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Running head: WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS
The effects of work hardening and early return to work interventions B00529042 Thomas Stanley Return to Work 4030 Dalhousie University August 19, 2011
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS The effects of work hardening and early return to work interventions Each year billions of dollars are lost through “lost time, decreased productivity, worker’s compensation costs, liability insurance and legal fees (Baker, Goodman, Ekelman, & Bonder, 2005, p. 21). The financial burden of occupational injuries has constantly been on the rise in Canada for the past few decades (Baker et al., 2005; Greenberg & Bello, 1996; TschernetzkiNeilson, Brintnell, Haws, & Graham, 2007). Not only are occupational injuries costly they have short term and long term affect on the injured employee including “financial effect of lost income, the psychological impact of lowered self-esteem, and potential changes in social status, including divorce and family separation” (Baker et al., 2005, p. 21). In the 1970’s the first interventions were being developed to help injured employees make a safe and successful return to work. In addition, these interventions lower the costs related to occupational injury (Sang, & Eria, 2005; Voaklander, Beaulne, & Lessard, 1995). Many return to work interventions have been implemented in Canada for example “work hardening, ergonomic approaches, job accommodation, education and prevention, and psychological approaches” (Baker et al., 2005, p. 23). The return to work process is a multidisciplinary collaboration with various health care professionals working with the transitioning employee. Various healthcare professional may include a physician, occupational therapist, physical therapist, psychologist, exercise therapist, and technical instructor. Their goals and objectives are the same; to return the employee back to “productive employment” (Baker et al., 2005; Voaklander et al., 1995). Most return to work interventions measure their effectiveness by asking two questions, what were the effects on the physical impairment? And secondly, did the employee return to work (Beissner et al., 1996)? But are these interventions really effective? Are they producing there desired outcome?
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS Due to the billions of dollars lost each year in Canada because of occupational injuries it is especially important to evaluate the cost effectiveness of these interventions. This paper will review the literature on the effects of work hardening and early return to work interventions. A significant number of research studies have been conducted on work hardening and early return to work interventions. Studies explore such avenues like the effects, predictors of success and the cost effectiveness of the interventions. Methods The peer reviewed articles used in this paper were found on the CINAHL database. The key search words included: accommodation, benefits, cost effective, early return to work, effects, functional restoration, injuries, interventions, modification, occupational, outcomes, programs, return to work, work conditioning, work hardening. A total of 10 peer reviewed articles are used in this paper. Although there are hundreds of return to work interventions available in Canada, many of them have the same elements and concepts, for this reason the paper will focus on the generally accepted theories and practices used today. Review of literature Work hardening interventions The goal of a work hardening intervention is to return the injured employee back to work in a timely manner; usually the intervention lasts about four to eight weeks. The intervention usually runs five days a week and commences with shorter hours then gradually builds up to eight hours. During this time the injured employee will be receiving necessary services and treatment (Greenberg & Bello, 1996; Johnson, Archer-Heese, Caron-Powles, & Dowson, 2001;
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS Voaklander et al., 1995). In the being stages of the intervention testing on the injured employee is usually completed. For example an injured employee with low back pain may undergo the following set of tests, “neuromusculoskeletal examination, including major joint range of motions, manual muscle testing of trunk and extremity musculature, and a functional capacity evaluation” (as cited in Greenberg & Bello, 1996, p. 38). The purpose of the functional capacity evaluation is to better understand the current functional and vocational status of the employee. Work hardening interventions were developed to concentrate on the injured employee’s “physical, functional, behavioral, and vocational needs” (as cited in Wiegmann, & Berven, 1998, p. 37). Work hardening activities include “graded work-simulation tasks, training in proper body mechanics, stretching and strengthening exercises, educational programs, as well as aerobic activities to increase cardiovascular fitness and endurance” (as cite in Wiegmann, & Berven,1998, p. 38). Another essential component intergraded into a work hardening intervention is that use of a psychologist or therapist to address the psychosocial issues of the injured employee (Wiegmann, & Berven, 1998). Common psychological issues addressed were “fear, anxiety, anger, depression, and other psychosocial barriers to successful return to work” (Beissner, Saunders & McManis, 1996, p. 1192) The goal of the work hardening physical activities is to increase the functions and strengthen to the injured area. Greenberg and Bello (1996) suggest that the “intensity of the tasks begins at approximately 25% of the maximum levels established by the functional capacity evaluation and is progressed by small weighted increments and/or increased task duration as tolerated” (38-39). Work hardening interventions often have work simulated activities the idea is to mimic the true work environment as closely as possible; for instance the “amount of resistance, positions, pace,
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS and frequency and duration of work-related tasks... using actual work materials when feasible” (Beissner et al., 1996, p. 1191). The results of work hardening interventions vary, however studies have reported results ranging from 45% up to 93% (Tschernetzki-Neilson et al., 2007). In a study by Niemeyer and colleague the results “found that approximately 48% of clients discharged from worker rehabilitation programs returned to their usual jobs, whereas 16% returned to modified work and another 14% went to work in different jobs than they had prior to injury” (Beissner et al., 1996, p. 1189). In another study of a work hardening intervention it reports 82.27% “return to work in some capacity when they were contacted at 3 months post program completion” (Johnson et al , 2001, p. 239) also important to note that the largest portion of that group returned to their preinjury position (Johnson et al , 2001). A multitude of studies has reported on the outcomes of work hardening interventions. Some of the effects of work hardening programs include increases in strength, range of motion, improvement of self- esteem, improvement in physical well- being, decrease in pain level, shorter disability time-lapse, decrease in stress and anxiety (Greenberg & Bello, 1996; Voaklander et al., 1995; Wiegmann, & Berven, 1998). Moreover, research has demonstrated that work hardening interventions effect the employees’ perception “shifting perceived responsibility for improvement in physical well-being from service providers to the workers themselves” (as cited in Wiegmann, & Berven, 1998, p. 84). Other effects on the employee’s vocational status include “improved income, return to work, or self-rated work capacity” (Beissner et al., 1996, p. 1189).
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS Early return to work intervention Studies have demonstrated that early return to work intervention is an important element in a successful and timely return to work. As the time off work increases the likelihood of the employee returning to work decreases (Niemeyer, Jacobs, Reynolds-Lynch, Bettencourt, & Lang, 1994; Tschernetzki-Neilson et al., 2007). The goal of early return to work intervention is to minimize the disability period and gradually re-enter the injury employee into the work environment. For early return to work the injured employee may need to return to modified or accommodated work, for example the employer may have to a modify the work schedule, “modify tasks, workstations and equipment, in order to maximize occupational performance and safety” (Shamberg, 2005, p. 186). The effects of early return to work interventions that have been reported include reduced sick leave, cost effective, decreased disability payments, greater satisfaction, perceptions of their abilities and pain levels improved, increased optimistic about being capable of work and were more confident in their abilities. (Tschernetzki-Neilson et al., 2007). As disability times increase the “psychological profile may also change, resulting in a lessening of coping skills and the development of pain-focused behavior (Greenberg & Bello, 1996, p.37). By implementing an early return to work intervention employees will have less disability days and the likelihood of becoming more disengaged, directly affecting the percentage of return to work (TschernetzkiNeilson et al., 2007). Cost effects The large cost of occupational injury in Canada makes evaluating the cost effectiveness of these interventions essential. Evidence is needed to demonstrate the cost benefits of these interventions due to the successes of reaching the desired outcomes, and ultimately returning
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS employees to work and thus decreasing the lost time, increasing productivity, and “decreasing worker’s compensation costs, liability insurance and legal fees” (Baker et al., 2005, p. 21). In one study conducted by Greenberg and Bello they concluded that their work hardening intervention was cost-effective for insurers, as in this case, saving an estimated $44,000 (Greenberg & Bello, 1996, p.37). The breakdown is as follows: the work hardening intervention was 27 days in duration (four to eight hour sessions) and included the functional capacity evaluation; the total cost was $5,400. It was estimated that “had not been closed via this program, the insurance company ... estimated a cost of $40,000 paid out for the indemnity settlement plus at least an additional $10,000 in medical costs” (Greenberg & Bello, 1996, p.42). In addition, research shows that “Workers' Compensation costs were lower for clients who participated in a worker rehabilitation program, compared with clients who received other forms of treatment” (Beissner et al., 1996, p. 1190). Limitations Due to the vast majority of interventions available today and not one of them is the exact same therefore it is difficult to compare them to one another. Variations in the program design, characteristics of the participants, the type of control group used and evaluations are all factors decreasing the significant of the comparison.
Conclusion In summary this paper examined the effects of work hardening and early return to work interventions and there costs effectiveness. Conclusions were made that there were positive effects from both interventions in aiding the injured employees return to work efficiently. It is
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS essential to evaluate the effects of these interventions because just like any other product people are buying into they must see results, in particular stakeholders.
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS References Baker, P., Goodman, G., Ekelman, B., & Bonder, B. (2005). The effectiveness of a comprehensive work hardening program as measured by lifting capacity, pain scales, and depression scores. Work, 24(1), 21-31. Beissner, K., Saunders, R., & McManis, B. (1996). Factors related to successful work hardening outcomes. Physical Therapy, 76(11), 1188-1201. Greenberg, S., & Bello, R. (1996). The work hardening program and subsequent return to work of a client with low back pain. Journal of Orthopaedic & Sports Physical Therapy, 24(1), 37-45. Johnson, L., Archer-Heese, G., Caron-Powles, D., & Dowson, T. (2001). Work hardening: outdated fad or effective intervention?. Work, 16(3), 235-243. Niemeyer, L., Jacobs, K., Reynolds-Lynch, K., Bettencourt, C., & Lang, S. (1994). Work hardening: past, present, and future -- the work programs special interest section national work-hardening outcome study. American Journal of Occupational Therapy, 48(4), 327339. Sang, L., & Eria, L. (2005). Outcome evaluation of work hardening program for manual workers with work-related back injury. Work, 25(4), 297-305. Shamberg, S. (2005). Occupational therapy practitioner role in the implementation of worksite accomodations [sic]. Work, 24(2), 185-194.
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WORK HARDENING AND EARLY RETURN TO WORK INTERVENTIONS Tschernetzki-Neilson, P., Brintnell, E., Haws, C., & Graham, K. (2007). Changing to an outcome-focused program improves return to work outcomes. Journal of Occupational Rehabilitation, 17(3), 473-486. Voaklander, D., Beaulne, A., & Lessard, R. (1995). Factors related to outcome following a work hardening program. Journal of Occupational Rehabilitation, 5(2), 71-85. Wiegmann, S., & Berven, N. (1998). Health locus-of-control beliefs and improvement in physical functioning in a work-hardening, return-to-work program. Rehabilitation Psychology, 43(2), 83-100.