Disability ranks as the largest public health problem in the United States. An interdisciplinary approach to treat the multifaceted implications of disability is needed to address concerns such as personal care, work and finances, social integration, and leisure (eSlide 6.1) . Strategies include restoration of functional capacity, prevention of deterioration in function, maintenance and improvement of quality of life (QOL), physical rehabilitation, and prevention of secondary complications (eSlide 6.2) .
According to Howard Rusk, “a rehabilitation program is designed to take a disabled person from his bed back to his job, fitting him for the best life possible commensurate with his disability and more importantly with his ability” (eSlide 6.3) .
Return-to-work addresses the following issues: discuss the concept of disability, economic assistance, and vocational rehabilitation strategies; review national data on disability and employment and policies supporting employment of people with disabilities (PWDs); consider the economic impact of disability; enumerate the incentives and disincentives for returning to work; and postulate that vocational rehabilitation serves as a rehabilitation treatment and disability prevention strategy for PWDs (eSlide 6.4) .
Concept of Disability
The World Health Organization provides a global common health language on disability known as the International Classification of Functioning, Disability, and Health (formerly the International Classification of Impairments, Disabilities, and Handicaps). This reflects the biopsychosocial model of disablement, with dynamic interactions between health conditions and conceptual factors. Dimensions of dysfunction are defined as follows: impairment is the loss or abnormality of body structure or of a physiologic or psychological function; activity is the nature and extent of functioning at the level of the person; and participation is the nature and extent of a person’s involvement in life situations in relation to impairment, activities, health conditions, and contextual factors; it can be restricted in nature, duration, and quality (eSlide 6.5) .
Data: Impairment and Disability
eSlides 6.6 and 6.7 show the 15 conditions with the highest prevalence of functional compromise or disability as well as the ranking of percentage of people with functional limitations for specific conditions.
Socioeconomic Effect of Disability
Work disability or work participation restriction affect direct expenditures (medical and personal care, architectural modification, assistive technology, institutional care, and income support), which lead to impoverishment, with a higher incidence of disabled people being below the poverty level. Employment and earnings data show disparities in salaries based on disability (eSlide 6.8) . Governments within the United States have responded by developing disability-related programs, such as Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid (eSlide 6.9) .
Treatment of the Injured Worker
Workers’ Compensation Medicine
Workers’ compensation medicine involves models that promote a safe return to work through functional capacity evaluation (FCE), work hardening programs (WHPs), functional restoration programs (FRPs), and treatment. An FCE tests the physical and cognitive demands of moderately or heavily strenuous work, such as perception, range of motion, strength, endurance, coordination, the ability to lift and assume certain postures, and the ability to tolerate standing, walking, and climbing. A WHP is a multidisciplinary “work-oriented treatment program” that consists of work tolerance screening and work capacity evaluation components with job simulation activities, psychological treatment, and an interdisciplinary pain program. An FRP restores the patient’s physical, psychosocial, and socioeconomic situation through a physician-driven interdisciplinary program that emphasizes the importance of function over pain elimination, pain acceptance, pain management, and proactive coping strategies. The sessions include intensive exercise program, cognitive-behavioral therapy, and ergonomic therapy.
Disability-Related Programs and Policies
Programs
Disability-related programs can be characterized as ameliorative or corrective. Ameliorative programs provide payment for income support and medical care. Corrective programs facilitate the individual’s ability to return to work and reduce or remove the disablement. Disability-related programs can be categorized into three basic types: cash transfers, medical care programs, and direct service programs.
Public Disability Policies
eSlide 6.10 reviews the prominent federal disability laws that mandate that housing and transportation be accessible, education for children with disabilities be appropriate, and employment practices be nondiscriminatory.
Three legislative actions deserve to be highlighted: (1) the Rehabilitation Act of 1973 extended civil rights protection to PWDs, including antidiscrimination and affirmative action in employment; (2) the Rehabilitation Act Amendments of 1978 broadened the responsibility of the Rehabilitation Services Administration to include independent living programs and created the National Council of the Handicapped; and (3) the Americans with Disabilities Act (ADA) of 1990 established a clear and comprehensive prohibition of discrimination based on disability.
Vocational Rehabilitation
Traditional Approaches to Vocational Rehabilitation
eSlide 6.11 shows the traditional approach, based on referral to a vocational rehabilitation counselor for diagnosis, evaluation, and adjustment training. Obtaining an employment history and performing vocational testing are important components of this approach.
Alternative Approaches to Vocational Rehabilitation (eSlide 6.12)
Sheltered Workshops
A sheltered workshop is a “public nonprofit organization certified by the U.S. Department of Labor to pay ‘subminimum’ wages to persons with diminished earning capacity.” This form of employment serves people with severe disabilities, including limited vision, mental illness, mental retardation, and alcoholism.
Day Programs
Day programs provide supervised vocational activity for people with severe disabilities, usually those with mental retardation or mental illness.
Home-Based Programs
Home-based programs include training in a variety of jobs, including telephone solicitation, typing, or computer-assisted occupations such as graphic designing, accounting, or drafting.
Projects With Industry
Projects With Industry is a federally sponsored collaborative program established by the Vocational Rehabilitation Act to enable competitive employment by providing specific job skills training.
Transitional and Supported Employment
Two newer strategies for returning PWDs to competitive, integrated, and gainful employment are transitional and supported employment. Transitional employment consists of providing job placement, training, and support services necessary to help people move into independent or supported employment. Supported employment requires ongoing support after placement, including counseling for the employee and co-workers, and assistance with transportation, housing, and other non–work-related activities.
Independent Living Centers
The independent living centers movement involves a combination of vocational and nonvocational services, such as housing, independent living skills, advocacy, and peer counseling, for PWDs.
Disincentives for Vocational Rehabilitation
Despite growing acceptance in the public and political arenas through better policies and attitudes, there are still a number of disincentives for vocational rehabilitation, a few examples of which include (1) “red tape” in getting cash and medical benefits from SSI and SSDI; (2) the risk of losing benefits once the PWDs are employed; (3) the pervasive stereotype of PWDs being unproductive, leading to the attitude that it is easier to give them a disability check than to implement the ADA; (4) employers’ negative attitudes toward employees with disabilities and ignorance of their vocational needs; and (5) the tendency of physiatrists and other physicians to label an individual as “totally and permanently disabled” or restrict their activities.
Incentives for Vocational Rehabilitation
In an effort to overcome disincentives, government policymakers have created incentives for PWDs and potential employers (eSlide 6.13) .
Incentives for Individuals
Incentives for the individuals include trial work period, substantial gainful activity, extended period of eligibility, impairment-related work expenses, “blind” work expenses, and plans for achieving self-support.
Incentives for Industry
Government policymakers have made various attempts to offer tax incentives to businesses and industries to make the workplace accessible. Examples include deductible expenses for barrier removal, Targeted Jobs Tax Credit, and the Work Incentives Improvement Act of 1999.
Disability Prevention
The public health model defines three categories of disability prevention: primary, secondary, and tertiary (eSlide 6.14) . Primary prevention is intended for healthy people to avoid the onset of a pathologic condition and for people with disabilities to prevent worsening of their impairments. Secondary prevention is aimed at early identification and treatment of a pathologic condition. Provision of assistive technology can be considered secondary prevention. Tertiary prevention focuses on arresting the progression of a pathologic condition and limiting disablement. Environmental modifications, changes in social attitudes, and reforms in legislation and policies are tertiary prevention strategies. Medical rehabilitation is traditionally considered a tertiary prevention strategy.
Conclusion
Holistic management is the key in the comprehensive rehabilitation of disablement. This approach maximizes physical, mental, social, and economic functions of individuals with disabilities through various interventions directed at human functioning. The physiatrist, as a team leader, collaborates with professionals outside the traditional medical rehabilitation team, such as those involved in vocational rehabilitation. This eventually improves QOL and function, which greatly affect the individuals and society in terms of significant socioeconomic consequences (eSlide 6.15) .
Related posts:
The Physiatric History and Physical Examination
History and Examination of the Pediatric Patient
Adult Neurogenic Communication and Swallowing Disorders
Psychological Assessment and Intervention in Rehabilitation
Practical Aspects of Impairment Rating and Disability Determination
Pain and the Injured Worker
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