Return to Work after MSK Injury in the Workplace: Factors leading to timely return and risk factors for delayed return

Author(s): Alexander M Senk, MD, Christopher Meserve, MD, Michael H Nguyen, MD, MPH

Originally published:10/06/2015

Last updated:10/26/2019

1. DISEASE/DISORDER

Definition

Occupational Safety and Health Administration (OSHA) defines occupational injury as an injury that results from a work accident or from a single instantaneous exposure in the work environment.  An occupational illness is an abnormal condition or disorder other than one resulting from an occupational injury, caused by an exposure to environmental factors associated with employment.  A work related disorder is a disorder that affects work. It may not necessarily be caused or aggravated by work.

Etiology

A systematic review lists heavy physical work, high body mass index, high psychosocial work demands, and smoking as primary risk factors for occupational injury.  An additional risk factor for neck pain is posture, and younger age is a risk factor for low back pain.  The same review indicates prolonged computer work, older age, female gender, awkward posture, and repetitive work as risk factors for wrist and hand pain 1.

Musculoskeletal injuries in the workplace are often related to cumulative trauma disorders, which mainly involve the upper extremity and back. Upper extremity nerve entrapments like carpal tunnel syndrome are prevalent as well. Both activities at work and outside of work that involve abnormal or poor posture (i.e. slouched posture or hyperextension/flexion of a joint). These positions can lead to increased pressure on nerves, shortened muscles leading to tightness, or weakness of muscles. Additionally, task repeatability with limited variety of tasks, decreased break time, increased expectations and an aging workforce 2.

Although upper extremity and back strains or sprains were among the most common injuries, an article describing general practitioner and occupational medicine provider reported cases highlights psychological causes of injury or illness at work and psychological barriers as a fairly common issue. This was attributed to the nature of the workplace. For example, a majority of the work-related injuries occurred in manufacturing, however many workers were seen from professions like police forces. Nevertheless, the majority of cases reported a fall or slip from ground level or a height, heavy lifting or carrying of items, or exposure to a harmful chemical or device (i.e. needle sticks) rather than psychological trauma related to altercations 3.

Epidemiology including risk factors and primary prevention

In 2018, the Bureau of Labor and Statistics recorded 2.8 million nonfatal workplace injuries and illnesses that occurred at a rate of 2.8 cases per 100 full-time equivalent workers. Nearly one-third of nonfatal occupational injuries resulted in days away from work.  Musculoskeletal disorders accounted for 34% of the days away from work cases in manufacturing alone.  Although the number of days away from work has decreased recently, the median days lost in manufacturing was found to be 12 as of 2018.  Sprains, strains and tears were the leading kind of injury in the manufacturing sector, and the days away from work due to this specific injury was 10 days4.  Men accounted for 61% of cases and workers age 45-54 years old had most worked days missed.  There were 212,080 back injuries.  The hand was the most commonly injured area in the upper extremity and the knee was the most common area in the lower extremity.  The median days away from work after injury were 13 for private industry, 14 days for local government, and 16 days for state government 5.

The National Institute for Occupational Safety and Health (NIOSH) reports demonstrate that two specific work groups have higher rates of back injuries: 1 – operators, fabricators, and laborers & 2— precision, production, and repair workers 6.  According to Liberty Mutual, the largest compensation insurer in the United States, work related musculoskeletal injuries cost employers 13.4 billion dollars annually.  Nationally, such injuries lead to a loss of 45-54 billion dollars annually 7.

For primary prevention, there is moderate evidence that lumbar supports are not effective in preventing or in the treatment of low back pain 8.  There is some evidence that the use of lumbar supports may be of value in preventing recurrent work related low back pain in high risk employees 9.  Nurses with mechanical lifting devices and lifting teams in their workplace are significantly less likely to have a musculoskeletal injury 10.  Exercise frequency significantly correlated with reduction in low back pain over a 10-year period 11.

A review suggests educational interventions focused on biomechanics are not effective in preventing low back pain 12.  A report showed that physical therapist led educational program of postal workers did improve subjects’ knowledge of safe behaviors but did not reduce the rate of low back injury, cost per injury, time off from work, or rate of related or repeated musculoskeletal injures 13.  Other reviews have concluded follow-up of education and yearly educational programs are critical to apply successful injury prevention strategies 14,15.  In a recent review of ergonomic interventions for upper extremity and neck among office workers, there was no evidence that arm supports and neutral posture mouse prevent work related musculoskeletal injuries 16.

Patho-anatomy/physiology

Repetitive use is the main reason for workplace injuries.  For example, nearly 65% of new occupational injuries could be attributed to repeated trauma.  Likely pathophysiology of repetitive use disorders, particularly for upper extremity injuries such as carpal tunnel syndrome, include inflammation followed by repair, fibrotic scarring, and nerve injury if applicable to the anatomic area 17.  Inflammation is hypothesized to be a contributor to pain and loss of function with repeated overstretch, compression, friction, and even ischemia.  This may cause prolonged activation of IL-6 and PGE2.  There has also been evidence of ischemic injuries with overuse injuries that are not associated with inflammation.  However, evidence remains limited due to small sample sizes and heavy dependence on animal models.

In terms of another common cause of workplace injury, low back pain has varied etiologies. This includes cumulative low back loads which have been shown to be a significant risk factor for the occurrence of low back pain later on in one’s life 18.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time):

Only 10% of compensation back patients are still receiving benefits at 3 months. Only 50% of those remaining will return to work 19.  There has been an upward trend among Social Security Disability Insurance claims from individuals with both mental health and musculoskeletal disorders, increasing from 30% in 1984 to approximately 52% in recent years 20.

Among patients with repetitive use injuries, pain is the most common reported complaint. These injuries are usually caused by three main domains: muscle, tendon, and nerve injury. Many times, these injuries occur in tandem in cases such as carpal tunnel syndrome where repetitive motions may lead to tenosynovitis causing narrowing of the carpal tunnel and subsequently compression of the median nerve.  This may lead to neuritis or nerve injury resulting in pain, dysthesias, muscle weakness and atrophy.  According to the Canadian Centre for Occupational Health and Safety, repetitive use injuries may progress through the following stages 21:

Early:  Symptoms of aching, discomfort and fatigue will occur with overuse.  Symptoms often resolve after discontinuation of activity.  There is no work performance reduction.

Intermediate:  Symptoms of aching, discomfort, and fatigue occur with overuse and persist after discontinuation of activity.  There is work performance reduction.

Late:  Symptoms of aching, discomfort, fatigue, and weakness persist with rest.  Inability to sleep and perform light work duties.

In general, treatment of these injuries is focused on restriction of aggravating movement, application of physical modalities such as cold and heat, therapy, exercise, and medications such as anti-inflammatories, and surgery in advanced cases. A graded approach to returning to work and performance of the offending activities should be undertaken with the guidance of a physician, physical therapist, occupational therapist, and other appropriate disciplines.

Specific secondary or associated conditions and complications

Up to 95% of claimants had comorbid personality disorders 22.  Claimants with premorbid depression have increased likelihood of developing chronic pain 23. Prolonged unemployment increases both physical and mental morbidity and mortality 24.

In terms of one of the most common injuries – low back pain, the specific cause is not always identified. Approximately 90% of all LBP patients have at times been diagnosed with nonspecific LBP 25.  Common biomechanical abnormalities leading to lower back pain include: muscular/ligamentous strain or sprain, obesity, herniated discs, stenosis of the central canal or foramen, facet arthritis, spondylolisthesis, degenerative disc disease, or osteoporosis leading to fracture. The preceding conditions, among many others, can lead to pain and any work injury can exacerbate pre-existing abnormalities possibly leading to further impairment and/or disability 26-28.

2. ESSENTIALS OF ASSESSMENT

History

A detailed history of the mechanism and timing of injury is critical in determining if the injury is work related.  If the chief complaints, history and physical findings do not correlate, this is suggestive of symptom magnification and raises suspicion of a non-work related or non-physiological etiology.  History should be compared to previous records for consistency.  In addition to a full medical, occupational, and exposure history, a history of previous claims and outcomes should be obtained.  This will identify risk factors for protracted recovery noted in subsequent sections.

Physical examination

A structured process of inspection, palpation, range of motion (active and passive), manual muscle testing, sensation, coordination, gait, balance, reflexes, and special testing is a good paradigm for a complete yet focused exam. Objective findings for neurological injury are reflex asymmetry and muscle atrophy.  Range of motion, manual muscle testing, and sensation may be self-limited.  Observation of functional difficulties (i.e. gait, don/doff clothes, arising from chair) should match the physical examination.

Waddell signs suggest non-physiologic etiology of pain but do not necessarily imply malingering.  Distraction techniques can be used in patients with self-limited evaluations.

Depending on the mechanism of injury, the physical exam should start with a general musculoskeletal exam broadening to a neurological exam.  To help direct treatment and optimize recovery, one should perform specific exam maneuvers to elucidate the most likely cause of injury or pain including underlying biomechanical faults.  It is imperative to ask clarifying questions throughout your exam as provocative tests, such as FADIR (flexion adduction & internal rotation), may elicit discomfort in the inguinal region or over the greater trochanter.  The former is suggestive of intraarticular pathology while the latter may suggest greater trochanteric pain syndrome.  If the location of the produced pain is not verified, the examination has lost its diagnostic value.

Clinical functional assessment: mobility, self care cognition/behavior/affective state

Patient activity at home will help to establish the lowest level of work restrictions if patient is not working.  Avoiding responsibilities at home beyond expectations may indicate other secondary gain issues or catastrophizing tendencies.  The Fear Avoidance Behavior Questionnaire, Neck Disability Index and Oswestry Disability Index can identify patients at risk. When evaluating a patient with a work-related injury, it is important to keep in mind and distinguish between aggravation (lasting or permanent worsening of a pre-existing injury or condition) and exacerbation (temporary worsening of a pre-existing injury or condition) of an injury. In terms of identifying the injury as a cause for disability, the patient and physician should be aware that an employer may apportion or assign the current injury to a previous work injury if one occurred in the past. This would happen under a certain set of circumstances where the employer identifies the disability caused by a current injury is due in part to a previous injury.

Laboratory studies

Laboratory studies may be needed to rule out medical causes of complaints particularly in patients lacking non-physiological risk factors that fail to improve as expected.  If history and physical support other possible etiologies of pain such as inflammatory arthritides or autoimmune disorders, further work-up may be warranted.

Imaging

Imaging should be considered to negate or identify pathology when a patient fails to progress appropriately.  Imaging is most frequently recommended to confirm the diagnosis when the pre-test probability (index of clinical suspicion) is high. Furthermore, caution must be taken to educate the patient that abnormal findings must correlate to symptoms to be reasonably considered for causation and treatment as abnormal findings in asymptomatic individuals are common 18.

Supplemental assessment tools

Self-report in the form of standardized questionnaires is utilized to assess functional limitations. Validated measures focusing on health-related quality of life include the Fear Avoidance Beliefs Questionnaire (FABQ), Neck Disability Index (NDI), Oswestry Disability Index (ODI), and Short Form 36 (SF- 36).

FABQ is a 16-question investigation how a patient’s fear avoidance beliefs about physical activity contributes to pain, with higher scores indicating more severe fear avoidance behaviors.

The NDI is a modification of the ODI and uses self-reporting measure for neck pain.

The ODI is the gold standard of low back functional outcome tools. ODI scores are converted into a percentile, with higher percentiles equating greater disability.

SF-36 considers physical, emotional, and social functioning, plus general health perceptions on a 0-100 scale with greater scores equating lesser disability.

Early prediction of outcomes

There are multiple factors that can help predict successful return to work or persistent disability. Many of the principles of chronic pain and its management end up applying to returning to work after musculoskeletal disorders/injuries. For example, almost 30% of people sustaining acute low back pain go on to have chronic low back pain.  Chronic intractable pain is often associated with comorbidities such as depression, behavioral disorders, substance abuse, prolonged disability, and secondary gain concerns.  Unfortunately, prolonged pain diminishes the likelihood of return to work, and those who are out for more than 6 months due to low back pain return to work at a rate of 50%.  The rate diminishes to 25% at 1 year and under 5% after 2 years 29.

Environmental

Job satisfaction is a stronger predictor than job activity for predicting the filing of a future back claim 19.  Multiple short duration jobs may indicate inability to get along with others.  For workers with longevity, recent changes at work (i.e. new supervisor, change in shift or duty requirements) may cause job dissatisfaction.

Organizational policies and practices that support individuals with musculoskeletal injuries (i.e. work accommodations and pain self-efficacy) increase the rate of return to work and work role functioning 30.

Social role and social support system

Social support from supervisors at work can improve outcome.  Loss of identity, financial loss and home stress may contribute to depression.

Washington State is the only state that will treat premorbid unrelated psychiatric illnesses that are “retarding recovery of an allowed industrial condition” in order to improve outcomes.

Professional issues

There is a balance between being a patient advocate and fulfilling insurance carrier desires for case closure.  Restrictions and off work status should be medically based.  The patient may need to be removed from work if the employer fails to follow restrictions.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Official Disability Guidelines (ODG) provides evidence-based recovery durations for specific diagnoses.  Different durations are provided if the diagnosis is not workers’ compensation.

At different disease stages

Traditionally, protection, rest, ice, compression and elevation (PRICE) have been employed after an acute injury.  However, others have more recently suggested a transition to PEACE & LOVE (protection, elevation, avoidance of anti-inflammatories, compression, education, load, optimism, vascularization, exercise) 31.

Residual impairments in strength and range of motion in the post-acute or post-surgical phase are addressed with physical or occupational therapy.

Sleep also plays a critical role in return to work as sleep disturbances were associated with increased higher alcohol consumption, greater body mass index (BMI), lower physical activity, higher anxiety and an increased likelihood of not returning to work 32.  Restorative sleep and decreased trouble falling asleep at baseline predict faster resolution of chronic widespread pain and improved musculoskeletal health 33.

In more protracted cases work conditioning or work hardening are used to improve work status and function.  Work conditioning addresses work endurance through the use of strengthening and cardiovascular conditioning.  Workers advance from daily one-hour to four-hour sessions.  Work hardening addresses task specific job deficits and the patient attends daily sessions for several hours up to a full work day.  A review shows that physical conditioning has no effect on absence duration for acute back pain and small effect at one year to reduce sick leave in workers with chronic back pain 34. Overall, when chronic pain secondary to an initial injury is obstructing return to work, there should be consideration of a referral to a comprehensive pain center with access to pain psychology among standard medical care and therapies.

Maximal medical improvement occurs when a patient has undergone the most expected healing, repair and treatment pathways (i.e. chronic medical treatments and rehabilitation).  At that time, the insurance carrier may request an impairment or disability rating.  Over 35 states and the federal government require the use of some edition of the “AMA Guides to the Evaluation of Permanent Impairment 35.”

Disability is defined by the Social Security Act as an “inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months 36.”  It is the purpose of the physician performing an Independent Medical Evaluation (IME) to systematically define this subjective term of disability. This evaluation includes: a narrative history, clinical status, results of objective exams or tests, the cause of the injury related to employment, MMI assessment, identifying diagnoses and functional impairments, severity or permanence of limitations/impairments, analysis of job tasks, and the ability to perform said tasks.

At times a work capacity evaluation (WCE) can be done by a physical or occupational therapist to provide further objective functional information. However, objective evaluations of job performance are effort dependent. In the context of return to work, disability is related to both work-related and medical problems. No matter the end result of an IME, the patient should be counseled that determination of MMI does not imply the lack of a need of ongoing or future medical appointments or treatments as clinically warranted. This clarification emphasizes the role of the physiatrist as a crucial member of the medical team whose primary aim is to preserve and possibly improve the function and quality of life of the patient through holistic and longitudinal care.

Special consideration should be given to patients with primarily psychological or mental health related barriers to returning to work. Among individuals with concurrent mental health and musculoskeletal disorders, a benefit is obtained from combined clinical and work-related interventions compared to clinical interventions alone 37. It is difficult to identify and define disability, especially in chronic pain patients. During examinations, patients with multiple physical and psychological barriers to returning to work exhibit significant pain behavior characteristics (i.e. catastrophizing), but some evidence shows that malingering is present in only about 1-10% of chronic pain patients 38.  Thus, it is important to take a holistic approach when evaluating these patients.

Coordination of care

Team members include the patient, physician, therapist, employer, insurance carrier, and occasionally case manager.  Return to work slips with clear restrictions should be provided to patients and insurance carriers at the end of each visit.  Clinic notes should be documented promptly.  Insurance carriers must act quickly to approve treatment and testing recommendations.  Therapists should contact physicians if the patient fails to attend or claims to be in too much pain to participate.  Employers should make efforts to accommodate workers with productive light duty work.  Consistent feedback from all members in regard to diagnosis, goals and work status is paramount to a successful outcome.

Patient & family education

Expectations and goals should be established at the first visit.  The patient should be informed that work restrictions are written based on the diagnosis and physical findings.  It is the employer’s decision whether to accommodate.  Family members with poor outcome experience may undermine treatment.  Activity within restrictions at home and work should be encouraged.

Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based

Functional Capacity Evaluations (FCE) which are limited from pain do not measure maximal functional abilities. The validity of FCE to determine safe return to work is questionable 39.  Non-physiological factors may be more important.

A recent study showed conservative treatment is superior to lumbar fusion for degenerative disc disease, herniation or radiculopathy in workers’ compensation 40.

Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Identification of risk factors for protracted disability such as noncompliance with treatment, poor participation in the therapy, refusing to return to work when able, weight loss or exercise noncompliance, inability to quit smoking, patient hostility, anger, disruptive behavior, catastrophizing, and fear avoidance behaviors are essential to predicting prognosis and time to case closure 41.  Avoiding time loss at work, integrating cognitive behavioral techniques and focusing on functional goals in therapy may minimize disability time and reduce claim costs.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Research confirms that musculoskeletal disorders are multifactorial in nature with physical, psychological and social components.  In an attempt to address the psychological contribution which may impair return to work, cognitive behavioral therapy (CBT) has resurfaced.  A recent study of worker’s compensation clients showed that re-employment was found more rapidly in the cohort undergoing CBT than those undergoing standard job search assistance.  Scores of anxiety, depression and stress were tallied in each group, and those who underwent CBT showed statistically significant decreases in each as compared to the control group 42.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Controversies and gaps in the evidence-based knowledge

Few studies use only workers’ compensation cohorts 40.  These studies consistently show worse outcomes when compared to similar studies excluding compensation patients.  Task specific causation studies are limited and often used inappropriately to infer causation for unstudied tasks.

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Original Version of the Topic

Kevin Komes, MD, Brian Toedebusch, MD, Rebecca Hogg, MD. Return to work after MSK injury in the workplace: timely return and risk factors for delay. Original Publication Date: 10/06/2015

Author Disclosure

Alexander M Senk, MD
Nothing to Disclose

Christopher Meserve, MD
Nothing to Disclose

Michael H Nguyen, MD, MPH
Nothing to Disclose

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