Some jobs are known for danger: firefighting, mining, lion taming. Other jobs hold more subtle risks that, though not fatal, can have a negative impact on daily living. Employees such as data entry clerks, UPS workers, and even PTs don't stare death in the face, but they do risk repetitive motion disorders, back strains, and other physical injuries that can make life extremely uncomfortable.

Oversight agencies have developed regulations to help limit physical injury to workers, but damage still occurs. In 2006, the US Department of Labor's Bureau of Labor Statistics reported 4.1 million cases of nonfatal injuries and illnesses associated with employment (3.9 million of these were injuries). The largest portion fell into the manufacturing, health care and assistance, and retail trade sectors, but the categories of finance and insurance; professional, scientific, and technical services; and education services also reported cases that resulted in days away from work and/or job transfers or restrictions.¹

Many injured employees require physical therapy to treat their injuries and get back to work, a common prescription. But they may also need help preventing the injuries from recurring. "We would get [patients with occupational injuries] stronger and return their range of motion and then send them off to work, and they would often come back injured again because we didn't train them to go back to the physical demands of their job," says Curt DeWeese, PT, and president of Work Injury Solutions and Physical Therapy, located in Webster, NY.

Efforts to better prepare patients for their work led to the realization that better descriptions of the work were needed. "We knew what a baseball player did but not what these patients did," DeWeese says. Without this knowledge, job-specific training can be difficult to achieve.

To build understanding, DeWeese uses tools from DSI Work Solutions, Duluth, Minn, such as functional job descriptions and functional capacity assessments, to not only improve patient care but also to prevent injury from occurring at all. He works on-site at companies to develop programs intended to eliminate work-related injuries. "We can't prevent everything. There are people who will develop low back strain or tennis elbow or carpal tunnel, but I try to focus first on prevention," DeWeese says.

Subsequently, DeWeese believes that industrial rehabilitation does not accurately describe the entire role of the PT. "Rehabilitation is only one portion," DeWeese says. In addition to prevention efforts and job analysis, DeWeese also takes on case management. "If someone is hurt, how do we get them back to work?" DeWeese asks. He suggests that oftentimes a "return-to-work facilitator" is needed to coordinate and ensure that every step in the process is taken.

To Keep On Working

Curt DeWeese, PT, uses a strain gauge to determine the push force required to move a cart.

Injuries can range from repetitive motion disorders to trauma to assault and violent acts. A survey conducted by the Liberty Mutual Research Institute for Safety, Boston, found that, in 2004, the leading cause of workplace injuries was overexertion; repetitive motion injuries were number seven (see sidebar on page 16 for the top 10).² The related injuries account for a large portion of the patients treated by DeWeese.

"The most common injuries include tendinitis problems in the elbows, wrists, hands, and shoulders," DeWeese says. He has noticed an increase in shoulder problems for professionals in the health care industry, where patients are sicker and sometimes larger. "There are more pushing and pulling forces needed to move these patients," DeWeese says. Back strains are common for those in materials handling or "anything that requires overexertion," DeWeese says.

Treatment of industrial rehabilitation patients does not differ significantly from those in a typical clinic program. "In the acute phase, we focus on function—what the patient can still do—maintaining respect for comfort level. In the last half or third of the program, we focus on work-specific training," DeWeese says. Goals include comfortable movement, improved range and strength, and the ability to complete functional tasks.

DeWeese also considers productivity. If a patient is able to continue working, one goal will be to avoid restricted or lost time ("keep them productive," DeWeese says). If an employee must leave the job, a goal is to get them back to useful work as quickly as possible, even if the work is modified. "For instance, if a full-time job requires the worker to lift 40 pounds, but he can only lift 20 pounds, we either reassign him to a position where he handles only 20 pounds or find a creative way to help him manage the 40 pounds," DeWeese says.

Although DeWeese has found that many patients want to return to work as quickly as possible, time limits for the process help to push progression. "Patients who stay on modified duty assignment without expiration parameters can get comfortable with not doing those portions of the job," DeWeese says. Fear of reinjury can also contribute to complacency.

Prevention Better Than Cure

The ideal goal, of course, is to prevent any injury from occurring whatsoever. Although PTs are typically not involved until after the damage has already happened, DeWeese believes that PTs specializing in industrial rehabilitation do have the opportunity to push prevention but must often be on-site to achieve this aim. "The approach of my practice is to work with companies to keep employees healthy—or to keep ‘well workers' well," DeWeese says.

Many times, the company doesn't understand how the process will work, so DeWeese offers to complete a small project as an example. Often this takes the form of a thorough analysis of one job. DeWeese prepares a list of work stressors, such as awkward postures; excessive weight that must be carried, pushed, or pulled; high grip forces; and highly repetitive motions along with their possible solutions.

The solution is generally presented as a three-phase process: phase one is relatively simple and can be implemented very quickly for "next-to-no cost"; phase two may require 4 to 6 weeks for completion and cost up to $400; phase three recommendations can take a year or two to implement and require capital investment, such as retooling a product line or introducing more expensive materials-handling equipment. DeWeese offers the solution in three phases because it is often easier for the company to digest. "If the first recommendation is a $10,000 fix, many companies will balk, and I haven't helped them," DeWeese says.

His philosophy is proactive rather than reactive. In setting up prevention programs, DeWeese identifies where injury risks lie and how to reduce those risks. "If we identify a job with a high risk of back strain, we determine how to make it less demanding so that back strain does not occur," DeWeese says.

DeWeese also provides early intervention. "Early symptoms often register as discomfort. So if someone complains about a sore elbow or pain that doesn't go away, the problem is still fresh and may be responsive to early intervention," DeWeese says. This could include stretching, modifications to work technique, or reassignment to another position (somewhere else on the line, for example) that uses different muscle groups. "My overall philosophy is that there is a therapeutic effect as long as we are not putting the patient in harm's way," DeWeese says.

On the Job

DeWeese evaluates an employee’s grip strength using a hand dynamometer.

DeWeese finds intervention easier when he is on-site, so his car has become his office. With a cell phone and a laptop, travel between clients is easy. Two part-time therapists help with the workload. On-site collaborators can include human resources professionals, ergonomics specialists, occupational therapists, company safety personnel, and/or purchasing professionals. DeWeese aims to be the catalyst that brings these individuals together to help a company address any potential injury issues, and he finds it more effective on-site.

A PT out of the clinic may feel like the proverbial fish out of water, but the role can be rewarding. "I learn something new every day that I go into the company environment. It might be from someone performing the job, a safety specialist, or an industrial hygienist, but as physical therapists we need to be open-minded about the opportunities that exist in work-injury prevention management and treatment," DeWeese says.

The biggest advantage to on-site programs is the ability to observe workers and intervene immediately if problems exist. "I can watch them to understand the demands of their jobs and what needs to happen, and I can intervene right at the point where they may be doing something wrong to show them proper technique, whether it's body mechanics or work postures," DeWeese says.

Other benefits include the ability to provide immediate feedback, better evaluate a worker's capabilities, understand where an injured worker might fit back in, and match people to specific jobs. DeWeese can accurately determine which tasks a worker can safely perform based on evaluation and observation. "We can provide clear return-to-work capabilities to supervisors based on actual performance rather than assuming, for instance, that a shoulder patient can only handle 15 pounds because that is typical," DeWeese says.

DeWeese believes that therapists can perform a similar role with potential hirees. With fewer people entering the workforce and the current population aging, he suggests it will help companies to better match people to the physical demands of their jobs before they are hired. "In the DSI Work Solutions model, it's called a job-function test and is developed based on the demands of the job," DeWeese says.

The needed physical tasks are defined, and the applicant is tested. The requirement is similar to a background check or required medical physical and designed primarily to ensure that the employee can do what he or she is being hired to do and will not be at risk for injury.

The Right Tools for the Job

Injury does happen, however, and can also be treated on-site despite the limitations in tools. DeWeese notes it is difficult to transport a full complement of clinical tools between clients, but their absence does not negatively impact patient care. "The greatest tools I have as a therapist are my hands and my knowledge of how the human body works, and I always have those with me," DeWeese says.

When he needs something a little more, however, DeWeese utilizes smaller equipment, such as sport cords and Therabands. Cardio exercise can be achieved with a jump rope or a simple step stool on which the patient can perform a step program. Other options include pedaling devices that turn a chair into an exercise bike for legs or provide a tabletop workout for arms. "These can be a bit more cumbersome," DeWeese notes.

To evaluate patients, DeWeese uses strain gauges to measure how much force is used to pull or push something (DeWeese uses products from Chatillon Force Management Systems/AMETEK, Largo, Fla, and Shimpo Instruments, Itasca, Ill), hand dynamometers to determine grip forces (DeWeese recommends those from JAMAR Technologies, Inc, Horsham, Pa), and a tape measure. "A good tape measure is always important when doing analysis, not treatment," DeWeese specifies.

DeWeese also recommends carrying a good ergonomic product catalog—or having it bookmarked online. "Oftentimes, the catalogs offer simple ways to modify handles or tools to make them fit into someone's hands better or provide specific products, such as knee pads for employees on their knees for long periods of time," DeWeese says.

"We employ an experiential training method," DeWeese describes. A faculty member will spend 3 or 4 days with the therapist(s), both in clinic and at a client site, where they will complete a job assessment. One day is spent on the job-function description, which is "unique in the way it simply categorizes the required tasks of each worker," according to DeWeese. The next day is devoted to job-function testing: how to build a test that mimics the demands of the job and the tools and templates associated with that process. Another day is spent on functional capacity assessment. "We take a volunteer through an actual test so all the therapists learn how the tests are done, how to achieve consistency and reproducibility, and how to accurately document what they see," DeWeese says.

The tools provide a basis for therapy as well as prevention and early intervention. DeWeese uses them successfully to regularly treat patients. He recalls one female client employed by Ultralife Batteries, Newark, NY, a manufacturer of batteries for military and commercial contracts. After 2 years on the job, she began to complain of chronic headaches, and neck and back pain, from which she suffered for 6 months. As part of her therapy, DeWeese worked with her to reposition her body and maintain healthy sitting postures; he provided stretches as well. The result was elimination of the pain and greater energy to work a full day and enjoy her family at night.

"A person can change basic things to feel a lot more comfortable," DeWeese says, noting this can happen before or after an injury occurs. Before, however, is better. "We want to look at a situation and prevent it from developing into a life-altering event," DeWeese says. He follows his patients back to work when possible to not only help them avoid reinjury but to open marketing opportunities with potential corporate clients. Their goal together is to keep well workers well.

Renee DiIulio is a contributing writer for Physical Therapy Products. For more information, please contact .

References

1. United States Department of Labor. Bureau of Labor Statistics. Workplace injuries and illnesses in 2006. Available at www.bls.gov/news.release/osh.nr0.htm. Accessed December 18, 2007.
2. The Liberty Mutual Research Institute for Safety. 2006 Liberty Mutual Workplace Safety Index. Available at: http://www.google.com/search?q=cache:tF1Zia6GV2kJ:www.libertymutual.com/omapps/ContentServer%3Fcid%3D1138344114861%26pagename%3DResearchCenter%252FDocument%252FShowDoc%26c%3DDocument+liberty+mutual+work+injury&hl=en&ct=clnk&cd=2&gl=us. Accessed November 26, 2007.