Two injured workers walk into a physician's office. One wants to return to work, the other doesn't. The one who wants to go back really isn't physically ready. The one who doesn't want to go back has adequately recovered. Does it sound like the beginning of a joke? This all-too-familiar scenario, however, is less than humorous to the worker who gets sent back to work too early or the worker who is held out from work longer than necessary. The employer loses either way, which means the cost of goods increases for everyone—just because poor return-to-work decisions are made.

ADVANTAGES OF FUNCTIONAL TESTING

Do you ever stop to ask yourself why many return-to-work decisions are made so poorly? Think for a moment about how these decisions are made. The patient completes a course of acute care and goes back to his physician for a release for work. He is seated on a treatment table when the physician enters the room. The physician spends less than a minute glancing at physical therapy notes and perhaps an MRI or x-ray. The physician then asks the patient if he/she feels ready to go back. The return-to-work decision is made within 5 minutes based on clinic notes that document range-of-motion measures, pain scores, and manual muscle tests, combined with the patient's willingness to return. Research shows that these clinical measures typically used to make return-to-work decisions are not closely correlated to function. Yet, day after day, and visit after visit, these measures are the only hard data used to make return-to-work decisions. Often, the physician is not even aware of the physical demands of the work to which the patient is being released.

Now let's fast forward to a better decision-making process—a process in which return-to-work decisions are made based on functional testing. Realize that we are not suggesting a full comprehensive, 3- to 4-hour functional capacity evaluation. Instead, let's assume that a brief functional return-to-work screen is performed as part of ongoing and discharge evaluations.

To do this type of assessment, the treating therapist would need to determine the three to four most physically demanding requirements of the job. To obtain job information, the therapist needs to ask the patient about job demands on the first day of treatment. Begin with open-ended questions such as: "Tell me a bit about your job. What do you do for work?" These types of questions get the patient talking about his work. They also let the patient know that you care about what he will have to do once he returns to the workplace.

Most patients enjoy telling clinicians about their work. Listen to the tonality and nuances of the description in addition to the content of what is said. Tonality and nuances can tell you a lot about the patient's feelings about the job, the employer, the supervisor, and fellow employees. They will provide clues as to the patient's eagerness to return to work. Once the patient starts talking, ask about the three or four hardest tasks from a physical standpoint and what makes those tasks so difficult. These questions will allow you to hone in on the key physical demands that will be the hardest for the patient to perform after returning to work.

The next step is to validate the patient's information and determine if the job demands have been formally documented. Ask the patient if you can contact his supervisor or the company's human resources department to get a written job description. If the patient can provide specific names and contact information for these individuals, it will save you a lot of time. If a case manager or insurance adjuster is involved, you will want to go through those professionals to get the job description or to request permission to talk to the employer.

The problem with many formal written job descriptions is that they have little or no specific information regarding the physical demands of the job. If this is the case, you will need to interview the employer to determine the physical demands of the job.

In some cases, you may be able to convince the case manager, insurance adjuster, or employer to allow you to come to the work site to view the job. This does not have to be a lengthy job analysis but rather a brief look at some of the more difficult aspects of the job. While on-site you may be able to make some important connections with the employer's management team. Once they view you as a valuable resource for getting their employee back to work, they will be more likely to consult you for future cases and for prevention work such as job analysis, post-offer screening, ergonomics, or employee training.

A CASE STUDY EXAMPLE

Once you obtain job demands information, you can incorporate brief functional screening into treatment. Consider the following case example: A 36-year-old Caucasian male who works for a manufacturer of bathroom fixtures sustains a strain to his low back while lifting a heavy ceramic sink. He is seen by an on-site occupational medicine physician who rules out a herniated disk and is sent to physical therapy for further evaluation and treatment 1 day after injury.

The therapist further evaluates and diagnoses the patient as having illial and sacral torsions with rotation of L4 and L5 to the right. The therapist begins manual therapy and lumbar-stabilization exercises, and interviews the patient regarding the physical demands of his job. A very structured home program is initiated that includes directions for positioning for relief of pain and specific guidelines for time spent sitting, lying, standing, and doing periodic walking and home exercises. The idea behind the structure is to minimize unstructured time, especially during the day. The patient is required to use an activity and exercise log to document compliance with the home program.

Before the second treatment, the therapist obtains a formal job description, but this description includes very little information regarding the physical demands of the job. The only physical requirements included on the job description are a 50-pound lifting requirement and a requirement of frequent walking. The therapist contacts the case manager, who gives her permission to talk to the employer for more specific job demands. The interview reveals that the 50-pound lift occurs from the floor to 36 inches above the floor. In the conversation with the employer, the therapist also clarifies that transitional duty is available. She also obtains permission from the employer to conduct an on-site job analysis.

On the second treatment, the therapist continues the manual therapy, progresses the patient's exercises, and conducts a brief functional screen, testing only below-waist lifting and walking. The functional test shows that the patient could lift only 20 pounds and walk occasionally (defined by the Department of Labor as up to one third of the day). Since the patient's abilities do not meet the job demands, the employer finds a transitional light-duty job for the patient in "cleaning and finishing small fixtures." This position requires lifting no more than 20 pounds. So the patient returns to transitional duty and continues therapy three times per week.

Before the third treatment, the therapist performs a job analysis of the original job to more thoroughly understand the job demands. From the more comprehensive job-demands analysis, the therapist determines the most physically demanding aspects of the job:

Table 1. First Evaluation

Table 2. Second Reevaluation

• Floor to 36 inches lift of 50 pounds;
• Pushing of up to 100 pounds for 100 feet;
• Stooping = Frequently (one third to two thirds of the day); and
• Squatting = Occasionally.

On the third treatment, the therapist continues manual therapy, progresses the exercise program, and reevaluates the functional abilities. This time a job-match table is introduced into the patient's progress (see Table 1).

The job-match table allows the therapist, patient, physician, case manager, adjustor, and employer to easily compare patient abilities to job demands. The therapist communicates the patient's improved lifting and pushing ability with the employer, and the patient is moved up to a second transitional-duty job with slightly increased physical demands. The patient continues therapy three times per week, including manual therapy, stabilization and strengthening exercises, general conditioning, and work-simulation activities. In addition, patient education in lifting technique, low back care, and safe work practices to minimize stress on the low back during work is provided through DVDs and written material.

A week later a second reevaluation shows improvements (see Table 2).

As a result of this assessment, the patient is able to resume squatting and pushing at work. He continues therapy as previously described with gradually less emphasis on manual therapy and increased emphasis on strengthening, conditioning, and work simulation. A final reevaluation 1 week later shows more improvement (see Table 3).

Table 3. Third Reevaluation

The comparisons of patient abilities to job demands clearly showed that the patient was ready to return to full duty work. The early focus on return to work and collaboration with the employer to create a transitional job allowed the patient to return to work several weeks earlier than would have been otherwise possible, minimizing the chances that this case would turn into one of permanent disability and/or litigation. Early incorporation of work simulation as part of therapy allowed the patient to progress in performing job demands in the more safe clinical environment before having to perform those demands at work. The therapist also combined manual therapy with active participation in therapeutic exercise and an aggressive home program that minimized downtime and yet allowed adequate time for recovery. Approaching the patient with an assumption of return to work from the first treatment goes a long way toward managing and preventing motivational issues that might otherwise dominate the course of care.

This case illustrates an ideal example of employer, therapist, and patient collaboration to promote successful treatment and return to work. In the world of return to work, however, ideal is not always possible. The employer may not welcome on-site job analysis and may not provide transitional light-duty work. If this is the case, then interviewing the employer to obtain information about job demands is the alternative to on-site analysis. To accommodate for the lack of transitional duty, an increased emphasis on work simulation in the clinic will be needed.

In summary, managing the work-injured patient with functional screening is an effective approach for early and safe return to work. It's an approach that creates cost savings for the employer and a better outcome for employees as well. Referral sources will appreciate the functional information in addition to traditional measurements of progress such as range of motion, muscle strength, and pain scores. The functional screening approach can differentiate your clinic from others in your market as well as provide important information to guide the return-to-work decision.

Deborah Lechner is the president of ErgoScience Inc, Birmingham, Ala. For more information, contact .

Companies that offer assistance in return-to-work programs, or work injury management solutions, include:

	Read related articles on work injury management on our Web site.
PTProductsOnline.com

BTE Technologies
(800) 331-8845
www.btetech.com

DSI Work Solutions Inc
(218) 625-1051
www.dsiworksolutions.com

ErgoScience Inc
(866) 779-6447
www.ergoscience.com

KEY Functional Assessments Inc
(800) 333-3539
www.keyfunctionalassessments.com

VALPAR International Corp
(800) 633-3321
www.valparint.com

WorkWell Systems Inc
(866) 997-9675
www.workwell.com