Currently, the biomedical model remains the most predominant framework for many researchers and professionals in clinical sciences and healthcare (Leibowitz, 1991; Schultz, Crook, Fraser, & Joy, 2000; Schultz et al., 2007; Turk, 1996). However, its use has been declining, mainly because it is no longer thought of as a complete or accurate conceptual framework due to the recognition of many nonmedical factors that impact disability (e.g., psychosocial factors, environmental influences, Cocchiarella & Andersoon, 2001; Cocchiarella, Turk, & Andersson, 2000; Hunt et al., 2002; Kelly & Field, 1994; Robinson, Turk, & Loeser, 2004; Schultz et al., 2000; Stowell & McGeary, 2005). Within the context of occupational disability, the biomedical and forensic models evolved. The biomedical model primarily involves two individuals [the patient (injured worker) and the treating physician], and the decision to RTW is mainly based upon the evaluation done by the physician, the treatment, and any recommendations involving the injury (Pransky, Shaw, Franche, & Clarke, 2004; Schultz et al., 2000). The forensic model (formerly known as the “insurance model”; Schultz et al., 2007) mimics the psychosocial approach (Hadjistavropoulos & Bieling, 2001; Sherman & Ohrback, 2006) by integrating cognitions and motivations, in the context of compensation-related factors arising from interactions between the injured worker and the disability benefit system. Finally, the biomedical model relies heavily on the quest for objective findings of impairment, whereas the forensic model attempts to explain the motivations that may influence the worker’s RTW decision. One commonality between the two models is that they both primarily rely on an individual focus on the patient (Schultz et al., 2007). Both models, however, do not apply well to those individuals with complex chronic pain conditions. Table 24.2 provides a summary of the features of the biomedical and forensic models.

The primary focus of ecological and economic models is taken from the viewpoint of the stakeholder, where the decision and determinants of RTW are conceptualized as reflective of a complex multisystem interaction among the workplace, disability payers, insurance carriers, and healthcare utilization professionals (Schultz et al., 2007). One noted strength of these models is their complex and multidimensional nature. However, these models do require more construct validity investigation and further development in order to understand the key contributions of the system components and their interactions (Schultz et al., 2007). To date, this goal has not been accomplished. The models, though, do differ in terms of their basic foundations. While the ecological/case management model is founded on a whole host of disciplines, including anthropology, health psychology, industrial/organizational psychology, nursing, occupational health and therapy, sociology, and social work, the economic model is tightly tied to the field of economics (Schultz et al., 2007). In addition, the ecological/case management model is focused on the role of systems and the impact of systems on the individual. Most of the input coming from Bronfenbrenner’s systems theory (Bronfenbrenner, 1979), involving the interaction of microsystems, mesosystems, and macrosystems (Baril & Berthelette, 2000; Friesen, Yassi, & Cooper, 2001; Krause & Ragland, 1994; Loisel et al., 2005; Loisel, Durand, et al., 2001), is incorporated in this ecological/case management model. Loisel et al., (2001, 2005) has presented and also empirically validated the most up-to-date ecological/case management model of RTW. Loisel’s conceptual model of RTW and secondary prevention is illustrated in Fig. 24.1. This model emphasizes that the most important stakeholders are the workplace, healthcare system, and compensation system, and the actions and attitudes of these stakeholders are crucial in conceptualizing RTW. The economic model focuses mainly on macrosystem factors (Baldwin & Johnson, 1995; Baldwin et al., 1996; Butler, Johnson, & Baldwin, 1995; Chirikos & Nestel, 1984; Johnson & Baldwin, 1993). Table 24.3 summarizes the key features of this model.

The ergonomic perspective of disability focuses on understanding the interactions among humans and other elements of a system and then applying these principles and methods to optimize human well-being (International Ergonomics Association, 2012). While the field of ergonomics covers three distinct disciplines (physical, cognitive, and organizational) in the context of disability, this section will focus on the physical and cognitive aspects of the model. Table 24.4 summarizes the major features of this model.

Currently, the focus of the earlier psychiatric perspective of disability, which centered primarily on psychopathology, has evolved into a broader psychosocial adaptation perspective (Schultz et al., 2007). According to the psychological/psychiatric perspective, RTW is considered a behavior, associated with sets of respective cognitions and affect. Additionally, in this model, occupational disability is no longer viewed as an individual attribute, but as a product of the interaction between the worker’s immediate social environment and other societal institutions (Baril & Berthelette, 2000; Olkin & Pledger, 2003; Schultz & Gatchel, 2005; Tate & Pledger, 2003). The concepts of expectations of outcome and efficacy in predicting an individual’s ability to achieve a desirable outcome, such as RTW, have been gaining empirical research support (Cole, Mondloch, & Group, 2002; Sandstrom & Esbjornsson, 1986; Schultz et al., 2004; Turner et al., 2006). This perspective suggests that Bandura’s social learning theory (Bandura, 1977, 1986) may still hold significant conceptual promise, this time in the RTW context. Some of the mechanisms underlying disability in this model focus on beliefs, expectations, perceptions, locus of control, self-efficacy, and coping skills of the individual (Burton, Tilloston, Main, & Hollis, 1995; Haldorsen, Indahl, & Ursin, 1998; Jensen, Romano, Turner, Good, & Wald, 1999; Linton, 2000; Turk & Gatchel, 2000). Recent work with this model has included not only the role of the individual’s cognitive-behavioral attributes but also psychosocial factors of systems including the workplace, unions, healthcare, and disability insurers (Franche, Baril, Shaw, Nicholas, & Loisel, 2005; Schultz et al., 2007; Stowell & McGeary, 2005; Sullivan, Feuerstein, Gatchel, Linton, & Pransky, 2005). Table 24.5 provides a summary of the features of this model.