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November 2004

By Nicole Matoushek, MPH, PT, CSHE, CEES

Rehabilitation professionals have treated injured workers for decades. In recent years, however, there has been an increase in the involvement and focus of the clinical management of injured workers. Rehabilitation professionals are now closely involved with the clinical management of the injured worker from the acute stage in the rehabilitation process through return to work. This involvement in specialized return-to-work programs and the determination of the readiness of return to work has created a niche to effectively and safely assist in the return of an injured worker to gainful employment.

The primary goal of worker rehabilitation is to return an injured worker back to the workplace and to his or her original position or to an alternative position with appropriate restrictions. The majority of patients will promptly return to work following injury and rehabilitation. On the other hand, the small percentage of injured workers who present with barriers of return to work tend to be the most difficult and expensive cases to manage. These individuals are candidates for specialized return-to-work programs and services.

Return-to-work programs and services can be effective methods in returning an injured worker back to work. There are several types of specialized return-to-work programs and services including: Functional Capacity Evaluations, Work Conditioning Programs, Work Hardening Programs, Transitional Work Programs, and Worksite Services.

FUNCTIONAL CAPACITY EVALUATIONS
Functional Capacity Evaluations (FCEs) are objective, work-specific tests performed on injured workers when the worker has not been able to successfully return to work. The objective of an FCE is to collect data regarding the level of participation, functional limitations, and work-specific abilities, and to evaluate safe working capacities to determine the return-to-work readiness. FCEs include: intake interview, subjective testing, neuromuscular testing, functional testing, and work-specific testing. Some examples of these tests are illustrated below:

Subjective tests: Dallas Pain Questionnaire, McGill Pain Questionnaire, visual and numerical pain intensity scales, analog scales, and pain drawings.

Neuromuscular testing: Range of motion, strength, balance, sensation, dexterity, grip, pinch, and gait.

Functional testing: involves measuring the participant's ability and tolerance in performing functional activities such as standing, walking, ascending and descending stairs, bending, overhead and forward reaching, carrying, lifting, and squatting.

Work-specific testing: involves assessing the participant's ability and tolerance in performing specified work activities. These work activities should match or simulate the actual job tasks that the individual will have to perform upon returning to work. An example would be, if assessing a painter, have the patient perform all of the essential functions required to perform the job as a painter, such as overhead reaching, climbing ladders, lifting and carrying, and balance. It is helpful to break down the essential work tasks into test circuits to test repeatability and endurance.

Once the evaluator has determined the participant's ability and activity tolerances in these tests, they must assess the participant's ability to safely return to work. Factors to consider include: functional limitations, effort level, magnification of symptoms, ability to follow directions, and the determined safe maximal lifting and activity levels. If there are indications that the participant is not at a level to return to work safely, a structured, goal-oriented return-to-work program may be indicated to prepare the participant for return to work.

WORK CONDITIONING
The objective of a work conditioning program is to prepare an injured worker for return to work or job retraining. These programs provide a goal-directed, work-specific treatment plan that prepares the individual to meet the physical and functional demands required to return to work.

An example where a work conditioning program may be appropriate for an injured worker is if a construction worker has sustained a shoulder injury and needs to return to his job. In this example, the worker may be unable to return to work due to continued physical limitations in strength and the ability to perform work-specific activities such as lifting, carrying, reaching, and dexterity. The work conditioning program should be job-goal-oriented and should involve work-specific activities that are increased in frequency, duration, and/or weight levels to recondition the patient to a safe level to return to work. In this example, the program may involve functional activity performance and simulation with lifting and carrying various materials or equipment and both repeated and sustained reaching, in conjunction with a general physical reconditioning regimen. Ideally, functional training should include work-specific tools and equipment and provide an opportunity for the participant to progress physical strength and endurance levels with the equipment.

Typically, work conditioning programs run from 6 to 8 weeks; some states limit the duration of these programs to 60 hours. Typical work conditioning sessions last from 1 to 4 hours, 3 to 5 days a week.

WORK HARDENING
The objective of a work hardening program is to prepare an injured worker for return to work or job retraining. These programs provide a goal-directed, work-specific treatment plan that prepares the individual to meet the physical, functional, psychological, behavioral, and vocational demands required to return to work. Work hardening uses an interdisciplinary team, which typically consists of the rehabilitation professional, treating physician, psychologist or behavioral specialist, and vocational rehabilitation professional, to meet program goals.

The physical rehabilitation aspect and program goals are very similar to those of the work conditioning program. For example, the plan of care must include physical reconditioning exercises in addition to real or simulated work activities in order to physically recondition the injured worker to his or her prior level of work function. However, the difference between the work conditioning and the work hardening programs is that the work hardening program will also require multidisciplinary team meetings, counseling, behavior modification sessions, and patient group meetings.

The typical duration for a work hardening program is up to 6 to 8 weeks. Typically, program sessions run from 4 to 8 hours a day, and are provided daily.

TRANSITIONAL WORK PROGRAMS The objective of transitional work programs is to utilize the work environment to return the injured worker to work. Transitional work programs are implemented at the worksite as opposed to the clinic environment. Transitional work programs are unique in that they involve a progressive increase in the work-specific activity levels. This is achieved by developing a treatment plan involving the injured worker at the worksite and assigning his or her actual work tasks. Typically, the injured worker presents with functional limitations in strength, endurance, diminished activity tolerance, or pain behaviors that prohibit a safe and successful return to work.

The transitional work program provides a graduated plan and work schedule for the individual to regain strength and endurance, and to improve positional and activity tolerances by practicing work activities. This approach allows the individual to be productive at the workplace and provides a forum for addressing pain limitations and pain behaviors, which may prevent the return to work. The transitional work programs use real work activities at the worksite in order to restore the individual's physical capacity and function so that the injured worker can return to work.

WORKSITE PROGRAMS AND SERVICES
The objectives of worksite programs and services are to address work-specific factors to either prevent work-related injuries or enable an injured worker to return to work. Worksite programs and services include:

Disability management
Treatment of the acutely injured worker
Ergonomic programs
Job task analysis services
Injury prevention training
Pre-employment testing
Employee health and fitness programs.

Worksite programs and services utilize the actual work equipment and work space that the worker uses in their job. Worksite programs are performed with the employee at their workplace using the actual tools and equipment of their job.

The worksite program approach provides an effective means for managing the injured worker's functional restoration. Ultimately, worksite rehabilitation produces successful return-to-work outcomes because it minimizes deconditioning, improves communication with all parties, improves work and positional tolerances, and facilitates the clinical management of the case.

Additionally, the worker remains at work or returns to work quicker, resulting in lower lost-time costs and a decrease in indemnity costs such as lost efficiency, decreased production, and employee training.

SUMMARY
Return-to-work programs and services can be effective methods in returning an injured worker back to their job. The primary objectives of return-to-work programs and services are to prevent work-related injuries and to successfully return an injured worker back to gainful and productive employment.

Nicole Matoushek, MPH, PT, CSHE, CEES, based in St Petersburg, Fla, has more than 11 years of experience in physical therapy, worker rehabilitation, and ergonomic consulting. She can be reached at www.ergorehabinc.com.

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November 2004