Reactivation of Injured Workers Involved in a W ork-Hardening Progralll FRANK M. AMBROSIUS, BARBARA K. ROUNDS, PETER B. HERKNER, MARK A. DEKRAKER, AND STEVEN R. BARTZ Professional Physical Therapy Services Incorporated, Grand Rapids, Michigan
This study examined 94 injured workers (IWs) treated in a work-hardening program over an 18-month time span. Of the 94 subjects, 78 (82.98 %) were contacted by telephone 1 year after discharge from therapy. Data examined include demographic, therapeutic, and return-to-employment information. Discriminant analyses showed that 74 of the 94 IWs were not working while involved in work hardening. Of these, 70 IWs (94.59 %) were released to gainful employment on discharge. At the time of the follow-up call, 53 of the IWs (67.95%) were still working. Of the 25 IWs not working, 18 (69.23%) were involved in litigation. The average subjective pain level for the nonworking group, on a 0-10 scale, was found to be twice that of the working group, 5.35 vs. 2.48 (p < .01). It was also discovered that 100 % of the IWs not working at follow up who were previously deemed noncompliant with work hardening were involved in a disputed claim. This study also found that noncompliant individuals were discharged from therapy much earlier than compliant subjects, after 5.5 versus 14.4 visits, and at a much lower cost, $798.39 versus $2,137.01. These results suggest that although "state-of-the-art" programming was administered, behavioral and psychosocialfactors (compliance and litigation) confounded the reactivation outcome process. Implications for future research directions are discussed. Keywords: Return to work; Follow up; Behavioral/Psychosocial factors
Industrial injuries are a major concern for our society. Nationally, low back injuries are the most frequently occurring work-related injury (Anderson, 1987; Caruso, Chan, and Chan, 1987). Back injuries account for 32 % of compensable injuries and 42 % of compensation costs (National Safety Council, 1985; Peters, 1990). In 1981, the cost of disability income payments and health care services for the occupationally disabled totaled $184 billion. Of the total, $114 billion covered health care benefits, with approximately $70 billion fi-
nancing wage replacement for time loss injuries (Lepping, 1990; Schwartz, 1984). The expedient rehabilitation and reactivation of injured workers (IWs) can greatly reduce these costs. One method for managing the IW uses functional and work-related activity as a treatment toward improving productivity and facilitating a return-to-work status. Work hardening, a highly structured and goal-oriented program, provides a vital link between an IW's functional capacity and the specific demands of ajob (Benner, SchilWORK 1994; 4(1):28-34 Copyright © 1994 by Butterworth-Heinemann
Reactivation of Workers after Work Hardening
ling, and Klein, 1987; Key, 1993; Wyrick et al., 1991). Programs should be individualized, work oriented, and all tasks should be structured and graded progressively. The goal of the program should be to improve the participant's occupational performance skills to allow effective functioning in homebound, sheltered, modified, or competitive work. Consideration should be given to actual capabilities, as well as practicing preventive care measures (Commission On Accreditation Of Rehabilitation Facilities, 1988; Holmes, 1985; Matheson et al., 1985; Tramposh, 1988). Successful return to work is dependent on appropriate and early medical intervention, a goaloriented interdisciplinary team, and cooperation from all involved parties (i.e., rehabilitation nurse, insurance company, employer, etc.). Active participation of employee, employer, and health care providers is also important for an expedient and cost-effective outcome (Peters, 1990; Tramposh, 1988). Few studies have attempted to measure the success of occupational therapy work programs (Creighton, 1985). The primary objective of this study was to examine IWs referred to a workhardening program and evaluate outcome criteria as measured by return to employment, health status, and/or case resolution.
METHODS This study included 96 former work-hardening patients treated at Professional Physical Therapy Services, Inc. (PPTS), in Grand Rapids, Michigan. These IWs were involved in the work-hardening program between June 1, 1990, and December 31, 1991, and met the criteria of having been discharged from the work-hardening program for >1 year. Exclusionary criteria for this study included former work-hardening patients who could not be reached for the survey (N = 16). However, their demographic, therapeutic, and release-to-employment data were examined. A total of 78 subjects (82.98 % of the total number of subjects) successfully completed the telephone survey. The average
29
number of weeks between discharge from work hardening and the follow-up survey was 63 weeks.
Procedures The initial assessment included an intake interview, physical examination, and a functional capacity assessment. This was administered by a registered occupational therapist (OTR) and consisted of pertinent functional, and work-related, and standardized tests.
Treatment At PPTS, the work-hardening program's primary goal is to facilitate case resolution by returning patients to their former employer in their usual and customary or alternate job. This has been best accomplished through structured and goal-oriented activities (Table 1). Close supervision, by either a certified occupational therapy assistant or OTR has proven necessary to monitor daily progress and for safety purposes. Activities and work hours were increased throughout the duration of the program until a release to employment or discharge from the program was recommended. A typical day in work hardening for the 94 IWs in this study, included stretching, aerobic conditioning, resistance training, job simulation, and functional activity training (Table 1). Various educational programs were rendered to provide additional instruction (i.e., symptom control, pain management, body mechanics positioning, and lumbar stabilization).
Discharge Discharge from the work-hardening program was determined through the combined input of the referring physician, OTR, client, employer, insurance carrier, and/or rehabilitation specialist. Criteria for discharge from the PPTS workhardening program included goals being achieved, the IW being deemed noncompliant, travel distance being too great, and/or medical contraindications. Home exercise programs were always provided andjob coaching was frequently granted to facilitate a smooth transition into the workplace.
30
WORK / JANUARY 1994
Table 1.
8:00 8:15 8:30 8:45 9:00 9:15 9:30 10:00 10:15 10:30 10:45 11:00 11: 15 11:30 11:45 12:00 12:30 12:45 1:00 1:30 1:30 1:45 2:00 2:15 2:30 2:45 3:00
Sample Schedule of Patients in Work Hardening Diane (Data Entry; 3rd Week)
Walter (Courier; 2nd Day)
Prework stretches Prework stretches Aerobic conditioning Aerobic conditioning Stickering Computer data entry Computer data entry Collating Filing Computer Data Entry Break Functional activities Biodex rehabilitation Biodex rehabilitation Bolt box stand telephone Lunch Aerobic conditioning Aerobic conditioning Resistive exercises (Body master equipment) Manual stretching exercises Computer data entry Computer data entry Stickering Filing Cool down exercises Day complete; modalities if needed
Prework stretches Prework stretches Aerobic conditioning Aerobic conditioning Resistive exercises (Body master equipment) (Body master equipment) Functional activities Job simulation Job simulation Break Job simulation Job simulation Job simulation Modality-ice pack Day complete
RESULTS Of the 94 IWs identified for this study, only 78 (82.98 % ) could be tracked for the telephone survey. The average length offollow up was 63 weeks. All IWs provided complete survey information, Demographic data can be found in Table 2. Seventy-four IW s were not working during their time in therapy. Seventy (94.59 % ) were released to gainful employment at the time of discharge. Thirteen IWs returned to new jobs, either with the same company or with a new employer. All 4 of the IWs not reactivated required additional medical intervention. Reactivation data can be found in Table 3. Of the 78 IWs contacted for the follow-up survey, it was found that 53 (67.95 %) were still working. Forty-six (58.97%) ofthe IWs were still employed in the same capacity as when they were
injured. Thirty-one IWs (40.8%) required further medical intervention since discharge from work hardening. The average subjective pain rating (0-1 0 scale) was significantly different between the IWs currently working (2.48) and the IW s not working (5.35), p < .010. This was interesting because the working group incurred three times the number of surgeries (43) than the nonworking group (14). A small percentage (32.9%) admitted to regular medication use, including aspirin, for pain control. Of the 26 IWs not working, 18 (69.23%) were involved in a disputed claim (see Table 4). Thirteen IW s were deemed noncompliant and were discharged from the work-hardening program. Of the 6 noncompliant IWs not working at the time of the follow-up survey, 100% were involved in litigation. Table 5 provides comparative data. Out of the 78 IWs followed for this study, 15 had
31
Reactivation of Workers after Work Hardening
Table 2.
Work-Hardening Demographic Information (n
94)
Women
Men Patients (n) Age (yr) Education (yr) Job Type, DOT Heavy (n) Medium (n) Light (n) Sendentary (n) Injury to RX (wk) Surgeries (n) Work hardening (sessions) Full days Half days Cost ($) Compliant (n) Disputed claim Noncompliant (n) Disputed claim
Table 3.
Group
60 37.56 ± 10.6 11.29 ± 2.0
34 43.65 ± 9.0 12.50 ± 1.7
94 39.74 ± 10.4 11.51 ± 2.1
35 (37.2%) 21 (22.9%) 4(4.2%)
6 (6.4%) 21 (22.8%) 7 (7.5%)
41 (43.67%) 42 (45.75%) 11 (11.70%)
34.09 ± 78.5 40 (42.5%) 13.33 ± 7.3 3.7 ± 3.6 9.6 ± 3.3 2009.9 ± 1144 55(58.5%) 13 (23.6%) 5(5.3%) 4(30.8%)
18.07 ± 19.2 17(18.1%) 9.86 ± 5.4 0.83 ± 1.3 9.0 ± 3.2 1430.1 ± 747 26(27.6%) 8 (30.7%) 8(8.5%) 7 (53.8%)
28.42 ± 64.3 57 (60.64%) 12.09 ± 6.8 2.87 ± 3.3 9.2 ± 2.3 1773.5 ± 1061 81 (86.17%) 21 (29.92 %) 13 (16.05%) 11 (84.46%)
o
Reactivation Information (n
94)
Men
Job status during therapy Not working Working accommodate Working regular Job status after therapy Continued working Returned accommodated Returned regular Returned new job Staying off because of medical condition
o
o
Women
Group
n
%
n
%
n
%
50 5 5
53.2 5.3 5.3
24 5 5
25.5 5.3 5.3
74 10 10
78.7 10.64 10.64
13 10 26 7 4
13.3 10.6 27.7 7.5 4.2
7 8 13 6 0
7.4 8.5 13.3 6.4
20 18 39 13 4
21.28 19.15 41.49 13.83 4.25
Reactivation: 74 not working at time of therapy; 70 (94.59%) returned to employment.
settled their litigation but 20 subjects were still waiting for their disputed claims to be settled. The cost for work hardening at PPTS was found to average $1,773.5; the mean number of sessions averaged 12.09. The average number of full-day sessions (4.5-7 hours daily) was 2.87 and half-day sessions (2-4 hours daily) averaged 9.20. Male IW s were found to require more therapy (13.8 visits) at a greater cost ($2, 114.37) tha:n their female counterparts (10.25 visits and $1,480.57;
p
= .010). Eighty of the 94 IWs were deemed compliant (85.39%). Noncompliant IWs averaged only 5.5 sessions at a cost of $798.00. Individuals classified in heavy job types required more therapy (13.97 visits) and cost ($2,192.23) than their counterparts in lighter jobs (8.43 visits and $1,145.50; p < .05). The average length of time between injury and therapy at PPTS was found to be 28.42 weeks. A significant time difference between IW s requiring
32
WORK / JANUARY 1994
Table 4.
Follow-up Data (n
78)
Follow-up telephone call (wk) Subjective pain rating (0-10)
Working during follow-up (n) Same job (n) Requiring medical intervention (n) Requiring medication (n) Litigation (n) Resolved Unresolved No litigation Home exercise program compliance* (n)
Men
Women
Group
63.95 ± 49.3 3.3 ± 2.57
61.16 ± 54.8 3.65 ± 3.2
63 ± 50.9 3.4 ± 2.8
N 35 30 21 15
% 44.9 38.5 26.9 19.2
N 18 16 10 11
% 23.1 20.5 12.8 14.1
N 53 46 31 26
% 67.9 58.9 40.8 32.9
10 1 39 22
12.8 1.3 50.0 28.2
5 19 4 18
6.4 24.4 5.1 23.1
15 20 43 40
19.2 25.6 55.1 51.3
• Average 3.12 workout sessions per week. Table 5.
Working versus Nonworking Data at Follow Up (n
Patients (n) Age (yr) Education (yr) Injury to PPTS referral (wk) Work hardening (sessions) Cost ($) Noncompliant (n) Noncompliant and pending litigation (n) Subjective pain (0-10) Surgeries (n)
surgery (15.81 weeks) and nonsurgical IWs (37 weeks) was found (p < .05). The time difference between IWs working at follow up (20.58 weeks) versus not working (42.27 weeks) was also significant (p < .01). Sixty (64%) IWs reported that they liked the work-hardening program. Their subjective pain rating was found to be lower (3.2) than IWs indicating that they did not like the PPTS workhardening program (4.6). Though not significant, the cost for IW s that liked work hardening averaged $2,070.63 versus $1,641.47 for IWs who did not like the program. Nineteen of the 78 IWs indicated that work hardening affected their return to employment more than any other component of their recovery (i.e., surgery, medication, physical therapy, etc.).
=
78)
Working
Not Working
53(67.95%) 37.24 11.63 20.58 12.82 1970.62 7 (13.21%) 5 (71.43%) 2.48 43 (81.13%)
25 (32.05%) 40.18 11.31 42.27 12.00 1738.12 6(24%) 6 (100%) 5.35 14 (56%)
DISCUSSION This study identified a number of demographic, therapeutic, and occupational factors that affect the reactivation process ofIW s with musculoskeletal injuries who have been involved in a workhardening program (Figure 1). Of interest is the finding that, after releasing a high percentage (94.59 %) of IW s to gainful employment, only 67.9% were still working at the time offollow up (63-week average). These data are in accordance with other authors reporting similar results (Bettencourt et al., 1986; Caruso, Chan, and Chan, 1987; Edwards et al., 1992; Haig and Penha, 1991; Lepping, 1990). An explanation for this would include other factors, behavioral and psychosocial, affecting outcome data. Consideration
Reactivation of Workers after Work Hardening
Figure 1. Work Hardening: Job Simulation. Source: Professional Physical Therapy Services, In-
corporated, 1992 .
of issues such as compliance with therapy, litigation, and subjective pain levels, although not empirically justified by these results, allows for the reporting of general observances. Previous studies of work-hardening programs have noted the importance of these extraneous factors (Edwards et aI., 1992; Haig and Penha, 1991). Whereas this study reported a 16.05% noncompliance rate, other authors have indicated anywhere from 10 to 23.8% noncompliance rates as being typical (Caruso, Chan, and Chan, 1987; Hanson and Walker, 1992; Lepping, 1990; Mooney and Hughson, 1992). Another important finding concerns the issues of compensation and/ or litigation. Greenough and Fraser (1989) concluded that compensation actually delayed recovery from musculoskeletal pain. Caruso, Chan, and Chan (1987) found workers' compensation status to be proportionate to return to work. This study found that IWs not working at the time of follow up and deemed noncompliant with their therapy were involved with litigation 100 % of the time . These data concur with Talo, Hendler, and
33
Brodie (1989) who found that 85.2% ofindividuals involved with litigation could not be returned to work . Furthermore, in this data set, subjective pain levels were reported higher in IWs not working and deemed noncompliant (5.35) than in working and compliant IWs (2.48; P < .010) . Further longitudinal research is needed in this area to determine the impact of compliance and litigation on various subgroups relative to reactivation . Despite the interdisciplinary and goal-oriented program approach , the cost was found to be quite low ($1,773.5 average) compared with other workhardening programs (Mooney and Hughson, 1992). At approximately $150.00 per session, these costs compare with studies conducted several years ago (Matheson, 1990). A possible explanation might include the fact that noncompliant IWs were discharged from therapy early (5.5 sessions vs. 14.0 sessions for compliant individuals) and at a minimal average expense of $798.39 versus $2,137.01. Also, most IWs referred to work hardening at PPTS experienced physical therapy for pain reduction and functional restoration before the initiation of work hardening.
SUMMARY The primary focus of this investigative study was to examine IWs referred to treatment within a work-hardening program and evaluate their reactivation 1 year after therapy. Demographic, therapeutic, return-to-work, and follow-up data were analyzed. The results suggest that many factors influence the reactivation process. Of the 74 IWs not working during therapy, 70 were released to employment (94.59%). At the time of follow up, only 67 .9% were still working. Compliance with therapy and litigation involvement were two factors confounding the return-to-work process of the IWs in this study. A high percentage of the nonworking group (69.23 %) were also involved in litigation. All IWs not working and deemed noncompliant with therapy were involved in litigation . Although a higher percentage of surgeries were incurred by the working group (81.13 % ) versus the nonworking group (56%), reported
34
WORK / JANUARY 1994
pain levels were found to be inversely related (2.48 for working subjects and 5.35 for nonworking subjects). The average cost for the work-hardening program was deemed low ($1,773.5). One possi-
ble explanation for this was the early discharge from therapy of IWs deemed noncompliant (5.5 visits vs. 14.4 for compliant subjects). Prospective studies are needed to further explore the process of reactivation. More interim follow up is needed to assist with the tracking of
these individuals. Furthermore, outcome justification studies are needed to establish managed care standards and costs.
ACKNOWLEDGMENTS We acknowledge the assistance of the entire staff at PPTS and the support of Robert Przybysz, L.P.T., A.T.C., and Kim Edgel, L.P.T,
REFERENCES Anderson, L. (1987). Educational approaches to management of low back pain. Orthop Nurs, 8, 43-46. Benner, C. L., Schilling, A. D., and Klein, L. (1987). Coordinated teamwork in California industrial rehabilitation.] Hand Surg, 12a, 936-939. Bettencourt, C. M., Carlstrom, P., Brown, S. H., Lindau, K., and Long, C. M. (1986). Usingworksimulation to treat adults with back injuries. Am] Occup Ther, 40, 12-18. Caruso, L. A., Chan, D. E., Chan, A. (1987). The management of work-related back pain. Am] Occup Ther, 41, 112-117. Commission on Accreditation Of Rehabilitation Facilities. (1988). National advisory committee recommendations for work hardening programs. Tucson, AZ: Author. Creighton, C. (1985). Three frames of reference in work-related occupational therapy programs. Am] Occup Ther, 39, 331-334. Edwards, B. C., Zusman, M., Hardcastle, P., Twomey, L., O'Sullivan, P., and McLean, N. (1992). A physical approach to the rehabilitation of patients disabled by chronic low back pain. Med] Aust, 156, 167-172. Greenough, C., and Fraser, F. (1989). The effects of compensation on recovery from low-back injury. Spine, 14, 945-955. Haig, A.J., and Penha, S. (1991). Worker rehabilitation programs: Separating fact from fiction. Work Rehabil Med, 154, 528-531. Hanson, C. S., and Walker, K. F. (1992). The history of work physical dysfunction. Am] Occup Ther, 46, 56-62.
Holmes, D. (1985). The role of the occupational therapy-work evaluator. Am] Occup Ther, 39, 308-313. Key, G. L. (1993). Industrial therapy: Too hot to handle. Physical Therapy Magazine, pp. 75-76. Lepping, V. (1990). Work hardening: A valuable resource for the occupational nurse. AAOHN, 38,313317. Matheson, L. N. (1990). Work hardening in the new age: Health care enters the industrial revolution. Am Occup Ther Assoc Work Progr, 4, 2-3. Matheson, L. N., Ogden, L. D., Violette, K., and Schultz, K. (1985). Work hardening: Occupational therapy in industrial rehabilitation. Am] Occup Ther, 39, 314-321. Mooney, V., and Hughson, W. G. (1992). Resurgence of work-hardening programs. West] Med, 156. National Safety Council. (1985). Accidentfacts. Chicago, IL: Author. Peters, P. (1990). Successful return to work following a musculoskeletal injury. AAOHN, 38, 264-270. Schwartz, G. (1984). Disability costs: The impending crisis. Bus Health, 25, 106-119. Talo, S., Hendler, N., and Brodie,J. (1989). Effects of active and completed litigation on treatment results: Workers compensation patients compared with other litigation patients.] Occup Med, 31, 265-269. Tramposh, A. K. (1988). Work-related therapy for the injured reduces return-to-work barriers. Occup Health Saj, 7, 55-57. Wyrick,J. M., Niemeyer, L. 0., Ellexson, M.,Jacobs, K., and Taylor, S. (1991). Occupational therapy work-hardening programs: A demographic study. Am] Occup Ther, 45, 109-112.
This study examined 94 injured workers (IWs) treated in a work-hardening program over an 18-month time span. Of the 94 subjects, 78 (82.98 %) were contacted by telephone 1 year after discharge from therapy. Data examined include demographic, therapeutic, and return-to-employment information. Discriminant analyses showed that 74 of the 94 IWs were not working while involved in work hardening. Of these, 70 IWs (94.59 %) were released to gainful employment on discharge. At the time of the follow-up call, 53 of the IWs (67.95%) were still working. Of the 25 IWs not working, 18 (69.23%) were involved in litigation. The average subjective pain level for the nonworking group, on a 0-10 scale, was found to be twice that of the working group, 5.35 vs. 2.48 (p < .01). It was also discovered that 100 % of the IWs not working at follow up who were previously deemed noncompliant with work hardening were involved in a disputed claim. This study also found that noncompliant individuals were discharged from therapy much earlier than compliant subjects, after 5.5 versus 14.4 visits, and at a much lower cost, $798.39 versus $2,137.01. These results suggest that although "state-of-the-art" programming was administered, behavioral and psychosocialfactors (compliance and litigation) confounded the reactivation outcome process. Implications for future research directions are discussed. Keywords: Return to work; Follow up; Behavioral/Psychosocial factors
Industrial injuries are a major concern for our society. Nationally, low back injuries are the most frequently occurring work-related injury (Anderson, 1987; Caruso, Chan, and Chan, 1987). Back injuries account for 32 % of compensable injuries and 42 % of compensation costs (National Safety Council, 1985; Peters, 1990). In 1981, the cost of disability income payments and health care services for the occupationally disabled totaled $184 billion. Of the total, $114 billion covered health care benefits, with approximately $70 billion fi-
nancing wage replacement for time loss injuries (Lepping, 1990; Schwartz, 1984). The expedient rehabilitation and reactivation of injured workers (IWs) can greatly reduce these costs. One method for managing the IW uses functional and work-related activity as a treatment toward improving productivity and facilitating a return-to-work status. Work hardening, a highly structured and goal-oriented program, provides a vital link between an IW's functional capacity and the specific demands of ajob (Benner, SchilWORK 1994; 4(1):28-34 Copyright © 1994 by Butterworth-Heinemann
Reactivation of Workers after Work Hardening
ling, and Klein, 1987; Key, 1993; Wyrick et al., 1991). Programs should be individualized, work oriented, and all tasks should be structured and graded progressively. The goal of the program should be to improve the participant's occupational performance skills to allow effective functioning in homebound, sheltered, modified, or competitive work. Consideration should be given to actual capabilities, as well as practicing preventive care measures (Commission On Accreditation Of Rehabilitation Facilities, 1988; Holmes, 1985; Matheson et al., 1985; Tramposh, 1988). Successful return to work is dependent on appropriate and early medical intervention, a goaloriented interdisciplinary team, and cooperation from all involved parties (i.e., rehabilitation nurse, insurance company, employer, etc.). Active participation of employee, employer, and health care providers is also important for an expedient and cost-effective outcome (Peters, 1990; Tramposh, 1988). Few studies have attempted to measure the success of occupational therapy work programs (Creighton, 1985). The primary objective of this study was to examine IWs referred to a workhardening program and evaluate outcome criteria as measured by return to employment, health status, and/or case resolution.
METHODS This study included 96 former work-hardening patients treated at Professional Physical Therapy Services, Inc. (PPTS), in Grand Rapids, Michigan. These IWs were involved in the work-hardening program between June 1, 1990, and December 31, 1991, and met the criteria of having been discharged from the work-hardening program for >1 year. Exclusionary criteria for this study included former work-hardening patients who could not be reached for the survey (N = 16). However, their demographic, therapeutic, and release-to-employment data were examined. A total of 78 subjects (82.98 % of the total number of subjects) successfully completed the telephone survey. The average
29
number of weeks between discharge from work hardening and the follow-up survey was 63 weeks.
Procedures The initial assessment included an intake interview, physical examination, and a functional capacity assessment. This was administered by a registered occupational therapist (OTR) and consisted of pertinent functional, and work-related, and standardized tests.
Treatment At PPTS, the work-hardening program's primary goal is to facilitate case resolution by returning patients to their former employer in their usual and customary or alternate job. This has been best accomplished through structured and goal-oriented activities (Table 1). Close supervision, by either a certified occupational therapy assistant or OTR has proven necessary to monitor daily progress and for safety purposes. Activities and work hours were increased throughout the duration of the program until a release to employment or discharge from the program was recommended. A typical day in work hardening for the 94 IWs in this study, included stretching, aerobic conditioning, resistance training, job simulation, and functional activity training (Table 1). Various educational programs were rendered to provide additional instruction (i.e., symptom control, pain management, body mechanics positioning, and lumbar stabilization).
Discharge Discharge from the work-hardening program was determined through the combined input of the referring physician, OTR, client, employer, insurance carrier, and/or rehabilitation specialist. Criteria for discharge from the PPTS workhardening program included goals being achieved, the IW being deemed noncompliant, travel distance being too great, and/or medical contraindications. Home exercise programs were always provided andjob coaching was frequently granted to facilitate a smooth transition into the workplace.
30
WORK / JANUARY 1994
Table 1.
8:00 8:15 8:30 8:45 9:00 9:15 9:30 10:00 10:15 10:30 10:45 11:00 11: 15 11:30 11:45 12:00 12:30 12:45 1:00 1:30 1:30 1:45 2:00 2:15 2:30 2:45 3:00
Sample Schedule of Patients in Work Hardening Diane (Data Entry; 3rd Week)
Walter (Courier; 2nd Day)
Prework stretches Prework stretches Aerobic conditioning Aerobic conditioning Stickering Computer data entry Computer data entry Collating Filing Computer Data Entry Break Functional activities Biodex rehabilitation Biodex rehabilitation Bolt box stand telephone Lunch Aerobic conditioning Aerobic conditioning Resistive exercises (Body master equipment) Manual stretching exercises Computer data entry Computer data entry Stickering Filing Cool down exercises Day complete; modalities if needed
Prework stretches Prework stretches Aerobic conditioning Aerobic conditioning Resistive exercises (Body master equipment) (Body master equipment) Functional activities Job simulation Job simulation Break Job simulation Job simulation Job simulation Modality-ice pack Day complete
RESULTS Of the 94 IWs identified for this study, only 78 (82.98 % ) could be tracked for the telephone survey. The average length offollow up was 63 weeks. All IWs provided complete survey information, Demographic data can be found in Table 2. Seventy-four IW s were not working during their time in therapy. Seventy (94.59 % ) were released to gainful employment at the time of discharge. Thirteen IWs returned to new jobs, either with the same company or with a new employer. All 4 of the IWs not reactivated required additional medical intervention. Reactivation data can be found in Table 3. Of the 78 IWs contacted for the follow-up survey, it was found that 53 (67.95 %) were still working. Forty-six (58.97%) ofthe IWs were still employed in the same capacity as when they were
injured. Thirty-one IWs (40.8%) required further medical intervention since discharge from work hardening. The average subjective pain rating (0-1 0 scale) was significantly different between the IWs currently working (2.48) and the IW s not working (5.35), p < .010. This was interesting because the working group incurred three times the number of surgeries (43) than the nonworking group (14). A small percentage (32.9%) admitted to regular medication use, including aspirin, for pain control. Of the 26 IWs not working, 18 (69.23%) were involved in a disputed claim (see Table 4). Thirteen IW s were deemed noncompliant and were discharged from the work-hardening program. Of the 6 noncompliant IWs not working at the time of the follow-up survey, 100% were involved in litigation. Table 5 provides comparative data. Out of the 78 IWs followed for this study, 15 had
31
Reactivation of Workers after Work Hardening
Table 2.
Work-Hardening Demographic Information (n
94)
Women
Men Patients (n) Age (yr) Education (yr) Job Type, DOT Heavy (n) Medium (n) Light (n) Sendentary (n) Injury to RX (wk) Surgeries (n) Work hardening (sessions) Full days Half days Cost ($) Compliant (n) Disputed claim Noncompliant (n) Disputed claim
Table 3.
Group
60 37.56 ± 10.6 11.29 ± 2.0
34 43.65 ± 9.0 12.50 ± 1.7
94 39.74 ± 10.4 11.51 ± 2.1
35 (37.2%) 21 (22.9%) 4(4.2%)
6 (6.4%) 21 (22.8%) 7 (7.5%)
41 (43.67%) 42 (45.75%) 11 (11.70%)
34.09 ± 78.5 40 (42.5%) 13.33 ± 7.3 3.7 ± 3.6 9.6 ± 3.3 2009.9 ± 1144 55(58.5%) 13 (23.6%) 5(5.3%) 4(30.8%)
18.07 ± 19.2 17(18.1%) 9.86 ± 5.4 0.83 ± 1.3 9.0 ± 3.2 1430.1 ± 747 26(27.6%) 8 (30.7%) 8(8.5%) 7 (53.8%)
28.42 ± 64.3 57 (60.64%) 12.09 ± 6.8 2.87 ± 3.3 9.2 ± 2.3 1773.5 ± 1061 81 (86.17%) 21 (29.92 %) 13 (16.05%) 11 (84.46%)
o
Reactivation Information (n
94)
Men
Job status during therapy Not working Working accommodate Working regular Job status after therapy Continued working Returned accommodated Returned regular Returned new job Staying off because of medical condition
o
o
Women
Group
n
%
n
%
n
%
50 5 5
53.2 5.3 5.3
24 5 5
25.5 5.3 5.3
74 10 10
78.7 10.64 10.64
13 10 26 7 4
13.3 10.6 27.7 7.5 4.2
7 8 13 6 0
7.4 8.5 13.3 6.4
20 18 39 13 4
21.28 19.15 41.49 13.83 4.25
Reactivation: 74 not working at time of therapy; 70 (94.59%) returned to employment.
settled their litigation but 20 subjects were still waiting for their disputed claims to be settled. The cost for work hardening at PPTS was found to average $1,773.5; the mean number of sessions averaged 12.09. The average number of full-day sessions (4.5-7 hours daily) was 2.87 and half-day sessions (2-4 hours daily) averaged 9.20. Male IW s were found to require more therapy (13.8 visits) at a greater cost ($2, 114.37) tha:n their female counterparts (10.25 visits and $1,480.57;
p
= .010). Eighty of the 94 IWs were deemed compliant (85.39%). Noncompliant IWs averaged only 5.5 sessions at a cost of $798.00. Individuals classified in heavy job types required more therapy (13.97 visits) and cost ($2,192.23) than their counterparts in lighter jobs (8.43 visits and $1,145.50; p < .05). The average length of time between injury and therapy at PPTS was found to be 28.42 weeks. A significant time difference between IW s requiring
32
WORK / JANUARY 1994
Table 4.
Follow-up Data (n
78)
Follow-up telephone call (wk) Subjective pain rating (0-10)
Working during follow-up (n) Same job (n) Requiring medical intervention (n) Requiring medication (n) Litigation (n) Resolved Unresolved No litigation Home exercise program compliance* (n)
Men
Women
Group
63.95 ± 49.3 3.3 ± 2.57
61.16 ± 54.8 3.65 ± 3.2
63 ± 50.9 3.4 ± 2.8
N 35 30 21 15
% 44.9 38.5 26.9 19.2
N 18 16 10 11
% 23.1 20.5 12.8 14.1
N 53 46 31 26
% 67.9 58.9 40.8 32.9
10 1 39 22
12.8 1.3 50.0 28.2
5 19 4 18
6.4 24.4 5.1 23.1
15 20 43 40
19.2 25.6 55.1 51.3
• Average 3.12 workout sessions per week. Table 5.
Working versus Nonworking Data at Follow Up (n
Patients (n) Age (yr) Education (yr) Injury to PPTS referral (wk) Work hardening (sessions) Cost ($) Noncompliant (n) Noncompliant and pending litigation (n) Subjective pain (0-10) Surgeries (n)
surgery (15.81 weeks) and nonsurgical IWs (37 weeks) was found (p < .05). The time difference between IWs working at follow up (20.58 weeks) versus not working (42.27 weeks) was also significant (p < .01). Sixty (64%) IWs reported that they liked the work-hardening program. Their subjective pain rating was found to be lower (3.2) than IWs indicating that they did not like the PPTS workhardening program (4.6). Though not significant, the cost for IW s that liked work hardening averaged $2,070.63 versus $1,641.47 for IWs who did not like the program. Nineteen of the 78 IWs indicated that work hardening affected their return to employment more than any other component of their recovery (i.e., surgery, medication, physical therapy, etc.).
=
78)
Working
Not Working
53(67.95%) 37.24 11.63 20.58 12.82 1970.62 7 (13.21%) 5 (71.43%) 2.48 43 (81.13%)
25 (32.05%) 40.18 11.31 42.27 12.00 1738.12 6(24%) 6 (100%) 5.35 14 (56%)
DISCUSSION This study identified a number of demographic, therapeutic, and occupational factors that affect the reactivation process ofIW s with musculoskeletal injuries who have been involved in a workhardening program (Figure 1). Of interest is the finding that, after releasing a high percentage (94.59 %) of IW s to gainful employment, only 67.9% were still working at the time offollow up (63-week average). These data are in accordance with other authors reporting similar results (Bettencourt et al., 1986; Caruso, Chan, and Chan, 1987; Edwards et al., 1992; Haig and Penha, 1991; Lepping, 1990). An explanation for this would include other factors, behavioral and psychosocial, affecting outcome data. Consideration
Reactivation of Workers after Work Hardening
Figure 1. Work Hardening: Job Simulation. Source: Professional Physical Therapy Services, In-
corporated, 1992 .
of issues such as compliance with therapy, litigation, and subjective pain levels, although not empirically justified by these results, allows for the reporting of general observances. Previous studies of work-hardening programs have noted the importance of these extraneous factors (Edwards et aI., 1992; Haig and Penha, 1991). Whereas this study reported a 16.05% noncompliance rate, other authors have indicated anywhere from 10 to 23.8% noncompliance rates as being typical (Caruso, Chan, and Chan, 1987; Hanson and Walker, 1992; Lepping, 1990; Mooney and Hughson, 1992). Another important finding concerns the issues of compensation and/ or litigation. Greenough and Fraser (1989) concluded that compensation actually delayed recovery from musculoskeletal pain. Caruso, Chan, and Chan (1987) found workers' compensation status to be proportionate to return to work. This study found that IWs not working at the time of follow up and deemed noncompliant with their therapy were involved with litigation 100 % of the time . These data concur with Talo, Hendler, and
33
Brodie (1989) who found that 85.2% ofindividuals involved with litigation could not be returned to work . Furthermore, in this data set, subjective pain levels were reported higher in IWs not working and deemed noncompliant (5.35) than in working and compliant IWs (2.48; P < .010) . Further longitudinal research is needed in this area to determine the impact of compliance and litigation on various subgroups relative to reactivation . Despite the interdisciplinary and goal-oriented program approach , the cost was found to be quite low ($1,773.5 average) compared with other workhardening programs (Mooney and Hughson, 1992). At approximately $150.00 per session, these costs compare with studies conducted several years ago (Matheson, 1990). A possible explanation might include the fact that noncompliant IWs were discharged from therapy early (5.5 sessions vs. 14.0 sessions for compliant individuals) and at a minimal average expense of $798.39 versus $2,137.01. Also, most IWs referred to work hardening at PPTS experienced physical therapy for pain reduction and functional restoration before the initiation of work hardening.
SUMMARY The primary focus of this investigative study was to examine IWs referred to treatment within a work-hardening program and evaluate their reactivation 1 year after therapy. Demographic, therapeutic, return-to-work, and follow-up data were analyzed. The results suggest that many factors influence the reactivation process. Of the 74 IWs not working during therapy, 70 were released to employment (94.59%). At the time of follow up, only 67 .9% were still working. Compliance with therapy and litigation involvement were two factors confounding the return-to-work process of the IWs in this study. A high percentage of the nonworking group (69.23 %) were also involved in litigation. All IWs not working and deemed noncompliant with therapy were involved in litigation . Although a higher percentage of surgeries were incurred by the working group (81.13 % ) versus the nonworking group (56%), reported
34
WORK / JANUARY 1994
pain levels were found to be inversely related (2.48 for working subjects and 5.35 for nonworking subjects). The average cost for the work-hardening program was deemed low ($1,773.5). One possi-
ble explanation for this was the early discharge from therapy of IWs deemed noncompliant (5.5 visits vs. 14.4 for compliant subjects). Prospective studies are needed to further explore the process of reactivation. More interim follow up is needed to assist with the tracking of
these individuals. Furthermore, outcome justification studies are needed to establish managed care standards and costs.
ACKNOWLEDGMENTS We acknowledge the assistance of the entire staff at PPTS and the support of Robert Przybysz, L.P.T., A.T.C., and Kim Edgel, L.P.T,
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