For an injured worker who has been away from the job for an extended period of time, re-entry into the workforce can prove challenging, both physically and psychologically.

Advanced work rehabilitation (level II return-to-work) programs can significantly improve the likelihood of a successful transition and help to prevent re-injury — if the right rehabilitative path is chosen.

However, factors such as time away from the job and degree of injury can complicate this decision.

In addition, the best practices for return-to-work programs have changed over the past few years, so it’s important for therapists and claims managers to understand the rationale behind and effectiveness of these updated concepts.

Workers’ compensation professionals who’ve been in the field for some time are probably familiar with the terms “work hardening" and "work conditioning” as options to prepare recovering employees to return to the workforce.

These terms have been updated to include newer, more flexible approaches, which are often referred to as “advanced work rehabilitation” or “level II return-to-work” programs. However, the program concepts continue to promote the goal of injured employees either staying at work or returning to work.

Confused yet?

The American Physical Therapy Association provides work rehabilitation guidelines, but many clinicians may not be aware of them or may have their own individualized definition. As a result, providers could prescribe more therapy than necessary or appropriate, or too little to adequately prepare for work re-entry.

By thoroughly examining the different types of rehabilitation programs in workers’ compensation, claims managers can provide the most appropriate care to an injured worker and, ultimately, allow them to return to work quickly and safely.

Work hardening and work conditioning

Work-hardening programs were first developed to prepare injured workers physically and mentally to return to full duty, while conditioning them to either handle the demands of their former job or improve physical function enough to re-enter the workforce.

Although the American Physical Therapy Association has broadened the formal definition, it was historically understood that work hardening addressed physical, functional, behavioral and vocational needs within a multidisciplinary model. Typically, work hardening was provided in multi-hour sessions, up to eight hours a day, five days per week for up to eight weeks in duration. The therapy often took place in a setting that simulated the actual work environment — a factory, store or warehouse — and addressed issues of productivity, safety and employee behaviors.

For the majority of cases, a work-hardening program was used for skilled laborers, such as bricklayers or construction workers, or for those with physically demanding jobs, such as firefighters who had been out of work for a year or more. The classic work-hardening program is rarely used any longer. Because so few injured workers actually need this intensive program, the costs have become prohibitive.

Work-conditioning programs currently consist of a customizable return-to-work approach that typically provides therapy for about four hours a day, three to five days a week, for up to eight weeks, and focuses on physical or occupational therapy. While work hardening uses real or simulated work activities, work conditioning uses physical conditioning and functional activities related to the injured employee’s occupation.

Work-conditioning programs tend to be fairly aggressive — almost like a “boot camp” — to get injured workers to the physical level at which they can perform their job duties.

Level II return-to-work programs

Work conditioning co-existed with work hardening, and eventually the two programs were merged to form the more current concept of level II return-to-work programs.

Currently, it’s common to hear the terms used interchangeably among payers, referral sources and providers. There are specialized pain programs and physician-led functional restoration programs with a substantially higher cost in the market available for highly involved, specific individuals. However, the majority of injured workers meet the criteria for a therapy-based work rehabilitation program.

Return-to-work programs today are:

- Tailored to the individual.
- Consist of warm-ups, stretching, full body conditioning and functional activities (for example, lifting, pushing and pulling, and non-material handling activities such as climbing, squatting, reaching or kneeling).
- Delivered by a single discipline, either physical or occupational therapy, and supported by other clinical personnel, such as assistants or athletic trainers.

The approach targets the injury combined with functional job deficits.

Modern return-to-work programs

The return-to-work program could extend from a single hour to multi-hour sessions, depending on the evaluation of the injured worker, the plan of care and options or availability for work reintegration. Although the program usually only involves a single discipline, other professionals can be involved as needed.

Having regular evaluations along with a clearly defined treatment plan is critical to the success of any work rehabilitation program.

When devising a program, employers should keep the following issues in mind:

- A return-to-work treatment plan, performed by physical and occupational therapists, addresses functional deficits or major limiting factors related to return-to-work and uses work-specific goals. For example, short-term goals could be increasing the injured employee’s lifting tolerance by 10 pounds in two weeks; a long-term goal could be increasing lifting capacity to 50 pounds to meet return-to-work requirements.
- The injured worker can be discharged when all the treatment plan goals are met, and the maximum benefit has been realized.
- An evaluation or report will also be generated, noting the reasons for discharge, the abilities or deficits as related to return-to-work goals, and recommendations regarding whether essential job functions for return-to-work are met. This will allow the primary treating physician to make final return-to-work determinations.

Both employers and payers will benefit from using level II return-to-work programs. After completing such a program, employees and employers know that the returning worker possesses the functional strength and ability required as measured by achieving pre-determined rehabilitation goals and objectives, effectively bridging the gap between the rehabilitative therapy and return-to-work worlds.

Today’s level II return-to-work programs continue to provide the intensive retraining and conditioning to get the injured worker prepared to report back to the workplace, but in a more streamlined and focused manner than historically defined work-hardening programs. They achieve the same goal — safe and effective re-entry into the workforce — at less cost and time than previous concepts.

Level II return-to-work success story

Recently, a firefighter was injured and was referred to a return-to-work program. The treatment plan focused on conditioning his leg muscles during functional work tasks specifically related to ladder climbing, pulling, carrying, lifting and walking on nonlevel surfaces. He performed these recommended movements for four hours a day, five days a week for four weeks. As a result of this comprehensive treatment plan, he was able to return to regular duty as a firefighter with no restrictions.

If, however, he had been referred to a physical therapist for 22 sessions and had not had a comprehensive conditioning plan, the result could have been much different. Without the intensive, specialized training, he could have experienced continued instability with functional job tasks, leading to dangerous situations and potential re-injury.

When treating an injured worker, it’s critical for care teams to keep in mind that collaboration is imperative throughout the life of a claim. As American Physical Therapy Association cites in its guidelines, common goals “appear critical for good clinical management and outcomes.”

When rehabilitation teams work together with a clear understanding of today’s terminology and desired outcomes, injured workers will get back to work faster and safer with the confidence that they can perform their job duties again.

Michelle Despres, PT, CEAS II, is the vice president and national product leader at Jacksonville, Florida-based workers' compensation rehabilitation provider Align Networks. Email her at mdespres@alignnetworks.com.

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