WORK A Journal of Prevention, Assessment & Rehabilitation
ELSEVIER
WorkS (1995) 143-146
Work hardening for sub-acute back injured workers: a new approach Caroline Lacroix* Clinique rnedicale Physergo, 5260, Avenue Verdun, Verdun, Quebec, Canada
Abstract ACTIDOS (ATD) is a program which takes an innovative approach to work hardening based on the needs of acutely back-injured workers. The success lies in the coordinated efforts of the interdisciplinary treatment team. ATD integrates the return to work process as an aspect of treatment and focuses on functional capacity rather than the elimination of pain. The program demonstrates encouraging outcome information: 85% of the workers in a specific group returned to work within the expected time.
Keywords: Back injury; Worker; Word hardening; Return to work; Team - - - - - - - _.•....... _ - -
1. Introduction
ACTIDOS (ATD) is a program which takes an active, interdisciplinary, innovative approach to work hardening based on the needs of acutely back-injured workers. A literature review on work-hardening programs indicates that they are usually conducted with chronic cases, e.g. clients who have been disabled for > 3 months. Those cases represent 76% of the total cost of workers' compensation in the Province of Quebec. These
* Tel.: + 1 (514) 767 8705; Fax: + 1 (514) 766 3472.
statistics provided the motivation to implement a program for sub-acute back-injured workers. The objectives of the program are: • • • •
To actively involve the injured worker through an interdisciplinary approach. To prevent chronicity. To be cost-effective for the workers' compensation board. To integrate the return to work process as an aspect of treatment.
This last point follows the new approach of the workers' compensation board of Quebec with its
1051-9815/95/$~9.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSDI 1051-9815(95)00116-3
144
C. Lacroix / Work 5 (1995) 143-146
new service called 'Keeping ties with work.' The organization now stresses intervention as soon as possible after the worker's injury in order to ensure his or her prompt and lasting return to work. The occupational therapist has an important multi-faceted role to play in this program; not only does he or she deal with the physical and psychosocial issues of the client but also with all factors involved with the return to work. This means frequent contacts with the employer to evaluate different possibilities of reintegrating quickly the employee into the work place. All decisions are taken after team discussion which involves the occupational therapist, physical therapist, physician as well as the worker. Clients entering the program are encouraged to take an active part in their treatment. The focus is on functional capacity rather than the elimination of pain as opposed to a more classical approach where they would play the role of the passive client. A new school of thought has emerged in the area of back injury which stresses the importance of early and active treatment (Spitzer, 1986). ATD follows this trend with its aggressive reconditioning program and an early return to work. Occupational therapists are all aware that people with disabilities should be guided by a bio-psychosocial model using an interdisciplinary approach. Every ATD client had an evident occupational injury as a consequence of an accident, but also as important is the interaction between their medical condition, physical capacities and psychosocial factors. This paper will outline the role of the occupational therapist through each phase of the program. The program aims for a 12 weeks maximum duration of treatment including gradual reintegration into the workplace. 1.1. Type of client People in the program should have a lesion affecting the lower back and have to be referred within 4 weeks following their accident. Usually in 75% of cases, symptoms resolve within 4 weeks. Those workers would not be seen in A TD since physicians would not referr them as they would
only take anti-inflammatory drugs with a brief period of rest before returning to work. 2. Program 2.1. Phase 1 The first phase lasts 2 weeks and the goals are to reduce pain, to begin mobilization, to teach biomechanics of the spine and stress management. Education is the key word early on. The occupational therapist conducts a back school of five daily sessions of 1 h each. The anatomy and biomechanics of the spine, postural hygiene and proper working techniques are discussed. Stress management is included along with an explanation to the relationship between pain and stress. Other topics of discussion could be job satisfaction, anger and frustration toward authority figures and family relationships. Clients with mental illnesses and low back pain are likely to remain out of work longer. It is suggested that the psychosocial components could be predictors of poor outcome but we do not know how they contribute to the return to work rate. Further research is needed in that area. The importance of relaxation in a daily routine is also incorporated. Clients will have the opportunity to experiment with different relaxation techniques as they come daily to our clinic. 2.2. Phase 2 Phase 2 of the program lasts from 2 to 6 weeks. This is the active part where workers are seen for 4 h each day, as opposed to the first phase where they were seen 2 h a day. The goals of this second phase are:
• • • • •
Pain, mobility and stress control. To increase physical fitness. To apply the principles of good postural hygiene. To introduce work simulations. To plan the return to work.
The occupational therapist evaluates the functional capacity rather than pain with respect to the work environment. But obviously, tests are
C. Lacroix /Work 5 (1995) 143-146
conducted to eliminate any serious condition assuring that we are dealing with musculoskeletal injuries only. Excessive inactivity is more harmful than beneficial, therefore gradual reintroduction to activities related to work tasks occurs. We like to avoid time spent rehearsing the invalid role, e.g. the client becoming more angry and depressed. We often relate with the injured athlete, for which we think in terms of returning them to competition as quickly as possible. Our worker's goal should be to return to work as soon as possible by keeping contact with his or her work environment and to remain professionally active. We teach them that they can do something for themselves by using proper body mechanics, postural exercises, diet, pacing activities and stress management. Work simulations are designed to prepare the worker, both physically and mentally, for an early, safe and healthy return to work. At this point it may imply a temporary increase in pain duration and intensity, but the focus is still more on their capacities. In chronic low back injuries, 84% of the cases had pain as a predominant factor in both the initial and final diagnoses (CSST, 1993). Some may undergo one treatment after another to try to get rid of the pain but they may have to learn to live with it. We want to return them to a high functional capacity level by helping them to engage in normal daily activities, to reduce the risk of future injury and at the same time, to experience reduction in their symptoms once the physical progression has been completed. Concern over proper lifting techniques must be balanced by common sense and awareness of all the factors involved at work. That is why, when necessary, the occupational therapist might go to the workplace for an evaluation to be able afterwards to reproduce it in the clinic. Attention is placed on manual handling techniques to gradually desensitize the fear of lifting in the workplace. The client's training is individualized to the tasks which are specific to his job requirements. As the condition progresses, the team discusses the possibility of returning the client to work. Will it be a temporary assignment? Will it be
145
modified or regular work? There could be many different possibilities. This is where the occupational therapist, with the knowledge of the individual's capacities versus the job requirements, can discuss with the employer the return to work with modification of tools, job process or workstation when necessary. This may include actual return to his or her previous job during a few hours a day or for part of the week while coming to the clinic as we could combine work and treatment. Arrangements for the best schedule possible are made. At this stage, we occasionally encounter resistance from the employers that are not receptive to the idea of modified work or temporary assignment. Some of them prefer to take the worker back only when the injury has been stabilized. This tends to increase the employer's compensation in the long run. This new tendancy of 'keeping ties with work' brings many changes at an administration level thus education towards employers and employees is tremendously important. We should be able to demonstrate that if an employee is assigned to a temporary job which involves no risk of aggravating his condition, he will not only contribute to his rehabilitation but decrease the total rehabilitation's cost. At the end of this second phase there are two options: The worker is still in treatment full-time, either because of his condition or he was unable to hold his job or the employer made no possibility of job assignment. (2) The worker comes part-time to treatment and goes to work part-time. (1)
2.3. Phase 3 Phase three should be the transition from modified to regular work. We continue what we started in the second phase and intensify the work simulations. If tolerance to specific tasks or activities is still a problem, we increase the time spent in our department. People may be coming for a few hours in occupational therapy as they gradually decrease the time spent in the physical therapy department. The critical occupational therapist duty is to be certain that the discharge employ-
C. Lacroix / Work 5 (1995) 143-146
146
ment plan is progressing smoothly and that the worker is going back to his previous job. 2.4. Phase 4 Phase four is the follow-up or tracking phase. Mter people are back to work, a telephone or written contact is maintained with the workers at regular intervals to inquire about their condition and their work. We want to know if they are pain-free while working, if they are still using proper working techniques and if they have reintroduced leisure activities in their schedule. These data do not merely provide information for quality assurance, but also provide valuable research material for publications and program modification. People are usually happy to be part of this program. The specific work training and the gradual and supervised work reinstatement make them feel less fearful of reinjuring themselves.
3. Outcome data From September of 1992 until December of 1993, 80 injured workers were treated in our program: •
• •
• •
Eighty-seven percent returned to their previous job in the expected time of 12 weeks with the average duration of treatment being of 8 weeks. The return to work was possible after 6 weeks of treatment for 58% of the cases. In 15% of the cases, the employer refused" the temporary assignment so we had to keep those workers longer in our program before their conditions would enable them to reinstate their work tasks. Our tracking demonstrated two relapses in the few months following the return to work. Only four out of 80 were not able to return to work and were consolidated with permanent disabilities.
4. Conclusion This paper attempted to illustrates that AID can be considered an effective program for acute back-injured workers. The potential success of
this approach lies in the coordinated efforts of the interdiciplinary treatment team. The occupational therapist supervises physical reconditioning, but focuses on functional task performance, e.g. lifting capacity, positional and activity tolerance, through work simulation and work hardening. Additionally, the occupational therapist is involved in addressing work related barriers to recovery that might interfere with the ultimate return to work goal. Psychosocial and behavorial issues affecting the worker during this period are also dealt with through counseling and educational classes. Members from each department work together to meet the individual needs of each client. Clear communication between the department is important if some patients want to attempt to sabotage their treatment by giving different information to different staff members. Communication with the employer is also a key to this approach aimed at getting the injured workers back on the job. The program objectives follow the workers' compensation board of the Province of Quebec as well as the mandate of the Minister of Health. More research is needed to prove that work hardening can help to save money and preserve the person as a whole. Healthy individuals, mentally and physically, will be more productive and less at risk of reinjury. References C.S.S.T. (1993) Keeping ties with work: for a prompt and lasting return to work. Montreal, Quebec. Department of Community Health, Sacre-Coeur Hospital. (1990) Experimentation d'un modele innovateur de prise en charge et de suivi des travailleurs accidentes du dos: rapport de l'etude de faisabilite et protocole de recherche. C.S.S.T. Etienne, A (1983) L'approche globale: poncif ou realite. CJOT 50: 5, 177-181.
Mitchell, R. and Carmen, G. (1990) Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 15: 6, 514521.
Ogden-Niemeyer, L. and Jacobs, K. (1989) Work Hardening: State of the Art. New Jersey: SLACK. Spitzer, W. (1986) Report of Quebec Task Force on Clinical Aspects of Vertebral Disorders Among Workers. Montreal: IRSST, p. 296.
ELSEVIER
WorkS (1995) 143-146
Work hardening for sub-acute back injured workers: a new approach Caroline Lacroix* Clinique rnedicale Physergo, 5260, Avenue Verdun, Verdun, Quebec, Canada
Abstract ACTIDOS (ATD) is a program which takes an innovative approach to work hardening based on the needs of acutely back-injured workers. The success lies in the coordinated efforts of the interdisciplinary treatment team. ATD integrates the return to work process as an aspect of treatment and focuses on functional capacity rather than the elimination of pain. The program demonstrates encouraging outcome information: 85% of the workers in a specific group returned to work within the expected time.
Keywords: Back injury; Worker; Word hardening; Return to work; Team - - - - - - - _.•....... _ - -
1. Introduction
ACTIDOS (ATD) is a program which takes an active, interdisciplinary, innovative approach to work hardening based on the needs of acutely back-injured workers. A literature review on work-hardening programs indicates that they are usually conducted with chronic cases, e.g. clients who have been disabled for > 3 months. Those cases represent 76% of the total cost of workers' compensation in the Province of Quebec. These
* Tel.: + 1 (514) 767 8705; Fax: + 1 (514) 766 3472.
statistics provided the motivation to implement a program for sub-acute back-injured workers. The objectives of the program are: • • • •
To actively involve the injured worker through an interdisciplinary approach. To prevent chronicity. To be cost-effective for the workers' compensation board. To integrate the return to work process as an aspect of treatment.
This last point follows the new approach of the workers' compensation board of Quebec with its
1051-9815/95/$~9.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSDI 1051-9815(95)00116-3
144
C. Lacroix / Work 5 (1995) 143-146
new service called 'Keeping ties with work.' The organization now stresses intervention as soon as possible after the worker's injury in order to ensure his or her prompt and lasting return to work. The occupational therapist has an important multi-faceted role to play in this program; not only does he or she deal with the physical and psychosocial issues of the client but also with all factors involved with the return to work. This means frequent contacts with the employer to evaluate different possibilities of reintegrating quickly the employee into the work place. All decisions are taken after team discussion which involves the occupational therapist, physical therapist, physician as well as the worker. Clients entering the program are encouraged to take an active part in their treatment. The focus is on functional capacity rather than the elimination of pain as opposed to a more classical approach where they would play the role of the passive client. A new school of thought has emerged in the area of back injury which stresses the importance of early and active treatment (Spitzer, 1986). ATD follows this trend with its aggressive reconditioning program and an early return to work. Occupational therapists are all aware that people with disabilities should be guided by a bio-psychosocial model using an interdisciplinary approach. Every ATD client had an evident occupational injury as a consequence of an accident, but also as important is the interaction between their medical condition, physical capacities and psychosocial factors. This paper will outline the role of the occupational therapist through each phase of the program. The program aims for a 12 weeks maximum duration of treatment including gradual reintegration into the workplace. 1.1. Type of client People in the program should have a lesion affecting the lower back and have to be referred within 4 weeks following their accident. Usually in 75% of cases, symptoms resolve within 4 weeks. Those workers would not be seen in A TD since physicians would not referr them as they would
only take anti-inflammatory drugs with a brief period of rest before returning to work. 2. Program 2.1. Phase 1 The first phase lasts 2 weeks and the goals are to reduce pain, to begin mobilization, to teach biomechanics of the spine and stress management. Education is the key word early on. The occupational therapist conducts a back school of five daily sessions of 1 h each. The anatomy and biomechanics of the spine, postural hygiene and proper working techniques are discussed. Stress management is included along with an explanation to the relationship between pain and stress. Other topics of discussion could be job satisfaction, anger and frustration toward authority figures and family relationships. Clients with mental illnesses and low back pain are likely to remain out of work longer. It is suggested that the psychosocial components could be predictors of poor outcome but we do not know how they contribute to the return to work rate. Further research is needed in that area. The importance of relaxation in a daily routine is also incorporated. Clients will have the opportunity to experiment with different relaxation techniques as they come daily to our clinic. 2.2. Phase 2 Phase 2 of the program lasts from 2 to 6 weeks. This is the active part where workers are seen for 4 h each day, as opposed to the first phase where they were seen 2 h a day. The goals of this second phase are:
• • • • •
Pain, mobility and stress control. To increase physical fitness. To apply the principles of good postural hygiene. To introduce work simulations. To plan the return to work.
The occupational therapist evaluates the functional capacity rather than pain with respect to the work environment. But obviously, tests are
C. Lacroix /Work 5 (1995) 143-146
conducted to eliminate any serious condition assuring that we are dealing with musculoskeletal injuries only. Excessive inactivity is more harmful than beneficial, therefore gradual reintroduction to activities related to work tasks occurs. We like to avoid time spent rehearsing the invalid role, e.g. the client becoming more angry and depressed. We often relate with the injured athlete, for which we think in terms of returning them to competition as quickly as possible. Our worker's goal should be to return to work as soon as possible by keeping contact with his or her work environment and to remain professionally active. We teach them that they can do something for themselves by using proper body mechanics, postural exercises, diet, pacing activities and stress management. Work simulations are designed to prepare the worker, both physically and mentally, for an early, safe and healthy return to work. At this point it may imply a temporary increase in pain duration and intensity, but the focus is still more on their capacities. In chronic low back injuries, 84% of the cases had pain as a predominant factor in both the initial and final diagnoses (CSST, 1993). Some may undergo one treatment after another to try to get rid of the pain but they may have to learn to live with it. We want to return them to a high functional capacity level by helping them to engage in normal daily activities, to reduce the risk of future injury and at the same time, to experience reduction in their symptoms once the physical progression has been completed. Concern over proper lifting techniques must be balanced by common sense and awareness of all the factors involved at work. That is why, when necessary, the occupational therapist might go to the workplace for an evaluation to be able afterwards to reproduce it in the clinic. Attention is placed on manual handling techniques to gradually desensitize the fear of lifting in the workplace. The client's training is individualized to the tasks which are specific to his job requirements. As the condition progresses, the team discusses the possibility of returning the client to work. Will it be a temporary assignment? Will it be
145
modified or regular work? There could be many different possibilities. This is where the occupational therapist, with the knowledge of the individual's capacities versus the job requirements, can discuss with the employer the return to work with modification of tools, job process or workstation when necessary. This may include actual return to his or her previous job during a few hours a day or for part of the week while coming to the clinic as we could combine work and treatment. Arrangements for the best schedule possible are made. At this stage, we occasionally encounter resistance from the employers that are not receptive to the idea of modified work or temporary assignment. Some of them prefer to take the worker back only when the injury has been stabilized. This tends to increase the employer's compensation in the long run. This new tendancy of 'keeping ties with work' brings many changes at an administration level thus education towards employers and employees is tremendously important. We should be able to demonstrate that if an employee is assigned to a temporary job which involves no risk of aggravating his condition, he will not only contribute to his rehabilitation but decrease the total rehabilitation's cost. At the end of this second phase there are two options: The worker is still in treatment full-time, either because of his condition or he was unable to hold his job or the employer made no possibility of job assignment. (2) The worker comes part-time to treatment and goes to work part-time. (1)
2.3. Phase 3 Phase three should be the transition from modified to regular work. We continue what we started in the second phase and intensify the work simulations. If tolerance to specific tasks or activities is still a problem, we increase the time spent in our department. People may be coming for a few hours in occupational therapy as they gradually decrease the time spent in the physical therapy department. The critical occupational therapist duty is to be certain that the discharge employ-
C. Lacroix / Work 5 (1995) 143-146
146
ment plan is progressing smoothly and that the worker is going back to his previous job. 2.4. Phase 4 Phase four is the follow-up or tracking phase. Mter people are back to work, a telephone or written contact is maintained with the workers at regular intervals to inquire about their condition and their work. We want to know if they are pain-free while working, if they are still using proper working techniques and if they have reintroduced leisure activities in their schedule. These data do not merely provide information for quality assurance, but also provide valuable research material for publications and program modification. People are usually happy to be part of this program. The specific work training and the gradual and supervised work reinstatement make them feel less fearful of reinjuring themselves.
3. Outcome data From September of 1992 until December of 1993, 80 injured workers were treated in our program: •
• •
• •
Eighty-seven percent returned to their previous job in the expected time of 12 weeks with the average duration of treatment being of 8 weeks. The return to work was possible after 6 weeks of treatment for 58% of the cases. In 15% of the cases, the employer refused" the temporary assignment so we had to keep those workers longer in our program before their conditions would enable them to reinstate their work tasks. Our tracking demonstrated two relapses in the few months following the return to work. Only four out of 80 were not able to return to work and were consolidated with permanent disabilities.
4. Conclusion This paper attempted to illustrates that AID can be considered an effective program for acute back-injured workers. The potential success of
this approach lies in the coordinated efforts of the interdiciplinary treatment team. The occupational therapist supervises physical reconditioning, but focuses on functional task performance, e.g. lifting capacity, positional and activity tolerance, through work simulation and work hardening. Additionally, the occupational therapist is involved in addressing work related barriers to recovery that might interfere with the ultimate return to work goal. Psychosocial and behavorial issues affecting the worker during this period are also dealt with through counseling and educational classes. Members from each department work together to meet the individual needs of each client. Clear communication between the department is important if some patients want to attempt to sabotage their treatment by giving different information to different staff members. Communication with the employer is also a key to this approach aimed at getting the injured workers back on the job. The program objectives follow the workers' compensation board of the Province of Quebec as well as the mandate of the Minister of Health. More research is needed to prove that work hardening can help to save money and preserve the person as a whole. Healthy individuals, mentally and physically, will be more productive and less at risk of reinjury. References C.S.S.T. (1993) Keeping ties with work: for a prompt and lasting return to work. Montreal, Quebec. Department of Community Health, Sacre-Coeur Hospital. (1990) Experimentation d'un modele innovateur de prise en charge et de suivi des travailleurs accidentes du dos: rapport de l'etude de faisabilite et protocole de recherche. C.S.S.T. Etienne, A (1983) L'approche globale: poncif ou realite. CJOT 50: 5, 177-181.
Mitchell, R. and Carmen, G. (1990) Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 15: 6, 514521.
Ogden-Niemeyer, L. and Jacobs, K. (1989) Work Hardening: State of the Art. New Jersey: SLACK. Spitzer, W. (1986) Report of Quebec Task Force on Clinical Aspects of Vertebral Disorders Among Workers. Montreal: IRSST, p. 296.
