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April 2002


Getting Back to the Daily Grind

By John Turner, MS, ATC, LAT, and Kate Hughes, PT, MS, OCS


John Turner, MS, ATC, LAT, and Kate Hughes, PT, MS, OCS
Client history, a specific job description, a determination of limitations, and a reintegration plan are important components for an effective return to work.

For industrial rehabilitation to maintain effectiveness, it must adapt to the ever-changing workforce. Work-related injuries and illnesses have become more varied, ranging from heart disease to musculoskeletal disorders, and even traumatic brain injuries. Work hardening programs must effectively encompass a client's return to work (RTW) needs in order to maximize the probability of success.1 When a client presents for evaluation of an occupational injury or illness, a history of the specific condition must be obtained in order to maximize the clinician's understanding of the condition to set goals and enable implementation of a specific RTW program.2 The date of injury may be identifiable, such as when a fall occurs, or a date of onset might not be as clear with conditions such as cumulative trauma disorders and cardiovascular disease.

The client's age and the number of years remaining until retirement may affect a clinician's RTW plan. Preexisting or multiple injuries or illnesses may also affect RTW planning. If a client sustains a low back injury and has limited ability to forward bend, RTW is possible if the client can fully squat. However, with a previous history of knee injuries and limited ability to squat, the addition of a low back injury may make RTW in the same job less likely.

The Job Description
A specific job description is an essential component of an individualized work hardening program.1 Every aspect of the program, from the initial functional testing to work reintegration, should focus on the client's essential physical job demands. However, most job descriptions are very general.3,4 Having specific data about the heights, weights, and number of repetitions for each of the essential job demands gives clear information on the requirements for return to regular duty.

Most jobs are categorized according to the US Department of Labor Dictionary of Occupational Titles (DOT) as sedentary, light, medium, heavy, or very heavy. Although this information is helpful in the rehabilitation process, a more detailed job analysis is preferred. This usually requires gathering information from the client or employer, or visiting the work site to complete a job analysis.


Hughes help an assembly line worker relearn hand tool use.
Testing
A functional capacity evaluation (FCE) is used to develop a specific industrial rehabilitation program or to determine work restrictions. In order to effectively measure the essential job demands, the evaluation must have the flexibility to measure specific tasks that are related to the client's job description and requires specific tools or equipment for measuring the client's abilities. Through the FCE, the clinician must identify limitations and set goals that will help the client RTW. An FCE prior to initiating industrial rehabilitation provides the clinician with the needed information to develop a specific program addressing essential job demands.5 If the client has been out of work for an extended period of time, the initial injury may not be the only factor preventing the client from returning to the previous job.

Rehabilitation
The ultimate goal of the industrial rehabilitation program is for the client to achieve gainful employment.6 A thorough assessment helps the clinician identify the client's limitations and develop an individualized rehabilitation program necessary to meet that goal. Individualized industrial rehabilitation programs include interventions such as exercise and manual therapy to specifically address and treat limitations that may not have been completely resolved in a traditional physical or occupational therapy setting. Industrial rehabilitation that incorporates individualized treatment should be followed by functional activities relating to the client's job demands to reinforce the treatment objectives. If the objective is to increase dorsiflexion to allow the client to return to regular duty, mobilizations to improve dorsiflexion are followed by floor level lifting activities. Poor body mechanics and motor control issues may become apparent once the client begins functional activities. Training the client to move more efficiently can help speed recovery, improve strength, and prevent secondary injuries.1

Client education about safe work practices and avoiding future injury must be incorporated into the individualized program. Factors that affect healing of the injury, including smoking, nutrition, joint protection, and exercise, should be reviewed with clients and can be completed in a group or one-on-one format. Establishing a schedule similar to a client's work schedule is crucial, especially for those who have been off work for extended periods and have developed poor sleeping habits due to lack of daily activities.

Case managers can provide valuable information and should be included as part of the rehabilitation team.7 Acting as a liaison with medical care and employer relations, the case manager can bridge the gap between these parties. If a client is not able to return to his or her previous job, vocational rehabilitation should be conducted concurrently with the industrial rehabilitation program. The client's RTW psychosocial issues should also be addressed throughout the program.

Based on the job description and the client's functional status, the clinician should identify tasks that can be replicated in the clinical setting. Work simulation with actual job site equipment is preferable. While equipment can be bought by the clinic, borrowing materials from the client's employer can ensure that the client will be simulating work with the actual materials they will be expected to handle upon RTW.

Reintegration
The longer a client is unable to work, the poorer the prospects for RTW.8 However, making a transition from being off work to full duty is often a giant leap. Reintegration is the final step in a successful RTW program, and allows the client to make a gradual transition into gainful employment. Encouraging the client to keep in contact with the employer can help bridge the communication gap, demonstrate the client's interest in RTW, and keep the client involved in the social community of the workplace. Communication between the clinician and the employer reinforces the intent for the client to RTW, and helps establish a reintegration plan. Reintegration includes RTW full duty, RTW with restrictions, gradually increasing the number of hours worked, modification of the work environment, or placement of the client in another job.

If clients return to work with restrictions, the restrictions should be specific to the job demands and based on an assessment of their functional abilities. The restrictions need to be reevaluated on a periodic basis, and altered as the client's ability changes. Some jobs lend themselves to RTW with restrictions better than others. An airline may not allow a flight attendant to RTW with restrictions if he can perform all job duties except opening the emergency exit, since the one duty the employee cannot do is critical to the safety of passengers and staff. Other employers may be able to accommodate restrictions depending on the type of job, number of employees, specific restrictions proposed, and safety concerns of the limitations.

A gradual decrease in the client's restrictions or an increase in the number of hours worked can help transition the client from rehabilitation to full employment. Traditionally, once the client returns to work, rehabilitation intervention ceases. However, other models that include a half-day industrial rehabilitation program with a half day at work allow the client to continue the progression of building endurance and strength, and improving physical job demands in a safe clinical environment, while benefiting from being in the work environment. As the program continues, reassessments of the restrictions can be made and new goals set. With continued communication between the clinician and employer, changes to modified duty restrictions bring the employee closer to the goal of regular duty.

REFERENCES
1. Bernacki EJ, Guidera JA, Schaefer JA, Tsai S. A facilitated early return to work program at a large urban medical center. J Occup Environ Med. 2000;42:1172-1177.
2. Wyman DO. Evaluating patients for return to work. Am Fam Physician. 1999;59:844-848.
3. US Department of Labor, Employment and Training Administration. Revised Dictionary of Occupational Titles Vol I. 4th ed. Washington, DC: US Government Printing Office; 1991.
4. US Department of Labor, Employment and Training Administration. Revised Dictionary of Occupational Titles Vol II. 4th ed. Washington, DC: US Government Printing Office; 1991.
5. Lechner DE, Roth D, Straaton K. Functional capacity evaluation in work disability. Work. 1991;1:37-47.
6. Beissner KL, Saunders RL, McManis BG. Factors related to successful work hardening outcomes. Phys Ther. 1996;76:1188-1201.
7. Linz DH, Ford LF, Nightingale MJ, et al. Care management of work injuries: results of a 1-year pilot outcome assurance program. J Occup Environ Med. 2001;43:959-968.
8. Waddell G. A new clinical model for the treatment of low back pain. Spine. 1987;12: 632-644.

John Turner, MS, ATC, LAT, is director of industrial rehabilitation and was instrumental in the program's inception, and Kate Hughes, PT, MS, OCS, is manager of industrial rehabilitation, both at TIRR Rehabilitation Centers in Texas.

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