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Worker Rehabilitation Programs Separating Fact From Fiction ANDREW J. HAIG, MD, and SUZANNE PENHA, RN, MSN, Neenah, Wisconsin
A few worker rehabilitation programs have had outstanding success in improving ability to function for persons with occupational back pain. Local programs must show that they have similar success. Because the definitions of terms such as "back school:' "work hardening:' and "functional restoration" are blurred at a local level, the choice of a program for an individual patient must depend primarily on the program's demonstrated success rate with similar patients. The chances of returning to work decrease as a function of time after injury. Therefore, referring physicians, insurers, and employers must be provided with information regarding results in terms of acute (O to 6 weeks), subacute (7 to 12 weeks), and chronic (more than 12 weeks) back pain. Other important variables include selection criteria, program cost, and dropout rate. We advocate standardized reporting of such data for all worker rehabilitation programs. A model "report to consumers:' described here, is a minimal obligation. The validity of a number of important internal quality assurance issues is uncertain. Ethical and legal pressures must be recognized. (Haig AJ, Penha S: Worker rehabilitation programs-Separating fact from fiction, In Rehabilitation Medicine-Adding Life to Years [Special Issue]. West J Med 1991 May; 154:528-53 1)
G ood news for back pain sufferers! Researchers have confirmed that acute low back pain disappears regardless of treatment 95 % of the time. 1 Only a small number require surgical treatment.' Thanks to a "sports medicine" approach to rehabilitating injured workers,2 eight of ten patients with chronic back pain can return to successful employment.3"4 So much for pipe dreams. Although excellent studies have shown these results, we all know that back pain is the most common cause of disability in the working-age population.5 The number of back-disabled persons is growing at an exponential rate. In fact, back pain costs this country tens of billions of dollars per year. Good research and bad results may be partly due to a difference in quality of rehabilitation. The good results are primarily from university-based groups dedicated to back pain. In contrast, treatment is much more difficult for community-based physicians who have limited access to expert systems of case management and rehabilitation. We do have local programs with names such as "back school," "work hardening," and "functional restoration," but it is difficult to judge the quality of these programs. Are these programs appropriate for a particular patient? Are they successful? Cost-effective? Ethical? In this article we aim to provide referring physicians, employers, insurers, and others the tools they need to assess the quality of care given to their patients. We begin with a description of the different programs, then address program selection, outcome measures, internal issues, and ethical controversies.
Worker Rehabilitation Programs Worker rehabilitation begins with the first interaction with the medical system. An acute care physician is the first line of defense against disability. Because 80% to 90% of
patients have no anatomically verifiable lesion and most patients improve regardless of the treatment given,' the physician's role in encouraging an early return to work is at least as important as "diagnose-treat-cure." We have shown that physician care consisting of urging patient participation in rehabilitation, an early assessment of medical and psychosocial causes for delayed recovery, and effective communication between the physician and the employer resulted in a substantial decrease of time away from work after acute injury.6 Others have shown that early mobilization in a family practice setting may be more effective than some other treatment methods.7 On the other hand, there comes a point when a formal rehabilitation program is more successful than an individual physician's efforts. Studies comparing worker rehabilitation programs with care in the community3'4 or even with care by the same specialist physician without the program8 show the inadequacy of physicians alone. Clearly physicians must define an end point beyond which their resources are not likely to be effective. The Quebec Task Force on Spinal Disorders, which extensively reviewed the literature on low back pain, recommends consultation with a specialist before the seventh week after injury if a patient has not returned to work.9 The "back school" concept was developed in Sweden to consist of four 45-minute group sessions that educate patients on anatomy, pathology, prevention, and working in pain-free postures.10 One randomized study showed that the Swedish Back School was more effective than placebo in terms of days missed from work over the year following the treatment of acute back pain.11 "Work hardening" has been defined rather precisely by the Committee on Accreditation of Rehabilitation Facilities."1 Work-hardening programs "use conditioning tasks that are graded to progressively improve the biomechanical,
From the Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee (Dr Haig), and the Center for Rehabilitation Services at Theda Clark Regional Medical Center, Neenah, Wisconsin (Dr Haig and Ms Penha). Reprint requests to Andrew J. Haig, MD, Medical Director, Center for Rehabilitation Services at Theda Clark Regional Medical Center, 130 Second St, Neenah, WI 54956.
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neuromuscular, cardiovascular, metabolic, and psychosocial fitness of the individual with real or simulated work activities."19'P1 The concepts are explained by Matheson and coworkers, who popularized these techniques.13 Although dozens of "how to" articles have been written on work hardening, little had been done to document its success until recently.8 14 Work hardening has generally been accepted as a reasonable treatment for some people with occupational back pain. One of the most exciting advances in the rehabilitation of persons with back pain is the finding3 and independent confirmation4 that 80% of persons with work-disabling chronic low back pain can return to meaningful work through a complex, intensive, interdisciplinary rehabilitation program based on the quantification and improvement of measurable functional variables. Only 40% of persons without this care returned to work. These are called "functional restoration" programs.
Problems in Execution If a local program replicates all elements of one of these three types of programs, it may be successful. We cannot realistically assume that programs are photocopies, however. Programs disregard formal definitions. They add or subtract from the format because of local resources or philosophy. They change the format in an attempt to improve outcome or reduce costs. Definitions have been confused. The most recent review of back schools1I shows that the term "back school" has been used for programs ranging from two lectures to a six-week inpatient hospital stay. Most of the programs that were significantly different from the Swedish Back School were not carefully studied against a control group. Their effectiveness cannot be judged. Local programs may change their names without changing the format to improve reimbursement. Local resources may differ. There is a trend for some employers to provide work-hardening activities at the work site. A competent pain psychologist or vocational counselor may not be available. The program may need to share space and staff with an inpatient therapy department. Differing philosophies may result in different executions. Although pain and function do not always correlate,2 local physicians and therapists may "back off' therapy intensity to varying degrees when pain behavior is present. Therapists may take an adversarial, supervisory, or collegial approach to patient interaction. When quantifying function, programs may not measure true maximum performance or may use expensive high-technology machinery to document improvement in areas that have no clinical relevance. The approach to psychological versus physical rehabilitation for work-related back pain is a hot topic. Studies have shown that patients with back pain are physically deconditioned3'4'16 and that strength below job requirements predisposed them to injury. 1I 18 Similarly, psychological and vocational behavior are important. 13,19 A randomized study showed that both a purely psychological and a purely physical approach resulted in equal success in returning patients to work.20 Sachs and co-workers report that their primarily physical "work tolerance" rehabilitation program is as effective as a multifaceted "functional restoration" approach to chronic disability.8 Elsewhere a low-intensity, less expensive, functional restoration approach is being used for persons with acute or subacute pain.
529
Program formats may change in an effort to improve results. For example, the functional restoration program Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE) recently published improved results with the addition of preprogram training and education.21 Other program elements need further study. How important is job simulation versus a generalized reconditioning approach? Does alcohol and drug treatment affect outcome? Do any of these approaches prevent reinjury? Back school, work hardening, and functional restoration have been well defined by the researchers who worked out and validated these concepts. In practice, these programs have been confused and intermingled for a number of reasons both good and questionable. Although the Committee on the Accreditation of Rehabilitation Facilities and the American Occupational Therapy Association have provided helpful guidelines for some types of worker rehabilitation programs, 22 the quality of a local program cannot reliably be judged by its adherence to rules. Proven results are the best indicator of future success.
Selecting the Right Program A referring physician's responsibility is to refer patients to the right program at the right time. A program's obligation is to delineate its approach and appropriately screen patients for admission. While back pain progresses along a continuum from acute to chronic, rehabilitation is often separated into discrete steps. It is useful to base the decision to advance to the next step on the cost-effectiveness of the treatment. Because the cost of an episode of acute back pain is mini-
mal, an inexpensive back school is reasonable. Patients whose acute back pain is likely to become chronic must be identified5 and referred to a more aggressive approach that may be cost-effective. The care of patients with subacute back pain has been somewhat more costly. Chronic pain is likely to develop in these patients without intervention. A work-hardening approach may be effective. Even more cost-effective may be a return to work on a gradual basis if a patient is physically and emotionally able to meet job demands. Work hardening may be ineffective in persons who are headed towards surgical treatment. Patients with many psychosocial issues usually need more than a simple physical conditioning approach. Patients with chronic back pain make up only 5 % of back pain sufferers, yet they account for 85 % of cost.1 If no medical or surgical cure is found, a functional restoration program may be indicated. Back school alone has been proved ineffective in this group.23 A work-hardening program that accepts patients who have chronic pain must demonstrate its effectiveness in this group separate from its subacute pain patients. The wishes of patients who decline to participate in an appropriate program should be respected. Unless the circumstances can be altered, active medical intervention should be ended and referral to a vocational counselor considered.
Measures of Outcome: All That Really Matters A sophisticated approach must be used when evaluating the effectiveness of individual worker rehabilitation programs. For example, a 70% return-to-work rate for patients with chronic low back pain
may
be excellent, but the same
percentage for acutely injured patients is worse than the natural history of the disease. In the model "report to con-
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sumers" (Figure 1), we provide guidelines that even the simplest program should be able to meet. More comprehensive approaches to proof of effectiveness are provided by others.24 Basic information on the program should include cost, number of days the program is designed to last, number of hours per day, and qualifications of the program staff. Persons with problems other than back pain should be excluded from all calculations. If one organization has two different programs (a back school and a work-hardening program, for instance), results should be described separately. Program variables must be separated according to the length of the time patients are disabled on admission. The Quebec review suggests a protocol in which patients are divided into those whose pain has been present 0 to 6 weeks, 7 to 12 weeks, or more than 12 weeks.8 Patient demographics should include the number of men and women, age (mean and standard deviation), and percentage with previous back operations. The number of worker's compensation cases, personal injury cases, and private insurance cases should be listed. Preinjury jobs should be subdivided as recommended by Mayer and associates into sedentary to light, light to medium, medium to heavy, and very heavy.2
The program dropout rate must be uniformly defined and presented to eliminate biases. Of the number of applicants screened, the program should reveal the number of applicants turned down and the number accepted who dropped out of the program. These numbers represent the program's willingness to accept patients with risk factors for chronicity (injury type, job, demographics, physical findings, and psyProgram Name to 6-Month reporting period Program cost (average for program completers) Program length (days) Program intensity (hours/day) OT Staff: MD PT Social Worker Psychologist Exercise Physiologist Vocational Counselor Nurse Others Patients Number screened .......... Number declined .......... Number admitted .......... Number dropped........... Of those admitted % Men .................. Age, yr (standard deviation).. Number postsurgery........ Job types % Sedentary-light........... % Light-medium............ % Medium-heavy........... % Very heavy ............. Results % Working at discharge*.... % Working at 6 monthst....
Subacute 7-12wk
0-6 wk
Chronic 12wk
_
(.
-.)
(-)
(_)
*Includes persons at work within 1 week of discharge. tlncludes persons at work or eligible to work but unemployed at 6 months after
discharge.
Figure 1.-A model of a report to consumers is shown for those participating in worker rehabilitation programs. This report would be used to inform thirdparty payers and employers of the progress of a program.
chological factors)22 as well as referral patterns. Reasons for dropout should be presented. Outcome measures should include the percentage who returned to work within a week of program completion and the percentage at work or eligible for work six months after program completion. Worker rehabilitation programs are highly motivated to demonstrate their effectiveness to referral sources. Their methods for doing so are often too variable to make meaningful comparisons between programs. The report to consumers included here provides a standardized comparison. It is recommended that referral sources request proof of program quality in this format. Internal Quality Issues We have found no study that validates the effect of a quality assurance program. Indeed, only programs that are hospital based, and thus subject to the rules of the Joint Commission on Accreditation of Healthcare Organizations, are under any pressure to do internal quality assurance studies. Until research better defines the factors that relate to quality outcome, regulating forces such as referring physicians, insurers, and accreditation organizations should accept a wide variety of program concepts but insist on an accurate reporting of outcome. It is intuitive, however, that successful worker rehabilitation programs get that way because of sound concepts, solid clinical skills, and talented administration. We will present without justification issues that are of concern to the managers of some successful programs. Addressing the methods of quality assurance is beyond the scope of this discussion. Established admission and discharge criteria must be followed. Patients with poor motivation, who are medical risks (cardiac, neurologic, orthopedic, and psychiatric), and those who might benefit more from an alternative therapy should be identified. The program should last for a predefined length and not be prolonged because of issues such as patient pain behavior. The staff must be experienced enough to separate their role in improving function from the usual role of curing disease. Staff burnout should be anticipated and addressed. The medical director should be effective in educating referrers, screening admissions, supporting anxious patients, dealing with acute events, providing medicolegal documentation, and coordinating the varied talents within the team. If there is no medical director, the administrator must perform some tasks and ensure that referring physicians are capable and willing to assume the others. Communication with referral sources, insurers, attorneys, and employers must be prompt, accurate, and complete. The effectiveness of patient and family education should be demonstrated. Program components must be effective. The rate of improvement from an exercise program should approximate that of normal persons. Patient effort in areas of strength, endurance, and flexibility should be objectively quantified and addressed constructively.2 Psychological approaches should result in tested objective improvement. " Ethical and Legal Issues Worker rehabilitation programs are in a unique and precarious position in the medicolegal system. A number of external factors may significantly affect program outcomes. Who is the customer? The injured worker is the object of
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the treatment, but bills are paid by the employer or the employer's worker's compensation carrier. Rehabilitation specialists who coordinate treatment are hired by the payers. They may operate on structured spending limits that discourage expensive but cost-effective treatments such as functional restoration. The referring physician's and patient's decision to choose a program may be substantially affected by these factors. What are the goals? Return to work is not necessarily the only obligation in the worker's compensation system. Although compensation laws differ from state to state, medical treatment that improves function in areas outside of work such as household chores and avocational interests may be compensable. What about the Americans With Disabilities Act?25 Many workers legitimately fear that when they complete a rehabilitation program their previous employer will not rehire them and, despite their capabilities, other employers will avoid hiring them because of the back injury. Employers are aware that the presence of a previous injury is a risk factor for new injury. Recent federal legislation, the Americans With Disabilities Act, makes it illegal to discriminate against a person with a disability.26 Although case law will determine the effect of the law, it is likely that an injured worker who is capable of returning to work with reasonable job modifications must be rehired by the employer and must not be discriminated against by future employers. It is hoped that this will not only shift responsibility for disabled persons to the private sector but also reduce the overall cost to society by increasing employment of this group. When does it all end? Case closure and assignment of a low permanent impairment rating are monetarily beneficial to the insurer but may be financially or emotionally unacceptable to the patient. Functional capacity evaluations, defined as "a measure of function quantitatively by direct or indirect means of a dynamic aspect of bodily activity necessary in daily living,"2 appear at face value to be useful in case closure. There is no evidence, however, that such tests have predictive value. Programs may be pressured into using data from functional capacity evaluations for case closure.
Conclusion Referring physicians have a central role in ensuring the quality of a worker rehabilitation program. By properly matching patients with the correct type of program, physicians encourage effective and cost-effective rehabilitation. By demanding sophisticated and meaningful outcome data, physicians ensure that programs are successfully executing the proposed rehabilitation. By understanding some of the internal quality issues, physicians can provide meaningful feedback to the local worker rehabilitation program about areas for improvement. Finally, if they understand the forces, both medical and social, involved in rehabilitating injured workers, referring physicians can act fairly toward all parties. We advocate a standardized reporting format. The model presented here is designed to be simple for all programs to
execute and for referral sources to digest. Some may argue that the format is too simplistic. We would not imply that such a report is bias-proof. A good program that compares poorly with its competitors may wish to provide additional evidence to explain the discrepancy. This evidence should be separated from the basic report format. It is essential that referring physicians recognize when their abilities to diagnose, treat, and cure do not match patients' needs to be rehabilitated. Early referral reduces suffering, disability, and the multibillion-dollar annual national loss due to occupational low back pain. REFERENCES 1. Frymoyer JW: Back pain and sciatica. N Engl J Med 1988; 318:291-300 2. Mayer TG, Gatchel RJ: Functional Restoration for Spinal Disorders: The Sports Medicine Approach. Philadelphia, Pa, Lea & Febiger, 1988 3. Mayer TG, Gatchel RJ, Mayer H, Kishino ND, Keeley J, Mooney V: A prospective two-year study of functional restoration in industrial low back injury-An objective assessment procedure. JAMA 1987; 258:1763-1767 4. Hazzard RG, Fenwick JW, Kalisch SM, et al: Functional restoration with behavioral support: A one-year prospective study of patients with chronic low-back pain. Spine 1989; 14:157-161 5. Frymoyer JW, Cats-Baril W: Predictors of low back pain disability: Clin Orthop 1987; 22 1:89-98 6. Haig AJ, Linton P, McIntosh M, Moneta L, Mead PB: Aggressive early management by a specialist in physical medicine and rehabilitation: Effect on lost time due to injuries in hospital employees. J Occup Med 1990; 32:241-244 7. Gilbert JR, Taylor DW, Hildebrand A, Evans C: Clinical trial of common treatments for low back pain in family practice. Br Med J (Clin Res) 1985; 291:791-794 8. Sachs BL, David JF, Olimpio D, Scala AD, Lacroix M: Spinal rehabilitation by work tolerance based on objective physical capacity assessment of dysfunction-A prospective study with control subjects and twelve-month review. Spine 1990; 15:1325-1332 9. Spitzer WO, LeBlanc FE, Dupuis M, et al: Scientific approach to the assessment and management of activity related spinal disorders-A monograph for clinicians: Report of the Quebec Task Force on Spinal Disorders. Spine 1987; 12(Suppl):s4-s55 10. Forssell MZ: The back school. Spine 1981; 6:104-106 11. Bergquist-Ullman M, Larsson U: Acute low back pain in industry-A controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand (Suppl) 1977; 170:1-117 12. Standards Manual for Organizations Serving People with Disabilities. Tucson, Ariz, Committee on Accreditation of Rehabilitation Facilities, 1989 13. Matheson LN, Ogden LD, Violette K, Schultz K: Work hardening: Occupational therapy in industrial rehabilitation. Am J Occup Ther 1985; 39:314-321 14. Creighton C: Three frames of reference in work-related occupational therapy programs. Am J Occup Ther 1985; 39:331-334 15. Linton SJ, Kamwendo K: Low back schools-A critical review. Phys Ther 1987; 67:1357-1383 16. Thomas LK, Hislop HJ, Waters RL: Physiological work performance in chronic low back disability. Phys Ther 1980; 60:407-411 17. Pederson DM, Clark JA, Johns RE, White GL, Hoffman S: Quantitative muscle strength testing: A comparison of job strength requirements and actual worker strength among military technicians. Milit Med 1989; 154:14-18 18. Chaffin DB, Park KS: A longitudinal study of low back pain associated with occupational weight lifting factors. Am Ind Hyg Assoc J 1973; 34:513-525 19. Gatchel RJ, Mayer TG, Capra P, Diamond P, Barnett J: Quantification of lumbar function-Part 6: The use of psychological measures in guiding physical functional restoration. Spine 1986; 11:36-42 20. Heinrich RL, Cohen MJ, Naliboff BD, Collins GA, Bonebakker AD: Compartherapy for chronic low back pain on physical abilities, ing physical and behavior psychological distress, and patients' perceptions. J Behav Med 1985; 8:61-78 21. Kohles S, Barnes D, Gatchel RJ, Mayer TG: Improved physical performance outcomes after functional restoration treatment in patients with chronic low-back pain-Early versus recent training results. Spine 1990; 15:1321-1324 22. Commission on Practice, American Occupational Therapy Association: Work hardening guidelines. Am J Occup Ther 1986; 40:841-843 23. Lankhorst GJ, Van der Stadt RJ, Vogelaar TW, Van der Korst JK, Prevo AJ: The effect of the Swedish Back School in chronic idiopathic low back pain-A prospective controlled study. Scand J Rehabil Med 1983; 15:141-145 24. Bloch R: Methodology in clinical back trials. Spine 1987; 12:430-432 25. Pub L No. 101-336, 104 Stat 327 26. Verville RE: The Americans With Disabilities Act: An analysis. Arch Phys Med Rehabil 1990; 71:1010-1013
Worker Rehabilitation Programs Separating Fact From Fiction ANDREW J. HAIG, MD, and SUZANNE PENHA, RN, MSN, Neenah, Wisconsin
A few worker rehabilitation programs have had outstanding success in improving ability to function for persons with occupational back pain. Local programs must show that they have similar success. Because the definitions of terms such as "back school:' "work hardening:' and "functional restoration" are blurred at a local level, the choice of a program for an individual patient must depend primarily on the program's demonstrated success rate with similar patients. The chances of returning to work decrease as a function of time after injury. Therefore, referring physicians, insurers, and employers must be provided with information regarding results in terms of acute (O to 6 weeks), subacute (7 to 12 weeks), and chronic (more than 12 weeks) back pain. Other important variables include selection criteria, program cost, and dropout rate. We advocate standardized reporting of such data for all worker rehabilitation programs. A model "report to consumers:' described here, is a minimal obligation. The validity of a number of important internal quality assurance issues is uncertain. Ethical and legal pressures must be recognized. (Haig AJ, Penha S: Worker rehabilitation programs-Separating fact from fiction, In Rehabilitation Medicine-Adding Life to Years [Special Issue]. West J Med 1991 May; 154:528-53 1)
G ood news for back pain sufferers! Researchers have confirmed that acute low back pain disappears regardless of treatment 95 % of the time. 1 Only a small number require surgical treatment.' Thanks to a "sports medicine" approach to rehabilitating injured workers,2 eight of ten patients with chronic back pain can return to successful employment.3"4 So much for pipe dreams. Although excellent studies have shown these results, we all know that back pain is the most common cause of disability in the working-age population.5 The number of back-disabled persons is growing at an exponential rate. In fact, back pain costs this country tens of billions of dollars per year. Good research and bad results may be partly due to a difference in quality of rehabilitation. The good results are primarily from university-based groups dedicated to back pain. In contrast, treatment is much more difficult for community-based physicians who have limited access to expert systems of case management and rehabilitation. We do have local programs with names such as "back school," "work hardening," and "functional restoration," but it is difficult to judge the quality of these programs. Are these programs appropriate for a particular patient? Are they successful? Cost-effective? Ethical? In this article we aim to provide referring physicians, employers, insurers, and others the tools they need to assess the quality of care given to their patients. We begin with a description of the different programs, then address program selection, outcome measures, internal issues, and ethical controversies.
Worker Rehabilitation Programs Worker rehabilitation begins with the first interaction with the medical system. An acute care physician is the first line of defense against disability. Because 80% to 90% of
patients have no anatomically verifiable lesion and most patients improve regardless of the treatment given,' the physician's role in encouraging an early return to work is at least as important as "diagnose-treat-cure." We have shown that physician care consisting of urging patient participation in rehabilitation, an early assessment of medical and psychosocial causes for delayed recovery, and effective communication between the physician and the employer resulted in a substantial decrease of time away from work after acute injury.6 Others have shown that early mobilization in a family practice setting may be more effective than some other treatment methods.7 On the other hand, there comes a point when a formal rehabilitation program is more successful than an individual physician's efforts. Studies comparing worker rehabilitation programs with care in the community3'4 or even with care by the same specialist physician without the program8 show the inadequacy of physicians alone. Clearly physicians must define an end point beyond which their resources are not likely to be effective. The Quebec Task Force on Spinal Disorders, which extensively reviewed the literature on low back pain, recommends consultation with a specialist before the seventh week after injury if a patient has not returned to work.9 The "back school" concept was developed in Sweden to consist of four 45-minute group sessions that educate patients on anatomy, pathology, prevention, and working in pain-free postures.10 One randomized study showed that the Swedish Back School was more effective than placebo in terms of days missed from work over the year following the treatment of acute back pain.11 "Work hardening" has been defined rather precisely by the Committee on Accreditation of Rehabilitation Facilities."1 Work-hardening programs "use conditioning tasks that are graded to progressively improve the biomechanical,
From the Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee (Dr Haig), and the Center for Rehabilitation Services at Theda Clark Regional Medical Center, Neenah, Wisconsin (Dr Haig and Ms Penha). Reprint requests to Andrew J. Haig, MD, Medical Director, Center for Rehabilitation Services at Theda Clark Regional Medical Center, 130 Second St, Neenah, WI 54956.
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neuromuscular, cardiovascular, metabolic, and psychosocial fitness of the individual with real or simulated work activities."19'P1 The concepts are explained by Matheson and coworkers, who popularized these techniques.13 Although dozens of "how to" articles have been written on work hardening, little had been done to document its success until recently.8 14 Work hardening has generally been accepted as a reasonable treatment for some people with occupational back pain. One of the most exciting advances in the rehabilitation of persons with back pain is the finding3 and independent confirmation4 that 80% of persons with work-disabling chronic low back pain can return to meaningful work through a complex, intensive, interdisciplinary rehabilitation program based on the quantification and improvement of measurable functional variables. Only 40% of persons without this care returned to work. These are called "functional restoration" programs.
Problems in Execution If a local program replicates all elements of one of these three types of programs, it may be successful. We cannot realistically assume that programs are photocopies, however. Programs disregard formal definitions. They add or subtract from the format because of local resources or philosophy. They change the format in an attempt to improve outcome or reduce costs. Definitions have been confused. The most recent review of back schools1I shows that the term "back school" has been used for programs ranging from two lectures to a six-week inpatient hospital stay. Most of the programs that were significantly different from the Swedish Back School were not carefully studied against a control group. Their effectiveness cannot be judged. Local programs may change their names without changing the format to improve reimbursement. Local resources may differ. There is a trend for some employers to provide work-hardening activities at the work site. A competent pain psychologist or vocational counselor may not be available. The program may need to share space and staff with an inpatient therapy department. Differing philosophies may result in different executions. Although pain and function do not always correlate,2 local physicians and therapists may "back off' therapy intensity to varying degrees when pain behavior is present. Therapists may take an adversarial, supervisory, or collegial approach to patient interaction. When quantifying function, programs may not measure true maximum performance or may use expensive high-technology machinery to document improvement in areas that have no clinical relevance. The approach to psychological versus physical rehabilitation for work-related back pain is a hot topic. Studies have shown that patients with back pain are physically deconditioned3'4'16 and that strength below job requirements predisposed them to injury. 1I 18 Similarly, psychological and vocational behavior are important. 13,19 A randomized study showed that both a purely psychological and a purely physical approach resulted in equal success in returning patients to work.20 Sachs and co-workers report that their primarily physical "work tolerance" rehabilitation program is as effective as a multifaceted "functional restoration" approach to chronic disability.8 Elsewhere a low-intensity, less expensive, functional restoration approach is being used for persons with acute or subacute pain.
529
Program formats may change in an effort to improve results. For example, the functional restoration program Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE) recently published improved results with the addition of preprogram training and education.21 Other program elements need further study. How important is job simulation versus a generalized reconditioning approach? Does alcohol and drug treatment affect outcome? Do any of these approaches prevent reinjury? Back school, work hardening, and functional restoration have been well defined by the researchers who worked out and validated these concepts. In practice, these programs have been confused and intermingled for a number of reasons both good and questionable. Although the Committee on the Accreditation of Rehabilitation Facilities and the American Occupational Therapy Association have provided helpful guidelines for some types of worker rehabilitation programs, 22 the quality of a local program cannot reliably be judged by its adherence to rules. Proven results are the best indicator of future success.
Selecting the Right Program A referring physician's responsibility is to refer patients to the right program at the right time. A program's obligation is to delineate its approach and appropriately screen patients for admission. While back pain progresses along a continuum from acute to chronic, rehabilitation is often separated into discrete steps. It is useful to base the decision to advance to the next step on the cost-effectiveness of the treatment. Because the cost of an episode of acute back pain is mini-
mal, an inexpensive back school is reasonable. Patients whose acute back pain is likely to become chronic must be identified5 and referred to a more aggressive approach that may be cost-effective. The care of patients with subacute back pain has been somewhat more costly. Chronic pain is likely to develop in these patients without intervention. A work-hardening approach may be effective. Even more cost-effective may be a return to work on a gradual basis if a patient is physically and emotionally able to meet job demands. Work hardening may be ineffective in persons who are headed towards surgical treatment. Patients with many psychosocial issues usually need more than a simple physical conditioning approach. Patients with chronic back pain make up only 5 % of back pain sufferers, yet they account for 85 % of cost.1 If no medical or surgical cure is found, a functional restoration program may be indicated. Back school alone has been proved ineffective in this group.23 A work-hardening program that accepts patients who have chronic pain must demonstrate its effectiveness in this group separate from its subacute pain patients. The wishes of patients who decline to participate in an appropriate program should be respected. Unless the circumstances can be altered, active medical intervention should be ended and referral to a vocational counselor considered.
Measures of Outcome: All That Really Matters A sophisticated approach must be used when evaluating the effectiveness of individual worker rehabilitation programs. For example, a 70% return-to-work rate for patients with chronic low back pain
may
be excellent, but the same
percentage for acutely injured patients is worse than the natural history of the disease. In the model "report to con-
WORKER REHABILITATION PROGRAMS
530
WORKER REHABILITATION PROGRAMS
530
sumers" (Figure 1), we provide guidelines that even the simplest program should be able to meet. More comprehensive approaches to proof of effectiveness are provided by others.24 Basic information on the program should include cost, number of days the program is designed to last, number of hours per day, and qualifications of the program staff. Persons with problems other than back pain should be excluded from all calculations. If one organization has two different programs (a back school and a work-hardening program, for instance), results should be described separately. Program variables must be separated according to the length of the time patients are disabled on admission. The Quebec review suggests a protocol in which patients are divided into those whose pain has been present 0 to 6 weeks, 7 to 12 weeks, or more than 12 weeks.8 Patient demographics should include the number of men and women, age (mean and standard deviation), and percentage with previous back operations. The number of worker's compensation cases, personal injury cases, and private insurance cases should be listed. Preinjury jobs should be subdivided as recommended by Mayer and associates into sedentary to light, light to medium, medium to heavy, and very heavy.2
The program dropout rate must be uniformly defined and presented to eliminate biases. Of the number of applicants screened, the program should reveal the number of applicants turned down and the number accepted who dropped out of the program. These numbers represent the program's willingness to accept patients with risk factors for chronicity (injury type, job, demographics, physical findings, and psyProgram Name to 6-Month reporting period Program cost (average for program completers) Program length (days) Program intensity (hours/day) OT Staff: MD PT Social Worker Psychologist Exercise Physiologist Vocational Counselor Nurse Others Patients Number screened .......... Number declined .......... Number admitted .......... Number dropped........... Of those admitted % Men .................. Age, yr (standard deviation).. Number postsurgery........ Job types % Sedentary-light........... % Light-medium............ % Medium-heavy........... % Very heavy ............. Results % Working at discharge*.... % Working at 6 monthst....
Subacute 7-12wk
0-6 wk
Chronic 12wk
_
(.
-.)
(-)
(_)
*Includes persons at work within 1 week of discharge. tlncludes persons at work or eligible to work but unemployed at 6 months after
discharge.
Figure 1.-A model of a report to consumers is shown for those participating in worker rehabilitation programs. This report would be used to inform thirdparty payers and employers of the progress of a program.
chological factors)22 as well as referral patterns. Reasons for dropout should be presented. Outcome measures should include the percentage who returned to work within a week of program completion and the percentage at work or eligible for work six months after program completion. Worker rehabilitation programs are highly motivated to demonstrate their effectiveness to referral sources. Their methods for doing so are often too variable to make meaningful comparisons between programs. The report to consumers included here provides a standardized comparison. It is recommended that referral sources request proof of program quality in this format. Internal Quality Issues We have found no study that validates the effect of a quality assurance program. Indeed, only programs that are hospital based, and thus subject to the rules of the Joint Commission on Accreditation of Healthcare Organizations, are under any pressure to do internal quality assurance studies. Until research better defines the factors that relate to quality outcome, regulating forces such as referring physicians, insurers, and accreditation organizations should accept a wide variety of program concepts but insist on an accurate reporting of outcome. It is intuitive, however, that successful worker rehabilitation programs get that way because of sound concepts, solid clinical skills, and talented administration. We will present without justification issues that are of concern to the managers of some successful programs. Addressing the methods of quality assurance is beyond the scope of this discussion. Established admission and discharge criteria must be followed. Patients with poor motivation, who are medical risks (cardiac, neurologic, orthopedic, and psychiatric), and those who might benefit more from an alternative therapy should be identified. The program should last for a predefined length and not be prolonged because of issues such as patient pain behavior. The staff must be experienced enough to separate their role in improving function from the usual role of curing disease. Staff burnout should be anticipated and addressed. The medical director should be effective in educating referrers, screening admissions, supporting anxious patients, dealing with acute events, providing medicolegal documentation, and coordinating the varied talents within the team. If there is no medical director, the administrator must perform some tasks and ensure that referring physicians are capable and willing to assume the others. Communication with referral sources, insurers, attorneys, and employers must be prompt, accurate, and complete. The effectiveness of patient and family education should be demonstrated. Program components must be effective. The rate of improvement from an exercise program should approximate that of normal persons. Patient effort in areas of strength, endurance, and flexibility should be objectively quantified and addressed constructively.2 Psychological approaches should result in tested objective improvement. " Ethical and Legal Issues Worker rehabilitation programs are in a unique and precarious position in the medicolegal system. A number of external factors may significantly affect program outcomes. Who is the customer? The injured worker is the object of
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the treatment, but bills are paid by the employer or the employer's worker's compensation carrier. Rehabilitation specialists who coordinate treatment are hired by the payers. They may operate on structured spending limits that discourage expensive but cost-effective treatments such as functional restoration. The referring physician's and patient's decision to choose a program may be substantially affected by these factors. What are the goals? Return to work is not necessarily the only obligation in the worker's compensation system. Although compensation laws differ from state to state, medical treatment that improves function in areas outside of work such as household chores and avocational interests may be compensable. What about the Americans With Disabilities Act?25 Many workers legitimately fear that when they complete a rehabilitation program their previous employer will not rehire them and, despite their capabilities, other employers will avoid hiring them because of the back injury. Employers are aware that the presence of a previous injury is a risk factor for new injury. Recent federal legislation, the Americans With Disabilities Act, makes it illegal to discriminate against a person with a disability.26 Although case law will determine the effect of the law, it is likely that an injured worker who is capable of returning to work with reasonable job modifications must be rehired by the employer and must not be discriminated against by future employers. It is hoped that this will not only shift responsibility for disabled persons to the private sector but also reduce the overall cost to society by increasing employment of this group. When does it all end? Case closure and assignment of a low permanent impairment rating are monetarily beneficial to the insurer but may be financially or emotionally unacceptable to the patient. Functional capacity evaluations, defined as "a measure of function quantitatively by direct or indirect means of a dynamic aspect of bodily activity necessary in daily living,"2 appear at face value to be useful in case closure. There is no evidence, however, that such tests have predictive value. Programs may be pressured into using data from functional capacity evaluations for case closure.
Conclusion Referring physicians have a central role in ensuring the quality of a worker rehabilitation program. By properly matching patients with the correct type of program, physicians encourage effective and cost-effective rehabilitation. By demanding sophisticated and meaningful outcome data, physicians ensure that programs are successfully executing the proposed rehabilitation. By understanding some of the internal quality issues, physicians can provide meaningful feedback to the local worker rehabilitation program about areas for improvement. Finally, if they understand the forces, both medical and social, involved in rehabilitating injured workers, referring physicians can act fairly toward all parties. We advocate a standardized reporting format. The model presented here is designed to be simple for all programs to
execute and for referral sources to digest. Some may argue that the format is too simplistic. We would not imply that such a report is bias-proof. A good program that compares poorly with its competitors may wish to provide additional evidence to explain the discrepancy. This evidence should be separated from the basic report format. It is essential that referring physicians recognize when their abilities to diagnose, treat, and cure do not match patients' needs to be rehabilitated. Early referral reduces suffering, disability, and the multibillion-dollar annual national loss due to occupational low back pain. REFERENCES 1. Frymoyer JW: Back pain and sciatica. N Engl J Med 1988; 318:291-300 2. Mayer TG, Gatchel RJ: Functional Restoration for Spinal Disorders: The Sports Medicine Approach. Philadelphia, Pa, Lea & Febiger, 1988 3. Mayer TG, Gatchel RJ, Mayer H, Kishino ND, Keeley J, Mooney V: A prospective two-year study of functional restoration in industrial low back injury-An objective assessment procedure. JAMA 1987; 258:1763-1767 4. Hazzard RG, Fenwick JW, Kalisch SM, et al: Functional restoration with behavioral support: A one-year prospective study of patients with chronic low-back pain. Spine 1989; 14:157-161 5. Frymoyer JW, Cats-Baril W: Predictors of low back pain disability: Clin Orthop 1987; 22 1:89-98 6. Haig AJ, Linton P, McIntosh M, Moneta L, Mead PB: Aggressive early management by a specialist in physical medicine and rehabilitation: Effect on lost time due to injuries in hospital employees. J Occup Med 1990; 32:241-244 7. Gilbert JR, Taylor DW, Hildebrand A, Evans C: Clinical trial of common treatments for low back pain in family practice. Br Med J (Clin Res) 1985; 291:791-794 8. Sachs BL, David JF, Olimpio D, Scala AD, Lacroix M: Spinal rehabilitation by work tolerance based on objective physical capacity assessment of dysfunction-A prospective study with control subjects and twelve-month review. Spine 1990; 15:1325-1332 9. Spitzer WO, LeBlanc FE, Dupuis M, et al: Scientific approach to the assessment and management of activity related spinal disorders-A monograph for clinicians: Report of the Quebec Task Force on Spinal Disorders. Spine 1987; 12(Suppl):s4-s55 10. Forssell MZ: The back school. Spine 1981; 6:104-106 11. Bergquist-Ullman M, Larsson U: Acute low back pain in industry-A controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand (Suppl) 1977; 170:1-117 12. Standards Manual for Organizations Serving People with Disabilities. Tucson, Ariz, Committee on Accreditation of Rehabilitation Facilities, 1989 13. Matheson LN, Ogden LD, Violette K, Schultz K: Work hardening: Occupational therapy in industrial rehabilitation. Am J Occup Ther 1985; 39:314-321 14. Creighton C: Three frames of reference in work-related occupational therapy programs. Am J Occup Ther 1985; 39:331-334 15. Linton SJ, Kamwendo K: Low back schools-A critical review. Phys Ther 1987; 67:1357-1383 16. Thomas LK, Hislop HJ, Waters RL: Physiological work performance in chronic low back disability. Phys Ther 1980; 60:407-411 17. Pederson DM, Clark JA, Johns RE, White GL, Hoffman S: Quantitative muscle strength testing: A comparison of job strength requirements and actual worker strength among military technicians. Milit Med 1989; 154:14-18 18. Chaffin DB, Park KS: A longitudinal study of low back pain associated with occupational weight lifting factors. Am Ind Hyg Assoc J 1973; 34:513-525 19. Gatchel RJ, Mayer TG, Capra P, Diamond P, Barnett J: Quantification of lumbar function-Part 6: The use of psychological measures in guiding physical functional restoration. Spine 1986; 11:36-42 20. Heinrich RL, Cohen MJ, Naliboff BD, Collins GA, Bonebakker AD: Compartherapy for chronic low back pain on physical abilities, ing physical and behavior psychological distress, and patients' perceptions. J Behav Med 1985; 8:61-78 21. Kohles S, Barnes D, Gatchel RJ, Mayer TG: Improved physical performance outcomes after functional restoration treatment in patients with chronic low-back pain-Early versus recent training results. Spine 1990; 15:1321-1324 22. Commission on Practice, American Occupational Therapy Association: Work hardening guidelines. Am J Occup Ther 1986; 40:841-843 23. Lankhorst GJ, Van der Stadt RJ, Vogelaar TW, Van der Korst JK, Prevo AJ: The effect of the Swedish Back School in chronic idiopathic low back pain-A prospective controlled study. Scand J Rehabil Med 1983; 15:141-145 24. Bloch R: Methodology in clinical back trials. Spine 1987; 12:430-432 25. Pub L No. 101-336, 104 Stat 327 26. Verville RE: The Americans With Disabilities Act: An analysis. Arch Phys Med Rehabil 1990; 71:1010-1013
