Date: Thu, 28 Sep 1995 22:17:59 -0400 From: "John D. Lloyd" Subject: "A Holistic Ergonomic Approach for Successful Return to Work" To: Multiple recipients of list SOREHAND The following is an article which I wrote and was published in several trade journals earlier this year. Subscribers to the sorehand discussion group may find the information particularly useful for the purpose of tailoring their own return-to-work strategy to facilitate rehabilitation while reducing the risk of reinjury. I hope that this article promotes further discussion and would be interested to read your comments. A Holistic Ergonomic Approach for Successful Return to Work John D. Lloyd, Principal Ergonomist The Ergonomics Institute, Hauppauge, NY Tel: (516) 979-ERGO / 3746 Fax: (516) 979-3416 E-mail: johnergo@li.net January 1, 1995 Abstract This article presents the opinion of a practicing ergonomist on developing successful return to work strategies based on holistic multi-disciplinary interaction. This system is not a approach recognized by the Worker's Compensation Board in each state. However, points are presented and discussed as to why this more effective and common-sense methodology should be lawfully introduced, therefore streamlining the worker's compensation process. Introduction Worker's Compensation insurers and employers, through astronomical and ever-increasing premiums, willingly paid a staggering $62,000,000,000 in lost time benefits and associated medical costs for occupational injuries in 1992 (1). Given the opportunity to reduce this tremendous burden on the American Business Community, should be not act ?. Studies have shown that once an employee has been injured on the job, the likelihood that the individual would successfully return to gainful employment is 48% (2). Moreover, individuals who remain out of work for a period greater than 6 months following injury incidence have only a 50% chance of resuming their productive livelihood (3). Should the rehabilitation process extend beyond one year the probability that the individual would ever return to work falls to only 25%, and continues to decrease as time increases (4). Thus, based on the above statistics it is the employers economic responsibility to the financial survivability of his company to ensure that work-related injuries are aggressively managed from the onset. It is likely that your facility does not have a definitive policy for the successful return to work of injured employees. General consensus is that this would detract from the primary purpose of doing business, and therefore becomes the sole responsibility of the involved clinician. But when your bottom-line is on the line, should you not consider more active participation in the process? Industry Accepted Return to Work Strategy Typically a clinician might, based upon logical judgment and years of experience, decide when the patient in his care has demonstrated a level of rehabilitation that would allow them to return to work. A release statement would then be prepared allowing the employee to resume active duty at his or her place of employment. This release statement might include direction for 'light duty' or 'restricted lifting capacity' for a given period or until further notice. But these directions for return to work are based upon little or no knowledge of the physical or biomechanical demands endured by the individual during the course of a typical work day. It is unlikely that the clinician has ever attended the individuals place of work to observe, let alone quantify, such demands and therefore it might be argued that the basis of such return to work restrictions are unfounded. Unrealistic and Illegal Return to Work Policies In today's world of uni-lateral, forward-thinking companies where employees share the same benefits as their employers, there are an unfortunate many who continue to apply the above scenario because their personal involvement in the return to work process in minimized. This includes a number of unconcerned employers whose return to work policy requires that their operators are accepted only when 100% rehabilitated and can perform necessary job tasks without restriction. But it is impossible to determine, given present injury status, what 100% of worker capacity is. What exactly does 100% mean anyway ? Not only does such a policy make no economic sense, but it is also in defiance of the American's with Disabilities Act. American's with Disabilities Act ADA legislation mandates that "no covered entity shall discriminate against a qualified individual with a disability ... providing the individual can perform the essential functions of the job with or without reasonable accommodation." This umbrella statement includes individuals with permanent or temporary disabilities. Therefore it is an employers legal responsibility to accept returning employees, even though they may not be 100% rehabilitated, and to ensure that appropriate accommodations are readily available to reduce the risk of re-injury. Appropriate workplace accommodations might include engineering controls such as lifting aids, workstation redesign, and / or administrative controls such as job rotation and enlargement. Functional Capacity Evaluation The new Functional Capacity Evaluation (FCE) performed by Physical Therapists, Occupational Therapists, Doctors of Chiropractic and other vocational specialists goes a long way to addressing the need for an objective approach to injury management and return to work planning. An FCE involves a thorough evaluation of a patients musculoskeletal abilities and their relation to an individuals performance. Testing procedures are usually performed at the clinician's office, where typical daily activities, such as walking, lifting, and climbing, are simulated and the individuals performance of these activities rated. The FCE report is particularly useful for the development of work-hardening or work-conditioning strategies, although with little or no attention given to interactive external factors, such as specific job-task demands or environmental conditions goals for the rehabilitation process are based on industry accepted norms. The Functional Capacity Evaluation is an excellent methodology for the assessment of internal factors which affect an individuals ability to perform necessary functions. However, even a superior rehabilitation program, which includes this technique for the assessment of an injured employees abilities, does not embrace the true potential of a successful return to work program. Flaws in the Return to Work Process Without attention to quantitatively determined physical demands and environmental conditions associated with specific task activities it is difficult for a vocational specialist to develop goals for a successful rehabilitation program. The absence of such goals makes it almost impossible to confidently ascertain the return to work qualification of an injured employee. The rehabilitation specialist may therefore impose unfounded restrictions upon the returning employee to reduce the risk of re-injury, with intention to evaluate the effectiveness of those restrictions during subsequent appointments. Inaccurate or unsuitable employee restrictions, based upon a lack of objective findings, may have undesirable effects upon returning the individual to gainful employment. 1. Unnecessary restriction of an otherwise qualified operator would cause the returning employee to produce below capacity, resulting in financial loss for the company. If that employee performs an essential function on a production line, the output of all members of the line is adversely affected due to such unfounded and unnecessary restrictions, thus multiplying the employer's financial loss. 2. Alternatively, a worker may return without adequate restrictions imposed. Performance of certain tasks may lead to re-injury of the employee, resulting in an extension of the rehabilitation process. Other factors which affect Return to Work Aside from overlooking essential physical demands analyses and neglecting to consider job-specific environmental conditions, an FCE does not evaluate certain other factors which affect the return to work qualification of injured employees. These factors may be behavioral or emotional in nature, and often only manifest themselves immediately prior to or at the time the operator returns to work. Symptoms of such factors include symptom magnification, hypochondrias, paranoia and resentment toward their employer, among others. Although difficult to evaluate, such factors can have a profound effect upon the success of an individualized return to work program. It is therefore necessary to investigate the existence and so address these disorders as part of a holistic approach to injury rehabilitation. Goals of an effective return to work strategy Before entering into discussion on this area of interest it is necessary to state the primary aim of any rehabilitation process. Many efforts to rehabilitate injured employees fail to address the problem effectively because this most elementary step was overlooked. The primary aim of a successful return to work strategy is to effectively and efficiently rehabilitated injured employees while minimizing the societal costs of health care. Contrary to popular practice, every effort should be made to return injured employees to the workplace as quickly and safely as possible. In the unfortunate event of a workplace injury, rapid communication between involved vocational specialists is necessary to determine if removing the injured worker is indeed the most appropriate action, considering, of course, the nature and extent of injuries sustained. Studies have shown, confirmed by the above statistics, that the sooner an injured worker is returned to active employment, the greater the probability of full recovery. As demonstrated thus far it is almost impossible for a return to work strategy to be effective without rehabilitation goals. These goals should be based not only on industry accepted lifestyle norms but also on actual physical demands imposed upon the individual during the course of a typical working day. Without the luxury of the results from a pre-injury Functional Capacity Evaluation, and most employers health insurance offers no coverage for this luxury, it is necessary to determine, through quantitative analysis as well as direct observation, the extent of these physical demands. Necessary information for a physical demands analysis can often be attained from a compilation of ADA prepared job descriptions and on-site data collection. In the absence of the injured employee it is acceptable for a colleague from the same department to simulate a variety of activities for data collection purposes. Techniques used to record this data vary by personal preference, but may include video, direct measurement of physical stressors, and subjective musculoskeletal discomfort interviews / questionnaires. What an effective RTW evaluation should include to attain these goals An effective return to work evaluation must not only be based upon effective evaluation techniques, but we must ensure that we are evaluating the process holistically. Generally, a return to work program would evaluate the nature of the injury and the characteristics of the individual. But as stressed throughout this discussion a third, and often omitted aspect requiring evaluation should be the demands of the job to which the patient is to return. The following areas should be considered: * job description * age and general health of the injured worker * nature of the injury * motivation and job satisfaction * presence of litigation * work environment Multi-disciplinary approach to successful return to work planning Several of the above discussion points make reference to the rehabilitation process involving more than one specialist. A successful return to work strategy should include representation from several vocational rehabilitation disciplines, as well as an appointed representative of the company. Based upon experience, a most effective and efficient strategic planning team would include a clinician, vocational specialist, occupational ergonomist and human resources personnel. A multi-disciplinary approach of this nature adds a degree of flexibility to the rehabilitation solution, thus offering the individual and company involved with a minimum exposure to risk of re-injury. The Rehabilitation System Model below presents a typical example of this multi-disciplinary involvement, including discussion of inherent benefits and drawbacks. The Ergonomist's Role The application of occupational ergonomics in the rehabilitation of injured workers is a point that has been widely discussed during recent years by vocational specialists from all disciplines. In fact, the only examining body that does not presently recognize the benefit of ergonomic involvement in the rehabilitation process is the Worker's Compensation Board. But then nobody claims that this authority practices efficiency. The introduction of ergonomics into the rehabilitation process for the purpose of quantifying external and environmental stressors that affect an individual's performance is a perfect compliment to the Functional Capacity Evaluation. Compatibility between physical abilities of the injured employee and biomechanical demands of the task are easily evaluated by comparing results from the two assessments. Where a mismatch between the two is evident, solutions must be developed both with respect to adaptation of the work-hardening program and risk factor reduction by ergonomic engineering and administrative controls. Even if a mismatch of results is not apparent it is likely that ergonomic hazards both with respect to the present injury and potential future injuries would be identified and addressed in all but a perfectly designed workstation. Since an individual did experience work-related trauma under the evaluated conditions it is unlikely that we have discovered the elusive perfect workstation at this time. This holistic approach, considering both internal and external factors, should result in a more effective and efficient return to work process, as stated in the primary aim. Clinician Assuming Role of Ergonomist Sometimes the clinician involved may choose to personally perform on-site data collection for the physical demands analyses. Although the rehabilitation specialist should be commended for their enthusiasm in this instance, it is essential to the success of the program that such activities be outsourced to and performed by occupational ergonomists who have achieved a high level of training and experience in this area. Introduction of the occupational ergonomist for task demands analyses will not only facilitate a successful rehabilitation process but also adds a level of flexibility to solution development. The involved clinician who has never worked alongside an occupational ergonomist on previous projects would also likely be pleasantly surprised at the refreshing compatibility between the two disciplines. Each having an opportunity to learn a great deal from the other's unique problem solving perspectives. Benefits The many benefits offered by this multi-disciplinary approach beyond the intended successful return to work are profound. Firstly, since the majority of shareholders within the American Business Community, specifically represented by those who frequently require the services of a rehabilitation specialist, have yet to fully embrace the philosophy of occupational ergonomics, this approach may serve as an excellent introduction. Given that the company is open-minded to a proactive approach to injury prevention, what employer would not accept the inherent financial benefits changing their current reactive stance to injury rehabilitation Including an ergonomist in the recovery process also produces a self-serving introduction to the underlying principles of ergonomics on the shop floor. As part of the rehabilitation process, a qualified ergonomist would instruct the returning employee on preferred work practices, to help minimize stressful postures. Upon realization of how much easier this makes the employees task it is likely that their colleagues would quickly learn and adopt the same principles of improved body mechanics. The results from the ergonomic workplace assessment may also serve as a powerful tool in a pre-employment screening examination. Given quantitative data which describes the physical demands of a specific tasks, the employer is able to utilize this information in any screening techniques they may presently use in the employee hiring process. It must be remembered, however, that the American's with Disabilities Act states that pre-employment screening examinations, if used, must be conducted for all applicants and not used as a discriminatory tool to eliminate unwanted, but qualified individuals. Conclusions Given that the primary aim of a successful return to work strategy is to effectively and efficiently return injured employees back to gainful and productive employment without incurring astronomical health care costs, I trust that the above discussion of a holistic ergonomic approach provides food for thought. In these days of skyrocketing health care and worker's compensation costs it makes more clinical and economic sense to aggressively manage workplace injuries from the onset, and ergonomics just may be the tool for the job. John D. Lloyd Tel: (516) 979-ERGO/3746 The Ergonomics Institute Fax: (516) 979-3416 Hauppauge, New York 11788 E-mail: johnergo@li.net ---------------------------------------------------------------------------- Cost effective occupational ergonomics consulting services ----------------------------------------------------------------------------