Historical Overview

Hand therapists and surgeons have long recognized the importance of work-oriented activities in the rehabilitation process as the ultimate treatment tool to restore range of motion (ROM), strength, and coordination. Work-oriented programs in hand therapy have two notable births: one in India and the other in the United States. In India in the early 1950s, hand surgeon Paul Brand recognized that to receive the optimal benefits from his surgical technique, the operated hands needed comprehensive rehabilitation, including work-oriented tasks. After World War II, Earl Peacock, MD, and Irene Hollis, OTR, organized a hand rehabilitation unit incorporating work-oriented therapy at the University of North Carolina at Chapel Hill. Fueled by an increasing commitment to the concept of comprehensive rehabilitation to return the injured worker to gainful employment, work program centers multiplied.

The growth of work-oriented programs required the development of standards and guidelines. In 1984, California occupational therapists and work evaluators developed work-hardening guidelines and program criteria that have served as the basis for the development of work-hardening programs in the United States. In the early 1980s, the American Occupational Therapy Association (AOTA) actively focused on the role and content of work hardening in rehabilitation with peer-reviewed articles and national education. In 2009, AOTA published new guidelines. In 1989, the Commission on Accreditation of Rehabilitation Facilities (CARF) published its first work-hardening standards manual covering a wide range of issues. During the past decade, CARF has not continued to focus on work-oriented programs. In 1991, the American Physical Therapy Association (APTA) “established the Industrial Rehabilitation Advisory Council (IRAC) to classify the levels of work rehabilitation to accurately reflect contemporary practice, to standardize terminology and to address the needs of patients/clients, providers, regulators and payers.” APTA then developed its own guidelines for work-conditioning programs for injured workers with only physical problems to apply to private practices, rural settings, small institutions, and industrial settings and subsequently developed guidelines for work-hardening programs as a viable alternative to the CARF standards. It has updated these standards, most recently in 2009.

The American College of Occupational and Environmental Medicine (ACOEM) has developed guidelines that worker compensation administrators in the State of California currently use as a basis for reimbursement. With a finger on this important pulse, APTA is reviewing these guidelines in consideration of how these might affect their own position. AOTA has collaborated with ACOEM to help define the occupational therapist’s role in rehabilitation, in chronic pain management, and in facilitation of return to work. The establishment of guidelines helps to set a standard that benefits both the clinician in establishing a quality program and the insurance companies and physicians who might refer to such programs. Ultimately, such guidelines assist the injured worker, advancing him or her to the next level of function.

As early as 1988, May identified that significant numbers of insurance claims adjusters did not recognize work hardening, and many described the low perceived efficacy of the program. These data foretold the ensuing problems that work-hardening programs would have in sustaining funding. By the year 2000, formal work-hardening programs in the United States had waned due to fewer referrals and inadequate reimbursement. Some work programs, such as ergonomic interventions and on-site return-to-work programs, became more prevalent. The types of injuries resulting from the 2003 Iraq war brought about renewed research into prosthetics that would permit a high level of function. The high number of surviving wounded also fostered development of return-to-work programs for soldiers with polytrauma including a combination of both orthopedic injury and head trauma. Both guideline development and the design of strategic programs will continue to evolve as do the unique needs of injured workers. However, research into program efficacy, although critically needed, has lagged.

The Evidence Regarding Work-Oriented Programs

The past decade has seen a dramatic decrease in literature pertaining to the practice and efficacy of work-oriented programs. A relatively small number of articles focus on back injury patients rather than those with upper limb disorders. Although one might conclude that back injuries have a higher incidence and more workdays lost, a recent bulletin from the U.S. Department of Labor and Statistics indicates relatively equal rates of both injury regions as well as little discrepancy in workdays lost in both government and private industry workers. The previously described decrease in funding for this therapeutic approach coupled with fewer practitioners has had the inevitable outcome of producing fewer research studies. Although many individual clinicians have taken work-oriented programs to more sophisticated levels, they have not always been the ones to study outcomes and report them. The literature contains articles that range from systematic reviews to randomized, controlled trials. Some studies look at the effectiveness of comprehensive programs, whereas others target a specific intervention. Interest in work programs extends across borders to first-world countries in North America and Europe. All but one of the succeeding paragraphs summarizes studies within the past decade.

Williams and colleagues performed a systematic review to evaluate the available evidence on workplace rehabilitation interventions for work-related upper extremity disorders (WRUEDs). Beginning with 811 abstracts, the reviewers ultimately chose 8 studies. The small sample sizes, lack of standardized outcome measures, and inadequate reporting of interventions and results of the studies limited their effectiveness. The findings of this review indicate that the current literature does not establish evidence of workplace interventions for WRUEDs. Their findings emphasized the need for further research in this area.

Meijer and colleagues studied the effectiveness of return-to-work treatment programs among patients with nonspecific musculoskeletal complaints, but primarily with low back pain. Eighteen high-quality studies were included in the review reporting on 22 treatment programs with almost 3600 participants. None of the studies reviewed reported negative findings, but the studies with the best return-to-work rates were noted within the treatment groups within the low back pain population. There was no substantive evidence that return to work was accelerated in similar studies of the upper extremity. The authors concluded that patient education about anatomy and pathophysiology (knowledge conditioning), psychological support, neuromuscular conditioning and work-oriented conditioning were essential components of a return-to-work program. They added that participants may also benefit from relaxation training exercises.

Stiens and colleagues addressed the challenges in determining rehabilitation intervention outcomes in patients with upper extremity overuse dysfunction. They describe several factors that interfere with outcome data collection. First, they cite the lack of homogeneity of pathophysiologic processes and diagnoses coupled with multiple secondary impairments, disabilities, and handicaps that limit personal performance. Next, they found that the particular experience of disablement and the expectations that each person brings to the rehabilitation process necessitate an individualized program with unique goals. Because of these factors, they believe that successful outcome measurement of the rehabilitation process must take into account the achievement of individual goals as well as objective scalar quantification of impairments, disabilities, and handicaps that are comparable between groups. Suggesting controlled, dosed treatment studies in “pure” diagnostic patient groups, they propose inclusion of individually devised patient assessments of accomplishment and satisfaction in addition to long-term quantitative reassessment of the person under all domains of disablement and work performance.

Bernaards and colleagues assessed the effectiveness of a single intervention targeting work style and a combined intervention targeting work style and physical activity on the recovery from neck and upper limb symptoms. Pain, disability at work, days with symptoms, and months without symptoms were measured at baseline and after 6 (T1) and 12 months (T2). Self-reported recovery was assessed at T1/T2. They concluded that a group-based work-style intervention focused on behavioral change was effective in improving recovery from neck/shoulder symptoms and reducing pain in the long term; however, the combined intervention was ineffective in increasing total physical activity.

Shaw and Feuerstein studied application of self-report measures of function and exposure assessment for generating workplace accommodations including modified duty in a study of case management services for WRUEDs. Their experience and findings suggest that, to improve the effectiveness and efficiency of accommodation efforts, researchers should develop new tools for assessing function and ergonomic exposures in the workplace to specify accommodations more directly.

Verhagen and colleagues performed a systematic review to determine whether conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments and ergonomic advice) play a major role in the treatment of most work-related symptoms of the arm, neck, or shoulder. They included 21 trials in total. Seventeen trials included people with chronic nonspecific neck or shoulder symptoms or nonspecific upper extremity disorders. Evaluating more than 25 interventions, the reviewers identified four main subgroups: exercise, manual therapy, massage, and ergonomics. They reported on the poor overall quality of the studies. Fourteen studies evaluated a form of exercise, and, contrary to their previous review, they found limited evidence of the effectiveness of exercises compared with massage and conflicting evidence when exercises are compared with no treatment. Their update found limited evidence for adding breaks during computer work and for some keyboard designs compared with other keyboards or placebo in participants with carpal tunnel syndrome.

Lieber and colleagues measured the efficacy of body mechanics instruction in four patients with low back pain using a standardized lifting protocol and compared their performance with 52 controls from an earlier study. The researchers measured static strength, weight lifted, number of lifts completed, and motion analysis data to describe the body mechanics before and after work hardening to evaluate treatment effects. They concluded that intensive instruction in body mechanics provided during the work-hardening treatment produced major changes in lifting styles, in terms of both starting postures and dynamic aspects of repetitive lifting. The computerized measurement procedures used in this study permitted more careful and detailed analyses of body mechanics, particularly dynamic aspects, than is possible with observational methods.

In an older study, Feurstein and colleagues investigated the long-term vocational outcome of a multicomponent rehabilitation program that includes physical conditioning, work conditioning, work-related pain and stress management, ergonomic consultation, and vocational counseling/placement. Two groups equivalent in measures of duration of work disability, pain severity, fear of reinjury, psychological distress, perceived work environment, age, and education level were exposed to either the comprehensive work rehabilitation intervention ( n = 19) or usual care ( n = 15). Return-to-work status was determined at an average of 1.5 years post-treatment. Findings indicated that 74% of the treatment group returned to work or were involved in state-supported vocational training in contrast to 40% of the control group ( P < 0.05). For those who returned to work, 91% of the treatment group were working full time in contrast to 50% of the control group ( P < 0.05). Although the treatment group demonstrated a higher return-to-work rate than controls, the work reentry rate was not as high as that with similar approaches with work-related low back pain (80%–88% return-to-work rate). The researchers believed that the findings suggested the need to modify treatment components to facilitate an increased return-to-work rate, including a greater emphasis on ergonomic and work-style modifications at the workplace to reduce the risks of repetitiveness, force, awkward posture, and insufficient work/rest cycles.

In this study, Himmelstein and colleagues evaluated the demographic, vocational, medical, and psychosocial characteristics of patients with WRUEDs and examined several hypotheses regarding the differences between working and work-disabled patients. Their findings, although cross-sectional in nature, suggest that, in addition to medical management, more aggressive approaches to pain control, prevention of unnecessary surgery, directed efforts to improve patients’ abilities to manage residual pain and distress, and attention to employer–employee conflicts may be important in preventing the development of prolonged work disability in this population. Therapists treating the work-injured population can help these patients with managing pain and distress. Some therapists in work-oriented programs act as liaisons between the injured worker and the employer, facilitating clear and constructive communication that can potentially mitigate employer–employee conflict.

The Work-Hardening Concept

The content of the work-hardening program sets it apart from other rehabilitation regimens. The use of work-oriented tasks to enhance performance is the hallmark of work hardening. Work hardening involves the patient in activities that simulate the resistance, repetition, duration, and biomechanics of the occupation that the patient hopes to assume or resume. Structured and graded tasks progressively increase stamina (energy at top speed), endurance (necessary for prolonged activity), physical tolerance, productivity, and confidence in the injured worker. Relying heavily on actual task replication, work-hardening programs use the concept of specificity. Stated simply, specificity requires that the reconditioning program place stress on the injured worker in a manner similar to which these systems (neuromusculoskeletal, cardiovascular, respiratory, and psychosocial) are required to perform in the workplace. Task performance refines movement and augments efficiency in the process of neuromuscular reeducation. Conditioning via work-related activities promotes increases in strength and endurance in the injured workers.

Work-oriented activities facilitate the accomplishment of one of the often understated goals of the work-hardening program: the maintenance or reinstatement of the injured person’s identity as a worker. Tamayo identified the environment of the work-hardening center as one of the most valuable components of the program. “The ultimate goal of work hardening … is to create a mindset in the injured worker that will prepare him physically and mentally to look forward to (and accept) returning to work after graduating from the program.” The work-oriented center prepares the body, mind, and spirit for return to work.

Work hardening has come to connote a multifaceted program that offers comprehensive services. To provide this intensely holistic approach, the APTA guidelines describe the availability of an interdisciplinary team with the skills needed to address the medical, psychological, behavioral, physical, functional, and vocational components of employability and return to work. The team members may include an occupational therapist, physical therapist, psychologist, and vocational specialist. However, according to McKenna, each organization individually decides how it will run its program and how much treatment a particular discipline will perform. No guideline requires that every client who enters the facility will receive treatment from all the core disciplines or stipulates the length of time that each of the disciplines treats the worker. McKenna goes on to explain that the facility’s responsibilities include the provision of appropriate services to meet the worker’s needs and that the worker’s initial screening process includes assessment to determine whether the worker needs the services of each discipline.

As the work-hardening model has matured, those providing services in work-oriented programs have identified a wider spectrum of programs to maximize health and facilitate return to work. These programs fill previously unmet needs and offer both prevention and a rehabilitation approach. The coalescence of other forms of work-oriented programs creates greater opportunity for all concerned with the well-being of the injured worker.

Contrasting Work Hardening and Work Conditioning

APTA adopted the following operational definitions : work conditioning is an intensive, work-related, goal-oriented conditioning program designed specifically to restore systemic neuromusculoskeletal functions (e.g., joint integrity and mobility, muscle performance including strength, power, and endurance), motor function (motor control and motor learning), range of motion (including muscle length), and cardiovascular/pulmonary functions (e.g., aerobic capacity/endurance, circulation, and ventilation and respiration/gas exchange). The objective of the work-conditioning program is to restore physical capacity and function to enable the patient/client to return to work. Given this definition, the pre- and post-program examination includes history, systems review, and selected tests and measures required to identify the patient’s/client’s individual work-related, systemic, neuromusculoskeletal restoration needs.

Work hardening is a highly structured, goal-oriented, individualized intervention program designed to return the patient/client to work. Work hardening programs, which are multidisciplinary in nature, use real or simulated work activities designed to restore physical, behavioral, and vocational functions. Work hardening addresses the issues of productivity, safety, physical tolerances, and worker behaviors ( Fig. 141-1 ). Based on this definition, the pre- and post-program examination includes all those components of the Work Conditioning Evaluation and also involves a multidisciplinary examination of functional, behavioral, and vocational status. The initial data help to identify patient/client eligibility, design a plan of care, monitor progress, and plan for discharge and return to work. According to APTA, physical therapists, occupational therapists, psychologists, and vocational specialists provide work-hardening services. The APTA guidelines make the following comparisons between the two work-oriented programs ( Table 141-1 ).

Practicing pushing and pulling a person seated in the wheelchair helped this injured worker regain motion, strength, and confidence to perform a task critical to her return to her regular work.

Table 141-1

Comparison of Work Hardening and Work Conditioning

Work Hardening	Work Conditioning
Addresses physiologic, psychological, cognitive, developmental, and interpersonal skills as well as functional, behavioral, and vocational needs within a multidisciplinary model	Addresses neuromusculoskeletal function: strength, endurance, movement, flexibility, and motor control
Requires work-hardening examination and evaluation	Requires work conditioning examination and evaluation
Uses an interdisciplinary team, including OT, PT, psychologist, and vocational specialist	Usually involves only one discipline: OT or PT
Uses real or simulated work activities and education as its primary modalities with some exercise and aerobic conditioning	Uses limited work tasks with more emphasis on exercise, aerobic conditioning, and education
Most appropriate for chronic cases and clients with global problems, especially those with vocational and/or psychological involvement	Most appropriate for early referrals and clients without psychological or vocational complications
Proportionately more costly, but cost-effective for appropriate clients	Proportionately less costly; cost-effective for appropriate clients
More comprehensive	More focused
Tends to require a greater amount of dedicated space	Less amount of dedicated space
Offers specificity of training via actual task replication	Offers general conditioning
Milieu creates a mindset in the injured worker that will prepare him or her physically and mentally to return to work	Although work oriented, milieu resembles gym area rather than work area.
Usually half- or full-day programs; provided in multihour sessions up to 8 hr/day, 5 days/wk, 8 wk	Usually offered as half-day program; provided in multihour sessions up to 4 hr/day, 5 days/wk, 8 wk

 

OT, occupational therapy; PT, physical therapy.

AOTA and APTA both define work hardening as a program that “addresses the whole person with respect to physical, physiological, psychosocial, cognitive, developmental and interpersonal skills.” In contrast, work-conditioning programs are “specifically designed to restore an individual’s systemic, neuromusculoskeletal function (strength, endurance, movement, flexibility, and motor control).” Work conditioning seeks to restore physical health and function so that the patient can return to work or prepare for vocational rehabilitation. Rehabilitation professionals concur that an interdisciplinary team provides work-hardening services, whereas work-conditioning programs usually involve only one discipline, usually occupational or physical therapy. Work tasks and education constitute work hardening’s primary modalities, with inclusion of some exercise and aerobic conditioning, whereas work conditioning uses limited work tasks with more emphasis on exercise, aerobic conditioning, and education.

Most rehabilitation personnel agree that work hardening, although sometimes more costly because of its comprehensive approach, is most appropriate and cost-effective for patients with chronic conditions and those with global problems, especially patients with vocational and psychological involvement. However, for early referrals and patients without psychological or vocational complications, work conditioning seems to offer a highly effective and less costly alternative. Although the dichotomy between these two services seems destined to gain national acceptance, many therapists advocate keeping the comprehensive work-hardening structure. McKenna believes that proponents of splitting work conditioning from work hardening lack a conceptual framework from which they offer work-hardening services to their patients. However, proponents of the two-tiered system have prevailed.

In many hand centers, therapists provide work-oriented programs that, on the continuum of work-oriented programs, fall between work hardening and work conditioning. These therapists carefully and holistically consider each patient to determine which services will most quickly provide optimal function. Although the therapist initially performs a solo assessment of needs without input from the individual disciplines such as vocational rehabilitation and psychology, these needs are regarded. The therapist may attempt to expand the team to meet these needs. Some therapists have, through continuing education, expanded their skills to include abilities such as vocational assessment and intervention. At times, the insurance carrier may resist expanding the team because of cost concerns or the desire to achieve case resolution without further complexity. No matter the program type, it is the therapist’s responsibility to remain sensitive to the patient’s needs and to provide a rehabilitation program that will maximize the many facets of patient function.

Program Philosophy

The work program’s philosophy is key to creating the setting that facilitates return to work. The program’s work orientation remains the foundation, but the therapist should not confuse this orientation with the creation of a harsh or negative experience for the participants. A supportive environment benefits all involved in the program. Just as the healthy workplace promotes camaraderie and positive spirit while workers get the job done as effectively and efficiently as possible, the ideal work-oriented rehabilitation setting promotes health and well-being while accomplishing the program goals for each participant. The injured workers should know that the program managers are working diligently to design the best program for them. The therapist maintains a neutral view of each worker/participant and does not hold preconceived notions about motivation or cooperation. The philosophy that the work program must be rigidly regimented, inflexible, and harsh will yield only failure. Not only will the injured workers be unable to benefit fully from such a program, but the therapists administering the program will find it unfulfilling. Caring and enjoyment can coexist with the serious and important goals of the work-oriented program.

Evaluation and Establishing Candidacy

To determine the worker’s candidacy for a work program and to establish the baseline against which the clinician compares future evaluations, the clinician performs a functional capacity evaluation (FCE). In different geographic areas, the FCE is also known as physical capacity evaluation, work capacity evaluation, work tolerance screening, and functional capacity assessment (see Box 140-2 ). The evaluation has five components :

• 1
  

  Intake or initial interview

  
  
• 2
  

  Subjective evaluation

  
  
• 3
  

  Neuromusculoskeletal examination

  
  
• 4
  

  Physical demand testing (activity testing)

  
  
• 5
  

  Reevaluation

Described in several texts and articles as well as in Chapter 140 , this chapter does not delineate the specifics of the FCE. If the evaluator identifies the worker as a work-hardening candidate, the evaluation findings create a baseline against which the therapist compares all future change in status.

The issue of determining candidacy is the most crucial decision of the entire work program process. Chapter 140 discusses candidacy issues relevant to feasibility, cognition, psychological qualities, and physical functioning for participation in the FCE ( Box 141-1 ). Determining candidacy for participation in an extended work program requires the comprehensive information gathered during the FCE. The therapist reviews the evaluation findings and combines this information with professional judgment and experience to determine whether the evaluee has the potential to benefit from a work program.

Assessment for candidacy must go beyond the accompanying diagnosis. People who participate in work hardening are those “whose medical condition does not prohibit participation in the program.” The initial pathologic condition must be stable. A person who is 5 weeks post–flexor tendon repair cannot participate in work hardening because the tensile strength of the repair at this point after surgery will not tolerate resistive activities and presents a high rupture risk. A person who experiences so much pain that he or she cannot complete the 30-second Purdue Pegboard Test cannot participate in work hardening because of lack of symptom control. In addition, the worker’s general health must be adequate to participate.

The evaluator must determine that “all systems are go.” The author recalls a hand-injured patient referred for a work-hardening program with the occupational goal of diesel mechanic. During the initial evaluation, he revealed that he had been hospitalized for a myocardial infarction 3 months before the evaluation. The evaluation was placed on hold until medical clearance to participate was obtained from the worker’s cardiologist. The evaluator should determine as early as possible that the worker can withstand increasing amounts of physical stress without threat to physiologic integrity as well as tissue homeostasis and continuity.

The evaluation does not cease once the worker enters the program. The therapist must perform periodic evaluations to establish program safety and efficacy. In the case of the patient who was 3 months post–myocardial infarction, periodic evaluation also meant daily monitoring of heart rate and blood pressure. Interim evaluations need not have the same intensive format as the initial evaluation, unless the therapist deems that this is warranted.

Everyone gains from the reevaluation process. The therapist obtains information needed to modify the program for optimal achievement of goals. The worker receives an indication of progress, or the lack thereof, made in the program. This may provide encouragement and/or reality orientation for the worker. When the insurance carrier receives the updates, it will recognize that the facility is monitoring the claimant and is not extending treatment beyond what is appropriate to the goals established at the outset. The reports keep the treating physician informed of patient status and provide data for required documentation.

When the worker has achieved program goals or has ceased to progress, the therapist performs the final evaluation. This may take the same form as the initial evaluation or the clinician may choose an abbreviated version. The write-up of the final evaluation includes the challenging conclusions and recommendations section in which the evaluator must render an opinion as to whether the worker can return to work. The recommendations may include further remedial programs such as dominance retraining or modified workstations and tools. This final report has both life-changing implications for the worker and economic ramifications for society.

Establishing the Treatment Plan

After the worker’s needs are identified and the baseline is established, the therapist develops the treatment plan. When this development process is formalized, it is called the individualized treatment plan (ITP). The ITP involves the same problem-solving approach as the treatment plan for every patient any therapist has ever treated.

Grading Participation

Another key concept of the work program process is activity gradation. Each activity should be available to the worker on a progressively more demanding basis. When designing work tasks, the therapist must maintain control over the demands of each activity. Gradation allows the worker to enhance ability within each physical demand and aptitude ( Box 141-2 ). Although increasing repetition and duration are valid grading approaches, simply adding to the time a worker engages in an activity will not necessarily achieve the return-to-work goal. The therapist grades as many factors as possible, including resistance, ROM, rate, accuracy, coordination, stimuli imparted, and complexity.

Box 141-2

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