CHAPTER

Work-Oriented Programs
KAREN SCHULTZ-JOHNSON, MS, OTR, CHT, FAOTA
141
 HISTORICAL OVERVIEW
THE EVIDENCE REGARDING WORK-ORIENTED
PROGRAMS
THE WORK-HARDENING CONCEPT
PROGRAM PHILOSOPHY
EVALUATION AND ESTABLISHING CANDIDACY
ESTABLISHING THE TREATMENT PLAN
PROGRAM LENGTH AND DURATION
CRITICAL POINTS

Clinicians should identify the patient’s work tasks early
in the therapy process.

Work-oriented activities facilitate the reinstatement of
the injured person’s identity as a worker.

The ideal work-oriented rehabilitation setting promotes
health and well-being while accomplishing the program
goals for each participant.
Clinicians should identify the patient’s work tasks early in
the therapy process and use them to establish goals and to
design the plan of care across the continuum of care.
Although less common now than in the 1980s and 1990s,
formal pro- grams such as focused work hardening continue
to have an important place in rehabilitation. Although some
clinics con- tinue to specialize in work-oriented programs,
many more clinics incorporate some work-oriented
treatment into the individual patient’s plan of care.
Transitioning patients from acute injury back to the
workplace continues to require knowledge of work-
hardening principles and practice. The strategic and
graded application of work-oriented tasks creates the
bridge between rehabilitation and return to work. This
chapter focuses on this essential component of upper limb
rehabilitation.
Work-oriented programs make up the core strategy to
help transition injured workers back to the workplace;
however, new, innovative programs offer creative
methods
SETTING UP THE PROGRAM
RETURN TO WORK PROGRAM TRENDS
ON-SITE UPPER LIMB REHABILITATION
FIREARMS TRAINING SYSTEM
IDEAL MODEL FOR POSTINJURY MANAGEMENT
SUMMARY: GOOD PRACTICE IN AN IMPERFECT
SYSTEM
to assist injured workers back to gainful employment.
Computerized feedback systems, such as the Firearms
Training System (FATS),1,2 generate a reliable level of feed-
back on the worker’s performance with which clinicians can
now confidently make objective decisions on essential job
functions.
Clinicians require a special skill set to set up and carry
out effective work-oriented programs. As a work-oriented
program administrator, a clinician must grasp the various
aspects of establishing a work program including projections,
marketing, staffing, physical plant, and equipment. When
working with individual workers, the clinician must know
how to establish candidacy, be able to design a treatment
plan, and generate the thorough documentation required by
these programs. Finally, a realistic appraisal of the place of
work-oriented programs within the worker compensation
system can help the therapist cope with or avoid inherent
pitfalls.
Historical Overview
Hand therapists and surgeons have long recognized the
importance of work-oriented activities in the rehabilitation
process as the ultimate treatment tool to restore range of
motion (ROM), strength, and coordination. Work-oriented
programs in hand therapy have two notable births: one in
India and the other in the United States. In India in the early
1950s, hand surgeon Paul Brand recognized that to receive
the optimal benefits from his surgical technique, the operated
1837
1838 PART 21 — THE INJURED WORKER
hands needed for injured workers with reimbursement. Some number of surviving
comprehensive only physical problems to work programs, such as wounded also fostered
rehabilitation, including apply to private practices, ergo- nomic interventions development of return-to-
work- oriented tasks.3 After rural settings, small and on-site return-to-work work programs for soldiers
World War II, Earl institutions, and industrial programs, became more with polytrauma15 including
Peacock, MD, and Irene settings and subsequently prevalent. The types of a combination of both
Hollis, OTR, organized a developed guidelines for injuries resulting from the orthopedic injury and head
hand rehabilitation unit work- hardening programs 2003 Iraq war brought trauma. Both guideline
incor- porating work- as a viable alternative to the about renewed research into development and the
oriented therapy at the CARF standards. It has pros- thetics that would design of stra- tegic
University of North updated these standards, permit a high level of programs will continue to
Carolina at Chapel Hill.4 most recently in function. The high evolve as do the unique
Fueled by an increasing 2 needs of injured workers.
commit- ment to the 0 However, research into
concept of comprehensive 0 program efficacy, although
rehabilitation to return 9 critically needed, has
the injured worker to . lagged.
1
gainful employment,
2
work program centers
multiplied.5 The American College of
Occupational and
The growth of work-
oriented programs required Environmental Medicine
The
the development of (ACOEM) has developed Evide
standards and guidelines. In guidelines that worker
1984, California compensation nce
administrators in the State
occupational therapists and
work evaluators developed of California cur- rently
Rega
work- hardening guidelines use as a basis for rding
and program criteria that reimbursement.13 With a
have served as the basis for finger on this important Work
the development of work- pulse, APTA is reviewing -
hardening programs in the these guidelines in
United States.6,7 In the early consideration of how these Orien
1980s,
Occupational
the American
Therapy
might affect their own
position. AOTA has
ted
Association (AOTA) collaborated with ACOEM Progr
actively focused on the role
and content of work
to help define the occu-
pational therapist’s role in
ams
hardening in rehabilitation rehabilitation, in chronic The past decade has seen a
with peer-reviewed pain management, and in dramatic decrease in
articles8 and national facilitation of return to literature pertaining to the
education.9 In work. The estab- lishment practice and efficacy of
2009, AOTA published of guidelines helps to set a work-oriented pro- grams.
new guidelines.10 In 1989, standard that benefits both A relatively small number
the Commission on the clinician in establishing of articles focus on back
Accreditation of a quality program and the injury patients rather than
Rehabilitation Facilities insurance companies and those with upper limb
(CARF) published its first physicians who might refer disorders. Although one
work-hardening standards to such programs. might conclude that back
manual covering a wide Ultimately, such injuries have a higher
range of issues.11 During guidelines assist the incidence and more
the past decade, CARF has injured worker, advancing workdays lost, a recent
not continued to focus on him or her to the next bulletin from the U.S.
work-oriented pro- grams. level of function. Department of Labor and
In 1991, the American As early as 1988, May14 Statistics16 indicates
Physical Therapy identified that significant relatively equal rates of
Association (APTA)12 numbers of insurance both injury regions as well
“established the Industrial claims adjusters did not as little discrepancy in
Rehabilitation Advisory recognize work harden- workdays lost in both
Council (IRAC) to classify ing, and many described government and private
the levels of work the low perceived efficacy industry workers. The
rehabilitation to accurately of the program. These previously described
reflect contemporary data foretold the ensuing decrease in funding for
practice, to standardize problems that work- this therapeutic approach
terminology and to address hardening programs would coupled with fewer
the needs of patients/clients, have in sustaining funding. practitioners has had the
pro- viders, regulators and By the year 2000, formal inevitable outcome of
payers.” APTA then work-hardening programs producing fewer research
developed its own in the United States had studies. Although many
guidelines for work- waned due to fewer individual clinicians have
conditioning programs referrals and inade- quate
taken work-oriented substantive evidence that
programs to more return to work was
sophisticated levels, they accelerated in similar
have not always been the studies of the upper
ones to study outcomes and extremity. The authors
report them. The literature concluded that patient
contains articles that range education about anatomy
from systematic reviews and pathophysiology
to randomized, controlled (knowledge condition-
trials. Some studies look at ing), psychological
the effectiveness of support, neuromuscular
comprehensive pro- grams, conditioning
whereas others target a
specific intervention.
Interest in work programs
extends across borders to
first-world coun- tries in
North America and Europe.
All but one of the suc-
ceeding paragraphs
summarizes studies
within the past decade.
Williams and
colleagues17 performed a
systematic review to
evaluate the available
evidence on workplace
rehabilita- tion
interventions for work-
related upper extremity
disorders (WRUEDs).
Beginning with 811
abstracts, the reviewers
ulti- mately chose 8 studies.
The small sample sizes,
lack of stan- dardized
outcome measures, and
inadequate reporting of
interventions and results of
the studies limited their
effective- ness. The
findings of this review
indicate that the current
literature does not establish
evidence of workplace
interven- tions for
WRUEDs. Their findings
emphasized the need for
further research in this
area.
Meijer and colleagues18
studied the effectiveness of
return- to-work treatment
programs among patients
with nonspecific
musculoskeletal
complaints, but primarily
with low back pain.
Eighteen high-quality
studies were included in
the review reporting on 22
treatment programs with
almost 3600 participants.
None of the studies
reviewed reported negative
findings, but the studies
with the best return-to-
work rates were noted
within the treatment groups
within the low back pain
population. There was no
CHAPTER 141 — WORK-ORIENTED PROGRAMS 1839
and work-oriented toms were measured at massage and conflicting evidence for adding breaks
conditioning were essential baseline and after 6 (T1) evidence when exercises during computer work and
components of a return-to- and 12 months (T2). Self- are compared with no for some keyboard designs
work program. They reported recovery was treatment. Their update compared with other
added that participants assessed at T1/T2. They found limited keyboards or placebo in
may also benefit from concluded that a group- participants with carpal
relaxation training based work-style tunnel syndrome.
exercises. intervention focused on Lieber and colleagues24
Stiens and colleagues20 behavioral change was measured the efficacy of
addressed the challenges in effective in improving body mechanics instruction
deter- mining rehabilitation recovery from in four patients with low
intervention outcomes in neck/shoulder symptoms back pain using a
patients with upper and reducing pain in the standardized lifting protocol
extremity overuse long term; however, the and compared their
dysfunction. They describe combined intervention was performance with 52
several factors that interfere inef- fective in increasing controls from an earlier
with outcome data total physical activity. study. The researchers
collection. First, they cite Shaw and Feuerstein22 measured static strength,
the lack of homogeneity of studied application of self- weight lifted, number of
pathophysiologic processes report measures of function lifts completed, and motion
and diagnoses coupled with and exposure assessment analysis data to describe
multiple secondary for generating workplace the body mechanics before
impairments, disabilities, accommodations including and after work hardening to
and handicaps that limit modified duty in a study evaluate treatment effects.
personal performance. of case management They concluded that
Next, they found that the services for WRUEDs. Their intensive instruction in
particular experience of expe- rience and findings body mechanics provided
disable- ment and the suggest that, to improve the during the work-hardening
expectations that each effectiveness and efficiency treatment produced major
person brings to the of accommodation efforts, changes in lifting styles, in
rehabilitation process researchers should develop terms of both starting
necessitate an new tools for assessing postures and dynamic
individualized program function and ergonomic aspects of repetitive lifting.
with unique goals. Because exposures in the workplace The computerized
of these factors, they to specify accommodations measurement procedures
believe that successful more directly. used in this study
outcome measurement of Verhagen and permitted more careful
the rehabilitation process colleagues23 performed a and detailed analyses of
must take into account the systematic review to body mechanics,
achievement of individual determine whether particularly dynamic
goals as well as objective conservative interventions aspects, than is pos- sible
scalar quantification of such as physiotherapy and with observational
impairments, dis- abilities, ergonomic adjustments methods.
and handicaps that are (such as keyboard In an older study,
comparable between adjustments and ergonomic Feurstein and colleagues25
groups. Suggesting advice) play a major role in investigated the long-term
controlled, dosed treatment the treatment of most vocational outcome of a
studies in “pure” diagnostic work-related symptoms of multicomponent reha-
patient groups, they the arm, neck, or shoulder. bilitation program that
propose inclusion of indi- They included 21 trials includes physical
vidually devised patient in total. Seventeen trials conditioning, work
assessments of included people with conditioning, work-related
accomplishment and chronic nonspecific neck or pain and stress
satisfaction in addition to shoulder symptoms or management, ergonomic
long-term quantitative nonspecific upper consultation, and
reassess- ment of the extremity disor- ders. vocational counseling/
person under all domains Evaluating more than 25 placement. Two groups
of disablement and work interventions, the equivalent in measures of
performance. reviewers identified four duration of work disability,
Bernaards and main subgroups: exercise, pain severity, fear of
colleagues21 assessed the manual therapy, massage, reinjury, psychologi- cal
effectiveness of a single and ergonomics. They distress, perceived work
intervention targeting work reported on the poor environment, age, and
style and a combined overall quality of the education level were
intervention targeting work studies. Fourteen studies exposed to either the
style and physical activity evaluated a form of comprehensive work reha-
on the recovery from neck exercise, and, contrary to bilitation intervention (n =
and upper limb symptoms. their previous review, they 19) or usual care (n = 15).
Pain, disabil- ity at work, found limited evidence of Return- to-work status was
days with symptoms, and the effectiveness of determined at an average
months without symp- exercises compared with of 1.5 years post-
treatment. Findings liaisons between the injured
indicated that 74% of the worker and the employer,
treatment group returned facili- tating clear and
to work or were involved in constructive
state-supported vocational communication that can
training in contrast to poten- tially mitigate
40% of the control group employer–employee
(P < 0.05). For those who conflict.
returned to work, 91% of
the treat- ment group were
working full time in
contrast to 50% of the
control group (P < 0.05).
Although the treatment
group demonstrated a
higher return-to-work rate
than controls, the work
reentry rate was not as
high as that with similar
approaches with work-
related low back pain
(80%–88% return-to-work
rate). The researchers
believed that the find- ings
suggested the need to
modify treatment
components to facilitate an
increased return-to-work
rate, including a greater
emphasis on ergonomic and
work-style modifications at
the workplace to reduce
the risks of
repetitiveness, force,
awkward posture, and
insufficient work/rest
cycles.
In this study,
Himmelstein and
colleagues26 evaluated the
demographic, vocational,
medical, and psychosocial
charac- teristics of patients
with WRUEDs and
examined several
hypotheses regarding the
differences between
working and work-disabled
patients. Their findings,
although cross- sectional in
nature, suggest that, in
addition to medical man-
agement, more aggressive
approaches to pain control,
prevention of unnecessary
surgery, directed efforts to
improve patients’ abilities to
manage residual pain and
distress, and attention to
employer–employee
conflicts may be important
in preventing the
development of prolonged
work disability in this
population. Therapists
treating the work-injured
pop- ulation can help these
patients with managing pain
and dis- tress. Some
therapists in work-
oriented programs act as