BACK TO THE ORIGINAL JOB: SOONER, SAFER

SUSAN J. ISERNHAGEN

Many improvements have been made in the return-to-work systems in the last ten years.  Yet, there remains one big black hole….the high number of days a worker is on light-restricted-transitional duty. 

The best employers have found a way to cut lost time days.  Despite the restrictions given, they find a way to put the worker in a very easy job to keep them at work.  Varying venues call it light or restricted or transitional duty (to all be called light duty for the rest of the article).  All mean different things to different people, but the bottom line is that creative case managers have found a way to at least bring workers back to the worksite.  Some of the work is “make-work”.  Some of it is from easy departments where simple and non-stressful tasks are done.  A few employers will even bring the person back to the original department doing lighter tasks. 

In settings where light duty has a time limit, most often the worker is in the lighter duty for the full number of days.  In some cases the new work is so appreciated by the worker and the supervisor is glad for some extra help, that there is almost a creation of a new light job that did not previously exist.  Both of these aspects prolong the time before full duty is reached.

On the downside of lighter duty is the perception of other workers toward the light worker that this work is less than meaningful.  In some workplaces, those on light duty have a “stigma” which creates a secondary barrier for the worker to return to the original job.

So, one problem solved (lost time days) is one problem created (excessive light duty days).  Many managers can identify the cost of a lost time day, but rarely can one be given a dollar figure for a modified duty days.  Light duty days have not had the focus that lost days have had.  The result is one more opportunity for change.  This article will focus on a solution that is beginning to work in the industries that have adopted it.

DEFINING THE FACTORS IN EXCESSIVE LIGHT DUTY DAYS
In analyzing the problem, both research and focus group interactions provide insight. 

Research points to several areas.  The first is that relationship to work must be kept from the beginning of the work injury episode if the time to return to work is to be optimized. Also, care must be taken to provide a return to work plan that meets the workers needs.  In reviewing worker surveys, Pransky (1) found that of the factors associated with both lost time and reinjury is“dissatisfaction with return to work accommodation”.  It ranked in the top three for both costs.

Part of the problem is that the medical system is created to treat “patients”.  Creating a “patient” from a “worker” is the first step in medicalizing a problem.  Consider this scenario:  a band press operator from a local industry comes to a medical practitioner (physician, therapist, or chiropractor).  If the first thoughts are “here comes a new back case” then the problem begins there.  The words of the practitioners will be “where does your back hurt? How much does it hurt? On a scale of 1-10 tell me exactly what level pain you are feeling.  In the pain chart the worker gets to do drawings that show exactly where the pain is, whether it is sharp or dull, etc.  The injured worker has instantly become a patient and the focus is on pain and the possible interpretation that healing will only be accomplished when pain is completely gone.

What would happen if the medical practitioner knew the person’s job and respected the fact that the worker was a valued and talented person.  (Sidebar:  when one observes and measures time and efficiency at work, it is amazing how skilled workers are and they perform routinely what most of us would find daunting.  They are due respect whatever their job is).  Perhaps the first medical encounter would be “Hello, Bob.  I understand you are a band press operator at the File Plant.  You are having difficulty with some of the lifting and bending at work because of your back.  Tell me what you have difficulty doing, what can you still do well, and what makes you better.  Our goal is to reduce your symptoms so you can return to work and your daily activities as soon and safe as possible.”  The person retains the worker role and the focus is now on regaining function as the outcome.

The critical pieces here are that the practitioner knows the job, respects the worker and uses function as the goal while remaining as a caregiver.

PROGRAMS THAT COMBINE MEDICAL CARE AND WORK SHOW RESULTS

Loisel and colleagues in Canada (2) have promoted the occupational focused Sherbrooke Model through many papers and research.  They demonstrated that when the medical care and the worksite are both involved, better outcomes are derived.  This is measured by less disability.

Lemstra and Olszynski (3) published research in one large plant in Canada.  They compared both the traditional medical model and a model of clinic-based physical therapy with an occupational management model in which the physician, an onsite therapist and worker combined healing with worksite ergonomic adaptations.  Also, assurance of good prognosis was given. The combined medical/worksite system of occupational management demonstrated considerably less disability costs than the clinic-based interventions.

THE MEDICAL RESTRICTION SYSTEM CAN BE A BARRIER
Physicians and the return to work/restriction system

An important work by physicians, Schweigert, McNeil and Doupe, of Ontario (4), discussed the outcomes of questionnaires to physicians.  The main findings were that the physicians were uncomfortable in the return to work process under workers compensation plans. They felt pressured to give more information than they could. They stated

• The main barrier is accommodated work
• Physicians lack knowledge about modified work
• Time is limited and it is difficult to deal with return to work issues
• There is not enough appropriate information.

In the U.S, when asked about their role in return to work, most physicians identify the “state restriction forms” as a main part of the information they provide. (see figure 1) They use the forms because “these are what we are given”.  Most don’t question that the various restriction forms are part of their job or that they should estimate restrictions required on lifting, pushing/pulling, bending etc.

Restrictions are often conservative estimates
There is a perception by many employers and case managers that the restrictions are more limiting than they should be.  They can feel great frustration at the conservative nature of these estimated restrictions as they prevent return to work.  Some do realize that most physicians feel they are acting in their patient’s best interest by being conservative with their restrictions.  Medical practitioners often feel they are the patient advocate against a tough and difficult workplace.  However, the restrictions are often so conservative that the worker must do activities at home that are beyond the restrictions.  Few believe that a worker at home will not have to do “lifting over 10# or some bending or use the right hand (when it these actions were forbidden on the work restriction form).

When asking the worker what their work requires, many physicians hear high estimates of work requirements such as having to push 300#.  If the job were evaluated what is often found is that the worker pushes a cart that has 300# of product on it and requires 45# to push it.  In other cases, the physician may perceive a job or a workplace as dangerous or difficult.  Physicians may feel that because they see a few injured workers from a plant that it is a dangerous place, not realizing that they don’t see the hundreds of others that work there doing their job safely and effectively.

In summary, in most cases, physicians have to ask their patient about their work because they don’t have a job description.  Physicians also may overestimate the difficulty of a workplace because they have never viewed the jobs.  Physicians who do get a job description often can’t read it because it is often too complicated and uses terms that they don’t understand.  (A converse statement is made by employers who don’t understand medical terminology.)

Jobs are multifaceted not generic
Another facet of the restriction problem is that the same form is used for all jobs.  The forms don’t take into consideration either the unique characteristics of a job or the modifications an employer could make on a temporary or permanent basis to alter a function.

As a first example, consider a job that has 10 tasks.  Only 2 of them require lifting 40# or more.  8 do not require lifting.  A generic form will consider this job as a 40# job.   Therefore a 20# restriction will keep the person off that job until the restriction level is slowly upgraded to 40#.  In fact, if the job tasks were specified, the restriction would allow the person to return to 80% of the job, but in the current model, neither the job description is written that way, nor is the restriction meant for only certain tasks.  It becomes a blanket restriction.

In a second example, there may be unique actions on the job.  If a patient pivot transfer in a nursing home requires a 50# lift, is this the same as someone lifting a 50# manhole cover from the ground, or someone lifting/sliding a 50# box on to a conveyer all at waist height?  The three tasks might read as 50# lifts, but they require different body actions and abilities.  An employer may wish better specificity in return to work, but the practitioner is filling in a blank.  Which type of lifting does he mean?  The physical requirements are not the same.

Just tell me what he can do and what he can’t do and let me make the decision!!
This is the comment that is heard most frequently from employers. What they need is information on what parts of the job the worker can do so that the decision to place the person back to work can be made by the supervisor. 

EMPLOYERS, MEDICAL PROVIDERS AND WORKERS BENEFIT FROM A COMMON METHOD FOR RETURN TO WORK INFORMATION.

If we listened correctly to the issues, then physicians need to give return to work information in a method that they feel comfortable. Being accurate and objective is important but they often don’t have the tools. Employers need the return to work information on what the worker can do at their original job or a transitional job.  Specificity will allow the employer to feel comfortable that the worker can do certain or all tasks of his/her assigned job.  Restrictions aren’t helpful as they are conservative and general.

If the medical providers and the employers have difficulty with clear communication, we also need to consider the worker.  If the worker is doing well at work one day and feeling injured/symptomatic/less functional on the next, it is the worker that has the largest problem.  Others manage processes, but the worker has the personal issue.  What does the worker think when given information that would make him/her feel “ill”?  Suddenly there is a question of health, worth, functionality.  Early on in most incidents, the injured party believes return to life and function is around the corner.  But, if caught in the medicalized moment, thoughts can turn to feelings of being harmed and not able.  When a restriction is given, the worker has two choices.  One is to follow it.  If it is too conservative then the worker can become a victim of the “glass back” syndrome.  “If I bend or lift I might be harmed more”.  Conversely, if the worker needs to do more at home and in life, then the worker also determines that he/she has more ability that the restrictions indicate.  So, there is not trust in the accuracy of the restriction and the worker is left not knowing at all what his/her limitations are.  Either way, the worker has entered an area of uncertainty.  Then, when decisions are made about return to work and the worker is not tested, it is clear that opinions are the driving forces.  (My employer doesn’t want me back….or my doctor is trying to protect me).  It becomes a battle of opinions in the worker’s eyes.

One more piece of information can be put into the picture..  Ask a medical professional what percent of workers on workers compensation eventually go back to their original job.  In focus groups, the range is from 50 to 90%.  When this question is posed to employer groups, (and it may be that the best and most progressive employers come to discussions on return to work), the figure is 95-98%.  The discrepancy in perception is interesting.  Are medical professionals more likely to be involved with hard cases or is it somewhat a self-fulfilling prophesy that workers don’t or shouldn’t return to their original job full time.

When we recognize this eventual high rate of return to regular duty, it is clear that the return to work goal should be the regular job-full time at the onset.   The worker should be matched against the job from the beginning.  If employers are desiring information so THEY can make the decision on how to place the worker back at work, then all specific job tasks need to be addressed, not just global lifting or bending restrictions.  The decision can be made for the real job, not a light job in a different department.  If it were known exactly which tasks could be done, the employer could put the employee back at those tasks.  The medical and rehabilitation goals would be set immediately toward the functions not yet able to be done. 

How does this work?  To derive correct information, the following happens.

• There is an objective, measured job description derived with both employee and supervisor input.  Areas of focus are determination of essential functions, measurement of forces, and documentation of positions and movement patterns.  To be read and utilized it is short and easy to understand.  The workers would agree that this reflects their job.
• A test developed from the description is developed.  It tests each function.  All functions are tested, not just the difficult ones.  The reason for this is to allow all tasks to be analyzed to let the employer/supervisor know what the worker CAN DO not just what cannot be performed.  The test is performed by a functional medical expert, such as a therapist. Safety during testing is important.  The scoring is simple and clear and shows the physician, the employer, the case manager and the worker just which tasks can be performed.  It is used as a main part of the return to work release.
• To be effective, the test is given the first week of injury.  If the case is of a musculoskeletal nature, it sets the rehab plan.  Each week thereafter, testing and upgrading is done.  It meets the need of keeping the original job the focus at all times and allowing the worker to retain that role

This procedure assures that the physician/provider has the correct work information, that the supervisor/employer has ability information specific to the job.  The worker feels very comfortable with return to work placement as he/she was tested rather than having estimates made.  Workers appreciate that the medical practitioners do understand their jobs.

JOB SPECIFIC TEST EXAMPLES: 

A sample return to work test form is seen in Figure 2
The use of ergonomic return to work modifications is seen in Figure 3

ESTIMATING FUNCTION VS TESTING FUNCTION

The process of job specific testing uses therapist based functional testing.  Research supports that this is superior to estimates. 

Brouwer (5) studied functional capacity estimates and testing by comparing what injured workers perceived their own capabilities, how physicians perceived those capabilities and actual reliable functional capacity testing of the same physical demand categories.  She found that when people (chronic low back patients) were asked what their capabilities were, their estimates were the lowest of the three.  The physicians” estimated somewhat more capability, but the highest level of ability was shown in actual participatory functional testing by therapists. 

Multiple reliability studies have been done on kinesiophysical functional testing  (6, 7, 8).  This requires identification of maximum safe function uses researched observational criteria rather than the participant’s statement of ability.  The studies show excellent reliability of the criteria based evaluation.

When objective testing is performed, the physician can use this evidence-based approach to release the worker to specific work.  It assists the medical decision making process. It saves the physician time and improves job specificity.

IMPLEMENTING JOB SPECIFIC TESTING SYSTEMS

Job specific testing is short and accurate and has the potential to save multiple light duty days and employer costs.  The worker returns to the original job much sooner, and productivity for the workplace is enhanced.
 
In order for the employer to obtain these benefits, it is necessary to have the job specific descriptions developed.  This adds the specificity of return to work decision making.  Once developed the tests can be used for all employees of the company immediately after injury.  Therapists who can provide the required services perform the tests. 

The physician/provider/chiropractor community discusses how to integrate the new information they receive. The focus on work and retaining worker identity continues.  The focus on function becomes more important than the focus on pain.  Objectivity is added to the decision making. 

Workers are involved.  As they see the job descriptions and tests be developed and understand the new process, they respond by appreciating the fairness of the system, or at the very least understanding that testing serves the return to work system by reducing subjectivity.  Unions, if in the industry, should be brought in at the stage of development of the job descriptions and tests, as their members will be participating.  As this benefits good decisions for workers, allowing time and discussion for union involvement is important and positive.

Most importantly, the internal management of the company must develop cohesive and directed policies for managing their injuries from the first minute.  Employers often feel outside the loop in work injury cases.  They wait for medical opinions and restrictions to be lifted although they do develop good light duty policies while they are waiting for the final releases.  In the job specific matching system, the employer is not a passive player.   With objective testing early, the employer receives the information needed for their decision making toward the original job.  They are a strong part of the process, not a passive part.  Employers need the information.  Job specific testing provides a means to obtain that information by using formats and options that are both in the medical realm and the employment realm.

While the return to work testing is often the first step in improving full return to work rates, there are other benefits.

If employers hire workers who misunderstood the job, quit, and cause additional costs of turnover, the use of the job function description in the hiring process makes the physical demands clearer to the applicant.

In cases of non-musculoskeletal problems, the job function description sent to the physician at the first visit, clarifies objectively the physical requirements of the job.  This prevents misunderstanding or overestimation of the difficulty of the job.

Employers who find high new hire injury rates utilize ADA compliant job-related post offer functional testing in addition to the other post offer services.  This assures the employer of the worker’s ability to do the physical demands of the job at hire.

If job specific testing is in place, it can also be used for transfers, non-workers compensation issues and benevolently and voluntarily for those with changing work abilities  (aging workers or those with changing medical conditions).

The job specific testing system also follows guidelines set forth by the American College of Occupational and Environmental Medicine  (ACOEM) (9).  To paraphrase portions, “physicians should be able to give specific return to work information including physical and functional limitations:  the physical capabilities should be matched against the demands of the job.  Specific restrictions include the exact weight and height for lifting, the amount of time per hour and per shift an activity can take place and postures to be avoided”.  ACOEM also states that upon request, the employer and employee must provide the physician with a written job description.

The job description development and job specific testing makes work for both the physician and employer easier and much more effective.

SUMMARY

Employers and medical professionals have made significant advancements in reducing lost time days in return to work management.  The costly item now, both in medical costs and productivity, is excessive light duty days.  While workers are back at the place of employment, they are delayed in reaching their final destination…the original job full time. 

Job specific testing can add objectivity to a process where a common format and common language is needed: work specific information.  Because the testing is medically based and yet performed on work specific activities, it provides both medical professionals and employers the bridge they need to assist the worker in return to work.
Workers are the focus of the system, not outside of the decision making. 

Either employers or physician/therapist providers can take the lead in the development of this job-testing tool.  The cornerstone for both will be communication, mutual respect, and outcome orientation.  If 95-98% of workers eventually return to the original job full time, this should be your goal from the first report of injury.  By providing sequential brief job specific testing return to the original job will be much sooner and safer.

Susan J. Isernhagen PT is C.O.O. of DSI Work Solutions inc.  She has developed leading edge programs in work injury management and prevention for the past twenty years.  Her specialties are functional testing, development of return to work systems within industry, and injury prevention.  She has been an invited speaker and consultant in 10 countries and has authored two occupational medicine texts: Work Injury Management and Prevention and The Comprehensive Guide to Work Injury Management.  She most currently is guest editor of the journal WORK for an issue on worldwide approaches to work injury management, published in June 2006.  She can be reached at sisernhagen@dsiworksolutions.com or www.dsiworksolutions.com. 

References

1. Pransky G et al, Work related outcomes in occupational low back pain.  Spine  27, 2002, 864-874.
2. Loisel P et al, Cost benefit and cost effectiveness of a disability prevention model for back pain management six year follow up study, Occup and Environ Med 59. 2002. 807-817
3. Lemstra M and Olszynski, The effectiveness of standard care, early intervention, and occupational management in workers compensation claims., Spine 25, 2003, 299-307
4. Schweigert MK, McNeil D, Doupe L, Treating physicians perceptions of barriers to return to work of their patients in southern Ontario, Occupational Medicine, 54,6,2004, 425-429.
5. Brouwer, S et al, Comparing self-report, clinical examination and functional testing to measure work limitations in chronic low back pain, Disability and Rehabilitation, (accepted)
6. Gross DP, Battie MC, Reliability of safe maximum lifting determinations of a functional capacity evaluation, Physical Therapy, 4, 2002, 364-372
7. Isernhagen SJ, Hart DL, Matheson LN, Reliability of independent observer judgments of level of lift effort in a kinesiophysical functional capacity evaluation, WORK, 12, 1999,145-153
8. Reneman MF et al, Test-retest reliability of lifting and carrying in a 2 day functional capacity evaluation, J Occup Rehab, 12, 2002,269-278
9. American College of Occupational and Environmental Medicine. The attending physicians role in helping patients return to work after illness or injury: www. ACOEM.org/guidelines.April 2002