Return to Work – What We Do is Part of Who We Are

When you meet a person for the first time often the first question we ask after we learn their name is “what do you do?”.  As a culture, we have long equated a person’s occupation with who that person is as an individual, and we extol the values of individual determinism, hard work, and dedication as the cornerstones of success.  So, by that measure, it makes sense that injured workers who have been removed from their work environment, begin to stagnate and suffer, far more than those who return reasonable work accommodations.  This stagnation will ultimately lead to increased length of treatment, and increased total indemnity costs as the case moves toward an impairment rating and future medical care.

When a patient is removed from their customary activities, including their employment, there are physical as well as psychosocial factors that will influence their recovery.

One of the biggest physical barriers that often accompanies time off from work is the treatment recommendation of “total rest”.  The patient has been told they should “go home and rest”, and upon receiving this recommendation, the patient then returns home to total bedrest, or does very little activity over the next couple of days. This will lead to blood stagnation, increased inflammation, stiffness, and increased pain.   According to a Cochrane review of the literature published in 2010, patients with acute low back pain who were advised on active rest had moderate improvements in both pain relief and functional status, compared to those patients who were advised to rest in bed or to remain otherwise sedentary (KT Dahm, 2010).  In this way, a return to light to moderate occupational activities will improve patient adherence to active rest and improve outcomes overall.

A second physical barrier to return to work is whether sedating medications have been prescribed for the injury, such as opioid analgesics or muscle relaxers.  These medications may cause the injured worker to spend a significant amount of time either sleeping or in another sedentary position, and will impair their ability to drive or operate the machinery that may be vital to their return to work.   As healthcare providers, it is important to thoroughly evaluate the overall risk of prescription medications in relation to both return to work, and quality of life for the injured worker and reserve these medications to situations of the greatest medical necessity.  It is also vital to take continuous inventory of the medication effects and to discontinue potentially sedating medications as soon as it is medically reasonable to do so.

Psychologic impairment can also be a direct effect of absence from meaningful work.  The effect of meaning of work on patient identity has been studied predominantly in cancer patients and patients with traumatic brain injury, but is applicable to any patient with an injury that could potentially result in time away from work.   What these studies have found is that ability to work is strongly correlated with overall measures of quality of life, and that many patients reported positive outlook associated with return to work as it added meaningfulness, structure, and a sense of identity back to their life.   Loss of meaningful employment and the associated loss of identity can lead to depression and the associated morbidity and mortality, including increased subjective pain, loss of pleasure associated with work and other activities, and lower expectations about the ability to return to work in the future.

Another psychological impact of injury can be the development of fear avoidance beliefs.  Patients with fear avoidance beliefs may intentionally limit their physical activity because of their fear of increased pain.   The development of these beliefs may explain why some patients go on to develop chronic pain, while others will have a nearly full recovery. Several psychosocial factors may influence whether a patient adopts an avoidance strategy because of acute pain.  It is important for the healthcare provider to be aware of the patient’s attitude toward fear of pain and to encourage the patient in ways to remain active despite some discomfort to promote healing and strengthening.  It is also important to note that these patients may require that the physician take a more active role in encouraging return to work despite the fear of pain and to counsel the patient that the symptoms of pain and discomfort do not necessarily mean that their injury is worsening, and they may also require more frequent follow-up for this purpose.

There are several ways that health care providers can improve patient return to work and improve the overall care delivered to injured workers as well as their outcomes.

Three important determinations the healthcare provider needs to make prior to releasing the patient to modified or full work duty is what is the risk of further or new injury, what is the patient’s maximum capacity to for work duties, and what is the patient’s tolerance to continue the duties.   Risk is the most straight forward of these determinants and involves thing the patient may be able to do but should not due to the potential for serious injury, for instance a patient with seizures would no longer be able to drive a commercial vehicle.  These are referred to as work restrictions and should not be done under any circumstance.    Capacity evaluates the patient’s physical capability of performing a task, while tolerance evaluates the patient’s perception of their ability to perform the task.    In most cases healthcare providers will weigh the patient’s self-report of pain, fatigue or other limitations more highly when prescribing modified work than the patient’s actual physical strength, flexibility and balance needed to perform at work.   Many physicians prescribe a functional capacity evaluation (FCE) to delineate any differences between perceived tolerance and actual physical capacity, but this method still has limitations as the patient is the one being asked to perform the tasks of the FCE and will still discontinue the activities when they feel they have reached a maximum level of exertion for either physical or psychological reasons.   A better method is work with the patient as an advocate for return to work as part of the recovery plan, to emphasize the importance of work in relation to quality of life, and to partner with the patient to achieve specific goals over time.   Empathic communication techniques are critical to establishing this type of cooperativity with injured workers, because until you have identified the patient’s individual concerns and biases, you will not be able to allay their doubts and fears.

For patients who are not meeting return to work benchmarks for their injury and comorbidities, or who have plateaued in making improvement, often a formal biopsychosocial evaluation is conducted.   It is recommended that these types of evaluations be completed early on in treatment for patients who seem to be exhibiting fear avoidance behavior or otherwise trying to obtain secondary gain.  For those patients who have progressed further into treatment, these tests should be administered as soon as possible, usually around the sixth week of treatment for someone who is not progressing appropriately.  Identification of biopsychosocial risk factors can assist the treatment team in devising a plan with the patient that may also include psychological interventions such as cognitive behavioral therapy to mitigate fear avoidance behavior, those with heightened focus on pain, those with somatization disorder, and patients who are catastrophizing or clinically depressed.  Early intervention is key to improving outcomes in patients with psychosocial comorbidities and can improve return to work and reduce overall indemnity.

A final barrier to return to work may be employers lack of accommodations.   When this barrier is encountered, it is important to work closely with employers to identify any potential reasonable work accommodations that can be offered to the injured worker.  Often the employer may not be aware of the things the injured worker CAN do and may focus instead on what they CANNOT do.   In the same way, the employer may fear further injury or exacerbation and deem that the injured worker cannot return until 100% improvement in reached.  It is important to discuss with employers the benefits of early return to work on the patient’s potential for full functional recovery.  At times, it may even be helpful to engage a licensed physical therapist to help the employer identify simple modifications and accommodations that can be made to the work environment to facilitate return to work.

It is our responsibility as healthcare providers to assist patients in returning to work as efficiently as possible by critically evaluating the actual risk for injury exacerbation and further injury, rather than relying completely on patient subjective report of tolerance for activity.   We can encourage our patients to participate in their own recovery and return to work by emphasizing its importance as part of the overall treatment plan.   Finally, when setting expectations, working with patients and employers, and physical treatment modalities are unable to return the patient to work, it is our duty to carefully assess the psycho-social factors.

Bibliography

• KT Dahm, K. B. (2010). Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database System Review.