Jordan Rinker, MD, MPH
Robert Eric Dinenberg, MD, MPH
Mauro Zappaterra, MD, PhD
Glenn Pransky, MD, MOH
Disability is commonly defined as a decrease in or inability to perform some or all functions related to personal, social or workplace demands due to a physical or mental impairment. This view is distinct from impairment, defined as a reduction in normal function. Impairment should not necessarily imply that work disability is present, unless there is a functional limitation that precludes the worker from performing some or all of the tasks required in their job, after considering available work accommodations.
The AMA’s Guides to the Evaluation of Permanent Impairment states that its impairment ratings are not intended to be used to rate disability because disability reflects a combination of medical and nonmedical factors. Critics point out that the numeric quantification of impairment, the aspect of the guides that encourages its expanding use, is not evidence based. State workers’ compensation programs inappropriately use the impairment ratings as a proxy for the extent of disability.
Work disability has not been consistently defined nor measured, and thus population data on incidence, prevalence, and causes are inconsistent. In developed countries, around one in six workers has or develops a significant health-related limitation in ability to work each year, and a third has a period of work absence as a result—mostly short-term absences due to temporary conditions. A small but important group develops long-term work disability. Although these persons are just a few percent of all workers with health-related work limitations, they account for the majority of total days lost from work due to health conditions.
Nearly one in five US adults is disabled from mental and behavioral disorders, musculoskeletal problems, and neurological conditions. About half of the disabled are severely limited and unable to work. Musculoskeletal disorders are the most frequent type of disability, but in some working age groups are now exceeded by mental health disorders. The relationships between work, disability, and mental health are interrelated with each one having a potential impact on the other (see Chapter 35).
Work disability is a complex issue that can involve multiple participants and concerns beyond a particular health-related condition and its treatment. Personal, workplace, medical, and societal issues can affect the extent of a disability and how return to work may succeed or fail. Social and environmental factors usually have a greater impact on disability and its prevention than health-related dimensions. The organizational work environment with supervisors, coworkers, unions, and management roles along with insurers, family, and society are recognized as major potentially modifiable influences on disability and return to work; the immediate workplace response to a worker with a potentially disabling condition is especially important. Health care providers and their medical systems (facilities, staff, insurers, administrators, medical records) must understand these influences and be able to collaborate with and at times influence nonmedical personnel, to achieve optimal prevention and management of work disability.
One model used to elaborate the various influences on work disability is the Arena Model, which emphasizes the broad range of factors affecting work disability. The World Health Organization’s International Classification for Health, Functioning and Disability (ICF) also combines elements of a medical and social model into a biopsychosocial model of disability.
The main implication of the Arena Model and other biopsychosocial models is the importance of having a broader perspective when evaluating persons for risk factors and making decisions about medical care and work disability. Understanding that the occurrence and duration of disability are influenced by many factors (both clinical and nonclinical) will assist the health care provider to facilitate a faster recovery by considering potential nonclinical interventions and communication at the personal, workplace, health care provider, and insurer levels.
Disability management is a global issue, and resources and access to care in developed countries is usually much more extensive than in the developing world. Community-based rehabilitation (CBR) programs have been established in developing countries to respond to the needs of disabled persons. CBR adopts a multidisciplinary method, using disabled persons, their families, community members, organizations, and government agencies to attempt to deliver rehabilitative services to persons in countries with limited resources. In addition, CBR programs educate communities on practical aspects of disability and practical rehabilitation and prevention strategies.
The clinician’s role in identifying and managing work disability should include early problem recognition, effective case management, and communication as needed with all involved parties with the goal of a safe return to full or partial functioning at work as quickly as possible. The holistic approach may need to consider multiple aspects of disability including medical, psychological, and social dimensions to assist those persons who are at high risk for long-term disability to stay at, return to, and remain in work.
RETURN TO WORK
All clinicians who evaluate and treat potentially disabling injuries and medical conditions must consider the importance of work. After a significant injury or illness, returning to work may require a stepwise process, with a continuum in the management of the individual and workplace to maximize functional capacity and productivity. The following evidence-based concepts should be integrated into their management of and advocacy for these persons.
1. Work can be therapeutic, promote recovery, and is an important part of rehabilitation.
2. Long periods out of work can cause or contribute to poor physical and mental health including excess mortality.
3. Advice to stay off work is a major clinical intervention with potentially serious long-term consequences.
4. Common health problems, such as musculoskeletal, cardiorespiratory, and mental health conditions, can often be accommodated at work, with appropriate modifications and support when needed.
5. Planning and supporting staying at or returning to work is an important part of the clinical management of disability
Clinicians must also be aware of the larger workplace issues that can affect the return to work (RTW) process. More recently, there has been emphasis on staying at work and shifting the focus to establish a collaborative environment between employee and employer that maintains productive employment. The Canadian Institute for Work and Health identified seven principles associated with successful RTW. These workplace-based interventions can include
1. Workplace commitment to health and safety by top management and labor across the organization.
2. Workplace offer of suitable early and safe modified work.
3. Coordination of RTW that ensures support for the returning worker without inconveniencing coworkers and supervisors.
4. Supervisors educated in safety and ergonomics and included in early communication and RTW planning.
5. Early and considerate contact with the injured or ill worker by the supervisor/employer.
6. Appointment of a RTW coordinator to facilitate planning, communication, and coordination among the involved parties.
7. Communication between employers and health care providers about workplace demands and RTW issues as needed, and with the approval of the injured or ill worker.
A successful stay at work and RTW process involves an understanding of all of these factors related to the recovery process in the person and the workplace. It is also important to recognize influences that facilitate staying at work once a person has returned. These may include perceptions that the work is appropriate with supportive workplace relationships, and a sense of job satisfaction. It is important to create a work environment in which the injured or disabled worker will feel successful and protected.
Workplace/Employer Roles
Early and positive contact by the employer has shown to be a strong predictor of earlier RTW. It is also most beneficial for the employer to have a people-oriented culture with training in supporting the employee, attempting to avoid adversarial reactions, and encouraging the worker to not only seek proper medical care, but also make workplace modifications available for some form of RTW (ie, part-time, graded increase in activity, or other modified work program—see below). Training supervisors at the workplace to respond positively to reports of potentially disabling conditions has been shown to significantly decrease the number of disabling episodes, and the length of disability in those who have to leave work due to injury or illness. The employer should communicate with the clinician(s) and provide employment/workplace related information that can help guide their understanding of work-related tasks. Ultimately, the decision to have an injured or disabled worker RTW in a temporary or permanently modified position is the responsibility of the employer. With the proper communication and support from the employer, the physical and psychological demands of work and any work restrictions can be addressed and possibly modified for a successful RTW process.
Modified Work Programs
Modified work programs have encompassed a diverse set of work-related changes, including changed work hours, (eg, flexible or reduced hours) reduced tasks performed, or more permanent workplace alterations such as modifying workstations or equipment. Similar to physical conditioning programs, they may incorporate a gradual exposure to work-related tasks to increase workload over time. Numerous studies have shown benefit with modified work programs in specific workplaces. In most instances, modified work is informally arranged by workers and supervisors, and the most successful arrangements are those where work modifications are adjusted as needed to ensure that the worker has appropriate tasks that are within their capabilities.
In addition, the employer may provide ergonomic worksite modifications and training, as well as consulting with a RTW coordinator. Ergonomic changes to the work environment may be preferable to the injured worker than worker-focused rehabilitation strategies. The ultimate goal of modified work programs is for the person to RTW as soon as possible in a safe environment that promotes recovery and prevents repeat injury or disability. Therefore, a balance must be met with returning to work and activity limitations, as the person should perform the duties within his or her functional abilities, with the appropriate workplace adaptations and social support.
Factors Affecting Return to Work
Studies have shown that there are over 100 different factors that may affect RTW and have been studied to determine predictors of RTW. These factors fall into different domains or categories including: individual worker characteristics (socio-demographic, psychological, attitudes and beliefs, health behaviors, clinical measures), injury descriptors and severity (pain and function), rehabilitation interventions and health care referrals, physical and psychosocial job characteristics, employer/employment factors, employer- or insurer-based disability prevention and disability management interventions, and administrative and legal factors, as well as social policy, legislative, and economic factors.
The management of an injured or disabled person may involve assessing for individual psychosocial and workplace factors that are obstacles to recovery and return to function. One approach to identifying these prognostic factors is using the concept of “flags,” which stemmed from the medical use of “red-flags” for the presence of signs and symptoms of a possible serious medical condition. In essence, the presence of a “flag” is best seen as a potential obstacle to recovery and working that might need to be addressed before a person can successfully RTW. The term “Yellow Flags” was initially coined to assist clinicians in recognizing individual psychosocial factors (such as perceptions about symptoms, recovery, and the workplace) that have shown to be correlated with poor clinical outcomes and increased likelihood of persistent disability. Later on “blue flags” and “black flags” were developed to further identify and separate personal and injury-related factors from workplace and other prognostic factors. The blue and black flag system represents a refinement from the yellow flag screening approach to draw clinical attention to both individual psychosocial and workplace factors contributing to disability.
Individual perceptions about work are categorized as blue flags. Black flags are related to the context in which the person functions, such as organizational, social, financial, and family issues as well as the physical demands and tasks of the job. Blue flags mark worker perceptions of a job that may be stressful, unsupportive, highly physically demanding, or unfulfilling. While black flags include objective measures of job characteristics that may be amenable to interventions such as ergonomics, their broad context of work, social, and insurance organizational structures are not as easily influenced by a clinician as are blue flags. The presence of these flags, often in combination, may explain why one worker with acute back pain will recover with no work absence while another will experience significant periods of work disability.
Individual-level factors that may predict prolonged work disability (blue flags):
• Perception of heavy physical demands
• Perceived inability to modify work
• Stressful work demands
• Lack of workplace social support
• Job dissatisfaction
• Poor expectation of recovery and RTW
• Fear of reinjury
Some workplace conditions that may predict prolonged disability (black flags) are
• Minimal availability of adjusted duties and graduated RTW pathways
• Lack of satisfactory disability management system (absence of reporting system, reporting discouraged, employer not interested)
• Job involving manual work or significant biomechanical demands that cannot be temporarily altered
• Job involving shift work or working unsociable hours
• Family or others unsupportive of RTW
There is inconsistent evidence of predicting RTW due to age, sex, education, use of nonnarcotic pain medication, and mental health issues other than secondary depression in the shorter-term setting. Psychosocial risk factors are greater predictors overall of delayed RTW and persistent disability than biomedical or ergonomic factors. The factors affecting RTW in the chronic phase may be different than those identified in the short term. As work disability becomes prolonged, secondary depression, loss of supportive work-place relationships, and physical deconditioning can become additional RTW barriers.
Two methods to identify blue and black flags in the context of low back pain include (1) using the clinical interview scenario or (2) using questionnaires, such as the Orebro Musculoskeletal Pain Questionnaire (OMPQ). The OMPQ is a self-report screening instrument that detects individual-level factors (Blue Flags) that predict work disability. The OMPQ can identify individual-level factors such as fear of reinjury, poor expectation of recovery or RTW, stress, job dissatisfaction, and heavy physical demands. Other individual-level factors and workplace conditions that may predict work disability from the preceding list may be identified through clinical interview or by conducting a workplace visit.
The Back Disability Risk Questionnaire (BDRQ) is another self-report questionnaire with a focus on work-place factors. It is designed to be administered within the first 14 days after the onset of work-related back pain. The BDRQ has been shown to have moderate validity to predict 1-month RTW. Six of the 16-item BDRQ questions (injury type, work absence preceding medical evaluation, job tenure, prior back surgery, worries about reinjury, expectation for early return-to-work, and stress) have been shown to predict presence of persistent pain, functional limitation, or impaired work status. An additional validated tool for screening persons for targeting interventions, based on identified risks for persistent disability due to low back pain, is the Keele Start Back Screening Tool.
Research suggests that the use of these patient questionnaires can also help identify persons in greatest need of early intervention to alleviate acute emotional distress. For back pain, there is strong evidence for the role of psychological distress/depressive mood in the transition from acute to chronic low back pain. Emotional distress has been shown to be a salient factor in delayed functional recovery even when measured in the first few days after pain onset. The Center for Epidemiologic Studies Depression (CES-D) scale is a short self-report questionnaire that measures depressive symptoms and has good predictive ability among chronic pain patients. The scale has been found to have a very high internal consistency and adequate test-retest reliability.
Health care providers can be instrumental in helping a person at risk of chronic disability or work loss. A stratified approach to management of RTW interventions should be considered by screening earlier on to determine which persons are at greater risk of delayed RTW and prolonged disability with the tools mentioned above. Once potential individual and workplace obstacles have been identified, health care providers can help develop an individualized plan of action to target each obstacle or flag and implement the plan. These high-risk persons may need additional evaluations for planning workplace and other appropriate interventions. Table 7–1 lists workplace factors (blue flags) that have been identified to be important for RTW, and some suggestions for possible questions and actions that may be coordinated among the employee, employer, and health care provider.
Table 7–1. Workplace factors (Blue Flags) important for RTW, and suggestions for interview questions and possible actions.
CLINICAL MANAGEMENT
Work disability should be addressed as a separate and important issue from their medical condition. A discussion about the nonmedical factors that may prevent RTW, possible solutions, and how the clinician may help within the context of RTW is an important goal of their medical care.
Poor disability management by the health care team may result in a significant risk of long periods away from work and protracted disability. Health care factors adversely affecting RTW have been attributed to fragmented and poorly coordinated care, which results in delayed or inappropriate diagnostic workups, extended treatment, prolonged and inappropriate activity restrictions, and long wait time for consultations. It has been recommended that improved communication between primary care providers and occupational medicine physicians or rehabilitation specialists may improve RTW decisions. Barriers to RTW may be that some health care providers lack the knowledge, awareness, and familiarity with disability and RTW issues, and are unable to determine proper activity limitations, restrictions, and outcome expectations. Primary care providers should consider referral to a source of RTW expertise (occupational medicine physician, physical therapist, occupational therapist, RTW coordinator) if a significant barrier to RTW develops between the employer and employee or other potential risk factors for prolonged disability arises.
The goal of disability management is to assist the person to maintain or return to their maximum functional work status as soon as possible after an injury, illness or chronic medical condition. Depending on the resources available, many people may be involved in disability management, to various degrees. In the majority of the developing world, disability management is usually self-directed with few available resources. There is good evidence from developed countries that early intervention with appropriate treatment, reassurance about activity, and staying at or returning to work with workplace accommodation is sufficient management for most people. It is important to encourage the injured or disabled person to continue as a productive member of the community by focusing on returning to their daily activities and work, as there are significant psychosocial and economic benefits. In addition, a large aspect of disability management lies in preventing further injury and disability.
In the injured worker setting, the fundamental goal of the clinical evaluation of work capacity is to determine whether a worker can stay at or return to some form of work, and if so, what specific tasks or duties they can perform. The longer they remain away from work, the less likely the chance of ever returning to work, and the more likely they will remain on permanent disability or unemployed. If a worker has been off work for 12 weeks, there is only a 50% chance of ever returning to work. By 12 months, the likelihood of returning to work is only about 2%. A coordinated approach including all involved parties, and especially the health care provider(s), worker, and employer has shown optimal results in staying at or returning to work.
Distinguishing impairment from disability is an important aspect when evaluating a person that has been injured or out of work due to a medical condition. A person may experience an impairment that does not result in disability, such as a below the knee amputation, where they have learned to walk and run with a prosthesis or a paraplegic who is fully independent in a wheelchair who works as an accountant. On the other hand, one can experience significant disability or activity limitations in the absence of significant physical impairment, such as a vascular surgeon or concert pianist who requires great hand dexterity with an injury to the median nerve to the hand.
The history can provide important information in limitations in function as well as extrapolating information for work functional capacity from their ability to perform common daily activities such as driving, sitting, walking, standing, bending over, lifting groceries or children, and climbing stairs. During the physical examination, the clinician can test range of motion, strength, sensation, and ask the person to demonstrate difficult activities. Level of effort and pain can be assessed while observing the person. A prediction of work function can then be made based on the clinical encounter along with a general understanding of the workplace.
The American College of Occupational and Environmental Medicine (ACOEM) developed a consensus document that outlines the issues and roles that a health care provider should consider when dealing with stay at work or return to work (RTW) concerns. The following components should be considered:
• Early in the course of treatment, discuss the expected healing and recovery times, as well as the positive role an early, graduated increase in activity has on physical and psychological healing.
• Ask about the impact of the medical condition on their ability to perform responsibilities at home and at work, and the availability of family and community support systems.
• When an injured or disabled person is able to stay at work or to return safely to some form of productive work, explain that resuming normal activities while symptoms continue to resolve is an important part of the rehabilitation process.
• Look for potential obstacles (flags) to the recovery of function and RTW as soon as practical. The care plan may need to be reevaluated and adjusted.
• Identified obstacles may need to be referred to appropriate parties involved in their health care and employment situation who can assist in addressing particular issues, such as benefits or claims payers, case managers, occupational health and safety professionals, human resources professionals, or workplace supervisors.
• Support direct communication between worker and employer early in treatment or rehabilitation in order to reduce social isolation and maintain the bond with the world of work.
• At each visit, provide guidance to the worker (and employer with authorization or as permitted by law) about what job functions are safe to do and realistic to expect. These “activity prescriptions” will naturally change over time.
• If the worker is able to do something productive, but there is no work available because of statutory prohibitions or employer policies, business practices, unwillingness or inability to make accommodations, or mitigate workplace risks, offer to contact the employer on the worker’s behalf.
In high-risk persons and those who feel unable to work, a clinician or physical therapist evaluation may be able to direct or suggest additional resources within the workplace and refer those who need it the most to outside therapies (ie, physical, behavioral, social services focused on work issues). By targeting appropriate and timely resources to these persons, the clinicians, therapists, and workplace may prevent prolonged sick leaves, long-term disability, and promote health care cost savings within the community and work-place. Delaying assessment of RTW risk factors until several months of work absence have occurred provides much less opportunity to consider simple interventions that can prevent prolonged disability.
Activity Prescriptions for Work
Providing workers, disabled persons, and employers with advice about work and activity is critical to their recovery, RTW, and prevention of prolonged disability. Clinicians can find resources for RTW assistance at Helping Workers Get Back to Work, a website that includes the attending doctor’s RTW desk reference (with information on the activity prescription form).
Whenever the clinical evaluation does not provide adequate information to determine specific physical activity or work limitations, the clinician may need to supplement the clinical information with other evaluations. In addition to workplace evaluations, one of the tools used to assist in translating impairment to job-relevant functional limitations are functional capacity evaluations.
Functional Capacity Evaluations
Functional capacity evaluations (FCEs) have been purported to obtain physical functional abilities for job placement, rehabilitation, work capacity, and disability evaluations. FCEs are performed in numerous ways and by a variety of practitioners. The two most widely used methods of determining functional capacity are performance-based tests, often using specific equipment and physical measurement instruments or job simulation, and self-assessments using questionnaires.
The typical performance-based FCE is a battery of standardized assessment measures addressing range of motion, strength, endurance, lifting, pushing, pulling, climbing, and other tasks designed to systematically measure a person’s physical functional capacity. Because these FCEs often use general standardized measures, there are significant limitations in predicting work ability, RTW, and disability. The predictive value of FCEs remains low partly due to the fact that it is difficult to accurately assess specific on the job physical requirements, and the predictive value of these standardized tests for job performance is low. An accurate job assessment is necessary to develop a job-specific FCE that simulates the actual physical demands of the job.
Another method of determining functional capacity is through self-report, or using a standardized questionnaire. Studies have demonstrated that performance-based measures assess different aspects of functional capacity than self-reported measures. Individual self-reports appear to provide a broader assessment of functional capacity related to not only physical attributes but also psychosocial aspects such as self-efficacy, and may provide a wider scope of information than the performance based measures. Four questionnaires used for FCEs have had high levels of both reliability and validity. These are the Pain Disability Index, Oswestry Disability Index, Roland-Morris Disability Questionnaire, and the Upper Extremity Functional Scale. The questionnaires mostly focus on issues of activities of daily living, and therefore their value in assessing ability to perform work related duties is uncertain at best. The combination of performance and nonperformance tests might have a greater predictive value for work participation, but this has not been demonstrated yet.
There remains debate as to the predictive value of FCEs in most RTW settings. In persons with musculoskeletal disorders, the overall predictive quality of FCEs for work participation is modest to poor. Some specific functional measures such as lifting tests have been shown to be predictive of greater work participation. However, their value for sustained RTW has not been demonstrated. Demographics (gender) and work status (amount of time off work) have been shown to be stronger predictors of RTW than the FCE.
The lack of evidence showing strong predictability of most FCEs (especially those lacking valid job simulations) for RTW elucidates the complexity of predicting disability and its multifactorial nature. There are likely many factors that affect performance on FCEs, including both physical and psychosocial elements. Similarly, successful RTW depends not only on physical capacity, but psychological, social, and other factors. The performance on FCEs should not solely be used to assess an individual’s functional capacity.
Physical Conditioning Programs
Physical conditioning programs including work conditioning, work hardening and functional restoration programs should be focused on RTW or improvement in current work status for those on modified duties. They all typically involve some form of physical activity such as structured exercise to either simulate or duplicate a work or functional task in a safe, supervised environment. They can involve a gradual and graded-activity process set to the person’s level of tolerance, which helps build strength, endurance, and confidence. These programs can occur either in a clinic or workplace-based environment. There is some evidence that physical conditioning in the workplace compared to the clinic-based environment has improved RTW outcomes in persons with musculoskeletal disorders. The workplace-based rehabilitation may be more effective by improving psychosocial well-being especially by maintaining connection with the workplace and not being separated from the work routine. However, the effectiveness of these programs in disability management remains limited with only small effects seen in the long term and for limited types of conditions namely subacute and chronic musculoskeletal disorders.
Vocational Rehabilitation
Since the 1970s vocational rehabilitation (VR) programs have been assisting people with injuries, and with various states of disability to RTW as contributing members of society. Vocational rehabilitation has many definitions and connotations depending on the locale, resources, work laws, and regulations in effect. The broadest scope includes “whatever helps someone with a health problem to stay at, return to, and remain in work.” The proposed definition for vocational rehabilitation from the International Classification of Functioning, Disability and Health is a “multi-professional evidenced-based approach that is provided in different settings, services, and activities to working age individuals with health-related impairments, limitations, or restrictions with work functioning and whose primary aim is to optimize work participation.” This definition encompasses the expansion of all services participating in the rehabilitation of the person. This approach includes both work-focused health care and employer-based accommodations, which is broader than the typical US program of vocational counseling and rehabilitation planning by a rehabilitation counselor for unemployed or permanently disabled workers. This wider emphasis also shifts the model from returning-to-work to staying-at-work.
There are a wide variety of VR services, depending on individual needs and resources available. The majority of persons with health issues does not need comprehensive vocational rehabilitation interventions and can be properly managed by the primary health care provider with minimal additional resources. When more complicated scenarios arise, a comprehensive stepwise approach may be necessary. VR services can assist persons with many needs, including obtaining appropriate treatments earlier on, determining activity limitations, and recommending workplace modifications after the first few weeks of disability. For those persons on disability for several months or years, VR can involve providing job support services, educating employers, communicating between health care providers and employers, as well as finding and entering training programs, job placement, finding new employment opportunities, determining alternate job options based on individualized skills and attributes, and even plan withdrawal from work. The programs can be at the individual or group level and can include counseling, planning, and proactive methods of maintaining and obtaining proper employment. VR can address work instability and incongruity, where there may be a mismatch between the skill of the individual and the duties required by the job description. If the person is still employed, VR may include a case manager or RTW coordinator who can assist with an evaluation of the work and work environment. Depending on the evaluations, the person may either return to the same work, return to the same work with modified duties or environment, or need to change jobs and find a new one that is more congruous with the capacity of the person.
Vocational rehabilitation has been shown to be effective in helping persons address the difficulties of work disability. On average approximately 60% of disabled persons who use VR programs become employed, though there is significant variability in employment based on the type of disability. There is strong evidence for effective VR interventions (when defined broadly) that improve work outcomes in musculoskeletal conditions.
Several strategies have been tested to manage work disability in those with chronic, serious mental disorders. The most effective approach is based on an individual placement and support model. Features include early resolution of medical issues, and a subsequent multidisciplinary team approach that deemphasizes medical aspects; career exploration in the job market based on client interests and motivation rather than sheltered workshops; and ongoing peer support with secondary vocational assistance, rather than a traditional train-and-place approach. Other innovations attempt to circumvent the link between health benefits and permanent disability certification, by providing full health insurance to persons with serious medical problems who wish to work. This allows persons with serious medical problems to take more flexible jobs (often part-time) that do not provide health insurance.
Persons and workplaces with complex cases or barriers to RTW may require closer supervision to help manage the interrelated risk factors and interventions, and may benefit greatly from a case manager or RTW coordinator. The case manager can assist in integrating the care plans and coordinating interparty communication, progress, and follow-up. Involvement of RTW coordinators has been shown to lead to significantly improved outcomes in cases with prolonged work disability. In addition, disabled persons may need to be monitored for compliance with the treatment plan. Interdisciplinary collaboration and involvement of worker and workplace is usually necessary to achieve a smooth transition back to work.
PREVENTION
Studies suggest that much of health-related work disability is preventable. The question of how best to prevent disability is an important one because a healthy workforce is an essential part of a vital nation. ACOEM urges the adoption of a new preventive-based paradigm centered at the workplace. They recommend primary prevention strategies that help people stay healthy and productive (like healthy workplace programs), secondary prevention strategies that catch problems before they manifest as work disability (like screening, health coaching, improved supervisor response and proactive work disability prevention programs), and tertiary prevention strategies (like disability and disease management, and RTW programs) that limit the disability impact of an injury or illness and minimize obstacles to work for disabled persons.
Evidence shows that good physical health, good mental health, positive health behaviors, and absence of chronic disease and its complications are all associated with low occupational and general injury rates and decreased health-related work disability. Efforts that help workers and those seeking work attain and maintain good physical and mental health and that prevent chronic disease or its complications can be viewed as interventions to prevent disability. Awareness of factors that put a worker or disabled person at risk for sustaining an injury and factors that, once an illness or injury has occurred, put them at risk for prolonged disability is an important first step for any action that aims to prevent disability.
Factors that put a person at risk for sustaining an injury or developing work disability include
• Obesity
• Smoking
• Drug and alcohol abuse
• Taking certain prescription medications
• Fatigue
• Sleep disorder or sleep deprivation
• Poorly controlled diabetes
• Fair or poor eyesight
• Fair or poor hearing
• Conflicts at work (with coworkers or supervisors)
• Depressive symptoms
These risk factors can be identified through discussions during a clinical encounter that include both personal and workplace issues, and through screening tools like health risk appraisals or assessments, or early disability risk prediction questionnaires.
Health Risk Assessments
A Health Risk Appraisal or Assessment (HRA) is a widely used screening tool that, through a self-report questionnaire, can obtain lifestyle data (like smoking, alcohol and/or drug use), personal medical history (including prescription medication use), self-assessment of physical function (like hearing, vision, sleep, fatigue, depressive symptoms), and physiological data (like height and weight). Health risk assessment refers both to the screening tool and the overall process to (1) collect information that identifies risk factors, (2) provide individual feedback, and (3) connect the person to an intervention designed to improve health and prevent disease. Biometric screening at the workplace and in communities (like a fasting blood sugar screen that could identify poorly controlled diabetes) informs this process and can lead to appropriate referrals to health care providers.
Health care providers who seek to prevent disability must include a focus on work aspects in their clinical encounter. Studies on shiftwork, for example, show that changes aimed at sleep deprivation as a safety issue have also demonstrated improvements in health conditions such as obesity, diabetes, and cardiovascular disease. In order to address work-related health risks, they must be elucidated in a work history or work analysis. Governments, insurers, and employers can use these population data to design their health plans to respond to the risks that exist among their workers and the community.
Studies of morbidity in populations with differing risk factors often use self-report functional status instruments like the Health Assessment Questionnaire (HAQ) Disability Index to measure disability. Longitudinal studies that used the HAQ Disability Index as a metric conclude that self-reported disability was postponed by 14–16 years in vigorous exercisers compared with controls and postponed 10 years in low-risk compared with higher-risk cohorts (risk based on current smoking, overweight/obesity, and inactivity). A “low-risk” person who does not use tobacco, is not overweight or obese, and is physically active may postpone disability, as defined by self-reported functional status, and is less likely to develop a chronic disease or sustain a work-related injury. A well-designed health promotion program in the workplace or community aims to move the workforce and communities into this “low-risk” category. Actions toward this goal are actions that might help prevent health-related work disability.
Participation in a health promotion program has been linked to subsequent improved resilience, manifest as shorter periods of work disability following common illnesses. The Centers for Disease Control and Prevention (CDC) launched the National Healthy Worksite Program (NHWP) to help companies of all sizes establish comprehensive healthy workplace programs. A useful tool used by NHWP is the CDC Worksite Health Scorecard that helps employers evaluate the extent to which they have implemented evidence-based healthy workplace strategies.
Secondary prevention strategies such as health coaching and proactive work disability prevention programs can be employed once risk factors for disability have been identified. Evidence shows that health coaching, particularly health coaching that engages participants with motivational interviewing, is an effective strategy to help people with behavior change. One-on-one coaching that focuses on health factors, work-related factors, and social/psychological factors is particularly valuable for those identified at higher risk for early work loss. Research indicates that workers who receive such care show better work ability, less burnout, and better quality of life.
Health coaches can be trained to deliver cognitive-behavioral-based programs. Cognitive-behavioral interventions have been shown to enhance the prevention of long-term disability; one randomized controlled trial looking at persons with acute back pain showed that the risk for developing long-term sickness-related disability leave was more than fivefold higher in the minimal intervention group compared to the cognitive-behavioral intervention group. The cognitive-behavioral intervention in this study included weekly group meetings with: (1) practice with problem solving, (2) skills training to give participants the opportunity to improve their coping skills, and (3) the development of a personal coping program.
While research shows that mental disorders like depression and anxiety are associated with impaired work functioning and long-term sick leave, and controlled trials demonstrate the effectiveness of cognitive-behavioral therapy (CBT) in improving mental health, CBT as typically delivered in outpatient settings lacks a focus on work. The integration of work-directed interventions with CBT components is a more effective strategy to prevent prolonged work absence for people who are on sick leave with mental health problems like depression or anxiety. A comparative outcome study that examined a work-focused CBT intervention and a regular CBT intervention among employees on sick leave due to common mental disorders (including depression and anxiety) concludes that employees who received work-focused CBT resumed work earlier than those who received regular CBT.
Work-focused CBT uses work and the workplace as a framework for customary CBT exercises and a context to reach treatment goals like activation, social contact, and increased self-esteem. Work-focused CBT can, for example, engage the participant in work-focused behavioral experiments to challenge dysfunctional thoughts. In addition to addressing behavioral and psychological risk factors, work-focused cognitive-behavioral interventions can help injured or disabled workers shift the way they perceive their work environment so perception-based risks (blue flags) can be addressed as well.
A comprehensive workplace health promotion program includes (1) health education programs, (2) a supportive social and physical environment, (3) integration of the program into organizational structure, (4) screening, including treatment and follow-up as needed, and (5) links to other assistance programs. A proactive work disability prevention program includes these same five elements as follows. First, health education programs educate and engage their workers in wellness activities aimed at work disability prevention. Second, a supportive social and physical environment at the workplace addresses wellness and risk factors for work disability. Third, a workplace disability management system (including a reporting system and early response to work disability) is integrated into the organizational structure. This system includes training supervisors to help employees with health conditions that might interfere with work ability to easily navigate the system and obtain alternate or modified duties and job accommodations when needed. Fourth, screening for factors that put a person at risk for sustaining an injury or developing work disability is linked to programs that address these risks (such as ergonomic interventions). Fifth, links to other assistance programs (employee assistance programs, RTW coordinators, case managers, and job training, for example) include appropriate referrals to health care professionals as needed.
Healthy workplaces that are proactive in disability prevention optimize the work environment and include strategies for both health protection and health promotion. Occupational safety and health interventions are designed to minimize workers’ exposures to job-related risks and workplace health promotion interventions aim to promote healthy behaviors. Approaches that integrate occupational safety and health with health promotion in the workplace may be more effective than occupational safety and health or workplace health promotion alone in preventing disability as well as RTW from a disability. Total worker health is the NIOSH strategy to integrate occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well-being. According to this strategy, a worker is best kept safe and healthy in an atmosphere where management is fully engaged in the well-being of its staff, where the environment is hazard-free and supportive, and where workplace policies, interventions, and the work environment all encourage healthier choices. The most important modifiable chronic disease risk factors (tobacco use, physical inactivity, and unhealthy diet) can be addressed not only to prevent chronic disease, but also to prevent occupational injuries and any subsequent work-related disabilities.
Research priorities for disability prevention include studying (1) the effectiveness of comprehensive workplace health promotion and health protection initiatives, and ways to maximize participation, (2) early interventions targeting specific disability risk factors, (3) enhanced disease self-management programs that include a work disability prevention component, (4) the impact of positive supervisor responses with both formal and informal workplace accommodations, and (5) proactive interventions designed to optimize the emotional well-being of the entire workforce. As more studies document the prevalence of presenteeism, research is needed to determine who is at risk for a transition to work absence, and how this can be prevented through focused interventions.
REFERENCES
CDC: National Healthy Worksite Program (NHWP). www.cdc.gov/nationalhealthyworksite/.
Hill JC: Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomized controlled trial. Lancet 2011;378:1560 [PMID: 21963002].
Keele University: STarT back screening tool. http://www.keele.ac.uk/sbst/.
Lagerveld SE: Work-focused treatment of common mental disorders and return to work: a comparative outcome study. J Occup Health Psychol 2012;17:220 [PMID: 22308965].
NIOSH: Total worker health. www.cdc.gov/niosh/twh/.
Pomaki G: Workplace-based work disability prevention interventions for workers with common mental health conditions: a review of the literature. J Occup Rehabil 2012;22:182 [PMID: 22038297].
Reme SE: Distressed, immobilized, or lacking employer support? A sub-classification of acute work-related low back pain. J Occup Rehabil 2012;22:541 [PMID: 22644216].
Washington Labor and Industry: Helping Workers Get Back To Work. http://www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/RTW/default.asp.
WHO: Community-Based Rehabilitation (CBR) Guidelines. http://www.who.int/disabilities/cbr/en/.
WHO: International Classification of Functioning, Disability and Health (ICF). http://www.who.int/classifications/icf/en/.
WorkSafe BC: Understanding return-to-work programs. http://www.worksafebc.com/health_care_providers/related_information/understanding_return-to-work/default.asp.
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SELF-ASSESSMENT QUESTIONS
Select the one correct answer for each question.
Question 1: Disability
a. is internationally defined as a decrease in or inability to perform some or all functions related to personal, social, or workplace demands due to a physical or mental impairment
b. is synonymous with impairment
c. presumes that impairment is present
d. in just a few percent of all workers with health-related work limitations accounts for the majority of total days lost from work due to health conditions
Question 2: Functional capacity evaluations (FCE)
a. precisely determine physical functional abilities for job placement, rehabilitation, work capacity, and disability evaluations
b. are performed solely by occupational physicians
c. include performance-based tests, often using specific equipment and physical measurement instruments or job simulation, and self-assessments using questionnaires
d. must include a battery of standardized assessment measures addressing range of motion, strength, endurance, lifting, pushing, pulling, climbing, and other tasks designed to systematically measure a person’s physical functional capacity
Question 3: Vocational rehabilitation
a. is required for the majority of persons with occupational injuries
b. typically involves providing job support services, educating employers, communicating between health care providers and employers, as well as finding and entering training programs
c. programs are at the individual but not the group level and include counseling, planning, and proactive methods of maintaining and obtaining proper employment
d. can address work instability and incongruity, where there may be a mismatch between the skill of the individual and the duties required by the job description
Question 4: Health risk appraisal or assessment (HRA)
a. is a research tool with limited clinical value
b. is a screening tool that is prevented from obtaining personal information
c. can obtain lifestyle data (like smoking, alcohol, and/or drug use), personal medical history (including prescription medication use), self-assessment of physical function (like hearing, vision, sleep, fatigue, depressive symptoms), and physiological data (like height and weight)
d. may not include biometric screening at the workplace
Question 5: Cognitive-behavioral therapy (CBT)
a. is required by workers’ compensation to improve mental health in workers
b. as typically delivered in outpatient settings has a focus on work
c. intervention among employees on sick leave due to common mental disorders (including depression and anxiety) has no measurable value
d. that is work-focused returns employees to work earlier than those who received regular CBT
Question 6: Individual factors that are associated with prolonged work disability (blue flags)
a. do not explain why one worker with acute back pain will recover with no work absence, while another will experience significant periods of work disability
b. include strong evidence of predicting RTW due to age, sex, education, use of nonnarcotic pain medication, and primary mental health issues
c. may be identified in the context of low back pain by using the clinical interview scenario or questionnaires such as the Orebro Musculoskeletal Pain Questionnaire (OMPQ)
d. include minimal availability of adjusted job duties and lack of a satisfactory disability management system at work