Factors Influencing Return to Work for Clients in a W ork-Hardening Center JANE M. GRALV, * SANG VI, * GAIL M. JENSEN,t MARIANNE GIBSON,:!: AND TOM LABORDE:!:
*Samuel Merritt College, Oakland, California; lDepartment of Physical Therapy, School of Pharmacy and Allied Health, Creighton University, Omaha, Nebraska; t Work Hardening Center, Summit Medical Center, Oakland, California This pilot study investigated whether a simple statistical analysis of selected intake data in the charts of work-hardening clients could differentiate those clients who returned to work from those who did not. Datafrom 24 workers' compensation clients were examined. Perceived pain on initial evaluation was the only statistically significant variable (p < 0.01). Lower pain levels correlated with a successful return to work. Statistical trends (p < 0.10) suggested that a lower hourly wage, a higher occupational metabolic equivalent level, and a marital status of married or cohabitating correlated with a successful return to work. Data were used to describe a client at risk - one with high levels ofpain, who was not in a physically demanding Job and lacked social support. Program recommendations were made to address these issues. It was concluded that as other work-hardening centers respond to the call for better outcome assessment, a similar design process could be used. Keywords: Work-hardening; Return to work; Workers' compensation; Outcome assessment
Each year, about half a million workers in the United States become seriously injured and cannot return to work for prolonged periods of time (Scheer, 1990). Many are never reemployed. Scheer (1990) estimates that only 48% of those who enter the disability support system eventually return to work. The social and economic costs of this are immense. The National Safety Council calculated the direct cost of work-related injuries in 1985 to be $16 billion per year (Peters, 1990). The social costs of human suffering, loss of self-
esteem, and reduced income are also great, although not easily calculated. At various points in the history of industrial rehabilitation, simulated work has been used as a part of the care of the injured worker. Lepping (1990) found its roots in the fields of vocational rehabilitation and occupational therapy and its beginnings as early as the 1940s. In the late 1970s, work simulation and related techniques were repackaged into a new service that came to be known as work hardening. The Commission on AccrediWORK 1994; 4(1):9-21 Copyright © 1994 by Butterworth-Heinemann
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tation of Rehabilitation Facilities (CARF) and the National Advisory Committee on Work Hardening defined work hardening in 1988 as follows: Work hardening is a highly structured, goal oriented, individualized treatment program designed to maximize the individual's ability to return to work. Work hardening programs, which are interdisciplinary in nature, use real or simulated work activities in conjunction with conditioning tasks that are graded to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, and psychosocial functions of the individual. Work hardening provides a transition between acute care and return to work while addressing the issues of productivity, safety, physical tolerances, and worker behaviors (Ogden-Niemeyer and Jacobs, 1989).
Work hardening can be viewed as applying a "sports medicine" approach to industrial injury. The injured worker is treated like a 40-hour-perweek athlete (Lepping, 1990; Ogden-Niemeyer and Jacobs, 1989; Matheson et al., 1985). The early focus of work-hardening programs on workers who had been unemployed for many years has shifted to include the more recently injured (Ogden-Neimeyer and Jacobs, 1989). Workhardening programs have grown quickly, at least partially in response to the expansion of state workers' compensation benefits to include mandatory vocational rehabilitation (Lepping, 1990). In 1984, Matheson et al. (1985) located 26 workhardening programs. In 1990, researchers were able to identify 252 programs (Wyrich et al., 1991). This rapid growth has meant that many programs have arisen in response to market demands with few standards or guidelines (Wyrich et al., 1991). In addition to rapid growth, the relatively recent development of work-hardening approaches may also account for a lack of research in this area. Little has been done to examine the effectiveness of work-hardening programs (Haig and Penha, 1991), and few individual centers routinely collect outcome data. A recent survey of 192 work-hardening programs indicated that only 45 % of the programs were reporting return-towork rates (Wyrick et al., 1991). Frequently, there is no explanation of what criteria were used to define a successful return.
Work-hardening services are intensive and lengthy. Program costs vary from $4,000 to $8,000 (Mayer et al., 1985). In this era of health care cost scrutiny, it is imperative that workhardening centers are better able to justify their programs. This is addressed in both the guidelines of CARF (American Occupational Therapy Association, 1986) and the American Physical Therapy Association (APTA) (American Physical Therapy Association, 1993). CARF guidelines call for admission criteria to admit "persons who are likely to benefit from the program." Recently formulated APT A guidelines call for systematic data collection for outcome assessment. Although most programs have initial screening tests, little is done to isolate factors that might further correlate with a successful return to work on program completion. Knowledge of these factors might help the staff refine initial screening tests to select appropriate clients for their program or to redesign their program for better outcomes. Work hardening has developed from the efforts of a number of professions such as occupational therapy, physical therapy, work evaluation, and industrial psychology. This interdisciplinary focus often creates a wealth of data, which are routinely collected in the initial screening and evaluation. The hypothesis of this study was that a statistical analysis of selected intake data would yield factors that could differentiate those clients who successfully returned to work from those who did not return to work. Research parameters were chosen from physical, psychological, and demographic areas. The criteria used for selection were that the data could be easily collected from client charts and that there was sufficient variation in the sample population in any particular trait for potential statistical significance. Although the factors we have isolated could have value for other work-hardening centers, our purpose was not to discover the definitive list of factors that influence return to work. Our purpose was to demonstrate the usefulness of a relatively simple analysis of readily available data to improve client selection or improve program content. Our hope is that all centers will be able to
Factors Influencing Return to Work
adapt this analysis to meet their individual program needs.
LITERATURE REVIEW Many researchers have looked at factors influencing return to work (RTW) in a variety of settings. None have looked specifically at work hardening. Only a few studies have examined the effectiveness of work-hardening centers. One of the most extensive was a prospective study of chronic back pain patients who received work-hardening services. Mayer et al. (1985, 1987) reported their findings after both a i-year and a 2-year follow up. In both of these follow-up surveys, the R TW rate of the treatment group was double that of the control group, who did not receive work-hardening services (- 85 and 40%, respectively). Although characteristics of the treatment and control groups were compared, the investigators did not compare any differences within the group of patients who received work-hardening services. A recent study by Tate (1992) examined data from 200 workers' compensation cases from one auto manufacturing company. Vocational rehabilitation interventions or lack of them were examined in both groups of workers who had returned to work and those who had not returned. Workhardening programs were included as an intervention. However, they were not isolated from numerous other services such as case management or independent medical evaluations, which could also have a major effect on R TW outcomes. In general, there is a long history of research examining factors that might be useful in predicting who can benefit from a variety of rehabilitation services (Ogden-Niemeyer and Jacobs, 1989; Haig and Penha, 1991). The factors that are frequently studied can be divided into three types: demographic factors, factors that describe the nature of the injury, and environmental/psychological factors. Clients are often studied in a particular setting, for example, a pain clinic or a rehabilitation center. Clients who have sustained a particular type of injury are also studied. Low back pain is particularly well researched (Lancort
11
and Kettelhut, 1992; Mayer et al., 1985, 1987; Matheson et al., 1985). There is not a great deal of consistency in the literature about which particular factors are significantly associated with successful R TW outcomes. Such inconsistency is not surprising because there is great variation in the research studies themselves. However, when multiple studies have found a particular factor to be significant, there is agreement about how that factor will relate to a successful outcome. For example, if age is found to be a significant factor, then it has a direct relationship with an unsuccessful R TW outcome.
Demographic Factors Length of time out of work is a variable that is most consistently found to be significantly related to outcome (Peters, 1990; Burgel and Gliniecki, 1986; Nachemson, 1983; Kasdan and McElwain, 1989) Peters (1990) found that the chance ofRTW was only 50% after 6 months of not working, and almost zero after 2 years. Age is another variable that is often found to be significant (Scheer, 1990; Tate, 1992; Milhous et al., 1989). As noted above, increasing age correlates with an increasing likelihood of an unsuccessful R TW. Greater income (Tate, 1992), education (Guck et al., 1989) and job seniority (Tate, 1992) are all associated with greater probability of R TW. Men and married people are also more likely to R TW (Tate, 1992).
Nature of the Injury The severity of the injury (Kasdan and McElwain, 1989; Murphy and Cornish, 1984; Bear-Lehmen, 1983) and its location (Matheson et al., 1985; Beals and Hickman, 1972; Tate, 1992) are often found to correlate significantly with outcomes. Severity of the injury has an obvious relationship with R TW. Spinal injuries in general and low back injuries in particular are indicators of a poor prognosis for R TW. Self-perceived pain levels have also been examined, particularly in patients with spinal injuries (Ogden-Neimeyer and Jacobs, 1989). Poor outcomes are associated with high pain levels that extend over large areas of the body (Murphy and Cornish, 1984). High self-
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perceived levels of disability are also associated with poor outcomes (Lancort and Kettelhut, 1992).
Environmental/Psychological Factors High physical work demands negatively correlate with RTW (Matheson et al., 1985; Milhous et al., 1989; Nachemson, 1983). There is some conflict in the literature with regard to physical conditioning level at the time of treatment. Matheson et al. (1985) state that work hardening works best with clients who are severely deconditioned. Milhous et al. (1989) found poor R TW outcomes with persons who had "low activity" levels. This conflict may be more apparent than real because the authors may be referring to different aspects of a person's physical state. Compensation for injury (Beals, 1984; Greenough and Fraser, 1989), low levels of financial hardship (Sheer, 1990; Bear-Lehman, 1983; Beals, 1984), and receipt of legal assistance (Peters, 1990; Taylor, 1989) all negatively correlate with R TW. Several researchers have also found a negative correlation with "disability behavior" (Taylor, 1989; Isernhagen, 1988). This behavior could be caused by the workers' compensation system, the health system in general, or other models oflearned behavior. Injured workers may be less likely to return to work when other family members are on disability (Ogden-Niemeyer and Jacobs, 1989). Psychological variables have been widely studied in the medical arena (Beals and Hickman, 1972; Nachemson, 1983; Bear-Lehman, 1983). Some studies have found psychological variables to be more predictive of outcomes than demographic data or the characteristics of the injury (Scheer, 1990). There is no agreement about which psychological tests might be predictive of RTW. The Minnesota Multiphasic Personality Inventory has been widely used to predict medical outcomes (Milhous et al., 1989; Beals, 1984). It has not been extensively used in work-hardening centers, and its usefulness in that setting has been questioned (Ogden-Niemeyer and Jacobs , 1989). Of the psychologically oriented variables used for this research project - namely, the Oswestry Low Back Pain Disability Questionnaire, the Numeric Pain Scale, the Millon Behavioral Health Inventory, and the Multidimensional Health Lo-
cus of Control- only the Oswestry has been used specifically in examining R TW factors. Lancort and Kettelhut (1992) found a high Oswestry score one of the predictors for an unsuccessful R TW . Several variables not included in our study might have value in other research projects. Ethnic background (Ogden-Neimeyer and Jacobs, 1989), gender (Matheson et al., 1989), education (Scheer, 1990), level of medication (Guck et al., 1989), symptom magnification (Peters, 1990), and prior job satisfaction (Beals and Hickman, 1972) have been found to be significant outcome factors in prior research.
METHOD This study used a statistical analysis of selected information in charts of clients in a single workhardening center.
Program Description The work-hardening program studied is a medical center-based program located in the San Francisco Bay area. It is a multidisciplinary program, with staff consisting of two physical therapists and one industrial psychologist. The program adheres to CARF guidelines and fits the general description of a multidisciplinary program described elsewhere (Ogden-Niemeyer and Jacobs, 1989). The program sees - 8-10 new clients per month. Most of them are receiving workers' compensation temporary disability benefits and were referred by their medical doctor. Most have the goal of returning to their usual and customary job. The minimum work-hardening program for a client is 4 hours/day, 3 days/week for 4 weeks. The maximum program is 4 hours/day, 5 days/week for 6 weeks. Program costs run from $3,380 to $7,700. Outcome data are currently collected.
Subjects Data were collected on clients who entered the program for work-hardening services over a 7-month period, namely, those who entered the work-hardeningcenterafterJuly 1,1992 and who exited before February 1, 1993. Excluded from the study were clients who were not receiving
Factors Influencing Return to Work
workers' compensation benefits, whose language skills were judged insufficient to accurately complete all forms, whose objective for work hardening was other than return to their usual and customary employment (i.e., vocational rehabilitation), who had an intervening service between work hardening and RTW, or who did not complete the program. Under these criteria, data were analyzed from a total of 24 clients.
Research Variables The factors chosen for analysis are given in Appendix 1. As stated above, factors were chosen that were thought to be particularly applicable to the work-hardening center under study. Most items are simple and descriptive with just a few complex items. The client metabolic equivalent (MET) level is a unit of biological energy expenditure related to a multiple of resting metabolic rate. The MET level requirements for jobs are given by the U.S. Department of Labor. The Department lists both a general description (i.e., light, medium, heavy) and a corresponding MET level for a wide variety of occupations (see Appendix 2). The MET level of the client on entry into the program was determined by a submaximal treadmill exercise stress test. The presence of radiating symptoms was intended to serve as a gross indicator of severity. The numeric 0 to 10 + Pain Rating Scale (selfperceived pain scale) and the Oswestry Low Back Pain Disability Questionnaire (self-perceived disability scale) have been widely used in workhardening and other rehabilitation centers (Fairbank et al., 1980). The pain scale used is reproduced in Appendix 3. The two psychological instruments-the Millon Behavioral Health Inventory and the Multidimensional Health Locus of Control (MHLC)were developed for use in medical settings and have been found to be reliable and valid (Wallston and Wallston, 1978; Milon, Green, and Meagher, 1982). The MHLC assesses the belief that one's health is or is not determined by one's own behavior. There are three subscales: internal health locus of control (IHLC), powerful other locus of control (POLC), and chance locus of control (CRLC).
13
The Millon Behavioral Health Inventory consists of 20 scales divided into four general areas: basic coping styles, psychogenic attitude scales, prognostic indices scales, and psychosomatic correlates scales. Six scales were chosen for inclusion in this study. Three coping styles were selected: sociable style, forceful style, and sensitive style. Of the psychogenic attitudes scales, future despair was chosen. This scale focuses on the person's willingness to plan and look forward to the future. Of the prognostic indices scales, pain treatment responsivity was chosen. High scores predict a course of treatment complicated by pain as an intrusive psychological issue. No psychosomatic correlates scales were analyzed because they did not appear to apply to the population under study.
Procedure Data were collected on two groups: clients who were relieved of duty and who were receiving workers' compensation temporary disability benefits, and clients who were on light or modified duty and whose medical and work-hardening services were being paid for by workers' compensation. Research variables were collected on a simple onepage form that was attached to the client's chart (see Appendix 4). Entries were made on an ongoing basis by the work-hardening staff as intake data became available. Outcome data were also collected by the workhardening staff on an ongoing basis. A successful R TW outcome was defined as follows. For those clients relieved of duty, R TW was defined as any employment lasting for at ~2 weeks that began within 30 days of program completion. For those clients on modified or light duty, a successful R TW outcome was defined as a return to full duty, within the same time frames.
Data Analysis Potentially, four groups of clients could have been analyzed: Group 1: relieved of duty/returned to work (relieved/RTW) Group 2: relieved of duty/no return to work (relieved/no R TW)
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Group 3: modified duty/returned to work (modified/RTW) Group 4: modified duty/no return to work (modified/no R TW) However, in our particular sample, all the clients who were on modified duty returned to work, so there were no members of group 4. For the variables listed in Appendix 1, all statistical models tested the null hypothesis that there was no significant difference between those who did and did not return to work. The variables can be divided into two types: categorical variables such as marital status, and continuous variables such as age. For categorical variables, the hypothesis was that those returning to work exhibited the same proportion of the various attributes as did those who did not return to work. This was tested by Fisher's exact test for dichotomous variables and with X} for nondichotomous variables. For continuous variables, the hypothesis was that the means of the groups were equal. This was tested with a Student t-test for two means. An SAS statistical program was used. The comparison groups were defined two ways: 1) differences between R TW and no R TW in the relieved-of-duty subset (groups 1 and 2 only) and 2) differences between R TW and no R TW, disregarding whether they were working during treatment (group 2 vs. groups 1 and 3 combined). Level of significance was set at p < 0.05. Because of the small sample size and particularly the small number of subjects in the group that did not return to work, trends in the data were also examined. Trends were defined as p < 0.10.
RESULTS Several results should be noted about the entire sample. Group means for pain at initial evaluation ranged from 5.7 to 8.8 on the 0 to 10 + pain scale (Table 1). All were above a rating of "strong." Sixty-eight percent of the sample population had pain that radiated from their primary injury. The group means for the Oswestry Disability Questionnaire ranged from 52 to 62 (Table 1). These fall in the category of "severe disability."
The group means for the MET level of occupation ranged from 2.7 to 4.3 (Table 1). This fell into the descriptive range of above "light" but below "medium-heavy." The comparison of client and job MET levels revealed that 75 % of all clients had an initial MET level greater than or equal to the MET level of their job (Table 2). The group mean scores for the Millon Behavioral Health Inventory (Table 1) indicated that none of the coping styles (sociable, forceful, or sensitive) had a high enough score to be considered a significant coping style. The mean scores for psychogenic attitude of future despair were considered average, with neither positive or negative consequences. The mean scores for the prognostic index of pain responsivity indicated little likelihood of a treatment complicated by this issue (Millon, Green, and Meagher, 1982). As shown in Table 3, the whole sample mean scores for the MHLC appeared closer to the normative scores of healthy adults or adults engaged in preventive behavior than to the normative scores of chronic patients. This was true of the outcome group scores as well, with the following exceptions. The group that had been relieved of duty and not returned to work had mean scores on the IHLC and CHLC that appeared closer to the normative scores of chronic patients. These scores, however, are statistically insignificantly different from the scores of the other outcome groups. An inability to distinguish statistically between outcome groups was also true of the variable of legal assistance. Half of the no R TW group had engaged the services of an attorney com pared with 22 and 11 % in the groups that had returned to work (Table 2), yet these differences were not statistically significant. Research variables that could distinguish statistically between outcome groups (p = 0.10 orless) are given in Table 4. Only the variable of "pain on initial evaluation" met the criteria of statistical significance set for the study (p < 0.05). A higher pain level on initial evaluation was found in the group that did not return to work in both sets of comparisons (the relieved-of-duty subset compar-
Factors Influencing Return to Work
Table 1.
15
Mean Results for Continuous Variables by RTW Outcome and Work Status All Groups (n = 24)
Group 1 (n = 9) Relieved/RTW
Group 2 (n = 6) Relieved/N 0 RTW
Group 3 (n = 9) Modified/RTW
Research Variables
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Age (years) Weeks out of work Hourly income Financial hardship' Current employment (years) MET level of occupation! MET level of patient! Difference in MET levels Pain at initial evaluationS Self-perceived disabilityll Millon 4 - sociable# Millon 6 - forceful' Millon 8 - sensitive# Millon D-future despair" Millon PP-pain responsivityll
39.00 15.00 14.10 0.92 6.50 3.70 5.30 1.60 6.60 55.00 43.00 50.00 42.00 43.00 46.00
11.00 17.00 4.96 0.13 5.50 1.80 2.60 3.00 2.10 17.00 26.00 29.00 34.00 28.00 27.00
42.00 22.00 10.71 0.87 7.80 3.80 5.30 1.50 5.70 53.00 44.00 59.00 44.00 40.00 46.00
14.00 11.00 3.65 0.19 7.60 1.60 3.10 3.70 1.00 14.00 26.00 31.00 35.00 25.00 22.00
34.00 29.00 15.98 0.88 5.50 2.70 4.60 1.90 8.80 62.00 27.00 41.00 48.00 49.00 56.00
11.00 23.00 5.76 0.10 3.50 0.90 2.20 1.90 2.70 22.00 25.00 29.00 53.00 42.00 47.00
39.00 0 16.43 1.00 5.90 4.30 5.90 1.50 6.00 52.00 49.00 46.00 36.00 43.00 41.00
8.00 0 4.04 0 3.90 2.10 2.40 3.00 1.70 18.00 26.00 29.00 25.00 27.00 22.00
• Postinjury income as a percentage of preinjury income. U.S. Department of Labor ratings, which range from 1.5, "sedentary" to 12.0, "very heavy." I Submaximal treadmill test in initial evaluation. So to 10 + pain rating scale, which ranges from 0, "nothing at all" to 10 + , "maximal." I 0-20, "minimal disability"; 20-40, "moderate disability"; 40-60, "severe disability"; 60-80, "crippled"; 80-100, "bed bound or exaggerating their symptoms." # Considered significant if score is ~75 . •• 0-35, Low level of concern; 35-75, average range; 75-85, potential serious impact; ~85, major area of concern. 11 0-60, Issue unlikely to complicate treatment; 61-75, possible complication; 76-84, diminished outcome likely; ~85, course of treatment complicated by psychological issue. 1
Table 2.
Results for Categorical Variables by RTW Outcome and Work Status
Research Variables Married or cohabitating Legal assistance Job MET>patient MET Other family on disability Radiating symptoms Primary location of injury
All Groups (n = 24)
Group 1 (n = 9) Relieved/RTW
Group 2 (n= 6) Relieved/No RTW
Group 3 (n= 9) Modified/RTW
0.50 0.25 0.25 0.16 0.68 2.90
0.56 0.22 0.33 0.22 0.63 3.10
0.17 0.50 0.17 0 0.83 2.80
0.67 0.11 0.22 0.22 0.62 2.80
Results give percentage of "yes" answers except for location of injury, in which 1 3 = spinal-lumbar, 4 = peripheral/other.
ison and the comparison that included workers on modified duty). In both cases, p = 0.01 (t-test). Three research variables met the criteria of a statistical trend (p < 0.10). In the comparison of the groups who were relieved of duty, higher
spinal-cervical, 2
spinal-thoracic,
hourly income tended to correlate negatively with R TW (p = 0.06, t-test). In the comparison of groups regardless of working status, people who were married or cohabitating showed a trend to return to work (p = 0.08, Fisher's exact test). In
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Table 3.
Multidimensional Health Focus of Control: Means of Research Groups and Normative Data IHLC
POLC
CHLC
All groups (n = 24) Group 1 (n = 9): relieved/RTW Group 2 (n = 6): relieved/no RTW Group 3 (n = 9): modified/R TW
26.79 (6.04) 27.44 (4.88)
Mean (SD) 19.79 (5.52) 19.98 (7.29)
16.79 (6.59) 16.56 (4.42)
24.67 (5.09) 27.56 (7.76)
18.83 (6.08) 20.33 (3.24)
17.33 (7.69) 16.67 (8.26)
Chronic patients Healthy adults Preventive health behaviors
25.78 25.55 27.38
Research and Comparison Groups
Table 4.
Normative Data 22.54 19.16 18.44
17.64 16.21 15.52
Research Variables that Could Distinguish Outcome Groups (p = 0.10)
Comparison
Research Variable
p Value, Test
Relieved-of-duty subset'
Pain at initial evaluation Hourly income Pain at initial evaluation MET level of occupation Married or cohabitating
0.01, t-test 0.06, t-test
Returned vs. did not, regardless of work status!
0.01, t-test 0.09, t-test
0.08, Fisher's exact test
• Group 1 (relieved of duty/RTW) vs. group 2 (relieved of duty/no RTW) 2 (relieved of duty/no RTW) vs. group 1 (relieved of duty/RTW) and group 3 (modified duty/RTW) combined.
T Group
this same comparison group, a lower occupational MET level tended to correlate with an unsuccessful RTW (p = 0.09).
DISCUSSION As the work-hardening industry matures and medical costs come under greater scrutiny, there will be an increased need for program analysis and outcome assessment. Better outcome assessments are likely to be demanded by third-party payers, referral sources, or by workers' compensation legislative reforms. Physical therapists, occupational therapists, and other health professionals involved in work hardening have several advantages in this quest. First, many potentially significant research variables are routinely collected in client charts. Second, most clients entering a work-hardening program have an easily measured functional objective - returning to work. The purpose of this
pilot project was to demonstrate the usefulness of correlating selected intake data to outcomes with a simple statistical analysis. This analysis yielded several noteworthy results about the sample as a whole. Most of the center's clients had only moderately physically demandingjobs. All group means fell below the "medium-heavy" category. Seventy-five percent of all clients had an initial MET level greater than or equal to the MET level of their job. This fact, plus the high number of people who were still working on light or modified duty while receiving work-hardening services (9 out of24), may reflect the trend toward earlier rehabilitation. Physical dcconditioning, per se, may be a less prominent factor in rehabilitation services as this trend continues. Other issues such as self-perceived pain and disability were more important to our sample. As shown in Table 1, group means for pain at initial evaluation were all above a rating of "strong."
Factors Influencing Return to Work
High levels of pain are known to be a complicating factor in work hardening (Ogden-Niemeyer and Jacobs, 1989). The group means for the Oswestry Disability Questionnaire ranged from 52 to 62. These fall in the category of "severe disability." Lancort and Kettelhut (1992) found an Oswestry score >55 to be one predictor of a negative R TW outcome in low back pain patients. The level of pain on initial evaluation was the only research variable that could statistically distinguish those groups who returned to work from those who did not (p < 0.01). This was true for both sets of comparisons. This finding - that high levels of pain correlate negatively with R TW has been consistently found in other research as well (Murphy and Cornish, 1984; OgdenNiemeyer and Jacobs, 1989). Taken in conjunction with generally high levels of pain in all groups in the study, this would indicate that pain management should be a critical part of this workhardening program. For clients with particularly high levels of pain, a special prework-hardening program could be recommended to focus on this issue. A theoretical model for such programs has been proposed, and several work-hardening centers have prework-hardening programs to address special client issues (Ogden-Niemeyer and Jacobs, 1989). Three statistical trends (p < 0.10) were also examined. Higher hourly income correlated negatively with R TW in the comparison of groups who had been relieved of duty. This is in contrast to prior research (Beals and Hickman, 1972). Several things might account for this finding. For both groups, the mean for disability replacement income was approximately the same: R TW, 88 % ; no RTW, 87%. Individuals in the lower paid group ($10.711hour) who returned to work may have less easily tolerated a drop in income than those in the higher paid group ($15.98/hour) who did not. Factors not calculated in this variable, such as overtime income, savings, or income generated by other family members, could also be confounding factors. People who were married or cohabitating showed a trend to return to work in the comparison of groups regardless of working status. This finding is supported by other research (Lancort and Ket-
17
telhut, 1992), and suggests that people without emotional support may be less successful in a work-hardening program. This is an issue that could potentially be addressed by the program. For example, consideration of a social support mechanism such as a weekly support group may be worthwhile. A lower occupational MET level tended to correlate with an unsuccessful R TW in the comparison of groups regardless of working status. As shown by Appendix 2, a mean MET level of 2.7 in the group with no R TW is reflective of a job demand between "light" and "light-medium." The groups that did return to work had a MET level mean of 4.1. This would be placed between the categories of "medium" and "medium-heavy." This contradicts findings in prior research (Matheson et al., 1985; Milhous et al., 1989; Nachemson, 1983). However, it is consistent with a picture of an unsuccessful client whose main problem is pain and disability, rather than deconditioning for a demanding job. It is also possible that the injuries of the workers in our sample predisposed them to be more successful if returning to a job with moderate levels of movements than to a more static or sedentary job. The two psychological instruments, the MHLC and the Millon Behavioral Health Inventory, did not appear useful for outcome correlation in this sample. Results were insignificant or within normal ranges except for the mean scores of the noR TW group on the IHLC and CHLC scales. These scores, however, were not statistically different from the other groups' scores. The major limitation of this study was the sample size. Making major program changes without further study would carry some risk. For example, a larger research project could find that MHLC would differentiate between outcome groups or that social support was not a valid issue. Furthermore, some of the variables may not be accurate measures of what they claimed to measure. The MET level of the client's job was derived from client description, not from an on-site visit. The MET level of the client was determined by a submaximal stress test, which may not be an accurate measure of MET level sustained over an 8-hour shift. In addition, our definition of what consti-
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tuted a successful R TW was chosen from a number of alternatives. A different definition may have yielded different results. Finally, any recommendations made would apply to past clients, but not necessarily to future ones. Shifts in client population, type of injuries, or industrial injury compensation patterns could radically alter the optimum program content. This suggests the need for constant data collection and periodic analysis. As medical record keeping shifts to the increasing use of computers, records could easily be kept in a format to facilitate this kind of analysis.
CONCLUSIONS For the clients in one urban work-hardening center, pain was a primary issue, but deconditioning was not. This is consistent with the shift toward earlier rehabilitation. Although not entirely supported statistically, the data in this study describe the type of client at risk in this program: one who
has high levels of pain, is not in a physically demanding job, and lacks social support. From this description, we were able to make suggestions for program improvement. As work-hardening centers respond to the need for better outcome assessment, they will require similar systematic data collection and analysis to build their own model for clients at risk.
ACKNOWLEDGMENTS Assistance from the following people is gratefully acknowledged: Shari Ser, PT, for assistance with data collection; Mita Giacomini, MS, for assistance with statistical analysis; Thomas Graly, MA, fOI assistance with computer programming and graphics. This paper was submitted in partial fulfillment of the requirements for the degree of Masters of Physical Therapy in the Department of Physical Therapy, Samuel Merritt College, Oakland, California.
REFERENCES American Occupational Therapy Association. (1986). Work hardening guidelines. Am] Occup Ther, 40, 841-843. American Physical Therapy Association. (1993, March). Guidelines for programs in industrial rehabilitation. PT Magazine, pp. 69-72. Beals, R. K. (1984). Compensation and recovery from injury. West] Med, 140, 233-237. Beals, R. K., and Hickman, N. W. (1972). Industrial injuries of the back and extremities.] Bone]oint Surg, 54-A, 1593-1611. Bear-Lehman, ]. (1983). Factors affecting return to work after hand injury. Am] Occup Ther, 37, 189194. Burgel, B. ]., and Gliniecki, C. M. (1986). Disability behavior: Delayed recovery in employees with work compensable injuries. AAOHN], 34, 26-30. Fairbank, ]. C., Couper, ]., Davies, ]. B., and O'Brien,]. P. (1980). The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy, 66, 271273. Greenough, C. G., and Fraser, R. D. (1989). The effects of compensation of recovery from low-back injury. Spine, 14, 947-955. Guck, T. P., Meilman, P. W., Skultety, F. M., and
Dowd, E. T. (1989). Prediction oflong-term outcome of multidisciplinary pain treatment. Arch Phys Med Rehabil, 67, 293-296. Haig, A. ]., and Penha, S. (1991). Worker rehabilitation programs: Separating fact from fiction. West] Med, 154, 528-531. Isernhagen, S.]. (1988). Work injury-Management and prevention. Rockville, MD: Aspen Publishers, Inc. Kasdan, A. S., and McElwain, N. P. (1989). Returnto-work programs following occupational hand injuries. Occup Med, 4, 539-545. Lancort, ]., and Kettelhut, M. (1992). Predicting return to work for lower back pain patients receiving worker's compensation. Spine, 17, 629-640. Lepping, V. (1990). Work hardening-A valuable resource for the occupational health nurse. AAOHN j, 38, 313-317. Matheson, L. N., Ogden, L. D., Violette, K., and Schultz, K. (1985). Work hardening: Occupational therapy in industrial rehabilitation. Am] Occup Ther, 39, 314-321. Mayer, T. G., Gatchel, R. ]., Kishino, N., Keeley, ]., Capra, P., Mayer, H., Barnett,]., and Mooney, V. (1985). Objective assessment of spine function following industrial injury: A prospective study with
Factors Influencing Return to Work
comparison group and one-year follow-up. Spine, 10, 482-493. Mayer, T. G., Gatchel, R. J., Mayer, H., Kishino, N. D., Keeley, J., and Mooney, V. (1987). A prospective two-year study of functional restoration in industrial low back injury.]AMA, 258, 1763-1767. Milhous, R. L., Haugh, L. D., Frymoyer, J. W., Ruess,J. M., Gallagher, R. M., Wilder, D. G., and Callas, P. W. (1989). Determinants of vocational disability in patients with low back pain. Arch Phys Med Rehabil, 70, 589-593. Millon, T., Green, C.J., and Meagher, R. B. (1982). Millon behavioral health inventory manual, (3rd Edition). Murphy, K. A., and Cornish, R. D. (1984). Prediction of chronicity in acute low back pain. Arch Phys Med Rehabil, 65, 334-337. Nachemson, A. (1983). Work for all. Clin Orthop, 179, 77-83.
19
Ogden-Niemeyer, L., and Jacobs, K. (1989). Work hardening-State of the art. Thorofare, NJ: Slack. Peters, P. (1990). Successful return to work following a musculoskeletal injury. AAOHN j, 38, 264-270. Scheer, S. J., (1990). Multidisciplinary perspectives in vocational assessment of impaired workers. Rockville, MD: Aspen Publishers, Inc. Tate, D. G. (1992). Workers' disability and return to work. Am] Phys Med Rehabil, 71, 92-96. Taylor, M. E. (1989). Return to work following back surgery: A review. Am] Ind Med, 16, 79-88. Wallston, K. A., Wallston, B. S., and Devillis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) scales. Health Educ Monogr, 6, 161-170. Wyrick, J. M., Ogden-Niemeyer, K., Ellexson, M., Jacobs, K., and Taylor, S. (1991). Occupational therapy work-hardening programs: A demographic study. Am] Occup Ther, 45, 109-112.
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WORK / JANUARY 1994
Appendix 1.
List of Variables Analyzed
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Age Marital status Number of weeks out of work Hourly income before injury Financial hardship (all preinjury after-tax income as a percentage of all postinjury, after-tax income) Length of current employment Legal assistance (currently working with attorney) Primary location of injury [spinal (cervical, thoracic, lumbar) or peripheral] Radiating symptoms MET level of occupation (by U.S. Department of Labor tables) MET level at initial evaluation (by center-administered submaximal exercise stress test) Difference between MET level of occupation and MET level at initial evaluation Other family members on disability Self-perceived pain level at initial evaluation (a visual, numeric scale ranging from 0, "nothing at all" to 10 + , "maximal") 15. Self-perceived disability level at initial evaluation (Oswestry Low Back Pain Disability Questionnaire)
Multidimensional Health Locus of Control scales IHLC 16. 17. POLC 18. CHLC Millon Behavioral Health Inventory: selected scales 19. Millon 4: sociable style (coping style) 20. Millon 6: forceful style (coping style) 21. Millon 8: sensitive style (coping style) Millon D: future despair (measures psychogenic attitude) 22. 23. Millon PP: pain responsivity (measures psychosomatic complication to treatment process)
Appendix 3.
Appendix 2. U.S. Department of Labor: Descriptions for MET Level Job Ratings MET Level
Description
1.5 2.0 2.5 3.0 3.5
Sedentary Sedentary-light Light Light-medium Medium Medium-heavy Heavy Very heavy
4.5
6.0 7.5-12.0
0 to 10 + Pain Rating Scale
Number
Description
10 + 10 9 8 7 6 5
Maximal Very very strong
4
3 2 1 0.5 0
Very strong Strong Somewhat strong Moderate Weak Very weak Very very weak Nothing at all
Factors Influencing Return to Work
Appendix 4. COMPUTER CODES ONLY 1. Name No (2) 2. Worker's Compo Yes (lj IF THIS CLIENT IS NOT RECEIVING WORKER'S CaMP. DO NOT COMPLETE THE REST OF THE FORM. For the job which client is receiving compensation: 3. Not Working (1) _ _ Light or Modified Duty (2) ___ Full Duty(3) _ _ Date of program entry _ _ _ _--: 4. Last day worked or Last day of full duty 5. Number of weeks out of work ., or Number of weeks of light duty 6. (a) Hourly wage prior to injury ~ __ (b) Average AFTER TAX wee~ 7. income Weekly --;-di'--sa--:b"7il""it-y7in-come (tax-free) 8. Other new (post-injury) supplemen-t""'alC:i-n-co-m-e per week AFTER TAX _.,--;-_ 9. 10. Calculation: percentage of pre-injury AFTER TAX income currently received: =N #8 + #9 = New weekly income = Original income = 0 = _ _ __ #7(b) % = N/O • 100 = Length of employment with the company _ _ 11 . Age 12. MaritalStatus: Married(1) __ Single(2) __ Divorced(3) __Separated (4) __ 13. Co-habltation(5) Other family member(s) currently on Disability? Yes (1) No (2) 14. Are you currently working with an attorney to help resolve your case? - 15. Yes (1) No (2) Medical Diagnosis 16. Area of primary complaint (check only one): Spinal-cervical (1) 17. Spinal-lumbar(3) Peripheral/other(4) Spinal-thoracic (2) -Are there radiating symptoms? Yes (1)--No (2) 18. POL of client's occupation 19. MET level of client's occupational POL _ __ 20. 21. MET level of client at initial evaluation Calculation of difference between MET-level-of occupation and MET level at 22. initial eva!. # 20 - # 21 = :-7::--:--::-:-:Pain rating scale at initial eva!. (0-10 +): 0 (1) 0.5 (2) 1 (3) 23. 2 (4) 3 (5) 4 (6) 5 (7) 6 (8)- 7 (9) - 8 (10)9(11)- 10('1"2') 10+(13) "Activity rating scale" at initial eva!.(0-100%) _ _ _ __ 24. Millon Behavioral Health Inventory (MBHI) 25. Multidimensional Health Locus of Control Scales IHLC 26. PHLC 27. CHLC 28. WHEN CLIENT IS DISCHARGED, COPY THIS SHEET FOR THEIR FILE. PLACE ORIGINAL IN RESEARCH FOLDER. Date of Discharge Date of Earliest Follow-up (74 days) ____ OUTCOMES RETURN TO WORK 29. 30. 31. 32.
Date client contacted _ _ _ _ _ _ _ __ Employed within 60 days of program completion and employed for more than 2 weeks OR returned to full duty. A. Did not complete program and (2) did not return to work _ _ __ (1) returned to work B. Completed program and (1) returned to work (2) did not return to work C. Was there an intervening service between work-hardening and return to work? (ie., vocational rehab.) yes no What was it? -
21
*Samuel Merritt College, Oakland, California; lDepartment of Physical Therapy, School of Pharmacy and Allied Health, Creighton University, Omaha, Nebraska; t Work Hardening Center, Summit Medical Center, Oakland, California This pilot study investigated whether a simple statistical analysis of selected intake data in the charts of work-hardening clients could differentiate those clients who returned to work from those who did not. Datafrom 24 workers' compensation clients were examined. Perceived pain on initial evaluation was the only statistically significant variable (p < 0.01). Lower pain levels correlated with a successful return to work. Statistical trends (p < 0.10) suggested that a lower hourly wage, a higher occupational metabolic equivalent level, and a marital status of married or cohabitating correlated with a successful return to work. Data were used to describe a client at risk - one with high levels ofpain, who was not in a physically demanding Job and lacked social support. Program recommendations were made to address these issues. It was concluded that as other work-hardening centers respond to the call for better outcome assessment, a similar design process could be used. Keywords: Work-hardening; Return to work; Workers' compensation; Outcome assessment
Each year, about half a million workers in the United States become seriously injured and cannot return to work for prolonged periods of time (Scheer, 1990). Many are never reemployed. Scheer (1990) estimates that only 48% of those who enter the disability support system eventually return to work. The social and economic costs of this are immense. The National Safety Council calculated the direct cost of work-related injuries in 1985 to be $16 billion per year (Peters, 1990). The social costs of human suffering, loss of self-
esteem, and reduced income are also great, although not easily calculated. At various points in the history of industrial rehabilitation, simulated work has been used as a part of the care of the injured worker. Lepping (1990) found its roots in the fields of vocational rehabilitation and occupational therapy and its beginnings as early as the 1940s. In the late 1970s, work simulation and related techniques were repackaged into a new service that came to be known as work hardening. The Commission on AccrediWORK 1994; 4(1):9-21 Copyright © 1994 by Butterworth-Heinemann
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WORK / JANUARY 1994
tation of Rehabilitation Facilities (CARF) and the National Advisory Committee on Work Hardening defined work hardening in 1988 as follows: Work hardening is a highly structured, goal oriented, individualized treatment program designed to maximize the individual's ability to return to work. Work hardening programs, which are interdisciplinary in nature, use real or simulated work activities in conjunction with conditioning tasks that are graded to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, and psychosocial functions of the individual. Work hardening provides a transition between acute care and return to work while addressing the issues of productivity, safety, physical tolerances, and worker behaviors (Ogden-Niemeyer and Jacobs, 1989).
Work hardening can be viewed as applying a "sports medicine" approach to industrial injury. The injured worker is treated like a 40-hour-perweek athlete (Lepping, 1990; Ogden-Niemeyer and Jacobs, 1989; Matheson et al., 1985). The early focus of work-hardening programs on workers who had been unemployed for many years has shifted to include the more recently injured (Ogden-Neimeyer and Jacobs, 1989). Workhardening programs have grown quickly, at least partially in response to the expansion of state workers' compensation benefits to include mandatory vocational rehabilitation (Lepping, 1990). In 1984, Matheson et al. (1985) located 26 workhardening programs. In 1990, researchers were able to identify 252 programs (Wyrich et al., 1991). This rapid growth has meant that many programs have arisen in response to market demands with few standards or guidelines (Wyrich et al., 1991). In addition to rapid growth, the relatively recent development of work-hardening approaches may also account for a lack of research in this area. Little has been done to examine the effectiveness of work-hardening programs (Haig and Penha, 1991), and few individual centers routinely collect outcome data. A recent survey of 192 work-hardening programs indicated that only 45 % of the programs were reporting return-towork rates (Wyrick et al., 1991). Frequently, there is no explanation of what criteria were used to define a successful return.
Work-hardening services are intensive and lengthy. Program costs vary from $4,000 to $8,000 (Mayer et al., 1985). In this era of health care cost scrutiny, it is imperative that workhardening centers are better able to justify their programs. This is addressed in both the guidelines of CARF (American Occupational Therapy Association, 1986) and the American Physical Therapy Association (APTA) (American Physical Therapy Association, 1993). CARF guidelines call for admission criteria to admit "persons who are likely to benefit from the program." Recently formulated APT A guidelines call for systematic data collection for outcome assessment. Although most programs have initial screening tests, little is done to isolate factors that might further correlate with a successful return to work on program completion. Knowledge of these factors might help the staff refine initial screening tests to select appropriate clients for their program or to redesign their program for better outcomes. Work hardening has developed from the efforts of a number of professions such as occupational therapy, physical therapy, work evaluation, and industrial psychology. This interdisciplinary focus often creates a wealth of data, which are routinely collected in the initial screening and evaluation. The hypothesis of this study was that a statistical analysis of selected intake data would yield factors that could differentiate those clients who successfully returned to work from those who did not return to work. Research parameters were chosen from physical, psychological, and demographic areas. The criteria used for selection were that the data could be easily collected from client charts and that there was sufficient variation in the sample population in any particular trait for potential statistical significance. Although the factors we have isolated could have value for other work-hardening centers, our purpose was not to discover the definitive list of factors that influence return to work. Our purpose was to demonstrate the usefulness of a relatively simple analysis of readily available data to improve client selection or improve program content. Our hope is that all centers will be able to
Factors Influencing Return to Work
adapt this analysis to meet their individual program needs.
LITERATURE REVIEW Many researchers have looked at factors influencing return to work (RTW) in a variety of settings. None have looked specifically at work hardening. Only a few studies have examined the effectiveness of work-hardening centers. One of the most extensive was a prospective study of chronic back pain patients who received work-hardening services. Mayer et al. (1985, 1987) reported their findings after both a i-year and a 2-year follow up. In both of these follow-up surveys, the R TW rate of the treatment group was double that of the control group, who did not receive work-hardening services (- 85 and 40%, respectively). Although characteristics of the treatment and control groups were compared, the investigators did not compare any differences within the group of patients who received work-hardening services. A recent study by Tate (1992) examined data from 200 workers' compensation cases from one auto manufacturing company. Vocational rehabilitation interventions or lack of them were examined in both groups of workers who had returned to work and those who had not returned. Workhardening programs were included as an intervention. However, they were not isolated from numerous other services such as case management or independent medical evaluations, which could also have a major effect on R TW outcomes. In general, there is a long history of research examining factors that might be useful in predicting who can benefit from a variety of rehabilitation services (Ogden-Niemeyer and Jacobs, 1989; Haig and Penha, 1991). The factors that are frequently studied can be divided into three types: demographic factors, factors that describe the nature of the injury, and environmental/psychological factors. Clients are often studied in a particular setting, for example, a pain clinic or a rehabilitation center. Clients who have sustained a particular type of injury are also studied. Low back pain is particularly well researched (Lancort
11
and Kettelhut, 1992; Mayer et al., 1985, 1987; Matheson et al., 1985). There is not a great deal of consistency in the literature about which particular factors are significantly associated with successful R TW outcomes. Such inconsistency is not surprising because there is great variation in the research studies themselves. However, when multiple studies have found a particular factor to be significant, there is agreement about how that factor will relate to a successful outcome. For example, if age is found to be a significant factor, then it has a direct relationship with an unsuccessful R TW outcome.
Demographic Factors Length of time out of work is a variable that is most consistently found to be significantly related to outcome (Peters, 1990; Burgel and Gliniecki, 1986; Nachemson, 1983; Kasdan and McElwain, 1989) Peters (1990) found that the chance ofRTW was only 50% after 6 months of not working, and almost zero after 2 years. Age is another variable that is often found to be significant (Scheer, 1990; Tate, 1992; Milhous et al., 1989). As noted above, increasing age correlates with an increasing likelihood of an unsuccessful R TW. Greater income (Tate, 1992), education (Guck et al., 1989) and job seniority (Tate, 1992) are all associated with greater probability of R TW. Men and married people are also more likely to R TW (Tate, 1992).
Nature of the Injury The severity of the injury (Kasdan and McElwain, 1989; Murphy and Cornish, 1984; Bear-Lehmen, 1983) and its location (Matheson et al., 1985; Beals and Hickman, 1972; Tate, 1992) are often found to correlate significantly with outcomes. Severity of the injury has an obvious relationship with R TW. Spinal injuries in general and low back injuries in particular are indicators of a poor prognosis for R TW. Self-perceived pain levels have also been examined, particularly in patients with spinal injuries (Ogden-Neimeyer and Jacobs, 1989). Poor outcomes are associated with high pain levels that extend over large areas of the body (Murphy and Cornish, 1984). High self-
12
WORK / JANUARY 1994
perceived levels of disability are also associated with poor outcomes (Lancort and Kettelhut, 1992).
Environmental/Psychological Factors High physical work demands negatively correlate with RTW (Matheson et al., 1985; Milhous et al., 1989; Nachemson, 1983). There is some conflict in the literature with regard to physical conditioning level at the time of treatment. Matheson et al. (1985) state that work hardening works best with clients who are severely deconditioned. Milhous et al. (1989) found poor R TW outcomes with persons who had "low activity" levels. This conflict may be more apparent than real because the authors may be referring to different aspects of a person's physical state. Compensation for injury (Beals, 1984; Greenough and Fraser, 1989), low levels of financial hardship (Sheer, 1990; Bear-Lehman, 1983; Beals, 1984), and receipt of legal assistance (Peters, 1990; Taylor, 1989) all negatively correlate with R TW. Several researchers have also found a negative correlation with "disability behavior" (Taylor, 1989; Isernhagen, 1988). This behavior could be caused by the workers' compensation system, the health system in general, or other models oflearned behavior. Injured workers may be less likely to return to work when other family members are on disability (Ogden-Niemeyer and Jacobs, 1989). Psychological variables have been widely studied in the medical arena (Beals and Hickman, 1972; Nachemson, 1983; Bear-Lehman, 1983). Some studies have found psychological variables to be more predictive of outcomes than demographic data or the characteristics of the injury (Scheer, 1990). There is no agreement about which psychological tests might be predictive of RTW. The Minnesota Multiphasic Personality Inventory has been widely used to predict medical outcomes (Milhous et al., 1989; Beals, 1984). It has not been extensively used in work-hardening centers, and its usefulness in that setting has been questioned (Ogden-Niemeyer and Jacobs , 1989). Of the psychologically oriented variables used for this research project - namely, the Oswestry Low Back Pain Disability Questionnaire, the Numeric Pain Scale, the Millon Behavioral Health Inventory, and the Multidimensional Health Lo-
cus of Control- only the Oswestry has been used specifically in examining R TW factors. Lancort and Kettelhut (1992) found a high Oswestry score one of the predictors for an unsuccessful R TW . Several variables not included in our study might have value in other research projects. Ethnic background (Ogden-Neimeyer and Jacobs, 1989), gender (Matheson et al., 1989), education (Scheer, 1990), level of medication (Guck et al., 1989), symptom magnification (Peters, 1990), and prior job satisfaction (Beals and Hickman, 1972) have been found to be significant outcome factors in prior research.
METHOD This study used a statistical analysis of selected information in charts of clients in a single workhardening center.
Program Description The work-hardening program studied is a medical center-based program located in the San Francisco Bay area. It is a multidisciplinary program, with staff consisting of two physical therapists and one industrial psychologist. The program adheres to CARF guidelines and fits the general description of a multidisciplinary program described elsewhere (Ogden-Niemeyer and Jacobs, 1989). The program sees - 8-10 new clients per month. Most of them are receiving workers' compensation temporary disability benefits and were referred by their medical doctor. Most have the goal of returning to their usual and customary job. The minimum work-hardening program for a client is 4 hours/day, 3 days/week for 4 weeks. The maximum program is 4 hours/day, 5 days/week for 6 weeks. Program costs run from $3,380 to $7,700. Outcome data are currently collected.
Subjects Data were collected on clients who entered the program for work-hardening services over a 7-month period, namely, those who entered the work-hardeningcenterafterJuly 1,1992 and who exited before February 1, 1993. Excluded from the study were clients who were not receiving
Factors Influencing Return to Work
workers' compensation benefits, whose language skills were judged insufficient to accurately complete all forms, whose objective for work hardening was other than return to their usual and customary employment (i.e., vocational rehabilitation), who had an intervening service between work hardening and RTW, or who did not complete the program. Under these criteria, data were analyzed from a total of 24 clients.
Research Variables The factors chosen for analysis are given in Appendix 1. As stated above, factors were chosen that were thought to be particularly applicable to the work-hardening center under study. Most items are simple and descriptive with just a few complex items. The client metabolic equivalent (MET) level is a unit of biological energy expenditure related to a multiple of resting metabolic rate. The MET level requirements for jobs are given by the U.S. Department of Labor. The Department lists both a general description (i.e., light, medium, heavy) and a corresponding MET level for a wide variety of occupations (see Appendix 2). The MET level of the client on entry into the program was determined by a submaximal treadmill exercise stress test. The presence of radiating symptoms was intended to serve as a gross indicator of severity. The numeric 0 to 10 + Pain Rating Scale (selfperceived pain scale) and the Oswestry Low Back Pain Disability Questionnaire (self-perceived disability scale) have been widely used in workhardening and other rehabilitation centers (Fairbank et al., 1980). The pain scale used is reproduced in Appendix 3. The two psychological instruments-the Millon Behavioral Health Inventory and the Multidimensional Health Locus of Control (MHLC)were developed for use in medical settings and have been found to be reliable and valid (Wallston and Wallston, 1978; Milon, Green, and Meagher, 1982). The MHLC assesses the belief that one's health is or is not determined by one's own behavior. There are three subscales: internal health locus of control (IHLC), powerful other locus of control (POLC), and chance locus of control (CRLC).
13
The Millon Behavioral Health Inventory consists of 20 scales divided into four general areas: basic coping styles, psychogenic attitude scales, prognostic indices scales, and psychosomatic correlates scales. Six scales were chosen for inclusion in this study. Three coping styles were selected: sociable style, forceful style, and sensitive style. Of the psychogenic attitudes scales, future despair was chosen. This scale focuses on the person's willingness to plan and look forward to the future. Of the prognostic indices scales, pain treatment responsivity was chosen. High scores predict a course of treatment complicated by pain as an intrusive psychological issue. No psychosomatic correlates scales were analyzed because they did not appear to apply to the population under study.
Procedure Data were collected on two groups: clients who were relieved of duty and who were receiving workers' compensation temporary disability benefits, and clients who were on light or modified duty and whose medical and work-hardening services were being paid for by workers' compensation. Research variables were collected on a simple onepage form that was attached to the client's chart (see Appendix 4). Entries were made on an ongoing basis by the work-hardening staff as intake data became available. Outcome data were also collected by the workhardening staff on an ongoing basis. A successful R TW outcome was defined as follows. For those clients relieved of duty, R TW was defined as any employment lasting for at ~2 weeks that began within 30 days of program completion. For those clients on modified or light duty, a successful R TW outcome was defined as a return to full duty, within the same time frames.
Data Analysis Potentially, four groups of clients could have been analyzed: Group 1: relieved of duty/returned to work (relieved/RTW) Group 2: relieved of duty/no return to work (relieved/no R TW)
14
WORK / JANUARY 1994
Group 3: modified duty/returned to work (modified/RTW) Group 4: modified duty/no return to work (modified/no R TW) However, in our particular sample, all the clients who were on modified duty returned to work, so there were no members of group 4. For the variables listed in Appendix 1, all statistical models tested the null hypothesis that there was no significant difference between those who did and did not return to work. The variables can be divided into two types: categorical variables such as marital status, and continuous variables such as age. For categorical variables, the hypothesis was that those returning to work exhibited the same proportion of the various attributes as did those who did not return to work. This was tested by Fisher's exact test for dichotomous variables and with X} for nondichotomous variables. For continuous variables, the hypothesis was that the means of the groups were equal. This was tested with a Student t-test for two means. An SAS statistical program was used. The comparison groups were defined two ways: 1) differences between R TW and no R TW in the relieved-of-duty subset (groups 1 and 2 only) and 2) differences between R TW and no R TW, disregarding whether they were working during treatment (group 2 vs. groups 1 and 3 combined). Level of significance was set at p < 0.05. Because of the small sample size and particularly the small number of subjects in the group that did not return to work, trends in the data were also examined. Trends were defined as p < 0.10.
RESULTS Several results should be noted about the entire sample. Group means for pain at initial evaluation ranged from 5.7 to 8.8 on the 0 to 10 + pain scale (Table 1). All were above a rating of "strong." Sixty-eight percent of the sample population had pain that radiated from their primary injury. The group means for the Oswestry Disability Questionnaire ranged from 52 to 62 (Table 1). These fall in the category of "severe disability."
The group means for the MET level of occupation ranged from 2.7 to 4.3 (Table 1). This fell into the descriptive range of above "light" but below "medium-heavy." The comparison of client and job MET levels revealed that 75 % of all clients had an initial MET level greater than or equal to the MET level of their job (Table 2). The group mean scores for the Millon Behavioral Health Inventory (Table 1) indicated that none of the coping styles (sociable, forceful, or sensitive) had a high enough score to be considered a significant coping style. The mean scores for psychogenic attitude of future despair were considered average, with neither positive or negative consequences. The mean scores for the prognostic index of pain responsivity indicated little likelihood of a treatment complicated by this issue (Millon, Green, and Meagher, 1982). As shown in Table 3, the whole sample mean scores for the MHLC appeared closer to the normative scores of healthy adults or adults engaged in preventive behavior than to the normative scores of chronic patients. This was true of the outcome group scores as well, with the following exceptions. The group that had been relieved of duty and not returned to work had mean scores on the IHLC and CHLC that appeared closer to the normative scores of chronic patients. These scores, however, are statistically insignificantly different from the scores of the other outcome groups. An inability to distinguish statistically between outcome groups was also true of the variable of legal assistance. Half of the no R TW group had engaged the services of an attorney com pared with 22 and 11 % in the groups that had returned to work (Table 2), yet these differences were not statistically significant. Research variables that could distinguish statistically between outcome groups (p = 0.10 orless) are given in Table 4. Only the variable of "pain on initial evaluation" met the criteria of statistical significance set for the study (p < 0.05). A higher pain level on initial evaluation was found in the group that did not return to work in both sets of comparisons (the relieved-of-duty subset compar-
Factors Influencing Return to Work
Table 1.
15
Mean Results for Continuous Variables by RTW Outcome and Work Status All Groups (n = 24)
Group 1 (n = 9) Relieved/RTW
Group 2 (n = 6) Relieved/N 0 RTW
Group 3 (n = 9) Modified/RTW
Research Variables
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Age (years) Weeks out of work Hourly income Financial hardship' Current employment (years) MET level of occupation! MET level of patient! Difference in MET levels Pain at initial evaluationS Self-perceived disabilityll Millon 4 - sociable# Millon 6 - forceful' Millon 8 - sensitive# Millon D-future despair" Millon PP-pain responsivityll
39.00 15.00 14.10 0.92 6.50 3.70 5.30 1.60 6.60 55.00 43.00 50.00 42.00 43.00 46.00
11.00 17.00 4.96 0.13 5.50 1.80 2.60 3.00 2.10 17.00 26.00 29.00 34.00 28.00 27.00
42.00 22.00 10.71 0.87 7.80 3.80 5.30 1.50 5.70 53.00 44.00 59.00 44.00 40.00 46.00
14.00 11.00 3.65 0.19 7.60 1.60 3.10 3.70 1.00 14.00 26.00 31.00 35.00 25.00 22.00
34.00 29.00 15.98 0.88 5.50 2.70 4.60 1.90 8.80 62.00 27.00 41.00 48.00 49.00 56.00
11.00 23.00 5.76 0.10 3.50 0.90 2.20 1.90 2.70 22.00 25.00 29.00 53.00 42.00 47.00
39.00 0 16.43 1.00 5.90 4.30 5.90 1.50 6.00 52.00 49.00 46.00 36.00 43.00 41.00
8.00 0 4.04 0 3.90 2.10 2.40 3.00 1.70 18.00 26.00 29.00 25.00 27.00 22.00
• Postinjury income as a percentage of preinjury income. U.S. Department of Labor ratings, which range from 1.5, "sedentary" to 12.0, "very heavy." I Submaximal treadmill test in initial evaluation. So to 10 + pain rating scale, which ranges from 0, "nothing at all" to 10 + , "maximal." I 0-20, "minimal disability"; 20-40, "moderate disability"; 40-60, "severe disability"; 60-80, "crippled"; 80-100, "bed bound or exaggerating their symptoms." # Considered significant if score is ~75 . •• 0-35, Low level of concern; 35-75, average range; 75-85, potential serious impact; ~85, major area of concern. 11 0-60, Issue unlikely to complicate treatment; 61-75, possible complication; 76-84, diminished outcome likely; ~85, course of treatment complicated by psychological issue. 1
Table 2.
Results for Categorical Variables by RTW Outcome and Work Status
Research Variables Married or cohabitating Legal assistance Job MET>patient MET Other family on disability Radiating symptoms Primary location of injury
All Groups (n = 24)
Group 1 (n = 9) Relieved/RTW
Group 2 (n= 6) Relieved/No RTW
Group 3 (n= 9) Modified/RTW
0.50 0.25 0.25 0.16 0.68 2.90
0.56 0.22 0.33 0.22 0.63 3.10
0.17 0.50 0.17 0 0.83 2.80
0.67 0.11 0.22 0.22 0.62 2.80
Results give percentage of "yes" answers except for location of injury, in which 1 3 = spinal-lumbar, 4 = peripheral/other.
ison and the comparison that included workers on modified duty). In both cases, p = 0.01 (t-test). Three research variables met the criteria of a statistical trend (p < 0.10). In the comparison of the groups who were relieved of duty, higher
spinal-cervical, 2
spinal-thoracic,
hourly income tended to correlate negatively with R TW (p = 0.06, t-test). In the comparison of groups regardless of working status, people who were married or cohabitating showed a trend to return to work (p = 0.08, Fisher's exact test). In
16
WORK / JANUARY 1994
Table 3.
Multidimensional Health Focus of Control: Means of Research Groups and Normative Data IHLC
POLC
CHLC
All groups (n = 24) Group 1 (n = 9): relieved/RTW Group 2 (n = 6): relieved/no RTW Group 3 (n = 9): modified/R TW
26.79 (6.04) 27.44 (4.88)
Mean (SD) 19.79 (5.52) 19.98 (7.29)
16.79 (6.59) 16.56 (4.42)
24.67 (5.09) 27.56 (7.76)
18.83 (6.08) 20.33 (3.24)
17.33 (7.69) 16.67 (8.26)
Chronic patients Healthy adults Preventive health behaviors
25.78 25.55 27.38
Research and Comparison Groups
Table 4.
Normative Data 22.54 19.16 18.44
17.64 16.21 15.52
Research Variables that Could Distinguish Outcome Groups (p = 0.10)
Comparison
Research Variable
p Value, Test
Relieved-of-duty subset'
Pain at initial evaluation Hourly income Pain at initial evaluation MET level of occupation Married or cohabitating
0.01, t-test 0.06, t-test
Returned vs. did not, regardless of work status!
0.01, t-test 0.09, t-test
0.08, Fisher's exact test
• Group 1 (relieved of duty/RTW) vs. group 2 (relieved of duty/no RTW) 2 (relieved of duty/no RTW) vs. group 1 (relieved of duty/RTW) and group 3 (modified duty/RTW) combined.
T Group
this same comparison group, a lower occupational MET level tended to correlate with an unsuccessful RTW (p = 0.09).
DISCUSSION As the work-hardening industry matures and medical costs come under greater scrutiny, there will be an increased need for program analysis and outcome assessment. Better outcome assessments are likely to be demanded by third-party payers, referral sources, or by workers' compensation legislative reforms. Physical therapists, occupational therapists, and other health professionals involved in work hardening have several advantages in this quest. First, many potentially significant research variables are routinely collected in client charts. Second, most clients entering a work-hardening program have an easily measured functional objective - returning to work. The purpose of this
pilot project was to demonstrate the usefulness of correlating selected intake data to outcomes with a simple statistical analysis. This analysis yielded several noteworthy results about the sample as a whole. Most of the center's clients had only moderately physically demandingjobs. All group means fell below the "medium-heavy" category. Seventy-five percent of all clients had an initial MET level greater than or equal to the MET level of their job. This fact, plus the high number of people who were still working on light or modified duty while receiving work-hardening services (9 out of24), may reflect the trend toward earlier rehabilitation. Physical dcconditioning, per se, may be a less prominent factor in rehabilitation services as this trend continues. Other issues such as self-perceived pain and disability were more important to our sample. As shown in Table 1, group means for pain at initial evaluation were all above a rating of "strong."
Factors Influencing Return to Work
High levels of pain are known to be a complicating factor in work hardening (Ogden-Niemeyer and Jacobs, 1989). The group means for the Oswestry Disability Questionnaire ranged from 52 to 62. These fall in the category of "severe disability." Lancort and Kettelhut (1992) found an Oswestry score >55 to be one predictor of a negative R TW outcome in low back pain patients. The level of pain on initial evaluation was the only research variable that could statistically distinguish those groups who returned to work from those who did not (p < 0.01). This was true for both sets of comparisons. This finding - that high levels of pain correlate negatively with R TW has been consistently found in other research as well (Murphy and Cornish, 1984; OgdenNiemeyer and Jacobs, 1989). Taken in conjunction with generally high levels of pain in all groups in the study, this would indicate that pain management should be a critical part of this workhardening program. For clients with particularly high levels of pain, a special prework-hardening program could be recommended to focus on this issue. A theoretical model for such programs has been proposed, and several work-hardening centers have prework-hardening programs to address special client issues (Ogden-Niemeyer and Jacobs, 1989). Three statistical trends (p < 0.10) were also examined. Higher hourly income correlated negatively with R TW in the comparison of groups who had been relieved of duty. This is in contrast to prior research (Beals and Hickman, 1972). Several things might account for this finding. For both groups, the mean for disability replacement income was approximately the same: R TW, 88 % ; no RTW, 87%. Individuals in the lower paid group ($10.711hour) who returned to work may have less easily tolerated a drop in income than those in the higher paid group ($15.98/hour) who did not. Factors not calculated in this variable, such as overtime income, savings, or income generated by other family members, could also be confounding factors. People who were married or cohabitating showed a trend to return to work in the comparison of groups regardless of working status. This finding is supported by other research (Lancort and Ket-
17
telhut, 1992), and suggests that people without emotional support may be less successful in a work-hardening program. This is an issue that could potentially be addressed by the program. For example, consideration of a social support mechanism such as a weekly support group may be worthwhile. A lower occupational MET level tended to correlate with an unsuccessful R TW in the comparison of groups regardless of working status. As shown by Appendix 2, a mean MET level of 2.7 in the group with no R TW is reflective of a job demand between "light" and "light-medium." The groups that did return to work had a MET level mean of 4.1. This would be placed between the categories of "medium" and "medium-heavy." This contradicts findings in prior research (Matheson et al., 1985; Milhous et al., 1989; Nachemson, 1983). However, it is consistent with a picture of an unsuccessful client whose main problem is pain and disability, rather than deconditioning for a demanding job. It is also possible that the injuries of the workers in our sample predisposed them to be more successful if returning to a job with moderate levels of movements than to a more static or sedentary job. The two psychological instruments, the MHLC and the Millon Behavioral Health Inventory, did not appear useful for outcome correlation in this sample. Results were insignificant or within normal ranges except for the mean scores of the noR TW group on the IHLC and CHLC scales. These scores, however, were not statistically different from the other groups' scores. The major limitation of this study was the sample size. Making major program changes without further study would carry some risk. For example, a larger research project could find that MHLC would differentiate between outcome groups or that social support was not a valid issue. Furthermore, some of the variables may not be accurate measures of what they claimed to measure. The MET level of the client's job was derived from client description, not from an on-site visit. The MET level of the client was determined by a submaximal stress test, which may not be an accurate measure of MET level sustained over an 8-hour shift. In addition, our definition of what consti-
18
WORK / JANUARY 1994
tuted a successful R TW was chosen from a number of alternatives. A different definition may have yielded different results. Finally, any recommendations made would apply to past clients, but not necessarily to future ones. Shifts in client population, type of injuries, or industrial injury compensation patterns could radically alter the optimum program content. This suggests the need for constant data collection and periodic analysis. As medical record keeping shifts to the increasing use of computers, records could easily be kept in a format to facilitate this kind of analysis.
CONCLUSIONS For the clients in one urban work-hardening center, pain was a primary issue, but deconditioning was not. This is consistent with the shift toward earlier rehabilitation. Although not entirely supported statistically, the data in this study describe the type of client at risk in this program: one who
has high levels of pain, is not in a physically demanding job, and lacks social support. From this description, we were able to make suggestions for program improvement. As work-hardening centers respond to the need for better outcome assessment, they will require similar systematic data collection and analysis to build their own model for clients at risk.
ACKNOWLEDGMENTS Assistance from the following people is gratefully acknowledged: Shari Ser, PT, for assistance with data collection; Mita Giacomini, MS, for assistance with statistical analysis; Thomas Graly, MA, fOI assistance with computer programming and graphics. This paper was submitted in partial fulfillment of the requirements for the degree of Masters of Physical Therapy in the Department of Physical Therapy, Samuel Merritt College, Oakland, California.
REFERENCES American Occupational Therapy Association. (1986). Work hardening guidelines. Am] Occup Ther, 40, 841-843. American Physical Therapy Association. (1993, March). Guidelines for programs in industrial rehabilitation. PT Magazine, pp. 69-72. Beals, R. K. (1984). Compensation and recovery from injury. West] Med, 140, 233-237. Beals, R. K., and Hickman, N. W. (1972). Industrial injuries of the back and extremities.] Bone]oint Surg, 54-A, 1593-1611. Bear-Lehman, ]. (1983). Factors affecting return to work after hand injury. Am] Occup Ther, 37, 189194. Burgel, B. ]., and Gliniecki, C. M. (1986). Disability behavior: Delayed recovery in employees with work compensable injuries. AAOHN], 34, 26-30. Fairbank, ]. C., Couper, ]., Davies, ]. B., and O'Brien,]. P. (1980). The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy, 66, 271273. Greenough, C. G., and Fraser, R. D. (1989). The effects of compensation of recovery from low-back injury. Spine, 14, 947-955. Guck, T. P., Meilman, P. W., Skultety, F. M., and
Dowd, E. T. (1989). Prediction oflong-term outcome of multidisciplinary pain treatment. Arch Phys Med Rehabil, 67, 293-296. Haig, A. ]., and Penha, S. (1991). Worker rehabilitation programs: Separating fact from fiction. West] Med, 154, 528-531. Isernhagen, S.]. (1988). Work injury-Management and prevention. Rockville, MD: Aspen Publishers, Inc. Kasdan, A. S., and McElwain, N. P. (1989). Returnto-work programs following occupational hand injuries. Occup Med, 4, 539-545. Lancort, ]., and Kettelhut, M. (1992). Predicting return to work for lower back pain patients receiving worker's compensation. Spine, 17, 629-640. Lepping, V. (1990). Work hardening-A valuable resource for the occupational health nurse. AAOHN j, 38, 313-317. Matheson, L. N., Ogden, L. D., Violette, K., and Schultz, K. (1985). Work hardening: Occupational therapy in industrial rehabilitation. Am] Occup Ther, 39, 314-321. Mayer, T. G., Gatchel, R. ]., Kishino, N., Keeley, ]., Capra, P., Mayer, H., Barnett,]., and Mooney, V. (1985). Objective assessment of spine function following industrial injury: A prospective study with
Factors Influencing Return to Work
comparison group and one-year follow-up. Spine, 10, 482-493. Mayer, T. G., Gatchel, R. J., Mayer, H., Kishino, N. D., Keeley, J., and Mooney, V. (1987). A prospective two-year study of functional restoration in industrial low back injury.]AMA, 258, 1763-1767. Milhous, R. L., Haugh, L. D., Frymoyer, J. W., Ruess,J. M., Gallagher, R. M., Wilder, D. G., and Callas, P. W. (1989). Determinants of vocational disability in patients with low back pain. Arch Phys Med Rehabil, 70, 589-593. Millon, T., Green, C.J., and Meagher, R. B. (1982). Millon behavioral health inventory manual, (3rd Edition). Murphy, K. A., and Cornish, R. D. (1984). Prediction of chronicity in acute low back pain. Arch Phys Med Rehabil, 65, 334-337. Nachemson, A. (1983). Work for all. Clin Orthop, 179, 77-83.
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Ogden-Niemeyer, L., and Jacobs, K. (1989). Work hardening-State of the art. Thorofare, NJ: Slack. Peters, P. (1990). Successful return to work following a musculoskeletal injury. AAOHN j, 38, 264-270. Scheer, S. J., (1990). Multidisciplinary perspectives in vocational assessment of impaired workers. Rockville, MD: Aspen Publishers, Inc. Tate, D. G. (1992). Workers' disability and return to work. Am] Phys Med Rehabil, 71, 92-96. Taylor, M. E. (1989). Return to work following back surgery: A review. Am] Ind Med, 16, 79-88. Wallston, K. A., Wallston, B. S., and Devillis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) scales. Health Educ Monogr, 6, 161-170. Wyrick, J. M., Ogden-Niemeyer, K., Ellexson, M., Jacobs, K., and Taylor, S. (1991). Occupational therapy work-hardening programs: A demographic study. Am] Occup Ther, 45, 109-112.
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Appendix 1.
List of Variables Analyzed
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Age Marital status Number of weeks out of work Hourly income before injury Financial hardship (all preinjury after-tax income as a percentage of all postinjury, after-tax income) Length of current employment Legal assistance (currently working with attorney) Primary location of injury [spinal (cervical, thoracic, lumbar) or peripheral] Radiating symptoms MET level of occupation (by U.S. Department of Labor tables) MET level at initial evaluation (by center-administered submaximal exercise stress test) Difference between MET level of occupation and MET level at initial evaluation Other family members on disability Self-perceived pain level at initial evaluation (a visual, numeric scale ranging from 0, "nothing at all" to 10 + , "maximal") 15. Self-perceived disability level at initial evaluation (Oswestry Low Back Pain Disability Questionnaire)
Multidimensional Health Locus of Control scales IHLC 16. 17. POLC 18. CHLC Millon Behavioral Health Inventory: selected scales 19. Millon 4: sociable style (coping style) 20. Millon 6: forceful style (coping style) 21. Millon 8: sensitive style (coping style) Millon D: future despair (measures psychogenic attitude) 22. 23. Millon PP: pain responsivity (measures psychosomatic complication to treatment process)
Appendix 3.
Appendix 2. U.S. Department of Labor: Descriptions for MET Level Job Ratings MET Level
Description
1.5 2.0 2.5 3.0 3.5
Sedentary Sedentary-light Light Light-medium Medium Medium-heavy Heavy Very heavy
4.5
6.0 7.5-12.0
0 to 10 + Pain Rating Scale
Number
Description
10 + 10 9 8 7 6 5
Maximal Very very strong
4
3 2 1 0.5 0
Very strong Strong Somewhat strong Moderate Weak Very weak Very very weak Nothing at all
Factors Influencing Return to Work
Appendix 4. COMPUTER CODES ONLY 1. Name No (2) 2. Worker's Compo Yes (lj IF THIS CLIENT IS NOT RECEIVING WORKER'S CaMP. DO NOT COMPLETE THE REST OF THE FORM. For the job which client is receiving compensation: 3. Not Working (1) _ _ Light or Modified Duty (2) ___ Full Duty(3) _ _ Date of program entry _ _ _ _--: 4. Last day worked or Last day of full duty 5. Number of weeks out of work ., or Number of weeks of light duty 6. (a) Hourly wage prior to injury ~ __ (b) Average AFTER TAX wee~ 7. income Weekly --;-di'--sa--:b"7il""it-y7in-come (tax-free) 8. Other new (post-injury) supplemen-t""'alC:i-n-co-m-e per week AFTER TAX _.,--;-_ 9. 10. Calculation: percentage of pre-injury AFTER TAX income currently received: =N #8 + #9 = New weekly income = Original income = 0 = _ _ __ #7(b) % = N/O • 100 = Length of employment with the company _ _ 11 . Age 12. MaritalStatus: Married(1) __ Single(2) __ Divorced(3) __Separated (4) __ 13. Co-habltation(5) Other family member(s) currently on Disability? Yes (1) No (2) 14. Are you currently working with an attorney to help resolve your case? - 15. Yes (1) No (2) Medical Diagnosis 16. Area of primary complaint (check only one): Spinal-cervical (1) 17. Spinal-lumbar(3) Peripheral/other(4) Spinal-thoracic (2) -Are there radiating symptoms? Yes (1)--No (2) 18. POL of client's occupation 19. MET level of client's occupational POL _ __ 20. 21. MET level of client at initial evaluation Calculation of difference between MET-level-of occupation and MET level at 22. initial eva!. # 20 - # 21 = :-7::--:--::-:-:Pain rating scale at initial eva!. (0-10 +): 0 (1) 0.5 (2) 1 (3) 23. 2 (4) 3 (5) 4 (6) 5 (7) 6 (8)- 7 (9) - 8 (10)9(11)- 10('1"2') 10+(13) "Activity rating scale" at initial eva!.(0-100%) _ _ _ __ 24. Millon Behavioral Health Inventory (MBHI) 25. Multidimensional Health Locus of Control Scales IHLC 26. PHLC 27. CHLC 28. WHEN CLIENT IS DISCHARGED, COPY THIS SHEET FOR THEIR FILE. PLACE ORIGINAL IN RESEARCH FOLDER. Date of Discharge Date of Earliest Follow-up (74 days) ____ OUTCOMES RETURN TO WORK 29. 30. 31. 32.
Date client contacted _ _ _ _ _ _ _ __ Employed within 60 days of program completion and employed for more than 2 weeks OR returned to full duty. A. Did not complete program and (2) did not return to work _ _ __ (1) returned to work B. Completed program and (1) returned to work (2) did not return to work C. Was there an intervening service between work-hardening and return to work? (ie., vocational rehab.) yes no What was it? -
21
