What if there was a treatment that was well accepted with scientific validity as being therapeutic, low risk, cheap and proven to improve outcomes and diminish claim duration? Believe it or not, but this treatment exists. It is called work.
Returning an injured worker to the work force is therapeutic and supported by evidence-based medicine and recommended by multiple medical entities including the AAOS, AMA, ACOEM, and most state guidelines, including ours here in Louisiana.
With my patients, I use this example: when an athlete is injured, do we tell them to go sit at home until they are well? No, we don't. We have them on the field to remain a member of the team, participating in exercise and rehab sometimes literally all day every day to get them back to full capacity. I then ask the patient who they think will return to play sooner: the person who was forced to sit at home or the one who was with the team? Most people understand this on an intuitive level. In fact, in my practice, a patient that comes to me after sitting being sedentary for a month or two often report worsening pain since the injury.
Why is this evidenced-based treatment – that is, work – met with so much resistance by employers and injured workers?
To answer this question, we must discuss the three factors that determine return to work. The three factors are risk, capacity, and tolerance.
Risk is assigned by a doctor and speaks to the risk of re-injury by returning someone to work. This is a factor which is typically overestimated by providers in an attempt to avoid liability. It may also be overestimated to avoid disrupting the patient-doctor relationship. The best example of this comes from the work of Dr. Eugene Carragee of Stanford. He wanted to understand the basis for holding someone out of work for six months after a simple lumbar discectomy. In his experiment, Dr. Carragee returned injured workers to work in one week after discectomy, and surprisingly, had no higher re-injury or re-herniation rates by doing so. Admittedly, it is very easy as a doctor to overestimate the risk of re-injury to protect oneself and keep the peace with the patient, but perhaps confrontation is necessary.
The next factor is capacity. Though it is hard to measure, it relates essentially to the maximum abilities of a patient at a given time. I have found length of absence from work is correlated with distance from true capacity, particularly if the absence is prolonged. Current capacity can actually improve towards full capacity by return to work, exercise, and return to normal activities of daily living. This is one reason why it is so important for employers to try to accept graduated work restrictions, rather than adhering to an “full duty or nothing” return to work strategy.
The third factor is tolerance and it is by far the most important. Tolerance refers basically to the amount of discomfort or inconvenience a patient is willing to accept to return to work. In most cases, tolerance is what effectively determines when a patient returns to work. This is really a biopsychosocial concept more than a true biomedical or purely physiological concept. Tolerance is often less than current capacity and influenced by rewards structure and the personality of the claimants.
For example, when I have a patient who has been unable to return to work for a very long period, he or she may ultimate accept permanent restrictions at maximum medical improvement (MMI). Then remarkably, when the same patient gets a much better job offer and needs a release to go back to work, I might ask, but what about your injury? The answer often is something like this: ever since I got this job offer, I have been so excited that I haven't been thinking about my injury anymore.
In reality, the old permanent restrictions may not have been necessary, but were probably based in large part on tolerance. Someone who doesn't like their job or boss, or who has family issues like a sick parent or child, or who finds their situation better at home than at work may choose not to tolerate any pain to return to work.
Further, fear avoidance behavior is a major factor here, in that our society tells us that we are not supposed to feel any pain. Pain is normal after an injury and doesn't necessarily get better from doing nothing. The “no pain no gain” mantra isn't necessarily true, but enduring some pain is normal after an injury to get better. The patient who is afraid to move their shoulder after rotator cuff surgery usually makes the situation worse because the shoulder gets stiff and painful.
Additionally, the manner in which someone is treated after an injury by their boss and coworkers can certainly influence tolerance. If it is a better deal financially to stay at work on light duty, then a worker is more likely to tolerate returning to work. A truck driver who makes $1,500-2,000 per week normally is unlikely to see much benefit in, and thus is unlikely to tolerate, performing a light duty clerical job for $8.50 an hour.
Educating employees at the time of hire and at regular intervals during their employment with the company that the company will accommodate and expect light duty throughout recovery from an injury might help, but the company has to be sure their rewards make sense. I can't proclaim strongly enough that this is a biopsychosocial concept and not purely physiological. The most powerful factor in return to work is the patient's desire to return.
Where do FCEs fall with respect to usefulness for return to work?
Functional capacity evaluations (FCEs) are inherently flawed because in most cases patients are asked to sign something that says they will not harm or injure themselves while doing the FCE. This makes the FCE effectively a tolerance test rather than a capacity test. Often, FCE results say the patient self-limited due to pain, but isn't that what they were told to do when they signed the consent to do the FCE?
At best, an FCE is a current ability test rather than a true test of capacity because capacity implies an optimally tuned patient – and as I've explained, someone who has not been working is not accessing their true capacity. In my practice, I find FCEs useful only for confirming that a claimant is consistently inconsistent, since there are so many hours of observed testing of the patient. Otherwise, an FCE is only slightly better than just asking a claimant what they think they can do at work, since we ask them not to risk pain or injury while doing the test.
In fact, some research comparing a full FCE with functional interviewing by a physical therapist found that performing an FCE did not lead to improvement in return to work rate or functional work level – just having a therapist discuss work ability performed nearly as well.
So where does this leave us to decide how to assign work restrictions?
There is often a lack of consensus from physicians on appropriate work restrictions. The best we can hope for are restrictions that are based on the risk of re-injury, but that take into account what the current capacity of the claimant is.
Often, gentle negotiations regarding tolerance, with gradual increases in work status, can be accepted by the claimant. Foreshadowing subsequent visits by setting expectations regarding return to work can also be helpful, as is an accommodating employer. Return to work is good for all stakeholders.
References:  Eugene Carragee et al Spine 1996; volume 21,#16: 1893-1897 and Spine 1999;24 (22); 2346-2351 Gross DP, et al. J Occup Rehabil 2014; 24(4): 617-30
ABOUT THE AUTHOR
Dr. Douglas Lurie, author of this guest post on Louisiana Comp Blog, is a board-certified orthopaedic surgeon withOrthopaedic Associates of New Orleans. He completed his Orthopaedic Surgery internship and residency at Ochsner Clinic Foundation in New Orleans, where he was a chief resident. In the workers' comp arena, Dr. Lurie has performed thousands of utilization reviews since the Medical Treatment Guidelines were implemented. He is also the National Medical Director for Propeer, a URAC-certified independent review organization.
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