To any clinician who treats injured workers, one of the most important questions is at what point and under what circumstances should the patient be returned to the job.
A patient returned to work too early may risk further injury or exacerbate the primary condition. However, a delayed return to work (RTW) may cause a variety of problems. With increasing time off work, the patient may become progressively deconditioned, and the likelihood of disability increases. Moreover, if the recover period is too extensive, the patient may not have a job to return to. The safe and expeditious RTW is not adequately addressed in most clinical training programs
After graduating from chiropractic college nearly 20 years ago, I still remember my first injured worker, a laborer at a warehouse who presented with a low back injury. I was very sympathetic and suggested that he take a few days off from his job. By the end of the week he was feeling much better and in my opinion was ready to return to work. When he asked me for a light duty prescription, I confidently pulled out a prescription pad that read "return to regular/light duty." I circled light duty, then in the space provided on the pad wrote, "restricted to lifting 20 pounds." I signed the official looking form and proudly gave it to my patient. He place the document in his wallet and scheduled his next appointment.
Whether or not restricting his lifting to an arbitrary 20 pounds actually helped I do not know. How was I to know what he could and could not do? Would it have been better to restrict him to five pounds or perhaps to no lifting at all? Did he actually need any type of work restrictions? What exactly does light duty mean, after all I continued to use the same form for several years and no one ever questioned it.
The practice of placing injured workers on any type of work or activity restriction should be based on some defined parameters. These should include an understanding of the nature of the injury, the characteristics of the individual, and the demands of the job to which the patient is to return. This may only be arrived at after a thorough examination of both the patient and the job. The following areas should be considered.
- job description
- age and general health of the injured worker
- nature of the injury
- Motivation and job satisfaction
- presence of litigation
- work environment
In addition to these factors, it is important to determine the RTW policy of the patient's employer. Too often the employer states emphatically that they will only take injured workers back when they are 100 percent. But was the worker 100 percent prior to the injury? And exactly what does 100 percent mean? In the mind of the employer, this typically implies that the patient must be pain-free before RTW. There is ample evidence in the literature that the sooner patients return, the better the overall outcome. In fact, one of the factors that adds to the disability role is the lack of a job to return to. For patients with back pain, those out of work for six months have only a 50 percent chance of ever returning to work. Those our of work for one year have only a 25 percent chance; with those out for two years, there is a strong probability that they will never go back to work.
A second RTW policy leaves the entire decision in the hands of the clinician. The company states that RTW may only take place when the doctor provides a complete release and return to regular duties. Light duty is nonexistent. The injured worker may return on an all or nothing basis. While the rationale for such a policy is easily understood, once again the outcome is often less than desirable. With the addition of the recent Americans with Disabilities Act (ADA), such a policy may actually be illegal. The ADA states: "No covered entity shall discriminate against a qualified individual with a disability ... providing the individual can perform the essential functions of the job with or without reasonable accommodation." The employer who will not allow an injured worker with a temporary disability to return to work until they are fully recovered is actually in defiance of the ADA. It is mandated that each employer provide reasonable accommodation to enable individuals to accomplish the essential functions of the job. This may include assistive devices, job rotation, job modification, etc.
Contrary to popular practice, every effort should be made to allow injured workers to return to work as quickly and safely as possible. Workers should be encouraged to remain on the job and employers should be encouraged to provide necessary accommodations for injured workers. Clinicians should work closely with human resource personnel to determine the most appropriate course of action. In these days of skyrocketing health care costs, it makes clinical and economic sense to keep people on the job whenever possible.
Paul Hooper, DC
Diamond Bar, California
