of correct posture and body mechanics and can be actively involved in the process. Additionally beneficial are changes to the work environment that improve conditions for the coworkers as well as the injured worker. Once the on-site ergonomic assessment is performed, it is anticipated that reports and recommendations from the clinician will be forthcoming in a timely manner. The research involved to find ergonomically correct equipment or tools for the worker can be very daunting. It is advisable, therefore, that the clinician maintain an organized resource library of available equipment to save considerable time and effort. Most ergonomic recommendations, if appropriately researched, can be very cost-effective to employers. No two injuries are the same. A cookie-cutter approach to rehabilitation is not acceptable. Work hardening, by itself, can be too costly. Modified work, by itself, does not advance the worker to the preinjury job level. There may not be a simple solution, yet the challenges in making sound return to work recommendations can be met. Successful return to work demands from the clinician a combination of skill, knowledge, experience, objectivity, and, above all, creativity. N Jeanne Griffin is the director of the Return to Work Center, a division of the Institute of Physical Medicine and Rehabilitation, Peoria, Ill, and a disability management specialist. She can be reached at: (309) 692-8155.
