As a society, we place great significance on the value of work and productivity. This value system is reflected in the amount of time the average adult spends in the workplace. Similarly, the expectation of safety in the workplace is recognized as a good business model. A healthy workforce decreases the rate of employee turnover and costs associated with training and hiring. Healthy workers also minimize costs associated with work absenteeism and loss of productivity. Many workers are able to sustain their level of productivity without interruption, but as with any system upset situations can develop, resulting in injury and impaired function.

The field of occupational and environmental medicine is particularly geared to manage these issues. Health care providers in this field are trained as advocates and champions of safer work environments but also aim to effectively and safely manage work injuries. The nature of work itself and the potential risks associated with specific work settings have changed significantly since the industrial revolution. The field of occupational medicine has evolved with these changes. Specialists in this field function as change agents who can often spearhead adaptation of best practice standards and laws affecting a larger population of workers and their workplace.

Health care providers can also have an impact on individual workers by interacting with stakeholders such as the injured worker, the employer, case managers, third-party administrators, union representatives, and lawyers in managing the medical claims.

Workers’ Compensation & Workplace Safety Regulation

Most people have some familiarity with the workers’ compensation system. In the United States, many employers are required to obtain insurance for workers’ compensation, and this coverage secondarily provides wage replacement and medical benefits to employees injured while performing their work duties. The general premise of this coverage also holds that employees are covered for all work-related injuries in this “no-fault” system. As such, employees do then have limited recourse to seek damages through the traditional tort system.

Many employers have developed active systems of minimizing costs associated with workers’ compensation coverage. Ideally this should involve development of safer processes aimed at reducing the risk of injury and illness. Some adaptations have been industry driven; others have emerged in response to regulatory mandates.

A. Regulation of Workplace Safety

The most recognizable regulatory body driving workplace changes in the United States is the Occupational Safety and Health Administration (OSHA). OSHA was created in 1970 by a congressional mandate (the Occupational Safety and Health Act of 1970) as a federal program and was tasked with the mission of improving workplace safety and enforcement of standards. Today, there are approximately 27 state-based OSHA programs, but these entities must still meet or exceed federal OSHA standards.

B. Risk Factors for Workplace Injury

OSHA estimates that annually approximately 3.3 million workers sustain serious injury in their workplaces. Some observers view this as a public health issue and have extensively studied the risk factors associated with work injuries. Such an analysis can include consideration of system failure, process failure, or human error.

In one study, three broad categories affecting work injuries were identified: human factors, job content, and environment. Human factors that influence the risk of work injury include work experience, baseline physical impairments, stress, and job satisfaction. More recently the issue of fatigue has been recognized as a predisposing factor in injury for various industries. Job-related factors can involve task order and scheduling. Environmental factors can involve physical hazards and stressors such as noise.

The study of injury prevention utilizes findings from all of these factors in addressing potential areas of harm, but absent full and self-sustaining automation, injuries to workers cannot be completely eliminated. Even with the best practices and systems, there remains a risk of injury.

C. Reporting of Workplace Injuries and Occupational Illness

In the workers’ compensation system, the time course of work injury management starts with reporting of the event by the injured worker. The time constraints under which a worker must report an injury are further defined by specific state requirements. The reporting timeline for an injury typically differs from that for an occupational-related disease, with longer time being allowed for the worker’s recognition of a disease or illness attributed to work exposures. To be compensable, an injury must arise out of or occur in the course of employment. For example, an employee who slipped while rushing down a ladder would be eligible for coverage of her injuries. In contrast, an employee who had a seizure episode while at work, fell, and fractured his wrist might not be eligible for coverage.

Evaluation of Workplace Injuries

In addition to performing a medical assessment, health care providers who manage workplace injuries should have some awareness that they likely will also be expected to supply an opinion about work-relatedness; that is, did the work task or work injury result in whatever diagnosis has been obtained? A stepwise approach to injury management should first and foremost revolve around establishing a medical diagnosis and determining the immediate needs of the worker. Escalation of care, when medically indicated, should not be delayed. Thereafter, the provider needs to address work-relatedness, as this determination will further inform the course of injury management. The health care provider will continue to treat the worker if the injury if deemed to be work related. Alternatively, the provider may refer the worker to a primary provider if the medical condition is not work related. In this case, as occurs in some primary care practices where the provider also functions as the treating physician (for general medical care) of record, this separation can be challenging.

The American Medical Association’s (AMA) Guidelines to the Evaluation of Disease and Injury Causation highlight a stepwise approach to this process starting with initial establishment and verification of a diagnosis. Thereafter, the provider should attempt to determine if a cause-and-effect relationship exists. In some cases, there is a very clear and easily determined relationship, as occurs when a worker falls after tripping on equipment in the workplaces and fractures a wrist. The determination is more difficult in the worker who attributes long-term changes or illness to work exposure, particularly if the condition is fairly common. This could be the case with occupationally related asthma, various degenerative musculoskeletal conditions, or neurocognitive conditions.

Although determination of work-relatedness can be challenging, the provider should take into consideration several variables, including the proposed length and severity of exposure; should explore the presence of similar conditions in coworkers or cohorts; and should also apply best practice with regard to what has been established in the literature about similar associations. Confounding factors, such as tobacco use, concurrent employment, and obesity, should be considered, particularly for degenerative conditions.

OSHA defines an injury or illness to be a work-related matter when the event or exposure occurs within the work environment and when work caused or contributed to the resulting condition or significantly aggravated a preexisting illness. Exceptions to this rule could include injuries or illness that surface at work but are solely due to non–work-related issues. An example would be the worker who has a stroke or heart attack—medical conditions that would not typically be attributable to work. Additional caveats to these examples depend on specific work settings and occupational exposure. In the case of firefighters, sudden cardiac death has increasingly been recognized as a significant risk associated with this profession, and, as such, an acute cardiac event could be attributed to work. The increased risk is linked to a combination of commonly identified factors, including age, family history, diabetes, and hypertension. Occupational exposures to gases such as carbon monoxide and hydrogen cyanide during active fire suppression have more recently been recognized as an additional risk factor in this occupation. As well, various studies have shown a strong enough association between cardiovascular disease and work activities in the fire service that this health problem typically is now recognized as a work-related issue for this job category.

Other exceptions when considering work-related injuries include injuries or illness sustained as a result of an employee eating, drinking, or preparing meals, assuming the illness is not due to food poisoning from food supplied by the employer or food otherwise contaminated in the workplace. Injuries sustained while the employee is engaged in personal tasks unrelated to employment, such as self-grooming or self-inflicted injuries, also are excluded. Mental illness is typically exempted but OSHA may allow for further consideration based on the opinions obtained from a physician or other licensed health care professional with appropriate training.

Osteoarthritic changes in the absence of acute radiographic findings present one of the more challenging scenarios for a provider who is asked to supply an opinion about causality. This is especially true when the injured worker either was not aware of this condition prior to injury or did not appreciate the extent of such findings. Osteoarthritis (OA) itself is a fairly common condition in the general population irrespective of occupational factors. Predisposing factors for OA include age (with an increased incidence in older persons), obesity, physical deconditioning, smoking, and certain metabolic syndromes. In the context of work injuries, research on the development of post-traumatic OA has included analyses of knee and ankle injuries, specifically fractures. In early reporting, some subjects were found to have radiographic changes on followup 2–4 years after a fracture injury, but these presented as localized changes. Future research into the role of trauma in localized OA may necessitate reconsideration of work-relatedness and OA; however, overwhelmingly the literature still requires that specific factors be present, such as a clearly defined injury. Moreover, the area of injury should correlate with the area of degenerative change. The presentation of OA may also appear prematurely, ahead of the normally anticipated onset, further minimizing the role of age and other non–work-related factors commonly identified in the general population.

In some state systems, the injured worker’s choice of initial health care provider is directed by a panel of medical providers selected by the employer or by the employer’s third-party administrator. In other states, an injured worker may be able to receive treatment through his or her private physician. In all instances, the assessment completed for a work injury should mirror the typical assessment completed in any medical setting. Pertinent differences include a focus on factors such as the injured worker’s mechanism of injury and prior medical history.

The goal in management of an injured worker’s care is restoration of prior function. In many cases, this can be achieved through conservative measures involving medication, therapy, and other modalities. During this period, the employee can either be released to resume work in a modified work capacity or placed out of work, depending on the opinion of the examining physician. Ideally, return to work in some capacity should be advised unless a provider truly feels that the injured worker is disabled and cannot function in a manner that allows completion of activities of daily living.

This decision can create tension in the provider’s interaction with some injured workers, who may have anticipated complete removal from work. Consider the example of a worker who sustains a lumbar sprain without signs of neurologic urgency. The American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines advise that persons with low back pain tend to improve with some form of aerobic exercise and maintenance of preinjury activity. Recognizing the importance of activity in the rehabilitative process, many leading organizations, including ACOEM, stress safe but early return to work. Should the injury require a need for escalation of care (eg, surgery or hospitalization), providers would need to consider other factors in making a recommendation for resumption of work. Various guidelines are available in these scenarios.

Approximately 60–80% of the general population will experience at least one episode of low back pain in their lifetime. This frequency remains true in the workplace. Within the context of workplace injuries, back pain represents one of the most commonly reported work-related complaints. Treatment for low back disorders also tends to be more expensive than other types of claims. Direct costs attributed to management of occupationally related back pain are estimated at $10.8 billion annually and represent an area of significant impact. The literature further demonstrates that at least 90% of back pain episodes have a mechanical cause, meaning there has been some injury to muscles, ligaments, bones, or discs. In most cases, resolution of symptoms is expected. Studies show that in 50% of these cases, patients report resolution of pain within a period of 1 week. By 8 weeks, more than 90% of patients are asymptomatic. Less than 5% of patients reporting an acute episode of pain progress to having persistent chronic symptoms. These parameters would exclude situations where a provider notes “red flags” or areas of clinical concern, such as weight loss, fevers, worsening pain, or bowel or bladder incontinence. Even in the setting of a workplace injury, clinicians should always consider the possibility of other nonmechanical pathology, which would significantly alter the treatment course.

Treatment options for work-related injuries should be consistent with best practice standards. Many providers utilize rehabilitative services in returning the injured worker to his or her preinjury baseline level of function. The duration of treatment can be further defined by various guidelines, such as those of ACOEM. Resolution of pain and an improvement in function are the initial goals of treatment. In cases of delayed recovery, defined in this setting as the presence of symptoms after an appropriate healing period, use of work conditioning programs should be considered.